Relatively speaking? Partners' and family members’ views and experiences of supporting breastfeeding: a systematic review of qualitative evidence

Abstract

This review aimed to synthesize qualitative evidence of views and experiences of partners and other family members who provided breastfeeding support for a relative. The Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence was followed. Seven databases: CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Maternal and Infant Care, and Web of Science were searched. Partners and other family members (e.g. grandmothers, siblings) of women in any countries were included. Included papers were critically appraised. The JBI meta-aggregative approach was used to analyze data and form synthesized findings. Seventy-six papers from 74 studies were included. Five synthesized findings were: (i) spectrum of family members' breastfeeding knowledge, experiences and roles; (ii) the complexity of infant feeding decision making; (iii) the controversy of breastfeeding in front of others; (iv) impact of breastfeeding on family; and (v) it takes more than just family members: support for family members. Partners' and family members’ views and experiences of breastfeeding support reflected multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors of the support they provided (or not). Healthcare professionals should engage them in breastfeeding discussions with the woman, and offer tailored and practical guidance relevant to help them to appropriately support the woman.

This article is part of the theme issue ‘Multidisciplinary perspectives on social support and maternal–child health’.

1. Introduction

Exclusive breastfeeding (EBF) for the first six months of an infant's life is recommended by the World Health Organization (WHO) [1] owing to its numerous health benefits to the infant and mother [2]. Despite many advantages that breastfeeding offers, breastfeeding rates have remained static with only 44% of infants under six months old worldwide exclusively breastfed in 2019 [3].

A previous review, published a decade ago, reported the importance of breastfeeding support from a range of key supporters for breastfeeding women, including family members, friends, community members, employers, and healthcare professionals (HCPs) [4]. Family members, particularly women's partners and infants' grandmothers, are highly influential in women's decisions to initiate and continue breastfeeding [5,6], mainly through providing social support which is vital to functioning relationships, involving emotional, instrumental, informational, and appraisal behaviours [7]. Myer et al. [8] in this issue contributed to the understanding of the impact of types of support on breastfeeding by providing evidence on associations between practical/emotional support and breastfeeding duration. However, there has been little insight into the family members' own perspectives on breastfeeding. As family members are known to influence breastfeeding practices, a comprehensive understanding of family members' views on breastfeeding and supporting breastfeeding is likely to be key in understanding how to improve breastfeeding outcomes.

Previous reviews have overlooked the holistic synthesis of qualitative evidence regarding the wider family, mindful of family structures which may extend beyond the ‘traditional’ nuclear families or biological families (for example, stepfamilies). As reviewed in Sear [9] in this issue, academic focus on the ‘traditional family’ potentially hampers attempts to understand and improve maternal and child health. Therefore, this review investigated partners' (any sex/gender) and wider family members’ (for example, grandparents, siblings, aunts/uncles, in-laws) perspectives and experiences of supporting breastfeeding.

2. Methods

This review was guided by the processes and principles recommended by the Joanna Briggs Institute (JBI) systematic reviews of qualitative evidence [10]. The review protocol was registered on PROSPERO (registration number: CRD42018093889). The review questions were as follows.

Primary questions:

• — what are partners' and family members’ views, including their attitudes and knowledge of breastfeeding?
• — what are partners' and family members’ experiences and perspectives of providing breastfeeding support to women? and
• — what are facilitators and barriers for partners and family members to support women to breastfeed?

Secondary question:

• — what are partners' and family members’ information and support needs to enable them to facilitate breastfeeding?

(a). Inclusion criteria

(i). Phenomenon of interest

Studies which investigated the perspectives of partners and family members surrounding breastfeeding and supporting breastfeeding were included. Literature that reported the perspectives of breastmilk donation, breast milk banks, and complementary feeding which focused on providing solid foods was excluded.

(ii). Types of participants

Studies were considered if they involved partners and family members who supported women in high, middle, and low-income countries as defined by the World Bank [11]. The definition of the family reflected a range of members (as defined by study authors), and could include partners of any sex or gender, grandparents, in-laws, relatives, aunts/uncles, nephew/niece, siblings, half-siblings, adopted siblings, stepsiblings, etc. Studies that included infants with medical conditions such as human immunodeficiency virus, pre-term infants, neonates and infants in intensive care units were excluded.

(iii). Types of studies

Qualitative primary research and extractable qualitative data presented in mixed methods research were included. Studies using only quantitative approaches were excluded. Grey literature, reviews, graduate and postgraduate dissertations, policy papers, opinion papers, and guidelines were excluded. Included studies were limited to publications in English and in peer-reviewed journals from 1990, when the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding [12] was introduced, to January 2020.

(b). Search strategy

This review followed JBI's three-step search strategy [10]. An initial search was conducted on MEDLINE and CINAHL to analyze keywords in the title, abstract and headings used in the studies. Next, a systematic search using all identified keywords was conducted in April 2018 on the following seven databases: CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus, Maternal and Infant Care, and Web of Science. Finally, reference lists of included studies and relevant reviews were screened for relevant studies. The search was updated in January 2020. Electronic supplementary material, S1 shows an example of the search strategy.

(c). Data collection and quality assessment

Studies were assessed following predefined inclusion criteria and subjected to a title and abstract screen using EndNote software. Papers selected for retrieval of full text were assessed to ensure they met inclusion criteria by two reviewers (KMCL and KYCL) independently, and verified by Y-SC. Data were extracted using a data extraction form developed for this review. The JBI Critical Appraisal Checklist for Qualitative Research [10] was used to assess the methodological quality of included papers by Y-SC and SB independently (electronic supplementary material, S2). Any disagreements were resolved via discussion between the two reviewers.

(d). Data synthesis

The JBI's three-stage process of synthesizing data was used. First, individual papers' findings including themes and authors’ observations were extracted. Categories were developed from the findings across included papers based on their similarity in meaning. ‘Unsupported’ findings which could not be supported by a direct quotation from a participant were not included in the categories. Following this, a comprehensive set of synthesized findings were formed from categories.

(e). ConQual assessment

The confidence of evidence of synthesized findings was assessed using ConQual according to the JBI guidelines [10,13]. Papers were pre-ranked as ‘high’ for qualitative papers, ‘moderate’ and ‘low’. Dependability (the appropriateness of study conduct to meet the study aims) and credibility levels of each synthesized finding were assessed based on relevant papers and data included in each synthesized finding. Each paper was allocated a dependability score based on five questions (questions 2, 3, 4, 6, and 7) of the JBI Critical Appraisal Checklist (electronic supplementary material, S2). The inclusion of unequivocal, credible or unsupported findings was used to assess credibility. Following dependability and credibility assessment, each synthesized finding was presented with a final ConQual level (electronic supplementary material, S3).

3. Findings

The search produced a total of 76 papers [14–89] which met the inclusion criteria, of which 25 were identified from the update search in January 2020 (electronic supplementary material, S4). Among the 76 included papers, 74 studies were reported, with two papers presenting findings from the same study [79,80]. The other study included two papers [28,29] that reported on different aspects of the study.

Forty-two papers were from high-income countries (United Kingdom (UK, n = 17), United States of America (USA, n = 12), Canada (n = 4), Sweden (n = 3), Australia (n = 6)); nine from upper-middle income countries ((Indonesia (n = 1), Brazil (n = 5), Iran (n = 2), South Africa (n = 1)); 20 from low-middle income countries ((India (n = 1), Pakistan (n = 2), Kenya (n = 3), Nigeria (n = 3), Cameroon (n = 1), Senegal (n = 1), Cambodia (n = 1), Zambia (n = 1), Tanzania (n = 4), Nepal (n = 2), Myanmar (n = 1)); and five from low-income countries ((Malawi (n = 2), Democratic Republic of the Congo (n = 1), Haiti (n = 1), Rwanda (n = 1)). Forty-seven papers included the experiences of partners only, 12 with the infant's grandmothers only, 14 from partners and grandmothers, and three involving partners, grandmothers and other family members (electronic supplementary material, S5).

The quality assessment found the included papers were of moderate to high quality. Five papers [20,42,54,65,71] scored 10/10. Other papers scored between 5 and 9. ‘Influence of the researcher’ and ‘the researcher's cultural or theoretical statements' were not described in several papers (electronic supplementary material, S2). The ConQual process [10,13] was followed to evaluate confidence in the level of evidence for each synthesized finding. The final ConQual score for the synthesized finding ‘Impact of breastfeeding on family’ was ‘low’, and for the other four synthesized findings was ‘moderate’ (electronic supplementary material, S3). Eighteen categories were developed from the findings to form five synthesized findings; table 1). Presented below are the synthesized finding and their categories. Synthesized findings, categories and supporting quotes are shown in the electronic supplementary material, S6.

Table 1.

Synthesized findings and categories.

synthesized findings	categories
spectrum of family members' breastfeeding knowledge, experiences and roles	mixed level of breastfeeding knowledge and understanding of breastfeeding benefits
	views on exclusive breastfeeding and insufficient breast milk
	views on colostrum
	influences of cultures and religions
	unveiling the reality of breastfeeding
	roles of partners and family members
the complexity of infant feeding decision making	breastfeeding is predominantly the woman's decision
	reconsidering breastfeeding decision/behaviour
	women under pressure to breastfeed
the controversy of breastfeeding in front of others	concerns with the sexualisation of breasts and privacy
	open for women to breastfeed in public
impact of breastfeeding on family	positive impact on couple and family relationships
	negative impact on couple and family relationships
	positive impact on parent–infant relationships
	negative impact on parent–infant relationships
it takes more than just family members: support for family members	access to and (un)helpfulness of support for family members
	infant feeding advice received from healthcare professionals
	need for tailored support, information, and education

(a). Synthesized finding 1: spectrum of family members' breastfeeding knowledge, experiences and roles

There was a broad spectrum of family members’ breastfeeding knowledge, experiences and roles with mixed views on breastfeeding benefits, EBF, insufficient breast milk, and colostrum. Cultures and religions influenced views on breastfeeding, with various roles played by family members in the infant feeding journey.

(i). Mixed level of breastfeeding knowledge and understanding of breastfeeding benefits

Family members had varied breastfeeding knowledge, although generally, family members held positive views of breastfeeding, such as it being ‘natural’, more beneficial than formula feeding, having benefits for the infant's and woman's health and immunity, good for mother–infant bonding and family planning, financially beneficial, and convenient, with some describing nutrients within breastmilk [18,21,23,25,27,28,30,32,36,38,40–43,46,50,56,59–62,64,65,67–74, 76,77,79–81,84,85,87,88]. Others thought formula feeding could cause behavioural concerns for the baby [64,72], and was for ‘the rich’ [87]. Few partners thought they were knowledgeable about breastfeeding [43,78], and many partners had limited knowledge on specific benefits and technical aspects of breastfeeding, and wanted to know more [25,63,84,88].

(ii). Views on exclusive breastfeeding and insufficient breast milk

In low-income settings, water or formula were offered to infants owing to the perceptions of insufficiency of EBF, related to a lack of money for good food for the woman to produce sufficient breastmilk, concerns of an increased risk of dehydration in hotter climates, and EBF viewed as a ‘western’ practice [14,17,33,48,57,60,67,69]. Contrastingly, in high-income settings, when insufficiency of EBF was discussed, this raised concerns about an infant's poor weight gain, and uncertainty over the quantity of milk the infant took. In some cases, family members had positive views on EBF including the frequency and duration of EBF [15,25,27,56,73,78,89].

(iii). Views on colostrum

Grandmothers from some South Asian countries described colostrum as ‘old milk’ which had been stored for a long time [44]. Nepalese grandmothers and partners, for example, thought colostrum was toxic to babies and should be discarded [50] which might not reflect breastfeeding women's views, while in other Nepalese communities, grandmothers believed colostrum was nourishing and thought only the first milk (khil) [54] should be discarded.

(iv). Influences of cultures and religions

Some partners and grandmothers specifically described breastfeeding as positive in their cultures, including in Bangladesh [60,68]: ‘Culturally it is a positive thing in terms of breastfeeding.’ (Partner; UK) [68, p. 390]. However, this was not universal, with one partner identified breastfeeding not being a common practice in his community [43]. In some African (Nigeria, Cameroon) and Asian cultures (Myanmar, Nepal), family members offered women-specific foods to aid breast milk quality and quantity, such as herbs, traditional medicines, teas, and soups [23,25,30,42,67,72,87]. Some partners and grandmothers such as those in Nigeria, Pakistan, African Americans in the USA, and white low-income men in Britain were concerned about the risk of disease (for example, tuberculosis and cancer) transmission via breastfeeding [23,40,72,87]. Religious views on breastfeeding were reported, such as referring to breastmilk as ‘God's gift’, with breastfeeding generally promoted in their religious practices/texts [44,62,64,72,87].

(v). Unveiling the reality of breastfeeding

Partners commonly presumed breastfeeding was ‘easy and natural’, but identified the reality of breastfeeding as a challenge [16,22,61,79,80]. They described breastfeeding challenges (cracked nipples, sleep disruption, lack of milk production, poor feeding/latching, unawareness of how frequent their baby would feed, time consumption) [16,43,61, 68,70,76,80,85], and emotional toll of breastfeeding on women [16,43,86], with partners grateful for women's commitment despite these challenges [16,63]. One grandmother in Wales described her concerns that negative experiences could deter her daughter from breastfeeding in the future [36].

(vi). Roles of partners and family members

Partners described that they provided practical, emotional, and technical support to women [16,22,25–28,35,43,46,47,50, 55,56,61,62,64,65,68,70,71,73,74,76,77,79,84,85]. Practical support included household chores, baby care, childcare for older children, and ensuring women ate well. Partners provided emotional support to the woman and/or their infants through finding other ways to bond with their baby by calming them, providing encouragement to the woman by offering praise and reassurance to continue to breastfeed, and alleviating feelings of women's loneliness by sitting with them when breastfeeding. Some partners found paternity/partner leave helpful to support the woman to breastfeed as they could care for older children [64]. Some partners could provide specific support, for example, on breastfeeding techniques (e.g. baby latching onto the breast) [28,77]. Work commitments and time constraints sometimes limited their ability to provide breastfeeding support [19,35,84].

Partners speculated on their role in contributing breastfeeding support. Some saw this as a shared responsibility but experienced their help being rejected or were unable to determine the woman's needs [22,35,62]. Partners believed it was a family member's duty to provide breastfeeding support [19,50,59,60,71], although some women's relatives discouraged breastfeeding because of their own negative experiences [49,63,73]. The same-sex female partners identified being open to co-breastfeeding and ensuring their breastfeeding partner's wellbeing [71]. Grandmothers considered they were key figures to support breastfeeding as they possessed greater knowledge and experience, and could share their knowledge with future generations [32,36,44,51,54,60,67,75, 83,84,89]. Inequality in the roles of parents during breastfeeding were described [71,74]. Some partners felt breastfeeding was solely the responsibility of the women [14,19,43,45, 55,62,64,71,73,79], a view which reflected religious and traditional gender role views that men should work and provide money, while their wife takes care of the children and house.

(b). Synthesized finding 2: the complexity of infant feeding decision making

Infant feeding decisions were complex for many families. Women were often the main decision maker but there was also pressure for women to breastfeed. Breastfeeding problems could result in families reconsidering and changing their breastfeeding decision.

(i). Breastfeeding is predominantly the woman's decision

Gender roles largely factored into infant feeding decision making with many partners believing this was not their role and was predominantly the woman's, as it was her body [18,19,22,24,26–28,38,43,59,63,64,68,71,81]. Many partners presumed their child would be breastfed [18,27,43, 61,63,71,80,81] and some partners had not discussed this with the woman [24,27,43,61]. Some grandmothers considered a woman's partner should have no say in infant feeding decision as it was a woman's choice to breastfeed or not [42]. Partners supported the woman's breastfeeding decisions [18,22,43,59,61,63,65,76,79] and some worked in partnership with the woman to make a joint decision [22,40,76]. Some grandmothers felt undermined when their breastfeeding advice was not enacted [60,75].

‘I don't think we [fathers] are entitled to [decide], to be quite honest. It's not our bodies.’ (Father; England) [22, p. 162]

(ii). Reconsidering breastfeeding decision/behaviour

Partners felt frustrated and helpless when the woman encountered breastfeeding problems, leading them to believe formula feeding was less problematic [80]. Some family members mentioned switching to formula feeding owing to breastfeeding challenges and inconvenience, including high demands on women, lack of sleep, unequal responsibility between partners and prioritizing a woman's wellbeing (e.g. stressed from unsuccessful breastfeeding) over breastfeeding [43,58,79,80]. Other reasons to switch to formula feeding included prioritizing infant health because of poor weight gain or weight loss [55,66,70,79,80], and women returning to paid employment [48,63,75]. In one study from Haiti, a natural disaster resulted in financial instability to afford nutritious food for women to produce breast milk [30]. Some family members preferred bottle feeding over breastfeeding as they could get involved and develop a stronger bond with the baby [29,35,46,58,61,71].

(iii). Women under pressure to breastfeed

There were examples of women under pressure to breastfeed from family members and/or HCPs. Partners in some cases pressured their breastfeeding partner to continue despite its challenges and the women wanting to stop [59,76]. In one study from Pakistan, a woman's sister-in-law who did not support breastfeeding pressured her relative to breast and bottle feed [64]. Some partners in one Swedish study discussed the pressure women received in the hospital to breastfeed [71].

‘I have always pushed it with her to. Even if she would want to stop I don't think I would just let her stop right away.’ (Father; Canada) [76, p. 117]

(c). Synthesized finding 3: the controversy of breastfeeding in front of others

Breastfeeding in front of others was controversial. Some family members were concerned about sexualization of breasts and protecting a woman's privacy, while others supported women breastfeeding in public.

(i). Concerns with the sexualisation of breasts and privacy

Partners identified the stigmatization associated with breastfeeding in public, and thought it should be avoided owing to the woman being uncomfortable with others potentially able to see her breasts [16,24,40,49,59,63,81]. Partners had concerns about the sexualisation of breasts, suggesting breastfeeding was a private action [16,40,60,63,74]. Some referred to a protective instinct for their partners and were only accepting of breastfeeding in public if women could do this discreetly [16,24,40,49,63,70,81]. Some grandmothers and partners felt breastfeeding was inappropriate in front of other children [40,63].

‘Some people can act very strangely if a woman breastfeeds in public,’ (Father; Ireland) [16, p. 173]

(ii). Open for women to breastfeed in public

Partners were aware of social issues related to breastfeeding in public, such as perceptions of breastfeeding as ‘arousing’ [77] and requiring ‘public nudity’ [65] but this did not deter partners from supporting women to breastfeed in public [77]. Some partners challenged those who thought breastfeeding in public was an issue [77] while others reported that they did not experience any issues with this, and that women should breastfeed in public for infants' benefits [74,86]. One partner from Britain felt that breastfeeding in public was subtle as not many people would note [40].

‘In a mall, I'm not going to let my kid go hungry just because someone's offended.’ (Rural, low-income father; USA) [77, p. 36]

(d). Synthesized finding 4: impact of breastfeeding on family

Family members spoke of the positive and negative impacts of breastfeeding on couple and family relationships, as well as parent–infant relationships.

(i). Positive impact on couple and family relationships

Partners found breastfeeding supported teamwork with their partner [31,55,81], brought them closer [72], and provided a sense of equality [71]. It helped when partners understood the impact breastfeeding would have on their intimacy [76]. Partners acknowledged these positive emotions and their willingness to emotionally and practically support their breastfeeding partners [71]. One grandmother from Australia mentioned her relationship with the infant's mother improved with the arrival of the infant [75].

‘We do things now more together, so we work through all the struggles together, so that's great.’ (Father; UK) [81, p. 151]

(ii). Negative impact on couple and family relationships

Partners and grandmothers shared similar views on breastfeeding as intruding on spousal relationships, as it caused an imbalance in the relationship, arguments, reduced sex appeal, and less quality time as a couple [14,18,68,71,74,76]. Additionally, one grandmother from Pakistan was jealous of her breastfeeding daughter-in-law as she was unable to successfully breastfeed when she was younger [64]. However, one partner from Canada reported that the overall benefits of breastfeeding outweighed the negative [76].

(iii). Positive impact on parent–infant relationships

Partners felt joy with observing mother-infant bonding from breastfeeding [16,27,46,56,61,62,68,71,76,85] and could bond with their baby in ways other than feeding [28,45,46,71, 74,76,79]. Some were confident they could bond with their baby at a later stage [29,35,71].

(iv). Negative impact on parent–infant relationships

Partners reported delayed relationship development with their infant, with some describing that they felt frustrated, excluded, and jealous of their breastfeeding partners [16,18, 25,27,29,35,46,58,61,63,71,73,74,85]. Others were concerned that their baby developed a sense of overattachment with the mother [20,35].

‘I felt very much excluded.’ (Father; Brazil) [74, p. 199]

(e). Synthesized finding 5: it takes more than just family members: support for family members

There were positive and negative experiences of support family members accessed and received from various sources including HCPs, with tailored support, information, and education needed to enable family members to better support women to breastfeed.

(i). Access to and (un)helpfulness of support for family members

Partners and grandmothers developed breastfeeding knowledge through antenatal classes, online resources, and discussions with their peer groups [18,25,27,28,38,40,43,48, 52,54,59,60,64,68,73,75,80,84,86]. Some partners attended antenatal classes provided by HCPs and/or privately [18,43,61,62,73,79,80]. In an Australian study, partners shared their experiences and offered emotional support to others through an app [86]. Positive attitudes towards leaflets and interventions were described by partners and grandmothers which offered advice on how to support the breastfeeding woman, underpinned by evidence [18,45]. Some partners encouraged other women's partners to attend breastfeeding classes in order to be able to support their partners [16,86].

There were mixed views among family members of experiences with HCPs. Partners and grandmothers reported that HCPs disregarded and excluded them when breastfeeding issues were discussed with the women, for example, leaflets, classes [18,25,26,37,48,61,62,68,70,73,75]. Sometimes daytime antenatal classes were inaccessible to partners owing to work commitments [27,80], or partners felt isolated if they were the only male in the group [80]. Some grandmothers were unable to access education classes or contact HCPs despite wanting to update their knowledge [48]. By contrast, some family members reported positive experiences with HCPs in private antenatal classes and felt like a true participant as they were included in discussions [18,63].

(ii). Infant feeding advice received from healthcare professionals

Although some partners were encouraged by HCPs to support breastfeeding, they felt that HCPs strongly promoted any breastfeeding [15,33,38,41,43,44,62,64,71,84] or EBF [15,22,27,33,43,61] but not other mixed breast and formula feeding. Some described receiving conflicting advice from HCPs [44,61,70,75,86,88] on breastfeeding techniques and positioning [18,28,80], possible breastfeeding challenges they may encounter with troubleshooting advice [25], and their role in supporting the woman [80]. Women were advised by HCPs to switch from breastfeeding to formula feeding when they had concerns about baby's weight loss [64,79,80] or poor milk supply [64].

(iii). Need for tailored support, information, and education

Partners wanted breastfeeding classes at flexible times, including evenings [79,80] and suggested programmes focused solely on partners so they could network and share experiences, preferably with a male HCP to lead the session [68,70,80,82,86,88]. Some wanted sessions to include different age groups [41,82], while younger partners wanted groups of similar ages as they found it difficult to relate to older partners [43]. Partners wanted specific information on breastfeeding benefits, ways to support the woman, breastfeeding challenges and troubleshooting advice [16,61,80], and a balanced approach towards other infant feeding practices [16]. Partners required evidence-based information with statistics to make informed infant feeding decisions [18], less text, and more pictures of families/partners [18,45,82]. More support and reassurance from HCPs was highlighted [85], with HCPs proactively explaining breastfeeding materials rather than just handing them out [45].

‘…I was always at work … it wasn't an evening which would have been easier to attend … ’ (Father of one; England) [80, p. 470]

Some partners wanted specific instructions from the women on support needed [74]. One suggested grandmothers should update their infant feeding knowledge, particularly on demand feeding, as their knowledge was outdated [45]. Similarly, grandmothers wanted to update their knowledge as they were unfamiliar with current breastfeeding recommendations [48]. More generally, breastfeeding education for the population to shift the social stigma associated with breastfeeding [16] and mandatory labour legislation to ensure partner leave [74] were suggested.

4. Discussion

(a). Breastfeeding knowledge gap compounded with wider influences of culture and society

To our knowledge, this is the first systematic review which focuses on breastfeeding experiences and views of all family members including partners, grandparents, siblings, and in-laws. Our review highlighted a gap in some family members' (particularly partners) breastfeeding knowledge and how best to support their partners. A partner's knowledge and positive attitudes to breastfeeding influenced breastfeeding initiation and duration [4,90]. Grandmothers considered their role was to communicate their breastfeeding knowledge across generations. Grandmothers have been identified as key influencers on breastfeeding uptake and duration [6], however, there was evidence that grandmothers, particularly those from low-middle income countries needed to update their breastfeeding knowledge to effectively support women.

The cultural and religious influences on breastfeeding knowledge and support, such as views on colostrum, EBF, and narratives surrounding insufficient breast milk supply were an important finding of this review. However, given the limited research into the cultural and religious influences on infant feeding [90], this should be a focus for future research.

We identified an ongoing prominence of stigmatization of breastfeeding in public, with all included papers reporting on this from high-income countries, except one from Brazil [74]. As well as better family support, public health promotion is needed to achieve a cultural change and normalize breastfeeding [91]. That a woman's breasts were viewed by some partners as sexual objects which should only be seen in private situations were echoed in Sihota et al.'s review [92]. We also found grandmothers and partners reported breastfeeding in public as inappropriate in front of other children [40,63]. To overcome stigma, better breastfeeding education, starting from schools, and positive promotion from media, policy makers, celebrities, and HCPs are required to influence a cultural shift [93].

(b). Importance of mental health and supporting family members to support women

Family members offered practical and emotional support to women who were breastfeeding. Emotional support from partners was associated with higher breastfeeding initiation [94] with some partners able to recognize the toll breastfeeding had on a woman's health and wellbeing. Women's desire to successfully breastfeed may stem from the strong promotion of (exclusive) breastfeeding, which triggered feelings of guilt if not achieved [95]. HCPs should consider this when advising partners and family members, using communication skills sensitive to the needs of the family without placing undue pressure on the woman. The frustration and helplessness partners felt when not able to help women struggling with breastfeeding, and feelings of being excluded highlight the importance of addressing partner's mental health as well as the woman's. The issue of conflicting advice from HCPs also needs to be addressed, as this was frequently raised as a problem by partners and family members and remains a critical area of practice development [96].

In common with others [97], we found family members, particularly partners, were excluded from breastfeeding interventions and classes. Involving partners and family members as early as possible in breastfeeding interventions could potentially maximize their support for breastfeeding women [98]. A key finding of the current review is that it could be challenging for partners/family members to deduce what support the woman wants, reflecting the dynamic of couple relationships. Breastfeeding interventions could improve couple relationships via better communication and shared decision making, and encourage partner support [99]. HCPs require more training on providing breastfeeding education tailored to the needs of family members likely to support women, and can adapt teaching as appropriate.

(c). Gender inequality and socio-economic status: can we bridge this gap?

Gender inequality was a leading influence on partner and family member's support. This was evident from views of traditional gender-informed roles in society, the biological incapacity of men to breastfeed, and a partner's inadequacy to form a strong bond with their baby. However, for same-sex female partners, gender inequality was not as profound. Some male partners overcame gender inequality via performing other tasks, such as domestic chores. Partners should be aware of unrealistically high expectations and of the effects of breastfeeding on family dynamics. Examples of realistic expectations could be provided during early teaching, such as in antenatal classes, including educating partners how they can offer support.

Cattaneo's [100] presentation of social inequalities on breastfeeding rates highlighted how disadvantaged groups faced many impediments to accessing healthcare services needed. Findings from low-income settings in our review showed partners' and grandmothers’ views of impacts of the environment and poverty on the quantity and quality of breastmilk a woman could produce. These views resulted in those supporting the woman suggesting mixed or formula feeding if possible, even though this was likely to be more expensive and potentially dangerous for the infant if the woman did not have access to a portable water supply and/or know how to safely mix formula feeds.

WHO recommended interventions such as paid leave, implementation of the International Code of Marketing of Breastmilk Substitutes, and Baby-Friendly Hospital Initiative, together with ongoing education and skills development, to help women in deprived communities to breastfeed in order to tackle social inequities [101]. HCPs and those responsible for maternity and infant policy should also ensure partners and family members are included as part of any interventions to enable them to provide breastfeeding support to women to bridge the gap of social inequalities.

(d). Strengths and limitations

The strengths of this review are the inclusiveness of the definition of partners and family members, including same-sex couples and non-restrictions to country settings, enabling us to identify possible cultural differences and differences between country settings. Limitations include: (i) only papers written in the English language were considered; (ii) findings from older papers may not reflect current breastfeeding issues; and (iii) the majority of the family members in the included studies were male partners followed by the infant's grandmother(s), suggesting further research is needed which is inclusive of other family members.

5. Conclusion

This review has shown that multi-faceted personal, social, financial, cultural, religious, emotional, psychological, and societal factors influence partners/family members' views on breastfeeding and types of support provided (or not) to women. Partners/family members also need support from HCPs to enable them to better support women, with much-needed improvement in services and resources they offer to partners and family members. HCP training should be strengthened regarding breastfeeding support, such as knowledge, delivery of breastfeeding advice and interventions, addressing mental wellbeing, and tailored support to the needs of the family.

Data accessibility

As this is a systematic review of qualitative evidence, the original data are available from published articles included in the systematic review. The references of the included studies are in the reference list. Data are also presented in the electronic supplementary material.

Authors' contributions

Y.-S.C. initiated the concept of the review. The review questions and design were developed by Y.-S.C. and D.B. K.M.C.L. conducted the search with guidance from Y.-S.C. K.M.C.L., K.Y.C.L., and Y.-S.C. screened and selected the papers according to the eligibility criteria. K.M.C.L., K.Y.C.L., and K.Y.W.L. carried out data extraction and Y.-S.C. verified extracted data. K.M.C.L., K.Y.C.L., and Y.-S.C. conducted the analysis. All authors agreed the final synthesized findings. Y.-S.C. and S.B. undertook the quality assessment and ConQual assessment. K.M.C.L., K.Y.C.L., and Y.-S.C. drafted the initial manuscript. Y.-S.C. revised drafts following feedback from D.B., S.B., K.Y.C.L., and K.M.C.L. All authors read and approved the final version of the manuscript.

Competing interests

We declare we have no competing interests.

Funding

We received no funding for this study.