Women’s experiences of formula feeding their infants: an interpretative phenomenological study

There were two main research questions in this study as follows: (1) What experiences do mothers have with formula feeding? (2) How do mothers make the decision to formula feed?

Interpretative phenomenological analysis (IPA) was used as the methodological approach in this study.28,29 IPA involves analyzing how individuals make sense of their experiences and actively engage in interpreting the events, objects, and people in their lives. It requires the interviewer to be reflexive and to realize that exploring the participants’ meanings is an interpretative role.30,31 IPA is based on the fundamental principles of phenomenology, hermeneutics, and idiography. It integrates ideas from phenomenology and hermeneutics. The result is a method that is descriptive on the one hand, because it is concerned with how things appear and with letting things speak for themselves, and interpretative on the other because it recognizes that there is no such thing as a noninterpreted phenomenon. IPA also relies on idiographic analysis, which means that it examines objects of interest in considerable detail, thus requiring relatively small sample sizes.28,32 This study used IPA to focus on how mothers perceive and understand their formula-feeding experiences.

A purposive sample of women who had given birth in any Hong Kong hospital was recruited to ensure that participants with knowledge of formula feeding would be selected. Purposive sampling is a type of nonprobability sampling that is commonly used in qualitative research, whereby the sample is selected on the basis of predefined criteria.33 Participant selection in this study was guided by the following inclusion criteria: (1) women with a child <12 months of age; (2) postpartum women who speak Cantonese, which is the Chinese dialect most commonly spoken in Hong Kong,34 or English; and (3) women who initiated formula feeding at the birth of their youngest baby or initiated breastfeeding at birth but changed to formula feeding before the age of 6 months. The original plan was to interview mothers who had never breastfed their infant, but it was difficult to recruit an adequate number of such participants. Therefore, the scope of eligibility was widened to include women who might have breastfed their infant in the past, but who were exclusively formula feeding their infant by the time of the interview. Women who met one or both of the following criteria were excluded from taking part in the study: (1) mothers <18 years of age; and (2) mothers of infants who require complicated care, such as infants with serious health or developmental problems that might severely affect the process of breastfeeding. The justification for the second criterion for exclusion is that a mother’s decision on how to feed her infant could well be affected if her infant has a complicated health condition.

Data were collected between July 2014 and September 2015. The primary concerns of IPA are the details of individual experiences and quality rather than quantity. Accordingly, IPA studies usually benefit from a concentrated focus on a small number of cases.35 Morse36 suggested that at least six informants be recruited for a phenomenological study, whereas Smith37 recommended between five and ten participants. The sample sizes in published IPA studies have ranged from one to fifteen participants.28 Finally, 16 women met the criteria for inclusion and were recruited to take part in this study. Data were collected until saturation was reached.

An unstructured interview was conducted with each participant in a location that suited her, such as a café. Data were collected between 3 and 12 months after the birth of the woman’s youngest baby. The interviews ran from 25 minutes to just >1 hour in length. The unstructured interview approach constitutes an attempt to implement IPA’s inductive epistemology to the fullest extent.35 Each interview had a single core question that did not direct the participants and permitted them to express whatever they felt was important, while at the same time maintaining a basic framework of inquiry. In this study, the initial opening question was as follows: Please tell me about your experiences of using formula milk to feed your baby. Prompts were used throughout the interviews to clarify questions or encourage responses. Demographic data on age range, age at marriage, level of education, and occupation were also collected from the participants.

Ethical approval was obtained for this study from the Hong Kong Polytechnic University prior to the commencement of the study, and the principles of nonmaleficence, autonomy, and confidentiality were strictly followed. An information sheet was provided to all eligible participants, and their written consent to participate in the study was obtained after they had been given an explanation of the purpose and procedure of the study. It was anticipated that the interviews might trigger an emotional response. If the participants were in emotional distress, the interviewer was prepared to terminate the interview and to refer the participant to a professional psychologist with the agreement of the participant. The participating women were assured that their participation was completely voluntary and that they could withdraw from the study at any time without penalty. All of the digital audiotaped data files were password protected, and pseudonyms were given to each participant. Their identities were protected by coded identifiers, and all information was kept strictly confidential.38 Participants’ names and code numbers were kept in different locations. All research data will be discarded 2 years after the completion of the study, with any documents that could reveal the participants’ identity to be shredded.

Data were analyzed using IPA, which is a method for analyzing qualitative data.28 The interviews were digitally recorded and transcribed verbatim. The initial stage of data analysis involved closely reading each transcript 10 times and listening to the audio recording. Notes were made in the left-hand margin of the transcript to reflect initial interpretations. The second stage of analysis involved reading the transcript in depth and making a note of anything important or interesting and/or of transitional significance. In the third stage, which involved clustering and organizing the emerging themes, connections were sought between those themes, and they were grouped together according to conceptual similarities, with each cluster assigned a descriptive label. The fourth stage involved searching for connections across emergent themes. Some themes were dropped at this stage if they did not fit well into the emerging structure or had a weak evidential basis. The fifth stage of data analysis involved systematically going through the transcripts of each one of the 16 participants and repeating the foregoing stages, and the sixth stage involved looking for patterns across the participants. The sequence was repeated many times until a level of data conceptualization that best captured the core themes in the entirety of the transcript texts was achieved.29

Rigor was enhanced by having two research supervisors review and countercheck the transcripts and emerging themes. Credibility, dependability, confirmability, and transferability were achieved through the use of audio recordings, field notes, participant quotes, and validations of findings by two supervisors, allowing the reader to verify the research process.39

In this theme, the experience of feeding their babies was a profound one for all of the mothers. The experience could fill them with happiness but also cause them to cry. Almost all of the participants described the feeding experience as unforgettable, and they told of the inner struggle that occurred during the process. Here, the concept of self-struggle refers to the struggle that occurs within an individual. It reflects an experience that occurs within a mother’s mind. Such a struggle is psychological in nature, involving an individual’s thoughts.40,41 The participating mothers knew that breastfeeding offered advantages to their babies, but for a variety of reasons they were unable to maintain the practice. Two sub-themes are used to anchor the discussion of the mothers’ feeding experience as follows: feeling like a milk cow and feeling trapped.

Almost all of the mothers described a decline in their family life and relationships after commencing breastfeeding, with the emergence of family conflict. Conflicts are inevitable in life, preventable but completely unavoidable, and they are part of living in this world, especially conflicts that occur suddenly and cause great loss of life, damage, or hardship.42,43 In Hong Kong, as in other Confucian-based societies where great emphasis is placed on maintaining harmonious relationships with others, individuals are encouraged to sacrifice themselves for the benefit of the family.42 However, after a baby’s birth, some women are expected to assume primary responsibility for much more than childrearing, which is shown by Macy’s experience as follows:

Ophelia also talked about the occurrence of family conflicts once she began breastfeeding her baby as follows:

One participant expressed the view that women should support their families by earning an income and complying with their mother-in-law’s opinions on childcare. Otherwise, women lose their value in the family and destroy family harmony. The foregoing is one example of how family conflict can occur. When such conflict is absent or alleviated, family members can be sources of emotional and practical support for mothers. However, family conflict makes breastfeeding much more difficult than it would otherwise be. In this case, Macy lost the support of her family, experienced the destruction of family harmony, and was not able to persist in breastfeeding her baby.

The participants in this study had experienced the transition from womanhood to motherhood. After their babies were born, many women returned to work. Dilemmas then emerged, as they were forced to struggle simultaneously with the pressures of work, baby care, and family life. Not every woman had the option of quitting her career. Interpersonal tensions refer to tension between individuals, whether they be coworkers, siblings, spouses, or neighbors.40,41

Three subthemes are used here to anchor the discussion on interpersonal tensions as follows: embarrassment, staring, and innocence.

The findings suggest a number of areas that need to be considered in planning an infant-feeding campaign. All mothers should receive help in making an informed decision about the optimal approach to feeding their babies given their individual situation and be provided with support to pursue their chosen feeding method. Fear of criticism from health-care professionals inhibits women from communicating and seeking help. Psychological assistance should also be provided. For example, the government or charitable organizations could facilitate an open discussion about the mother’s expectations both after having given birth and upon returning to work, as well as offer other forms of support at the interface between leaving and returning to work. This support could include practical support in the form of baby care or psychological help to reintegrate into the workplace. Women who feed their babies formula milk make up a substantial proportion of Hong Kong society. Hence, they must not be ignored. Not every woman chooses to breastfeed or is able to do so. Women must be supported when they make the difficult decision to initiate formula feeding early.

This study had a number of limitations that should be noted. First, the sample was restricted to women alone. Hence, the experiences of fathers with regard to formula feeding need to be explored in a future study. Second, the data on formula feeding were self-reported by the participants and, thus, may be subject to recall bias. Finally, the study did not make any comparisons between mothers who breastfed and those who formula fed and, hence, did not examine the differences between the two groups