J. appl. health sci.

2017; 3(2): 137-143

Attitudes toward Breastfeeding and

Breastfeeding Practice: Lack of Support
for Breastfeeding in Public as a Factor
in Low Breastfeeding Rates

1
Željka Buturović education. Support for public breastfeeding was lower
1
Suzana Ignjatović than support for breastfeeding in general. Even highly
1
Mirjana Rašević engaged and informed mothers, who are very support-
ive of breastfeeding in general, are not very supportive
1
Institute of Social Sciences Belgrade of public breastfeeding. The same tendency was found
in the general public represented by non-parents in our
sample. A widespread disapproval of public breastfeed-
ing could present practical obstacles to breastfeeding.
These findings indicate that attitudes toward breast-
feeding should be taken into account in future policies
Summary aimed at supporting breastfeeding.

Serbia is a country with one of the lowest breastfeeding

rates in the world: 51% of women initiate breastfeeding
and only 13% exclusively breastfeed for 6 months. Since
Serbian social and health policies are rather favourable,
the focus should be placed on psychosocial and cul-
tural factors and attitudes as factors in breastfeeding
decisions. Public breastfeeding is one of the most con- Keywords: infant feeding, breastfeeding in public, breastfee-
troversial issues. Lack of support for public breastfeed- ding obstacles, attitudes toward breastfeeding
ing could, by discouraging women from breastfeeding
more openly, significantly contribute to low rates of
Article received: 09.07.2017.
breastfeeding and its short duration.
The aim of this study was to determine to what extent Article accepted: 15.10.2017.
mothers, fathers, and non-parents were supportive of
public breastfeeding, independently and compared to
DOI: 10.24141/1/3/2/1
their other attitudes about breastfeeding. A survey of
1884 Serbian adults – mostly highly engaged mothers –
was conducted online. The average support for uncov- Author for correspondence:
Suzana Ignjatović
ered breastfeeding in public was 6.3 on a 10-point scale.
Institute of Social Sciences, Kraljice Natalije 45,
There was a statistically significant variation in support 11000 Belgrade, Serbia
for public breastfeeding by breastfeeding intensity Email: [email protected]
(among mothers), parenting status and gender. There Phone: +381 64 3299442
were no significant differences in support by age and
138 Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143

first and second child, and two years for their third and
each subsequent child.14 Women’s health services are
Introduction
provided in public primary health centres and by gy-
naecologists. Acceptable rates of over 95% of antenatal
care and assistance during delivery by skilled person-
While welfare/family policies and public health initia- nel have been achieved; 94% of women were visited by
tives remain an important consideration in breastfeeding a community nurse during the week after the delivery
success1, recent studies have also shown a link between and the average number of postnatal visits by a com-
breastfeeding attitudes and infant feeding choices2, per- munity nurse after birth is 4.3.13 However, a recent sur-
ceived breastfeeding efficacy3 and duration of breast- vey has shown some issues in maternity care, especially
feeding4, thus shifting the focus from socio-demographic, when it comes to inadequate breastfeeding initiation at
institutional and biomedical factors to psychological and hospitals, including “baby-friendly” wards.15
psychosocial factors and attitudes.4,5 The most recent
WHO position paper stating that promotion of breast- On the other hand, attitudes toward breastfeeding in
milk substitutes and complementary foods undermines public are more problematic. Images of public breast-
breastfeeding (including “growing-up milks” advertised feeding in the media and public spaces are rare. A re-
for older children) is likewise consistent with the view that cent anthropological study of breastfeeding mothers in
breastfeeding attitudes play a significant role in the deci- Serbia shows that mothers are receiving mixed messag-
sion to breastfeed and the duration of breastfeeding. 6 es with respect to breastfeeding, including comments
such as “breastfeeding is unhealthy and primitive” by
In line with this, attitudes toward breastfeeding in their partners and others.16
public have been given an increased importance as a
Since these issues have not been systematically inves-
research subject.4,7,8 Experiencing discomfort can be
tigated so far, here we explore the possibility that a lack
one of the reasons for avoiding breastfeeding in public,
of support for breastfeeding in public plays a role in Ser-
especially when adequate facilities are not available,
bian low breastfeeding rates. We focused on respond-
ultimately leading to breastfeeding cessation. Difficul-
ents’ opinion about uncovered breastfeeding in public,
ties related to breastfeeding in public affect all women,
both as a proxy of mother’s readiness to breastfeed in
regardless of socio-economic and class aspects.7
public as a part of her daily routine and as the most
Though overall attitudes toward breastfeeding are gen- critical part of the general public’s readiness to accept
erally positive (for example, the United States)9, negative breastfeeding in public spaces.
attitudes toward public breastfeeding appear to be com-
mon. In their study of Australian GP registrars, Brodribb
and colleagues10 found the mean score for the attitude
“Women should not breastfeed in public places, on a 1-5
scale” to be M=4.3. According to Scott and colleagues,2
28% of fathers of breastfed infants in Scotland agreed Methods
that women “should not breastfeed in public places
such as restaurants”. Another survey from Western Aus-
tralia showed a decreasing trend in negative attitudes to-
ward breastfeeding in different public spaces (shopping Design and sample
centres, restaurants, workplace) over years (1995-2009); This study is a part of a larger project that aims to un-
however, there is still a small but substantial proportion derstand Serbian parents’ attitudes and adjustments
of those who opt for “It depends (on how obvious it is)”.11 during the first year of a baby’s life. As a part of this
Over half of respondents from New York City were unsup- larger project, a 74-item questionnaire, which included
portive of public breastfeeding (50.4%), but significant socio-demographic questions as well as items address-
differences were identified by education, age, and race.12 ing personal experiences with parenthood and breast-
feeding, and life satisfaction, was created. The Institu-
Serbia has one of the lowest breastfeeding rates in the
tional Review Board of the Institute of Social Sciences
world: only 13% of mothers exclusively breastfeed for
approved the purpose and procedures of the study.
6 months13, despite relatively favourable institutional
conditions. Employed mothers are entitled to one year The questionnaire was posted online using Google Forms.
of full-rate equivalent paid maternity leave for their Various popular parenting newspapers and blogs agreed
Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143 139

to add the survey link to their websites for a limited pe- tested using analysis of variance and t-tests. In addition,
riod. The data collection commenced on January 19th, the average score was calculated out of ten questions
2015 and ended on April 18th, 2015. The respondents were related to positive breastfeeding attitudes, and this new
informed about the purpose of the study on the first page variable was used in a logistic analysis as one of the pre-
of the online questionnaire. Analyses were conducted us- dictors of the mother’s support for public breastfeeding.
ing SPSS on a cleaned-up sample of 1884 respondents
(mothers, fathers, and non-parents) who answered all
relevant demographic and breastfeeding questions.

Measurement Results
In this study, a subset of items from the larger question-
naire was utilized, including demographic questions,
Majority of the sample were women (95%) and 94% were
an item about breastfeeding in public and items about
parents. The average age was 34.6 years (SE=.14). 22%
breastfeeding knowledge and attitudes. The latter ex-
of the sample had a high school education or less, 13%
amined to what extent respondents agreed with a list
had some college education, 39% were still in college,
of statements, measured by eleven 10-point Likert-type
and 25% had a college degree. The crux of our results is
items. These statements covered different domains:
presented in Table 1. The distribution of support for pub-
health and psychological benefits for the baby (“Breast-
lic breastfeeding on a scale from 1 to 10 was trimodal,
feeding is necessary for bonding between the mother
clustering around values 1, 5, and 10. 31% of respondents
and child”, Breastfeeding is necessary for the develop-
chose values less than five (including 19% of those who
ment of the baby’s immune system”, “A breastfed child
chose the lowest value 1), 12% chose the value 5 and 30%
is healthier”, “A breastfed child is more intelligent, and
chose the value 10. Analyses of variance showed that vari-
this improves its life prospects”); breastfeeding benefits
ation in support for breastfeeding by education (F=1.15,
for the mother (“Breastfeeding reduces the risk of breast
p>0.05) and age (r=0.01, p>0.05) were not significant.
cancer”, “Breastfeeding benefits the mother’s weight
However, there were statistically significant differences
regulation after giving birth”), moral and other norms
between parents and non-parents (t=3.99, p<0.01) and
related to breastfeeding (“The mother’s diet is very im-
between men and women (t=2.04, p<0.05).
portant for the baby’s health”; “The mother’s duty is to
try hard to succeed in breastfeeding”) and economic
benefits of breastfeeding (“Breastfeeding is the most Table 1. Support for breastfeeding in public
by gender, education and parenting status
cost-effective option for the family”; “Breastfeeding is
the most practical and simple way of infant feeding”). Women who breastfeed in public should do it
The question about breastfeeding in public was phrased freely, without covering their breasts
in a somewhat extreme modality, explicitly asking about Variable n Mean
the most problematic aspect of breastfeeding in public Total 1884 6.25 (6.10-6.41)
– an uncovered breast: “A woman should be allowed to Sex
breastfeed in public freely without covering her breast”. Male 104 6.82 (6.26-7.38)
Female 1780 6.22 (6.06-6.38)
Education
High school or less 419 6.12 (5.79-6.46)
Data analysis
Some college 248 5.97 (5.54-6.41)
College graduate 740 6.33 (6.09-6.58)
Data analysis consisted of two parts. In the first part, we Graduate degree 477 6.39 (6.09-6.69)
compared attitudes toward public breastfeeding among Parenting status
mothers, fathers and non-parents. In the second part, we Mother 1683 6.30 (6.13-6.46)
looked at possible relationships between breastfeeding
Father 88 6.90 (6.28-7.15)
attitudes and the duration of breastfeeding among moth-
Non-parent 113 5.02 (4.41-5.63)
ers. Differences in the outcome variable among three
Note. Numbers in parentheses denote 95% confidence intervals.
groups of respondents by demographic variables were
140 Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143

Figure 1. Attitudes toward breastfeeding and breastfeeding in public broken down by parenting
status. Whiskers indicate standard error of the mean for each score.

Overall lukewarm support for public breastfeeding Table 2. Support for breastfeeding in public
is somewhat contrary to some of the attitudes of our among mothers by duration of breastfeeding
sample toward breastfeeding (Figure 1). Since Cron-
Women who breastfeed in public should do it
bach’s alpha for these 10 items was .87, we calculated freely, without covering their breasts
their average as a measure of positive breastfeeding at-
titudes. The mean ten-item positive breastfeeding atti- Variable n Mean
tudes score was 6.96 (95% CI = (6.88, 7.12)). The Pearson
correlation between ten-item positive breastfeeding at- Total 1884 6.25 (6.10-6.41)
titudes score and attitudes toward public breastfeeding Breastfeeding duration
1652
was r=.19 (p<0.01). (mothers only)
Short time non-exclusive 296 5.68 (5.27-6.09)
In the second part of the analysis, we looked at associa-
tions between mothers’ duration of breastfeeding and <6 months, exclusive 90 4.91 (4.16-5.66)
their attitudes toward public breastfeeding (Table 2). 6+ months, exclusive 821 6.94 (6.71-7.16)
1643 mothers have rated their breastfeeding intensity 6+ months non-exclusive 304 5.96 (5.59-6.34)
on a scale from 1 to 10: the mean was 7.65 (SE=0.07). Haven’t tried 17 5.41 (3.63-7.19)
Breastfeeding duration was significantly related to at-
Attempted to breastfeed, but
titudes toward public breastfeeding (F=13.18, p<0.05): it did not work out
124 5.50 (4.84 – 6.16)
support for uncovered public breastfeeding was the
Note. Numbers in parentheses denote 95% confidence intervals.
highest among mothers who exclusively breastfed for
six months or more and lowest among those who did
not try breastfeeding. However, even among these most A dichotomized public breastfeeding support variable,
intensively breastfeeding mothers, 23% chose a level where mothers who chose 7 or lower on 1-10 group
lower than 5 for uncovered public breastfeeding and were assigned to one group and the rest to the other,
13% chose level 1. The Pearson correlation between was created and used as an outcome variable for a lo-
self-reported breastfeeding intensity and attitudes to- gistic regression with predictors of positive breastfeed-
ward public breastfeeding was r=.14 (p<0.05). ing attitudes and breastfeeding duration. Compared
Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143 141

to mothers who breastfed exclusively for six months se that are the issue. This is consistent with the findings
or longer, mothers who breastfed non-exclusively for from Morris et al, which revealed nudity (sexualisation
six months or more were significantly less likely (AOR = of the breast) to be just one of the factors in opposition
.60; 95% CI, 0.46-0.78) to be supportive of public breast- to breastfeeding (aversion to bodily fluids and embar-
feeding, and so were those who breastfed exclusively rassment of being caught looking are also relevant fac-
for less than six months (AOR = 0.40; 95% CI, 0.25-0.65). tors), others relating loosely to a ‘change of rules’ (com-
There was also an increase in odds of supporting public pared to the past, other countries, manners etc.).18
breastfeeding (AOR = 1.22; 95% CI, 1.14-1.30) for each
Although media images of pregnant and post-natal bod-
one-point increase in positive breastfeeding attitudes.
ies are very common in Serbia, those of breastfeeding
are not. Mass public breastfeeding events have not been
well received by the general public.19 Recently, “breast-
feeding benches” were installed in three Belgrade public
parks, which can increase exposure to public breastfeed-
Discussion
ing.20 This is important because it has been shown that
even posters showing breastfeeding mothers can gradu-
ally lower discomfort in observers, and thus lead to bet-
Our study suggests that a significant portion of highly ter acceptance of breastfeeding in public.21 Acker at al.
engaged Serbian parents is strongly opposed to pub- showed that, even when people are aware of the benefits
lic breastfeeding: almost a fifth of our sample chose of breastfeeding, they are not comfortable with breast-
the strongest disapproval level of ‘1’ on a 1-10 scale. feeding because it draws attention to highly sexualized
Furthermore, while breastfeeding rates in Serbia are parts of women’s bodies, and it presents a violation of
among the lowest in the world, mothers in our sample gender role stereotypes about female modesty.22
breastfed at very high rates. Despite that, their support
for public breastfeeding was lukewarm. Even among The normalization of breastfeeding in public by present-
mothers who breastfed most intensively – those who ing human milk as food instead of perception of milk
breastfed exclusively for 6 months or more – 23% dis- as a bodily fluid18 and exposure to breastfeeding22 have
approved and 13% very strongly disapproved of uncov- been emphasized in recent studies. Acker et al.22 found
ered public breastfeeding. that parental exposure to breastfeeding makes them
more comfortable with breastfeeding in public, and we
Since our sample contained a highly disproportionate have also found parents to be more accepting of public
number of breastfeeding mothers, it therefore very likely breastfeeding than non-parents. Consistent with that,
contained a disproportional number of respondents who Shafer et al. showed that personal breastfeeding expe-
were highly supportive of public breastfeeding. Conse- rience of the mother’s support network (including her
quently, it is highly unlikely that support for public breast- mother, partner, and health care provider) significantly
feeding in Serbia is anything but significantly lower than influenced the type of advice on pursuing breastfeeding
the already middling value we observed in our study. given to new mothers.23 Taken together, this speaks to
Clearly, further studies using representative samples and the possibility that lack of familiarity with breastfeeding
a wider range of outcome variables are needed. In con- reinforces negative attitudes toward it and especially to-
trast to other similar studies (for example, Mulready-Ward ward the sensitive issue of breastfeeding in public. The
and Hackett12), we found no variation across age and edu- relationship between breastfeeding visibility, attitudes
cation, suggesting that these attitudes are widely shared. and practice in Serbia requires further examination.
The lukewarm support for public breastfeeding is un-
likely to be due to generalized uneasiness with nudity
among Serbs. On the contrary, Serbian attitudes to-
ward nudity are rather relaxed: a vast majority of wom-
en of all ages wear bikinis, topless women at beaches Conclusion
do not draw attention and female children often do not
wear swim tops till elementary school. A recent media
analysis has shown a high level of tolerance in the me- Our exploratory findings of Serbians’ attitudes toward
dia for sex-related content and nudity.17 It appears that breastfeeding in public are consistent with the view
it is nude nursing breasts rather than nude breasts per that broader breastfeeding culture, in addition to so-
142 Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143

cio-demographic and institutional factors, plays a role 10. Brodribb W, Fallon A, Jackson C, Hegney D. Breastfee-
in breastfeeding rates. As a link between familiarity ding and Australian GP registrars—their knowledge and
and practice, acceptance of public breastfeeding could attitudes. J Hum Lact. 2008;24(4):422-430.
play an important part in fostering a more supportive 11. Meng X, Daly A, Pollard CM, Binns CW. Community Atti-
tudes toward Breastfeeding in Public Places among
breastfeeding culture.
Western Australia Adults, 1995-2009. J Hum Lact.
2013;29(2):183-189.
12. Mulready-Ward C, Hackett M. Perception and attitudes:
breastfeeding in public in New York City. J Hum Lact.
2014;30(2):195-200.
Funding Acknowledgement
13. Statistical Office of the Republic of Serbia and UNICEF.
Serbia Multiple Indicator Cluster Survey 2014; Serbia Ro-
ma Settlements – Multiple Indicator Cluster Survey 2014.
This research was supported by the Ministry of Educa- Belgrade: Statistical Office of the Republic of Serbia and
tion, Science and Technological Development of the Re- UNICEF; 2014.
public of Serbia (project grants: III 47010 and III 47006). 14. Zakon o radu. Službeni glasnik Republike Srbije. 24/2005,
61/2005, 54/2009, 32/2013, 75/2014.
15. Arsenijevic J, Pavlova M, Groot W. Shortcomings of Ma-
ternity Care in Serbia. Birth. 2014;41(1):14-25.
16. Srdić-Srebro A. Materinstvo: prirodni zakon ili soci-
okulturni konstrukt? Etnološko-antropološke sveske.
References 2014;23:37-50.
17. UNICEF. Označavanje TV sadržaja i zaštita dece – analiza
programa nacionalnih emitera. Beograd: UNICEF; 2013.
1. Lubold AM. The effect of family policies and public health 18. Morris C, Zaraté de la Fuente GA, Williams CE, Hirst C. UK
initiatives on breastfeeding initiation among 18 high-in- Views toward Breastfeeding in Public: An Analysis of the
come countries: a qualitative comparative analysis rese- Public’s Response to the Claridge’s Incident. J Hum Lact.
arch design. Int Breastfeed J. 2017;12(34):1-11. 2016;32(3):472-480.
2. Scott JA, Shaker I, Reid M. Parental Attitudes Toward 19. Krstić Lj. Dojenje na javnom mestu nije sramota! Be-
Breastfeeding: Their Association with Feeding Outcome ogradske mame doje decu na Adi. Blic [Internet]. 2014
at Hospital Discharge. Birth. 2004;31(2):125-131. [pristupljeno 31.01.2017.]. Dostupno na: http://zena.
3. Schafer EJ, Campo S, Colaizy TT, Mulder PJ, Breheny P, blic.rs/Bebe/23248/Dojenje-na-javnom-mestu-nije-sra-
Ashida S. First-time mothers’ breast-feeding maintenan- mota-Beogradske-mame-doje-decu-na-Adi
ce: role of experiences and changes in maternal percep- 20. Klupa za dojenje u Zemunu. Studio B [Internet]. 2016
tions. Public Health Nutr. 2017;7:1-10. [pristupljeno 31.01.2017.]. Dostupno na: http://studiob.
4. Buturović Ž, Ignjatović S, Rašević M. Challenges of Early rs/klupe-za-dojenje
Motherhood: Breastfeeding Difficulties and Life Satisfac- 21. Vieth A, Woodrow J, Murphy-Goodridge J, O’Neil C,
tion. Stanovništvo. 2016;54(1):1-14. Roebothan B. The Ability of Posters to Enhance the
5. Scott JA, Diet GD, Kwok YY, Synnott K, Bogue J, Amarri S, Comfort Level with Breastfeeding in a Public Venue
et al. Comparison of Maternal Attitudes to Breastfeeding in Rural Newfoundland and Labrador. J Hum Lact.
in Public and the Association with Breastfeeding Durati- 2016;32(1):174-181.
on in Four European Countries: Results of a Cohort Stu- 22. Acker M. Breast is Best…But Not Everywhere: Ambiva-
dy. Birth. 2015;42(1):78-85. lent Sexism and Attitudes Toward Private and Public
6. Grummer-Strawn LM, Zehner E, Stahlhofer M, Lutter Breastfeeding. Sex Roles. 2009;61(7-8):476-490. doi:
C, Clark D, Sterken E, et al., on behalf of the WHO/UNI- https://doi.org/10.1007/s11199-009-9655-z
CEF NetCode. New World Health Organization guidance 23. Schafer EJ, Williams NA, Digney S, Hare ME, Ashida S. So-
helps protect breastfeeding as a human right. Matern cial Contexts of Infant Feeding and Infant Feeding Deci-
Child Nutr. 2017;13(4):e12491. sions. J Hum Lact. 2016;32(1):132-140.
7. Boyer K. Affect, corporeality and the limits of belonging:
Breastfeeding in public in the contemporary UK. Health
Place. 2012;18(3):552-560.
8. Newell L. Disentangling the politics of breastfeeding.
Child Geogr. 2013;11(2):256-261.
9. Nelson JM, Li R, Perrine CG, Scanlon KS. Public Opini-
ons About Infant Feeding in the United States. Birth.
2016;43(4):313-319. doi: https://doi.org/10.1111/birt.12248
Buturović Ž. Attitudes toward Breastfeeding and Breastfeeding Practice... J. appl. health sci. 2017; 3(2): 137-143 143

Stavovi prema dojenju i praksa dojenja: nedostatak podrške

dojenju u javnosti kao čimbenik niskih stopa dojenja

1
Željka Buturović dojenju u javnosti niža je od podrške dojenju općenito.
1
Suzana Ignjatović Čak i vrlo angažirane i informirane majke, koje u velikoj
1
Mirjana Rašević mjeri podupiru dojenje općenito, ne podržavaju dojenje
u javnosti. Ista tendencija otkrivena je u široj javnosti
Institut društvenih nauka Beograd
1
koju u našem uzorku predstavljaju osobe koje nisu ro-
ditelji. Opće neodobravanje dojenja u javnosti moglo bi
biti praktična prepreka dojenju. Ovi rezultati ukazuju na
to da je stavove o dojenju potrebno uzeti u obzir u bu-
dućim politikama za podršku dojenju.

Sažetak

Srbija je zemlja s jednom od najnižih stopa dojenja u

svijetu: 51 % žena započne s dojenjem, a samo 13 % is-
ključivo doji šest mjeseci. S obzirom na to da su srpske
društvene i zdravstvene politike poprilično pogodne,
potrebno je usredotočiti se na psihosocijalne i kultur-
ne čimbenike te stavove kao čimbenike u donošenju
odluke o dojenju. Dojenje u javnosti jedno je od naj-
kontroverznijih pitanja. Nedostatak podrške dojenju u
javnosti mogao bi biti važan uzrok niskih stopa dojenja
i njegova kratkog trajanja zbog obeshrabrivanja žena da
slobodnije doje.
Cilj je ovog istraživanja utvrditi u kojoj mjeri majke,
očevi i osobe koje nisu roditelji podržavaju dojenje u
javnosti, samostalno i u usporedbi s njihovim drugim
stavovima o dojenju. Istraživanje koje je obuhvaćalo
1884 odraslih Srba, većinom vrlo angažiranih majki,
provedeno je putem interneta. Prosječna podrška za
nepokriveno dojenje u javnosti iznosila je 6,3 na skali
od 1 do 10. Postoji statistički značajna razlika u podrš-
ci dojenju u javnosti prema intenzitetu dojenja (među Ključne riječi: hranjenje d,ojenčeta, dojenje u javnosti, pre-
majkama), roditeljskom statusu i spolu. Nema značaj- preke dojenju, stavovi o dojenju
ne razlike u podršci prema dobi i obrazovanju. Podrška