Physicality of Breastfeeding - Stigma/Social Bias associated with High BMI. How the Capability, Opportunity, Motivation Behavior Model can help!
Original Research
Exploring Successful Breastfeeding Behaviors Among Women Who Have High Body Mass Indices
Sharleen L. O’Reilly, PhD¹,² , Marie C. Conway, PhD¹, Eileen C. O’Brien, PhD¹, Eva Molloy, BSc²,
Hannah Walker, BSc², Eimear O’Carroll, BSc², and Fionnuala M. McAuliffe, MD¹
Journal of Human Lactation 2023, Vol. 39(1) 82–92
© The Author(s) 2022
Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/08903344221102839
journals.sagepub.com/home/jhl
Abstract
Background: Women with high body mass indices are at risk of lower breastfeeding rates but the
drivers of successful breastfeeding in this population are unclear.
Research Aim: We aimed to (a) explore the barriers and enablers to breastfeeding among women with
high body mass indices and (b) map specific behaviors suitable for intervention across the
antenatal to postpartum periods.
Methods: This was a prospective, cross-sectional qualitative study. We conducted semi-structured
interviews with women with high body mass indices who successfully breastfed for 6 months or more
(n =20), partners (n = 22), and healthcare professionals (n =19) in Ireland during 2018. Interviews
were audio recorded, and transcribed verbatim. Data were inductively coded using reflexive thematic
analysis and deductively mapped within the Capability, Opportunity, Motivation–Behavior model.
Results: The three themes developed were knowledge, support, and self-efficacy. Knowledge supported
a participant’s psychological and physical capability to engage in breastfeeding. Support was
related to the social and physical opportunity to enable performance of breastfeeding behaviors.
Self-efficacy influenced reflective and automatic motivation to perform breastfeeding behaviors. A
multifactorial intervention design is needed to support successful breastfeeding.
Conclusion: The barriers and enablers identified for participants with high body mass indices were
similar to those for the broader population; however, the physicality and associated social bias of
high body mass indices mean that additional support is warranted. Antenatal and postpartum
breastfeeding services need a multifaceted, inclusive, and high-quality program to provide the
necessary support to women with higher body mass indices.
Keywords
breastfeeding, breastfeeding barriers, breastfeeding experience, breastfeeding support, Capability,
Opportunity, Motivation Behavior-Model, Ireland, positive deviance, qualitative methods
Background
In 2014, 38.9 million and 14.6 million pregnant women globally had a pregnancy with a body mass
index (BMI) ≥ 25 and 30 respectively (Chen et al., 2018). The prevalence of obesity and overweight
are increasing worldwide (NCD Risk Factor Collaboration, 2017) and are linked to lower breast-
feeding rates (Ramji et al., 2018; Mangel et al., 2019). In Australia, women with obesity were
reported to have 9% less breastfeeding initiation (Bish et al., 2021), and lower breast- feeding
initiation rates have also been reported in the United States (Kair & Colaizy, 2016) and France
(Boudet-Berquier et al., 2018). A lower likelihood of sustained breastfeeding among women with high
BMIs also has been reported as
prevalent globally (Boudet-Berquier et al., 2018; Chen et al., 2020; Joham et al., 2016).
Successfully establishing and sustaining breastfeeding has numerous health benefits,
¹University College Dublin Perinatal Research Centre, School of Medicine, University College
Dublin, National Maternity Hospital, Dublin, Ireland ²School of Agriculture and Food Science,
University College Dublin, Dublin, Ireland
Date submitted: December 7, 2021; Date accepted: May 7, 2022.
Corresponding Author:
Sharleen L. O’Reilly, PhD, and Associate Professor Sharleen O’Reilly, School of Agriculture and
Food Science, University College Dublin, Belfield, Dublin 4, Ireland.
Email: Sharleen.oreilly@ucd.ie
O’Reilly et al. 83
including reduced childhood obesity (Sirkka et al., 2021) and increased postpartum weight loss
(Dalrymple et al., 2021). Given that the number of women of childbearing age with high BMIs is
rising, improving their breastfeeding rates would contribute towards reductions in obesity in later
life. The measurable difference in breastfeeding outcomes among women with high BMIs supports
potentially different behav- ioral factors influencing their infant feeding decisions and the need
to understand these better to facilitate breastfeeding outcomes.
Most behavioral research undertaken to date has exam- ined what barriers exist for breastfeeding in
women with high BMIs. The barriers commonly reported include lack of support (Chang et al., 2020),
lack of confidence, difficulty finding suitable breastfeeding clothes (Garner et al., 2017),
formula feeding culture, and embarrassment of feeding in public (Chang et al., 2020). The
mixed-methods review undertaken by Chang and colleagues (2020) explored issues relating to larger
breasts, delayed onset of lactation, and psy- chosocial factors. Limited research exists on what is
known to contribute to and to support successful extended breast- feeding in women with high BMIs.
Researchers have focused on stakeholder groups in isolation with little data collected from
partners and healthcare professionals involved in sup- porting this population.
Breastfeeding is a multifaceted and multilevel behavior, which means a complex intervention design
is required to address it. The U.K. Medical Research Council’s guidance (Skivington et al., 2021)
about developing and evaluating complex interventions recommended that the development phase
involve identifying or developing theory about changes required. We have used two theoretical
frameworks, the Capability, Opportunity, Motivation-Behavior (COM-B) Model and positive deviance,
to ground our work.
The COM-B Model of behavior has been widely used to map behaviors suitable for intervention design
(Michie et al., 2011). It synthesizes 14 behavioral constructs and proposes that behavior is the
result of the interaction between capabil- ity (psychological or physical), opportunity (social or
physi- cal), and motivation (reflective or automatic; Michie et al., 2011). The COM-B model is
widely used to examine barriers and enablers at multiple levels, including those of the patient,
the provider, and the system (McDonagh et al., 2018).
One of the most efficient ways to improve health out- comes within population subgroups is to
identify individu- als already practicing the desired health behavior, in this case extended
breastfeeding, and to study how they have adopted these behaviors using an approach called positive
deviance (Rose & McCullough, 2017). The health behaviors identified through this approach are
likely to be both accept- able and sustainable because they are already being prac- ticed by the
desired population subgroup within existing resources (Bradley et al., 2009; Marsh et al., 2004, ).
The positive deviance approach typically consists of four steps (Bradley et al. 2009). The first
two are explored in this
Key Messages
• Breastfeeding is 10%–20% lower in women with high body mass indices (≥ 25 kg/m²). Factors to
support successful breastfeeding for this popula- tion are not well understood.
• Personal knowledge and knowing how to manage
physical breastfeeding challenges supported par- ticipants’ breastfeeding capability.
• Participants reported that breastfeeding opportu-
nity was supported by social influences, resources, and environments, while breastfeeding
motivation was fostered by self-efficacy.
• Understanding successful breastfeeding behaviors will help develop evidence-based interventions
to increase breastfeeding rates in women with high body mass indices.
study, which are the identification of “positive deviants” who are individuals demonstrating the
desired health behav- ior and conducting in-depth qualitative analyses to generate insights about
the behaviors that will allow development of suitable interventions.
The final two positive deviance approach steps are testing the intervention in representative
samples and working in partnership with key stakeholders to disseminate the new intervention. These
steps will be conducted based on the findings of this study. For the purposes of this study, both
the women and partners were considered “positive deviants.” This study aimed to (a) explore the
barriers and enablers to breastfeeding in women with high body mass indices, and
(b) map specific behaviors suitable for intervention across the antenatal to postpartum periods.
Method
Research Design
This was a prospective, cross-sectional qualitative study per- formed using a semi-structured
interview guide. This design enabled us to explore both barriers and enablers to successful
breastfeeding behaviors and to map those behaviors for inter- vention development. Ethical approval
was granted by the National Maternity Hospital Ethics Committee (EC.19.2017).
Setting and Relevant Context
This study was conducted in Ireland, a high-income country with low breastfeeding rates.
Breastfeeding upon discharge from maternity services is 58.5% (Health Service Executive, 2021),
which normally occurs on Day 2 postpartum. At 6 months, about 25% of mothers are breastfeeding and
less than 10% are exclusively breastfeeding (Purdy et al., 2017). Women are entitled to paid (26
weeks, with 2 weeks
84 Journal of Human Lactation 39(1)
mandated to be prior to the baby’s due date) and unpaid maternity leave (up to 16 weeks) alongside
job protection during that time. Ireland has a public health system that pro- vides maternity
services for free, or women can opt for pri- vate care for an additional cost. The services
provided within the antenatal period include education classes about preg- nancy, birth, and
parenting. These classes are not mandatory to attend, and breastfeeding preparation is covered
within many of these classes. Additional breastfeeding education can be accessed privately through
International Board Certified Lactation Consultants (IBCLCs). The BMI of women becoming pregnant in
Ireland aligns with other high- income countries and, on average, one in two women enter pregnancy
with a high BMI as categorized using the World Health Organizations (WHO) classifications (Reynolds
et al., 2019).
Sample
The target population consisted of women with high BMIs who had exclusively breastfed for more than
6 months, part- ners of women who had exclusively breastfed for more than
6 months, and HCP staff within the National Maternity Hospital. The inclusion criteria varied; for
women, a BMI ≥ 25kg/m² and exclusive breastfeeding for 6 months or more within the previous 2 years
were required, for partners it was being the main support for a woman who had breastfed suc-
cessfully for 6 months or more within the previous 2 years, and for HCPs being a registered HCP
involved in providing breastfeeding support (obstetricians, midwives, dietitians, and IBCLCs) and
being employed by the National Maternity Hospital. A sampling target of 20 participants for each
stake- holder group was set for the interviews based on previous research experience, but we
determined that a sufficient sam- ple had occurred when our major categories showed depth and
variation in their development. This sampling frame yielded high quality informational power,
whereby the greater information the sample holds, the lower number of participants needed (Malterud
et al., 2016). The final sample size was 61, with 20 breastfeeding participants, 22 partners,
and 19 HCPs.
Data Collection
Data were collected between March and December 2018. Women were recruited through open
advertisement on Irish social media sites including Facebook groups and pages, with leaflets
circulated and posters placed in the National Maternity Hospital, Dublin. Partners were recruited
through social media advertisements, posters in the National Maternity Hospital, and word of
mouth. HCPs were recruited via posters and direct invitation. A participant information sheet and
consent sheet were provided to all individuals who expressed an interest in taking part. The
research team con- tacted all individuals expressing an interest in participating by phone and
confirmed their eligibility prior to answering
any questions, receiving provisional verbal consent, and organizing the research interview.
Informed consent was provided prior to or at the start of each interview and partici- pants were
asked to sign the interview consent form. Only those with signed consent proceeded to interview.
A qualified midwife with more than 10 years midwifery experience and a lived experience of extended
breastfeeding of all her children for 6 months or more (JC) performed the interviews with
participants and partners. A final year BSc Human Nutrition student (EOC) with no personal
experience of breastfeeding, apart from their extended family, com- pleted formal interview
training and conducted the HCP interviews. Interviews were audio recorded using a digital device.
Interviews with participants and partners were con- ducted by telephone by JC in a quiet room and
lasted approx- imately 1 hr. HCP interviews were conducted by EOC via telephone or face-to-face in
a private room. These interviews lasted approximately 30 min. No relationships existed between any
interviewer and participants. The interviewers did not disclose any information about their
professional or lived experience with breastfeeding during these interviews. The study objectives
and recording of interviews were explained to participants before the interviews began. All
question topics (breastfeeding experience and knowledge, attitudes, key supports) were covered in
the semi-structured interview (Supplementary Materials Table 1). Background information about age,
education level, and number of chil- dren was obtained at the start of the participant and partner
interviews. Trustworthiness was established through pilot testing of the interview guides,
maintaining interview field notes, member checking, triangulation, clarifying bias to ensure
accuracy, and using multiple data coders (Lub, 2015). Interviews were also used to identify any
“emotional truths” conveyed during discussions of barriers and enablers encountered. Emotional
truths are insights or observations within the positive deviance approach that could resonate
affectively with a target audience and can influence decision- making. The HCP interviews were
conducted to add the pro- vider perspective and maternity service context to the
COM-B analysis.
Participant confidentiality was maintained by allocating a study ID to each participant allowing
for all names and par- ticipant details to be removed during data transcription. Audio recordings
were stored on a secure computer with password protection and deleted once transcribed verbatim and
checked for accuracy. Transcripts were stored on a secure, password protected computer. The
interviews were transcribed verbatim by trained members of the wider research team, specifically by
BSc Human Nutrition students (HW, EOC, AG, EOG, SC).
Data Analysis
Demographic data were analyzed and presented as numbers (%). HW and EOC performed the data analysis
of the tran- scripts independently and neither researcher had any lived
O’Reilly et al. 85
Table 1. Data Analysis Structure.
Theme Theme Definition Category Category Definition
Knowledge supports a woman’s capability to engage in BF behavior
Support provided by social, environmental and resources enable
the performance of BF behaviors
Self-efficacy impacts motivation to perform BF behaviors
Note. BF = breastfeeding.
How personalized knowledge of BF benefits, mental preparation, healthcare professional support,
potential physical difficulties women may face, and the experience of others contributes towards
extended BF
How the opportunity to perform BF behaviors are influenced by social supports, the physical
environment, and resources available
The importance of self-efficacy and determination in extended BF
1. Personalize BF benefits
2. Antenatal mental preparation needed
3. Peer-shared tacit knowledge
4. Healthcare professional knowledge inconsistent
5. Knowledge of potential latch problems
6. Physical health important
1. Social support importance
2. Reduced support of BF due to omnipresent formula feeding and loss of BF culture
3. BF support services and groups variable
4. Awareness raising needed
5. BF friendly environments
6. Lack of lactation support in maternity services
7. BF aids
1. Self-efficacy is important
2. Determination drives the habit
1. Descriptions of how BF benefits are applied to personal circumstances
2. Descriptions of mental preparation supporting readiness to breastfeed
3. Descriptions of peer-sharing practical knowledge through a variety of routes
4. Descriptions of healthcare professional knowledge being variable and potentially conflicting
5. Descriptions of challenges with latching due to larger breast volume or tongue- tie
6. Descriptions of importance of overall physical health and staying healthy to engage in BF
1. Descriptions of social supports that supported or inhibited BF behaviors
2. Descriptions of formula feeding as the norm in Ireland and suppressing BF in cultures where BF
is normal
3. Descriptions of different support groups and services impacting BF experience positively and
negatively
4. Descriptions of different healthcare professionals needing greater education and awareness to
support BF
5. Descriptions of environments such as workplaces, home and social settings that either supported
or inhibited BF
6. Descriptions of lactation services being insufficient within maternity settings
7. Descriptions of BF aids such as pillows, co-sleeper cot, lanolin improving BF
1. Descriptions of self-efficacy attributes supporting BF or body image negatively impacting
self-efficacy
2. Descriptions of determination positively driving BF and cultural norms facilitating the
determination
experience of breastfeeding other than extended family members or receiving lectures on
breastfeeding. Reflexive thematic analysis was applied inductively (Braun & Clarke, 2006, 2019).
Initially the transcripts were read and reread to familiarize researchers with the data and, after
this, they gen- erated codes relating to the first research aim. Initial themes were developed
using these codes and subsequently refined so that they contained a pattern of shared meaning
under- pinned by a central concept (Table 1). Finally, the themes were named and defined and a
consensus discussion involv- ing an experienced researcher (SOR, academic HCP with more than 15
years’ experience, and a lived experience of extended breastfeeding several children) resolved any
dis- crepancies. The transcripts were then coded deductively by a third researcher (EM, BSc Human
Nutrition final year
student, no personal experience of breastfeeding as per HW and EOC) using the COM-B domains as
shown in Figure 1 (Michie et al., 2011) and a reflexive thematic analysis approach used for this
secondary analysis. When the COM-B barrier and enabler analysis was complete, the behavioral
enablers were mapped onto existing lactation services across the antenatal and postpartum time
points to address the sec- ond aim.
Results
Characteristics of the Sample
Participants and partners interviewed were aged 25–49, had a child who was breastfed for a minimum
of 6 months and
86 Journal of Human Lactation 39(1)
Figure 1. The Capability, Opportunity, Motivation-Behavior (COM-B) Model (Michie et al., 2011).
maximum of 30 months, and the majority had completed third level education (Table 2). Nineteen
HCPs, including obstetricians, midwives, dietitians, and IBCLCs participated, whose practice
experience ranged from 8 months to 30 years (Table 3). Three themes developed were knowledge,
support, and self-efficacy following data analysis (Table 1), which are visually represented in
Figure 2 where specific barriers and enablers are identified, and how these relate to the COM-B
model.
Themes
Knowledge. From the psychological capability perspective, both participants and partners described
personalized breast- feeding benefits. Participants spoke frequently about breast- feeding being
best for their baby as a strong motivator “Because I knew that was the best for my baby. That was
the best choice for baby, yeah. That’s why I never gave up” (Par- ticipant 8). Partners also
described breastfeeding’s financial benefits that it would “save you a ton of money” and had family
benefits “I think that. . .it’s very good for the child’s immune system and it’s very natural and
in our kids were they were rarely sick. . .. I think it’s very good for the bond-
ing process as well” (Partner 7).
Antenatal mental preparation and acknowledging breast- feeding as being difficult at times was an
important enabler for all. Participants described how knowledge of what was normal for
breastfeeding would have helped them feel more prepared for breastfeeding:
I wish I’d informed myself a lot more. I thought I was, but I wasn’t quite prepared because I
didn’t have that background information, like from my mum or. . .you know, even just that kind of
information that filters in of what’s normal and what isn’t. (Participant 6)
For partners, mental preparation to support their partner’s breastfeeding journey was described as
“the baby isn’t going to come out and feed perfectly. . .. If you know that beforehand then maybe
it might be easier just to stick with it” (Partner 1). Peer-shared tacit knowledge through the
lived experiences of others provided participants with important emotional reassurance. In
particular, social breastfeeding groups were mentioned as useful resources for this knowledge “So I
didn’t get to go [to antenatal classes]. I would’ve went on to like. . .like Facebook pages. .
.breastfeeding pages to kind of—because you get an idea of what to expect” (Participant 13).
Partners identified that inconsistent healthcare profes- sional knowledge and information made them
feel “like I don’t know who to believe.” This inconsistency was further
identified as a barrier by HCPs:
One of us will say “you have to feed like every 3 hours,” another one will “oh you can go up to 6
hours.” It just depends on the midwife. I think we all really need to be preaching from the same
book; I think that’s a massive issue. (HCP9)
The importance of consistent pre-discharge information and continued consistent advice from public
health nurses and family practitioners in the community was also raised.
O’Reilly et al. 87
Table 2. Participants’ Characteristics of Participants and Their Partners (n = 42).
Participants
n=20 (47.6%)
Partners
n=22 (52.4%)
Characteristic Age
n (%)
n (%)
18-24 0 (0) 0 (0)
25-29 5 (25) 2 (9)
30-34 4 (20) 5 (23)
35-39 4 (20) 12 (55)
40-44 6 (30) 2 (9)
45-49 1 (5) 1 (5)
Level of education
None 0 (0.0) 1 (5)
Secondary education, vocational certificate 3 (15) 4 (18)
Undergraduate 6 (30) 9 (41)
Postgraduate 11 (55) 8 (36) Number of Children
1 7 (35) 12 (55)
2 9 (45) 7 (32)
3 2 (10) 2 (9)
4 1 (5) 1 (5)
5 1 (5) 0 (0)
Breastfeeding duration (months)
6-12 7 (35) 7 (33)
13-18 6 (30) 4 (19)
19-24 2 (10) 5 (24)
25-29 0 (0) 2 (9)
>30 5 (25) 3 (14)
Table 3. Characteristics of Healthcare Provider Participants (n =19).
Female Participants
Experience
Type of Healthcare Provider
n (%)
(years)
Obstetricians (n=5) 4 (80) 4 – 19
Midwives (n=10) 10 (100) <1 – 30
Dietitians (n=1) 1 (100) 25
Lactation consultants (n=2) 2 (100) 18 – 43
Pharmacists (n=1) 1 (100) 10
Latch describes how the baby fastens to the breast during breastfeeding. Some participants noted
that latching was not easy and required considerable effort to address. The physi- cality
associated with having a high BMI, notably breast size, was a barrier acknowledged by participants
and a con- tributor to latching problems “The size of my breasts prob- ably were hindering things a
little bit” (Participant 20). Conversely, partners noted that mothers being physically well was
important for breastfeeding. One stated:
I think for both of us, because she needs to be physically well to be able to feed and manage that
kind of energy drain that does come along with it. . .so she needs to be physically well for that
and mostly she needs to be able to. . .you know, deal with the baby and the neediness kind of part
of it as well. (Partner 13)
Support. The importance of social support was well described by both HCPs and participants. They
described having a sup- portive partner and family members with a lived experience of
breastfeeding, for example, a mother or sister, as critical supports: “that’s why you need your
mammy and your sisters and anyone around you that has done it. You know, experi- enced people
that’d be able to help” (Participant 12). Unsup- portive attitudes of older generations, and body
image, specifically stigma associated with body image, were high- lighted as barriers by
participants. Partners spoke of feeling
88 Journal of Human Lactation 39(1)
Figure 2. Themes Alongside Barriers and Enablers Mapped Onto the Capability, Opportunity,
Motivation-Behavior (COM-B) Model.
“a little bit useless” (Partner 20) but acknowledged their role in supporting their breastfeeding
partner.
Participants described reduced support for breastfeeding due to omnipresent formula feeding and
loss of breastfeeding culture. Participants found “everyone’s very encouraging of quitting. . .”
(Participant 12) and hospitals were quick to offer formula as a solution to any feeding issue: “I
think if you’re not, if you’re not supported, or if people, like, in the hospital—the one negative
I’d say about the hospital is they are, well for me, I found they were quick to offer a bottle
(Participant 4).
HCPs identified cultural differences in language with over- seas-born women asserting that they
would breastfeed, whereas Irish women would say “I’d like to breastfeed” (HCP 8).
Breastfeeding support services and group experiences were variable, but participants identified
them as important:
The lactation consultant—definitely a moment for me that just really. . . just gave me the fire in
some ways. . . as soon as she kind of said to me you’re doing okay and she was—that moment was a
fantastic moment to be honest. (Participant 4)
Partners reinforced these benefits “like breastfeeding Facebook groups and that and she’s found
them great you know there’s a lot of people there going through the same kind of stuff and there’s
a lot of good information” (Partner 7). HCPs highlighted the need for “more awareness maybe that
they
[women with high BMIs] might be a particularly high-risk group that should be given extra support”
(HCP 13).
Participants described negative or positive breastfeeding environments and how it was the people
within the setting that determined its positivity or negativity, rather than the physical
environment. The workplace was commonly identi- fied as a non-supportive environment, with one
participant stating:
I work in a very. . .male dominated environment and, eh, it was kind of seen to “Oh breastfeeding
oh” and it was kind of like “Yeah sure, you’re breastfeeding twins—like who does that?!” kind of,
and I had a very, very negative experience in terms of the workplace. (Participant 15)
Participants reported hospital services as lacking, inaccessi- ble, or under-resourced and seeking
private IBCLC support. While critical, it came at a financial and emotional cost “[I] had to go
looking for it [breastfeeding help] at all times, I had to beg in the hospital to get them to send
up a lactation con- sultant” (Participant 15). HCPs felt that providing sufficient lactation
support would reduce the practice of infant formula top-ups and improve breastfeeding outcomes:
I think that the postnatal wards are understaffed and that the midwives can’t give the women the
attention that they need especially with their first-time babies and a lot of babies end up needing
top ups and. . .like, I really think with proper support that that shouldn’t be necessary (HCP1).
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Participants, partners, and HCPs described aids being a facilitator particularly in the earlier
part of breastfeeding. Participants mentioned “The lanolin, I swear by it. You have to have that,
yeah, [in the] early days” (Participant 2); while partners referred to “the chair and the pillow
kind of helped a lot just for getting the right position and comfort and they were probably the two
main things” (Partner 5). HCPs spoke specifically of breastfeeding pillows being use- ful for
positioning: “I do find pillows are really, really nec- essary for larger women to give them
support and make sure that the baby is up and nice and high and everything. . .” (HCP9).
Self-Efficacy. The critical nature of self-efficacy was expressed by all groups. Participants
stated:
I think when you set your mind to breastfeed and you really want to do it, [it] doesn’t matter. You
know if you are overweight, if you are depressed, or you know like—I think it’s personal. For
example, I had postnatal depression, you know, I am overweight and I still breastfeeding.
(Participant 8)
HCPs described the Irish culture as a barrier to self-efficacy and the need to be proactive and
build this key attribute:
I think that if we were more proactive in some areas that it might be helpful for woman, especially
in relation to woman with a high BMI. I think what we come across a lot of times is that there are
body image self-efficacy issues, that woman have [a] huge amount of misconceptions about their own
ability to breastfeed. (HCP16)
Partners reiterated how a lack of support made it easy for women to give up on breastfeeding and
how it was a woman’s own determination that seemed to enable her to continue:
I suppose she felt nearly that she was failing, in a way, because she couldn’t do it, but she
was—she was just so determined, but I suppose if the supports were more, well I know, I think more
women would continue, if you know what I mean. Because I think it would’ve been very easy for
[woman’s name] to give up, but she was—she was just so determined in herself to do it. (Partner 21)
HCPs spoke of the women who sought their support as demonstrating greater self-efficacy, whereas
less prepared women appeared to give up quicker.
Intervention Mapping
The COM-B model barrier and enabler analysis findings were subsequently mapped onto a
multifactorial breast- feeding intervention (Table 4) divided across the antenatal to postpartum
periods to support successful breastfeeding in women with high BMIs.
Discussion
Our findings build upon previous qualitative explorations and demonstrate considerable overlap in
perceptions of women, partners, and HCPs on barriers and facilitators to successful breastfeeding.
All stakeholders emphasized the potential for increased provision of health services and edu-
cation as a way of changing the knowledge, self-efficacy, and social support given to women with
high BMIs for suc- cessful breastfeeding. Stakeholders emphasized the need to normalize
breastfeeding as optimal infant feeding and ensure all maternity service systems support this as
routine care. This was key in, their eyes, to maximizing the effectiveness of any improved
services. The interaction between themes mirrored the COM-B model’s hypothesized relationships
between components (behavior can change capability, moti- vation, and opportunity as can motivation
be influenced by opportunity and capability). We saw aspects of psychologi- cal capability (HCP
knowledge inconsistent) and physical capability (latch problems) influencing breastfeeding partici-
pants’ reflexive motivation (self-efficacy). Equally, engaging in the behavior of learning to
breastfeed altered the partici- pant’s psychological and physical capability, consolidated her
reflexive and automatic motivations, and increased the positive social opportunities to engage
further in that behav- ior. These additional interactions highlight the complexity of breastfeeding
as a behavior and the need for multilevel and multifactorial intervention to create meaningful
change.
Systematic reviews have highlighted that the barriers and enablers to breastfeeding for women with
high BMIs were similar to other women, but that the extent of the experience may be more
problematic for women with higher BMIs because of their weight status (Chang et al., 2020; Lyons,
Currie & Smith, 2019; Lyons, Currie & Peters, 2019). The physicality of breastfeeding and the
stigma and social bias associated with high BMIs were pronounced findings in our results, which
aligns with previous work (Incollingo Rodriguez et al., 2020; Lyons, Currie & Smith, 2019). Our
findings also demonstrated that, when participants with high BMIs were provided with the right
support, in a way that is acceptable to them, they breastfeed for extended periods. However, it is
important to highlight that it remains to be seen if providing a tailored intervention using the
findings of this study and testing it via a randomized clinical trial will deliver increased
extended breastfeeding rates in this popula- tion. Antenatal and postnatal education needs to be
inclusive of this growing population and should provide resources that help address social bias and
stigma (Incollingo Rodriguez et al., 2020). A Cochrane review on interventions for sup- porting
breastfeeding in women with overweight or obesity (Fair et al., 2019) highlights social support and
provision of education and breastfeeding aids, for example breast pumps, as important. Our positive
deviance approach showed that there is commonality with other breastfeeding intervention
90 Journal of Human Lactation 39(1)
Table 4. Multifactorial Intervention Design for Supporting Breastfeeding in Women With High Body
Mass Indices.
Timing
Themes
Intervention Component
Antenatal (Hospital)
Immediate postpartum (Hospital)
Medium term postpartum (Community/peer-to- peer support)
Knowledge Education Education/training for hospital staff
to increase BF knowledge, focus on being aware that women with high BMIs require extra support and
possibly BF aids. Interactive class/ classes covering benefits of BF, BF technique, common issues.
Materials including representative images of BF women with high BMIs. Standardized materials
developed with ensure fidelity of education delivery.
Resources Provide local links to resources such as
websites, BF groups within handout, places to breastfeed outside the home, and suggestions for
suitable BF clothes.
Consultation with IBCLC/ specialist midwife
Reinforce local links to support services and provide information on BF aids.
Lactation support offered by phone or drop-in clinic
Access to IBCLC/BF counsellors/ public health nurses with lactation training
Support networks including La Leche League, Cuidu, etc.
Support Build social support
Workforce planning
Support person attending antenatal class/classes
Additional time allocation for engaging support person
Increased lactation support services
Drop-in lactation clinic and support network referral
Additional lactation support services
Self –Efficacy
Problem solving
Common issues presented with solutions in words of participants
Consultation with IBCLC/ specialist midwife
Support networks developed
Note. BF = breastfeeding; BMI = Body Mass Index.
designs that should be exploited to ensure any intervention developed fits within routine antenatal
services but are adapt- able to the needs of at-risk populations.
To improve breastfeeding, we need to focus on targeting theoretically sound and evidence-based
factors using best- practice complex intervention design. The evidence supports the capability of
women to engage in breastfeeding being positively underpinned by knowledge, women in particular
recognizing the health benefits for optimal child nutrition and health outcomes (Lyons, Currie &
Peters, 2019). The importance of partners in supporting women to engage in breastfeeding is also
acknowledged in previous work. Mothers who felt they had positive support from their part- ners via
active involvement or verbal encouragement were more confident and able to breastfeed than those
whose part- ners were ambivalent, or those who had negative partner support (Bhario & Elliott,
2018). Encouragement from part- ners also resulted in increased breastfeeding duration and
exclusivity, as did assisting with breastfeeding difficulties and helping with household duties
(Davidson & Ollerton, 2020; Ogbo et al., 2020). Previous researchers have high- lighted that
partners’ understand the benefits of breastfeed- ing and have empathy for their breastfeeding
partner, but at times report feeling left out of the infant-feeding process (Crippa et al., 2021).
Our findings confirm partners’ impor- tant role in supporting their breastfeeding partner’s
capabil- ity by having access to knowledge in an inclusive manner
that subsequently enables them to feel prepared to help with successful breastfeeding. The
inclusion of a support partner in future antenatal breastfeeding interventions is essential to the
building of social support and increasing a woman’s motivation to engage in the behavior. Another
important ingredient in antenatal breastfeeding interventions is resourc- ing HCP services so that
specific and tailored support can be provided (Balogun et al., 2016; Lyons, Currie & Peters, 2019).
The failure to build additional resources into an inter- vention will result in diminished effects,
a lack of sustain- ability in the intervention over time, and potentially a widening of the gap in
breastfeeding rates between women with higher and lower BMIs.
Limitations
The study sampling frame is a potential limitation—namely, the partners were not matched to the
participants interviewed and they were not required to state if their own partner had a high BMI.
This limited our ability to associate how the rela- tionship between the partner and breastfeeding
participant’s experience interact. Participant response bias and researcher bias are two additional
limitations. We did not formally record the participant ethnicity, which limits our ability to
explore the influence of specific ethnic factors on breastfeed- ing. Another limitation was the
interviews occurring at a single time point. Longitudinal data would have the potential
O’Reilly et al. 91
to provide greater understanding of behavioral changes that may occur over time. A final limitation
was that the partici- pants and partners may or may not have experienced lacta- tion support
services provided by the participating HCPs or the maternity service that the HCPs were employed
by. While indicative of their lived experience, their views may or may not represent the experience
that the participant or her partner would experience if they were to attend that maternity
hospital.
Conclusions
The positive deviance approach enabled the broader under- standing of successful breastfeeding for
women with high BMIs from a variety of stakeholder perspectives. Future research needs to test a
complex breastfeeding intervention for this population using a randomized clinical trial design,
after the behavior change techniques required to deliver the intervention with fidelity have been
mapped.
Acknowledgments
We are grateful for the time and knowledge supplied by partici- pants. We would like to thank
Joanne Courtney for the conduct of the interviews with women and partners. We would also like to
thank Anna Gouldson, David Byrne, Sophie Callanan, and Ellen O’Grady for transcribing the
interviews.
Author contribution(s)
Sharleen O’Reilly: Conceptualization; Data curation; Formal anal- ysis; Methodology; Supervision;
Writing – original draft; Writing – review; editing
Marie Conway: Formal analysis; Writing – review; editing
Eileen O’Brien: Data curation; Methodology; Writing – review; editing
Eva Molloy: Investigation; Writing – review; editing Hannah Walker: Investigation; Writing –
review; editing Eimear O’Carroll: Investigation; Writing – review; editing
Fionnuala McAuliffe: Conceptualization; Resources; Writing – review; editing
Disclosures and Conflicts of Interest
The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors received no financial support for the research, author- ship, and/or publication of
this article.
Ethical Statement
Ethical approval was granted by the National Maternity Hospital Ethics Committee (EC.19.2017) on
November 9, 2017.
ORCID iDs
Sharleen L. O’Reilly https://orcid.org/0000-0003-3547-6634 Fionnuala M. McAuliffe
https://orcid.org/0000-0002-3477
-6494
Supplementary Material
Supplementary Material may be found in the “Supplemental material” tab in the online version of
this article.
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