Review of Current Literature



ABSTRACT

Title: Support of public breastfeeding in the Northampton, Amherst and Greenfield communities

Author: Yael Borensztein, Nursing

CE Type: Independent Capstone Thesis

Approved By: Maud Low, Nursing

Approved By: Cynthia Jacelon, Nursing

The American Academy of Pediatrics and the World Health Organization recommend breastfeeding as the superior source of nutrition for infants, yet, in the U.S., only 74% of mothers initiate breastfeeding, and only 43.1% of mothers are breastfeeding at six months. Current research suggests that breastfeeding in public is a significant barrier to the maintenance and duration of breastfeeding. In an attempt to survey and assess the level of support regarding breastfeeding in public in three local Massachusetts communities (Northampton, Amherst, and Greenfield); assess the level of awareness within these communities regarding a recent amendment to chapter 111, which protects the rights of women breastfeeding in public; and to increase local awareness of supportive businesses in each community, a convenience sample of 79 locally owned businesses throughout the three communities were surveyed. A tool designed to identify the level of breastfeeding acceptance, awareness of section 221 of chapter 111, and to identify supportive businesses was utilized. The results demonstrated that most local businesses were supportive of the law (92%, n=79), and comfortable with breastfeeding in public (88%, n=79), but that most businesses (59%, n=79) were not previously aware of the amendment to chapter 111 of the Massachusetts General Laws. These results indicate a need for further promotion of the legal protection in place for breastfeeding women, as well as for further research regarding public opinions of breastfeeding in public.

Acknowledgements

I would like to acknowledge several people without whom this project would have been impossible. Firstly, Maud Low for her support, guidance and encouragement, and for pushing me to accomplish what I never knew that I could. Cynthia Jacelon also served as an essential source of support and guidance to this project.

Finally, this project could not have happened without the crucial feedback and contributions of Tanya Lieberman, IBCLC, and for that I thank her endlessly.

Introduction

In 1997, the American Academy of Pediatrics (AAP) released a policy statement entitled “Breastfeeding and the Use of Human Milk.” This policy statement emphasizes the importance of breastfeeding and provides recommendations to pediatricians and health care professionals regarding the initiation and maintenance of breastfeeding. The 2005 revision of the policy statement adds more recent research to support the benefits of breastfeeding. The AAP found that breastfeeding is “uniquely superior for infant feeding,” (“Breastfeeding,” 2005) in that it provides significant health benefits to both the mother and infant. Breastmilk, being species-specific, has been found to reduce the incidence of infectious diseases such as otitis media, respiratory tract infections, and diarrhea. Additionally, U.S. postneonatal infant mortality rates have been found to be reduced by 21% in breastfed infants (“Breastfeeding,” 2005). Among breastfed infants, lower rates of obesity, asthma, diabetes mellitus, and leukemia have also been noted. Breastfed infants also tend to show slightly enhanced cognitive development (“Breastfeeding,” 2005). Breastfeeding also provides maternal benefits such as a decreased risk for postpartum hemorrhage, decreased menstrual blood loss, increased child spacing and a more rapid return to pre-pregnancy weight. Breastfeeding also provides a reduction in maternal risk for breast cancer, ovarian cancer and osteoporosis (“Breastfeeding,” 2005).

The American Academy of Pediatrics recommendations for breastfeeding are as follows:

“exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life and provides continuing protection against diarrhea and respiratory tract infection. Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child (“Breastfeeding, 2005).”

The World Health Organization (WHO) supports this recommendation with the following statement:

“Breastfeeding is the ideal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of their family and the health care system. Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is recommended by WHO as the perfect food for the newborn, and feeding should be initiated within the first hour after birth. Exclusive breastfeeding is recommended up to 6 months of age (“Breastfeeding,” 2009).”

The 2005 National Immunization Survey found U.S. rates of breastfeeding initiation to be 74.2%. These rates drop to 43.1% at 6 months, and 21.4% at one year (“Breastfeeding Among U.S. Children,” 2008). The Healthy People 2010 initiative set goals for U.S. rates to reach 75% at initiation, 50% at six months, and 25% at one year (“Maternal, infant,” 2000). While the 2005 survey results point towards a trend in this direction, the goals are not yet reached, nor do the goals line up with the AAP and WHO recommendations. As evidenced in many studies, breastfeeding in public can be a major obstacle to the maintenance of breastfeeding (Clifford & McIntyre, 2008; Hauck, 2004). The discrepancy between the current rates, the Healthy People 2010 goals, and the AAP recommendations seems to indicate a need for research and intervention regarding any barriers to breastfeeding duration, including support of breastfeeding in public.

The United States does not have a particularly outstanding history regarding the protection and promotion of breastfeeding. In the late 1970s, the International Code of Marketing of Breast-Milk Substitutes, “the Code,” was developed as a set of marketing recommendations at a WHO and UNICEF international meeting due a referral by Senator Edward Kennedy (Walker, 2007). Initially, in 1981, the U.S. was the only country to vote against the adoption of the Code, which limits the marketing and promotion of breastmilk substitutes. Although it joined the consensus in endorsing the Code in 1994, no part of the Code is legislated in the United States (Walker, 2007). In 1990, a WHO/UNICEF policymakers’ meeting created the Innocenti Declaration, which specified targets to be attained by governments by 1995, including the establishment of the Baby-Friendly Hospital Initiative, implementing the Code, and enacting legislation to protect breastfeeding women in the workplace. Although the document was signed by the U.S., it has not implemented any of the Innocenti goals (Walker, 2007).

Currently, only two items of federal legislation exist concerning breastfeeding. The first is the Breastfeeding Promotion Program, in which “the Secretary [of Agriculture] is directed to promote breastfeeding as the best method of infant nutrition, to foster wider public acceptance of breastfeeding in the United States, and to assist in the distribution of breastfeeding equipment to breastfeeding women,” (Weiber, 2005). Lastly, section 629 of the Consolidated Appropriations Act of 2005, states that “notwithstanding any other provision of law, a woman may breastfeed her child at any location in a Federal building or on Federal property, if the woman and her child are otherwise authorized to be present at the location,” (Weiber, 2005).

In Massachusetts, Section 221 of Chapter 111

“allows a mother to breastfeed her child in any public place or establishment or place which is open to and accepts or solicits the patronage of the general public and where the mother and her child may otherwise lawfully be present; specifies that the act of a mother breastfeeding her child shall not be considered lewd, indecent, immoral, or unlawful conduct; provides for a civil action by a mother subjected to a violation of this law,” (An act to, 2009).

Passed in January of 2009, this new amendment serves as one of the focuses of this study.

Review of Current Literature

Breast milk as the optimal source of nourishment for infants is now widely accepted on a global scale, formally supported and encouraged by the World Health Organization (“Breastfeeding,” 2009) as well as the American Academy of Pediatrics (“Breastfeeding,” 2005). According to the Centers for Disease Control and Prevention’s 2005 National Immunization Survey, 75% of mothers initiate breastfeeding in the United States, yet this figure drops to 50% at 6 months (“Breastfeeding among,” 2008). Much of the literature available suggests that a major deterrent to successful breastfeeding duration is a lack of community support and acceptance of breastfeeding in public, something a woman must be able to do in order to meet the daily nutritional needs of her infant.

This literature review will discuss the existing literature regarding breastfeeding in public. The articles will be discussed by type of study, separated by reports on women’s experiences breastfeeding publicly, studies analyzing results from the national HealthStyles surveys, and reports on interventions designed to increase acceptability of breastfeeding in public. Of the fifteen articles reviewed, nine are written about studies or discussions that have taken place in the UK and Australia, suggesting a lack of American based research regarding breastfeeding in public. In Australia, 83% of mothers initiate breastfeeding (“Breastfeeding in Australia,” 2001), while in the UK, 79% of primiparous mothers and 73% of multiparous mothers initiate breastfeeding (Bolling, Grant, Hamlyn & Thornton, 2007).

Women’s Experiences Breastfeeding in Public

In 2008, an essay was published regarding the need for support and promotion of breastfeeding in the UK (Daniel, 2008). Daniel compares the abundance of smokers’ lounges in the workplace, before a blanket ban on indoor smoking, to the lack of appropriate breastfeeding locations both in and out of the workplace, stating that “women need spaces where they can sit and nurse their children in comfort and safety when out in public,” (Daniel, 2008). In a 2007 discussion of a recent breastfeeding ad campaign by the U.S. Department of Health and Human Services, Spear states that “the prevailing American mindset is, ‘If you must breastfeed your baby, please do not do it in front of me,’” and discusses the inextricable link between breasts, sex, and the sexual identity of women in the United States (Spear, 2007). The discussion also addresses an incident in which a woman was asked to leave a Starbucks Coffee location in Maryland when breastfeeding and ends with an emphasis on the value of knowing the state law regarding breastfeeding in public (Spear, 2007). Similarly, in a column written in 2001, Tracy states that an important strategy for successful breastfeeding in public is to do “location scouting” ahead of time (Tracy, 2001).

Clifford & McIntyre (2008) performed a thorough review of literature to determine the individuals that support and influence a mother’s decision to breastfeed in public in Australia. The databases Medline, CINAHL and PsychINFO were used to identify English language research articles published since 1996 in peer reviewed journals. The review determined that there are ten key groups or individuals that strongly influence a mother’s decision to breastfeed in public. These individuals and groups are made up of the father of the baby, other family members and friends, lactation consultants, doctors, midwives, nurses and other health professionals, peer counselors, breastfeeding support groups, employers, and the community (Clifford & McIntyre, 2008). Of note is the influence of the community on the mother’s decision to breastfeed publicly, and the determination that the community “is generally not supportive of breastfeeding in public,” (Clifford & McIntyre, 2008). The authors also emphasize that, though “breastfeeding in public is an essential part of breastfeeding successfully… [it] is a major barrier to breastfeeding,” (Clifford & McIntyre, 2008).

An earlier study done by Hauck in 2004 had discovered similar influential factors through a series of interviews with 33 Western Australian women who had recently breastfed their infant. Through these interviews, Hauck analyzed the maternal process of managing the later stages of established breastfeeding to determine the factors affecting a woman’s decision to breastfeed in public. This study determined that the most influential factors consisted of the woman’s confidence with the skill of breastfeeding, her ability to be discreet, her body image, her previous experiences with breastfeeding in public, the age of the child, the audience present during breastfeeding, the feelings of her partner, the location at which she is breastfeeding, and her perceptions of societal expectations about breastfeeding (Hauck, 2004). Hauck’s results correspond with those of Clifford & McIntyre (2008), especially pertaining to the influence of the partner’s feelings and the breastfeeding location on the decision to breastfeed in public. Hauck’s study provides specific opinions stated by breastfeeding mothers, such as the emphasis placed on the need for discretion by one mother: “they don’t like to see my breasts and in the same token I don’t think I need to expose it;” and the difficulty women experience identifying an appropriate location: “we’d always be hunting around… trying to find some place or juggling in the car,” (Hauck, 2004). Hauck emphasizes the importance of breastfeeding location availability by explaining that “as a community challenged to promote breastfeeding, we must continue to lobby for appropriate facilities for women wishing to breastfeed while out in the community,” (Hauck, 2004).

Sheeshka et al. (2001) conducted a two-part field study in Ontario, Canada to observe the amount and types of attention given to women breastfeeding in public versus those bottle-feeding in public. The researchers recorded observations of women breastfeeding and bottle-feeding in shopping malls and restaurants and later compared these results to mothers’ perceptions of the type and amount of attention received. Significantly more total attention was recorded while infants were being breastfed as opposed to bottle-fed, yet there was no significant difference between negative or positive looks (Sheeshka et al., 2001). The authors felt that this study was important given that the available research on breastfeeding in public and the related social reactions was very limited and concluded that, though research in other types of public settings is warranted, “public health professionals and their community partners could advocate for policies to create and support baby-friendly environments” in order to promote a “breastfeeding culture,” (Sheeshka et al., 2001).

Similarly, Scott and Mostyn (2003) conducted a series of focus groups in Scotland to evaluate the acceptability and effectiveness of an ongoing peer-supported breastfeeding intervention and, furthermore, to identify women’s experiences breastfeeding in a “bottle-feeding culture.” Nineteen mothers were recruited to participate in four focus groups from a list of 668 women who had received support from a peer-support volunteer during the intervention time frame. A predetermined list of topics was used to conduct each focus group, yet the conversation was allowed to flow as naturally as possible, and recurrent themes were recorded for discussion. Of these themes, breastfeeding in public was determined to be a major cause of embarrassment or fear for breastfeeding women, leading to social isolation. Scott and Mostyn emphasize the confession made by many women that they would go to great lengths to avoid having to breastfeed in public. One woman, however, explained how she reached the stage of overcoming this fear and embarrassment by stating that “it’s all done as very discreetly as possible. The more people see it, the more natural it is… my baby is crying, he’s hungry, I’m going to feed him,” (Scott & Mostyn, 2003).

HealthStyles Survey Reports

Regarding the public opinion of breastfeeding in the US, much of the research has been done utilizing the HealthStyles survey (“HealthStyles,” 2007). The HealthStyles survey is one of a pair of linked mail surveys sent to a sample of U.S. adults, drawn to be nationally representative of U.S. demographic characteristics. The HealthStyles portion of the survey focuses on health orientations and practices and has been administered annually since 1995. The HealthStyles survey obtained 2,636 responses in 1999, 2,369 in 2000 and 4,025 in 2003 (“HealthStyles,” 2007). All responses are rated on a lickert scale from “strongly agree” to “strongly disagree.” The HealthStyles survey has three main limitations. While it provides a representation of public opinion, it does not provide direct evidence as to how the public’s opinions ultimately affect an individual woman’s breastfeeding behavior, and the closed-ended questions do not allow for the explanation of reasons behind answers. Additionally, the attitudes drawn from the survey reflect only the opinions of individuals willing to sit down and complete a long survey (Li, Fridlinger & Grummer-Strawn, 2002).

Li, Fridlinger & Grummer-Strawn (2002) analyzed twelve breastfeeding items on the survey to describe the public perceptions on breastfeeding constraints in the US. The authors found that 45% of respondents agreed with the statement that “a mother who breastfeeds has to give up too many lifestyle habits,” and that 31% of respondents agreed that “one-year-old children should not be breastfed by their mother,” as well as that “babies ought to be fed cereal or baby food by 3 months old.” Additionally, 27% of respondents agreed that “it is embarrassing for a mother to breastfeed in front of others,” (Li, Fridlinger & Grummer-Strawn, 2002). The authors felt that these sentiments support the fact that

“to make breastfeeding in public acceptable, the perception that breastfeeding in public is a normal occurrence must be strongly promoted. Counseling and educational material to promote breastfeeding need to address the potential negative reaction to breastfeeding in public and to provide mothers with strategies for coping with the difficulties restricting their social activities,” (Li, Fridlinger & Grummer-Strawn, 2002).

In 2007, changes in the responses to items related to breastfeeding in the HealthStyles survey were analyzed to identify changes in public attitudes toward breastfeeding between 1999 and 2003, (Li, Rock & Grummer-Strawn, 2007). Four of the breastfeeding items on the HealthStyles survey were examined:

1. “Mothers who breastfeed should do so in private places only.”

2. “I am comfortable when mothers breastfeed their babies near me in a public place, such as a shopping center, bus station, etc.”

3. “Feeding a baby formula instead of breastmilk increases the chances that the baby will get sick.”

4. “Infant formula is as good as breastmilk.”

Although the study did not find a significant change between the two surveys, the trend was toward reduced acceptability of breastfeeding. The proportion of respondents agreeing with the statement “mothers who breastfeed should do so in private places only” increased by up to 5%, and those who agreed with the statement “I am comfortable when mothers breastfeed their babies near me in a public place…” decreased by up to 7.6%. The biggest drops were among respondents of low socio-economic backgrounds or those with a high school diploma or less, which is consistent with the findings of Li, Fridlinger & Grummer-Strawn (2002) that “the negative perceptions on barriers to breastfeeding were… more common among people with lower household incomes and those with less education.” The authors of this 2007 analysis of the HealthStyles survey also emphasize the point that “it is important to engage the community to accept breastfeeding as a normal, desirable, and achievable activity for women of all cultures and socioeconomic background” (Li, Rock & Grummer-Strawn, 2007).

In a previous study utilizing the HealthStyles survey, Hannan, Li, Benton-Davis and Grummer-Strawn (2005) utilized the HealthStyles survey to map regional variation in public opinions toward breastfeeding in the United States. Using survey results between 1999-2001, the authors determined that, though the sample size was too small to map by states, the New England region was among those least informed about the benefits of breastfeeding, yet had one of the highest rates of acceptability of breastfeeding in public. People from the East South Central, East North Central, Middle Atlantic and South Atlantic regions of the United States showed the lowest rates of acceptability of breastfeeding in public. Pacific and Mountain regions, however, were consistently positive about the health benefits of breastfeeding, breastfeeding in public, breastfeeding at work, and breastfeeding duration (Hannan, Li, Benton-Davis & Grummer-Strawn, 2005).

Interventions to Increase Breastfeeding Acceptability

Prior to the HealthStyles studies, McIntyre, Turnbull and Hiller (1999) had taken the idea of collecting public opinion on breastfeeding to the community and conducted a survey of restaurant and shopping center managers in Adelaide, South Australia in order to investigate the potential problems a mother may experience breastfeeding in public. The study revealed that 48.2% of 66 shopping center managers were supportive of breastfeeding, and 33.3% of 82 restaurant managers were supportive of breastfeeding. The authors reveal that, additionally, very few managers did not allow breastfeeding, consistent with the fact that breastfeeding is legally allowed everywhere in Australia (McIntyre, Turnbull & Hiller, 1999). Like many of their peers, the authors emphasize the importance of providing the community with information and an increased awareness of the fact that breastfeeding in public is protected by legislation in all states and territories of Australia in order “to help create a supportive environment for breastfeeding mothers.” They add that

“if managers of public places… were made aware that breastfeeding is allowed… perhaps they would be less likely to ask a mother to move to a more secluded spot or to stop breastfeeding. If the community was made more aware [of the legislation], then perhaps they would be generally more accepting and supportive of breastfeeding” (McIntyre, Turnbull & Hiller, 1999).

In addition to reporting on public opinions about and women’s experiences with breastfeeding in public, a limited amount of research has been published regarding interventions designed to promote awareness and acceptability of breastfeeding in public.

In 2000, Lobely and Walker published an article summarizing and reporting on the results of “The Blue Mountain Breastfeeding Intiative.” This initiative set out to identify and promote the amount of support from the local community, businesses and services in the Blue Mountain region of Australia as the authors felt that “the idea that breastfeeding mothers must remain out of the public in order to breastfeed their babies most certainly restricts women’s lives and ultimately will inhibit the pleasure and simplicity of breastfeeding,” (Lobely & Walker, 2000). The initiative provided supportive businesses and services with “breastfeeding welcome here” stickers to indicate their support for women breastfeeding in public. The initial survey consisted of three questions: “is breastfeeding welcome on your premises?” “would you display a sticker that identifies you as welcoming to breastfeeding mothers?” and “would you appear on a brochure that lists participating businesses?” Initially, 68 stickers were distributed but, upon further implementation, 217 stickers were distributed throughout the community. The initiative succeeded in identifying businesses and services displaying supportive attitudes toward breastfeeding in public as well in increasing local women’s level of awareness of suitable “breastfeeding friendly” venues in the local community (Lobely & Walker, 2000).

On a larger scale, Boyd and McIntyre (2004) reported on the results of “an action research plan aimed to improve community acceptability of breastfeeding in public through the accreditation and promotion of breastfeeding-friendly venues in Australia.” In collaboration with the Australian Breastfeeding Association (ABA), Boyd and McIntyre created “breastfeeding welcome here” kits consisting of a presentation folder, with the ABA logo on the cover, which contained an evaluation survey, reply paid envelope, and sticker with the ABA logo and the words “breastfeeding welcome here.” Businesses were then surveyed to meet the criteria of having a welcoming attitude towards breastfeeding in public shared by all staff members and management, a smoke free environment, and “enough room to move a pram,” (Boyd & McIntyre, 2004). Upon meeting the criteria, the business was provided with a “breastfeeding welcome here” kit. In collaboration with various nationwide organizations, the intervention was successful in distributing 17,248 kits throughout Australia, and ultimately identifying 1,200 breastfeeding-friendly venues throughout the nation, thus encouraging a “national approach to promoting breastfeeding-friendly venues through the use of a distinct and acceptable logo,” (Boyd & McIntyre, 2004).

More broad interventions have also been examined in the literature on breastfeeding in public, including Entwistle’s 2008 report on the “Breast Buddy” campaign, an initiative designed to encourage women between the ages of 16 and 25 to breastfeed, which was launched during the UK’s National Breastfeeding Awareness Week. This awareness week also saw the launch of “breastfeeding friendly places,” an initiative designed to praise retailers, work places, shopping centers and retail locations for being welcoming and supportive of breastfeeding mothers in the area, much like the Blue Mountain Initiative (Lobely & Walker, 2000) and the collaborative approach implemented by Boyd and McIntyre (2004) in Australia. Another intervention implemented in the UK was Rogers’ and Hickman’s (2008) creation of a “Baby Café,” at which breastfeeding mothers are triaged to receive the appropriate level of support and guidance to ensure successful maintenance of breastfeeding. (Rogers and Hickman, 2008). This intervention, however, is isolated to the community of Halifax in West Yorkshire and requires that mothers feel confident enough breastfeeding to leave the home and risk breastfeeding in public. Rogers and Hickman, however, report that 94% of the 936 mothers attending the service found it helpful, and 75% found that attending the Baby Café has helped them to continue to breastfeed.

Within the limited amount of literature available regarding breastfeeding in public, a few themes are consistent. As levels of acceptability for breastfeeding in public continue to trend toward decreased acceptability (Li, Rock & Grummer-Strawn, 2007), studies emphasize, almost unanimously, that there is a need to increase the levels of awareness regarding legislation protecting the rights of breastfeeding women, as well as the need to advocate for policies and resources to provide comfortable and safe locations for women to breastfeed in public. The Australian literature reporting on interventions to increase awareness and identify supportive, “breastfeeding friendly” locations does, however, demonstrate that well-implemented interventions can have a positive and far-reaching impact on the acceptability and awareness of breastfeeding in public. Finally, the lack of U.S. based literature and interventions indicates the strong need for continued research within the nation.

Goals

The goals of this study are three-fold. The first is to survey and assess the level of support regarding breastfeeding in public in the local communities of Northampton, Amherst and Greenfield, Massachusetts. Second is to assess the level of awareness within these communities regarding the recent passing of the amendment to chapter 111, protecting the rights of women breastfeeding in public, and the third goal is to increase local awareness of supportive, or “breastfeeding-friendly,” businesses in each community.

Methods

A convenience sample of locally owned businesses in each town center was chosen based on their proximity to each other, and the variety in the type of establishment available. This also allowed for time-efficient surveying. Ultimately, 36 businesses were surveyed in Northampton, 25 in Amherst and 18 in Greenfield. While the three towns differ in population sizes (Northampton: 29,289; Amherst: 35,228; and Greenfield: 18,666), each town contains between 4,337 (Greenfield), to 5,878 family households (U.S. Census Bureau, 2000), allowing mother and infant health issues, such as breastfeeding, to carry equal importance.

A tool was constructed based on previous studies, such as the Blue Mountain Initiative (Lobely & Walker, 2000), as well as basic questions reflective of simple attitudes toward breastfeeding in public.

|Tool |

1. That you are aware of, has a woman ever breastfed on your premises?

2. Before my explanation of it, were you aware of this recently passed law regarding a woman’s right to breastfeed in public?

3. Do you support the passing of this law?

4. Before this law, would you have been comfortable allowing breastfeeding on your premises?

5. Would you like a breastfeeding welcome here sticker?

The interviewer approached an employee and was asked to be directed to an available employee who would be willing and able to respond to five yes-or-no questions regarding breastfeeding in public. The participant was then asked for his or her title within the store (ie. employee, manager or owner), reassured that his or her answers would remain anonymous, and told that the five questions could be answered with “yes,” “no,” or “unsure or indifferent.” The gender of the participant was also noted. Before beginning, the interviewer described the amendment to chapter 111 of Massachusetts State Law, which protects the rights of women breastfeeding in public. The participant was then asked to answer the five questions.

The resulting data was compiled into a series of tables demonstrating the overall results for each town, as well as the results of each town by gender (see Appendices A, B, C and D). The data was also compiled into tables demonstrating the resulting data from the three towns combined.

Results and Discussion

The overall results reflected a positive and supportive attitude toward breastfeeding in public throughout the three local communities. The questions which most reflected this attitude were “Do you support the passing of this law?” and “Before the passing of this law, would you have been comfortable allowing a woman to breastfeed on your premises?” The responses to these two questions, for all three towns combined, were as follows:

|Do you support the passing of this law? |

|n=79 |

|Yes |92% (73) |

|No |3% (2) |

|Indifferent |5% (4) |

|Before the passing of this law, would you have been comfortable allowing a woman to breastfeed on your premises? |

|n=79 |

|Yes |88% (70) |

|No |8% (6) |

|Indifferent |4% (3) |

Ninety-two per cent of the total sample (n=79) supported the amendment to Chapter 111, and eighty-eight per cent felt comfortable allowing a woman to breastfeed within their premises, regardless of the law, reflecting an extremely positive and accepting attitude toward breastfeeding in public.

Among the three towns, Amherst (n=25) demonstrated the most positive responses to these two questions. One hundred per cent of all employees surveyed responded that they positively supported the amendment to Chapter 111, and 92% of Amherst respondents felt that they were comfortable allowing women to breastfeed within their premises. It is important to note that only one individual (4%) responded that they would not have felt comfortable allowing breastfeeding on his or her business’s premises before the passing of the law, and the other 4% consisted of one individual who felt indifferent about allowing women to breastfeed.

Although the largest sample, Northampton (n=36) demonstrated the least positive responses to these two questions. While there was still a positive majority, the percentage dropped from 100% (Amherst), and 94% (Greenfield), to 86% of Northampton respondents that supported the amendment to Chapter 111. Additionally, only 86% of Northampton respondents would have felt comfortable allowing breastfeeding on their premises, as compared to 92% in Amherst and 89% in Greenfield. Though these discrepancies are minimal and the overall trend is positive, it is important to note that they are consistent by town, with Amherst demonstrating the most positive support and Northampton with the least.

In terms of awareness of the amendment to Chapter 111, 41% of all respondents (n=79) were previously aware of the law:

|Are you aware of this recently passed law regarding a woman’s right to breastfeed in public? |

|n=79 |

|Yes |41% (32) |

|No |59% (47) |

Forty-four per cent of both Amherst and Greenfield respondents indicated that they were aware of the law, while 36% of Northampton respondents indicated awareness of the law.

Finally, responses to the “Breastfeeding Welcome Here” sticker were generally consistent:

|Would you like this “Breastfeeding welcome here” sticker? |

|n=79 |

|Took to show owner |51% (40) |

|Affixed sticker at entrance |29% (23) |

|Refused sticker |20% (16) |

The only notable difference was the resulting data from Greenfield, where 39% of respondents took the sticker to the owner, 28% affixed the sticker at the entrance, and 33% refused the sticker. This is likely due to the fact that Greenfield demonstrated the most even distribution of participants between owners (33%), managers (28%), and employees (39%). This even distribution reflected the level of authority respondents had in terms of ability to affix the sticker at the entrance. In Amherst and Northampton, about 50% of each sample consisted of employees or sales associates, which corresponds with the 51% of the entire sample that took the sticker to show to the owner of the establishment. Ultimately, 23 of the 79 businesses surveyed agreed to affix the “Breastfeeding Welcome Here” sticker at the entrance to their establishment.

Gender differences were generally insignificant except that more women (47%) than men (75%) were previously aware of the amendment Chapter 111.

Limitations

This study, as an extremely preliminary community assessment, has several limitations. Firstly, using a convenience sample of businesses in each town center does not allow for a thoroughly accurate representation of the different types of businesses throughout each town. Businesses in more isolated or less populated regions of each town could potentially answer the questions differently, thus providing a different perspective to the overall assessment. Furthermore, utilization of a convenience sample within these three towns is not generalizable to the New England region due to the generally liberal population inhabiting the three towns.

Another limitation is that time did not allow to limit surveys to owners exclusively. Doing so would have provided a much more accurate representation of the number of businesses that are supportive enough to display the sticker. Additionally, the utilization of a “yes or no” survey did not allow for any explanation behind responses given, and the overall small sample size when towns were split by gender causes percentage results to look more remarkable or significant than they truly are.

Conclusions and Implications

Overall, the results yielded substantially positive results, indicating that Northampton, Amherst and Greenfield businesses are generally supportive of breastfeeding in public. However, due to the lack of awareness of recent legislation, section 221 of Chapter 111, women still run the risk of experiencing discrimination due to a lack of knowledge on the behalf of business owners or employees. This fear could continue to prevent women from comfortably breastfeeding in public, despite being ultimately protected. Increased awareness of this legislation can reassure breastfeeding women that they will not meet any opposition, however unfounded it may be.

To further explore the culture of breastfeeding in the area, studies are warranted to examine and identify the percentage of the local population that initiates breastfeeding, as well as any other factors that may prevent women from initiating and continuing to breastfeed. It would also be interesting to conduct a qualitative study to investigate the reasoning behind each survey answer. Research is also needed to explore the perceptions of the local public regarding breastfeeding in public areas, as well as the public’s awareness of section 221 of Chapter 111. By increasing and strengthening the network of public support towards breastfeeding, both public and private, communities can work toward creating a strong culture of breastfeeding, thus enhancing and promoting the health of all future generations.

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