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Social Science & Medicine 65 (2007) 2147–2159 Being a ‘good mother’: Managing breastfeeding and merging identities Joyce L. Marshall a, , Mary Godfrey b , Mary J. Renfrew c a University of York York, Health Sciences Area 4, Seebolm Rowntree Building, Heslington, North Yorkshire, YO 10 5DD, UK b University of Leeds, UK c University of York, UK Available online 6 August 2007 Abstract Breastfeeding is not simply a technical or practical task but is part of the transition to motherhood, the relationship between mother and baby and the everyday experience of living with a new baby. Discussion of breastfeeding must therefore include the individual’s personal and social context. This paper explores how women in England who have chosen to breastfeed their baby accomplish this task during the early stages of motherhood and the relative weight attached to different factors, which impinge on decision-making. Our findings, based on observing 158 interactions between breastfeeding women and midwives or health visitors from one Primary Care Trust in the north of England, UK, and in- depth interviews with a sample of 22 of these women, illustrate the dynamic between breastfeeding, becoming and being a ‘good mother’ and merging multiple identities as they embrace motherhood. In this context, the value attached to breastfeeding as synonymous with being a ‘good mother’ is questioned. In managing the balance between ensuring a healthy, contented baby and the reality of their daily lives, women negotiate the moral minefield that defines ‘good mothering’ and the diverse conceptions and influences that shape it—including health professionals, their social networks and the wider social and structural context of their lives. The implications for policy and practice are discussed. r 2007 Elsevier Ltd. All rights reserved. Keywords: Breastfeeding; Motherhood; Identity; UK Introduction The benefits of breastfeeding for both the health of the baby and the breastfeeding mother are well established (e.g. Fewtrell, 2004; Howie, Forsyth, Ogston, Clark, & du V Florey, 1990; Kramer et al., 2001; Labbok, 2001; Rosenblatt & Thomas, 1993; Wilson et al., 1998) and the most recent expert guidance promotes exclusive breastfeeding for 6 months and continuing to give breastmilk at least up to age two (World Health Organisation, 2003). Within medicalised expert discourse, breastfeeding has assumed the status of moral imperative, inseparable from the conception of ‘good mother- ing’ (Carter, 1995; Murphy, 1999). The act of breastfeeding is not simply about meeting the nutritional needs of babies; it is also imbued with social, emotional, sexual and cultural meaning for mothers, for ‘significant others’ and for those within ARTICLE IN PRESS www.elsevier.com/locate/socscimed 0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2007.06.015 Corresponding author. Tel.: +44 1904 321831. E-mail addresses: [email protected] (J.L. Marshall), [email protected] (M. Godfrey), [email protected] (M.J. Renfrew).

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Social Science & Medicine 65 (2007) 2147–2159

www.elsevier.com/locate/socscimed

Being a ‘good mother’: Managing breastfeedingand merging identities

Joyce L. Marshalla,�, Mary Godfreyb, Mary J. Renfrewc

aUniversity of York York, Health Sciences Area 4, Seebolm Rowntree Building, Heslington, North Yorkshire, YO 10 5DD, UKbUniversity of Leeds, UKcUniversity of York, UK

Available online 6 August 2007

Abstract

Breastfeeding is not simply a technical or practical task but is part of the transition to motherhood, the relationship

between mother and baby and the everyday experience of living with a new baby. Discussion of breastfeeding must

therefore include the individual’s personal and social context. This paper explores how women in England who have

chosen to breastfeed their baby accomplish this task during the early stages of motherhood and the relative weight attached

to different factors, which impinge on decision-making. Our findings, based on observing 158 interactions between

breastfeeding women and midwives or health visitors from one Primary Care Trust in the north of England, UK, and in-

depth interviews with a sample of 22 of these women, illustrate the dynamic between breastfeeding, becoming and being a

‘good mother’ and merging multiple identities as they embrace motherhood. In this context, the value attached to

breastfeeding as synonymous with being a ‘good mother’ is questioned. In managing the balance between ensuring a

healthy, contented baby and the reality of their daily lives, women negotiate the moral minefield that defines ‘good

mothering’ and the diverse conceptions and influences that shape it—including health professionals, their social networks

and the wider social and structural context of their lives. The implications for policy and practice are discussed.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Breastfeeding; Motherhood; Identity; UK

Introduction

The benefits of breastfeeding for both the healthof the baby and the breastfeeding mother are wellestablished (e.g. Fewtrell, 2004; Howie, Forsyth,Ogston, Clark, & du V Florey, 1990; Kramer et al.,2001; Labbok, 2001; Rosenblatt & Thomas, 1993;

e front matter r 2007 Elsevier Ltd. All rights reserved

cscimed.2007.06.015

ing author. Tel.: +441904 321831.

esses: [email protected] (J.L. Marshall),

ds.ac.uk (M. Godfrey), [email protected]

.

Wilson et al., 1998) and the most recent expertguidance promotes exclusive breastfeeding for 6months and continuing to give breastmilk at leastup to age two (World Health Organisation, 2003).Within medicalised expert discourse, breastfeedinghas assumed the status of moral imperative,inseparable from the conception of ‘good mother-ing’ (Carter, 1995; Murphy, 1999). The act ofbreastfeeding is not simply about meeting thenutritional needs of babies; it is also imbued withsocial, emotional, sexual and cultural meaning formothers, for ‘significant others’ and for those within

.

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1In the UK midwives can visit women until their baby is 28

days old but most visits tend to occur within the first 10 days after

birth. Health visitors visit women on a few occasions at home

before suggesting they attend a child health clinic.

J.L. Marshall et al. / Social Science & Medicine 65 (2007) 2147–21592148

the wider social and cultural milieu (Maher, 1992;Vincent, 1999). Infant feeding practices and knowl-edge and beliefs about breastfeeding vary acrosscountries, cultures, socio-economic position, as wellas between individuals (Maher, 1992; Palmer, 1993;Van Esterik, 1989). Moreover, expert opinion hasdiffered across countries and changed over time ashave women’s feeding practices, reflecting inter aliainterpretations of evidence, social and economicconstraints of industrial and post-industrial societiesand the changing role of women (Henschel & Inch,1996; Palmer, 1993). In the UK although around70% of women start to breastfeed only 28% areexclusively breastfeeding their babies after 2 months(Hamlyn, 2002), a pattern that has been largelysustained for the last 20 years. This is in contrastto the situation in some other countries; forexample Norway where 99% of women start tobreastfeed and 85% are still breastfeeding, 44%exclusively, at 4 months (Lande et al., 2003), in partattributed to more favourable governmental policiesaround maternity leave and child care (Yngve &Sjostrom, 2001).

The reasons why many women who start tobreastfeed do not persist for long are likely to beboth multidimensional and interactive; technical orskills related (Minchen, 1998; Renfrew, Fisher, &Arms, 2000), social and cultural (Maher, 1992;Phoenix et al., 1991), and reflect the changingpatterns of women’s participation in the labourmarket (Kosmala-Anderson & Wallace, 2006).

Being a mother, and indeed breastfeeding, do notoccur within a social or historical vacuum (see forexample Arnup, 1990; Blum, 2000). Social networksprovide women with a framework within which tomake sense of their experiences and thereforeprovoke feelings of responsibility that are culturallylocated (Miller, 2005). Social constructions of‘good’, ‘bad or ‘normal’ mothers are usually implicitbut the ‘moral minefield’ can affect the initialdecision to breastfeed (Murphy, 1999, p. 205) andthe continuing process of infant feeding (Murphy,Parker, & Phipps, 1998). Women encounter con-siderable contradictions in relation to infant feed-ing; although it has been argued that there is anormative imperative to breastfeed as the healthyoption for babies (Murphy, 1999, 2000), it is alsoclear that breastfeeding women are rarely seen in theUK and other western countries where rates arelow (Hamlyn, 2002; Nicoll, Thayaparan, Newell, &Rundall, 2002). This means that new mothersmay lack embodied knowledge of breastfeeding

(Hoddinott & Pill, 1999) which may have contrib-uted to loss of confidence in women’s bodies(Dykes, 2005) and this is further complicated bymedia representations of the breast as sexual(Henderson, 1999; Henderson, Kitzinger, & Green,2000; McConville, 1994). Recognition of suchtensions and contradictions facing women as theytry to make sense of the relationship between theirchanging sense of self and their baby, whilstsimultaneously maintaining a positive self-image,is an important starting point in understandingwomen’s responses to breastfeeding and the kind ofsupport they might find helpful.

In this paper, we explore breastfeeding in thecontext of everyday living with a new baby and weconsider how it is valued and managed within thewider context of becoming and being a mother andthe shift in identity, which that implies. We thendraw out the policy and practice implications of ourfindings.

The study

This qualitative study included observation of 158encounters between women who had chosen tobreastfeed and health professionals (midwives andhealth visitors) in the community setting, followedby in-depth interviews with women (22) and theirhealth professionals (18). In this paper we draw onobservational data and interviews with women tofocus on an in-depth understanding of the widerbreastfeeding experience for women. Full ethicscommittee approval was obtained for the study. Inthe accounts below pseudonyms are used to protectrespondents’ identities.

Field work was carried out in the north ofEngland between August 2000 and January 2002.A geographical location (one Primary Care Trust)comprising rural, suburban and inner city areas wasselected in order to study interactions betweenhealth professionals and breastfeeding women froma range of socio-economic and ethnic groups. Healthprofessionals working within these areas wereaccompanied during their daily work and interac-tions with breastfeeding women were observed.1 Theresearcher was introduced to each woman by thehealth professional, full information was provided

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both verbally and as a written copy, and consentobtained. All but two women approached agreed totake part but there was some evidence that healthprofessionals acted as gatekeepers; for example notfacilitating access to young, teenage mothers. Theresearcher was introduced as a midwife who wasdoing research, which meant that women may haveidentified her with the health professionals makingthe introductions. However, care was taken topresent the research in a non-judgemental way,placing emphasis on understanding how both healthprofessionals and breastfeeding women made deci-sions. Notes were recorded at the time to capture‘concrete data’ (Spradley, 1980) and were laterexpanded using the principles detailed by Schatzmanand Strauss (1973). The nature and number ofinteractions observed with each health professionalare summarised in Table 1. Most encounters werewith women after the birth of their baby (117), andof these 71 were with midwives and 46 with healthvisitors (see Table 1) thus in the majority of theobservations women were in the early stages ofmotherhood.

Table 1

The nature and number of interactions observed with each health prof

Health professional (ID) Postnatal visits C

i

Rural area

Midwife 1 (MW1) 10 N

Midwife 2 (MW2) 14 N

Midwife 3 (MW3) 9 N

Health visitor 1 (HV1) 2 1

Health visitor 2 (HV2) 2 5

Health visitor 3 (HV3) 2 7

Suburban area

Midwife 4 (MW4) 6 N

Midwife 5 (MW5) 17 N

Health visitor 4 (HV4) 1 6

Health visitor 5 (HV5) 0 1

Health visitor 8 (HV8) 0 3

Inner City area

Midwife 6 (MW6) 2 N

Midwife 7 (MW7) 7 N

Midwife 8 (MW8) 1 N

Midwife 9 (MW9) 1 N

Midwife 10 (MW10) 4 N

Health visitor 6 (HV6) 2 0

Health visitor 7 (HV7) 0 1

Health visitor 9 (HV9) 0 2

Health visitor 10 (HV10) 2 0

Total 82 3

After the observational phase, some women wereinvited to take part in an in-depth interview.Women were selected based on factors that havebeen shown to impact on breastfeeding outcomesuch as socio-economic position, age, ethnicity andparity with the aim of achieving a diverse sample(Tables 2 and 3). All interviews were carried out byone researcher (JM), in women’s homes, at a time oftheir choosing and were tape-recorded and fullytranscribed. Most of the interviews took placebetween 3 weeks and 4 months after the birth(Table 3). The interview topic guide was developedfrom a review of the relevant literature andpreliminary analysis of the observational data.Women were asked about their breastfeedingexperiences, and the meanings they ascribed tothem, and the knowledge, information and supportthey drew upon from formal and informal sources,including family, wider social networks and healthprofessionals.

Data were organised according to analyticalheadings. Concepts of importance to participantswere initially identified using domain analysis

essional

hild health clinic

nteractions

Antenatal clinic

interactions

Total

interactions

/A 6 16

/A 5 19

/A 5 14

0 N/A 12

N/A 7

N/A 9

/A 8 14

/A 8 25

N/A 7

N/A 1

N/A 3

/A 0 2

/A 5 12

/A 4 5

/A 0 1

/A 0 4

N/A 2

N/A 1

N/A 2

N/A 2

5 41 158

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Table 2

Summary characteristics of women interviewed

Characteristics of 22 women

interviewed

Geographical area

Rural 10

Suburban 6

Inner city 6

Woman’s age

16–24 6

25–30 9

431 7

Ethnic group

White UK 16

White other 1

Asian 3

Afro-Caribbean 1

Iraqi 1

Age of baby at interview

Birth to 6 wks 10

7 wks to 16 wks 10

17 wks to 6 mo 2

Mode of feeding at interview

Exclusive breastfeeding 11

Mixed feeding 4

Formula feeding 7

Parity

First baby 16

Subsequent baby 6

J.L. Marshall et al. / Social Science & Medicine 65 (2007) 2147–21592150

(Spradley, 1980); these were then used as a basis forcoding using the computer package NVivo. Exam-ples of the kinds of issues that emerged at this stagefrom women’s perspectives included: the problemsthat they encounter when feeding their baby;sources of knowledge about breastfeeding; andwomen’s perceptions of their interactions withhealth professionals and significant others. Eachset of coded data was then reread and diagramswere used to map out cultural categories and thelinkages between them. This led to improved codingthat was less disjointed and better captured thesituation as women experienced it. Initial accountswere very descriptive (Wolcott, 2001) but capturedthe range and frequency of respondents’ experience.Through comparative analysis we then sought tomake sense of women’s experiences, account forpatterns and provide explanations. Trustworthinesswas enhanced by initial familiarisation and con-tinually interacting with the data throughout theanalysis. Once writing commenced this includedchecking the data for examples of disconfirming

cases. Reflexivity was encouraged by involvement ofall three authors, with different views and back-grounds (social science and clinical), at all stages ofthe research.

Findings

Factors shaping the decision to breastfeed

All of the women in this study had breastfed theirbaby from the outset. For most of them, theirintention took explicit shape during the later stageof pregnancy.

I hadn’t really thought about it early in mypregnancy, it was when I went to antenatalclasses that I made my mind upy I decided fromthat point that I wanted to certainly give it a go.(Katie M2.4)

Consistent with other studies (e.g. Dykes, 2005;Murphy, 2000; Schmied & Lupton 2001); mostwomen provided as explanation for their decisionthe benefits to the baby’s health. In this they haddrawn from a range of sources, including theirencounters with health professionals that breast-feeding was the ‘best’ way to feed their baby. Anumber of them articulated their sense of obligationto breastfeed from the way professionals equatedbreastfeeding with a healthy baby. Katie again:

There is also quite a strong pressure really therefor new mothers who feel that they have to orought to give it a go because of all thisinformation that’s loaded onto you at the classesabout how its so much better for the baby andyou just think, well God I really ought to do itfor the sake of the baby. (Katie M2.4)

Whilst most women said they ‘did it for the baby’a few ‘had never thought of doing anything else’; itwas a, taken for granted, implicit decision. Asillustrated by Emily:

I don’t think I ever thought, oh I’m notbreastfeeding. Along with the baby came breast-feeding - that was just the way it was. (EmilyM2.2)

For these women, breastfeeding was what theirown mothers had done, and it was perceived as the‘normal’ thing for them to do. Even so, they werealso aware that other women did not share theirsense of what was ‘normal’. This is illustrated in thefollowing field note from an interaction with

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Table 3

Detailed information about women interviewed

ID Age Ethnic group First baby age Feeding at time of

interview

Detail of feeding practice Occupation

M1.1 Jenny 30 White UK Yes 6 wks Breast Gave formula once overnight Bank clerk

M1.2 Miriam 34 White UK Yes 6 wks Formula Never really established BF Commercial for magazine

M1.3 Deborah 29 White UK Yes 12 wks Formula Fully BF for 6 wks. BF until 10 wks Recruitment researcher

M1.4 Holly 32 White UK Yes 14 wks Breast One formula feed on one occasion Sales

M1.5 Paula 22 White UK No 5 wks Breast Exclusive Admin assistant

M1.6 Jane 31 White UK No 7 wks Formula BF for 3 wks then introduced formula Housewife and studying (degree)

M1.7 Emma 39 White UK No 6 wks Breast Exclusive Civil servant

M1.8 Francine 26 White EU Yes 6 wks Formula BF not established—expressed for 3 wks Waitress

M1.9 Amelia 31 White UK Yes 5 wks Breast+1 formula Exclusively BF for 4 wks. Recruitment consultant

M1.10 Laura 27 White UK Yes 15 wks Formula Exclusively BF for 3 Mo Ticket selling

M2.1 Sarah 31 White UK Yes 9 wks Breast Exclusive Doctor

M2.2 Emily 22 White UK Yes 12 wks Breast & formula BF exclusively for 10 wks Housewife Temporary jobs

M2.3 Lisa 31 White UK Yes 15 wks Breast Exclusive Physiotherapist

M2.4 Katie 28 White UK Yes 8 wks Breast+1 formula Not specific about when formula started Bank–customer service

M2.5 Lata 27 Asian Iraqi Yes 6 mo Breast and weaning Excusive until weaning University lecturer

M2.6 Priya 30 Asian Indian No 4 mo Breast Exclusive. Started to intro solids at 4mo Housewife PG education

M3.1 Sally 21 White UK Yes 12 days Breast Exclusive Temporary jobs.

M3.2 Natasha 25 White UK No 17 days Breast One formula feed when out Intends to return to work full time

M3.3 Hannah 19 Afro Caribbean Yes 6 wks Breast One formula feed in hospital At college

M3.4 Janine 27 White UK No 3 wks Formula Breastfed for almost 3 wks Housewife

M3.5 Lydia 24 Asian Indian Yes 9 wks Formula Breast-fed for 3 wks Customer services advisor

M3.6 Aliya 23 Asian Pakistani Yes 12 wks Breast Exclusive Personal assistant now not

working

Note: Codes 1 denotes rural area, 2 suburban area and 3 inner city area.

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Gemma, a young, single, woman attending a childhealth clinic:

Gemma said ‘my mum breastfed me, and myboss breastfed her children’. The older mothersthat she knew were all very supportive but heryounger friends were saying things like ‘Ohyou’re not going to do that’. She said ‘that mademe more determined to be honest’. (12HV43110)

There was also some evidence that women’spartners could influence the infant feeding decision,for example Jenny said ‘you know it’s what I wantto do and what my husband thinks’. Whilst mostwomen said they discussed feeding with theirpartner, unusually, Natasha described how thischanged her decision completely:

Well my family never breast fed they’ve all bottlefedy so I was going to bottle feed buty his[partner’s] family have always breast fed so we’vesaid we’ll just try it, he sort of persuaded me togive it a goy so it was him really who changedmy mind. (Natasha M3.2)

Whilst the moral nature of the breastfeedingenterprise was apparent (Murphy, 2000) womenalso considered other elements of their identitywhen making infant feeding decisions; for exampleSally from the inner city area said:

And I wasn’t sure about breastfeeding at firsteither when I first found out I was pregnant. ycos breasts are more sexual than kind ofnurturing, now, I suppose is how you view them,and I thought no my breasts are for my man notmy baby. You know, so I was into bottles andobviously you kind of read about the benefits andwhat have you and then once you see the babyit’s the most natural thing in the worldy Youjust want to do it, it comes from instinct. (SallyM3.1)

We now turn to consider breastfeeding asaccomplishment and the factors that impinge on itover time.

Women’s experiences of breastfeeding

In the postnatal period women were confrontedwith a series of practical, social, emotional, culturaland material challenges and constraints as theysought to both nurture their babies and embracemotherhood. Indeed, confidence (including threatsto it) and uncertainty emerged as key concepts

relating to women’s experiences of breastfeeding.The building up of confidence and reduction inuncertainty, both in themselves as ‘good’ mothersand their ability to breastfeed, was not a simplelinear process. Moreover, the challenges theyencountered assumed different forms throughoutthe breastfeeding trajectory as we now considerin detail.

Learning to breastfeed: ‘Getting started’

Acquiring the physical skills of breastfeeding wasof paramount importance to women. All womenrecruited to this study had their baby in hospitaland their uncertainty and vulnerability was amarked feature of this early period. Like theAustralian women in Schmeid and Lupton’s study(2001) for some women (particularly those encoun-tering problems with breastfeeding) the reality didnot live up to expectations. For example Sally said:

I had a very idealistic I will be perfect atbreastfeeding straight away. You know I’ve readthat many books of instructions on how tobreastfeed that I had thought, that’s it, I can dothis straight off this is going to be a piece of piss,and it wasn’t. (Sally M3.1)

Some women, particularly those who experiencedproblems feeding their baby from the outset,described receiving conflicting information and/orinadequate support for breastfeeding in hospital.For example Sally again:

Every single midwife that came in had an entirelydifferent opinion on what to do and it was just, itwas far too confusing (Sally M3.1)

and Laura said:

I just might as well have been on the moonbecause it was touch and go whether anyone everkind of came in your roomy I don’t think it wastill the following night [24 h later] that anyonehad come and shown mey [how] to feed him.(Laura M1.10)

A common form of help from hospital midwiveswas practical ‘hands on care’ in which the midwifedirectly helped the baby latch onto the breast. Forsome women, this provoked a mixed reaction:

It was helpful but it was also a bit of a shock, thatthey were just so, you know they just got hold ofyour boob and they put it, it felt a bit like a cow.(Holly M1.4)

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Holly goes on to explain how she made sense of thisexperience:

And you thought, you know they [midwives]were just so confident I suppose and just so, everyday this happens, just grabbing hold of some-one’s boob and putting it in a baby’s mouth andit’s not normal to people who haven’t had ababy. (Holly M1.4)

Facets of Holly’s account were mirrored in theexperiences of other women, in particular the ‘handson’ doing or being told what to do with little or noexplanation to enable them to understand why suchsuggestions might work.

For example Miriam explained:

M: She [the midwife in hospital] was trying allthese different positions and we did get it in theend.

JM: Was she explaining what she was doingwhile she was doing it? Or was she just trying?

M: No I don’t think she was particularlyexplaining. She was sort of saying, you know‘Try to get the baby’s body to face towards you’(Miriam M1.2)

We return later to the kind of help and knowledgethat women said they needed to develop skills forbreastfeeding.

Keeping going at home

For everyone leaving hospital and going homewas perceived as a major transition when theyexperienced heightened vulnerability in terms ofconfidence in both themselves as mothers and theirability to breastfeed. Although only one woman(Miriam M1.2) experienced pain and discomfortsimilar to that described in a recent study conductedin Canada and the United States (Kelleher, 2006),for many, the sense of not knowing what to do wasoverwhelming in the first days after leaving hospital.Holly described how she felt:

Thursday night was just a nightmare becausesuddenly I was at home with my husband; well hedidn’t know really how to do it. There was nomidwife there. (Holly M1.4)

Even women who encountered few problems withbreastfeeding described feelings of uncertainty andneeded reassurance that they were ‘doing it right’ asLisa explained:

I suppose the other concern was that, was she ornot? Was she on me all right? Was she latchingon okay? Becausey in hospital no one actuallysat down and saw me feed hery (Lisa M2.3)

Women often received help with breastfeedingfrom both health professionals and members oftheir social network. Holly received practical helpfrom a midwife and was also in telephone contactwith a friend who was experiencing similar pro-blems. Sally received help from her mother who hadbreastfed:

y So my mum was helping her latch on and wemanaged finally, she got hungry enough and thenshe took to it and theny my mum kind ofcarried on getting her started with me. (SallyM3.1)

This was reinforced by the community midwife inwhom she had complete trust:

She [the midwife] is really reassuring, she is socalm and confident about everything she doesyshe just tells you what to do and you believe herand it works, you know. (Sally M3.1)

Heath professionals recognised the need tosupport women to build up their confidence withboth breastfeeding and mothering, and much oftheir work was ‘emotional labour’ (Nettleton, 1995,pp. 151). Although health professionals also pro-vided practical or technical information, womenemphasised the emotional elements of these inter-actions. This is particularly well illustrated by thefollowing excerpt from the interview with Katie:

Katie: The first 3–4 days I was just beside myselfbecause I was just so tired.JM: And that’s because he wasn’t sleeping atnight?Katie: Yes, at all, I just seemed to be feeding allthe time and very little sleep, I was in tears a lotof the time and I just really wanted to make itwork and if Beverley (MW5) hadn’t have come tosee me every day I am quite sure I would havegiven up and gone on to bottle because some-thing psychologically kept telling me that I musthave been doing something wrong. (Katie M2.4)

Later in the interview when asked specificallywhat the midwife was doing for her, Katie said:

Well I don’t think she really did anything inparticular, I was doing everything right I think itwas just I needed somebody who was in that

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profession who could say you are doing reallywell and keep going—someone to keep me going.(Katie M2.4)

Beverley felt Katie required extra support andvisited her frequently. Field note records of twointeractions between Katie and Beverley show thatBeverley actually did much more than offer Katieemotional support; she watched Katie feed her babyand offered suggestions for improving her own andthe baby’s position, telling Katie that she had‘corrected it [the baby’s position and attachment] alot more’. She suggested that Katie should have arest in the afternoon ‘because you don’t know whatkind of night you are going to have’ and told her‘the first 8 weeks are the hardest’. In the second ofthe two observed interactions in response to Katieasking whether she had ‘got through the mostdifficult bit yet’ she said:

MW5: ‘You’re doing well’, she gave a longexplanation of supply and demandy ‘they [thebreasts] settle down to produce what he’swanting.’ ‘So he’s got to go there to increasethe supply.’ (7MW51109)

Such information (practical and technical) wasoffered with attention to Katie’s emotional andpsychological well-being. A combination of helpand support that addressed a specific problem,explanations that helped women to understand themechanisms whereby something might work, andattention to women’s emotional well-being were allperceived as important.

Women, as they gained confidence in theirabilities as new mothers, felt able to find their ownsolutions to situations and problems they encoun-tered. This sometimes meant feeling able to discountsuggestions from health professionals. For exampleAmelia said the midwife ‘had lots of tips for the firstweek’ but she also said ‘you felt you could takethem or leave them if you wanted to’. Specificinformation that could be used or discounted wasconsidered most helpful.

Although women generally expected health pro-fessionals to know and to be able to help them, theydid not passively accept what was offered butcarefully weighed it up, assessing whether it workedfor them. For example, Jenny, when advised by thehealth visitor to offer a formula feed in the night asa solution to frequent feeding, did this initially, butlater sought further help from a breastfeedingcounsellor to help her to continue to breastfeed.

Whereas Katie introduced a formula feed eachevening without seeking advice from health profes-sionals.

I wasn’t sure there was enough milk

Women often became concerned about producingsufficient milk for their baby. The underlyingproblem was the inability to directly observe thequantity of breast milk the baby was taking. Priyawas concerned her second baby was not gainingsufficient weight at 4 months old:

y The only sort of issue is, I wish there wassome kind of marker, to say how much she hashad you know. (Priya M2.6)

In the absence of unequivocal observable evi-dence, women drew upon indirect cues garneredfrom midwives. They described various ways ofknowing they were providing enough milk, such as:the baby appearing healthy and having wet anddirty nappies; the way their breasts felt in relation tofeeds; their ability to express milk; and the babygaining weight. Such cues often took the form ofquestions and were frequently observed in interac-tions, examples include:

MW4: ‘‘Are you still feeling the breast filling andemptying?’’ (2MW41105)MW5: Can you hear him swallowing?(4MW53007)She [the midwife] asked several questions aboutthe baby’s nappies and then said ‘‘So the milk’sgoing through if they’ve [baby’s stools] gone toyellow’’. (7MW51109)

Women frequently made comments that empha-sised the visible signs suggesting ample milk;illustrated in the following excerpts from twodifferent women:

M: ‘‘Me pads are getting damp.’’ (4MW53007)M: My milk seems to have come iny. It wasrunning down my army. (1MW40807)

These might be considered ways of making theinvisible visible, thereby increasing women’s con-fidence in their ability to provide sufficient milk fortheir baby. However such cues were not foolproof.If their baby was unsettled, this alone couldundermine women’s confidence in their milk supply;but could also be a trigger for friends or family whowere ambivalent or negative about breastfeeding tosuggest they were not doing it right. Paula, who hadexperienced few problems with breastfeeding her

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second baby, described what happened at a familygathering; her baby became unsettled, cried andneeded feeding more frequently than usual provok-ing some family members to question whetherbreastfeeding was adequate:

yThey were saying ‘oh you need to talk to yourhealth visitor or midwife, because it doesn’t lookas if you’ve got enough milk there or it might notbe strong enough. (Paula M1.5)

Paula explained how these comments upset herbut reassured herself by drawing on the empiricalknowledge that her baby was gaining weight:

In the end I just turned around and said ‘well heis putting on weight so that’s good enough forme’ you know. (Paula M1.5)

Whilst ‘insufficient milk’ has been described asthe acceptable ‘public face’ of breastfeeding cessa-tion (Whelan & Lupton, 1998), its specific influencehere related to the lack of observable evidence thatthe baby was getting adequate nutrition. Further,women in this study, of all social classes, relatedapocryphal stories of friends or relatives who hadnot had ‘enough milk’ to feed their baby or knew ofsomeone whose ‘milk had dried up’.

Many women found the knowledge that theirbaby was gaining weight reassuring. It was almostalways health professionals who weighed babies;midwives in the early postnatal period in women’shomes, and health visitors later on at child healthclinics. Weight was often seen as an importantcriterion for assessing a baby’s progress and this wassometimes led by women as the following field noteillustrates:

Beverley (MW5) said that since the baby wasasleep she would visit again. Sarah seemedsurprised she was not going to weigh him. Therewas some discussion then whether to wake thebaby up to be weighed or not. Sarah left theroom to consult her husband and came backfollowed by her husband saying: ‘‘We’ll wakehim and get him weighed.’’ Beverley (MW5)asked them to wake the baby and undress him.Whist the parents did this between them saying‘‘we’re cruel parents’’ with the baby on Sarah’sknee the midwife took the scales out of her bag.She weighed the baby who had gained weightwell. Sarah asked how much weight the babyshould gain.

MW5: ‘‘They usually gain about an ounce aday.’’

Sarah: ‘‘So he’s gained more than he has to.’’(6MW51009)

Whilst for most women knowing the baby’sweight was seen as positive, emphasising weightcould undermine women’s other ways of knowing.Lisa described how a comment from her healthvisitor at a postnatal visit in her home increased heruncertainty and undermined her confidence:

y They [health visitors] were wanting me to goup to the clinic because I remember them saying‘with a breastfed baby you don’t know how muchthey are getting, so I’d like you to come up everyweek initially so I can weigh her’y She’d gotdirty, wet nappies, she was healthy, so thatactually saying that to me worried me more thanjust saying you know ‘it would be nice to comeup and make sure everything is alright’. (LisaM2.3)

Also not all babies were found to have gainedweight each time they were weighed as Jennyexplained:

y One week he didn’t put on much weight, ordidn’t put on any weight I don’t think at all. Soshe [Jenny’s mother] said ‘Oh well you know youcan’t be feeding him right’ or ‘perhaps youshould have him on a bottle by now’ sort ofthing. (Jenny M1.1)

This lack of weight gain did not fit with Jenny’sexperience of breastfeeding for long periods and shebecame concerned that something was not right.She sought and received help from a midwife toimprove the way her baby was breastfeeding andwas then able to make sense of the situation andcontinued to breastfeed.

Changes in the baby’s feeding pattern, frequentfeeding or an unsettled baby often underminedwomen’s confidence in their milk supply but thiscould be alleviated if women were able to makesense of why this was happening and see it as atransitory phenomenon. Reassurance that the ba-by’s behaviour was ‘normal’ was important tosome women but for others if they were findingthe baby’s behaviour very difficult, being toldthis was normal served to reinforce the problemand gave it a sense of permanency. A commonexplanation offered by health professionals fora baby suddenly feeding more frequently was that

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he/she must be ‘having a growth spurt’; this seemedto be a positive explanation for most women.Possibly because the word ‘spurt’ suggests that thesituation is going to be short-lived but also becausegrowing is seen as a positive thing for a baby to do.It contrasts with the idea of not being able toproduce enough milk for their baby and provides anexplanation (based on understanding the physiologyof the production of breastmilk). The temporalnature of the behaviour change, combined withexplanation enabling women to understand why itwas happening, made it easier for some women tocontinue. For example Jenny said:

y A couple of weeks ago I thought I was gonnagive up, when he was having his growth spurt,because I was just so tired all the timey But I’vesort of got through that and I realise that he mayhave more growth spurts, but now that I knowthat that’s what it is, rather than, cos that waswhen I thought I wasn’t producing enough milkfor him. (Jenny M1.1)

Whilst a primary concern was their ability toproduce enough milk for their baby many womenwere also struggling to manage the balance betweenensuring the health of their baby (which for thesewomen included breastfeeding) and other aspects oftheir lives.

Being a ‘good mother’

Women sought to understand all the differentkinds of knowledge, including the practical aspectsand the value of breastfeeding within the context ofevents that were happening in their lives. They madesense of situations in various ways but with theunderlying aim of preserving their idea of them-selves as a good mother (see also Murphy, 2000,2004). Whereas their decision to breastfeed at theoutset was primarily couched in terms of benefits tothe baby’s health and the subordination of theirown needs to those of the baby, that Hays (1996)has characterised as ‘intensive mothering’, thepractical reality produced a more complex picture.Thus, it was generally easier for women to equategood mothering with breastfeeding if they wereconfident they were ‘doing well’ and perceived theirbaby to be healthy and happy. Hannah, a 19 yearold, expressed this in terms of knowing the babywas gaining weight:

Hannah:y it went well it was fine, I kept feedingher and she’s never been off since. She’s beenputting a lot of weight on that’s all.

JM: Yeh. And what did you feel about that?

Hannah: I was pleased because I knew it was cosof breast-feeding. (Hannah M3.3)

But when a baby was not seen as healthy orcontented (either in terms of behaviour or measur-able outcomes such as weight), this underminedwomen’s confidence and left them open to thecharge of bad mothering. Laura described herfeelings after a visit to the Child Health Clinicwhere she had been told her baby, who was about 3months old, had not gained sufficient weight:

y Obviously with the weight thing. I mean thatreally kind of got me, I thought ‘God I’m thisawful mother’, you know I’d been trying so hardto keep this breastfeeding up and now you’retelling me I’ve got the undernourished, you knowthis baby that didn’t put any weight on. (LauraM1.10)

Sarah felt that her son’s ‘grouchy spell’ when shevisited her mother-in-law was interpreted as evi-dence that she ‘was not coming up to scratch’ as amother. Prefacing her narrative with a descriptionof people she knew, particularly her mother-in-lawas having bottle-fed their babies, she continued:

I think she was quite horrified to see Simondidn’t sleep (pause) at ally and she was youknow ooh he’s not very settled, he’s not verysettledy I felt pretty bad I mean, he was at hisworst reallyy and they also made a big dealevery time he was grouchy like ‘ooh babies don’tcry for no reason there must be something wrongwith him’ and passing him round and saying tome ‘have you fed him, have you fed him, he’shungry, have you fed him?’ (Sarah M1.2)

Among immediate family, then, the equation ofbreastfeeding with being a ‘good mother’ was oftencontested and often contradictory qualities of ‘goodmothering’ were conveyed by individuals withinwomen’s social networks and by health profes-sionals. Women were not passive recipients of suchmessages but negotiated their way through thesecontradictions to maintain a positive self-identity.There were three specific contexts in which socialand structural constraints of women’s lives chal-lenged the ideology of intensive motherhood (Hays,1996; Ribbens McCarthy, Edwards, & Gillies,

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2000). These were resuming activities that were ofvalue to them; involving partners in the ‘baby work’and getting back to work.

In their quest to balance the needs of the babywith managing the routines of daily life, whetherthis was caring for other children, doing houseworkor resuming valued activities, women were oftenchallenged by the unpredictable nature of breast-feeding, especially when outside their home. Forexample, Deborah said:

I felt very restricted. I am not somebody thatwould openly breastfeed in public anyway. yIjust felt like I needed a little bit of life for me aswell, which is probably quite selfish. yAnd Ineeded silly things like I wanted my hair cuttingand flashing and stuff like that, and I justthought ‘how am I going to do it?’. Abigail isjust not going to be good for three hours therewas just no way. So that’s when I decided to givemyself something back as well as Abigail.Because I knew it is right what they say, a babyfor the first three months I suppose effectively aparasite really they take all the goodness out ofyou. And she was taking everything from me andI was tired. Like I say, I just thought somethinghas to give here. But I did feel guilty and I did gothrough that. (Deborah M1.3)

Deborah had stopped breastfeeding by the timeshe was interviewed but women who continued tobreastfeed sometimes described making complexarrangements to enable them to continue. Forexample Amelia said:

y It’s just going for my hair cutting and I’vebeen invited to a lunchy I mean it’s only for acouple of hours, but I’d have had to take her,depending on how the feeds werey So what I’lldo is I’ll breastfeed her in the morning and then,Stephen, my husband’s going to come home atlunch time andy I’ll feed her, hopefully, before Igo and then leave him with a bottle so if shewakes up he can give her that. Hopefully shewon’t wake up and then I’ll just come back atthree and, hopefully she won’t have needed ity(Amelia M1.9)

Some mothers and partners placed high value onsharing the feeding as one facet of assuming someshared responsibility for the baby. However, thiscould also have the unintended outcome of dis-couraging women from breastfeeding, for exampleboth Amelia and Katie introduced a formula feed a

day so that their partner could feed the baby,whereas Lisa and Laura attempted to express milk.Lisa described this as ‘such a faff all this expressingand sterilising’ and Laura said:

So I’d be up feeding him one minute, expressingthe next so that we’ve got, you know enough inthe freezer. Yet he still wouldn’t get up in themiddle of the night with him. (Laura M1.10)

Of the 22 women interviewed 14 were planning toreturn to work, (3 part-time and 2 not until theirbaby was a year old) many of them citing economicreasons as explanation. For example Emma said:

I go back at the end of January, which I am notlooking forward toy I had an extra month withKaren [first child]. We can’t afford to do that thistime unfortunately. (Emma M1.7)

Sometimes women could see benefits to returningto work for example Paula said:

So yes, it does seem enough. I’d go back to worknow if I could do a couple of hours a day just toget out really and have a conversation. It maysound nasty to some people, but you still needyour own time really. (Paula M1.5)

All these examples illustrate the complexity of thedifferent roles and identities women attempt tofulfil; not only are they striving to maintain theiridentity as a good mother, within the context ofdifferent perceptions of this, but they are alsomerging this with other pre-existing identities aswomen, wives and workers.

Discussion

This exploration of women’s experiences providesinsight into the ways their responses to breastfeed-ing are informed by diverse social, emotional andpractical concerns. We suggest that the conceptionof breastfeeding as synonymous with good mother-ing is more contested than has previously beenpresented (e.g. Carter, 1995; Murphy, 1999, 2000,2004). Indeed, for many women in this study, theirdecision to breastfeed was portrayed as counter tonormative practice within their immediate familyand they actively sought out ‘allies’ as one facet of astrategy to increase confidence and reduce uncer-tainty. These included not only health profes-sionals but ‘experiential experts’ (those amongtheir peers and family who were breastfeeding orhad breastfed). So although discourse emphasises

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breastfeeding as best, women are exposed to aconsiderably more diverse set of values andinfluences across their social networks. Further,structural factors, such as women’s changingrelationship to the labour market, both constrainaction and contribute to changing norms aroundmotherhood.

For women breastfeeding is generally equated withgood mothering when the baby is seen as healthy andhappy but this is more difficult to sustain if, forexample, a breastfed baby is feeding often but notgaining weight, or is unsettled (see also Oakley,1979). Women’s accounts of ‘significant others’response to breastfeeding indicate that it is obser-vable signs that the baby is contented and thrivingthat signify ‘good mothering’ but the causal linkagesbetween breastfeeding, a healthy baby and thereforegood mothering are evidenced in the baby’s beha-viour. Maintaining breastfeeding in the absence ofsuch evidence leaves them open to the charge ofbeing unsuccessful or poor mothers, unless contex-tual factors (e.g. unfamiliar environment), thetemporary or episodic nature of the behaviour (notsleeping or crying) or an anticipated stage in thebaby’s development (growth spurt) can provideplausible explanation. An ideology of intensivemotherhood where the baby’s needs are paramount(Murphy, 2000) and the responsibility of the baby’swelfare lies solely with the mother does not fit withcontemporary women’s lives (Murphy, 2004; Phoe-nix et al., 1991). Women weigh up competing beliefsand goals, for example, between frequent feeding andmaintaining their own health and well-being, andtheir decision-making around feeding is not onlyshaped by expert discourses but by the practicalrealities of their daily lives as in combining breast-feeding (or not) with going back to work.

In this study health professionals not onlyprovided technical expertise but also, particularly inthe early days, carried out a great deal of ‘emotionalwork’ (Nettleton, 1995) (as illustrated by the inter-action with Katie). The more swiftly women learn thetechnical skills (with support if necessary) the morethe emotional challenge of breastfeeding diminishes.To this end for women two things are particularlyimportant: firstly, the need to understand the reasonwhy things might work to resolve infant feedingissues, and secondly, recognition of cues to reassurewomen that feeding was going well. A significantfeature of such cues is that they are observable orexperiential indicators—weight gain, colour of thebaby’s stools, feeling the breasts filling up. It has

been suggested that health professionals give detailedand specific advice in their encounters formulated asa ‘set of rules for healthy infant feeding’ (Murphy,2003, p. 438). This implies that one solution suits alland this was not the case in this study. Most healthprofessionals, particularly when visiting women intheir own homes, gathered knowledge about wo-men’s contextual circumstances in order to providespecific information relating to the problem or issueconcerning each woman.

The tension between the public health imperativeto breastfeed and the practical tasks of providingsupport for individual women has previously beendiscussed (Murphy, 2000; Schmied & Lupton, 2001)and health professionals, such as midwives and healthvisitors, are often linked with the medicalisation ofbreastfeeding (Carter, 1995; Murphy, 2000, 2003). Itis a moot point as to whether the practice ofprofessionals in relation to infant feeding is shiftingfrom a medical discourse. It is notable that the WorldHealth Organisation Global Strategy for Infant andYoung Child Feeding (2003) and the second Inno-centi Declaration on Infant and Young Child Feeding(2005) clearly state that babies should be breast-fed,but this is followed by the suggestion that womenneed ‘skilled practical support’ and recognition of thesocietal challenges. Having an impact on such issueswill require broader societal changes, includingrevised national policy and law, for example toaddress employment issues that constrain women’sability to breastfeed and work in paid employment.

This study has highlighted the need to not onlyfocus on the normative and ideological imperativesof breastfeeding and how women manage them butto explore these in the context of women’s changinglives, the multiple and diverse conceptions of ‘goodmothering’ and the values attached to differentfeeding practices. The other side of the coin is toconsider how and in what ways ‘expert’ ormedicalised discourse in breastfeeding not onlyshapes, but also is in turn affected by changingsocieties and changing lives.

Acknowledgements

This study was supported by a Department ofHealth Fellowship Award. We would like to thankthe breastfeeding women, midwives and healthvisitors who made the research possible, also KarlAtkin for helpful comments on earlier drafts of thisarticle and the anonymous reviewers for theirhelpful comments.

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