Strengthening the evidence to support and enable women to breastfeed beyond infancy

Introduction: The World Health Organization (WHO, 2023) recommends a woman continue breastfeeding for two years and beyond with supplementary solid food. However, the current global prevalence of breastfeeding beyond the infancy age of one year is at an all-time low. This thesis set out to strengthen the evidence to enable breastfeeding beyond infancy for women globally. This was achieved by 1) Establishing the full extent of what is understood about enablers, barriers and interventions for women breastfeeding beyond infancy, 2) Determining the significance of identified enablers and barriers by measuring them against a diverse range of women, 3) Understanding the identified significant enablers and barriers further through examining experiences of those continuing to breastfeed beyond infancy. Methods: Firstly, a critical realist review considered theoretical perspectives and synthesised the body of evidence for understanding a woman’s ability to continue breastfeeding. Secondly, a primary investigation, using an online cross-sectional design, obtained data from 19,006 women with experience breastfeeding at least one child for a minimum of one year. A quantitative analysis explored relationships between enablers and barriers for those breastfeeding or who had breastfed for ≥ 2 years and those who had discontinued before this age. A content analysis explored qualitative insights from women continuing to breastfeed between the ages of 1 to < 2 years at the time of data collection. Results: Participants aged >35 years or those residing in the American continent were significantly less likely to breastfeed to ≥ 2 years. Those with multiple children or identified as Asian, part of an Indigenous, First Nation or Pacific Islander ethnic group, or a mixed ethnic group, were atheists or from an ‘other’ smaller religious group were significantly more likely to breastfeed to ≥ 2 years. Participants who stated that their social circle was more likely to consist of mothers who breastfeed beyond infancy and who use online peer support were significantly more likely to breastfeed to ≥ 2 years. Those participants breastfeeding or had breastfed for ≥ 2 years were significantly more likely to have experienced a negative response from a health care professional. Participants were also significantly less likely to be breastfeeding or had breastfed for ≥ 2 years if they experienced a negative response to breastfeeding in public. The content analysis for participants breastfeeding 1 to < 2 years revealed insights suggesting that convenience, satisfaction, and health benefits are important influential factors to support continued breastfeeding. There is also a need to change social perceptions and increase wider knowledge to enable continued breastfeeding for ≥ 2 years. Conclusion: These results indicated that women with specific characteristics need tailored support. Delivering a combination of interventions will have a variation of benefits for a diverse range of parents. Additionally, more work is needed to educate society at large to foster the normalisation of breastfeeding beyond infancy globally. Finally, healthcare professionals need evidence-based training to be able to give appropriate support to those currently breastfeeding beyond infancy.