Midwifery 31 (2015) 532–539

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Midwifery
journal homepage: www.elsevier.com/midw

Barriers to breast-feeding in obese women: A qualitative exploration

Alice Keely, MSc (Research Midwife)a,n, Julia Lawton, PhD Social Anthropology (Professor
of Health & Social Science)b, Vivien Swanson, PhD Psychology (Senior Lecturer in
Psychology)c, Fiona C. Denison, MD, MRCOG, MBChB (Senior Lecturer/Honorary Consultant
in Maternal & Fetal Medicine)a
a
MRC University of Edinburgh Centre for Reproductive Health, Queen's Medical Research Unit, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
b
Centre for Population Health Sciences, University of Edinburgh, Medical School, Teviot Place, Edinburgh EH8 9AG, UK
c
Department of Psychology, University of Stirling, Stirling FK9 4LA, UK

art ic l e i nf o a b s t r a c t

Article history: Objective: to explore the factors that influence breast-feeding practices in obese women who had either
Received 9 August 2014 stopped breast-feeding or were no longer exclusively breast-feeding 6–10 weeks following the birth of
Received in revised form their babies, despite an original intention to do so for 16 weeks or longer. Specifically (i) to identify the
20 January 2015
barriers to successful breast-feeding and reasons for introducing formula and/or stopping breast-feeding,
Accepted 1 February 2015
and (ii) to explore the women's views and experiences of current breast-feeding support services.
Design: descriptive, qualitative study comprising semi-structured face-to-face interviews. Interviews
Keywords: were audio recorded and transcribed. The data were analysed using thematic analysis.
Breast-feeding Setting: participants recruited from one large maternity unit in Scotland and interviewed in their homes.
Obesity
Participants: 28 obese women at 6–10 weeks following birth.
Caesarean section
Findings: three major themes emerged from the data analysis: the impact of birth complications, a lack
of privacy, and a low uptake of specialist breast-feeding support. Impact of birth complications: 19 of 28
women had given birth by caesarean section and some felt this led to feeling ‘out of it’ post-operatively, a
delay in establishing skin-to-skin contact, and in establishing breast-feeding. Lack of privacy; several
women described reluctance to breast feed in front of others, difficulties in achieving privacy, in hospital,
at home and in public. Low uptake of postnatal breast-feeding support; despite experiencing problems
such as physical difficulties during breast-feeding or a perception of low milk supply, breast-feeding
support services were underused by this sample of women. A small number of the women in this study
used breast-feeding clinics and reported finding these useful. A further small number felt they benefitted
from the support of a friend who was successfully breast-feeding.
Conclusion and implications for practice: midwives should be mindful of the presence of additional factors
alongside maternal obesity, such as caesarean delivery, physical difficulties when breast-feeding, poor
body image, and lack of confidence about sufficient milk supply. Scope for innovation within hospital
policies with regard to both the facilitation of early skin-to-skin contact and privacy in postnatal
accommodation could be explored in future research. Women should be provided with information
about the provision and specific purpose of breast-feeding support groups and services and encouraged
to access these services when appropriate. Future research could assess the usefulness of sustained
breast-feeding support by health professionals, as well as partner involvement and formal peer support
for this group of women. The education and training needs of health professionals in terms of supporting
this group of women to breast feed may also usefully be explored.
& 2015 Elsevier Ltd. All rights reserved.

Introduction

Despite sustained health promotion campaigns over many

years, breast-feeding rates in the UK remain low compared with
n
the rest of Europe (McAndrew et al., 2012). A number of high
Corresponding author.
quality studies have explored women's infant feeding practices
E-mail addresses: 40136837@napier.live.ac.uk (A. Keely),
j.lawton@ed.ac.uk (J. Lawton), vivien.swanson@stir.ac.uk (V. Swanson), and experiences within the general childbearing population
fiona.denison@ed.ac.uk (F.C. Denison). (Murphy, 1999, 2000; Avishai, 2007). Many of these have focused

http://dx.doi.org/10.1016/j.midw.2015.02.001
0266-6138/& 2015 Elsevier Ltd. All rights reserved.
 A. Keely et al. / Midwifery 31 (2015) 532–539
on social and cultural factors which influence women's experi-
ences and decision-making with regard to breast-feeding. Findings
from these studies suggest that breast-feeding is experienced as a
complex and demanding task by many women, who may encoun-
ter difficulties or negative experiences (Murphy, 2000; Avishai,
2007). The evidence from previous research highlights that
many women feel under-prepared for the challenges involved in
establishing and maintaining breast-feeding (Murphy, 2000), that
pregnancy and birth events can have a major impact on the
establishment of breast-feeding (Avishai, 2007), and that both
formal and informal support networks may be important factors in
determining longer term breast-feeding success (Britton et al.,
2007).
As the prevalence of maternal obesity has increased in the past
two decades, it has emerged as an important determinant for
breast-feeding uptake and duration (Department of Health, 2004).
In addition to increased risk of pregnancy and birth complications
(Denison et al., 2014), obese women are less likely than normal
weight women to initiate breast-feeding and are more likely to
stop breast-feeding earlier (Amir and Donath, 2007; Wojcicki,
2011). One recent study found that among first time mothers in
Denmark, maternal obesity was associated with nearly double the
risk of early cessation of exclusive breast-feeding (Kronborg et al.,
2012). This is a concern not only due to the potential health
benefits of breast-feeding for both the mother and the baby but
also because of the complex associations between maternal and
offspring obesity (Heslehurst, 2011). It has recently been acknowl-
edged that strategies for interventions to support obese breast-
feeding mothers are urgently needed (Mellor et al., 2013). In a
mixed-methods study, conducted in France, which included a
telephone interview at one and three months post partum, Mok
et al. (2008) found that early introduction of formula milk to
supplement breast milk was more common among obese women.
The authors compared weight gain in the first three months of life
of babies of obese and non-obese mothers. They found more obese
women reported feeling uncomfortable breast-feeding in public,
more obese women perceived their milk supply to be inadequate
and fewer sought specialist support with breast-feeding. The
telephone interviews were structured and the authors concluded
that further research is required to better understand the percep-
tions of obese mothers regarding infant feeding. To address this
gap, we undertook a qualitative investigation using face-to-face,
semi-structured interviews to explore the views and experiences
of obese women who initiated breast-feeding when their babies
were born, and intended to continue exclusively breast-feeding
until at least 16 weeks later, but who were no longer exclusively
breast-feeding, or had stopped breast-feeding 6–10 weeks later.
Aims and objectives
The aims of the study were: to explore the factors that
influence breast-feeding practices in obese women who had either
stopped breast-feeding or were no longer exclusively breast-
feeding at 6–10 weeks despite an original intention to do so for
16 weeks or longer. Specifically (i) to identify the barriers to
successful breast-feeding and reasons for introducing formula
and/or stopping breast-feeding, and (ii) to explore the women's
views and experiences of current breast-feeding support services.
Methodology
An interpretive qualitative approach was used (Rubin and
Rubin, 1995). The data analysis process was iterative, taking place
alongside data collection. This allowed for the exploration of
533
themes which emerged during data collection (Mason, 2002)
enabling interview questions and sampling to be revised as the
study progressed. This is described in further detail below.
Semi-structured interviews were chosen for this study as these
afforded the flexibility needed to gain an in-depth understanding
of women's personal experiences and decision-making (Brett-
Davies, 2007), including issues which might be unforeseen at the
study's outset. In addition, one-to-one interviews afforded privacy,
to encourage the women to discuss sensitive issues.
Recruitment and sampling
Inclusion criteria for the study were: any woman who had
given birth to a single baby at 437 weeks gestation, breast-
feeding at first feed but no longer exclusively breast-feeding at 6–8
weeks’ postnatal, and BMI at the start of pregnancy of 430 kg/m2
(defined as obese). Exclusion criteria were: any woman whose
baby had been admitted to the neonatal unit, any woman not
being discharged home with her baby (as separation from the
baby presents challenges in establishing breast-feeding which
were beyond the focus of this study), age o18 years old, multiple
pregnancy or inability to give informed consent.
Participants were selected purposively in order to achieve a
sample that was broadly representative of childbearing women in
Scotland in terms of age and social class, as breast-feeding
initiation and duration is associated with social class (Kelly and
Watt, 2005) and age (Hodinott et al., 2006). Maternal demographic
information was checked via electronic maternity notes prior to
approaching participants.
The women’s babies were 6–10 weeks old at the time of the
interviews. Figures from the Scottish NHS Information Services
Division (ISD Scotland) identify 6–8 weeks following birth as a
time by which many babies are no longer exclusively breast fed,
and for this reason it was decided to conduct our interviews at this
time, or as soon as possible after eight weeks.
Recruitment to the project commenced on 5th January 2011
and was completed on 20th March 2013. A break in recruitment
and data collection occurred between January and November 2012
as the research midwife took maternity leave. Women were
approached on the postnatal ward and provided with a participant
information sheet and, if they agreed, completed a screening
questionnaire. They were asked if they would be willing to be
contacted via telephone at a later date to discuss taking part in the
study. Those who agreed were then telephoned 4–6 weeks later to
discuss their current infant feeding method and whether or not
they would be willing to take part in an interview. In all, 55
women were successfully followed up via telephone during the
initial phase of qualitative data collection. Women were recruited
to the qualitative study in two phases. During the initial phase of
qualitative data collection, 17 obese women were recruited to
participate in one-to-one semi-structured interviews. Of the 38
women who did not participate at this stage, 23 were still
exclusively breast-feeding at the time they were contacted and
therefore ineligible, two had moved away from the area and a
further 13 declined to participate. During phase two, 30 women
were followed up via telephone; of these 11 were exclusively
breast-feeding when contacted, five declined to participate and
one further woman agreed to participate but was not in when the
interviewer called at her home and did not answer follow-up
phone calls. A further 11 participants were recruited at this stage.
Data collection
Interviews took place in participants’ homes between March
2011 and April 2013. The interviews were informed by a topic
guide which was developed to address the study aims and in light
534 A. Keely et al. / Midwifery 31 (2015) 532–539
of a review of the literature. A range of topics were explored in
each interview, including: (1) experience of pregnancy, previous
experience of infant feeding and antenatal feeding intentions,
(2) experience of feeding support from health professionals,
(3) relationships with and influence of partner, family and friends
in infant feeding experience and decisions, (4) body image –
historically, in pregnancy and after birth, including experiences
of and/or feelings about breast-feeding in public, (5) physical
experiences of breast-feeding, (6) experiences of postnatal infant
feeding information and support. Following the initial 17 inter-
views, the topic guide was expanded to include further questions
and prompts, to achieve greater depth and richness within the
data. A further 11 women were then recruited and interviewed
during phase 2 of data collection. No new findings or themes
emerged during the later interviews. Consequently, after 28 inter-
views had been conducted it was concluded that data saturation
had been reached.
Interviews lasted between 45 minutes and 2 hours and 30
minutes. Interviews were digitally recorded and transcribed in full
(with consent). Brief notes were made during interviews and
expanded upon as soon as possible following the interview.
Data analysis
Thematic analysis was used to formally analyse and unearth
patterns in the data. Audio recordings were transcribed using a
professional transcription service. Thematic content analysis was
carried out. Using an interpretive approach, themes were devel-
oped in an iterative and inductive way, involving the breaking
down and reassembling of data in a coding process (Braun and
Clarke, 2006). This involved multiple readings of the transcripts, in
order to become immersed in the data. This was followed by
preliminary coding of the data and the development of themes
from these codes (e.g. breast-feeding in public). Once all of the
interviews had taken place the coding frame was more fully
developed. Coded datasets were subjected to further in-depth
analyses to identify sub-themes (e.g. breast-feeding in hospital;
breast-feeding at home; breast-feeding in public) and illustrative
quotations. The final step was the identification of links between,
and overlapping of, themes (Rubin and Rubin, 1995) and the
development of three major themes (e.g. seeking privacy). Regular
team meetings took place to discuss our interpretations and to
reach agreement on key findings. The final category system was
agreed by three researchers and accepted as being representative
of the data.
Ethical approval was granted by South East Scotland Research
Ethics Committee 2 on 20th October 2010 (Ref 10/S1102/55).
Pseudonyms are used below.
Findings
Only one study participant, an Indian woman, was from
an ethnic minority background. All of the other women were
Caucasian, 24 from the UK, one from the Republic of Ireland, one
from Australia and one from America. This sample is thus broadly
representative of the population of the city from which we
recruited, where 8% of the population are from mixed or multiple
ethnic groups (Scottish Government, 2011)
All the women in this study had a BMI between 30 and 46 kg/m2
at the start of pregnancy. All the women confirmed that, at the time
their babies were born, they intended to exclusively breast feed for
at least 16 weeks (and many for up to six months). However, all had
stopped breast-feeding or had introduced formula feeding along-
side breast-feeding by 6–10 weeks following the birth of their
babies, and for several this had occurred within just a few days.
Analysis of these women's accounts highlighted a complex mix
of influences on their infant feeding decisions. These were
grouped into three main themes – the impact of birth complica-
tions, a lack of privacy and a low uptake of specialist breast-
feeding support. These themes are expanded and are reported in
more detail below.
Impact of birth complications: caesarean section, skin-to-skin
contact and early feeding: ‘I couldn’t just pop up and shut the
curtains…’
Many of the women in this sample experienced pregnancy and
birth complications and spent several nights in hospital following
the birth of their babies. Seven women had a spontaneous vaginal
delivery (SVD), two had a forceps delivery and 19 gave birth by
emergency caesarean section (emCS). In several cases these
women felt a caesarean delivery led to a delay in skin-to-skin
contact being established with their babies:
‘I was just shaking all over, like complete shaking so I was like,
‘I don’t feel like I can hold him’’ [Eve 37, 1st baby, emCS]
‘I wanted skin to skin contact but she was still wrapped up so I
didn’t really have that…I wanted skin to skin contact, you
know?’ [Lydia 27, 1st baby, emCS]
In addition, for several other women, the immediate post-
caesarean period, including the first time they breast fed, was
difficult to remember. Phrases such as ‘I was kinda out of it’[Liz] ‘I
honestly can’t really remember’ [Eve] ‘I don’t remember feeding
him..’ [Julie] were common during interviews with women who
had had a caesarean birth.
Lack of privacy: breast-feeding in front of others: ‘…I’ll not
be able to do it when I’m out.’
In hospital
A caesarean section delivery necessitates a postnatal hospital
stay of several days. For the vast majority of the women in this
study, this was in a four-bedded bay in a large, busy postnatal
ward, where partners were allowed all-day visiting, other visitors
were permitted at certain times of the day and where privacy was
thus difficult to achieve. For some, such as Kirsten, who had
problems latching her baby on initially, trying to manually express
breast milk in this environment was described as presenting
additional difficulties:
‘..obviously because.. like, it’s… like, a shared ward as well, it's
not like your own room. So you’ve constantly got people
coming in and out when you’re trying to express into… like a
little syringe. So, it wasn’t the best. I was fine breast-feeding
him, because obviously he's on your breast, but it was a bit
different when you’re sitting like massaging your breasts and
trying to catch milk in a syringe and stuff’ [Kirsten 30, 1st
baby, emCS]
Interviewer: ‘And there are curtains, I guess…?’
‘Yeah, but they open them. You shut them and then someone
will come along and come in and check on you, and then leave
them open. Because I’d had a [caesarean] section as well, I
couldn’t just like pop up and shut the curtains. I had to get
someone to shut them for me.’ [Kirsten]
Many women described feeling a similar lack of privacy while
in hospital immediately following birth and only one woman,
Diana, was accommodated in a private side room. She described
 A. Keely et al. / Midwifery 31 (2015) 532–539
considering herself lucky as this had a door and also a curtain
between her and the ward's main corridor:
‘…because then I was able to sit up in the chair and kind of feed
her without kind of being worried over male visitors or male
people coming in.… I had the curtain across like, you know, so
even when, like, my father-in-law came in I was able to kind of
like cover myself over quickly. You know, stuff like that’ [Diana
40, 1st baby, emCS]
At home
Once back at home, several participants still struggled to
achieve privacy in the early postnatal days. Many women had
either a series of visitors or relatives staying in their home
immediately following their discharge from hospital. May, for
example, had experienced problems from birth with feeding her
baby, and had struggled for weeks before switching to exclusively
formula feeding. Her parents and grandmother live hundreds of
miles from her and came to stay for several weeks immediately
following the birth of her baby. May felt the lack of privacy she
experienced while her extended family were staying with her was
an important factor in her decision to switch to formula:
‘…there wasn’t much privacy and I had to get up into another
room every time, in private, and go and feed her. She wasn’t
having any of it… and then I would try again… and then I
would have to get up again. It was more that privacy part of it
that I found that I didn’t like.’ [May 30, 1st baby, emCS]
Another participant, Isla, also described her reluctance to breast
feed in front of visitors. Isla had a large extended family living
nearby and a busy social life. She said her reluctance to breast feed
in front of friends and family was an important factor in her choice
to use formula. In addition, and in common with several other
women, feeding outside the home posed difficulties for her. She
breast fed her baby only for a few days, but the prospect of feeding
in public caused her anxiety:
‘I kind of thought about it, like, I could express and stuff like
that, but I think… just the thought of being somewhere and not
having enough and having to do it [breastfeed] was in the back
of my mind. I worried about that.’ [Isla 26, 1st baby, SVD]
Another participant, Daisy, also acknowledged that her unwill-
ingness to feed in front of others was a key factor in her decision to
switch to bottle feeding. During her interview, she spoke openly
about having a long history of trying to lose weight, acknowl-
edging ‘I think it is something I will always battle with’. In
common with a small number of others in the sample, Daisy
spoke of a period of eating-disordered behaviour. She described
feeling very negatively about her body,
‘Aye…. like for me being 23, if you were to chop my head off
and look at my body, you would think it was the body of
someone much older’. [Daisy 23, 2nd baby, emCS]
and about her breasts in particular:
‘I have always had funny breasts, sort of… they have never sat
how they should’, even before I had kids. They have always
been, like… saggy. I don’t know why. I never would have went
out without a bra or anything, because before I had kids, I had
breasts that looked like I had had about five kids. They were
awful. [Daisy 23, 2nd baby, emCS]
She described how she had found it difficult to breast feed in
front of other people. In addition to her new baby, she had a three
year old child (who she had also breast fed for just a few days), and
535
several family members living nearby who visited often. This
meant additional challenges in finding sufficient time and privacy
in order to establish breast-feeding, and after a few days Daisy
opted to switch to bottle feeding:
‘Obviously the positive about the breast-feeding was that it's
better for them, but there is a lot more negatives, as in I’ll no[t]
be able to do it when I’m out, if people come and visit I’ll not do
it, and so I thought, I will just bottle feed him and then that way
it is easier for everybody.’ [Daisy 23, 2nd baby, emCS]
Several other women spoke of feeling self-conscious about
exposing their bodies in public in order to breast feed and how
they had felt relieved at not having to worry about this once they
had switched to formula. Melanie described how she had not liked
feeding in public because she had ‘really big boobs and [they are]
very hard to hide’. Camille held a similar view, believing small
breasts were ‘more decent’ when feeding in public. Daisy, simi-
larly, shared her concerns about exposing her stomach when
lifting her t-shirt in order to breast feed. In her interview, she
reported that: ‘I would never have done that, because obviously
my belly would be hanging out then.’ Others had concerns about
the potential for prolonged exposure of their breasts in the first
days or weeks, when a new baby can be difficult to latch onto the
breast. This prospect had worried Charley because, as she told us, ‘I
don’t really like my body that much’ [Charley 23, 1st baby, emCS]
Breast-feeding support: ‘I felt like I was failing..’
Physical difficulties
A small number of women spoke about the intimate topic of
the physical experience of breast-feeding, about problems or
worries they had had regarding their physical size and any
practical help they had received to overcome specific difficulties.
One of these was Nancy, who described how her midwife had
helped her to latch her baby on when she was struggling with
each feed:
‘I discussed it with Pam, my midwife… [she said] often ladies
with big breasts can struggle because they are more floppy and
slide out their mouths and things a lot. You have got to hold the
breast as well as the baby and stuff’ [Nancy 35, 1st baby, SVD]
Daisy also shared her perception that her physical size and the
shape of her breasts had made breast-feeding challenging. Daisy's
midwife had observed her feeding her infant and given her advice:
‘..she told me to sort of bring him in underneath because like
my boobs aren’t sitting up here and it would be easier, but then
you do that… and because my arms are big they would be over
his face, and poor bairn couldn’t feed because he couldn’t
breathe.’ [Daisy 23, 2nd baby, emCS]
Early introduction of Formula
Many women in this study used formula milk to top up breast
feeds within the first few days after the birth. One of these was
Nancy, who described how she and her husband had made the
decision on their first night at home from hospital that they would
give their son formula milk:
‘…nine hours or something like that trying to feed him. He was
just crying and I remember… I could hear his belly rumble. He
was starving and he obviously wasn’t getting anything. I was
sitting and I was in tears and I said to [my husband]: ‘What am I
going to do?’ And he says, ‘He needs to eat, so you need to give
him formula.’ So I did. I’m welling up now thinking about it. I
536 A. Keely et al. / Midwifery 31 (2015) 532–539
was really quite upset about it, but I gave him it’. [Nancy 35, 1st
baby SVD]
Some women believed that giving formula milk to their infants
led to further difficulties in establishing breast-feeding. Some, like
Connie, felt they had not been well-informed about the implica-
tions of introducing bottles for feeding very early on:
‘Maybe if someone had said to me when I gave him his first top
up of Aptamil: ‘You do realise if you start topping him up you’re
probably not going to get him over to the breast?’ [But..] there
wasn’t that level of information given to me’ [Connie 29, 1st
baby, SVD]
The role of partners
In common with Nancy (above), many other women described
their partners as key to their decision to introduce formula milk.
One of these was Isla, whose partner suggested introducing
formula in response to her discomfort and distress:
‘He kept saying, ‘Just..if it’s that sore.. just stop, because it's not
the end of the world’. He was like, ‘There's no point torturing
yourself for it’’ [Isla 26, 1st baby, SVD]
Another woman, Rosie, described how, despite experiencing
problems, she wanted to continue in her efforts to breast feed, but
that her husband disagreed:
‘I think I cried most of the night on day three, and again I think
it was guilt as well, except that I didn’t really want to stop. I
kept saying ‘I’ll just keep trying. I’ll wait another day and see
what happens.’ And he just sort of said, ‘It's just not worth it,
just stop’. He went to Tesco and came back with all the Aptamil
and everything we needed’ [Rosie 30, 1st baby, emCS].
Other women described their partners being concerned that
their baby wasn’t getting an adequate supply of breastmilk. One of
these women was Sally:
‘I don’t think [my husband] quite understood about the breast-
feeding - that it is normal every half an hour and it is normal
for [the baby] to cry for a feed. And he got quite distressed and
he was just like ‘We will just give him a bottle’ and gave him a
bottle and then he wouldn’t go back on the breast’ [Sally, 26, 1st
baby, emCS]
In addition, several other women described their partners as
quick to suggest the introduction of formula when they began to
experience breast-feeding problems.
breast-feeding clinics
A small number of women in this study visited an NHS
breast-feeding clinic and in the main they described their experi-
ences positively. One woman who visited a clinic was Angela, who
was finding breast-feeding painful and was diagnosed with thrush
when she attended. Camille also attended several times and
described how helpful she found her visits:
‘I went to the [location] clinic on a Friday, which was great and
they would really inspire me for about three days. And then on
kind of day three or four I would be like, ‘I can’t do it, I can’t do
it’ and I would go back thinking ‘I’m going to tell them I can’t do
it’ and they would make me feel better again…’ [Camille, 31, 1st
baby emCS]
However, many more women did not attend, despite the
problems they described. A variety of reasons for this were
reported. Some, like Sally, felt they had not had a good under-
standing of the purpose of the service:
‘Well, I kind of knew about them, but I thought you would only
go to something like that if you had latching on problems and I
never had latching on problems..’ [Sally, 26, 1st baby, emCS]
Hannah also chose not to access a breast-feeding clinic and
described several factors contributing to this decision, which, like
Sally, included a misconception about the purpose of the service:
‘…the first couple of weeks you’re kind of in the house aren’t
you? You dinnae want to go out… and then, when you do start
to venture out, you’ve got everybody that wants you to come
and see them, or wants to come and see you, so by the time I
was ready to go to the breastfeeding group we were having
issues, and I did’nae really want to go because I felt like I was
failing, so…’ [Hannah, 33, 1st baby, SVD]
Two further women believed that the purpose of the service
was to facilitate social support for women who were breast-
feeding and an additional woman echoed Hannah's sentiments
when she cited her feelings of ‘failing’ with breast-feeding as a
reason for not attending. Daisy referred again to her lack of
confidence (discussed above) when explaining why she did not
go to a clinic:
‘It's maybe the kind of person I am. I am not really into going to
groups where I don’t know anybody… maybe because I’m not
very confident’ [Daisy 23, 2nd baby, emCS]
The physical discomfort associated with recovering from a
caesarean childbirth as well as the practicalities of transport
arrangements (women are advised not to drive for six weeks
following a caesarean section) prevented other women, like Lydia,
from attending and accessing breast-feeding support:
‘…I didn’t go because I wasn’t driving and [my husband] went
back to work and um… I couldn’t have… I think I was still quite
sore when I came home. I was quite sore from the [caesarean]
section and the thought of going out for that first week when I
was home didn’t really appeal’ [Lydia 33, 1st baby, emCS]
Other Sources of support
Several women said they would have preferred to receive
support from health professionals in their own homes. One of
these was Sue:
‘I think if there was – I mean there is never, ever going to be a
resource in the NHS for it to happen - but if there is somebody
you could phone and they pop up and see you straight away
and physically help you. I think that's obviously utopia, isn’t it?’
[Sue 32, 1st baby emCS]
Another woman, Sally, received support from a clinical support
worker who visited her at home regularly:
‘[my midwife]… got me a clinical assistant who does breast-
feeding to come in and sit with me and help me and talk me
through it. It was all stuff I already knew but I just needed
somebody to be there and help me…’ [Sally 26, 1st baby, emCS]
Sally also had the support of a friend who was also breast-
feeding, which she described as having been vital in encouraging
her to continue to breast feed. She was mixed feeding at the time
of our interview:
‘It took me about 8 weeks, 9 weeks to be able to do it in public
because I was really paranoid about my body and how I looked.
Even now I hate how I look… but it was actually my friend who
 A. Keely et al. / Midwifery 31 (2015) 532–539
has just got a… such a carefree attitude. She was like ‘So? They
will just need to get over it’. And if it wasn’t for her I probably
wouldn’t breastfeed in public, but now I don’t have a problem
at all. It doesn’t bother me, but because of her, because she was
so, ‘Oh, I just whip them out anywhere and just breastfeed.’ She
was like: ‘It doesn’t bother me. And practise in the mirror first
to make sure you didn’t see anything.’ [Sally 26, 1st baby, emCS]
Another woman, Angela, described how she took trips out with
her neighbour, who was also breast-feeding:
‘If it wasn’t for my neighbour I don’t think I would actually have
had any support. Because she was going through the same
thing, we sort of offered each other support’ [Angela 36, 3rd
baby, SVD]
For these women the support of a friend, who provided
practical tips and companionship on trips out with their babies,
was very important in enabling them to continue breast-feeding
alongside formula feeding.
Discussion
This study explored the views and experiences of 28 obese
women who initiated breast-feeding when their babies were born,
but who were no longer exclusively breast-feeding, or had stopped
breast-feeding 6–10 weeks later. Using qualitative methods, we
accessed the women's perceptions of the complex and interweav-
ing factors which influenced their experiences and decisions
surrounding infant feeding. In common with the findings of
previous studies (Murphy, 1999; Avishai, 2007), many women
had found their infant feeding experiences challenging, both
physically and emotionally, and several women became upset as
they recounted their stories.
Three major themes emerged from the data analysis: the
impact of birth complications, a lack of privacy, and a low uptake
of specialist breast-feeding support. The findings highlight the
negative impact a combination of these factors can have on obese
women's breast-feeding experiences. These findings are discussed
below, before we consider the implications for future clinical
practice and research.
The impact of caesarean section
A high number of study participants gave birth by emergency
caesarean section (emCS). Maternal obesity increases the risks of
labour and birth complications, and the chance of successful
vaginal delivery decreases as maternal BMI increases (Leddy
et al., 2008). The women's accounts highlight their perceptions
that operative delivery negatively affected their experiences of
breast-feeding in a variety of ways. Several women experienced a
delay in establishing skin-to-skin contact following caesarean
delivery, for example. Facilitating skin-to-skin contact between
mother and baby can indeed be made more challenging by the
operative procedures and monitoring that are required immedi-
ately following a caesarean delivery, and initial breast-feeding can
be significantly delayed following caesarean compared to vaginal
birth (Rowe-Murray and Fisher, 2002). There is evidence that
caesarean section is associated with early introduction of formula
milk and early cessation of breast-feeding (Lindau et al., 2014).
Further, researchers in Canada found that, regardless of maternal
BMI, giving birth by caesarean section can negatively affect breast-
feeding self-efficacy, an important predictor of breast-feeding
duration and success, in the immediate postpartum period
(Dennis, 2006). A recent review of the evidence regarding early
537
skin-to-skin contact following caesarean childbirth found that,
with appropriate collaboration, skin-to-skin contact during cae-
sarean surgery can be implemented, and that early skin-to-skin
contact following caesarean delivery may decrease the time to first
breast feed and decrease formula supplementation in hospital
(Stevens et al., 2014).
Lacking privacy
Giving birth by caesarean section necessitates a postnatal
hospital stay of several days, and indeed evidence from a US study
demonstrates that overweight and obese women have longer
postnatal hospital stays, regardless of mode of delivery (Chu
et al., 2008). In the UK, this hospital stay will typically be in a
shared ward. The women in this study experienced giving their
first few breast feeds in such an environment, and many described
the challenges this presented in maintaining the privacy they
wanted. This was particularly challenging for those women whose
mobility was impaired during the first few postnatal days. The
exposure of her breasts and other parts of her body during
childbirth and the postnatal period may be difficult for any
woman, regardless of her BMI. However obesity is a highly
stigmatised condition (Brewis, 2014), and one which a woman is
unable to hide, even when she can control the exposure of her
flesh during day-to-day life. The loss of that control whilst
recovering from childbirth and establishing breast-feeding in such
a public environment was clearly extremely difficult for some
women in this study. There is evidence that obese women may
experience physical difficulties latching their baby on to the breast
and in finding comfortable feeding positions (Barnes et al., 1997),
and the findings of this study support this, as some women spoke
of their physical difficulties due to the size and shape of their
breasts. These difficulties with latching the baby on may also lead
to prolonged exposure of the breast at the start of a feed, prior to
the woman having the opportunity to ‘cover up’, and this may
heighten feelings of vulnerability and a reluctance to breast feed in
a public environment. Indeed, some participants described giving
a formula feed whilst in hospital in order to avoid breast-feeding
in such circumstances.
Upon hospital discharge, many women described the chal-
lenges involved in achieving and maintaining privacy when
breast-feeding at home when visitors called, and in public places,
and several women cited avoiding the exposure of their breasts in
public as a perceived advantage of formula feeding. It has been
suggested that poor body image may be a particularly influential
factor in breast-feeding problems in obese women (Hauff and
Demerath, 2012) and the findings of this study support this.
Several women spoke candidly about this highly sensitive subject,
and gave specific reasons related to their physical size, for their
reluctance to expose their breasts and their bodies in public.
breast-feeding support
Despite the problems the women described, it appears that
specialist breast-feeding clinics were under-used by this study
sample and that, for many, the specific purpose of breast-feeding
clinics was not well understood. Some women described a lack of
self-confidence and indeed some cited the fact that they were
experiencing problems as a reason for not using the service. The
small number of women who attended breast-feeding clinics
described positive experiences, which suggests others may have
benefitted from using the service, had they attended. Support from
a friend who was also breast-feeding, or from a midwife or clinical
support worker who provided individual support at home, was
538 A. Keely et al. / Midwifery 31 (2015) 532–539
valued more highly by several women than the expert help
available at a breast-feeding clinic. This may be due, in many
cases, to an acknowledged reluctance to breast feed in public,
added to the mobility and transport difficulties experienced by
some women whilst recovering from a caesarean section.
Several of the women in this study shared common problems
during their experiences of breast-feeding their babies. One of
these was a perception of insufficient milk supply, which is an
often cited reason for introducing formula milk among new
mothers, regardless of BMI (Gatti, 2008; Redsell et al., 2010;
Renfrew et al., 2012). However, there is evidence that obese women
may more commonly perceive their milk supply as insufficient
compared to other women (Mok et al., 2008; Guelinckx et al., 2012).
Almost all of the women who were concerned about their
breast milk supply, or who found breast-feeding physically diffi-
cult or painful, recounted their partners sharing their concerns and
being involved in the decision to introduce formula. There is
evidence that the attitude of a woman's partner to breast-feeding
is an important factor the initiation and continuation of breast-
feeding (Shaker et al., 2004), thus education and information for
partners will also be an important factor in establishing and
maintaining successful breast-feeding in this group of women.
In addition, some women described having physical difficulties
finding comfortable positions and latching the baby onto the
breast. Two women spoke about the help they received from their
midwives, who discussed the challenges that larger women or
women with larger breasts can experience. However, many parti-
cipants felt they did not receive enough support or information to
help them when they took the decision to introduce formula milk.
Although health professionals cannot provide round-the-clock
breast-feeding support following hospital discharge, several
women felt they may have benefitted from extra support in their
own homes. It may be that, via timely intervention and with
detailed history-taking and tailored support, some participants
could have been helped to continue to breast feed for longer.
Strengths and weaknesses
The main strength of our study was the use of an open-ended
exploratory design, which allowed new and unanticipated issues
to arise from the data. A key limitation was that we only recruited
from one maternity unit, which limits the potential generalisa-
bility of the findings, in particular potentially with regard to
women from ethnic minority groups. In addition, we acknowledge
that, as we used semi-structured interviews, this may have led to
participants retrospectively re-interpreting and re-telling their
stories, in order to reposition and present themselves as ‘good
mothers’.
Conclusion
It is vitally important that obese women who have made the
decision to breast feed are adequately supported to do so, in terms
of the health benefits for them and their babies, and also with
regard to their self-efficacy and emotional well-being. Midwives
should be mindful of the presence of combined factors alongside
maternal obesity, such as caesarean delivery, physical difficulties
when breast-feeding, the lack of privacy afforded by busy post-
natal wards, and a lack of confidence regarding milk supply, all of
which may increase the risk of breast-feeding difficulties and the
need for extra support. Training is needed to increase midwives’
confidence in discussing obesity when supporting women to
breast feed, and weight in pregnancy has been identified by
midwives as a sensitive issue which can be difficult to raise and
discuss (Schmied et al., 2011; Macleod et al., 2013). An exploration
of midwives’ training and education needs with regard to
breast-feeding support with this group of women might form
the focus of future research.
Early facilitation of skin-to-skin contact between mother and
baby forms part of hospital practices UK-wide (Brodribb et al.,
2013). An exploration of what is safe and practical regarding the
facilitation of very early skin-to-skin contact following caesarean
section could help to minimise the delay which many women
experience.
Our findings suggest that obese women need to be made aware
of the provision of breast-feeding clinics and support groups, and
it should be ensured that they understand the specific purpose
and provision of these services and encouraged to attend when
appropriate. Midwives and other health professionals should be
aware that obese women may be less likely to attend specialist
breast-feeding clinics despite being at higher risk of experiencing
breast-feeding problems and failure, and that in some cases
they may need additional tailored support in their own home.
Evidence is also needed to investigate the usefulness of partner
involvement in support and education, and future research may
usefully explore the views of partners regarding obesity and
breast-feeding, as well as the effectiveness of peer support inter-
ventions to increase confidence with breast-feeding within this
group of women.
Conflict of interest
None declared.
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