I S S U E SAN D I N N O VAT I O N S I N N U R S I N G PRAC T I C E

Infant feeding attitudes of expectant parents: breastfeeding and formula

feeding
Iolanda Shaker BS MPH HV RM RGN
Public Health Practitioner, Greater Glasgow Primary Care NHS Trust, Glasgow, UK

Jane A. Scott PhD MPH RPHNutr

Lecturer, Division of Developmental Medicine, Human Nutrition Section, University of Glasgow, Glasgow, UK

and Margaret Reid MA PhD

Professor and Head of Division of Community Based Sciences, Department of Public Health and Health Policy, University of Glasgow, Glasgow, UK

Journal of Advanced Nursing 45(3),

Submitted for publication 27 August 2002

Accepted for publication 15 August 2003

Correspondence: SHAKER I . , SCOTT J . A . & REID M . (2004) 260

Jane Scott, 268
University Department of Human Nutrition, Infant feeding attitudes of expectant parents: breastfeeding and formula feeding
Glasgow Royal Infirmary, Glasgow G31
Background. Research has indicated that parental attitudes are strong predictors of
2ER,
choice of infant feeding. Identification and understanding of the infant feeding attitudes
UK.
E-mail: j.a.scott@clinmed.gla.ac.uk of mothers and their social networks should be an early step in the design and
implementation of breastfeeding interventions.
Aim. To compare the infant feeding attitudes of parents of breastfed infants with those of
parents of formula fed infants.
Methods. A survey was carried out with a convenience sample of pregnant women
(gestational age 812 weeks) attending three maternity clinics in Scotland in 2000.
Expectant mothers and their partners (n 108 couples) completed the 17 item Iowa
Infant Feeding Attitude Scale. Demographic information was collected by face-to-face
interview and the method of feeding at discharge from hospital was obtained from
medical records.
Results. Parents of breastfed infants had more positive attitudes towards breast-feeding
than parents of formula fed infants, and were more knowledgeable about the health
benefits and nutritional superiority of breastfeeding. Fathers of both breastfed and
formula fed infants were more likely than their partners to disapprove of women
breastfeeding in public. Parents considered their chosen method of feeding to be the
more convenient alternative. Mothers of formula fed infants were more likely to think
that women who occasionally drink alcohol should not breastfeed.

Conclusion. Parents of formula fed infants had several misconceptions about

breastfeeding. Use of the Iowa Infant Feeding Attitude Scale could help health
professionals identify and address these in infant feeding discussions in the early
antenatal period. Efforts should be made to
include fathers in these infant-feeding
discussions.

Keywords: infant feeding attitudes, breastfeeding, expectant couples

260 2004 Blackwell Publishing Ltd

Issues and innovations in nursing practice
Background
Over the last few decades numerous efforts have been made by
researchers to identify the factors that determine how a woman
will feed her infant and, if she chooses to breastfeed, how long
breastfeeding will continue. Most research of an epidemiological
nature has focused on the association between breastfeeding rates
and maternal socio-demographic characteristics, biomedical
factors and, more recently, hospi-tal practices (Piper & Parks
1996, Clements et al. 1997, Scott et al. 2001). Factors such as
maternal and paternal breast-feeding knowledge and attitudes
have been less well studied, but have been shown to be
predictive of the infant feeding decision and may be more
important determinants of infant feeding behaviour than
demographic characteristics (Dungy et al. 1994). Furthermore,
parental attitudes may provide much greater potential as
intervention targets than unmod-ifiable demographic factors
(Losch et al. 1995).
This finding is in keeping with the Theory of Reasoned Action
(TRA), which states that there is one primary determinant of
behaviour, namely the individuals intention to perform it (Ajzen
& Fishbein 1977). The intention to perform a behaviour is in turn
influenced by the individuals attitude toward performing the
behaviour and their percep-tion of the social (or normative)
pressure exerted on them to perform the behaviour (Elder et al.
1999). The attitudes and advice offered by various individuals in
a womans social network have been suggested to exert an
influence on her infant feeding decision (Losch et al. 1995). In
particular, her partner and her mother have been shown to be
independently associated with the decision to breastfeed and with
duration of breastfeeding (Scott et al. 2001).
In traditional societies breastfeeding women are supported by
a doula. This person (frequently the mother of the new mother)
supports the new mother emotionally, provides practical advice
and guidance and helps her with household duties, allowing her
time to relax, establish her milk supply and become adjusted to
her infants needs (Barron et al. 1988). The concept of a doula is
common in most of the world except Western societies (Hall
1978). An outcome of social changes in modern societies is the
loss of support for women to breastfeed, which traditionally was
provided by the doula. When the extended family is absent,
women may rely heavily on partners to support their
breastfeeding decision and to help with household
responsibilities (James et al. 1994).
Until recently, most research investigating factors influen-cing
the decision to breastfeed has focused on characteristics of the
motherinfant pair, with relatively little attention being paid to
the role of the father. Earlier research demonstrating
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268
Infant feeding attitudes of expectant parents
that married women were more likely to breastfeed than single
women (Rassin et al. 1984, Samuels et al. 1985, MacGowan et
al. 1991) suggested that fathers play some role in mothers
decisions to breastfeed. More recent research focusing on fathers
indicates that they participate in and influence the choice of
infant feeding method, and influence duration by acting as key
supports or deterrents to breast-feeding by the mother (Jordon &
Wall 1993).
In a study in the United States of America (USA), Littman et
al. (1994) demonstrated that strong approval of breastfeeding by
the father was associated with a high incidence of breastfeeding
(981%) compared with only 269% breastfeeding when the
father was indifferent to feeding choice (P < 0001). Similarly,
Scott et al. (2001) in an Australian study showed that women
who perceived their partners to prefer breastfeeding were more
likely to initiate breastfeeding than women who perceived their
partners to prefer bottle-feeding or to be ambivalent about how
they fed their infant (OR 913; 95% CI 4831726). Fathers
attitude was associated also with breastfeeding duration. Women
who perceived their partners preferred bottle-feeding or were
ambivalent about the feeding method were more likely to have
stopped breastfeeding at any time compared with women who
perceived their partners to have a preference for breastfeeding
(RR 172; 95% CI 129222). The association between
paternal attitudes and breastfeeding initiation and duration was
independent of socio-demographic factors such as maternal age
and level of education.
Giugliani et al. (1994) reported that fathers opinion about
breastfeeding was the most important factor related to
breastfeeding, regardless of maternal age, educational level,
ethnic group and marital status. Women who said that their
partners favoured breastfeeding were significantly more likely to
breastfeed, compared with those whose partners either preferred
bottle-feeding or were ambivalent about infant feeding (OR
328; 95% CI 671595). Similarly, Birenbaum et al.
(1989) reported that husbands opinions about breast-feeding
appeared to be the major determinant of initiation of
breastfeeding in a population of Israeli women. The results of
these studies, which have used multivariate analysis (Birenbaum
et al. 1989, Giugliani et al. 1994, Scott et al. 2001), both
support and strengthen the findings of previous studies as they
have controlled for potentially confounding demographic and
biomedical variables.
Studies investigating the relationship of parental attitudes and
mothers infant feeding choice are limited, however, in that they
have usually failed to include the attitudes of both parents and
instead have studied fathers (Giugliani et al. 1994, Littman et al.
1994, Scott et al. 2001, Pollack et al.
261
I. Shaker et al.
2002) or mothers (Dungy et al. 1994, De la Mora et al. 1999)
separately. Few reported studies have simultaneously repor-ted
the attitudes of both female and male partner (Freed et al. 1993,
Shepherd et al. 2000). Furthermore, the attitudes of fathers and
other sources of social support have usually been reported
indirectly by mothers (Giugliani et al. 1994, Littman et al. 1994,
Arora et al. 2001, Scott et al. 2001). Women, however, may not
accurately predict the infant feeding attitudes of others, as
revealed in a study in the USA (Freed et al. 1993) showing that
fathers had more positive attitudes than their partners expected.
Finally, only a few of the cited studies (Freed et al. 1993, Dungy
et al. 1994, De la Mora et al. 1999) reported measuring infant
feeding attitudes with an instrument that had been evaluated for
validity, that is ability to predict feeding method.
The study
Purpose
The purpose of this paper is to report and compare the infant
feeding attitudes of both mothers and fathers of breastfed infants
with the attitudes of mothers and fathers whose infants were
being formula fed at discharge, using a previ-ously validated
instrument.
Sample
Potentially eligible subjects were women attending three
maternity clinics serving the southern suburbs of Glasgow on the
days that one of the researchers (IS) was in attendance.
Recruitment took place over a 12-week period in the autumn of
2000.
Convenience sampling was used and all women (n 170)
attending for their booking-in clinic (approximate gesta-tional
age 812 weeks) were invited to participate. Mothers who agreed
to participate were given a self-administered infant feeding
attitude scale to complete and return to the research staff in a
sealed envelope. They were also requested to have the person
identified as being their primary source of support complete the
attitude scale, to be returned in a postage-paid, self-addressed
envelope. Personal and demo-graphic data (age, age left school,
parity, whether living with husband/partner or other and social
class), previous feeding information and intended feeding
method were obtained from mothers by face-to-face interview.
Information on method of feeding at discharge from hospital was
obtained from the medical notes.
All but one woman agreed to participate in the study.
However, infant feeding attitude questionnaires were com-
262 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268
pleted by only 129 women (76%) and their primary supporter.
The majority of women (n 111) nominated their husband or
partner as their primary source of support. Initially it was
planned to investigate also the attitudes of other people identified
as being a womans primary source of support. However, due to
the relatively limited number of other people (e.g. the womans
mother) nominated by the remaining women (n 18) as their
primary source of social support, it was decided to limit the
analysis to those who nominated their husband or partner.
Furthermore, studies of Western mothers suggest that a womans
partner is a more important influence on feeding decision
(Giugliani et al. 1994, Scott et al. 2001) and source of social
support than other family members or friends (Bryant 1982,
Matich & Sims 1992).
Information on feeding method at discharge was not available
for a small number of participants and this paper reports and
compares the infant feeding attitudes of the 108 expectant
couples (woman and partner) for which this information was
available. A sample of this size was sufficient to allow the
proportion of women who breastfed to be estimated with a
precision of 9% (based on a 95% CI). Given the early stage of
pregnancy, it was assumed that the husband or partner nominated
by the mother was the infants father, and he is referred to as
either the infants father or the womans partner throughout the
paper.
Iowa Infant Feeding Attitude Scale
The Iowa Infant Feeding Attitude Scale (IIFAS), which has
previously been tested for reliability and validity in a series of
studies of women in the USA (De la Mora et al. 1999), was used
to assess each parents infant feeding attitudes. The IIFAS was
found in these earlier studies to have good internal consistency,
having a Cronbachs alpha of 085 in the two studies involving
both breastfeeding and formula feeding mothers. Validity for the
measure was clearly indicated by the ability of scores on the
IIFAS to predict choice of feeding method as well as duration of
both exclusive and partial breastfeeding.
The IIFAS consists of 17 attitude questions (presented in Table
2 and 3) and participants were asked to respond to each
individual item using a bi-polar 5 point scale (strongly disagree
strongly agree). Approximately half of the items were worded in
a manner favourable to breastfeeding and the remaining
favourable to formula feeding. Items that favoured formula
feeding were reverse scored (i.e. 1 5, 2 4, 4 2 and 5 1)
and a total attitude score was computed via an equally weighted
sum of responses to the individual items. Total attitude scores
range from 17, reflecting positive
Issues and innovations in nursing practice Infant feeding attitudes of expectant parents

formula feeding attitudes, to a high of 85 indicative of attitudes
that favoured breastfeeding.
Data analysis
The relationship of the socio-demographic factors to infant
feeding method was analysed using the independent t-test for
normally distributed continuous data and the chi-square test for
categorical data. The means of the total attitude scores were
compared using the independent t-test. As responses to the
individual attitude items were not normally distributed, the
MannWhitney U-test was used to compare the attitudes of
breastfeeding mothers with those of formula feeding mothers and
the attitudes of fathers whose infants were breastfed with those
of fathers whose infants were formula fed. Due to the large
number of statistical comparisons, a Bonferroni adjustment (P
005/number of comparisons) was made to minimize the risk of
mass significance. Only P-values 0001 were considered
statistically significant.
Results
Maternal age of the sample ranged from 16 to 42 years, with an
having their first baby (519%), had left school after age 16
years (528%) and lived with their husband or partner
(880%). There was no significant association between method
of feeding and any of the demographic variables measured (Table
1).
The majority of women (815%) had decided on how they
would feed their baby by the time of the booking clinic. Over
half (611%) indicated that they intended to breastfeed, just
under one quarter (204%) intended to formula feed, and the
remainder (185%) were undecided. Following delivery, just
over half (509%) of women were exclusively formula feeding
their infants and just under half (491%) were breastfeeding at
discharge from hospital.
There was a strong association between intended and actual
feeding behaviour (v2 38995, d.f. 2, P < 0001). The
majority of women (955%) who indicated that they would
formula feed did so at discharge. Whilst the majority of women
who intended to breastfeed (727%) followed through on their
intention, more than one quarter (273%) who indicated their
intention to breastfeed were formula feeding on discharge from
hospital. The majority of women (80%) who were undecided at
the booking interview about how they would feed their infant left
hospital formula feeding.

average of 287 years (SD 51 years). Most women were

Table 1 Demographic characteristics of mothers and relationship to feeding method*

All Breastfeeding Formula feeding

mothers mothers (n 53) mothers (n 55)

Age (years) <

P 0043
<25 19 (176) 297 46 277 54
2529 40 (370)
30 and older 49 (454)
Age mother left school (years) <
P 0025
16 51 (472) 168 097 164 092
>16 57 (528)
Living arrangement 2
v 3997, df 1, P 0046
Live with husband/partner 95 (880) 50 (526) 45 (474)
Other 13 (120) 3 (231) 10 (769)
Parity 2
v 0941, d.f. 1, P 0332
Primiparous 56 (519) 30 (566) 26 (473)
Multiparous 52 (481) 23 (434) 29 (527)
DEPCAT score 2
v 0335, d.f. 2, P 0846
12 15 (139) 7 (467) 8 (533)
35 54 (500) 28 (519) 26 (481)
67 39 (361) 18 (462) 21 (538)
Intended feeding method 2
v 38995, d.f. 2, P < 0001
Formula feeding 22 (204) 1 (45) 21 (955)
Undecided 20 (185) 4 (200) 16 (800)
Breast feeding 66 (611) 48 (727) 18 (273)

*Results are given as mean SD or number and percentage.

<
Independent t-test.
DEPCAT score is a measure of social deprivation where 1, lowest level of deprivation; 7, highest level of deprivation.

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268 263
I. Shaker et al.

Comparison of mothers infant feeding attitudes
Breastfeeding mothers had significantly higher total attitude
scores, favouring breastfeeding, when compared with those who
chose to formula feed (650 83 vs. 551 79,
P < 0001). The MannWhitney U-test was used to compare
the responses of both groups of mothers to individual scale
items.
The results reveal some interesting findings in relation to
mothers attitudes and knowledge about breast and for-mula
feeding (Table 2). In general, mothers of breastfed infants
appeared to be more aware of the nutritional superiority of breast
milk and were more likely to believe that breastmilk is the ideal
food for infants (868% vs. 564%, P < 0001).
Similarly, mothers of breastfed infants appeared to be more
aware of the health benefits associated with breast-feeding. They
were more likely to agree with the state-ment that breastfed
infants are healthier than formula fed infants (604% vs.
255%, P < 0001) and more likely to
disagree with the statement that the benefits last only as long as
the baby is breastfed (906% vs. 618%,
P < 0001).
The majority of both groups of mothers agreed that
breastfeeding is cheaper than formula (P 0284). In general,
women were likely to believe that their chosen method of
feeding was the more convenient way to feed an infant. For
instance, mothers of breastfeeding infants were more likely to
believe breastfeeding to be more convenient than formula
feeding (585% vs. 273%, P < 0001), and mothers who
were formula feeding infants were more likely to agree that
formula feeding was the more convenient method (527% vs.
170%, P < 0001). Women who chose to breastfeed were less
likely to agree with the statement that a mother who occasionally
drinks alcohol should not breastfeed her baby (208% vs.
545%, P < 0001). The majority of women from both groups
disagreed with the statement that women should not breastfeed in
public places such as restaurants (P 0319). Mothers who
chose to breastfeed were more likely to believe that mothers who

Table 2 Comparison of the infant feeding attitudes of breastfeeding and formula feeding mothers, using MannWhitney U-test

Mothers breastfeeding Mothers formula feeding

at discharge (n 53) (%) at discharge (n 55) (%)

SA A N D SD SA A N D SD P-value

1. The benefits of breast milk last only as long as the baby 00 38 57 264 642 55 73 255 273 345 <0001
is breast fed*
2. Formula feeding is more convenient than breastfeeding* 57 113 283 264 283 345 182 236 127 109 <0001
3. Breastfeeding increases mother infant bonding 528 245 113 38 75 400 109 255 127 109 0004
4. Breast milk is lacking in iron* 00 19 358 340 283 00 36 564 164 236 0302
5. Formula fed babies are more likely to be overfed than 113 170 491 189 38 91 91 418 200 200 0019
breast fed babies
6. Formula feeding is the better choice if the mother plans 75 340 208 245 132 291 182 382 55 91 0019
to go out to work*
7. Mothers who formula feed miss one of the great joys 208 283 264 152 94 91 73 200 182 455 <0001
of motherhood
8. Women should not breastfeed in public places such 38 57 151 189 566 36 18 127 164 655 0319
as restaurants*
9. Breastfed babies are healthier than formula fed babies 264 340 283 75 38 91 164 382 145 218 <0001
10. Breast fed babies are more likely to be overfed than 19 38 415 283 245 00 36 327 345 291 0131
formula fed babies*
11. Fathers feel left out if a mother breasts feeds* 00 170 151 453 226 127 182 200 200 291 0185
12. Breast milk is the ideal food for babies 642 226 38 38 57 327 236 364 36 36 <0001
13. Breast milk is more easily digested than formula 453 245 226 57 19 273 164 473 73 18 0009
14. Formula is as healthy for an infant as breast milk* 00 57 434 321 189 109 273 400 145 73 <0001
15. Breastfeeding is more convenient than formula 283 302 302 94 19 109 164 436 218 73 <0001
16. Breast milk is cheaper than formula 755 208 19 19 00 745 109 145 00 00 0284
17. A mother who occasionally drinks alcohol should not 57 151 208 377 208 455 91 291 91 73 <0001
breastfeed her baby*

*Variables reverse scored to calculate total infant feeding attitude score.

SA, strongly agree; A, agree; N, neutral; D, disagree; SD, strongly disagree.

264 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268
Issues and innovations in nursing practice Infant feeding attitudes of expectant parents

formula feed miss out on one of the great joys of motherhood mothers who formula feed miss out on one of the great joys of
(491% vs. 164%, P < 0001).
motherhood (528% vs. 291%, P 0001).

Comparison of fathers infant feeding attitudes Discussion

The fathers of breastfed infants had significantly higher total
attitude scores, favouring breastfeeding, compared with fathers
of formula fed infants (627 76% vs. 551 88, P <
0001), and were more likely to believe that breast milk is the
ideal food for babies (925% vs. 564%, P < 0001) and that
breastfed babies are healthier than formula fed babies (585%
vs. 291%, P 0001) (Table 3). In keeping with the findings
for mothers, both groups of fathers were likely to agree that
breastfeeding was cheaper than formula feeding, and were more
likely to think that the most convenient method of infant feeding
was the method chosen by their partner. Fathers of breastfed
infants were more likely to agree that breastfeeding increases
mother infant bonding (887% vs. 618%, P < 0001) and
that
Use of the IIAFS has not been reported outside the USA,
although the scales original developers recommended that it be
used with more diverse samples, including different ethnic
groups as well as members of a womans social network. This is
the first study to report the use of the scale with expectant
fathers. Use in this current study revealed that the scale had good
internal reliability, having a Cronbachs alpha of 079 and
077 for mothers and fathers, respectively. The results also
indicate that scale has validity in terms of predicting choice of
feeding method. That is, mothers of breastfed infants had
significantly higher scores than mothers of formula fed infants
and fathers of breastfed infants had significantly higher scores
than fathers of formula fed infants.

Table 3 Comparison of the infant feeding attitudes of fathers with breastfed infants and fathers with formula fed infants, using MannWhitney U-test

Fathers of breastfed infant Fathers of formula fed infant

(n 53) (%) (n 55) (%)

SA A N D SD SA A N D SD P-value

1. The benefits of breast milk last only as long as the baby 38 94 170 283 415 109 18 327 200 345 0238
is breast fed*
2. Formula feeding is more convenient than breastfeeding* 75 189 283 245 208 364 200 327 18 91 <0001
3. Breastfeeding increases mother infant bonding 604 283 38 19 57 273 345 218 91 73 <0001
4. Breast milk is lacking in iron* 00 38 472 189 302 18 18 600 145 218 0218
5. Formula fed babies are more likely to be overfed than 00 302 509 132 57 127 127 473 109 164 0476
breast fed babies
6. Formula feeding is the better choice if the mother plans 132 283 264 189 132 309 291 255 91 55 0010
to go out to work*
7. Mothers who formula feed miss one of the great joys 189 340 283 151 38 109 182 236 182 291 0001
of motherhood
8. Women should not breastfeed in public places such 151 132 113 226 377 164 36 200 164 436 0633
as restaurants*
9. Breastfed babies are healthier than formula fed babies 283 302 321 57 38 164 127 345 182 182 0001
10. Breast fed babies are more likely to be overfed than 19 57 453 302 170 18 36 436 255 255 0452
formula fed babies*
11. Fathers feel left out if a mother breasts feeds* 19 94 57 415 415 73 164 91 200 473 0626
12. Breast milk is the ideal food for babies 302 226 453 00 19 345 218 327 91 18 <0001
13 Breast milk is more easily digested than formula 302 226 453 00 19 182 164 636 00 18 0063
14. Formula is as healthy for an infant as breast milk* 19 00 377 509 94 127 182 436 200 55 <0001
15. Breastfeeding is more convenient than formula 245 151 321 245 38 164 36 345 309 145 0019
16. Breast milk is cheaper than formula 698 189 94 19 00 727 91 145 36 00 0960
17. A mother who occasionally drinks alcohol should 151 170 321 208 151 236 164 364 218 18 0099
not breastfeed her baby*

*Variables reverse scored to calculate total infant feeding attitude score.

SA, strongly agree; A, agree; N, neutral; D, disagree; SD, strongly disagree.

2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268 265
I. Shaker et al.
In this study, mothers and fathers of breastfed infants appeared
to be more knowledgeable about the nutritional superiority and
health benefits of breastmilk, compared with parents of formula
fed infants. Shepherd et al. (2000) reported a similar finding in
another recent Scottish study, suggesting that the decision to
formula feed may be due, at least partly, to lack of awareness of
the benefits of breastfeeding. Murphy (1999), however, reported
that mothers who chose to formula feed also knew that
breastfeeding was reputed to be healthier for babies. This
suggests that differences in attitudes may not necessarily reflect a
knowledge deficit but that parents of formula fed infants, in
particular mothers, may structure their responses to excuse or
justify their feeding choice. Murphy (1999) describes the infant
feeding decision as a moral minefield, and the action of a woman
to acknowledge the superiority of breastfeeding yet choose to
formula feed exposes her to the charge that she is a poor mother
who places her own needs, preferences or convenience above the
babys welfare (p. 187).
An unsurprising finding of this study was that both mothers
and fathers believed that their chosen method of feeding was the
more convenient way to feed their infant. Similar findings were
reported by Shepherd et al. (2000), and probably reflect a
difference in womens definition of convenience as much as a
difference in attitudes. For instance, women who choose to
breastfeed may define convenience as being able to breastfeed
when and wherever they wish and not having the burden of
preparing bottles. On the other hand, women who choose to
formula feed may define convenience as being able to go out for
extended periods and leave the feeding and care of their infant to
others.
Mothers formula feeding at discharge were more likely than
breastfeeding mothers to agree with the statement that a mother
who occasionally drinks alcohol should not breastfeed. It may be
that mothers of formula fed infants who consume alcohol
mistakenly believe that the occa-sional, moderate intake of
alcohol is prohibited when breastfeeding, and that their decision
to formula feed reflects a genuine desire to protect their infants
health. Alternatively, this could be used as a socially acceptable
justification for choosing to formula feed. Similarly, there is
some evidence that women who smoke think they cannot or
should not breastfeed. While smoking and consumption of
alcohol are not encouraged, the occasional use of either
substance is not prohibited. The Canadian Paediatric Society
(1998) clearly states that occasional alcohol intake should not
preclude breastfeeding and that, even if a mother continues to
smoke, breastfeeding is still the best choice.
266 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268
While there are recommendations for moderate alcohol intake
whilst breastfeeding (Schulte 1995), further research is needed to
determine whether mothers are receiving confused messages
about use of alcohol and smoking when breastfeeding.
There was no difference in the attitudes of fathers in either
group to women breastfeeding in public, and fathers in general
were more likely than mothers to strongly agree that women
should not breastfeed in a public place such as a restaurant (61%
vs. 40%, P < 0001). Shepherd et al. (2000) also found that
Scottish fathers of both formula fed and breastfed infants were
more embarrassed than their partners with women breastfeeding
in front of non-family members. This attitude is not confined to
Scottish men, and a study in the USA reported that a majority of
fathers of both formula feeding (78%) and breastfeeding (71%)
infants believed that breastfeeding was not acceptable in public
(Freed et al. 1992). Attitudes towards breastfeeding in public
may be changing in the USA, however, as a recent study revealed
that fewer men thought that breastfeeding was either
unacceptable in public (29%) or embarrassing (34%) (Pollack et
al. 2002).
Limitations of the study
A limitation of the study is the possibility that the question-naires
taken home to be completed by the womans primary source of
support were not in fact completed by the person nominated. It is
possible that the women may have comple-ted the questionnaire
for the nominated person. It is more likely, however, that women
with partners who were not interested in completing the
questionnaire would simply fail to return them, as was the case
for almost one quarter of women who initially agreed to
participate. It is also possible that the husband or partner
nominated by the woman was not in fact the infants father. We
think that this is unlikely, given the early stage of pregnancy at
which women attended the booking-in clinic. Questions of
paternity may be sensitive, and we did not think it appropriate to
ask this question of women in a face-to-face interview. Another
possible limitation of the study is that women who attended the
clinic on the days that the researcher was present were in some
way different from those who attended on other days. We have
no reason to suspect this, as women are able to attend any of the
clinics during the week, subject to availability, and thus the
clinics attended by the researcher are representative of those
available in the area. Despite these limitations, the results of the
study revealed some interesting differences in the attitudes of
parents of breastfed and formula fed infants and add to our
understanding of infant feeding attitudes.
Issues and innovations in nursing practice
What is already known about this topic
Maternal and paternal infant feeding attitudes are strong
predictors of choice of feeding method and breastfeeding
duration.
Parents of breastfed infants are more knowledgeable about
the benefits of, and have more favourable atti-tudes to,
breastfeeding than parents of formula fed infants.
Few studies have simultaneously studied the infant feeding
attitudes of both parents or used a reliable and valid
instrument to assess attitudes.
What this paper adds
It indicates that parents of formula fed infants continue to
have poorer knowledge of breastfeeding than the parents of
breastfed infants.
It highlights potential areas to be targeted by breast-feeding
information programmes.
It suggests that the Iowa Infant Feeding Attitudes Scale
could be used to identify the attitudes of expectant parents
in the early antenatal period.
Information collected by the Iowa Infant Feeding Atti-tude
Scale could be used to identify parents with neutral
attitudes who might be most responsive to targeted
intervention activities.
Conclusions
Attitudes are an important determinant of behaviour, and
favourable attitudes towards breastfeeding are necessary in order
to support this infant feeding method. Parents of breastfed infants
had more positive attitudes towards breastfeeding than parents of
formula fed infants and were more knowledgeable about the
health benefits and nutri-tional superiority of breastfeeding. The
difference in atti-tudes may be explained in part by knowledge
deficits, but it is likely that parents of formula fed infants, in
particular mothers, structure their responses to justify their infant
feeding decisions.
An understanding of parental knowledge about and attitudes
towards infant feeding is necessary to inform the design of
effective breastfeeding promotion interventions. The role of the
father in the infant feeding choice needs to be recognized, and
health professionals must find ways of involving partners in
infant feeding discussions. Currently few opportunities exist for
fathers to learn about breast-
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 45(3), 260268
Infant feeding attitudes of expectant parents
feeding and to prepare themselves to offer the emotional and
practical support required by their partners.
The IIFAS used in this study is simple to use and score, and
could be used in the early antenatal period to identify the
attitudes of expectant couples. While parents with attitudes that
strongly favour either breast or formula feeding are unlikely to
be swayed, it is possible that information and guidance provided
to undecided couples, with neutral attitudes, during the antenatal
period may favourably influ-ence their decision to breastfeed.
Acknowledgements
The assistance of the women and partners who participated in
this study is gratefully acknowledged.
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