How can services better support women with a body mass index ≥25 kg/m2 to breastfeed: a qualitative study.

doi:10.21203/rs.3.rs-4643103/v1

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How can services better support women with a body mass index ≥25 kg/m2 to breastfeed: a qualitative study.

https://doi.org/10.21203/rs.3.rs-4643103/v1

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Aim: This study explores the experiences and perspectives of women with a Body Mass Index (BMI) ≥25 kg/m² on infant feeding.

Subject and methods: Women with a BMI ≥25 kg/m² have lower rates of initiating, maintaining and exclusive breastfeeding than women with a BMI <25 kg/m². There is limited qualitative research on this topic, particularly for women living with overweight (BMI ≥25 kg/m²-29.9 kg/m²). Eighteen women with a BMI ≥25 kg/m² living in the North East of England and an infant under eighteen months of age participated in a semi-structured interview concerning infant feeding practices during May and June 2021. Participants were recruited through social media platforms. An inductive thematic analysis was undertaken to analyse the interview data.

Results: Two overarching themes were identified: lower confidence and a perceived negative judgement from others for living with higher weight. These themes reduced women’s confidence in their ability to breastfeed and led to negative experiences or avoidance of public feeding. Difficulties with latching and positioning in relation to body shape also reduced confidence in breastfeeding further. Due to these barriers, women felt that they required additional, tailored support to achieve breastfeeding.

Conclusion: Improving breastfeeding support for women with a BMI≥25 kg/m² requires a whole systems approach involving education systems, healthcare professionals and the community. The impact of terminology, such as labelling a women’s pregnancy ‘high risk’, on women’s breastfeeding confidence needs to be considered further.

Breastfeeding is a public health priority and is the most effective intervention in promoting health for both mother and baby [1]. Research indicates health benefits of breastfeeding to both mother and child [2-5] and the World Health Organisation (WHO) recommends exclusive breastfeeding for the first six months of the child’s life [6].

Prevalence rates of breastfeeding in England are considerably lower than the rest of the world [7], with the six to eight weeks exclusive breastfeeding rate at 48% and the 6-month rate at 1% in 2019/20 [8]. For comparison, the 6-month exclusive breastfeeding rate ranges from 13% to 39% across Europe [9].

Several systematic reviews have identified that women with a BMI ≥25 kg/m² report lower rates of initiating, maintaining and exclusively breastfeeding [10-12]. As a meta-analysis demonstrated that for every one-point increase in BMI score, there was a 4% increase in likelihood of non-initiation and cessation [13], it is important to understand the perspectives of both women living with overweight (BMI ≥25-29.9 kg/m²) as well as women living with obesity (≥30kg/m²). Recent literature has mainly focused on women living with obesity [14], with the perspectives of women with an overweight BMI being under-researched. A qualitative approach is required to understand the perspectives and experiences of women with a BMI ≥25 kg/m² concerning infant feeding.

There are many factors involved in a women’s decision and ability to breastfeed [10]. A meta-synthesis by Lyons et al. [14] explored perspectives of women with a BMI >30 kg/m², classifying barriers to successful breastfeeding as: the psychological effect of medicalised pregnancy, negative perceptions of the body’s ability to feed and the requirement of additional and prolonged support. Evidence for how women living with overweight or obesity experience breastfeeding support initiatives is limited [11].

This study explores the experiences and perspectives of women with a BMI ≥25 kg/m² on infant feeding. The study setting was the North East of England, where 63% of women are living with overweight or obesity, the highest rate in England [15].

Qualitative research can add depth to our understanding of a topic. An interpretative phenomenological approach was adopted in this study which considers the importance of perception, rather than examining an object or subject alone [16].

Purposive sampling was used initially to identify primary participants, with snowball sampling used to further aid recruitment. A recruitment video was shared across Twitter and Facebook groups with a link to an online survey. Participants were asked to complete the online survey to assess eligibility and to report demographic data such as BMI category (overweight or obese). This enabled the employment of maximum variation sampling, to gather the widest range of participants’ perspectives. The recruitment strategy also included targeting charities working with mothers from ethnic minority groups to achieve maximum variation within the sample.

One-to-one semi-structured interviews were undertaken with 18 women residing in the North East of England with a BMI ≥25 kg/m². Women were eligible to participate in the research regardless of whether they used breast and/or formula infant feeding practices. A topic guide, informed by the literature [17], was used to encourage discussion around feeding practices.

Patient and Public Involvement (PPI) was incorporated into the development of the video and social media post used to recruit participants. This involved surveying 26 women and identifying that half were aware of the term ‘BMI’, which defined the terminology used in the social media recruitment post. The language use throughout was in line with the guidance of the charity, Obesity UK [18]. Participants were offered a £10 voucher for taking part.

Interviews took place in May and June 2021 over an online platform, ‘Zoom’ or by telephone. Face-to-face interviews could not be offered due to the lockdown restrictions associated with Covid-19. Data saturation criteria were applied to indicate when to stop the recruitment process. Saturation was determined when interview data resulted in no further themes, data or codes [19]. Following perceived data saturation, two further confirmatory interviews were undertaken, which did not identify any new themes.

Interviews were transcribed verbatim to ensure accuracy. Following transcription, transcripts were anonymised, with pseudonyms replacing participant names and identifiable data were replaced with generic descriptors (e.g. [hospital]).

In line with an interpretative methodology, an inductive thematic analysis was conducted. This allowed for the reporting of key concepts across participant perspectives which can provide findings that are informative in the development of policy and practice. Thematic analysis followed the method proposed by Braun and Clarke [20], including the seven steps of: transcription, reading and familiarisation, coding, searching for themes, reviewing themes, defining and naming themes, and finalising the analysis.

Data analysis occurred alongside data collection, with the interview schedule adapted as themes emerged. Three researchers (SC, JR and NH) individually coded two interview transcripts and then came together in two data meetings to consider different perspectives and shared interpretations within the data. Collaborative coding reduced potential bias and maximised validity with multiple viewpoints and knowledge within the data coding. Participants have been given pseudonyms and illustrative quotes are provided in Table 2.

This study gained ethical approval from Newcastle University (Reference number: 2084/10472). Anonymised data will be kept for ten years as per Newcastle University’s research practice.

The recruitment survey was completed by 92 potential participants. Of these, 27 women requested to take part, with 24 scheduling an interview and 18 completing the interview, with six cancelling or not attending. No participants withdrew from the study following the interview. The interviews ranged between 29 and 61 minutes in length, with a mean length of 49 minutes.

Participants were aged between 24 and 44 years with infants aged between six and 14 months and were from areas with a deprivation decile score ranging from 1-10 [21]. 10 participants self-described as living with obesity and 8 as living with overweight. Participant characteristics are detailed in Table 1.

Table 1. Participant characteristics

Pseudonym	Age	Parity	Deprivation decile*	Self-reported weight category	Feeding method	Interview mode
Abby	29	Primiparous	10	Overweight	Breast	Video call
Bryony	35	Multiparous	10	Overweight	Mixed	Video call
Clara	24	Primiparous	2	Overweight	Formula	Telephone
Dana	29	Multiparous	8	Obese	Breast	Telephone
Erin	37	Multiparous	10	Overweight	Breast	Video call
Felicity	31	Multiparous	6	Obese	Breast	Video call
Georgia	33	Multiparous	9	Obese	Breast	Video call
Holly	30	Multiparous	5	Overweight	Formula	Telephone
Isla	35	Primiparous	5	Obese	Mixed	Video call
Jessica	38	Multiparous	3	Overweight	Breast	Video call
Keeley	31	Multiparous	9	Obese	Breast	Video call
Lyra	32	Multiparous	9	Obese	Formula	Video call
Molly	33	Multiparous	5	Overweight	Breast	Telephone
Natalie	29	Multiparous	4	Obese	Mixed	Video call
Orlagh	44	Primiparous	10	Overweight	Breast	Telephone
Phoebe	32	Primiparous	1	Obese	Breast	Video call
Quinn	38	Multiparous	4	Obese	Breast	Video call
Rosie	33	Multiparous	3	Obese	Breast	Video call

*Deprivation deciles identified by the Index of Multiple Deprivation (Ministry of Housing, 2019), with 1= 10% most deprived area in England, 10= 10% least deprived area in England

Generally, participants felt that living with overweight or obesity created additional barriers to breastfeeding throughout their pregnancy as well as following the birth. Two overarching themes were identified in the data: confidence and judgement.

Confidence

This overarching theme describes how participant’s viewed higher weight to reduce confidence in body image and belief in their ability to cope with initiating and maintaining breastfeeding; “I can’t do it” (Bryony). Lower confidence also increased concerns around breastfeeding in front of others.

Judgement

‘Judgement’ captures how the participants negatively judged themselves as well as their perceived negative judgement by others. Participants generally felt that higher weight was judged negatively by others, particularly by professionals involved in their care and others around them; “I don’t want to be lifting my top up, thinking it’s not just people looking at your boobs hanging out, but also, “Oh my gosh, look at her rolls of fat” (Jessica).

The two overarching themes weave through three identified themes: ‘confidence in ability’, ‘breastfeeding in public’ and ‘additional support needs’ (shown in the thematic diagram, Figure 1). Quotes supporting themes are shown in Table 2.

Table 2: Quotes supporting themes and subthemes

Themes	Subthemes	Quotes
1. Confidence in ability	The physical impact of higher weight	“[being labelled a “high risk” pregnancy] kicks you off in a negative headspace straightaway” (Felicity) “I think possibly, because obviously having a higher BMI, your body works harder anyway, trying to keep you going with your day-to-day activities, obviously having that extra weight and whatever. So, I think if any- I know breastfeeding is tiring anyway, but it possibly tires you out more because obviously your body is working harder because of your higher BMI anyway. And then you factor in the energy it takes making the milk and feeding baby” (Phoebe) “My belly- it feels like everything is in the way of trying (…) it wasn’t all this petiteness, that we could just slot a baby in there” (Quinn).
	Is baby getting enough?	“The health visitor was there and kept asking what my diet was like and like sort of implied that it was my diet...I wasn't getting enough like nutrition and that was why he wasn't putting weight on.” (Abby) “I saw this sign and it's…erm…“babies, they are what you eat” (…) and you feel like you shouldn't have a treat, you shouldn’t have that chocolate bar or you shouldn't have that Mcdonalds or that takeaway because you're exhausted and you’re thinking “is that going to affect the baby? Is it going to make them be overweight in the future?”” (Keeley)
2. Breastfeeding in public	Less discrete	“And I’ve seen comments on pictures on social media where people say, “You don’t need to have your whole boob out,” but actually it’s quite hard not to. If you’ve got quite big ones, then it’s going to be out anyway. So yes, I think that is the thought that people are thinking – “You're showing something.” With my little girl, I felt like, if I tried to do a cradle hold, my nipple just slipped out of her mouth, and I had to hold my boob. So, I had no hands free, because I was trying to hold the baby with one hand and position my boob in her mouth with the other hand. (Jessica)
	Social acceptability	“You're already conscious that people are looking at you, because people still do have that mindset of looking and going “oh a bigger woman”” (Isla).
Additional support needs	Tailored care	“The way it works for a slimmer person isn't the way it works for a larger person. It’s not one-size-fits-all” (Quinn). “Something over the phone is not really going to be very helpful, I think you need to be physically there, see how the babies latching and the mums holding them.” (Bryony)
	Building trust with healthcare professionals	“You can ask questions in a different way, so you would know what may offend us and what might not offend us or how you can approach, a situation differently [it is unhelpful] if you say, “oh you've got a bit of a bigger tummy, do you want help with that,” instead of saying “how do you find the position? Are you sore down there, do you think [your caesarean scar is] catching?” (…) It's just focusing more on what could be causing it.” (Isla) “I wonder now if, maybe if it had been my midwife, I might have said, “This is shit.” Whereas when it’s somebody that you don’t know, you sort of go, “Oh yes, everything is fine. Oh yes” (Rosie).

Confidence in ability

‘Confidence in ability’ contains two subthemes: ‘the physical impact of higher weight’ and ‘is baby getting enough?’. Participants perceived more physical difficulties through pregnancy and birth due to higher weight, which impacted on their confidence in their ability to establish and maintain breastfeeding. Initiating breastfeeding after birth was described as a key moment, with many barriers to overcome, where low confidence impeded progress in overcoming these barriers. Confidence in breastfeeding ability was negatively impacted when mothers described feeling judged for living with higher weight. Women also questioned their ability to provide for the child nutritionally through breastfeeding, due to a perceived poor diet.

The physical impact of higher weight

All but one participant described how they wanted to breastfeed, and this was considered very important for mental wellbeing, placing pressure on the women. Breastfeeding was considered difficult, which did not match the expectations of first-time mothers. Breastfeeding was considered a lone responsibility that was taxing on participant’s “mental load” (Bryony). Women described the importance of their breastfeeding experience immediately after birth, “if that first experience isn't lovely, then it’s quite a difficult place to come out of” (Rosie).

Breastfeeding barriers linked to higher weight included medicalisation of the birth and complications for both mother and baby which led to reduced confidence and reduced determination to breastfeed. Breastfeeding was considered the more difficult infant feeding choice and as “being overweight and being pregnant puts a lot more pressure on your body” (Isla) and can leave you feeling “sluggish” (Holly), higher weight was considered to exacerbate breastfeeding difficulties.

A ‘high risk’ pregnancy is a label given to pregnant women living with obesity by healthcare professionals in England. For those categorised as having a ‘high risk’ pregnancy due to their weight, this reduced confidence, with women expecting to be unable to breastfeed. For example, participants felt reduced to a number, leading to feeling out of control as birthing options were reduced; “it felt like all my options were being taken away because of my weight” (Isla).

Is baby getting enough?

Participants described concerns around their ability to provide enough milk to their infant in the early stages of breastfeeding, leading to increased stress and buying bottles and formula milk in case they were unable to breastfeed. Discussions with healthcare professionals concerning the importance of diet in producing good quality breast milk lowered confidence, with women feeling negatively judged for living with higher weight. Participants felt guilty about their diet but described post-birth as a difficult time to eat healthily; “I'm trying to lose weight but I'm just so tired and under so much stress with other things” (Keeley).

Breastfeeding in public

‘Breastfeeding in public’ contains two subthemes: ‘less discrete’ and ‘social acceptability’. Breastfeeding in front of others was considered stressful even if this was in their home, particularly for first-time mothers. Practical difficulties with feeding discretely centred mainly on positioning and latching. This led to feeling stressed which women perceived to then stress their infant. Women felt that the public expected them to be covered up and they would be judged negatively for showing skin; this was perceived to be more negative due to their higher weight. It was also felt that living with a higher weight drew more attention when public feeding; “I do have quite large breasts anyway. So, it would be a bit, kind of, ‘Hello Boys’” (Orlagh). This attention was unwanted as women described low body confidence.

Less discrete

Due to larger breasts or body shape, participants described difficulties latching or needing to adopt alternative feeding positions that made it more difficult to be discrete when breastfeeding. For those requiring alternative positions, such as the rugby ball position, it was uncomfortable and required comfort aids. Larger breasts had to be held so as not to “suffocate the baby” (Rosie) which also made it difficult to feed discreetly in public as you’re “essentially holding onto your boobs. Which isn't great” (Rosie).

Social acceptability

Women felt that breastfeeding in public remained a taboo, where “there’s always a comment” (Molly), even from family or friends. Breastfeeding was not considered the norm, particularly when relatives had formula fed. Mothers felt embarrassed by what they considered taboo subjects, such as leaking milk.

Showing skin was described as a barrier to public feeding due to the perceived judgement from others of higher weight. Participant’s felt that more skin was on show due to higher weight and larger breasts as well as the need to use alternative feeding positions. For some, using wraps to cover up or sitting in a corner helped with this, whereas others chose to feed in their car or avoided public feeding altogether. Women worried about receiving negative comments, although only a few reported receiving them. Having friends who were currently or had previously breastfed was important in normalising and building confidence to maintain breastfeeding.

Additional support needs

‘Additional support needs’ contains two subthemes: ‘tailored care’ and ‘building trust with healthcare professionals’. With lower confidence and perceived negative judgement, participants felt that support was key in overcoming barriers to breastfeeding, particularly in the initial weeks. Where women experienced self-blame around breastfeeding barriers, they considered encouragement and a non-judgemental approach to be paramount in maintaining breastfeeding.

Tailored care

Participants felt that professionals needed to know them as an individual to tailor care to their specific needs, with their needs being different due to higher weight. For those with larger breasts, participants required specific support with positioning, latching and comfortable feeding positions. For some, body shape also determined the need for alternative feeding positions. Face-to-face appointments were considered essential in providing support with positioning and latching. Staff competence was also considered key in providing tailored care. When women felt that professionals were not offering the right support, they looked elsewhere or withdrew from asking for support. The use of BMI was seen as placing them “in a box” (Keeley), whereas understanding them as a person with their specific difficulties would be more beneficial; “people aren’t a number,” (Isla).

Building trust with healthcare professionals

The physical impact of higher weight on breastfeeding meant that it was considered imperative that women received consistent support to allow them to build trust with their healthcare professional. Where continuity was provided, trust was developed which allowed for honest discussions and feedback around care received and support needs.

Sensitive language use by healthcare professionals regarding higher weight was also important in building trust, feeling valued and reduced participant’s perceptions of negative judgement. It was more beneficial when women were “asked, rather than told” (Felicity) as this increased confidence in the mother as an expert in her experiences.

The study set out to explore infant feeding perspectives and experiences of women with a BMI ≥ 25 kg/m², including those with an overweight or obese BMI. We found a perceived lower level of confidence and increased experience of negative judgement adversely impacted participant’s breastfeeding journey. Confidence was reduced due to physical difficulties associated with higher weight and being labelled a ‘high risk pregnancy.’ Concerns around breast milk quality and supply further reduced confidence in women’s ability to breastfeed and contributed to early cessation.

Body shape was considered an important barrier that made initiating breastfeeding more difficult for women with higher weight. Women described difficulties with latching and positioning, as well as difficulties in feeding discretely and perceiving negative judgement from others for showing skin. The findings from this study indicated that consistent support was crucial in preventing early cessation of breastfeeding. This included employing sensitive language to provide tailored care and encouragement (see ‘building trust with healthcare professionals’ in Table 2).

Participants considered breastfeeding to be the harder infant feeding choice, experiencing numerous barriers in the early initiation stage. A meta-synthesis by Lyons et al. [14] described a consensus of breastfeeding posing more barriers to women living with obesity. This may indicate that reducing confidence by labelling women ‘high risk’ negatively influences exclusive breastfeeding, leading to women feeling out of control of their feeding choices [17]. The impact on intention to breastfeed was not discussed in the literature, however, this study identified that being labelled a ‘high risk’ pregnancy due to their weight reduced confidence and adversely impacted intention to breastfeed.

Mothers voiced not producing enough milk for their “hungry baby” and questioned whether the milk quality was sufficient due to their higher weight. This is in keeping with the qualitative literature for women with a BMI ≥ 25 kg/m² which has described concerns about undersupply and “mistrust in their bodies” [22] affecting breastfeeding maintenance [14;23]. Quantitative literature indicates that women living with obesity can experience delayed lactogenesis II [10], which may contribute to explaining this finding.

Difficulties establishing a latch with larger breasts and requiring alternative feeding positions were also identified within the literature [14;23–25]. Participants valued physical help from healthcare professionals to support with latching and positioning [17;26]. The need to prolong appointments to prevent early cessation for women living with higher weight was also identified [17;23–24]. The study builds upon the literature by identifying the importance of sensitive language use regarding higher weight within appointments with healthcare professionals. Where women felt negatively judged for their weight, they described withdrawing from the support available. This is important for healthcare professionals to consider when embarking on discussions around subjects such as diet and the impact on breast milk quality, where women felt negatively judged and less confident in their decision to breastfeed.

Consistent with the literature, public breastfeeding was generally considered a stressful experience [14]. Low body confidence and difficulties feeding discretely exacerbated this stressful experience (see Table 2 for further quotes capturing this experience). Mirroring the findings of McKenzie et al.’s [25] study with women living with obesity, participants felt that the difficulties experienced with ‘public’ feeding were situational, including breastfeeding in private settings around family and friends. This study identified that women living with overweight similarly experience situational public feeding difficulties.

Strengths and limitations

A major strength of the study was the PPI in designing the social media advert and video, as well as the participant information sheet, considering sensitive language around the two stigmatising topics of higher weight and breastfeeding. The study had representation from women in both the overweight and the obese BMI categories (see Table 1), where other qualitative studies in the field have focused predominantly on women living with obesity.

As all participants were based in the North East, these findings considered the needs of women with a BMI ≥ 25 kg/m² in this region but it is likely that our findings are relevant to women with a higher weight living in other parts of the UK. As interviews were conducted with mothers who had given birth during Covid-19, some experiences may not be applicable to a non-Covid-19 environment. However, similarities were found with studies conducted prior to the Covid-19.

A limitation of this study is that the recruitment was through social media as this opens the study up to selection bias. Due to the nature of the recruitment, women who are isolated from ‘mum and baby’ groups online are likely to have been excluded from the sample. Only one participant was from a non-white British background (see Table 1), despite efforts within the strategy to target recruitment through charities working with mothers from ethnic minority groups. The study also did not recruit any single mothers and therefore these findings and recommendations may not be relevant to this population.

A further limitation was that participant’s weight was self-reported at the time of the study. Self-reporting is a subjective measurement and may be inaccurate. Saying this, a study has highlighted the value of participant’s perception of weight on their experience of breastfeeding barriers [27].

Recommendations

It is important that maternity networks are made aware of the findings of the study and that they support their dissemination. To reduce the barriers associated with public breastfeeding, a whole systems approach to being ‘baby friendly’ is needed within the community setting.

For women living with higher weight, continuity of carer is important in supporting breastfeeding. Within antenatal classes, alternative feeding positions and other common difficulties associated with higher weight could be routinely discussed. Resources could include a diversity of body shapes to normalise breastfeeding for mothers living with higher weight. As part of one-to-one support provided by healthcare professionals, it is important that women feel that their specific individual needs are considered, rather than being defined by their weight.

Within the professional education system, breastfeeding barriers related to living with higher weight could be incorporated into teaching programmes around complexities, where higher weight is not part of the curriculum [1]. This could support the development of a competent workforce offering tailored care where required, in line with the UNICEF Baby Friendly Initiative [1].

Future research would benefit from targeting populations underexplored in this study such as single mothers and mothers from Black, Asian and minority ethnic groups.

BMI: Body Mass Index

WHO: World Health Organisation

UNICEF BFI: United Nations Children’s Fund: Baby Friendly Initiative

Acknowledgements:

The PPI group for support with the development of the language used in the study documents and Roslyn Nunn, North East Regional Lead – National Infant Feeding Network (NIFN) for support with education recommendations.

This project was undertaken as part of an MSc dissertation at Newcastle University in conjunction with the North East and North Cumbria Integrated Care Systems Public Health Prevention in Maternity team. JR is part-funded by the National Institute of Health Research Applied Research Collaboration North East and North Cumbria. There are no conflicts of interest.

Funding

JR is part-funded by the NIHR Applied Research Collaboration North East and North Cumbria.

No funding was received to assist with the preparation of this manuscript.

Conflicts of interest/Competing interests

The authors declare that they have no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Newcastle University.

Code availability

Not applicable

Authors' contributions

Susan Cooke: Designing the study, conducting and analysing interviews and write-up of the study.

Dr. Nicola Heslehurst: contribution to research design, methods, supervision, analysis and write-up of the study.

Rebecca Scott: contribution to research design, methods, supervision and write-up of the study.

Prof. Judith Rankin: contribution to research design, methods, supervision, analysis and write-up of the study.

Acknowledgements

Ethics approval

This study received ethical approval from Newcastle University (Reference number: 2084/10472). The ethics statement is below:

This study was approved by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee. This committee contains members who are internal to the Faculty. This study was reviewed by members of the committee, who must provide impartial advice and avoid significant conflicts of interests.

Consent to participate and consent for publication

Informed consent was obtained from all subjects to participate in the study.

The manuscript does not include information or images that could lead to identification of a study participant.

All methods were carried out in accordance with relevant guidelines and regulations.

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No competing interests reported.

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How can services better support women with a body mass index ≥25 kg/m2 to breastfeed: a qualitative study.

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