The Influence of Social Networks and Norms on Breastfeeding in African American and Caucasian Mothers: A Qualitative Study

Abstract

Background: Social networks and subjective norms (individuals' perceptions of what other people think) can be influential in decision-making. Although there are data about the importance of support in initiation and duration of breastfeeding, no studies have explored the influence of women's social networks and the norms within those networks on breastfeeding.

Research Aim: To investigate, through qualitative methods, the influence of mothers' social networks and subjective norms, both within and outside of her network, with regard to breastfeeding practices.

Materials and Methods: Twenty-eight mothers participated in focus groups or individual interviews. Probing questions concerning breastfeeding intent, initiation, continuation, and support with regard to social networks and subjective norms were asked. Themes were developed in an iterative manner from coded data. Matrix coding queries assessed patterns in the data and compared quotes based on the respondents' race and social network type.

Results: General themes that emerged were the importance of breastfeeding experience within one's social network, the influence of the infant's father, handling disagreement within one's network, and the effects of social norms that exist outside of one's network. Mothers described support for breastfeeding from network members as especially important when breastfeeding was not the norm within the network. There were no differences in themes by race or social network type.

Conclusion: Breastfeeding behavior is influenced by a mother's social network, regardless of her race or social network type. Even when breastfeeding is not normative within one's social network, by relying on one network member to support them, mothers may be able to resist the opposing norms of their social network. Since breastfeeding is known to be beneficial to infants and mothers, education or interventions to improve breastfeeding rates may be more effective if they include individual network members who can provide strong support to new mothers.

Introduction

Breast milk is well established as the best source of infant nutrition with benefits, including associations with increased immunity, higher cognition, and a lower risk of infant mortality, including sudden infant death syndrome (SIDS).¹ The protective effect of breastfeeding against SIDS increases with duration and exclusivity of breast milk feeding.^2–4 Recent data from the Centers for Disease Control and Prevention (CDC) indicate that in 2013, 81.1% of mothers initiated breastfeeding, 51.8% continued breastfeeding for 6 months, and 30.7% continued throughout the 1st year. The CDC also reports that 60% of mothers stop breastfeeding sooner than they want to wean.⁵ Barriers to breastfeeding include the mode of delivery,⁶ return to work,^7,8 and lack of prenatal breastfeeding education.⁹

Social networks describe the structure of one's social interactions and personal relationships.¹⁰ Individual's social network may comprise immediate and extended family members, friends, coworkers, and/or health professionals. These individuals can strongly influence one's decisions regarding breastfeeding. A study of first-time African American (AA) mothers showed that support from family members, friends, public health nurses, and church members impacted the decision to initiate, continue, or stop breastfeeding.¹¹ Thus, when trying to improve breastfeeding rates, it is important to understand these social networks.

We have found that there are two types of social networks for mothers of young infants—exclusive networks and expansive networks. Exclusive networks are more restricted and largely comprised kin, whereas expansive networks include friends, colleagues, and others in addition to kin.¹²

Social norms are the behaviors that members within a group (i.e., the social network) perceive to be normal or acceptable.^13,14 Although the norms within a social network are often established by the practices and beliefs of the majority of individuals in the network, they can also be established by the stated opinions of one or two more influential members, whose judgment dictates what others believe is acceptable. Individual network members often adhere to these norms to avoid social stigma.

Although breastfeeding is a personal experience, the decisions to initiate and continue breastfeeding are guided by one's norms,¹³ and influenced by the explicit or implicit opinions of others in one's social network regarding the pros and cons of breastfeeding and the optimal duration of breastfeeding.¹⁵ The influence of these norms varies by individual. For instance, a first-time mother may be more influenced by a norm than a multiparous mother who has previous experience with either breast or formula feeding.¹⁶

Given the importance of breastfeeding on infant and maternal health, we conducted a qualitative study of AA and Caucasian mothers to better understand mothers' perceptions of and reactions to the norms pertaining to breastfeeding, both within and outside of their social networks, and how these influence breastfeeding decisions.

Materials and Methods

Design

We analyzed qualitative data from AA and Caucasian mothers regarding their social networks, breastfeeding norms inside and outside their social networks, and the influence of these networks and norms on their decisions regarding breastfeeding initiation, continuation, and cessation. We used both focus group interviews and individual in-depth semistructured interviews to accommodate more mothers' schedules (mothers who could not participate in focus groups could participate in individual interviews). In addition, the two interview formats can be used to obtain a wide range of possible responses. Participants who might be reticent in one-on-one interviews may be more likely to participate in a group of people with similar backgrounds¹⁷; however, participants may be more likely to discuss socially sensitive topics in individual interviews.¹⁸ This study was approved by the institutional review boards of Children's National Medical Center and the University of Virginia.

Sample and setting

Custodial mothers of healthy term infants living in the metropolitan Washington, DC, area were recruited from a birth hospital and through respondent-driven sampling to participate in a larger quantitative survey about their personal social networks if they were English-speaking, AA or Caucasian, >18 years of age, and their infants were full term (>36 weeks gestation) and did not have medical conditions requiring subspecialty care. The goal was to recruit two-thirds AA and one-third Caucasian women to approximate the population of Washington, DC, as a whole. Each mother signed written informed consent upon enrollment. From this sample, we selected a subsample¹⁹ whom we predicted, based on their child's age, their race and their parity, would have a broad range of attitudes and opinions, to participate in focus groups or individual interviews. Each qualitative interview participant signed a separate written informed consent before the interview.

Data collection

All focus groups and individual interviews were conducted between July 2016 and January 2018. Focus groups were stratified by race and parity (primiparous or multiparous), as homogeneity of group participants has been shown to increase the comfort level of participants, making them more willing to share their thoughts and opinions.²⁰ All authors worked together to develop interview questions. The same interview guide was used for both interview formats, and questions were modified iteratively as qualitative data analysis proceeded. All interviews were conducted by trained facilitators (R.O., A.M.). In both interview formats participants were first asked broad open-ended questions (e.g., Who gave you advice about how to feed your baby?), which were then followed up by more specific probing questions (e.g., Did you feel pressured to breastfeed or formula feed?) to clarify responses. Focus group interviews averaged 2 hours in duration, and individual interviews averaged 90 minutes in duration. Each focus group and individual interview participant received a $75 gift card for their time.

Data analysis

All qualitative interviews were video- and audio-recorded and transcribed by a HIPAA-compliant transcription company. To maximize accuracy and eliminate bias from the transcription process we used a multistep process to review the interview transcripts. After initial transcription, the video- and audio-recordings and transcript of each interview were simultaneously reviewed by an author (R.O.) to ensure accuracy. All discrepancies in the transcription were reviewed by additional authors who listened to the recordings to reach consensus.

Once finalized, we analyzed transcripts line by line, using standard qualitative analytic techniques. Qualitative analysis software (NVivo 11 plus²¹) was used to organize, sort, and code the data (quotations). We developed and revised themes in an iterative manner, as patterns within data became more apparent.²² Authors met on a regular basis to review the emerging themes and patterns and to come to consensus on the major themes.

The two interview formats (individual and focus group interviews) were initially analyzed separately, and then compared to ensure thematic consensus of both formats. Matrix coding queries were also conducted to assess patterns in the data and compare quotes based on the respondents' race and social network type. We used concurrent triangulation, or the use of multiple sources for verification of findings,²³ of the focus group interviews and the individual interviews to corroborate findings.²⁴ In addition, we confirmed findings by presenting to physicians and maternal and child health care professionals for peer review and feedback.

Results

We conducted eight focus groups (median 3.5 participants, range 2–6 participants) and two individual interviews with 28 mothers, and reached thematic saturation. Participant demographics are described in Table 1 and were similar to the demographics of the larger study sample. At the time of the interview, the mean maternal age was 30.4 years (range 20–44 years), 71.4% of the mothers were AA, and more than half of the mothers were primiparous. More than one-third (39.3%) of mothers reported exclusive breastfeeding, whereas 21.4% reported partial breastfeeding. Social network types were characterized as exclusive for 18 women, and expansive for 10 women.

Table 1.

Characteristics of Participants (n = 28)

	n (%)
Age: mean 30.4, range 20–44, years
18–24	5 (17.9)
25–29	10 (35.7)
30–34	5 (17.9)
≥35	8 (28.6)
Race/ethnicity
Black/African American	20 (71.4)
Caucasian	8 (28.6)
Marital status
Married	17 (60.7)
Never married	10 (35.7)
Separated/divorced	1 (3.6)
Number of children
1	15 (53.6)
2 or more	13 (46.4)
Infant gender
Male	18 (64.3)
Female	10 (35.7)
Breastfeeding
Breastfeeding exclusively at the time of focus group	11 (39.3)
Breastfeeding partially at the time of focus group	6 (21.4)
Not breastfeeding at the time of focus group	11 (39.3)
Social network type
Exclusive	18 (64.3)
Expansive	10 (35.7)

Central themes

The central themes that emerged regarding social networks, social norms, and breastfeeding were (1) importance of breastfeeding experience within one's social network, (2) influence of infant's father on breastfeeding, (3) handling disagreement within one's network regarding breastfeeding norms, and (4) effect of social norms that exist outside of one's network. Because a matrix coding query to assess any differences in themes by race or social network found that themes were consistent in all interviews, we did not stratify results further. These themes, with illustrative quotes (Q), are discussed as follows. Information about the speaker's race, social network type, and breastfeeding status are noted for each quote.

Importance of breastfeeding experience within one's social network

Mothers experienced varying levels of support from their social networks (Table 2). Many mothers said they wanted to breastfeed because it was normative (e.g., everyone had breastfed) in their social network (Q1, Q2) and they felt network members were supportive of and encouraged breastfeeding. They often pointed to the baby's grandmother, even if she herself had not breastfed (Q3), or friends (Q4, Q5) who had experience raising their own children, as the most important sources of support.

Table 2.

Importance of Breastfeeding Experience Within One's Network

Q1	“Yeah, I mean, my sisters did it. I don't know that I would have felt as strongly had my sisters not nursed.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q2	“I didn't really know anything. I just knew my mom did it. My sisters did it. Everybody did that…That was pretty much all I really knew… My mom nursed 14 kids.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q3	“And I was bottle fed and my mom had three kids and she said she tried and tried. She was like, ‘You're just so lucky.’ So, my mom was basically my biggest supporter, like, ‘Just keep breastfeeding. Keep breastfeeding.’” (AA, exclusive social network, exclusively breastfeeding)
Q4	“We also had a family friend who had 6 or 7 children, and she nursed them all. She was also a doula or something as well, and she would come over my house and help me out and show me.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q5	“I had a couple of friends who; like one friend who had a kid a year older than our kid and so I talked to her for advice and then I had two friends from my mom's group who were breastfeeding at the same time, one who was also trained to be a lactation consultant so I probably asked her for advice a lot also.” (Caucasian, exclusive social network, partially breastfeeding)
Q6	“I called my mom one time and she said, ‘That was like 30 years ago, I don't remember all that stuff.’ She's like, ‘Call your sister.’ So I did talk to my sister, but also that woman that came over our house who was a family friend…helped me really the most because she could be there. And it wasn't just over the phone. So that was the most helpful. But also, I did talk to my sister when I had like mastitis or different things.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q7	“Actually most of my good friends around here breastfed and were totally supportive. But I was formula fed, and my mom's like, ‘You can just give the kid formula. They're not going to die.’ And my best friend from home didn't breastfeed her kids and she was like, ‘They're fine.’… My network here is very much into breastfeeding but my mom and my best friend from home were like, ‘Why are you stressing yourself out?’” (Caucasian, exclusive social network, exclusively breastfeeding)
Q8	“And my mom, …she's just like, ‘Ew, boobies. Just put it in a bottle.’ So, my husband is mainly the rock of my support.” (AA, expansive social network, exclusively breastfeeding)

AA, African American.

The degree of social network support mothers felt when they experienced difficulty breastfeeding varied widely and was often dependent on the prior breastfeeding experience of both individual members and the network as a whole. Breastfeeding mothers reported reaching out to network members when they were struggling with breastfeeding. In networks supportive of breastfeeding, women were often referred to network members with additional or more recent experience for help in solving problems (Q6), even if those women were more peripheral in the network.

Some mothers described different supports from network members who had breastfed their children than from those who had not, with network members who had formula-fed believing that breastfeeding was not important (Q7). Some women in networks, where breastfeeding was not normative, were able to overcome the negative norms with the support from a key network member, such as the infant's father (Q8).

Influence of infant's father on breastfeeding

Many mothers agreed their baby's father was very supportive of breastfeeding (Table 3). Some fathers demonstrated their support by attending to the mother's needs as she was breastfeeding (Q9). Other fathers assisted with bottle feeds (formula or breast milk) to help with the mother's transition to work (Q10), so that the mother could sleep (Q11), or to give the mother respite from nursing and breast pain (Q12). Particularly when breastfeeding was not the norm, mothers emphasized that the support of their husbands allowed them to get through the challenges of breastfeeding (Q13, Q14).

Table 3.

Influence of Infant's Father on Breastfeeding

Q9	“My husband was great in terms of like helping to position the baby when you're first trying to figure it out and you can't get comfortable. He would bring me snacks or water or the things that you need when your hands are otherwise occupied.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q10	“…when I went back to work, my husband [was] on parental leave for 3 months so he was going to be the primary caretaker. We want[ed] to make sure he would be able to feed our son while I was at work. And so, we were doing bottle once a day and then breast the rest of the time.” (AA, exclusive social network, exclusively breastfeeding)
Q11	“[The father] did the night routine so I can get a head start sleeping. That way, when [it was] 3 a.m. and [the baby] wanted to breastfeed, I'd just get up at 3 a.m. And I've had a lot of sleep, so I was chipper and perky.” (AA, exclusive social network, partially breastfeeding)
Q12	“There was one point when I went to a lactation consultant because I was like having a lot of pain when I breastfed the baby, and they told me to pump just for two days. And I was trying to do that, and he would help with bottle feeding the baby.” (AA, exclusive social network, partially breastfeeding)
Q13	“I recently found out my husband's side didn't either, they were formula fed. So this was new to both families. It's almost like a culture shock. And I was skeptical about it at first because my boob's a little A cup, so I was like, ‘I'm going to try, but I doubt I'll be successful.’… And my husband was very supportive.” (AA, expansive social network, exclusively breastfeeding)
Q14	“I was about to give up. But my husband reinforcing the benefit of it and the fact that I was enjoying it when it was successful, that's what kept me going. But it was very hard.” (AA, expansive social network, exclusively breastfeeding)
Q15	“She wanted to continue, but her husband was selfish too… ‘Those boobies aren't for milk, those boobies are for me.’” (AA, expansive social network, exclusively breastfeeding)
Q16	“Because he didn't want me to have a greater bond with the baby than him and he didn't want the baby to have to be so reliant on me.” (AA, expansive social network, partially breastfeeding)

AA, African American.

In contrast, several mothers described the additional challenges faced when the baby's father was opposed to breastfeeding. One mother described the challenge when the father of a friend's baby opposed breastfeeding because he considered the breast a sexual organ (Q15). Another described her partner's concern that breastfeeding would impair his ability to bond with the infant (Q16).

Handling disagreement with one's network regarding breastfeeding norms

Several mothers reported that they disagreed with network members about whether or not to breastfeed (Table 4). Some mothers wanted to breastfeed despite network opposition and negative norms toward breastfeeding (Q17, Q18), and some described being determined to continue to breastfeed just to challenge the norm (Q19). Conversely, there were some mothers for whom the norm within the network was to breastfeed, but they had no desire to conform to the norm (Q20). When the norm was to breastfeed, some mothers described feeling pressured to breastfeed (Q21, Q22) and some felt strongly that they would be judged if they did not breastfeed or would be subjected to social shaming if breastfeeding was unsuccessful (Q23, Q24). However, other mothers were confident that their personal network would be supportive of their effort even if they were unable to nurse or had to stop sooner than intended (Q25, Q26).

Table 4.

Handling Disagreement with One's Network Regarding Breastfeeding Norms

Q17	“I'm the first person in my family to do a lot of things, and breastfeeding is one of them, so everyone in my family is like, ‘Put that thing back in there.’” (AA, expansive social network, exclusively breastfeeding)
Q18	“I will say that, I tell my boyfriend's mom, because she's older than my mom. She's like in her 60s. She wasn't like breastfeed like that. Their side of the family, like her and his sister, they were like, she was making it seem like I couldn't continue breastfeeding for as long as I did or longer, or like it's foreign or something. Like, ‘Breastfeeding? How is the baby going to eat and be full?’ …It was like breastfeeding …was weird…But for some reason to me, in my mind, I thought they were thinking that breast milk is foreign or is it going to fill the baby up enough. I'm like, it's the naturalest thing to breastfeed. I don't know. I got that kind of pushback but that was it.” (AA, exclusive social network, partially breastfeeding)
Q19	“It was kind of frustrating, because I would go home and sometimes with my boyfriend and I'm like, ‘Why does your mom act like breastfeeding is so weird or something?’ Like, I can't continue to do it once I go back to work, which I did. I did it for maybe like a month-and-a-half, and I'm back to work. But more of it, doing it for that long was to show her like, ‘See, I'm breastfeeding longer than I said I was.’ So that made me continue to push to do it…” (AA, exclusive social network, partially breastfeeding)
Q20	“[My aunt] used to be a nurse. She was just like it's best for the baby. I was like, ‘I don't want to do it.’” (AA, exclusive social network, not breastfeeding)
Q21	“My son's father, he was like ‘you better not give him that formula.’” (AA, exclusive social network, partially breastfeeding)
Q22	“For the baby now, everybody [supports breastfeeding]. But it's more pressure because my mother-in-law, she'll come and lift my shirt up for the baby. She will. It irritates me. ‘He hungry, he hungry, he hungry.’ And I'm like, ‘No, no, no, no.’… I had to explain to her even if I put the milk in a bottle, it's still breast milk. ‘No, no, he need the bond, that's your bonding.’ I'm like,‘That's not the only way the baby can bond.’ Because other babies, they don't breastfeed, their mothers still bond with the baby. But for me it's more pressure…. Everybody wants me to breastfeed. Me, I want to breastfeed him too, but I don't need no one helping me… So yeah, now everybody is breast, breast, breast, breast, breast, breast, breast, breast, breast.” (AA, expansive social network, exclusively breastfeeding)
Q23	“I feel like they put so much emphasis on the breastfeeding, it's like putting mothers who bottle feed to shame and making them feel bad about themselves.” (AA, exclusive social network, not breastfeeding)
Q24	“I always felt like if I didn't get through it, then would other people be judging me?” (Caucasian, exclusive social network, exclusively breastfeeding)
Q25	“I feel like the society has set up women who they shame [for] bottle feeding. I think that's an awful thing because you don't know that mother who can't breastfeed. You don't know why she's choosing or if she physically cannot produce…While I agree with breastfeeding, I feel like they put so much emphasis on the breastfeeding, it's like putting mothers who bottle feed to shame and making them feel bad about themselves. And I don't know if this could contribute to postpartum but that would stress me out. That would make me depressed if I couldn't produce enough for my child.” (AA, exclusive social network, exclusively breastfeeding)
Q26	“The three sisters-in-law, they were like, ‘Look, if it doesn't work, that's cool.’ And I think that they had that attitude because it didn't work for them, and their babies were all on formula. And so I feel like I had maybe more support if breastfeeding doesn't work. ‘That's fine. It didn't work for us and we're cool with that.’” (Caucasian, exclusive social network, exclusively breastfeeding)

AA, African American.

Effect of social norms that exist outside of one's network

Mothers described social norms regarding infant feeding outside of their personal social networks (Table 5). These norms could be categorized as “general public norms” and “workplace norms.” For the former, a large proportion of mothers felt that there was social stigma against breastfeeding in public, and that this could make them and/or their companions uneasy (Q27). For the latter, the challenges mothers felt in the workplace were largely dependent on their employers' social norms around breastfeeding. Some mothers, in anticipation of the difficulty of pumping breast milk at work, stopped breastfeeding or pumped additional breast milk before returning to work (Q28). Other mothers felt frustrated about inadequate breaks for pumping breast milk during the workday (Q29). On the contrary though, several mothers felt very supported in the workplace especially if their bosses or coworkers were also parents of young children (Q30, Q31).

Table 5.

Effect of Social Norms That Exist Outside of One's Network

Q27	“People look at me all the time. Because I used to maybe just have on a sweater and I would just cover it but you can still see my breast and I was just like I had no—my fiancé was like, ‘Put it away.’ He would always try and cover me and something like that.” (AA, exclusive social network, partially breastfeeding)
Q28	“I don't physically breastfeed anymore because my job is just too crazy but I pump[ed] so much that I actually have breastmilk still saved.” (AA, exclusive social network, partially breastfeeding)
Q29	“And they [work supervisors] asked me to stop pumping at nine months [because] I asked for two 20-minute breaks a day. So I stopped pumping at about ten months…I taught elementary school, so I would be with students until 1:30. From 8:00 to 1:30 I was with the students nonstop. I asked for a break for someone to cover my lunch…and just no one would show up anymore. I had days where I come home just soaked and in so much pain.” (Caucasian, exclusive social network, exclusively breastfeeding)
Q30	“My office was great. I mean, I had to make a lactation room out of another room, because there had never been anybody else there who had pumped before. My office is like super young, and most of the people with kids were guys. So I had to do it, but everyone was like, ‘That's great. Sure. Go for it,’ and like helped me change the room in the way I needed to.” (Caucasian, exclusive social network, partially breastfeeding)
Q31	“My boss is a guy but he has four kids and his wife breastfed all of them so he was like, ‘You should get yourself a hospital-grade pump,’ like he was super supportive.” (Caucasian, exclusive social network, partially breastfeeding)

AA, African American.

Discussion

Although prior studies have looked at women's motivation to breastfeed and the importance of social support in continuing breastfeeding,^11,25 no other qualitative study has explored how a mother's social network and the norms inside and outside of her network influence breastfeeding. Our findings indicate that regardless of race or social network type, breastfeeding experience within the social network, fathers' opinions about breastfeeding, mothers' comfort with handling disagreement within her network about breastfeeding, and the social norms that exist outside of the network impact maternal breastfeeding decisions and build upon the prior work.

As expected, mothers in our sample were affected by the norms of their own social networks. Some mothers felt pressured to breastfeed by a variety of network members, including health professionals or relatives who were health professionals, family members who had breastfed and who believed that breastfeeding was the norm, and partners who were opposed to formula feeding. Other mothers cited social network pressures to not breastfeed, particularly from women who had not breastfed their own children and partners who were concerned about bonding with the infant or saw the breast as a sexual symbol. As expected, these opinions consistently affected mothers' decisions to initiate or continue breastfeeding.

Also consistent with prior studies indicating that matriarchal and partner influence play a major role in the initiation and continuation of breastfeeding,^9,26 mothers in our study, in addition to relying on friends with prior childrearing experience, frequently cited their infants' fathers and grandmothers as most often influencing their decision to breastfeed. Interestingly though, for mothers in our study who wanted to breastfeed, support from these specific individuals was not always critical.

As important as social norms are in the decision to initiate and continue breastfeeding, several women described their capacity to defy their social network's norms. In some cases mothers had to strongly resist familial pressures to formula feed. Others though, reported that network members were supportive of changing the norm and encouraged them to breastfeed even if they had not breastfed themselves.

In many cases, to resist negative social norms, women had to look beyond their primary social supports. For example, although many women primarily sought advice on most infant-related concerns from their own mothers and relatives, when they were not supportive of breastfeeding, mothers who wanted to breastfeed looked to more distant network members for emotional or informational support specifically regarding breastfeeding.

This suggests that although close relative supports are important, if women are motivated to breastfeed, those outside a mother's inner circle, such as lactation consultants and peer educators, may be able to fill voids when the social norm is to not breastfeed. This also suggests that when one woman in a social network successfully breastfeeds, she is likely to be sought out as the support for other women in the same network. Ultimately, this has the promise of altering the norm of the entire network in favor of breastfeeding.

The importance of network supports in initiating and continuing breastfeeding has been well documented,^9,26 but prior studies have not looked at mother's perception of the social implications of not breastfeeding. With the advent of Baby Friendly^® hospitals and the recent emphasis on exclusive breastfeeding in birth hospitals, some women cited feeling social pressures to breastfeed and concern that if they struggled they would be perceived as a failure.

Both breastfeeding and nonbreastfeeding mothers experience shame through feelings of fear, humiliation, inferiority, and inadequacy.²⁷ Consistent with this, some mothers in our study cited feeling subject to social shaming if they failed to breastfeed. Interestingly though, other mothers acknowledged those pressures and yet still felt that if their attempts to breastfeed were unsuccessful, their own network would be accepting of their decision, citing previous support for women who had opted to formula feed after difficulties with breastfeeding. Although promoting breastfeeding to network members can lead to higher breastfeeding rates, if women feel shamed by the network, it may not only affect their decision to either initiate or continue breastfeeding, but also may make them less likely to rely on network support in other important realms, including infant safety.

Consistent with previous research,^28,29 we found that social norms outside of a woman's personal social network influenced her decision to continue breastfeeding once she returned to work. Most important were the established norms regarding pumping breast milk in the workplace. When the workplaces had prior experience with women who pumped at work, mothers returning to work did not seem to view pumping as a barrier to continued breastfeeding. Similarly, even women who were the first employees in their company to pump felt accommodated and supported in the workplace if they had coworkers with personal or family experience with breastfeeding. Women who worked in places where pumping breast milk was not the norm reported the stress of finding time and a private location to pump as reasons for ceasing exclusive breastfeeding. Based on this, changes in workplace social norms regarding breastfeeding are likely to positively impact the number of women who continue to breastfeed after returning to work.

It is notable that based on our data, women with both exclusive and expansive social networks had similar experiences. Although one might expect those with expansive networks to find it easier to identify a peripheral network member for support, or to defy network norms, the fact that a single individual could provide adequate support seems to have negated these network differences. For example, a woman with an exclusive network, whose mother and sister were opposed to breastfeeding, may have continued breastfeeding because her husband supported it or vice versa. Similarly, those with exclusive networks reported looking outside their immediate network for support, specifically with breastfeeding. This is further evidence that even in close-knit families without a strong history of breastfeeding, new mothers can successfully breastfeed if given the appropriate encouragement as they are often willing to expand their networks specifically for this topic.

Limitations

We acknowledge that this study has several limitations. Although our study population included women with a wide spectrum of feeding practices, it was limited to those who self-identified as AA or Caucasian and who were from a single geographic region. In addition, qualitative research, although it can provide insight into a wide range of opinions, cannot be used to determine prevalence of any one viewpoint. Thus, although we reached thematic saturation, these results may not be generalizable to other groups or geographic regions. However, our findings are consistent with other qualitative studies.^11,30,31 Nonetheless, further study in other geographic and racial/ethnic groups will be important to determine if the influence of social networks and norms is consistent.

Conclusions

Social networks and norms play a major role in influencing breastfeeding behavior among mothers of newborn infants and can have a constructive or destructive influence on the mother's decision to initiate or continue breastfeeding. However, as important as social norms are in the decision to initiate and continue breastfeeding, by relying on one network member to support them, mothers were often able to resist the opposing norms of their social network and sustain breastfeeding efforts. Any evidence-based recommendations or education regarding breastfeeding should not be limited to the mother alone but should also include individual network members who can provide strong support.

Disclosure Statement

No competing financial interests exist.

Funding Information

This project was supported by the National Institute for Minority Health and Health Disparities 1R01MD007702. The study sponsor had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. The authors have no other funding sources.