The ten categories identified as assisting Australian, Irish and Swedish women to continue breastfeeding for six months, incorporate the individual (mother), inner social (partner and baby within immediate family), outer social (informal support either face to face or online), and societal support (health professionals, work environment and breastfeeding being regarded as the cultural norm). These categories fit within an ecological model highlighting factors that influence breastfeeding such as the mother/infant dyad, the family, the health care system, the community and societal/cultural factors [21]. Our findings align with the ecological model which highlights how multiple coordinated efforts through targeted interventions must incorporate all factors within an ecological model to effectively promote and support breastfeeding.
The support required to assist breastfeeding women is complex and multi-faceted. The promotion and support of breastfeeding is a collective societal responsibility as the world does not always provide a supportive and enabling environment for breastfeeding women [22]. Components of an enabling environment for breastfeeding includes ‘individual determinants’ including mother and infant attributes and mother-infant relationship; ‘setting determinants’ such as health systems and services, family and community and workplace and employment; and ‘structural determinants’ including social trends, advertising, and media. “Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women’s work and employment conditions, and health-care services to enable women to breastfeed” (p.491) [22].
All women in this international study cited how their knowledge of breastfeeding health benefits assisted in their efforts and reinforce the importance of knowledge dissemination through parent education and individual health professional consultations. Evidence must inform best practice in parent education, whether group or individual consultation [23]. Diligence must continue where knowledge can be shared with parents but also to address areas where knowledge may be lacking. For example, a Finish study found that prospective parents had deficiencies in knowledge around how to increase lactation, the sufficiency of breast milk in the first four months and within the context of hot summers, plus the management of alcohol consumption whilst breastfeeding [24].
Our category ‘breastfeeding was going well’ illustrates the importance of women receiving positive reassurance of their breastfeeding performance to build self-efficacy. Bandura who constructed the social cognitive theory claims that individuals need enough knowledge about behaviors affecting health but must also believe they have the capability for adoption of the behavior [25]. Individuals with self-efficacy believe they are capable of successfully performing certain behaviors [25]. As evidence suggests, self-efficacy can increase through mastery experience (past experience or successful initial attempts), verbal persuasion (trust and encouragement by a credible significant others), vicarious experience, or physiological and affective states [26–28]. Although our international participants acknowledge their own determination as important, constant struggles without some degree of success may be overwhelming. Women may experience difficulties during the early stages of breastfeeding and it is important that advice and support is timely. This support is particularly important in the early postpartum period as a longitudinal cohort study in Sweden found that 27 % of mothers had breastfeeding problems in the first month which was associated with early cessation [29]. In fact, an American study found that 60 % of women ceased breastfeeding earlier than desired and difficulties with lactation such as attachment issues; sore, cracked or bleeding nipples and pain [30].
Our international breastfeeding women acknowledged the importance of support from health professionals which is supported in the literature. An Australian mixed methods study reported that women relied on health professionals for advice and support revealing a theme of ‘not giving up despite difficulties’ [31]. Support from others who can encourage individuals to believe they have the ability to achieve what they seek (verbal persuasion) are especially important when struggling with difficulties [26, 27]. The extent and timeliness of services being able to offer early problem resolution when women are struggling in ‘those first few weeks’ is essential [31]. For example, effective breastfeeding technique is associated with increased breastfeeding self-efficacy [32] and demonstrates how Bandura’s mastery experience can increase breastfeeding self-efficacy [26, 27].
Irish women in our study did not rank health professional support as highly as Australian or Swedish women who ranked this support in their top three categories. Perhaps in an environment where this formal support is not readily accessible, these resourceful women used informal networks available either face to face through family, friends or their partner or through online media. Although Australian and Swedish women also cited partner and informal face to face contact within their top five rankings, use of informal online support were ninth and tenth, respectively. Evidence around the important of both informal and formal support has been widely known [33]. A recent UK study explored women’s experiences with Baby Café breastfeeding support groups and found that mothers valued a combination of professional and peer support provided by the Baby Care services: the social support from other mothers was regarded as central to being able to meet their breastfeeding goals [34].
The use of informal online support through social media such as Facebook was highly cited by Irish mothers. Bandura claimed that self-efficacy can increase through role models in social media and individuals can observe attitudes, styles of competencies and attainments of different people [26, 27] but limited evidence is available around the use of social media to support breastfeeding women. A Twitter based educational campaign on awareness, knowledge and breastfeeding practices in Saudi Arabia reported a slight increase in initiation with women confirming a willingness to continue exclusive breastfeeding (n?=?484) [35]. A qualitative design explored the use of social media amongst 14 first time African American mothers and eight support persons [36]. Although acknowledged as an important vehicle to disseminate information, social media is not being used to its full potential and opportunities to create innovative, health interventions around infant feeding are not only recommended [36] but deemed essential for Generation Y who are online and connected [37].
Fathers and family members such as maternal grandmothers do influence a woman’s infant feeding decision [38, 39]. Although father presence is associated with greater initiation, a negative relationship between practical support from fathers and grandmothers and breastfeeding has been noted [40]. Fathers are acknowledged as providing essential support for their breastfeeding partners and initiatives to improve their knowledge around breastfeeding must continue to be a research priority as suggested from a pilot study with inner-city fathers in Ohio [41].
Awareness of the potential for clashes between idealism and the reality experienced within and between families and health professionals suggests that a family-centered narrative approach may be beneficial in acknowledging family goals particularly in the presence of breastfeeding problems [42]. Infant behaviors that can be misinterpreted as breastfeeding problems or perceptions of insufficient milk [43] and reflect misunderstanding of normal infant crying, an unsettled restless baby or frequent awakenings at night: it has been suggested that teaching child development to parents could be a useful strategy to extend breastfeeding duration [44].
The category of breastfeeding being noted as the cultural norm was similarly ranked eighth by all international women which is interesting given Australia and Sweden have high initiation rates and comparable prevalence up to 6 months. However, Irish women where initiation rates are lower also ranked cultural norm as eighth out of the ten categories. This highlights that acknowledging breastfeeding as a cultural norm was important for these international women who all breastfed to at least six months and whose personal and social environment reinforced the normality of breastfeeding. Individual’s everyday network may include important role models (vicarious experience) because they reinforce that individuals “just like you” can be successful and are essential for increased self-efficacy [27]. In fact, further research has been recommended across pre-conception and throughout the perinatal period to better support women choosing to breastfeed and cultivate breastfeeding as a cultural norm [45].
We found that mothers in this study cited felt that breastfeeding facilitated bonding and enabled them to feel closeness with their infant. Mothers enjoyed the closeness and therefore had a positive experience of breastfeeding. When individuals are happy, relaxed and calm (physiological and affective states) they may achieve higher self-efficacy [26–28]. It has been suggested that social and professional support should include help for mothers to relax and focus on their feelings of closeness with their infant [46].
Limitations must be considered when interpreting our findings as our Australian, Irish and Swedish women are not representative of all breastfeeding women in these countries. Women self-selected to participate in response to our recruitment strategies and represent a cohort of highly educated women who have continued to breastfed a recent child beyond six months. As social media platforms were used for recruitment in Sweden and Ireland, this may have contributed to the importance of online support in our findings.