Exploring Higher Rates of Breastfeeding Among Civilian Military Wives: A Mixed Methods Study


 Background: As compared to the United States general postpartum population, civilian military wives encounter unique challenges that can impede their ability to breastfeed, including geographic replacement and physical and emotional challenges. Yet despite these challenges, civilian military wives demonstrate higher rates of breastfeeding initiation and duration in the United States postpartum population as a whole. The purpose of this study was to explore factors contributing to the high rate of breastfeeding initiation and duration among civilian military wives and to determine what might be learned from these factors for intervention design for the broader population of postpartum mothers. Methods: The sample consisted of 28 civilian military wives whose ages ranged from 18-45. The study was conducted online using a concurrent mixed-methods design. Results: Seven main themes with 16 subthemes emerged from the descriptions of the semi-structured interviews. The results of the Breastfeeding Self-Efficacy Scale-Short Form score was 55.2 (SD = 5.73). The results of the integrative analysis revealed that factors within the military environment influence a sense of community, thus supporting their breastfeeding self-efficacy (BSE). Additionally, supportive and pro-breastfeeding healthcare facilitators (especially lactation consultants) throughout the prenatal, intrapartum, and postpartum periods described by civilian military wives were associated with high levels of breastfeeding self-efficacy among civilian military wives. Moreover, high levels of breastfeeding self-efficacy related to breastfeeding skills and duration were associated with the accessibility of resources within the military environment, breastfeeding health and economic benefits, and setting of a breastfeeding goal. Conclusions: Using a concurrent mixed-methods design, this study identified facilitators from the descriptions of civilian military wives that they believed promote their higher rates of breastfeeding initiation and continuation, quantified their high level of breastfeeding self-efficacy, and identified descriptive factors that contributed to both areas lacking in the literature among this population.


Introduction
Leading breastfeeding authorities recommend breastfeeding exclusively for the rst six months of a newborn's life. 1 This recommendation derives from the holistic health bene ts that breastfeeding provides for both mother and infant. 2 Physical newborn health bene ts can include protection from numerous chronic diseases, such as diabetes, obesity, allergies, and heart disease. 3 Mental-emotional health bene ts for breastfeeding mothers include maternal-newborn bonding and decreased symptoms of maternal depression. 4 From a community perspective, breastfeeding provides economic advantages, as it partially or wholly supplants costly infant formula. 5 The United States (U.S.) national rates of breastfeeding for initiation and duration to six months are 83.2% and 57.6% . 6 These remain below the Healthy People 2020 breastfeeding goals of 100% initiation and 60.6% continuation to six months. 6,7 As compared to the U.S. general postpartum population, civilian military wives (CMWs) encounter unique challenges that can impede their ability to breastfeed, including geographic replacement and physical and emotional challenges. 8 Yet despite these challenges, CMWs demonstrate higher rates of breastfeeding initiation and duration compared to the U.S. postpartum population as a whole. 9,10,8 As of 2015, the Department of Defense (DoD) indicated that military active-duty and reserve members were married to 1,012,251 civilian spouses. 11 This gure does not include unmarried partners or dual-military member marriages. Within military-a liated communities, CMWs assume a unique role framed by the military core values, experience stress related to partner deployment, and demonstrate resilience despite these challenges. 12 CMWs represent a unique group due to multiple factors, including younger marriages, geographical replacement, and family separation. 12 Children of parents sent out on repeated deployments experience anxiety and decreased well-being. 12 CMWs, on average, marry younger-between the 20 to 25 years of age in comparison to their non-military-a liated civilian counterparts. 12,13 Younger-age marriages correlate with higher divorce rates in both civilian and military populations. 14 CMWs are less likely to be employed than their non-military a liated civilian counterparts and, if employed, on the whole, make less than their nonmilitary a liated civilian counterparts. 15 The lives of CMWs involve stress from deployments of their loved one to consequences of war as well as the regular challenges that couples of childbearing age encounter. 12 Because military service demands geographic replacement, CMWs move more (2.4 times more) than their civilian counterparts. 15 This geographic replacement can create a dual role of a tied migrant and a tied stayer. 13 As a tied migrant, CMWs keep the family together by moving with the service member despite the loss of employment or educational situation. 13 As a tied stayer following the move to be with the service member, CMWs are bound to the location of their spouse's assignment, limiting their ability to obtain a job or schooling. 13 It can be argued that a dual marriage occurs between a CMW, her active-duty spouse, and the designated military branch. CMWs thus face challenges beyond those typically experienced by married, childbearing couples, including displacement from familiar resources and expectations. CMWs must uphold the same values as their military partners: honor, courage, and commitment. These unique context demands of CMWs require effective coping skills to manage the personal sacri ces they have made in support of their service member partner. 16 CMWs encounter unique challenges that can impede their ability to breastfeed such as a lack of support due to geographical movement and physical and emotional challenges. 12,8 Despite these challenges, CMWs demonstrate higher rates of breastfeeding initiation (92.2%) and duration at six months (61.7%) in comparison to the U.S. breastfeeding population initiation (83.2%) and duration at six months (57.6%) rates. 6,9 This study provides descriptions of prevalent factors associated with breastfeeding and duration among CMWs as well as describes the types of breastfeeding resources CMWs felt were effective in meeting their breastfeeding goals. Additionally, this study examined breastfeeding self-e cacy in CMWs. The insight gained from exploring factors associated with higher rates of breastfeeding initiation and duration among CMWs has the potential to lead to the development and transferability of effective breastfeeding interventions.

Purpose And Aims
The purpose of this study was to explore factors contributing to the high rate of breastfeeding initiation and duration among CMWs and to determine what might be learned from these factors for intervention design for the broader population of postpartum mothers. Research aims were to: 1) Describe prevalent factors associated with breastfeeding initiation and duration among CMWs; 2) Examine breastfeeding self-e cacy (BSE) in CMWs and, 3) Identify attributes of breastfeeding facilitators that are reported by CMWs and to further identify which attributes of CMWs' BSE are associated with characteristics of the individual and which are associated with the military environment. The Health Promotion Model (HPM) guided this study by informing coding categories in the data analysis phase.

Study Design
Nola Pender's Health Promotion Model (HPM) provided theoretical guidance (for this study) into the potential transferable personal characteristics and experiences that affect breastfeeding behaviors of CMWs. Some examples of the transferable personal characteristics and experiences of CMWs included positive health behaviors that result in improved health, improved functional ability, and satisfaction with well-being at all stages of development. 17 The HPM posits that several factors in uence an individual's ability to engage in positive health behaviors which include: personal factors, perceived bene ts of action, perceived barriers of action, perceived self-e cacy, activity related to affect, interpersonal in uences, situational in uences, commitment to plan of action, immediate competing demands and preferences, and health promoting behavior. 18 The results from the literature review and the HPM were used to inform the interview guide and study design.
A concurrent mixed-methods design was used; it is a type of design in which qualitative and quantitative data were collected in parallel, analyzed separately, and then merged to best understand the research problem. 19 Snowball sampling was used to recruit participants from a Facebook site devoted to supporting breastfeeding among active-duty and civilian military wives. 20 From the Facebook site, potential informants were directed to a Qualtrics link. Potential informants completed a ve-item survey that included inclusion and exclusion criteria as well as sample questions to review which offered potential informants' insight about questions that were asked of them.
Sensitive security issues revolved around CMWs and the nature of their partners' active-duty situation or the military-a liated community as well as their breastfeeding experience that could increase stress and anxiety within the study participants. A disclaimer in Qualtrics indicated that participants at any time may choose not to answer a question (for any reason) or further participate in the study. This disclaimer allowed the potential participants to withdraw from the study and continue to receive the Amazon gift cards in the event they did not want to continue with the study. Con dentiality of participant information was a primary focus and concern during this study. Therefore, any information gathered from the participants was solely shared with the dissertation committee members. Once the informant had been identi ed as an eligible participant via Qualtrics, she was sent an invite for an initial meeting via email. Contact was made through email to obtain study consent and to determine the informants' availability for their qualitative interview meeting via Zoom.

Measures
The Breastfeeding Self-E cacy Scale-Short Form (BSES-SF) was used to identify the degree of a CMW's con dence in her ability to carry out breastfeeding or breastfeeding self-e cacy. 21 Interview data gathered from the participants supported the exploration into the unique breastfeeding facilitators among CMWs. The interviews were conducted via Zoom. The rationale for conducting virtual interviews is that social media promotes access to hard-to-reach, geographically displaced populations. 22 The quantitative component of this study was a cross-sectional, retrospective descriptive, non-experimental design, whereby the researcher investigated the level of breastfeeding self-e cacy among CMWs.

Analysis
Qualitative content analysis was used to analyze the data retrieved from the semi-structured interviews.
Quantitative data analysis involved rst measuring the reliability of the BSES-SF to determine internal coherence and homogeneity within the measurement tool. Cronbach's Alpha (a) was assessed to determine internal consistency. Descriptive statistics from the socio-demographic characteristic questionnaire and the mean BSES-SF score as well as the individual items scores were analyzed. The results were compared with the results from Dennis's original BSES scale research as well as more recent scores from other BSE studies within the literature. A meta-matrix approach was used to perform analytic integration of the qualitative and quantitative analysis. Matrices assist with the identi cation of patterns of regularities and anomalies and promote a fuller exploration of all the data simultaneously. 23

Sample Characteristics
The sample (Table 1) consisted of (n = 28) CMWs whose ages ranged from 18-45. The majority of the sample (50%) reported being between 28-33 years of age. The second largest age group reported an age group ranging from 22-27 (28.6%). About 78.6% of the sample identi ed as Caucasian; 3.6% identi ed as African American; 10.7% identi ed as Hispanic; 3.6% identi ed as Asian; and, 3.6% identi ed as other.

Qualitative Findings
The experiences described by breastfeeding CMWs that contribute to their higher rates of breastfeeding were demonstrated from the qualitative portion of this study. However, there were similarities in their perspectives and descriptions of military life and breastfeeding experience (hectic but worthwhile), military community facilitators, healthcare facilitators, breastfeeding bene ts, determination of a breastfeeding goal, supportive resources, and providing advice from others. The theme Contrary Case represents isolated situations that did not conform to the positive ndings described by the participants (Table 2). structure] is that the pediatricians at each base that we've been to, and we've seen--sometimes, you don't always get to see your same pediatrician. All of them are super supportive of breastfeeding, even extended breastfeeding, when I was weary about it." "The nurses were fantastic. They were friendly. They didn't just make small talk on and they were informative and they listen when I said when I would be concerned about something. When I had any question they waited, you know, hear the question before they started answering they didn't dismiss anything you know right away they seemed genuine."

4.
Breast is Best Subthemes: 4a. Health Bene ts 4b. Costeffective "So [the reason I chose to breastfeed was because] I'm just very exposed to breastfeeding in general and the bene ts of breastfeeding. I feel like I just felt like something. If you want to provide your baby with the optimal, you know, nutrition and the optimal start in life. I just feel like breastfeeding has so many bene ts." "And I mean, also, just like I feel like it's the most bene cial in every way, even from a cost saving perspective, like you don't have to buy formula." "There's a lot of support groups [including breastfeeding and military wife speci c that helped support my breastfeeding duration]. Mom2Mom support groups that you can go too. And they've also got La Leche League here and actually somebody in our, our neighborhood. We live on base and one of the leaders is also a military wife. So, there's actually a whole lot of support for breastfeeding here." "Support with the lactation consultants [helped with breastfeeding continuation past six months] because that I mean is a huge resource, especially when you don't know if they're getting enough, you know, especially with your rst child." "So, it was good to have someone [like another CMW] that was also breastfeeding."

Advice for Others
Subthemes: 7a. Prepare for Breastfeeding 7b. Stick with it "[I would tell other breastfeeding CMWs to] take it day by day or hour by hour or whatever is going to get you through it. However, take it slowly if you need to be successful. Every milestone is a win, right, and then I would tell them, you know you will get through the day to day. Find yourself, whatever your support [you will need such as] groups going to be, so if it's going to be a friend, even if it's someone that you have to call on the phone. There's a resource here."

Contrary Case
"Um, [my experience having a baby and breastfeeding in a military hospital] was very horrible, to be honest. And my rst pregnancy, I saw a doctor that was unbelievably rude and very forgetful. He was very old and the hospital would not transfer me out of his service, then I changed the type of TRICARE that we had. So, I could see a civilian provider, because the clinic was still… it was just overworked and they were so busy, it was too crazy and there wasn't enough quality care."  CMWs have a high degree of positive coping ability and willingness to take on and overcome challenging day-to-day tasks for the sake of their family and their spouse's job. Although, breastfeeding can present them with challenges, they take it on without any hesitation. CMWs translate and use these attributes to take on breastfeeding challenges and do whatever it takes to persevere and overcome those breastfeeding challenges. With all of the extra day-to-day challenges as a result of spousal deployment or forced geographical movement, CMWs described strategies used to manage breastfeeding during these situations. CMWs described that the mobility of breastfeeding as well as not having to deal with formula and bottles allows them to manage situations of spousal deployment and forced geographical movement. Additionally, support from other military families and maintaining their commitment during these challenging situations increased their feelings of accomplishment and satisfaction with management of the situation.

Resources, Hectic but Worthwhile & Military Community Facilitators
Q56: Manage to breastfeed even if my baby is crying CMWs described a multi-faceted approach for how they manage challenging breastfeeding situations. For example, seeking out Lactation Consultants, social media, and vicariously breastfeeding through peers. This was apparent during the interviews. During the interview if their infant started to cry and tug at them, they effortlessly started to breastfeed their infant. CMW attributes of multi-tasking due to their hectic life and feeling the freedom to breastfeed within their environment contribute to their ability to manage breastfeeding even if their infant is crying.

Q57: Keep wanting to breastfeed
Having breastfeeding goals assists CMWs with achievement of a primary breastfeeding duration of one year. However, recommendations from the WHO and the acceptance within the military environment further supports their desire to extend breastfeeding duration. For the CMWs, the military is their current family. CMWs felt free to breastfeed uncovered on and off the base. CMWs described facilitators that contributed to their con dence to breastfeed in front of their military family members include the sense of respect that is felt and manifested within the military environment and the acceptance that is a standard way of life within this environment.

Hectic but
Worthwhile & Breastfeeding goal Q59: Be satis ed with my breastfeeding CMWs described that being them has its challenges, but also there is a payoff or rewards for being them. They endure the hard work, embrace the suck, and reap the rewards of travel, feelings of pride for their spouse and the duties he performs for the sake of their country. CMWs also describe their sense of pride with accomplishing and extending breastfeeding goals.

Quantitative Findings
The ndings from the quantitative statistical analysis demonstrate that CMWs have high levels of BSE.
Descriptive statistics revealed reliability that was previously shown was supported in this study and with this sample. When mean item statistics was compared with the BSES item statistics shown in other samples by Dennis 21 and Rowe 24 , the results of CMWs were higher showing higher levels of BSE among CMW in our sample compared to others.

Integrative Analysis Findings
The integrative analysis revealed that factors within the military environment in uence a sense of community, thus supporting their BSE in these areas. Additionally, supportive and pro-breastfeeding healthcare facilitators (especially lactation consultants) throughout the prenatal, intrapartum, and postpartum periods described by CMWs were associated with their high level of BSE. Moreover, high levels of BSE related to breastfeeding skills and duration were associated with the accessibility of resources within the military environment, breastfeeding health and economic bene ts, and setting of a breastfeeding goal.

Discussion
The current study added to the existing literature by exploring the relationship of factors that contribute to higher levels of breastfeeding self-e cacy among CMWs and those factors described by CMWs that contribute to their higher breastfeeding rates. The predominant themes of hectic but worthwhile, military community facilitators, healthcare facilitators, breast is best, breastfeeding goal, resources, advice for others can inform the development of future nursing interventions to support higher rates of breastfeeding for other populations.
Breastfeeding bene ts, having a breastfeeding goal, freedom to choose their healthcare provider and delivery facility, accessibility of supportive resources such as La Leche League support groups, lactation consultants, social media, and peer-mentors were highly valued and described by CMWs in this study as contributing to their high level of BSE and breastfeeding duration. Therefore, the integration of the prominent themes (and subthemes) into interventions that target lower BSE in other populations has the potential to improve breastfeeding initiation and duration among those population.

Strengths
A mixed methods approach was used for this study. According to Field 25 "Mixed methods potentially offer depth of qualitative understanding with the reach of quantitative techniques". The BSES-SF provided quanti able validation that CMWs in this study experienced higher levels of BSE. Moreover, CMWs in this study demonstrated higher levels of BSE when participants' means were compared with the BSE item statistics found in Dennis Breastfeeding Self-E cacy Scale 21 and Rowe 24 . However, the ndings from the BSES-SF alone was insu cient to identify factors that contributed to higher levels of BSE within the sample. The qualitative arm of this study provided reasons described by the participants that contributed to their high level of BSE. Teddlie and Tashakkori 26 warn that despite the type of mixed methods research design employed by a researcher, an enhanced understanding will only result if the research strands are effectively integrated together through a systematic process. In this study, a convergent validation of the ndings resulted from the systematic integration process using a meta-matrix.

Limitations
The prominent race represented in this study were Caucasians (78%) who outnumbered 3.6% of the sample who identi ed as African American, 10.7% identi ed as Hispanic, 3.6% identi ed as Asian, and 3.6% identi ed as other. Within the breastfeeding literature, ethnic disparities re ect those of under-represented ethnic groups. 27 Breastfeeding provides health and psychosocial bene ts for all mothers, but minority mothers are disproportionately affected by adverse health outcomes that can be improved by breastfeeding. 27 Other notable areas re ecting a lack of diversity within the sample included educational level, household income, military branch, and military rank. Simply put, the respondents were better educated, had more nancial resources and higher rank than the general population of CMWs which could limit the application of our ndings to all CMWs. Another limitation was that a technical oversight contributed to the participants not lling out one of the BSES-SF 14-items. The item not addressed by the participants was I can always continue to breastfeed my baby for every feeding. Based on the overall BSES-SF mean score of 55.2, the omission of this item may have impacted the overall score and comparability to other studies. For that reason, we report individual item response means compared to other studies and did not explicate in great detail the whole scale results.

Implications
There is limited data about the higher rates of breastfeeding of civilian military wives within the literature.
Future CMW breastfeeding studies should aim to recruit samples that re ect ethnic diversity, educational level, household income, military branch, and military rank and have larger sample sizes, especially for asking quantitative questions.

Conclusion
Nurses play a pivotal role in the delivery of health education and possess the power to support positive health practices as well as to promote disease prevention behaviors. Breastfeeding is a health promotion activity that provides physical and psychosocial bene ts for both the mother and her infant. 2 For these reasons, leading maternal and newborn health organizations have endorsed breastfeeding as a preferred feeding method because of its numerous health bene ts. 28,1,7 The U.S. national rates of breastfeeding for initiation and duration to six months are 83.2% and 57.6%. These remain below the Healthy People 2020 breastfeeding goals of 100% initiation and 60.6% continuation to six. 6,7 Over the past 20 years, the Breastfeeding Friendly Initiative has improved breastfeeding outcomes. 29 However, more strategies are needed to improve breastfeeding outcomes to meet the recommended breastfeeding goals.