This was an observational study using an online cross-sectional survey. A theoretically based survey of breastfeeding mothers with children under 2 years was undertaken in Finland in 2016/7 and a comparison survey completed in 2017 in the UK. In both countries, participants were approached via third sector organisations with a breastfeeding and early parenting support role. Although study recruitment is often carried out via formal health services, we wanted to represent the fact that new mothers may seek out both generic (focused on parenting) and breastfeeding specific support, from both informal and formal sources. These different types of support may have different functions and impacts. Using on-line recruitment methods also allowed us to obtain large comparable samples over a relatively short timespan. Data on stress and support was also considered useful to help participating organisations to plan future services. The survey was carried out by researchers from the University of Stirling and Helsinki Metropolia University and distributed using the ‘Qualtrics’ (Qualtrics XM, 2016) package. Paper copies were available but not requested. Early parenting stressors and strains were primary outcomes. Breastfeeding stress, self-efficacy and breastfeeding and parenting support were main predictors. Demographic information was used for sub-group analysis, including comparison of uniparous and multiparous women.
Recruitment and participants
The survey was open to mothers of children with at least one child of 2 years or under. Only those currently breastfeeding their youngest child were included in this analysis. It was available in Finnish, Swedish (a second language in Finland) and English. The survey link was circulated via contacts in local breastfeeding groups, and social media, and with their permission, was posted on websites of non-government organisations supporting breastfeeding and early parenting in Finland, including:
Respondents in the UK (n = 533) were from England (210, 13%), Scotland (306, 20%), Wales (5,1%) and Northern Ireland (12,2%), with 1017 (65%) from Finland.
Sample size and statistical power
Studies using demographic and psychological variables as predictors of stress generally show a medium effect size using multiple regression analysis. Using the G*Power package  for an effect size of r2 = 0.3, with power of 0.90 and alpha 0.01 a sample of approximately 102 women in each country was required. To carry out secondary analysis we aimed to recruit substantially more participants in each context.
Inclusion/ exclusion criteria
The study included women who had ever breastfed their child of 2 years old or under. This paper reports data from those currently breastfeeding. There were no exclusion criteria, although we were not able to offer translation of the survey into other languages, which may have excluded some women.
Validated measures were used where possible. To encourage completion and reduce participant burden, measures were shortened, and where necessary modified to remove items inappropriate for the target population.
Maternal age, education level, residence and financial security were proxy variables for socio-economic status and potential predictors of infant feeding distress and general stress [5, 13].
Parental status: coded according to status - with partner or single parent.
Age: 4 groups from 18–24 to over 50. Group: 1 = 18–24, 2 = 25–34, 3 = 35–49, 4 = 50 and over.
Education: Due to some differences in education systems in each country, highest level of education was measured in four categories, scored 1–4: Secondary, Further education (including vocational), University and Postgraduate.
Residence was assessed as own (owned) home vs other, and ‘urban’, ‘suburban’, ‘rural’ (recoded as urban/rural).
Financial security was assessed on a 6 point scale: ‘Meeting my normal household expenses is..’: from 1 ‘very difficult’ to 6 ‘very easy’.
Parenting and Infant feeding variables
Childbirth: delivery method was coded in categories as vaginal; planned C-section; unplanned C-section.
Skin-to-skin contact immediately after delivery was coded ‘yes/no’.
Overall birth experience was rated on a 5 point scale from 1 = very bad to 5 = very good.
Children: Number and ages of children living at home, recoded as uniparous/multiparous.
Youngest child’s age was coded as 0–11 months; 12–23 months; and 23 months and over.
Infant Feeding: We asked women ‘how are you currently breastfeeding your baby?’ with responses coded as only breastmilk; mixed breastmilk and formula; only formula or ‘does not apply’ for weaned infants (not included in this analysis).
The survey used validated psychological measures for Professional Support , and modified measures of Parental Stress , Role Strain , and Breastfeeding Self-efficacy  as described below. Breastfeeding attitudes  and shared parenting measures  had been used in previous research. Parenting and breastfeeding support measures were developed for the study.
To compare breastfeeding attitudes we used 7 items from Swanson and Power (2005) relevant to new parents . For example, breastfeeding is: natural, painful, convenient; rated on a 5 point Likert scale from (1) ‘strong disagreement’ to (5) ‘strong agreement’. Three items are reverse scored. Items were summed to create total scores, possible range 7–35. Higher scores represent more positive attitudes to breastfeeding. Cronbach’s α. = 0.71.
Parenting and breastfeeding stress
We utilized 8 items from Park et al.’s (2015) 9 item Postpartum Stress Scale , to measure sources of stress, including; relationships, being a mother, fussy baby, finances, work, own health, sleep, and health concerns, measured on a 4 point scale (scored 0–3) from ‘not at all stressful’ to ‘very stressful’, score range 0–24. Cronbach’s α. = 0.77. One item measuring ‘breastfeeding stress’ was excluded as we measured this separately.
Parenting role strains
Six items relevant to parents of children in this age group were summed, taken from Berry and Jones’ (1995) 18 item Parenting Stress Scale . The measure reflects ‘strains’ including positive and negative outcomes of the parental role. Participants are asked about their experience of being a parent (e.g. ‘Caring for my baby sometimes takes more time and energy than I have to give’). Excluded items were those more relevant for older children included ‘having children has been a financial burden’. Items were rated from ‘strong agreement’ to ‘strong disagreement’ on a 5-point scale (scored 1–5). Positive items (eg ‘I am happy in my role as a parent’) were reversed so higher scores represented more role strain, score range 6–30, Cronbach’s α. = 0.73.
At the time of the study we could identify no suitable measure of common breastfeeding stressful situations. We developed a scale (8 items, summed) from literature review based on ‘the daily hassles’ approach , asking participants to rate the stressfulness of common breastfeeding situations (e.g. insufficient milk, breastfeeding outside of home, using a breast pump) rated from ‘not stressful’ (1) to ‘a lot of stress’ (5), possible score range 8–40. Cronbach’s α. = 0.80.
Timing of breastfeeding stress
We asked: ‘At what time point did you experience most stress around breastfeeding?’ Fixed choice time points were based on breastfeeding duration data points from the UK Infant Feeding Survey 2010  from ‘at birth’ to ‘over 1 year’ (1–10).
(BFSE) was measured using four summed items from the Breastfeeding Self-efficacy Scale Short Form , representing general breastfeeding confidence,]: e.g. ‘I am able to determine that my baby is getting enough milk’, ‘I can cope with breastfeeding’, ‘I keep wanting to breastfeed’, ‘I am satisfied with my breastfeeding experience’, rated on a 5 point Likert scale from ‘strong disagreement’ to ‘strong agreement’, possible score range 5–20. Higher scores indicate greater self-efficacy, Cronbach’s α. = 0.80.
This was investigated in relation to their youngest child.
Informal Parenting Support
Asked for their main source of support with the youngest child: coded as partner, family, and others (including friends, peer supporter, volunteers), and how helpful this support was? (1 = ‘very unhelpful’ to 5 ‘very helpful’).
Measured instrumental support from partners, using 7 items adapted from Swanson et al. (2015). Parents are asked who spends the most time in each activity: ‘getting up in the night to look after the baby’, ‘changing nappies’, ‘feeding the baby’, ‘playing with the baby’, ‘taking the baby out’, ‘soothing the baby’, and ‘babysitting/caring for baby in the daytime’; rated on a 5-point scale from ‘mother does all of the time’ to ‘father does all of the time’, scored from minus 2 to plus 2. Zero represented equal engagement in parenting tasks. Total scores were calculated, (range -14 to + 14). Higher scores represented more partner support, Cronbach’s α. = 0.75.
Formal Professional Support
From health and social care professionals was measured using Mercer’s (2004) 10 item CARE (Consultation and Relational Empathy) measure . Participants are asked to think about experiences of parenting their youngest child, and rate statements: ‘The professionals who support me have’: e.g. ‘made me feel at ease, introduced him/herself, explaining his/her position, been friendly and warm towards me, treated me with respect; not cold or abrupt’, on a 5-point scale from ‘strongly agree’ (5) to ‘strongly disagree’ (1), and items summed. Higher scores reflect more support, Cronbach’s α. = 0.94.
Asked ‘where did you access breastfeeding support for your youngest child?’ multiple responses were possible, scored present (1) or absent (0). Support was categorised as Formal: including maternity hospital, and baby clinics; Informal support: incuded Facebook support groups; other peer support; doula; family; other. Total formal and informal breastfeeding supports were calculated.
Incentives for completion
To enhance the response rate and reach of the questionnaire, we offered a small prize draw incentive for completion, using online shopping vouchers of 25 UK pounds or Euros.
Prior to administering the survey we obtained Ethical Approval from the University of Stirling (Scotland) and The Finnish National Board on Research Integrity (TENK). The main ethical issue was participation in the prize draw which required an email address. Consent for the questionnaire was sought in introductory text and implied by completion. The survey was anonymous including no identifiable data. Analysis took place at the University of Stirling. Data was stored on password-protected computers only accessed by the researchers. To mitigate breastfeeding or parenting distress or for those who lacked social support, we included signposting to support services. Wording of the questionnaire was considered carefully and reviewed by professionals in the field.
Descriptive analysis compared demographics, social support, parenting and breastfeeding variables for participants in Finland and the UK. Effect sizes were reported as Cramers V for chi square (strong association > 0.5) and Cohens d for t-tests. Main analysis compared women in Finland and the UK with sub-group analysis of uniparous and multiparous women. Given the inequality in sample size, where there was significant heterogeneity of variance between these groups, (tested using Levene’s test) Welch’s correction was applied . Following exploratory correlation analysis (Pearson’s r), significant (p > 0.05) demographic, breastfeeding-related, and social support variables were entered into linear regression in blocks to predict parenting stressors and role strain. Interaction terms were created by multiplying breastfeeding stress and social support variables to investigate moderation effects of social support, and entered in a final step. Values less than p = 0.05 were considered significant. Analyses were conducted using SPSS v27.