The role of emotions and injunctive norms in breastfeeding: a systematic review and meta-analysis

Abstract

Breastfeeding has many known benefits, but rates vary globally. We propose two main reasons why psychological theory and interventions have not been successful to date in explaining breastfeeding behaviours. Specifically, prior research underestimates the importance of (1) specific emotions and (2) wider injunctive influences (i.e., societal and moral norms about what women feel they ought to be doing) in the breastfeeding experience. Therefore, we conducted a systematic review of quantitative, qualitative, and mixed-methods studies that explored whether injunctive norms and/ or specific emotions are associated with breastfeeding behaviours (i.e., intentions, initiation and duration). Seventy-two papers were included in this review; data were extracted and quality appraisals conducted for all included studies. A meta-analysis of effect sizes was performed with the quantitative data. A convergent qualitative synthesis of the data was conducted, resulting in the following line of argument: Breastfeeding is a social behaviour and not a personal/individual behaviour. From this line of argument, three themes with associated sub-themes were developed, highlighting the importance of both specific emotions and injunctive norms on breastfeeding behaviours. These influences are discussed in relation to both theoretical and practical implications, as well as future research.

Self‐conscious emotions and breastfeeding support: A focused synthesis of UK qualitative research

“…Careful emotion work is required to avoid feeling guilt, shame, embarrassment or even humiliation. As indicated in a recent review (Russell et al, 2021 ), those supporting breastfeeding are often entering an emotionally complex situation where mothers can feel embarrassment about breaching social norms, guilt about not meeting perceived moral obligations to breastfeed (or to fulfil duties incompatible with breastfeeding) and shame about perceived ‘failures’. Supportive interactions that do not shame or humiliate women further and that support positive emotion are vital.…”

“…Contemporary notions of ‘good mothering’ can imply total focus on optimising the child's health, well‐being and development, regardless of cost to the mother (Head, 2017 ), with the implication that mothers have a duty to breastfeed (Woollard & Porter, 2017 ). Infant feeding practices are therefore shaped not only by social conventions but also by moral injunctions (Russell et al, 2021 ). This creates a ‘moral minefield’ that mothers must negotiate to demonstrate to themselves and others that they are a ‘good mother’ regardless of feeding method (Johnson et al, 2013 ; Ryan et al, 2010 ).…”

Infant feeding and internalized stigma: The role of guilt and shame

“…The two studies included different inclusion criteria, Study 1—baby under 2 years and Study 2—baby under 6 months, which may have impacted the results. This is an important point to consider as prior research also uses variable age ranges and outcome measures (Russell et al, 2021).…”

“…Emotional factors have been found to play an important role in breastfeeding outcomes (Shepherd et al., 2017). In relation to the emotions that women experience in response to infant feeding, prior evidence has indicated that women experience a range of self‐conscious emotions, such as shame, guilt, and embarrassment (Russell et al, 2021). This review also identified that these self‐conscious emotions can be both anticipated and experienced and are strongly related to societal and moral norms.…”

A behavioral economic demand analysis of mothers' decision to exclusively breastfeed in the workplace

“…Nevertheless, previous research has documented various risk factors for early cessation of breastfeeding. Such factors can be categorized into the following six groups: (a) the presence of barriers to breastfeeding, such as lactation difficulties and concerns about milk supply (e.g., Hornsby et al, 2019; Odom et al, 2013); (b) demographic factors, such as age and socioeconomic status (e.g., Bosnjak et al, 2009; Coleman et al, 2009); (c) social factors, such as support from families and norms (e.g., Russell et al, 2021; Tchaconas et al, 2017); (d) health‐related factors, such as smoking and life stress (e.g., Cohen et al, 2018; Dozier et al, 2012); (e) cognitive factors, such as self‐efficacy and attitudes toward breastfeeding (e.g., Brockway et al, 2017; Nnebe‐Agumadu et al, 2016); and (f) previous breastfeeding experiences (e.g., Huang et al, 2019). Moreover, various attempts have been made to improve the rate of exclusive breastfeeding, which include breastfeeding education/support provided antenatally (Lumbiganon et al, 2016) or postnatally (National Institute for Health and Care Excellence, 2021), as well as providing financial incentives for continuation of breastfeeding (e.g., Furman, 2017; Washio et al, 2017).…”