Attitudes toward Breastfeeding in Perth, Australia: Qualitative Analysis

JANE

A. SCOTT, C O L I NW. B I N N S , RUTH V. A R N O L D

School of Public Health, Curtin University of Technology, Perth, Western Australia, 6001

ABSTRACT Breastfeeding is promoted as the preferred method of feeding for infants up to at least the age of 4 to 6 months. While the majority of Australian mothers initiate breastfeeding, approximately half have terminated breastfeeding before 6 months p0stpartum.A series of focus groups were conducted to identify societal attitudes to breastfeeding that may have a negative impact on breastfeeding duration.Analysis of the dominant themes to emerge from the focus group interviews indicate that (1) there is general agreement that breastfeeding in public is socially acceptable,provided the woman does so discreetly; (2) appropriate facilities should be provided in places frequented by young families where mothers can breastfeed in private, should they choose to do so; (3) fathers should be included in all pre- and perinatal breastfeeding classes and the content of the classes should be expanded to incorporate the importance of the supporting role of the partner; (4) breastfeeding classes should address the issue of breastmilk insufficiency (real and perceived) to allay the common concerns of mothers; and (5) teenage girls and boys should be the target of school-based breastfeeding education programs that address the psychological and sexual aspects of breastfeeding, in addition to the nutritive and health benefits.

INTRODUCTION Breastfeeding is recognized as one of the "most natural and best forms of preventive medicine"' and is promoted as the preferred method of feeding for infants up to at least the age of 4 to 6 months.' In Australia, the current goal is for 90% of infants to be breastfed on hospital discharge and for 80% to be either fully or partially breastfed at 6 months of age.3 However, in spite of the widespread support for breastfeeding among the general public and health professionals alike, the majority of infants in Australia and other Western countries have been taken from the breast before 6 months of age.4s5

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Address for correspondence: Jane Scott, B.App.Sc., Grad. Dip. D~et.,M.P.H., PFK Edinburgh Ltd., Institute for Medlcal Research, 7 Walker Street, Edinburgh, Scotland EH3 71Y.Tel: 44 131 220 4456: Fax: 44 131 220 4666. O I ~ ~ ; S O C I E T YFOR NUTRITION EDUCATION

Despite the fact that the public is often confronted with the sight of bare breasts on public beaches, television, film, and in magazines, many people are embarrassed, or in some cases even offended, by the sight of a woman breastfeeding in pub1ic.A~a result, women fromwestern cultures are often embarrassed or apprehensive about breastfeeding in public. This embarrassment may contribute to the early termination of breastfeeding. Most research in the area of breastfeeding has concentrated on either the nutritional and health benefits of breastfeeding o r the epidemiology of breastfeeding. Limited research has been conducted into the psychosocial or behavioral aspects of breastfeeding, especially in Australia. However, in order to encourage and support breastfeeding in general, and to increase the social acceptability of breastfeeding in public, it is necessary to first explore and understand public attitudes toward breastfeeding. The use of more objective quantitative research methods such as face-to-face, telephone, or mail surveys often do not provide useful insights into determinants of intimate and sensitive health behaviors such as sexual practices or, in this case, the practice of breastfeeding.An alternative, qualitative research technique is the focus group that attempts to uncover, understand, and explain the feelings and opinions that exist in a target group.'j While quantitative research attempts to identify what people do and how many do it, qualitative research focuses on the underlying reasons for why people do it. Focus groups are commonly used in market research and are being used more frequently in health promotion planning . ~ are frequently used to identify needs for and r e s e a r ~ hThey services and programs, to pretest materials and strategies as a means of process evaluation during the implementation phase of programs, and, following implementation, to supplement quantitative impact and outcome evaluation data.6-'0 While various researchers have identified that certain groups of women are embarrassed or uncomfortable with breastfeed~ have explored the reasons behind their ing in p ~ b l i c , " . 'few embarrassment. For this reason, a series of focus groups were conducted to (1) identifj attitudes and beliefs related to breastfeeding not readily detected using quantitative research techniques and (2) generate questions and terminology for a survey instrument to be used in a large prospective study of breastfeeding practices among women &om socioeconomically disadvantaged groups, to be conducted at a later date.

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METHODS

Photograph 5: A mother breastfeeding a toddler dressed in play clothes and sandals. The majority of participants appeared to be candid in their responses and comfortable with the topic discussed. Conversations were tape-recorded (with the consent of participants) and later transcribed. Data analysis. Each transcript was read and analyzed independently by two separate analysts US and R A ) to Analysis of the focus reduce the risk of biased interpretati~n.~ group discussions followed the procedure recommended by Kreuger.13Summaries of the focus groups were written at the completion of each discussion. Each analyst read these summaries in one sitting and made notes on potential trends and patterns. Strongly held opinions and frequently held opinions were noted. The transcripts of the focus groups were then reviewed with each analyst marking sections of the transcript that related to each of the photographs used to trigger discussion. At this time, participant comments thought worthy of future discussion were marked. Each of the corresponding tapes was listened to during this process to ensure that participants were correctly identified and that statements were accurate and complete. Particular attention was paid to the tone and intensity of the oral comments to ensure that correct emphasis was placed on the written comments.At the end of this process, a variety of dominant themes had been identified by each analyst. Each analyst re-read the transcripts and listened to the tapes concentrating on one theme at a time.A summary of each theme was prepared with particular attention being placed on identi+ing themes or patterns across the groups as well as themes that related to respondents with similar characteristics.A final report was prepared that highlighted dominant themes and illustrated them with selected comments. In general, there was good inter-rater reliability, and the dominant themes discussed in this paper were readily and independently identified by both analysts. A limiting factor in the study is the fact that only one focus group was held with each of the fathers' and nursing mothers' groups. This introduces a potential for bias as, in focus group design, one strong individual can influence a whole group. However, while recognizing this as a design flaw, it does not appear to have significantly influenced the results as, in most cases, the themes identified in these two groups were common across all groups.

A total of 10 focus groups were conducted involving 79 participants. Group size ranged from 4 to 16 with most groups comprising from 5 to 9 participants. Each focus group ran for 60 to 90 minutes and was led by a trained moderator of the same sex as participants to avoid potential problems of awkwardness and embarrassment. As a wide range of opinions was desired, a number of different groups were interviewed: 1. Mothers of infants and small children (Mothers'group = 22 participants-4 groups); 2. Fathers of infants and small children (Fathers'group = 7 participants-1 group); 3. Male university students (Students'group = 25 participants-2 groups); 4. Adolescent girls (Girls' group = 1 8 participants-2 groups); and 5. Nursing Mothers Association of Australia (NMAA) members and counsellors (NMAA group = 9 participants-1 group).
With the exception of male students and NMAA members and counsellors, participants were recruited from busy shopping centres in two low-income areas in Perth. University students were recruited on campus and NMAA participants were recruited directly from a local branch of the NMAA.AU potential participants were advised that they would be discussing infant feeding practices. Child care was available for the groups involving mothers and a $10 participation fee was paid to each of the male university students and adolescent girls. N o attempt was made to randomly select participants as the primary objective of the focus groups was to generate concepts and ideas rather than provide representative data. Certain predefined topics were addressed in the initial focus groups and these topics, as well as issues and concerns raised in early interviews, directed the course of subsequent interviews. In order to allow the conversation to proceed as naturally as possible, the topics were not always raised in the same sequence or posed in exactly the same way for each focus gr0up.A series of five photographs were used to trigger discussion and explore participants' attitudes to breastfeeding in general and, in particular, breastfeeding in public. The photographs were specifically taken for use in the focus groups and were enlarged to 20 X 30cm-size prints for easy viewing.They featured women breastfeeding in a variety of situations: Photograph 1: A mother discreetly breastfeeding an infant on a public bus. Photograph 2: A mother discreetly breastfeeding an infant in a cafeteria in mixed company. Photograph 3: A mother discreetly breastfeeding at a private social gathering in mixed company. Photograph 4: A mother breastfeeding an infant in the privacy of her own home, wearing a bathrobe that was opened to reveal both breasts.

FINDINGS A N D INTERPRETATIONS Content analysis revealed a number of distinct themes with relevance for breastfeeding promotion. Breastfeeding in public. In most cases, breastfeeding in public was seen by mothers and fathers of young infants and children as being routine, necessary, and often unavoidable. In

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Scott et al./AUSTRALIAN BREASTFEEDING ATTITUDES to be an "excretory function and breast milk is considered dirty and defiling." In the author's opinion, it seems incongruous that while most people would bristle with horror at the thought of eating or drinking in the toilet, they accept and even promote breastfeeding in a toilet as being a suitable alternative to breastfeeding in public. Unlike the mothers studied by Jones,15 who were generally embarrassed to breastfeed in front of others, especially men, women in this study were not particularly embarrassed to breastfeed in public or in mixed company. However, they were sensitive to the feelings of others and recognized that men, in particular, might be embarrassed or awkward in their presence. Mothers were in general quite happy, and in several instances preferred to use nursing rooms, if available. However, in many instances, these rooms were either nonexistent, inadequate, or difficult to find.

general, the fathers interviewed had no problems with their wives breastfeeding in public and defended their right to do so:
I mean either they cry or you feed them-$your baby is screamingyou don't have a lot of choice . . . you just feed to keep the baby quiet.

(Mothers' group) The male university students considered it appropriate, under certain conditions, for women to breastfeed in public. In particular, if the child demanded to be fed, it was preferable to breastfeed the child than to let the child cry and annoy other people. However, among this group were some who thought that while it was acceptable on public transport, where there was no alternative, it was less acceptable in a public place such as a restaurant. Several believed that if facilities were available, for example, a restroom or toilet, the mother should leave the group and breastfeed in private. Other students considered it inappropriate for a woman to be expected to breastfeed in a toilet. Fathers, in particular, were likely to object to their wives having to breastfeed in a toilet. Adolescent girls were least likely to approve of breastfeeding in public but, while most said they would like to breastfeed their future children, they indicated that they would bottlefeed when in public, as breastfeeding was embarrassing. Their opinions expressed in response to the photograph of the woman discreetly breastfeeding on a bus were generally one of shame or disgust. However, a few did indicate approval and support:
That is just so shamejul. That's the worst. (Girls' group)

When asked if it would be appropriate to breastfeed on the bus if the baby was screaming, most girls still indicated that it was inappropriate and that the mother should be prepared with a bottle. Others were less offended by this scenario but, nevertheless, would still be embarrassed to breastfeed their own child on a bus. Adolescent girls were inclined to think that a woman should find somewhere else to breastfeed. In response to the photograph of the woman breastfeeding at the cafeteria, several thought that the act of breastfeeding would put other people off their food. When presented with the possibility of there being no nursing room available, a number of girls suggested that the mother retire to the toilet. Even then, several indicated that they still would not like to breastfeed in the toilet if other women were present. A number of mothers suggested that they had no alternative but to breastfeed in public because of a lack of facilities. Other mothers had resorted to breastfeeding in the toilet rather than breastfeed in public:
What else can you do f i the baby is screaming hungry, in a restaurant or in a hotel or something?You go to the toilet, sit down on the lid, and feed the baby. Where else are you going to do it? (Mothers' group)

Discreet breastfeeding. A strong theme to emerge from all groups was the issue of discreet breastfeeding. With the exception of adolescent girls, there was a general acceptance of women breastfeeding in public as long as it was performed discreetly, that is, with a minimum of the breast showing. Overt public displays of breastfeeding were not considered socially acceptable by any of the groups interviewed. Even the NMAA members and counsellors, a group most likely to defend a woman's right to breastfeed in public, did not support the idea of indiscreet breastfeeding, suggesting that such behavior did not give breastfeeding a nice image.This suggests that women who breastfeed in public in a conspicuous fashion, that is, with their breasts overly exposed, will do little to advance the social acceptance of breastfeeding in public. Most groups had a similar reaction when shown the photograph of the woman breastfeeding at home with her robe open.They considered it appropriate for home but inappropriate to show as much breast when in public. Indiscreet breastfeeding was associated by some university students with left-wing radicals, greenies,* and feminists:
If you saw that in a public place you'd have every male in the population checking it out. It's not discreet and you're advertising. That's when . . . you'd create a commotion . . . (Fathers' group)

A second photograph of a woman discreetly breastfeeding in public received general approval, with the exception of adolescent girls.

Embarrassment with witnessing breastfeeding. Many of the male university students indicated that while they were not offended by the sight of a woman breastfeeding, they did experience a degree of embarrassment or awkwardness.They were less likely to feel embarrassed if they felt that the mother was comfortable with breastfeeding in front of them.

Morsel4 explored the possibility that breastfeeding women are banished to the toilet because breastfeeding is considered

*An Australian slang term used to describe a comm~tted conservationist. In this context, lt is used d~sparagingly.

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Fathers were also aware that their male friends, particularly those without children, might be embarrassed when they saw a woman breastfeed. There was general consensus among the mothers and the fathers that others were more embarrassed at the sight of a woman breastfeeding than the mother actually was with breastfeeding in front of people. Some mothers and fathers thought that older people were more likely to be embarrassed than younger people.While most mothers anticipated being embarrassed breastfeeding in public before they had their baby, they noted that they were quite comfortable once they had publicly breastfed for the first few times.
I thought I would be embarrassed when Ijrst started feeding-granted, I was embarrassed thejrst few days but then Ijust got over it. (Mothers' group)

whether people were comfortable with a woman breastfeeding in their presence.

Sexual role of breasts versus functional role o f breasts. The theme of the sexual versus the functional role of the breast was explored. Most young men agreed that their embarrassment at seeing a woman breastfeed stemmed from the sexual role of the breast. They and the adolescent girls acknowledged the incongruity of the two roles:
Yeah, we pay to look sometimes and yet we object to women, or some people object to women, breastfeeding in public. (Students' group)

Adolescent girls were the group least comfortable with either the idea of witnessing a woman breastfeed in public, or with being in the company of a woman who was breastfeeding in public, even if they were doing so discreetlyThis reaction was similar to that described in studies from otherwestern countries and, in general, adolescents do not consider breastfeeding in public to be socially acceptable. Canadian teenagersI6were slightly more liberal than English teenagers" but still did not consider it appropriate to breastfeed "on the bus,'' in "restaurants," "the park," or "at the shops." Breastfeeding should be confined to the privacy of the home. In both the Canadian and English groups, acceptance decreased as the presence of others, especially males, was added to the scene. Male university students in this study also felt awkward in the presence of a breastfeeding woman, but recognized their right to breastfeed in public. Their embarrassment was minimized if they were in some way forewarned that the mother was going to breastfeed in their presence.
Breastfeeding etiquette. Another theme that emerged from the preceding theme in the two focus groups with university students was the concept of breastfeeding etiquette. They acknowledged that, while it was a woman's right to breastfeed in public, they were less embarrassed if the woman first asked their permission to breastfeed in front of them, or at least acknowledged that she was going to breastfeed in front of them:
I'd still expect her-ifshe was in someone else's home and the kid was screamincl'd expect her to say "Is it all right iflfeed?"(Students'group)

In response to a question about how they would feel if their wife or girlfriend were to breastfeed in front of their friends, a number of the university students indicated that they would not like it or that they would be embarrassed. Comments such as "for my eyes only" suggested a certain degree of territorialism or ownership of their partners' breasts. A common theme that emerged among university students was their concern at being considered, by either the mother or their male friends, to be ''pervingWt o n the woman's breasts.Adolescent girls and a number of the mothers also thought that men were embarrassed at the sight of a woman breastfeeding because they might be thought to be perving or staring at the woman's breasts.
Theyfeel like apervert, like even ifthey are not, they stillfeel it. (Girls'
group)

However, fathers strongly resented the suggestion that a woman should ask permission to breastfeed:
It's nothing to do with the otherpeople; it's her individual right that she is going to breastfeed. (Fathers' group)

Fathers' support of breastfeeding. In general, the fathers interviewed in these focus groups were very supportive of their partners' desire and right to breastfeed, both at home and in public. In contrast, Freed et a1.,18 in a U.S. study, found that the majority of fathers whose partners intended to either breastfeed (71%) or bottlefeed (78%) did not believe that breastfeeding in public was acceptable.This difference in attitudes might contribute to the lower breastfeeding initiation and duration rates in the U.S., when compared with Australia.4,5However, not all Australian fathers are as supportive as the fathers interviewed in this focus group. Some of the mothers described situations in which their partners were less than supportive, particularly with breastfeeding in public. Fathers are known to play an important role in mothers' decisions to breastfeed and influence duration by serving as key supports or deterrents to breastfeeding by the mother.I9 Freed et a1.18 found that partners ofwomen who intended to bottlefeed their infants were more likely to believe that breastfeeding was bad for a woman's breasts and interfered with sex, compared with partners of women who intended to breastfeed their infants. They were also unaware of the benefits to their child. It might be expected that these fathers would discourage their partners from attempting to breast-

In one group, the adolescent girls scoffed at the idea of asking other people's permission to breastfeed. However, in the second group, this was suggested as a way of establishing

'An Austral~anslang verb derlved from the word pervert. In t h ~ s context, it implies starlng In a voyeurist~cmanner.

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Scott et al./AUSTRALIAN BREASTFEEDING ATTITUDES

feed, or if their partners did initiate breastfeeding that they would not contribute to successful breastfeeding by supporting them through difficult periods. Freed et al.ls contend that it is unrealistic to expect fathers to intuitively possess background on the nature of breastfeeding and its benefits to infants. They recommend that fathers be included in all breastfeeding education courses currently taught in hospitals.

Prolonged breastfeeding. When shown a picture of a toddler breastfeeding, most of the recent mothers recruited from the shopping centres considered the child too old to be breastfed.A few mothers expressed very strong, negative feelings toward the photograph. In general, fathers also thought that the child was too old to still be breastfed, but recognized that it was the woman's right to continue to breastfeed:
Ifit was a ewe that would begreat, but I don't want a child at that age hanging o f [ m y breast]. (Mothers' group)

and responsibility of breastfeeding or because they are unprepared for motherhood and have unrealistic expectations about breastfeeding. Members of the NMAA suggested that high self-esteem contributed to successful breastfeeding. A number of mothers terminated breastfeeding because of breastmilk insufficiency. Members of the NMAA recognized breastmilk insufficiency as being a major concern for new mothers. In general, young mothers recruited from the shopping centers were more likely to think that breastmilk insufficiency was a common problem compared with members of the NMAA:
Medical things tell you that it doesn't happen at all. But, that's a load of rubbish. (Mothers' group)

There was general consensus among the university students that up to 12 months was an appropriate length of time for a child to be breastfed. Most expressed some concern over the appropriateness of breastfeeding toddlers, especially with regard to the effect that this practice might have on the psychological development of the child. Comments such as "that poor kid's going to have an enormous lot of trouble" and "missing a step in the maturity process" were common. Concern was expressed also by mothers and fathers that prolonged breastfeeding would make the child too dependent on the mother. There was almost unanimous agreement among the adolescent girls that the toddler was too old to be breastfed. Several thought that it would cause the child to be too dependent on the mother and were disgusted at the possibility of a woman breastfeeding an older child in public."By the time the child can walk" was generally agreed upon as an appropriate age by which a child should be weaned. There appears to be a culturally approved age by which time a child should have been weaned from the breast.This is not necessarily measured in terms of chronological age but is more related to a child's development. Most people thought that by the time a child can either walk, eat family foods, or ask for the breast-in short, becomes an aware person-that she/he should have been weaned. Morset4theorized that:
Breastfeeding is a dynamic relationship involving signijicant others beyond the "nursing couple,"and the attitudes of these "others"change toward the breastfeeding mother over the course oflactation. Initially, these signijicant others support the mother in her breastfeeding. But when the infant is considered "old enough to wean," these others alsofacilitate weaning.14

The tendency for women everywhere to doubt the adequacy of their breastmilk was highlighted in a number of groups. This doubt makes mothers susceptible to the influence of family and friends who readily suggest that the quantity and/or quality of the mother? milk may be deficient in some way. Breastmilk insufficiency was often self-diagnosed by mothers on the basis of a child crying more frequently, not sleeping through the night, or having changed its feeding patterns.This suggests an ignorance of the individuality of the breastfeeding experience and events, such as growth spurts, which may result in a temporary change in feeding behavi ~ r . HillZ1 ~ ' suggests that a fussy infant can erode a mother's confidence in her ability to breastfeed, particularly if her level of confidence is shaky before the birth. It is apparent that many women have already decided to stop breastfeeding prior to visiting a health professional for confirmation of their diagnosis of breastmilk insufficiency, as they often stop feeding despite advice and encouragement to the contrary.

RECOMMENDATIONS While the rights ofwomen to breastfeed in public should be recognized, nursing rooms should be provided for those women who wish to breastfeed in private. However, it was apparent from the discussions that these facilities were often unavailable, inadequate, or difficult to find. Public places frequented by women and families with young children, for example, family restaurants, cinemas, department stores, and shopping complexes, should provide attractive, well-maintained, and easy to locate facilities where mothers can breastfeed in private, should they choose to.Town planners should consider the needs of breastfeeding women when approving building plans for major public venues and require (or at least advocate for) the inclusion of nursing rooms. These rooms may be adjacent to but should be separate from the female toilets. However, even if these facilities are provided, it should be recognized that breastfeeding intervals are not always predictable and that seclusion might be neither convenient nor possible at the time the infant demands to be fed. Teenage girls and boys, while recognizing the benefits and importance of breastfeeding, often experience embarrassment

Reasons for terminating breastfeeding. There was a perception among some of the mothers and fathers that some women terminated breastfeeding because they reached a stage where they had done their bit and it was now time to regain their life. It was suggested also that some women may switch to bottlefeeding because they are overwhelmed by the intimacy

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and awkwardness when witnessing a woman breastfeed.They are inclined to think that women should isolate themselves rather than breastfeed in public.This attitude, if carried into adult years, may result in the early discontinuation of breastfeeding. This group should be the target of school-based breastfeeding education programs. Classes should deal with the sexual and social aspects of breastfeeding as well as the nutritive and protective roles. Discussions and breastfeeding demonstrations should be incorporated into health education, home economics, and life skills curricula. There is evidence that fathers participate in and influence the choice of feeding method and influence duration by acting as key supports or deterrents to breastfeeding by the m~ther.'*,'~The degree of support provided by the father will depend on his commitment to and expectations of breastfeeding. However, few opportunities exist for fathers to prepare themselves to offer the emotional and practical support required by their partners.I8 Fathers should be included in pre- and perinatal breastfeeding education classes currently taught in hospitals and clinics.The amount of time spent on nutrition in these classes should be expanded to allow for discussion of the supportive role fathers can play for the breastfeeding mother. It would seem that women everywhere doubt the adequacy of their breastmilk and insufficient breastmilk is the most commonly cited reason for early termination of breastfeeding2' In most cases, women make a self-diagnosis of breastmilk insufficiency on the basis that the baby cries, or does not appear satisfied, after nursing.This suggests an ignorance of the individuality of the breastfeeding experience. In very few cases is perceived breastmilk insufficiency substantiated with evidence of infant growth failure.22Breastfeeding education should address the issue of breastmilk sufficiency and insufficiency (real and perceived) and anticipatory guidance should be provided to help mothers manage transient breastmilk insufficiency should it occur.

Promotion Grant.The assistance of Mr. Steve Jones, who led the male focus groups, is much appreciated.

REFERENCES
1. Yeung DL, Pennell MD, Leung M, Hall J. Breastfeeding: prevalence and influencing factors. Can J Publlc Health 1981;72:323-31. 2. National Health and Medical Research Council. Dietary Guidelines for Australians. Canberra:Australian Government Publishing Service, 1992. 3. Nutbeam D,Wlse M , Bauman A, Harris E, Leeder S. Goals and targets for Australia's health in the year 2000 and beyond. Canberra:Australian Government Publishing Service, 1993. 4. Ryan AS, Rush D, Krieger FW, Lewandowski GE. Recent declines in breast-feeding in the United States, 1984 through 1989. Pediatrics 1991; 88:719-27. 5. Palmer N. Breast-feeding-the 42:13-8. 6. Basch CE. Focus group interview: an underutilized research technique for improving theory and practice in health education. Health Educ Q 1987; 14:411-48. 7. Mullis R M , Lanslng D. Using focus groups to plan worksite nutrition programs. J Nutr Educ 1986;18:S32-4. 8. Trenkner LL,Achterberg CL. Use of focus groups in evaluating nutrition education materials. J Am Diet Assoc 1991;91:1577-81. 9. Brown JE,Tharp T M , McKay C , Richardson SL, et al. Development of a prenatal weight gain intervention program using social marketing methods. J Nutr Educ 1992;24:21-8. 10. Schwaller MB, Shepherd SK. Use offocus groups to explore employee reaction to a proposed worksite cafeteria nutrition program. J Nutr Educ 1992;24:33-6. 1 1. Holt GM,Wolkind SN. Early abandonment of breast feeding: causes and effects. Child Care Health Dev 1983;9:349-55. 12. Wright HJ, Walker P. Prediction of duration of breastfeeding in prlmiparas. J Epidemlol Community Health 1983;37:89-94. 13. Kreuger RA. Focus gr0ups.A practical guide for applied research. Newbury Park, CA: Sage Publications, 1988. 14. Morse JM."Euch, those are for your husband!" Examination of cultural Australian situation.J Food Nutr 1985;

CONCLUSIONS It would appear that the awkwardness and embarrassment experienced by adolescent girls and young men in the presence of a breastfeeding woman diminishes for both sexes once they have children of their own. In these focus groups, both mothers and fathers of infants and young children were quite comfortable with the idea of a woman breastfeeding in public and generally viewed it as being natural and necessary rather than an offensive and socially unacceptable behavior. This attitude needs to be adopted by the general public where breastfeeding should be seen as both socially desirable and acceptable.

associated with breast-feeding. Health Care for values and assumpt~ons Women International 1989;11:223-32. 15. Jones DA. Attitudes of breast-feeding mothers: a survey of 649 mothers. Soc Scl Med 1986;23:1151-6. 16. Ellis DJ. Secondary school students' attitudes and beliefs about breastfeeding. J School Health 1983;53:600-4. 17. Gregg JEM. Attitudes of teenagers in Liverpool to breast-feeding. Br Med J 1989; 299:147-9. 18. Freed GL, Fraley JK, Schanler RJ.Attitudes of expectant fathers regarding breast-feeding. Pediatrics 1992;90:224-7. 19. Jordon PL,WallVR. Supporting the father when an infant 1s breastfed.

J H u m Lact 1993;9:31-4.
20. Bear K, Tiggs BB. Management strategies for promoting successful breastfeeding. Nurs Pract 1993;18:50-60. 21. Hill PD. Insufticient milk supply syndrome. NAACOG's Clinical Issues

ACKNOWLEDGMENTS This research was supported by a Commonwealth Department of Health and Community Services National Health

1992;3:605-12. 22. Hillervik-Lindquist C, Hofvander Y, Sjolin S. Studies on perceived breast milk insufficiency. 111. Consequences for breast milk consumption and growth.Acta Paediatr Scand 1991;80:297-303.