Abstract
Background
Almost all babies are breastfed in Papua New Guinea (PNG); yet appropriate breastfeeding practices are not always followed.
Aim
To explore the perspectives of first-time mothers in rural PNG on how the language and discourse of grandmothers about infant feeding influence their breastfeeding practices.
Methods
A critical discourse analysis (CDA) approach was used to theoretically frame the analysis of twenty first-time mothers’ narratives.
Findings
Analysis revealed three themes: (i) prescribed knowledge repository, (ii) social control and dominance, and (iii) disapproval and role conflict, which provides an understanding of grandmothers’ differing views and positions on infant feeding practices and their influence on breastfeeding.
Conclusion
This study shows that grandmothers remain influential in infant feeding practices in rural PNG. There appears to be a societal expectation that empowers grandmothers in the maternal decision-making processes regarding breastfeeding practice. Grandmothers’ influence includes the early introduction of complementary foods to infants less than six months old. Interventions aimed at promoting, protecting, and supporting breastfeeding need to include grandmothers.
Keywords
Statement of Significance
Problem or issue
Despite World Health Organizations (WHO) recommendations for exclusive breastfeeding of babies for the first six months of life, appropriate breastfeeding practices are not always followed in PNG. Grandmothers in rural PNG are deeply involved in new mothers’ lives and decision-making in line with societal expectations. There is limited information concerning the influence of these grandmothers on new mothers’ breastfeeding practices.
What is already known
There is emerging global research indicating that grandmothers are key players in mothers’ breastfeeding decisions. Grandmothers’ support with household chores and helping care for older children can be beneficial for breastfeeding by allowing more time together for the mother and baby. However, if they lack contemporary knowledge or provide information contrary to the WHO recommendations [
[1]
], their involvement may have a negative effect on the mother’s decision to initiate breastfeeding and continue exclusive breastfeeding for up to 6 months.World Health Organization (WHO). Exclusive breastfeeding for optimal growth, development and health of infants 2019. 〈https://www.who.int/elena/titles/exclusive_breastfeeding/en/〉.
What this paper adds
This study supports the notion that grandmothers may adversely impact exclusive breastfeeding practices. Grandmothers' involvement in infant feeding practices is a cultural expectation and remains influential, often contradicting recommended breastfeeding practices. Breastfeeding interventions should consider a grandmother-inclusive approach.
1. Introduction
Timely initiation of breastfeeding within one hour after birth and exclusive breastfeeding for the first six months, followed by continued breastfeeding up to two years of age, is recognised globally as an optimal intervention for improving maternal and child health [
[1]
]. Breastfeeding has significant physiological, psychological, and immunological benefits for mothers and infants, as well as societal and economic benefits [World Health Organization (WHO). Exclusive breastfeeding for optimal growth, development and health of infants 2019. 〈https://www.who.int/elena/titles/exclusive_breastfeeding/en/〉.
2
, 3
, 4
]. Notably, breastfeeding reduces infant morbidity and mortality, promotes postpartum recovery, protects against chronic diseases (i.e., breast cancer, ovarian cancer, Type 2 diabetes and cardiovascular disease), and improves overall maternal well-being [3
, 5
, 6
]. Not only is breastfeeding beneficial for the short and long-term health of the individual, it has been estimated that women who breastfeed contribute positively to the national economy through their supply of breast milk [6
, 7
]. Thus, the economic cost of promoting, protecting, and supporting breastfeeding in comparison to its significant positive impact on maternal and child health makes breastfeeding a valuable health promotion strategy [[6]
].Despite the substantial health and economic benefits of exclusive breastfeeding, it remains an unattainable goal for low- and middle-income countries [
3
, 6
]. The predisposition to the timely initiation and duration of breastfeeding is influenced by multiple interconnected factors such as health, psychosocial, cultural, political, and economic factors [8
, 9
, - Kronborg H.
- Foverskov E.
Multifactorial influence on duration of exclusive breastfeeding; a Danish cohort study.
PLOS ONE. 2020; 15e0238363https://doi.org/10.1371/journal.pone.0238363
10
]. Amongst these factors, sociodemographics (age, education, employment), birth mode, poor social support, lactation issues, social norms, and access to health services influence breastfeeding practices [- Cohen S.S.
- Alexander D.D.
- Krebs N.F.
- Young B.E.
- Cabana M.D.
- Erdmann P.
- et al.
Factors associated with breastfeeding initiation and continuation: a meta-analysis.
J. Pediatr. 2018; 203https://doi.org/10.1016/j.jpeds.2018.08.008
9
, - Kronborg H.
- Foverskov E.
Multifactorial influence on duration of exclusive breastfeeding; a Danish cohort study.
PLOS ONE. 2020; 15e0238363https://doi.org/10.1371/journal.pone.0238363
10
, - Cohen S.S.
- Alexander D.D.
- Krebs N.F.
- Young B.E.
- Cabana M.D.
- Erdmann P.
- et al.
Factors associated with breastfeeding initiation and continuation: a meta-analysis.
J. Pediatr. 2018; 203https://doi.org/10.1016/j.jpeds.2018.08.008
11
, 12
, 13
]. Furthermore, the early introduction of complementary feeding established on erroneous assumptions about breastfeeding can affect its initiation and continuity. These breastfeeding practices are also permeated by family traditions and attitudes, perceived social myths and norms, and traditional knowledge transmitted and steered through generations, including which foods to introduce, the timing of their introduction, and who should feed infants [12
, 14
, 15
].- Nsiah-Asamoah C.
- Doku D.T.
- Agblorti S.
Mothers’ and Grandmothers’ misconceptions and socio-cultural factors as barriers to exclusive breastfeeding: a qualitative study involving Health Workers in two rural districts of Ghana.
PLoS One. 2020; 15e0239278https://doi.org/10.1371/journal.pone.0239278
In many societies around the world, social and cultural structures provide prominent positions for grandmothers, authorise them to serve as mentors and advisors to first-time mothers and caregivers (a perceived familial obligation), which can impact breastfeeding [
16
, 17
, 18
, 19
]. There is growing evidence that grandmothers’ lack of breastfeeding knowledge and experience with evidence-based breastfeeding practices encourages early supplementation of semi-solid foods, including water or formula, disrupting maternal milk supply [20
, 21
]. In rural Ghana and Myanmar, grandmothers believed that breast milk was watery in nature and unsatisfying, and that introducing infant formula and complementary foods was necessary for a child’s growth and development [15
, - Nsiah-Asamoah C.
- Doku D.T.
- Agblorti S.
Mothers’ and Grandmothers’ misconceptions and socio-cultural factors as barriers to exclusive breastfeeding: a qualitative study involving Health Workers in two rural districts of Ghana.
PLoS One. 2020; 15e0239278https://doi.org/10.1371/journal.pone.0239278
22
]. A Brazilian study also found that grandmothers were oblivious to signs of sufficient breast milk, and giving food to babies before six months was considered appropriate [[20]
]. Assumptions that early introduction of complementary foods could benefit the child can impact the mother’s decision to initiate breastfeeding, as well as exclusive breastfeeding [[23]
]. These misconceptions, beliefs, and practices influence the ability of mothers to initiate timely breastfeeding and practice exclusive breastfeeding [20
, 22
]. However, these misconceptions and perceptions do not appear to affect the breastfeeding practices of all mothers, and some report positive influences from grandmothers that promote and support breastfeeding [23
, 24
].In PNG, breastfeeding practice is almost universally observed across diverse sociocultural and gender constructs. Data from the recent Demographic and Health Survey in PNG reported an estimated 62% of infants less than six months of age were exclusively breastfed [
[25]
]. Despite the high exclusive breastfeeding rates, suboptimal breastfeeding practices and the early introduction of complementary semi-solid foods have been reported. For instance, foods other than breast milk given to infants aged less than six months were plain water (5%), non-milk liquids or other milk (3%), and complementary foods (24%) [[25]
]. Previous studies in PNG found social norms, poor dietary intake, breastfeeding knowledge, and maternal factors to be significant predictors of suboptimal breastfeeding and childhood malnutrition [26
, 27
, 28
, 29
]. A recent study conducted in rural PNG demonstrated that maternal perceptions and attitudes about breastfeeding within the family unit and social support networks have a significant influence on mothers’ decisions to breastfeed and their actual breastfeeding behaviours [[12]
]. Improving and encouraging the continuity of breastfeeding requires an understanding of the practice and its influences within the household and social contexts of PNG.There is a dearth of research into the influence of grandmothers on the infant feeding practices of first-time mothers in PNG, although prior studies conducted in PNG have found that maternal, sociocultural, and health-related factors influence breastfeeding practices [
12
, 28
, 30
]. It is thus important to gain a better understanding of the influence of grandmothers, as they remain important influencers within household and social contexts. This research was aimed at exploring how grandmothers’ language and discourse influence the breastfeeding practices of first-time mothers during the infant’s first six months of life. For this study, the term “grandmother” refers to both the paternal and maternal grandmother of a child, including the grandmother-in-law, who has interacted and communicated with first-time mothers regarding infant feeding practices.2. Methods
2.1 Study design
This qualitative study builds on a previous study [
[12]
] that explored factors influencing early weaning and breastfeeding duration among first-time mothers in rural PNG. Fairclough's [[31]
] critical discourse analysis (CDA) provided the theoretical framework for the study. CDA is a methodological approach broadly recognised as the three-dimensional framework that analyses a text and how discourse is developed and given control, including the context ‘engaged’ in a dialectical relationship [[31]
]. The application of CDA in this study was to examine language usage and the discourse of grandmothers about breastfeeding practices from the perspective of first-time mothers.This approach enabled the recognition of the role of participants’ understanding and researchers’ interpretations in knowledge formation. Phenomenological social perception, which focused on participants' lived experiences and subjectivity of social interactions, informed language and discourse theory and this study [
[32]
]. Subjectivity refers to a person's sense of self in relation to the world, as mediated by their own thoughts and feelings about themselves and others [[33]
].- Northoff G.
- Smith D.
The subjectivity of self and its ontology: From the world–brain relation to the point of view in the world.
Theory Psychol. 2022; https://doi.org/10.1177/09593543221080120
Throughout the research process, the principal researcher (MKM), who is a qualified maternal and child health nurse from PNG, remained conscious of his own perspectives on the factors influencing breastfeeding practices, based on his maternal and child health knowledge and experiences in rural PNG. The principal researcher’s conscious subjectivity enabled unbiased consideration of the words, phrases, and metaphors used by first-time mothers to elicit a better understanding of the influential and dominant discourses of grandmothers in this setting.
The study received ethical approval from the PNG Medical Research Advisory Committee (MRAC # 21.20).
2.2 Setting
The study was conducted in a rural community in the Okapa District of PNG’s Eastern Highlands Province. The province consists of six administrative constituencies that represent an estimated 13% of the total population [
[34]
].2.3 Sampling, participants, and recruitment
Purposive sampling was used to recruit women who had breastfeeding experience. Purposive sampling is a form of non-probability sampling used in qualitative research [
[35]
]. The sample is recruited based on predetermined criteria to identify a specific theme, concept, or phenomenon [[35]
]. Study participants were first-time mothers who met the following criteria: those who had given birth to their firstborn child; those who had started semi-solid foods or additional fluids other than breast milk before six months; those who had a child under the age of two; and they had a grandmother living in the same household for the past twelve months.Twenty first-time mothers were recruited. The maternal mean age was 25 years, ranging from 19 to 32 years. More than half (n = 11) attained primary school education. The majority of participants (n = 16) received antenatal care, and more than half (n = 11) had supervised births in a health facility. The mean age of their babies was 9 months, ranging from 3 to 12 months at the time of the interview.
2.4 Data collection
Data were collected through focus group discussions and semi-structured in-depth interviews between December 2019 and January 2020. The study objectives and methodology were explained to the participants, and they voluntarily consented to participate. The participants' informed consent was obtained verbally and documented. Participants were informed that they could withdraw from the study at any time without incurring any repercussions. Participants' confidentiality was ensured, their personal data was anonymised, and pseudonyms were applied throughout the research process.
Firstly, two focus group discussions were conducted using a semi-structured interview guide. These sessions were moderated by the principal researcher (MKM) and were designed to explore first-time mothers’ experiences regarding grandmothers’ influence on breastfeeding practice, as well as to gain insight into their maternal roles in the study setting. The participants were initially asked in general about their infant feeding practices, followed by experiences and perceptions of grandmothers’ position within the household and social support networks. Two specific questions on grandparents' influence regarding breastfeeding practices guided the focus group discussions and interviews: What roles do grandmothers play regarding infant feeding practices, and how does their involvement influence the breastfeeding behaviour of first-time mothers? A list of topics was used as a guideline to facilitate the discussions: grandmothers’ experiences with grandparenting and childcare, exclusive breastfeeding practices, child’s growth and development, knowledge transfer, and maternal decision-making. The two focus groups lasted approximately 55 min each.
Secondly, semi-structured face-to-face interviews were conducted with eleven first-time mothers. The same topic list that was used in the focus group discussions was adapted for the interviews. The topic list was reassessed to allow the participants to be more flexible and adequately articulate their experiences and perspectives on the key constructs of grandmothers' influences regarding breastfeeding practices. The interviews lasted between 45 and 50 min.
Both focus group discussions and interviews were conducted at a mutually convenient prearranged location and time with the researcher in Tok Pisin (a lingua franca of PNG). To ensure the credibility of the data, probing questions [
[36]
] were applied, such as “Can you please explain a little more when you mentioned…?” Participants were also given the opportunity to think and reflect on their experiences and were assured that any response would be respected and valued. Data were audio-recorded with consent from the participants. Each participant was given an anonymous identifier beginning with P for “interview participant” and FGD for “focus group discussion.” Field notes documented key themes and phrases expressed by participants. At the end of each focus group discussion and interview, participants were given a baby pack containing baby shampoo and disposable diapers as rewards for their participation. All audio-recorded data were transcribed verbatim and later translated into English by the principal researcher (MKM).- DeJonckheere M.
- Vaughn L.M.
Semi-structured interviewing in primary care research: a balance of relationship and rigour.
Fam. Med Com. Health. 2019; 7e000057https://doi.org/10.1136/fmch-2018-000057
2.5 Data analysis
The study's theoretical framework [
[31]
] incorporates text analysis, context, and social practice allowed the exploration of the accounts of interpersonal interactions inherent in the discourse between the participants and the grandmothers. These accounts were from the participants’ perspectives. Discourse analysis was used to determine how language and narratives (discourses) influenced breastfeeding participants' perceptions, experiences, and behaviours. The discourse-analytical approach further allowed for the critical analysis of social phenomena and insight into first-time mothers' experiences regarding grandmothers' communication and knowledge transmission about breastfeeding practices.Three analytical discourse processes have been described: from the interpretation of discourse practices to descriptions of textual analysis and back again to the interpretation of both the text and the discourse practices in context [
[31]
]. The analysis begins with an observation, field notes, and observational summary and the apparent discourses were extrapolated and categorised. Then, a textual analysis of interaction data was conducted, which involved a close examination of the use of recurring words, phrases, metaphors, ideas, and beliefs related to breastfeeding practices expressed in common themes. This iterative process allows for initial reflection on the content of the discourse and the meaning established in the data. Themes were defined and further filtered to capture the essence of each theme, and then consolidated, revised, and organised into final coded themes. This approach to analysing different discourse genres allowed the researchers to understand how language is used in texts and contexts, which enabled the identification of patterns and themes in the data.The narratives of the participants were presented through ‘denaturalism’ [
[37]
], which eliminated the mechanics of the conversation such as pauses, laughter, idioms, and vocalisations, leaving the content for analysis. To improve readability and comprehensibility, grammatical errors were rectified while retaining the original content of the narratives. Transcripts were synchronised exhaustively, and the coded extracts and the coding process were analysed continually until all sub-themes were reorganised into key themes. The themes and codes were reviewed by an independent reviewer who was not involved in this study. Research team members then evaluated these themes and phrases to improve the overall credibility and reliability of the data.2.6 Rigour
The study's rigour was strengthened in consultations with one author, who read the interview transcripts and concurred with the emerging themes. Credibility, appropriateness, suitability, and confirmability of the data [
[36]
] were achieved using field notes, audio transcripts, and participant narratives. The authors validated the research design, the appropriateness of the method, and the findings because of the potential for subjectivity that is inherent in this type of research. Any data discrepancies identified during the coding process and analysis were discussed with the research team and resolved by consensus.- DeJonckheere M.
- Vaughn L.M.
Semi-structured interviewing in primary care research: a balance of relationship and rigour.
Fam. Med Com. Health. 2019; 7e000057https://doi.org/10.1136/fmch-2018-000057
3. Findings
Analysis revealed three overarching themes that reflect the participants’ experiences of grandmothers’ influence on breastfeeding practices: (i) Prescribed knowledge repository; (ii) Social control and dominance; and (iii) Disapproval and role conflict. These themes provide insight into grandmothers’ differing views and influence regarding breastfeeding practices. Participants' narratives in this study are based on their interactions and experiences with grandmothers in this context. Indentation and italics are used to highlight direct quotes from the participants.
3.1 Prescribed knowledge repository
"Prescribed knowledge repository" is the study's first theme and relates to grandmothers' language and knowledge about breastfeeding practices. Grandmothers were respected as specialists in the knowledge and practice of breastfeeding and infant feeding. Some first-time mothers emphasised the importance of intergenerational knowledge transfer and practice in infant feeding across generations. Grandmothers’ experiences enabled some participants to feel more confident with infant feeding and childcare during this period, as illustrated by the following two participants:
She (grandmother) was the one that showed me how to put the baby on my breast, change the diaper and so on. I learned most of the things from my grandmother. (P2)
Grandmothers know better […]. They taught us how to feed our babies and maintain this practice. They shared their knowledge and experiences about infant feeding and childcare. We see that what they (grandmothers) said (to us) was important […], and we’ve learned from them. (P3)
Respect for authority is compelling and valued by the culture, implying that grandmothers should be respected for their traditional knowledge and experience. Participants maintained that knowledge transfer within the family unit is a common phenomenon and remains justifiable. The following comment provides insight into how respect for grandmothers’ knowledge and experience regarding infant feeding led to suboptimal breastfeeding practices:
It is our custom. She (grandmother) shared her knowledge and experience about feeding semi-solid foods (to my baby). It’s our practice here, so it’s not wrong. She’s been doing this for some time with other (new) mothers […], and their babies have grown healthy too. (FGD1, P3)
3.2 Social control and dominance
The second theme, “social control and dominance,” describes participant narratives of grandmothers’ dominant influence on breastfeeding practices. Participants’ discourses described a situation in which grandmothers were very involved, as well as being authorised for their social role within the household and the wider community. Grandmothers dominated maternal roles by demonstrating to the participants how to breastfeed their babies, including the type of complementary foods to give. Participants indicated that grandmothers exerted the most influence and were expected by the culture to assume responsibility for infant feeding and childcare to support and guide inexperienced first-time mothers rather than doing it themselves. This perspective is summed up in the following comment:
She (grandmother) told me that new mothers are not experienced […] and know little about infant feeding. So she showed me how I should breastfeed my baby […]. She’s more experienced, so when she got involved, I didn’t say anything. (FGD2, P1)
Besides breastfeeding support, grandmothers' discourses were that first-time mothers are required to adhere to their advice and guidance if they are not lactating or have difficulty initiating breastfeeding. Grandmothers undermined the first-time mothers' sense of self and trust in their bodies and dominated the postnatal period. They were influential in their beliefs and actions that supplementing breastfeeding with complementary foods would benefit the child. The following comments from two of the participants are representative of the participants’ experiences of the way that grandmothers derided their breastfeeding attempts and undermined their efforts, leading to an early cessation of breastfeeding:
“Susu wara ino kam” (breast milk isn’t coming) […]. I wasn’t able to breastfeed. I applied warm compress on my breast […]. But my baby’s grandmother was the one that gave sips of fluids and some mashed foods to my baby. I didn’t breastfeed much. (FGD2, P5)
She (grandmother) put me under pressure when the milk didn’t come. She kept on talking, so before the milk comes, I started giving (baby) semi-solid foods. She has done that to other new mothers too. So, I just followed. (P2)
3.3 Disapproval and role conflict
The third theme, “disapproval and role conflict,” refers to grandmothers’ perspectives on the breastfeeding practices of first-time mothers. Grandmothers appeared to be oblivious to suboptimal breastfeeding and placed less emphasis on exclusive breastfeeding. They further viewed first-time mothers as being ‘inexperienced’ with breastfeeding and childcare. The majority of participants highlighted how important it was for the grandmothers to recognise their maternal responsibilities in terms of infant feeding practices. As one participant explained:
I told my grandmother that the nurses told us (mothers) that we must only breastfeed our babies for six months […]. I want my grandmother to understand and support me. It was important, but she didn’t […]. She argued that I am not breastfeeding my baby enough and started giving foods like sweet potato or ripe banana to my baby. She didn’t understand. (FGD2, P4)
Nearly all the participants were motivated to breastfeed and anticipated they would receive the necessary support and guidance from the grandmothers. They found instead that grandmothers were not satisfied with how they were breastfeeding and exerted pressure on them to make their behaviour conform better to their views and practices. The following comments from two of the participants provide examples of how the grandmothers’ disapproval was transmitted:
[…] when she (grandmother) saw me breastfeeding only, she was not happy that I did not follow her advice. She told me give her (baby) some foods, although I didn’t want it. I really wanted to breastfeed as well. (P7)
They (grandmothers) were not satisfied that I was giving only breastfeeding to her (baby), so they offered other foods like plain water, milk, and juice [.]. They believed that it (breast milk) makes the baby weak and not strong. (FGD2, P3)
4. Discussion
This study explored grandmothers’ language and discourses that influence the breastfeeding practices of first-time mothers in a rural community in PNG. This exploration was through the perspectives of first-time mothers as they shared anecdotes of their interactions and experiences with grandmothers in household and social contexts. This is the second paper from a study on factors influencing breastfeeding duration and early weaning with the same study cohort [
[12]
].While breastfeeding remains critical for child health and development [
3
, 6
], the findings of this research suggest breastfeeding remains a challenge when household and social factors negatively impact first-time mothers. Grandmothers have knowledge that has been validated by their experiences. Knowledge and discourse surrounding infant feeding and childcare from grandmothers is perceived to be trustworthy and acceptable by the culture [[18]
]. They serve as expert advisors and knowledge repositories in relation to child care, including infant feeding practice [16
, 38
]. Their knowledge and experience with infant feeding has been found to have strong cultural significance that differs from evidence-based practices [[18]
], leading to attitudes and practices that can support or discourage breastfeeding [[39]
]. The findings of this study suggest that grandmothers lack evidence-based knowledge regarding breastfeeding practice. This study also provides a baseline explanation of social and cultural aspects of the infant feeding practices perceived to be accepted by the culture in this context and why these practices were seen to impede breastfeeding.- Angelo B.H.
- de B.
- Pontes C.M.
- Sette G.C.S.
- Leal L.P.
Knowledge, attitudes and practices of grandmothers related to breastfeeding: a meta-synthesis.
Rev. Lat. Am. Enferm. 2020; 28https://doi.org/10.1590/1518-8345.3097.3214
As with previous studies [
17
, 18
], findings from this research suggest that grandmothers' inadequate knowledge of proper infant feeding practices and their creation of a negative, unsupportive environment can be barriers to successful breastfeeding outcomes. Evidence suggests that grandmothers’ lack of knowledge and misconceptions about the evidence-based recommendations for exclusive breastfeeding are recognised to contribute to complementary feeding and early weaning (semi-solid foods, formula) [15
, - Nsiah-Asamoah C.
- Doku D.T.
- Agblorti S.
Mothers’ and Grandmothers’ misconceptions and socio-cultural factors as barriers to exclusive breastfeeding: a qualitative study involving Health Workers in two rural districts of Ghana.
PLoS One. 2020; 15e0239278https://doi.org/10.1371/journal.pone.0239278
17
, 18
, 23
, 39
]. Several participants in this study acknowledged that their decision to exclusively breastfeed was compromised by their unquestioning acceptance of the information provided by grandmothers about the appropriateness of the foods and fluids (other than breast milk) administered by grandmothers. This finding is consistent with studies conducted in Brazil [- Angelo B.H.
- de B.
- Pontes C.M.
- Sette G.C.S.
- Leal L.P.
Knowledge, attitudes and practices of grandmothers related to breastfeeding: a meta-synthesis.
Rev. Lat. Am. Enferm. 2020; 28https://doi.org/10.1590/1518-8345.3097.3214
17
, 20
] and Spain [[18]
] that reported the way that culturally informed practices or social myths perpetuate misinformation about complementary foods as appropriate to supplement breast milk. This study found a relationship between grandmothers’ knowledge transfer to first-time mothers and shorter breastfeeding duration.In many societies, grandmothers' social influence and perceived control over infant feeding within their household and social units is an expected social norm [
17
, 20
]. There is a clear hierarchy of authority and involvement within family systems that respond to the needs of first-time mothers, with grandmothers positioned as the foremost authorities [[17]
]. The findings of this study further highlighted that grandmothers exerted a dominant influence on the breastfeeding practices of first-time mothers. As described by study participants, grandmothers' language, discourses, and behaviour were found to undermine and devalue breastfeeding and were unsupportive of WHO recommendations for optimal breastfeeding practice. Such influence of grandmothers in decision-making for first-time mothers remains a common thread across diverse cultures [39
, - Angelo B.H.
- de B.
- Pontes C.M.
- Sette G.C.S.
- Leal L.P.
Knowledge, attitudes and practices of grandmothers related to breastfeeding: a meta-synthesis.
Rev. Lat. Am. Enferm. 2020; 28https://doi.org/10.1590/1518-8345.3097.3214
40
]. Whilst grandmothers embrace the societal perception that they have the power, influence, and experience with infant feeding, this study’s findings demonstrated a lack of understanding about evidence-based breastfeeding practices.- Concha N.
- Jovchelovitch S.
Grandmothers: Central scaffolding sources impacting maternal and infant feeding practices in Colombia.
Matern. Child Nutr. 2021; 17e13162https://doi.org/10.1111/mcn.13162
In this study, the involvement of grandmothers appeared to provide shared and supportive maternal roles; however, their involvement for many of the participants negated first-time mothers' intuition and knowledge that exclusive breastfeeding should be continued for up to six months. There was a direct and influential interaction between grandmothers and first-time mothers regarding maternal decisions about infant feeding and custodial care. Grandmothers' authority was internalised by the participants' sociocultural and familial dispositions. The participants let the grandmothers have their way and were silent in the face of the grandmothers’ disapproval of how they were breastfeeding. They also spoke about the way that, instead of the support they had been expecting, the guidance and pressure from grandmothers created conflicting views and stressful situations, as well as the feeling of being dissatisfied and disempowered is consistent with findings of a recent study [
[41]
]. For the first-time mothers in this study, the lack of informed and evidence-based approaches from grandmothers was associated with both perceived and actual criticisms of optimal breastfeeding experiences. Maternal autonomy was denied and the participant’s decision to exclusively breastfeed was compromised.Grandmothers’ disapproval of breastfeeding and the lack of maternal autonomy can have a negative impact on infant nutrition and health [
[17]
]. Recognising first-time mothers’ willingness to embrace the dominant influence of grandmothers, particularly during the breastfeeding period, indicates where health worker interventions should be directed to have the greatest impact [[42]
]. This research also sheds light on the need for context-specific breastfeeding interventions that can position grandmothers to provide appropriate breastfeeding support and guidance. The implementation of inclusive and contextual communication approaches to reach grandmothers and communities may enable a first-time mother's decision to breastfeed. Accurate and up-to-date information from health workers on infant feeding practices and support services is required to translate breastfeeding into evidence-based practice [43
, 44
]. With relevant evidence-based information and support from health workers, first-time mothers will have adequate breastfeeding knowledge and be able to take responsibility for their maternal roles.- Ranch M.M.
- Jämtén S.
- Thorstensson S.
- Ekström-Bergström A.C.
First-time mothers have a desire to be offered professional breastfeeding support by pediatric nurses: an evaluation of the mother-perceived-professional support scale.
Nurs. Res. Pract. 2019; 20198731705https://doi.org/10.1155/2019/8731705
In the study setting, breastfeeding education and support have been more focused on the interventional strategies that convince mothers to commit to breastfeeding and less focused on exploring social and household factors influencing actual breastfeeding practices. Within the household and social contexts, grandmothers’ breastfeeding and infant feeding practices are largely influenced by their knowledge and experience [
17
, 18
]. Interventions to promote, protect, and support breastfeeding need to be coordinated in a manner that incorporates evidence-based practice and a grandmother-inclusive approach with appropriate resources. Grandmothers’ involvement may also help improve their knowledge and practices about infant feeding and therefore their support of first-time mothers, including the mother's confidence and ability to achieve optimal breastfeeding outcomes in such sociocultural contexts.4.1 Strengths and limitations
One strength of this research study is that data about a grandmother’s influence on breastfeeding practices was collected from first-time mothers who were currently experiencing that influence in the study context. Another strength is that the findings are consistent with those of similar studies investigating grandmothers’ influence on maternal decision making and breastfeeding in other populations. These perspectives may not, however, reflect the grandmothers’ views on breastfeeding practices. One of the limitations of this study is that the principal researcher (MKM) is a resident of the same district as the participants. Interactions with someone from the same social community may elicit socially undesirable answers. Another limitation is that this study was conducted in a single rural district, with a small sample size. It did not capture the experiences of other first-time mothers in the province, whose experiences may be different from the first-time mothers in this study. As a result, all findings must be interpreted within this context.
4.2 Implications for future research
This study adds to the understanding of how the language and discourse of grandmothers negatively influence breastfeeding practices within household and social contexts from the perspective of first-time mothers. Further research is needed to explore grandmothers' perceptions and experiences of infant feeding in order to design context-specific interventions to influence their attitudes and facilitate their knowledge and support.
5. Conclusion
This study adds to the growing body of evidence that grandmothers can have a significant impact on first-time mothers’ breastfeeding practices. The study’s findings highlight first-time mothers’ experiences and perspectives about how grandmothers’ dominant discourses influenced their breastfeeding practices and maternal responsibilities. Grandmothers’ influence often includes the introduction of complementary foods before the infants are six months old, contributing to suboptimal breastfeeding practices. There appears to be an established sociocultural expectation that sanctions grandmothers’ participation in maternal breastfeeding decision-making, which is contrary to the WHO recommendations. For maximum impact, nutrition interventions aimed at promoting, protecting, and supporting breastfeeding practices need to include grandmothers, so they can connect to and expand upon their intrinsic knowledge and experience to improve their support of evidence-based breastfeeding practices.
Funding
This research received no specific grant fromany funding agency in the public, commercial, or not-for-profit sectors.
Ethical statement
This research received ethics approval from the Papua New Guinea Medical Research Advisory Committee (MRAC #: 21.20). Informed consent was obtained from the participants prior to participating in the research.
Authors’ contribution
MKM– conceived and designed the study, conducted the interviews, analysed the data, and drafted the manuscript. LMK – assisted with interviews, reviewed and contributed to the manuscript. CH – reviewed and advised on study design, and contributed to revising the manuscript with a significant intellectual contribution. All the authors read and agreed on the content and views expressed in the manuscript.
Conflict of Interest
The authors declare no conflict of interest.
Acknowledgements
The authors wish to thank the first-time mothers of Ke-efu community in the Okapa district, Eastern Highlands Province, who generously gave up their time and voluntarily participated in this research. We thank Bridget Ferguson, Dr Tanya Capper and Dr Florence West who initially provided important feedback and suggestions to strengthen the quality of the manuscript. I also would like to offer special thanks to Kensory Maviso (dad), who, although no longer is with me, continues to inspire me to stay positive and work hard.
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Article info
Publication history
Published online: August 10, 2022
Accepted:
August 1,
2022
Received in revised form:
August 1,
2022
Received:
December 28,
2021
Identification
Copyright
© 2023 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
