Breastfeeding provides various health benefits for infants, including increased protection against childhood infectious diseases and improvements to early childhood cognitive development, as well as a lower likelihood of developing ovarian or breast cancer for women who breastfeed.1 Accordingly, the World Health Organization recommends that infants be breastfed exclusively for at least the first six months of life.2 In New Zealand, although the right to breastfeed is technically protected by legislation against gender-based discrimination, breastfeeding in public is not specifically protected by the law.3 This subtle legal distinction has important implications, as policies that protect the right to breastfeed in public increases breastfeeding rates.4

In 2017, approximately 77% of all newborn infants were exclusively or fully breastfed at two weeks of age, 72% were breastfed exclusively at six weeks, before dropping to 58% at three months.5 Although there are many factors that may contribute to the reduction in breastfeeding rates (eg, personal factors), social attitudes towards breastfeeding may be a critical barrier to breastfeeding in public. However, few studies have been conducted in New Zealand that directly examine levels of public support for breastfeeding in public. We address this oversight by investigating attitudes towards public breastfeeding using a large, national sample of New Zealand adults.

Two factors that might contribute to the decrease in breastfeeding rates are the lack of legislation and the lack of facilities supporting breastfeeding in public spaces. For instance, mothers may feel discomfort and embarrassment with the idea of breastfeeding in public.6 Hyper-awareness of public scrutiny and the perceived unacceptability of public breastfeeding may lead to feelings of awkwardness and unwanted exposure.7 Due to these fears, mothers may avoid breastfeeding in public or withdraw from breastfeeding earlier than they would otherwise.8 Additionally, people may perceive breastfeeding inside the home as more acceptable than breastfeeding in public spaces.9 Taken together, both the perceived acceptability of breastfeeding by mothers, as well as the public’s attitude in general, may constrain women’s breastfeeding options.

Research on support for breastfeeding in public has yielded inconsistent results, suggesting that there is considerable cross-cultural variability in attitudes and norms. In a community survey conducted in rural Newfoundland and Labrador, 51.9% of respondents indicated that they would be uncomfortable around a woman breastfeeding in public.10 Similarly, a survey of New York City residents found that 50.4% of respondents were unsupportive of public breastfeeding.11 Yet other studies identify high levels of support for breastfeeding in public. A study conducted in Tennessee, US, found that people’s comfort with being around a breastfeeding mother in a public space increased from 58.4% in 2004 to 66.5% in 2008.12 Comparatively, positive attitudes were observed in a study of Canadian adults in Ottawa, where 75% of respondents thought it was acceptable for women to breastfeed in restaurants and shopping malls.13 Similarly, a study of Western Australian adults found relatively high support between 1995 and 2009, with around 70% of participants believing it was acceptable to breastfeed across a range of public settings (eg, public transport, shopping malls).14

The present study

Attitudes towards breastfeeding in public in New Zealand has been largely overlooked in recent years. As such, a review of decade-old research is warranted. Echoing themes from the international literature, qualitative research reveals that New Zealand mothers experience various social barriers, including public scrutiny when negotiating the decision to breastfeed in public.15,16 Similarly, a quantitative study in New Zealand showed that many mothers felt embarrassed when breastfeeding in public and, as a result, reduced the duration of their breastfeeding.17 Finally, a study of Māori women’s and whānau experiences with breastfeeding indicated that almost half of participants perceived that breastfeeding in public was seen as unacceptable by the general public.18 However, societal attitudes towards public breastfeeding has yet to be investigated in New Zealand.

The aim of this study was to address this oversight by examining attitudes towards public breastfeeding in New Zealand using a national sample of adults. First, we examined rates of public support for breastfeeding in public. Second, we explored sociodemographic factors associated with public breastfeeding support. In doing so, we address a notable gap in the literature by assessing how sociodemographic characteristics are associated with public breastfeeding support in New Zealand. Furthermore, we also address how religious affiliation relates to societal support for public breastfeeding, a previously unexplored factor in the extant literature.

Method

Participants

Participants (N=19,598) were from Time 8 (2016/17) of the New Zealand Attitudes and Values Study (NZAVS) and were limited to those for whom complete data were available. The NZAVS is an ongoing nationwide longitudinal panel study of New Zealand adults aged 18 and older. Ethical approval of the study was granted by the University of Auckland Human Participants Ethics Committee. See Table 1 for demographic characteristics and comparisons between the weighted and unweighted sample.

Table 1: Unweighted and weighted demographic characteristics of the sample (N=19,598; Time 8 (2016/17) of the NZAVS).

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1Children ever given birth to, fathered or adopted.
2Participants may identify with more than one ethnicity.

Sampling procedure

The initial Time 1 (2009) NZAVS sample were randomly sampled from the 2009 New Zealand Electoral Roll. Sampled participants were sent a postal questionnaire with the option to participate in the study. In following waves, booster sampling of adults aged 18–65 was conducted to increase the sample size and address sample attrition. Specifically, random samples were drawn from the 2012, 2014 and 2017 New Zealand Electoral Rolls and then incorporated into the study at Time 4 (2011/12), Time 5 (2013/14) and Time 8 (2016/17), respectively. Additional participants were recruited from an unrelated survey featured on a New Zealand news website at Time 3 (2011).

Measures

Opposition to breastfeeding in public

Time 8 (2016/17) of the NZAVS included a measure of opposition towards breastfeeding in public. Participants were asked to rate their agreement to the following item, “Women should avoid breastfeeding in public”, using a 7-point Likert scale with anchors at 1 (Strongly Disagree) and 7 (Strongly Agree).

Sociodemographics

A variety of sociodemographic variables were also measured. These included gender, age, ethnicity (European/Pākehā, Māori, Pacific Nations descent, Asian descent), religious affiliation, parental status, the number of children the participant had given birth to, fathered or adopted, relationship status (serious romantic relationship), employment status, education (11-unit ordinal rank of qualifications according to New Zealand Qualifications Standards),19 population density (urban vs rural), birthplace (being born in New Zealand or outside of New Zealand) and a measure of area-level socioeconomic deprivation (New Zealand Deprivation Index 2013).20

Analysis procedure

Regression analyses were conducted in Mplus. Descriptive statistics and bivariate correlations of all measures were examined in SPSS. Post-stratification sample weighting was applied to all analyses to adjust for sample biases in gender, ethnicity and region.21 Due to the large sample size, statistical significance was defined as p<.005.

Results

Overall support for breastfeeding in public

Overall, most participants strongly supported public breastfeeding, as indicated by low agreement with the statement “Women should avoid breastfeeding in public” (M=2.02, SD=1.52). Based on weighted sample estimates, 75.3% of participants supported public breastfeeding (rating their agreement to the statement as 1 or 2), whereas only 5.2% of the sample were opposed to public breastfeeding (ratings of 6 or 7). A further 19.5% of participants expressed neutral views towards public breastfeeding (ratings of 3 to 5). Post-stratification sample weighted means, standard deviations and bivariate correlations across all measures are summarised in Table 2.

Table 2: Descriptive statistics and bivariate correlations across sociodemographic factors and attitudes towards public breastfeeding.

**p<.001, *p<.005
Weighted correlation coefficients, means, and standard deviations.
a0 = women, 1 = men.
bDummy-coded; 0 = no Māori identification, 1 = Māori identification.
cDummy-coded; 0 = no Pacific identification, 1 = Pacific identification.
dDummy-coded; 0 = no Asian identification, 1 = Asian identification.
e0 = yes, = 1 no.
f11-unit ordinal rank of qualifications, 0 = no qualifications, 1–3 = partial/full secondary school, 4–6 = non-undergraduate tertiary qualifications, 7 = undergraduate degree, 8–10 = post-graduate qualifications.
g0 = rural, 1 = urban.
hArea-level socioeconomic deprivation; 1 = least deprived, 10 = most deprived.
i1 = Strongly Disagree, 7 = Strongly Agree.

Sociodemographic correlates

A multiple linear regression was conducted to examine sociodemographic correlates of opposition to public breastfeeding. All variables were entered into the model simultaneously. Ethnicity was dummy-coded, with European/Pākehā assigned as the reference category. Table 3 displays the results of these analyses. To these ends, men, relative to women, (B=0.19), being older (B=0.02) and identifying with a religion (B=0.27) correlated positively with opposition to breastfeeding in public. In contrast, being a parent (B=-0.28), having more children (B=-0.06), being in a relationship (B=-0.14) and education (B=-0.06) correlated negatively with opposition to women breastfeeding in public.

Table 3: Multiple linear regression of sociodemographic correlates of opposition to breastfeeding in public.

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*p<.005, **p<.001.
R2=.078, p<.001.
Weighted regression coefficients.
Opposition to breastfeeding in public; 1 = Strongly Disagree, 7 Strongly Agree.
a 0 = women, 1 = men.
b Dummy-coded; 0 = no Māori identification, 1 = Māori identification.
c Dummy-coded; 0 = no Pacific identification, 1 = Pacific identification.
d Dummy-coded; 0 = no Asian identification, 1 = Asian identification.
e 0 = yes, = 1 no.
f 11-unit ordinal rank of New Zealand qualifications; 0 = no qualifications, 1–3 = partial/full secondary school, 4–6 = non-undergraduate tertiary qualifications, 7 = undergraduate degree, 8–10 = post-graduate qualifications.
g 0 = rural, 1 = urban.
h Area-level socioeconomic deprivation; 1 = least deprived, 10 = most deprived.

As for ethnic group differences, Māori (vs European/Pākehā) expressed less opposition towards public breastfeeding (B=-0.13), whereas Asian peoples were more opposed to breastfeeding in public (B=0.48). Conversely, there was no difference in attitudes towards public breastfeeding between participants of Pacific Nations descent and European/Pākehā (p=.41). Likewise, employment status, population density, birthplace and area-level socioeconomic deprivation were unassociated with attitudes towards public breastfeeding (ps>.005).

Discussion

The present study examined support for breastfeeding in public in New Zealand. Most participants (75.3%) agreed that women should be able to breastfeed in public, whereas 5.2% were unsupportive of breastfeeding in public (19.5% of our sample were neutral on the issue). These results are optimistic compared to past research in New Zealand which suggested that mothers perceived public breastfeeding as being embarrassing and unaccepted by society.16–18 Additionally, these results are comparable to levels of support in similar Western nations. Russell and Ali found that a majority (78.2–80.9%) of people from Ottawa, Canada thought that breastfeeding in a restaurant and/or a shopping mall was acceptable.13 Similarly, a study from Western Australia found that around 70% of people thought that it was acceptable to breastfeed across a range of public areas (eg, restaurants and public transport).14 Nevertheless, we found higher levels of support for breastfeeding in public than comparable surveys from the US, where just over half of participants were supportive of public breastfeeding.10,11

We found that men expressed greater opposition to public breastfeeding relative to women. This finding is notable, as past research has revealed inconsistent gender differences in support for public breastfeeding. For example, in Western Australia and Canada, men expressed greater support for public breastfeeding than did women.13,14 Conversely, Mulready-Ward and Hackett found no gender differences in support for breastfeeding in public in New York City,11 whereas another US-based study found that women were more comfortable than men with the idea of breastfeeding in public.22

Age was also correlated positively with opposition to public breastfeeding, which is consistent with past work which revealed that people over 44 years old in Western Australia and people older than 65 in New York City were more unaccepting of public breastfeeding relative to younger age groups.11,14 Yet our results conflict with research from Tennessee which showed that older age groups (25–65+) were more comfortable with women breastfeeding in public than the youngest age group (18–24).12 Explaining the apparent cross-cultural discrepancies in public support for breastfeeding would be an important direction for future research.

Although past research has largely overlooked the association between religious affiliation and public breastfeeding support, our results reveal that participants who identified with a religion were more opposed to public breastfeeding than were their non-religious counterparts. These results appear consistent with past research showing that maternal religious affiliation and engagement negatively correlates with breastfeeding initiation and duration.23 The circumstances under which breastfeeding occur may, however, influence perceptions of its acceptability. Specifically, breastfeeding within the home is generally more accepted than breastfeeding in public.9 As such, although religious affiliation may be related to support for breastfeeding in general, the perceived acceptability may be qualified by where the breastfeeding occurs. Given these findings, primary and community care providers should consider families’ religious beliefs when providing consultation about breastfeeding and breastfeeding locations.

Perhaps unsurprisingly, we also found that both being a parent and the number of children participants had correlated positively with support for public breastfeeding. This is consistent with research showing that having more children at home was linked to greater perceived acceptability of public breastfeeding.13 However, Mulready-Ward and Hackett did not find a relationship between having children younger than 12 years old in the home and comfort with being around a woman breastfeeding in public.11

Additionally, being in a relationship was associated with greater support for public breastfeeding. This finding is consistent with a study from Tennessee, which showed that participants in a relationship were more likely to feel comfortable with women breastfeeding in public.12 We also found that there was no difference in support for public breastfeeding between those who were employed or those who were unemployed (including those who are retired). These results might contradict past research which found that retired people (relative to full-time employed individuals) and unemployed people were more opposed to public breastfeeding.13,24

Our results also demonstrated that education correlated positively with support for breastfeeding in public. This finding is consistent with international research, which found that higher education was linked to greater support for public breastfeeding in Western Australia,14 the US11,12 and Canada.13

Past research has also found that birthplace affects attitudes towards breastfeeding in public. Russell and Ali found that participants born in Canada were less supportive of public breastfeeding, although those whose native language was neither English nor French were particularly opposed to breastfeeding in public.13 Conversely, another study found that participants born outside of Australia were less accepting of public breastfeeding.14 Yet a survey from New York City found that birthplace had no effect on support for breastfeeding in public.11 Our results further complicate these findings by showing that being born in New Zealand (relative to being born outside of New Zealand) was unrelated to attitudes towards public breastfeeding. Collectively, these findings demonstrate the need to attend to cross-cultural norms to understand the influence birthplace has on support for public breastfeeding, as there appears to be cross-country variability in attitudes towards public breastfeeding. Although our results suggest that birthplace is unrelated to public breastfeeding attitudes, breastfeeding support tailored for mothers born outside of New Zealand remains important to address. Primary care providers could help by increasing awareness of societal support of public breastfeeding in New Zealand.

Finally, our results suggested that, relative to European/Pākehā, Māori were more supportive, whereas Asian peoples were less supportive, of public breastfeeding. Our findings echo results from New York City which revealed that Asian peoples were less supportive of public breastfeeding than their Caucasian counterparts.11 Likewise, our finding that Māori participants were more supportive of public breastfeeding complements a previous qualitative study by Glover and colleagues on Māori mothers and their whānau, which suggested that they perceived society as unaccepting of public breastfeeding.18 Considering the high levels of support found in the current study, the perceived norms around public breastfeeding may have changed in the decade since the Glover study.

Implications

Many women who breastfeed perceive society to be unaccepting of breastfeeding in public—a perception that may lead them to avoid public breastfeeding or stop breastfeeding altogether.7,8 However, fostering community support for breastfeeding may counteract these restrictive trends. Indeed, co-worker support of breastfeeding in workplaces predicts greater self-efficacy to continue breastfeeding.25 As such, the high levels of support observed in the current study may help to counteract the fear and embarrassment some women may feel when deciding whether or not to breastfeed in public.6 Consistent with this perspective, community acceptance of breastfeeding in general correlates positively with the perceived ease of breastfeeding.26

Thus, our findings could benefit clinical practice and public health initiatives aimed at fostering breastfeeding. Given that past research shows that Māori communities may perceive society as being unaccepting of public breastfeeding,18 primary and community care providers could utilise our findings to assuage fears of public judgement associated with public breastfeeding. In turn, these targeted campaigns could increase breastfeeding rates in communities with traditionally lower rates of breastfeeding (eg, Māori and deprived communities).5,27 Furthermore, as our findings suggest that Asian peoples express the least amount of support for public breastfeeding, public health campaigns could specifically target this population when trying to bolster support for breastfeeding in public.

Limitations

Although our study makes a number of important contributions to the literature, it is worth noting some of its limitations. Due to the omnibus format of the NZAVS survey, there was only enough space for a single-item measure of support for breastfeeding in public. As such, we were unable to assess the perceived acceptability of breastfeeding across a range of locations. Yet research demonstrates that there may be key differences in support depending on location. For example, breastfeeding is seen as more acceptable in shopping malls than in restaurants.13 Similarly, the perceived importance of discretion or the effort on the part of the mother to “cover-up” when breastfeeding was not assessed. This is an oft-noted factor when people consider the acceptability of breastfeeding in public.14 As such, future work in New Zealand should examine situational variability in support for breastfeeding in public. Such research could help to inform public health initiatives aimed at reducing the stigma associated with public breastfeeding, as well as to increase the number of facilities available for women who breastfeed in public spaces.

Finally, we were unable to assess people’s (dis)comfort with being around someone breastfeeding in public. To these ends, past research reveals differences in support depending on the perceived acceptability and comfortability with breastfeeding in public.11 Specifically, people report being more comfortable in the presence of a breastfeeding mother than they rate the acceptability of breastfeeding in public. These critical contradictions suggest that attitudes towards public breastfeeding are multifaceted and that a multitude of factors (including one’s affective responses to, and the location of, breastfeeding) should be considered when assessing support for breastfeeding in public.

Concluding comments

The present study provided the first comprehensive overview of support for public breastfeeding in New Zealand. To these ends, our findings provide an optimistic outlook on societal attitudes, as most participants indicated that women should be allowed to breastfeed in public. Despite high levels of support, our results also indicated that key sociodemographic variables predicted support for, and opposition to, breastfeeding in public. Specifically, being a woman, identifying as Māori, being a parent, being in a relationship, being employed and having higher education were associated with greater support for public breastfeeding, whereas being older, identifying with an Asian ethnicity and identifying with a religion were associated with more opposition to public breastfeeding. Collectively, these results provide a snapshot of populations in New Zealand who express more or less support for breastfeeding in public. Future public health initiatives should consider these results when developing and implementing targeted campaigns aimed at increasing support for breastfeeding in public.

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