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A systematic review of men's views and experiences of infant feeding: implications for midwifery practice

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It is understood that men can perform an important role with respect to infant feeding, although questions remain as to how significant this role might be. In addition, much of the research on men and infant feeding is information gathered from women, rather than from the men themselves. In order to explore these issues further, a systematic review of the qualitative research in infant feeding has been carried out, focusing only on studies that have sought to elicit men’s own views and experiences. Evidence was identified through a variety of search strategies including database searching and manual citation searches, as well as searching the grey literature for unpublished data. A total of 20 research papers were included in the review and each study was summarised and analysed thematically to produce a synthesis. Five major analytical themes were identified: men’s knowledge of infant feeding; men’s views of health promotion; men’s role in infant feeding; men’spositive views on breastfeeding; and men’s negative views on breastfeeding. This paper explores these themes in the context of what the research implications might be for midwives and their practice.
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Original article. © MIDIRS 2018.
ORIGINAL
A systematic review of men’s views and
experiences of infant feeding: implications for
midwifery practice
Sarah Earle, Robin Hadley
It is understood that men can perform an important role with respect to infant feeding, although
questions remain as to how signicant this role might be. In addition, much of the research on men
and infant feeding is information gathered from women, rather than from the men themselves.
In order to explore these issues further, a systematic review of the qualitative research in infant
feeding has been carried out, focusing only on studies that have sought to elicit men’s own views
and experiences. Evidence was identied through a variety of search strategies including database
searching and manual citation searches, as well as searching the grey literature for unpublished
data. A total of 20 research papers were included in the review and each study was summarised and
analysed thematically to produce a synthesis. Five major analytical themes were identied: men’s
knowledge of infant feeding; men’s views of health promotion; men’s role in infant feeding; men’s
positive views on breastfeeding; and men’s negative views on breastfeeding. This paper explores these
themes in the context of what the research implications might be for midwives and their practice.
Introduction and background
The World Health Organization (WHO) has endorsed
global targets designed to improve the nutrition and
well-being of infants, young children and mothers
(WHO 2014), recognising that current standards of
nutrition are sub-optimal. In particular, WHO aims to
increase rates of exclusive breastfeeding in the rst six
months of life by at least 50%. Current rates of
breastfeeding are much lower than this. In low- and
middle-income countries, the rate of exclusive
breastfeeding to six months was 37% in 2013 (Rollins
et al 2016). In high-income countries, the rate of
breastfeeding to 12 months is known to be 20%
although there is considerable variation between
countries. In the United Kingdom (UK), for example,
the rate of exclusive breastfeeding to 12 months is less
than 1% (Victora et al 2016).
MIDIRS Midwifery Digest 28:1 2018 91
Infant Nutrition
Although it is widely recognised that breastfeeding is
advantageous for mothers and babies, the UNICEF
Baby Friendly Initiative standards clearly state that
women should be able to choose their infant feeding
method and that they should be supported in their
choice of feeding (Royal College of Midwives (RCM)
2014). Supporting mothers to breastfeed or bottle
feed their infants successfully is a fundamental aspect
of good postnatal care. However, recent reports
indicate that midwives and maternity support
workers do not always have the time to support
women effectively in their chosen method of infant
feeding (RCM 2014).
Previous research has indicated that men can be
inuential with respect to infant feeding decisions
(Bar-Yam & Darby 1997, Earle 2002, Rollins et al
2016), although many studies have drawn on the
views and experiences of women rather than men.
Given the potential signicance of men’s role in infant
feeding and in supporting women, it is important to
explore their role more fully. The aim of this review
was to explore men’s views and experiences of infant
feeding, drawing on original qualitative research from
data elicited only from men (ie husbands and partners
including biological and non-biological fathers). The
paper concludes by considering the implications of
these ndings for midwifery practice.
Methods
Identication of studies
A systematic review of the qualitative research on
men’s views and experiences of infant feeding was
carried out between April and August 2016 using a
combination of search strategies using the Centre for
Reviews & Dissemination’s (CRD) (2009) guidance.
Database searching using keywords, titles and
abstracts was conducted via four databases
(CINAHL, Cochrane, PubMed and Scopus). Manual
searches were also carried out using citations from the
selected studies. The grey literature was also searched
using Google (rst 100 hits), as well as a number of
specialist sites.
Selection of studies
Papers were selected for inclusion if they discussed
men’s views and experiences of infant feeding and if
they reported original qualitative data elicited from
men. Studies were only included where direct
quotations from men were given (Noyes & Lewin
2011). For pragmatic reasons, the systematic review
was restricted to studies published between the 1st
January 2000 and 30th March 2016. Studies published
in languages other than English and Spanish were also
excluded as were papers that drew on secondary data
analysis or literature reviews.
Author 2 (RH) conducted the database searches and
manually searched citations. Both authors conducted
the manual search of other sources. RH screened
paper titles and abstracts and identied papers that
did not meet inclusion criteria and removed
duplicates; Author 1 (SE) checked titles and abstracts
independently and agreed whether papers met criteria
for inclusion. Eligible papers were shortlisted and
both authors individually assessed full-text articles
separately and then met to discuss their reasoning.
There were no differences in judgment.
A total of 121 records were identied through
database searching and an additional 85 through
other sources. After removing duplicates, 176 records
remained and were screened using keywords, title and
abstract. Following screening, 39 full-text articles
were read to assess for eligibility. Of the 39 articles
assessed, 20 met the criteria for inclusion.
Quality appraisal
Quality appraisal of the selected studies was
conducted by both authors using the approach and
criteria described by Walsh & Downe (2006), which
is suitable within a qualitative research tradition.
None of the studies were excluded from the review
based on quality appraisal although it was used
reexively to provide context for data analysis.
Data summary and synthesis
Two main approaches were used to analyse the data.
Firstly, the studies were summarised (Table 1) and
secondly, they were analysed using a process of
inductive thematic analysis (Braun & Clarke 2006).
There are many methods that can be used in the
systematic review of qualitative studies (Barnett-Page
& Thomas 2009); in this review, the ndings of each
paper and the primary data (quotes) were used to
carry out a line-by-line coding. The qualitative data
analysis software package QSR NVivo 11 for Mac
was used in data analysis, which was conducted by
both authors.
Findings
Twenty papers were included in the review and ve
major analytical themes emerged: men’s knowledge of
infant feeding; men’s experiences of health promotion;
men’s role in infant feeding; men’s positive views on
breastfeeding; and men’s negative views on
breastfeeding. These themes are discussed and
summarised in Table 1.
Men’s knowledge of infant feeding
Most of the studies (n=17) were concerned with how
men learn about breastfeeding (Table 1). Analysis of
the data shows that men are not especially
knowledgeable and do not consider themselves experts.
Some men seek to inform themselves about infant
feeding whereas others do not because they believe that
women are the experts. For example, this sentiment
was neatly expressed by one of the participants in
Mitchell-Box & Braun’s (2012:e44) study:
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‘…she knows all that stuff… [I] let her deal with that part.
When men do seek to inform themselves, the data
suggest that men learn about feeding from many
sources including searching the internet, reading books,
attending antenatal classes and from other people:
‘I went on the internet and did some reading myself.
(Brown & Davies 2014:517)
Our ndings indicate that men strongly value
experiential knowledge and advice from their partners
(Sweet & Darbyshire 2009), family members and
friends (Schmidt 2000, Anderston et al 2010, Brown
& Davies 2014):
‘Not many of my friends had babies and they tended
to bottle-feed. I wanted to know how other dads felt
and whether they felt excluded or fed up.(Brown &
Davies 2014:520)
Men seldom reported receiving information from
health professionals, including midwives, (Sweet &
Darbyshire 2009, Anderson et al 2010, Avery &
Magnus 2011) although when they did, tended to
value advice from professionals who had had their
own children:
‘[…] You know, like is this person telling me this
and they probably don’t even have any children?’
(Anderson et al 2010:527)
This review indicates that health promotion can play
an important role in relation to men’s views and
experiences of infant feeding.
Men’s experiences of health promotion
Half of the studies reviewed (n=10) discussed men’s
experiences of health promotion and support (see
Table 1). The majority of men said that they felt either
directly or indirectly excluded from health promotion:
‘When we went to antenatal classes they did a session
on breastfeeding. They sent all the dads down the pub
that night.(Brown & Davies 2014:518)
Although the majority of studies did not refer to
midwifery specically, some men did also report
feeling patronised by midwives:
‘One midwife actually told me in front of my wife
that breastfeeding was a good thing as it would make
her breasts bigger. I’m not that shallow. (Brown &
Davies 2014:519)
All the studies that explored health promotion sought
to make recommendations for practice. In ve studies,
men said that health promotion needed to be more
‘father-friendly’, suggesting that classes should be
arranged at appropriate times (for example, in the
evenings) and that health promotion literature should
show positive images of men and breastfeeding
(Sherriff et al 2009, Sherriff & Hall 2011, Mitchell-
Box & Braun 2012, Brown & Davies 2014, Sherriff
et al 2014).
In addition to valuing advice and information based
on experiential knowledge, the ndings of this review
indicate that men also value information that is
factual and specic, as well as pragmatic and realistic.
Table 1. A summary of the thematic analysis
Analytical research themes
Men’s
knowledge of
infant feeding
Men’s experiences
of health
promotion
Men’s role in
infant feeding
Men’s positive
views on
breastfeeding
Men’s negative
views on
breastfeeding
Study references
Anderson et al (2010) 3 3 3
Avery & Magnus (2011) 3 3 3 3
Brown & Davies (2014) 3 3 3 3 3
Datta et al (2012) 3 3 3 3
Engebretsen et al (2010) 3 3 3 3
Harwood (2011) 3 3
Henderson et al (2011) 3 3 3
Hoddinott et al (2012) 3 3 3 3
Mitchell-Box & Braun (2012) 3 3 3 3
Mithani et al (2015) 3 3 3 3 3
Okon (2004) 3 3 3 3
Pontes et al (2009) 3 3 3
Rempel & Rempel (2011) 3 3 3 3
Schmidt & Sigman-Grant (2000) 3 3 3
Sherri et al (2009) 3 3 3 3
Sherri & Hall (2011) 3 3 3 3
Sherri et al (2014) 3 3 3 3 3
Smith et al (2006) 3 3
Sweet & Darbyshire (2009) 3 3 3 3
Tohotoa et al (2009) 3 3 3 3 3
MIDIRS Midwifery Digest 28:1 2018 93
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Men were critical of health promotion that focused
on the mantra ‘breast is best’ without explaining how
and why this might be so:
‘I read somewhere that if you breastfed you saved
£500 a year on formula and bottles and things and
were saving the NHS money too. I like figures.
(Brown & Davies 2014:518)
It was also important to men to receive information
about infant feeding that would help them to support
their partner:
[I would prefer] a no b******t idea of what to
expect and how to help even if that means doing
nothing but being there with her and the baby.’
(Tohotoa et al 2009:9)
Men disliked information that was overly positive,
idealistic or vague, instead valuing information that
could be of practical use to them. This preference
links very clearly to men’s perception of their role in
infant feeding.
Men’s role in infant feeding
Thirteen of the selected studies reported men’s views
and experiences on infant feeding decisions (Schmidt
& Sigman-Grant 2000, Okon 2004, Sherriff et al
2009, Sweet & Darbyshire 2009, Anderson et al
2010, Engebretsen et al 2010, Avery & Magnus 2011,
Harwood 2011, Rempel & Rempel 2011, Datta et al
2012, Mitchell-Box & Braun 2012, Brown & Davies
2014, Sherriff et al 2014). The data suggest that men
consider themselves less knowledgeable about infant
feeding than women and, thus, they tend to leave the
decision making to women:
‘I’d like to see her face if I walked in and said, you
know, “I’ve decided.”’ (Avery & Magnus 2011:151)
The studies reviewed indicate that only in exceptional
circumstances do men exert a stronger inuence
(Engebretsen et al 2010, Rempel & Rempel 2011).
Many of the studies analysed (n=13) considered men’s
role specically in relation to breastfeeding (Schmidt
& Sigman-Grant 2000, Okon 2004, Smith et al 2006,
Pontes et al 2009, Sherriff et al 2009, Sweet &
Darbyshire 2009, Anderson et al 2010, Avery &
Magnus 2011, Harwood 2011, Rempel & Rempel
2011, Datta et al 2012, Sherriff et al 2014, Mithani et
al 2015). The review highlights how men perceive
their role as one where they provide either practical
or emotional support to their partner. In terms of
providing practical support, this often referred to
taking on household chores, looking after other
children, or maintaining breast-pump equipment:
‘She’s got two objectives: to look after the baby and
to look after herself. My objectives are to look after
everything else […].’ (Datta et al 2012:7)
In relation to the provision of emotional support, men
referred to needing to be patient and understanding
during a ‘difcult time’ and taking on the role of
‘cheer-leader’ when women were tired and upset and
felt like stopping breastfeeding. Men also spoke about
trying to be encouraging and appreciative of their
partner’s efforts:
[You] gotta let them know that they’re beautiful and
what they are doing is beautiful.(Rempel & Rempel
2011:118)
In summary, men’s role in infant feeding is to provide
practical and emotional support for women and not
to make decisions regarding infant feeding.
Men’s positive views on breastfeeding
Most papers in this review (n=16) discussed men’s
positive views on breastfeeding, associating this with
a greater likelihood that women will initiate and
maintain breastfeeding (Table 1). Our analysis
highlights that men expressed positive views when
breastfeeding is normalised.
In ve of the studies, men specically referred to the
ideology of ‘breast is best’ (Sherriff et al 2009, Sweet
& Darbyshire 2009, Henderson et al 2011, Sherriff &
Hall 2011, Brown & Davies 2014). In other studies
(n=13), men described breastfeeding as ‘natural’ or
‘healthier’ for babies in comparison with formula
feeding:
‘I don’t know, it’s just a normal part of life, nature’s
way of feeding the babies, so, yeah, it’s just the
normal thing to do.(Sweet & Darbyshire 2009:545)
And in one study, breastfeeding is described as ‘a gift
of nature’ (Mithani et al 2015:252).
The data also highlight that positive views of
breastfeeding prevail in cultures where breastfeeding
within the family (and in public) is acceptable, or
even expected. For example, in Okon’s (2004) UK
study, which included men from different ethnic
backgrounds, normalised cultures of breastfeeding
had a positive impact on the decision to breastfeed.
One man said:
At home (Nigeria)… most of the time our parents did
breastfeed.(Okon 2004:390)
In the Pakistani study by Mithani et al (2015) religious
beliefs were seen to be a major facilitating factor for
initiating breastfeeding, as one father commented:
‘ ...because I want to follow the guidance of the
Quran... if God has given diet for the child, how can
we human beings disrespect and devalue the child’s
right[…]?’ (Mithani et al 2015:254)
Men held positive views on breastfeeding for other
reasons too. This included the fact that breastfeeding
was seen as transient (Pontes et al 2009), as well as
cheap and convenient (Schmidt & Sigman-Grant
2000, Brown & Davies 2014). It was also thought to
have a positive effect on women’s bodies (Henderson
et al 2011). However, some men also expressed
negative views on breastfeeding.
MIDIRS Midwifery Digest 28:1 201894
Infant Nutrition
Men’s negative views on breastfeeding
The ndings of this review reveal that men sometimes
held negative views on breastfeeding and that this was
inuenced by a number of factors but, in particular,
men’s feelings of embarrassment or exclusion (Table 1).
In cultures where breastfeeding was not the norm,
men often expressed embarrassment about women
breastfeeding in public, or at home in front of family
members. Eight of the studies discussed men’s worries
about breastfeeding in public (Pontes et al 2009,
Tohotoa et al 2009, Avery & Magnus 2011,
Henderson et al 2011, Rempel & Rempel 2011,
Mitchell-Box & Braun 2012, Brown & Davies 2014,
Sherriff et al 2014). It was also clear from the data
that the sexualisation of women’s breasts was one
aspect of this:
‘I think it’s the sight of somebody with their breasts
out in public [makes me uncomfortable]. Not the
actual act of feeding a child… but it’s just more like
seeing someone’s breasts exposed in public, and that’s
always got sexual connotations as far as men are
concerned.(Henderson et al 2011:64)
In 13 of the studies reviewed, the data highlight how
men can feel excluded from the process of pregnancy,
childbirth or infant feeding, leading to negative views
about breastfeeding (Schmidt & Sigman-Grant 2000,
Okon 2004, Pontes et al 2009, Sweet & Darbyshire
2009, Tohotoa et al 2009, Avery & Magnus 2011,
Harwood 2011, Rempel & Rempel 2011, Sherriff &
Hall 2011, Hoddinott et al 2012, Mitchell-Box &
Braun 2012, Brown & Davies 2014, Sherriff et al
2014). The data suggest that men feel excluded from
bonding with their baby as well as excluded from
their partner and the mother-infant dyad. In some
instances, this led to considerable tension:
‘I’m really ashamed at it now but I did take it out
on my partner sometimes by being miserable with
her or even shouting sometimes. I felt excluded and
stressed but it wasn’t her fault […].’ (Brown & Davies
2014:517)
The literature also shows that other factors can
inuence negative views on breastfeeding, eg where
men regard bottle feeding as more convenient (Sherriff
et al 2009, Sweet & Darbyshire 2009, Sherriff & Hall
2011, Hoddinott et al 2012, Mitchell-Box & Braun
2012) or believe that formula feeding is safer for
babies (Mithani et al 2015). Men also reported
feelings of helplessness and guilt in not being able to
support their partners, which also led to negative
views on breastfeeding (Avery & Magnus 2011,
Brown & Davies 2014, Sherriff et al 2014).
Discussion and implications for midwives
This review has examined the qualitative literature on
men’s views and experiences of infant feeding and ve
main themes were identied. In contrast to previous
research, which had indicated that men are involved
in making decisions about infant feeding, this review
shows that men are rarely involved in decision
making. The review indicates that men are, however,
involved in supporting women’s decisions.
Interestingly, while this review sought to focus on
infant feeding, in many of the studies reviewed, infant
feeding was synonymous with breastfeeding. This
emphasis is likely to reect policy and practice
concerns with the promotion of breastfeeding, even
though supporting women’s choice of infant feeding,
regardless of how she chooses to feed her baby, is
most important. It is also interesting to note that in
the 20 papers included in this review, only ve
referred to midwives or midwifery. In three of these
(Engebretsen et al 2010, Hoddinott et al 2012, Brown
& Davies 2014), midwives are referred to in passing
within the data but no implications for midwifery are
drawn. In the fourth paper (Rempel & Rempel 2011)
reference is made to men accessing professional
breastfeeding support (eg from midwives) and in the
fth paper (Sherriff & Hall 2011), there is a eeting
mention of midwives within the context of a
discussion of how health visitors could best engage
with men. Although this review did not originally seek
to focus specically on midwifery, it is very surprising
that there is so little discussion within the literature of
the role of midwives in relation to men’s involvement
in infant feeding.
This review has highlighted how men learn about
infant feeding from a variety of sources. The data also
suggest that they value experiential knowledge as well
as that which is factual, practical and specic, rather
than theoretical or idealistic. However, men rarely
learn about infant feeding from health professionals,
such as midwives. Many men indicate that they feel
excluded from health promotion and would like to be
more involved by health professionals; this would
indicate that there is a potential gap in service
provision that could be addressed by midwives.
Overall, the review suggests that men consider
themselves less knowledgeable about infant feeding
than their female partners and therefore they tend to
leave the decision making to women. Only very rarely,
and in some very culturally specic contexts, do men
impose their views on women. On the whole, men see
themselves as having a supporting role. The data
suggest that this support takes a variety of forms
ranging from the provision of emotional support,
looking after other children in the household, dealing
with housework, or helping to clean bottles and
breast pumps. Considering men’s reported preference
for knowledge and information that is practical and
specic, midwives can enable men to feel condent by
providing them with concrete ideas on how they can
support their partners.
Many of the papers reviewed the issue of
breastfeeding as synonymous with infant feeding and
focused on the signicance of men’s views on
MIDIRS Midwifery Digest 28:1 2018 95
Infant Nutrition
breastfeeding. In the studies that explored this issue,
men’s positive views on breastfeeding were associated
with the likelihood that women would initiate and
maintain this practice. The data indicate that men are
more likely to be positive about breastfeeding when it
is normalised within their culture. When breastfeeding
is normalised it is more likely to be regarded as
‘normal’, ‘natural’ and, therefore, desirable.
Conversely, the studies reviewed indicate that when
men hold negative views of breastfeeding then this is
likely to be a barrier to women’s initiation and
continuation of breastfeeding. Men who report
negative views on breastfeeding tend to be
embarrassed by it and describe themselves as feeling
excluded. They also tend to report feelings of
frustration in not being able to support their partners
when breastfeeding problems occur. Men report
feeling excluded from health promotion and some
men feel excluded from the process of infant feeding.
Midwives can play a role in ensuring that whatever
method of infant feeding women choose, men have
practical strategies at their disposal, and therefore feel
empowered to support women. These ndings also
suggest that midwives can play an important role in
normalising breastfeeding within their communities.
This review has a number of limitations including the
fact that only studies published in English or Spanish
between January 2000 and March 2016 were
included. It is also important to note that the studies
in the review were quite homogenous in so far as they
had recruited men to the research with partners who
were either already involved in breastfeeding or
planning to breastfeed in the future. Future research
in this area could aim for greater heterogeneity and
should seek to involve men that are more involved
with women formula feeding, bottle feeding or using
mixed feeding methods. Future studies should also be
cautious not to conate infant feeding with
breastfeeding. Given the evident lack of focus on
men’s involvement in breastfeeding and midwifery,
future research could also seek to examine the
relationship between these issues more fully.
Dr Sarah Earle, Senior Lecturer in Health, School of Health,
Wellbeing & Social Care, The Open University, Walton
Hall, Milton Keynes, MK7 6AA.
Dr Robin Hadley, Independent Researcher.
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... Fathers reported 'a lack of support from healthcare practitioners and government policies' (Machin 2015, p. 36) with a notable absence of support from NHS staff before and after the birth (ibid, p. 48). A literature review of infant feeding found that men felt excluded and isolated from perinatal processes as evidenced by non-inclusion in antenatal classes and a lack of advisory material for fathers (Earle and Hadley 2018). ...
Chapter
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Fatherhood is seen as a natural right—a transition that is the ultimate sign that a man is virile, and bestows concomitant status, rights and privileges. The demographic, social, and economic changes across the last few decades have led to increased scrutiny of parenthood. Much of the focus is on fertility trends and the impact of childlessness for women. However, although there are more childless men than childless women, there is very little research literature on the impact of male involuntary childlessness.
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The importance of breastfeeding in low-income and middle-income countries is well recognised, but less consensus exists about its importance in high-income countries. In low-income and middle-income countries, only 37% of children younger than 6 months of age are exclusively breastfed. With few exceptions, breastfeeding duration is shorter in high-income countries than in those that are resource-poor. Our meta-analyses indicate protection against child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes. We did not find associations with allergic disorders such as asthma or with blood pressure or cholesterol, and we noted an increase in tooth decay with longer periods of breastfeeding. For nursing women, breastfeeding gave protection against breast cancer and it improved birth spacing, and it might also protect against ovarian cancer and type 2 diabetes. The scaling up of breastfeeding to a near universal level could prevent 823 000 annual deaths in children younger than 5 years and 20 000 annual deaths from breast cancer. Recent epidemiological and biological findings from during the past decade expand on the known benefits of breastfeeding for women and children, whether they are rich or poor.
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ABSTRACT This study explored fathers’ perceptions about breastfeeding infants. A qualitative exploratory study design was used. Study setting was urban and semiurban areas of Karachi, Pakistan. In-depth interviews were conducted with 12 fathers. The following themes emerged from the data collected: knowledge and awareness and enabling and impeding factors. Most fathers seemed eager to get involved and assist their partners in proper breastfeeding practices because they believed that doing so is in accordance with their faith. Fathers felt that adequate support from their family members and employers could enable them to encourage their partners to initiate and maintain exclusive and optimum breastfeeding practices. Exploring fathers’ perception regarding breastfeeding in the context of Pakistan is still a new field of study.
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Breastfeeding is recognized as the most appropriate method of infant feeding (UNICEF, 1999a), yet past research suggests that it declines during the early postpartum period (Foster et al, 1995). More importantly, recent studies have suggested that partners may influence breastfeeding decisions (Jackson, 2000) so their roles significantly reinforce more recent findings (Hamlyn et al, 2002). This small qualitative study explores partners' perceptions of breastfeeding, the extent of influence on breastfeeding decisions, and how health promotion can contribute to the uptake of breastfeeding. In this article, an open-ended, in-depth guide was used during the interviewing of eight male participants. The findings were analysed using thematic analysis. The findings indicate that partners have significant influence on a mother's infant-feeding decisions by their use of language, and that partners are greatly influenced by their perceptions of gender.