A Grandmothers’ Tea: Evaluation of a Breastfeeding Support Intervention

Abstract

This study’s purpose was to evaluate an intervention to facilitate grandmothers’ knowledge and support of breastfeeding. A pilot study with a quasi-experimental two-group posttest design was used to evaluate whether the intervention made a difference in grandmothers’ knowledge, attitudes, and intent to recommend breastfeeding. The 26 grandmothers in the intervention group attended A Grandmothers’ Tea program; the 23 grandmothers in the control group received written information. The intervention group had greater posttest knowledge scores than the control group but had no significant differences in attitudes or intent. However, a significant difference was evident between the attitude scores of grandmothers who breastfed their infants and of grandmothers who did not breastfeed their infants regardless of receiving the intervention.

Increasing breastfeeding rates is one of the goals set by Healthy People 2020, a national public health initiative (U.S. Department of Health and Human Services [U.S. DHHS], 2011b). Researchers who investigated factors that predict improved breastfeeding rates concluded that grandmothers are important to successful breastfeeding because their knowledge, attitudes, and experiences influence mothers’ decisions to initiate and continue breastfeeding (Arlotti, Cottrell, Lee, & Curtin, 1998; Barton, 2001; Bentley et al., 1999; McIntyre, Hiller, & Turnbull, 2001; Whelan & Lupton, 1998). Mothers often turn to grandmothers rather than to their health-care providers for information and support about infant-feeding issues, particularly as their infants grow (Barton, 2001; Bland, Rollins, Coutsoudis, & Coovadia, 2002; Grassley & Nelms, 2008; Heinig et al., 2009). Nankunda, Tylleskär, Ndeezi, Semiyaga, and Tumwine (2010), in their evaluation of an intervention using individual peer counseling in Uganda, concluded that grandmothers and husbands are key players in mothers’ breastfeeding decisions. In a study conducted in Germany, the maternal grandmother’s attitude regarding breastfeeding predicted duration up to 4 months (Kohlhuber, Rebhan, Schwegler, Koletzko, & Fromme, 2008). The Surgeon General’s Call to Action to Support Breastfeeding recognizes the importance for mothers of grandmothers’ support for breastfeeding (U.S. DHHS, 2011a).

Mothers often turn to grandmothers rather than to their health-care providers for information and support about infant-feeding issues, particularly as their infants grow.

Many women who are becoming grandmothers, however, may have limited experience with breastfeeding. New mothers have reported that formula is the infant-feeding method most often chosen by their female relatives (Bentley et al., 1999; Cricco-Lizza, 2004; Meyerink & Marquis, 2002). This lack of experience may reflect the low breastfeeding rates reported in the United States between 1970 and 1992. Breastfeeding rates were lowest in 1971 when less than 25% of women initiated breastfeeding and only 5% continued for a minimum of 6 months. The rates peaked in 1982 when 62% of women initiated breastfeeding and 27% were breastfeeding at 6 months. By 1992, the prevalence of breastfeeding initiation and continuation had declined to 52% and 18%, respectively (Cadwell, 2002; Ryan, Wenjun, & Acosta, 2002).

Lack of breastfeeding knowledge and experience influences grandmothers’ support. In the United States, grandmothers who are unaware of the current American Academy of Pediatrics (Gartner et al., 2005) recommendations about the sufficiency of exclusive breastfeeding in the baby’s first 6 months may advocate the giving of supplements such as water or formula, which can undermine a mother’s milk supply (Banks, 2003; Grassley & Eschiti, 2008). This occurs internationally. Grandmothers in Malawi encourage early introduction of other foods (Kerr, Berti & Chirwa, 2007). Susin, Giugliani, and Kummer (2005) concluded that early supplementation of breastfeeding with formula increases with daily contact from the maternal grandmother. In their study of breastfeeding in Taiwan, Chen, Liu, Merrett, Chuo, and Wan (2008) found that a shorter duration of breastfeeding is more likely when the grandmother is the primary caregiver, particularly if the mother works outside the home. They recommended providing families information about how to express and store breastmilk. A grandmother who has not breastfed may evaluate breastfeeding using knowledge and language that reflects experience with formula feeding and, thus, undermine a new mother’s breastfeeding confidence (Banks, 2003; Bryant, Coreil, D’Angelo, Bailey, & Lazarov, 1992; Grassley & Nelms, 2008).

Many women who are becoming grandmothers, however, may have limited experience with breastfeeding.

Researchers who study factors that predict improved breastfeeding rates recommend that health-care providers include grandmothers in discussions with their pregnant clients about breastfeeding (Kerr et al., 2007; Nankunda et al., 2010; Susin et al., 2005). Research findings indicate that grandmothers can offer more effective support when interventions address their breastfeeding concerns. We found three research studies that described interventions to facilitate grandmothers’ breastfeeding support. Winterburn, Jiwa, and Thompson (2003) included grandmothers in home visits by midwives in Australia to promote breastfeeding. Aubel, Touré, and Diagne (2004) taught grandmothers in Senegal current breastfeeding information through songs, stories, and group discussion. Ingram, Johnson, and Hamid (2003) used focus groups and home visits to develop pamphlets promoting breastfeeding among South Asian grandmothers living in Great Britain. Banks (2003) described a project within a Canadian First Nations community that addressed grandmothers’ breastfeeding concerns and, during talking circles led by a community breastfeeding advocate, demonstrated effective ways grandmothers could support new mothers.

Because research about interventions designed for grandmothers is limited, Grassley and Eschiti (2007, 2008) conducted focus groups to identify grandmothers’ breastfeeding concerns and mothers’ perspectives of the breastfeeding support they needed from their infants’ grandmothers as the foundation for developing an intervention. Grandmothers (n = 33) and mothers (n = 30) participated in separate focus groups moderated by the researchers. The mothers’ group identified the essence of support as grandmother breastfeeding advocacy, which they defined as valuing breastfeeding and offering loving encouragement. They thought that grandmothers needed to acknowledge and discuss their perceptions of breastfeeding as a barrier to getting enough rest or to their bonding with their grandchild. Mothers also identified myths that grandmothers need to confront about breastfeeding, such as the notion that most women cannot produce enough milk. Finally, mothers wanted grandmothers to have current breastfeeding knowledge (Grassley & Eschiti, 2008). Grandmothers wanted to be helpful. They agreed with the mothers that grandmothers need to update their knowledge. They identified “two generations learning together” as an effective way to facilitate grandmothers’ knowledge and support of breastfeeding (Grassley & Eschiti, 2007, p. 25).

During the process of developing an intervention, we discovered that A Grandmothers’ Tea project had been developed by the Illinois State Breastfeeding Task Force (2011) to facilitate grandmothers’ breastfeeding support and was available online. This interactive curriculum encompasses the themes illuminated by focus groups in previous studies (Grassley & Eschiti, 2007, 2008). In this curriculum, grandmothers are invited to learn about breastfeeding through three activities that pose possible breastfeeding scenarios. The Grandmothers’ Apron activity updates grandmothers’ knowledge about the benefits of breastfeeding. During the Grandmothers’ Cell Phone activity, grandmothers talk about breastfeeding myths and barriers. In the Grandmothers’ Necklace activity, participants create a beaded necklace to remind them of ways they can offer support through loving encouragement, updating their breastfeeding knowledge, and being helpful. One of the researchers in our group attended a workshop to learn how to conduct A Grandmothers’ Tea and received permission to use the curriculum in our study, whose purpose was to evaluate an intervention to facilitate grandmothers’ knowledge and support of breastfeeding.

METHODS

A pilot study with a quasi-experimental two-group posttest design was used to test one hypothesis: Grandmothers who participate in the intervention will demonstrate higher scores for attitude, knowledge, and intent to recommend breastfeeding than grandmothers in the control group. The intervention group attended an interactive educational event, A Grandmothers’ Tea (Illinois State Breastfeeding Task Force, 2011); the control group received materials written for grandmothers about breastfeeding via the U.S. Postal Service. We began data collection after receiving approval from the institutional review board at our institution and from the participating hospitals.

Setting and Sample

The setting of this study was two hospitals in a large urban metroplex in the Southwestern United States. The convenience sample comprised 49 grandmothers (intervention group n = 26; control group n = 23). Grandmothers were recruited through the host hospitals’ childbirth classes. Expectant parents were given written information about the study to give to their mothers who then contacted us if they were interested in participating. Inclusion criteria included grandmothers who were expecting a grandchild and who could speak and read English. Grandmothers were placed in either the control group or intervention group, based on their personal preference. Most of the grandmothers in the control group lived outside the area, whereas the grandmothers in the intervention group lived locally. Expectant mothers were invited to come with their mothers or their partners’ mothers to one of the teas.

Instruments

The four data collection instruments were a demographic questionnaire, the Iowa Infant Feeding Attitude Scale, the Infant Feeding Test, and the Intent to Recommend Breastfeeding Scale. The Participant Information Form provided demographic data such as race, education level, and information about grandmothers’ infant-feeding experiences.

Attitudes were measured using the Iowa Infant Feeding Attitude Scale (IIFAS) developed by de la Mora, Russell, Dungy, Losch, and Dusdieker (1999). The IIFAS is a 17-item scale that was developed as “a simple, easily administered instrument that will measure maternal attitudes toward infant feeding” (de la Mora et al., p. 2363). The scale is a Likert-type five-option response scale, with responses ranging from strongly disagree to strongly agree. Possible summative scores for the IIFAS range from 17 to 85. The researchers defined “attitudes” as beliefs about infant feeding. The IIFAS has been used in several studies to measure mothers’ infant-feeding attitudes (Bishop, Cousins, Casson, & Moore, 2008; de la Mora et al., 1999; Dungy, McInnes, Tappin, Wallis, & Oprescu, 2008; Persad & Mensinger, 2008; Shaker, Scott, & Reid, 2004) and in one study of fathers’ infant-feeding attitudes (Shaker et al., 2004). The IIFAS has demonstrated very good internal consistency. A Cronbach’s alpha of .86 was reported by de la Mora et al. Dungy et al. measured the infant-feeding attitudes of mothers (Cronbach’s α = .74) and of members of the mothers’ support networks (Cronbach’s α = .89), which included grandmothers. Shaker et al. used the scale to compare infant-feeding attitudes of expectant parents (mothers and fathers) of breastfed infants with the attitudes of expectant parents of formula-fed infants. The Cronbach’s alphas reported were .79 for mothers and .77 for fathers. Cronbach’s alpha for the 17-item IIFAS measure for our study was .78, indicating very good reliability of the instrument, which was also comparable to the reliability values reported in the literature. Our investigation was the first study that included grandmothers only.

To explore potential grandmother breastfeeding attitudes that reflected findings from a previous study (Grassley & Eschiti, 2008), we constructed four additional statements and added them to the end of the IIFAS. Two statements asked grandmothers about duration of breastfeeding: “A mother and baby should breastfeed for as long as it is satisfying,” and “The longest a mother should breastfeed is 12 months.” Two statements reflected mothers’ perceptions of grandmothers’ concerns: “When a woman breastfeeds, it is difficult to have anyone help her take care of the baby since she is the only one who can feed the baby,” and “The best way for a grandmother to help a new mother who is breastfeeding is to give the baby a bottle of formula.” The Cronbach’s alpha for the IIFAS with the addition of our four items raised the Cronbach’s alpha to .82 for the sample of grandmothers in our study. Items on both the original IIFAS and the additional items that reflect negative statements regarding breastfeeding were reverse-scored for statistical analysis.

Knowledge, defined as current information about breastfeeding best practices (Gartner et al., 2005), was measured using the Infant Feeding Test (IFET) developed by Grossman, Harter, and Hasbrouck (1990) to evaluate an antepartal educational breastfeeding intervention. In a previous study, the test, which has two equivalent forms, had a Kuder Richardson 20 reliability estimate of .60 and .69, respectively. Participants receive a possible summative score of 0–20. The Kuder Richardson 20 for the IFET for our study was .53, indicating a fairly weak relationship among the test items, which is slightly lower than in previously published studies (Grossman et al., 1990). We received permission to use both the IIFAS and the IFET instruments for our research project.

Intent to recommend breastfeeding was measured by the Intent to Recommend Breastfeeding Scale, a one-item scale that we developed for the purpose of our study. It is a 100 mm visual analog scale ranging from 0 (disagree) to 100 (agree). Participants were asked to mark where on the continuum they would place their intent to recommend breastfeeding to new mothers.

Study Procedures

Table 1 explains the study procedures for each group. Participants in the intervention group attended one of four grandmothers’ teas that lasted about 90 minutes each. The study was explained and consents were signed at the beginning of the event. After experiencing the activities, each participant completed the four data collection instruments. Participants in the control group were mailed a research packet that contained a letter explaining the study, an informed consent form, written educational materials about how grandparents can support breastfeeding, and the four data collection instruments. Control group participants were instructed to read and sign the consent form, read the written breastfeeding educational materials, and then complete the four instruments. Study materials were then mailed back to the researchers in a self-addressed stamped envelope.

TABLE 1. Comparison of Control Group and Intervention Group Activities.

	Control Group	Intervention Group
Research packet	Mailed packet with letter, consent forms, research instruments, and self-addressed stamped envelope to return packet to researchers.	Given packet with letter, consent forms, and research instruments at A Grandmothers’ Tea.
Breastfeeding information resources	Written information mailed: Ishii, K. D., & Heinig, M. J. (2005). What grandparents can do to help a breastfeeding mother. Journal of Human Lactation, 21(1), 67–68. Texas Department of Health. (n.d.). Support your daughter (13-06-12080) [Brochure]. Retrieved from http://www.dshs.state.tx.us/wichd/bf/pdf/13-06-12080.pdf Thunder Bay Breastfeeding Coalition. (2007). Grandparents: Providing support to the breastfeeding relationship [Brochure]. Retrieved from http://www.tbdhu.com/NR/rdonlyres/1D587E35-0B3A-4C2D-A4AA-A3676C6153EB/0/2007GrandparentsBF.pdf	Attend A Grandmothers’ Tea (http://www.illinoisbreastfeeding.org) Grandmothers’ Apron: Discussion of health benefits. Grandmothers’ Cell Phone: Discussion of breastfeeding myths and barriers, using scenarios. Grandmothers’ Necklace: While creating beaded necklaces, discussion of scenarios that remind grandmothers of ways they can offer breastfeeding support to new mothers.
Research instruments	Participants instructed to complete the four instruments using pencil-and-paper forms after reading the above materials, which were mailed back to researchers.	Participants completed the four instruments using pencil-and-paper forms at the end of the tea. These forms were collected by the researchers.

Statistical analysis of the demographics was used to evaluate equivalency of the groups. An independent t test was used to test the hypothesis that grandmothers who participate in the intervention will demonstrate higher scores for attitudes, knowledge, and intent to recommend breastfeeding than grandmothers in the control group. SPSS version 15 was used for analysis.

RESULTS

Eighteen of the 26 grandmothers attended the teas with their daughters or daughters-in-law. This seemed to facilitate conversation between mothers and grandmothers during the teas. Table 2 describes the characteristics of the sample. One-way ANOVA was used to evaluate the similarity of demographic characteristics of the intervention and control groups. The control and intervention groups were similar with respect to the following: education level, F(1, 47) = 3.43, p = .07; race, F(1, 47) = 1.84, p = .18; participant was breastfed, F(1, 47) = 3.26, p = .08; and participant breastfed her infants, F(1, 47) = .49, p = .49. The groups were also similar regarding age: t(47) = 1.55, p = .13 (two-tailed).

TABLE 2. Summary of Demographic Characteristics of Grandmothers.

Characteristic	All (N = 49)		Intervention (n = 26)		Control (n = 23)
	n	%	n	%	n	%
Age (in years)
44–52	14	24.4	11	44.2	3	12.9
53–61	22	44.9	8	30.6	14	60
62–79	13	26.3	7	26.7	6	25.9
Mean (SD)	56.8 (7.6)		55.3 (7.4)		58.6 (7.5)
Education level
High school or GED	2	4.1	2	7.7	0	0
Some college	14	28.6	8	30.8	6	26.1
2-year college degree	8	16.3	6	23.1	2	8.7
4-year college degree	11	22.4	55	19.2	6	26.1
Graduate education	14	28.6		19.2	9	39.1
Race
African American	2	4.1	2	77.0	0	0
White	47	95.9	24	92.3	23	100
Did your mother breastfeed you?
Yes	26	53.1	16	61.5	10	43.5
No	20	40.8	10		10	43.5
Unknown	3	6.1	0	38.5	3	13
Did you breastfeed?
Yes	43	87.8	22	84.6	21	91.3
No	6	12.2	4	16.4	2	8.7

An independent t test found that the intervention group had higher posttest knowledge scores than the control group but had no significant differences in attitude scores or intent to recommend breastfeeding. Table 3 displays a summary of the analysis. Further exploratory analysis revealed potential differences in IIFAS scores between grandmothers who breastfed (n = 43) and grandmothers who did not breastfeed (n = 6). Dungy et al. (2008) divided the 17-item total IIFAS score into conceptual ranges for attitude, including positive to breastfeeding (70–85), neutral (49–69), and positive to formula feeding (17–48). The mean scores on the original 17-item IIFAS in this study for grandmothers reflect a conceptual difference in attitude between grandmothers who breastfed and grandmothers who did not breastfeed. Grandmothers who breastfed (M = 74, SD = 4.2) fell in the positive-to-breastfeeding range (70–85), and grandmothers who had not breastfed (M = 60, SD = 11.9) fell in the neutral range (49–69). A Mann-Whitney U test was conducted to analyze the statistical difference between these two groups because the data were not normally distributed. A statistically significant difference was found (U = 27.5, p = .002) between the attitude scores of grandmothers who breastfed their infants and the attitude scores of grandmothers who did not breastfeed their infants, regardless of receiving the intervention. Table 4 displays the analysis for the comparison of overall scores of the attitude measure (IIFAS) and the specific items that were significantly different between breastfeeding and nonbreastfeeding grandmothers.

TABLE 3. Comparison of Control and Intervention Groups With Regard to Knowledge, Attitude, and Intention Measures (N = 49).

Measure	Group (n)	M (SD)	t (df )	sig (two-tailed)
Knowledge (Infant Feeding Test)	Control (23)	17.6 (1.6)	–2.35 (47)	.02
	Intervention (26)	18.6 (1.3)
Attitude (Iowa Infant Feeding Attitude Scale)	Control (23)	89.2 (7.7)	.57 (47)	.33
	Intervention (26)	87.2 (14.6)
Intention to Recommend Breastfeeding	Control (20)	15.2 (23.4)a	.98 (43)	.57
	Intervention (25)	9.5 (15.2)

^aLower scores indicate higher intention to recommend breastfeeding.

TABLE 4. Comparison of Participants (N = 49) Who Breastfed and Did Not Breastfeed With Regard to Attitude Measure Total Score and Individual Items.

Measure	Group (n)	Median (Range)	U	sig (two-tailed)
Attitude (Iowa Infant Feeding Attitude Scale total score)	BFN (6)	74.5	27.5	.002
	BFY (43)	90.0
1. The nutritional benefits of breastmilk last only until the baby is weaned from breastmilk.	BFN (6)	4.0(3)	53.0	.008
	BFY (42)	5.0(4)
2. Formula feeding is more convenient than breastfeeding.	BFN (6)	2.5(4)	60.5	.013
	BFY (42)	5.0(4)
3. Breastfeeding increases mother–infant bonding.	BFN (6)	5.0(3)	89.0	.016
	BFY (42)	5.0(1)
7. Mothers who formula feed miss out on one of the greatest joys of motherhood.	BFN (6)	3.0(4)	66.0	.046
	BFY (42)	4.0(4)
8. Women should not breastfeed in public places, such as restaurants.	BFN (6)	3.0(3)	63.5	.042
	BFY (42)	4.0(4)
10. Breastfed babies are more likely to be overfed than formula-fed babies.	BFN (6)	4.0(3)	67.0	.04
	BFY (42)	5.0(4)
11. Fathers feel left out if a mother breastfeeds.	BFN (6)	3.0(1)	55.0	.014
	BFY (42)	4.0(3)
12. Breastmilk is the ideal food for babies.	BFN (6)	4.0(4)	36.0	.000
	BFY (42)	5.0(4)
14. Formula is as healthy for an infant as breastmilk.	BFN (6)	3.0(4)	65.5	.031
	BFY (43)	5.0(3)
15. Breastfeeding is more convenient than formula feeding.	BFN (6)	3.5(4)	43.5	.001
	BFY (43)	5.0(3)
16. Breastmilk is less expensive than formula.	BFN (6)	5.0(1)	95.0	.048
	BFY (43)	5.0(1)
17. A mother who occasionally drinks alcohol should not breastfeed her baby.	BFN (6)	2.0(3)	44.5	.006
	BFY (42)	4.0(4)
18. The longest a mother should breastfeed her infant is 12 months.	BFN (6)	2.5(2)	62.5	.035
	BFY (43)	4.0(3)
19. When a woman breastfeeds, it is difficult to have anyone help her take care of the baby since she is the only one who can feed the baby.	BFN (6)	3.5(2)	49.0	.008
	BFY (43)	4.0(3)

Note. Only items with significant differences (p < .05) are displayed in the table. BFN = did not breastfeed; BFY = did breastfeed.

DISCUSSION

Study results suggest that participation in an intervention may facilitate grandmothers’ breastfeeding knowledge, which has been identified by both grandmothers and mothers as desirable (Grassley & Eschiti, 2007, 2008). The literature supports that grandmothers can benefit from being given updated information about breastfeeding. South Asian grandmothers in the United Kingdom expressed a positive response to being given an educational pamphlet developed for them and being given an opportunity to have a midwife answer their questions about breastfeeding. Several of the grandmothers described changes they made in the support they offered to new mothers (Ingram et al., 2003). The breastfeeding scenarios that guide discussion during A Grandmothers’ Tea share similarities to an intervention conducted among Senegalese grandmothers. Aubel et al. (2004) found that using “problem-posing stories” followed by open-ended questions facilitated grandmothers’ breastfeeding knowledge and support (p. 951).

In contrast, no differences were found in intent to recommend breastfeeding and attitudes between the intervention and the control groups in our study. The IIFAS scores of the majority of grandmothers in both groups indicated a positive attitude toward breastfeeding. This could be for two reasons: first, most grandmothers who participated in the study had breastfed their children and over half were breastfed by their mothers, which suggests that they would have been predisposed to a positive attitude. This does not, however, diminish the importance of grandmothers’ attitudes about breastfeeding. Positive breastfeeding attitudes by members of a women’s social network, which include grandmothers, were strongly associated with mothers’ positive attitudes toward breastfeeding (Dungy et al., 2008). For women in Northern Ireland, maternal grandmothers were identified as being the greatest influence for women who chose to breastfeed (Bishop et al., 2008).

For more information about the Grandmothers’ Tea project and to download the curriculum and other materials, visit the website of the Illinois State Breastfeeding Task Force (http://www.illinoisbreastfeeding.org/) and click “Task Force Projects.”

Second, the original intent of the IIFAS was to predict women at risk for not breastfeeding or for early weaning (de la Mora et al., 1999). The IIFAS has been shown to discriminate positive attitudes toward breastfeeding from positive attitudes toward formula feeding, which was found in our study. The conceptual and statistical analysis of the data in our study revealed that grandmothers who had breastfed had significantly more positive attitudes toward breastfeeding than did grandmothers who had not breastfed. The differences between these two groups of grandmothers related to the nutritional, psychosocial, and economic benefits of breastfeeding (IIFAS Items 1, 3, 7, 10, 12, 15, and 16), breastfeeding in public (IIFAS Item 8), duration of breastfeeding (IIFAS Item 18), and the advantages of formula feeding (IIFAS Items 2, 11, 14, 17, and 19) may be indicative of the trends in public attitudes toward breastfeeding in the United States. In their analysis of changes in attitudes between 1999 and 2003, Li, Rock, and Grummer-Strawn (2007) found a significant increase in public perception that formula is “as good” as breastmilk and a trend toward decreased acceptability of breastfeeding in public. These issues were of particular concern to mothers who participated in a focus group study. Mothers wanted grandmothers to communicate that they valued breastfeeding as important and desirable. Mothers also needed grandmothers’ support for breastfeeding in public, which included feeling comfortable breastfeeding in front of extended family members (Grassley & Eschiti, 2008).

Study Limitations

This study has limitations that limit the generalizability of its findings. The sample size was small. The small representation of grandmothers who had not breastfed, the lack of randomization into the intervention and control groups, and the posttest-only design limit the conclusions that can be drawn from the study.

Implications for Perinatal Educators

Despite its limitations, this pilot study does provide some meaningful direction for perinatal education and future research. Perinatal educators are encouraged to explore the curriculum for A Grandmothers’ Tea, which can be accessed online (http://www.illinoisbreastfeeding.org). The grandmothers and mothers who attended the teas in our study appeared to enjoy their interactions with one another and with the class content.

The findings of this study have implications for perinatal educators. First, A Grandmothers’ Tea supports Action 2 of the Surgeon General’s Call to Action to Support Breastfeeding, which is to “develop programs to educate fathers and grandmothers about breastfeeding” (U.S. DHHS, 2011a, p. 39). The report recommends the development of various strategies to accommodate the breastfeeding mother’s extended network. The difficulty in recruiting grandmothers who did not breastfeed for our study suggests that these grandmothers may be reticent to attend an educational event explicitly about breastfeeding. Therefore, perinatal educators might embed content about breastfeeding into a class for expectant grandparents whose focus is new baby care.

The findings related to breastfeeding attitudes suggest that information related to the differences between human milk and formula milk and how these influence infant and lifelong health be included in perinatal education classes. Other topics for class dialogue might include grandmothers’ comfort with breastfeeding in public and extended breastfeeding beyond a year as well as identifying ways to be helpful to new mothers beyond feeding their infants a bottle. These grandmothers might also respond to participating in an online community where they can exchange information about breastfeeding and being a grandmother. Examples can be found in the literature of online communities for expectant parents (Kouri, Turunen, Tossavainen, & Saarikoski, 2006), mothers of infants and toddlers (Hall & Irvine, 2009), and new fathers (Hudson, Campbell-Grossman, Fleck, Elek, & Shipman, 2003). Whatever approach is taken, perinatal educators need to communicate to grandmothers that they value their experiences and perspectives. Grandmothers who did not breastfeed may feel defensive about their infant-feeding decisions because of the current emphasis on the health benefits of breastfeeding (Grassley & Eschiti, 2007). Perinatal educators can invite grandmothers to share their experiences and validate the cultural context in which these experiences took place. See Table 5 for more strategies for perinatal education.

TABLE 5. Educating and Involving Grandmothers in Breastfeeding Support.

Education
Create grandparenting classes where breastfeeding information is embedded among other topics such as car seat safety and infant/child CPR. Facilitate grandparenting network groups, focus groups, or online discussion groups through community organizations like churches or YMCAs and include breastfeeding as a topic of discussion. Educate grandparents along with parents about breastfeeding basics, pumping, and storage of expressed breastmilk during the postpartum hospital stay.
Involvement and Support
Encourage dialogue between grandmothers and daughters about infant-feeding choices both past and present. Encourage grandmothers to share their stories regarding their own infant-feeding choices. Acknowledge grandmothers’ concerns and fears regarding breastfeeding. Encourage grandmothers and daughters to attend prenatal care visits and pediatric visits together.

Recommendations for Future Research

Further research is indicated. A randomized two-group pretest/posttest design to evaluate the intervention with a larger and more diverse sample size might yield more meaningful results. In this study, most of the grandmothers attended with their daughters or daughters-in-law, which did not take into account the potential complexity of mother–daughter relationships. Some daughters may be more open to help from their mothers than from others; some grandmothers may have difficulty honoring their children’s choices. Therefore, another study could be conducted using a series of two meetings—one where grandmothers attend on their own and then a second meeting for the expectant family that might include the father, mother, and grandparents so that grandparents and parents receive the same information about breastfeeding.

Grandmothers’ perceptions of the support they offered new mothers after attending A Grandmothers’ Tea could be explored. Using dimensions of social support identified by House (1981), grandmothers could be interviewed or surveyed about the ways they offered praise and encouragement (appraisal and emotional support), correct information (informational support), and help with household chores or managing visitors (instrumental support). Mothers’ perceptions of grandmothers’ breastfeeding support after attending an educational intervention such as A Grandmothers’ Tea could be investigated. Exploration of grandmothers’ breastfeeding attitudes and how their attitudes influence grandmothers’ support is needed in order to plan strategies that address their beliefs about breastfeeding, particularly grandmothers who did not breastfeed. This exploration could begin with a mixed method study that combines surveying grandmothers about their breastfeeding attitudes, using the IIFAS, with qualitative interviews about the grandmothers’ perceptions of breastfeeding.

Changing grandmothers’ attitudes about breastfeeding extends beyond providing them with information.

CONCLUSIONS

Grandmothers are an important source of support to new mothers. They may benefit from educational interventions about breastfeeding that have been designed for them. From this study, it appears that changing grandmothers’ attitudes about breastfeeding extends beyond providing them with information. Attitudes about breastfeeding appear to be influenced by grandmothers’ experiences with breastfeeding. Further study is needed to understand the infant-feeding experiences and perceptions of breastfeeding of grandmothers who did not breastfeed in order to plan innovative approaches to influencing their attitudes and facilitating their knowledge and support.

Biography

JANE S. GRASSLEY is an associate professor in the School of Nursing at Boise State University in Boise, Idaho. BECKY S. SPENCER is employed by the University of Kansas Medical Center in Kansas City, Kansas. BECKY LAW is the manager of childbirth education and lactation at Texas Health Harris Methodist Hospital in Forth Worth, Texas.