INCREASING BREASTFEEDING IN WIC PARTICIPANTS USING INFORMATION ABOUT FORMULA COST AS A MOTIVATOR

Despite the widely documented health benefits of breastfeeding, breastfeeding rates continue to fall short of Healthy People 2020 Objectives, particularly among women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The amount of formula supplied by WIC often is insufficient to fully cover the infant’s demands, thus mothers need to purchase extra cans of formula in addition to what is provided by the WIC Program. However, prior to deciding whether to breastfeed or formula feed their infants, mothers may not be aware of the amount spent monthly on the purchase of extra formula. This information is not currently presented in WIC educational materials. This study assessed these costs, investigated mothers’ perceptions of these costs, and assessed mothers’ opinions about whether providing information about costs would influence their decision to breastfeed. This research utilized a two-phase descriptive design. A total of 30 nonbreastfeeding WIC mothers were asked to take a survey in Phase I, to assess their cost buying extra cans of formula, and total of 14 pregnant WIC women were interviewed in Phase II to assess their perceptions about the cost and opinions about breastfeeding educational material. It was found in Phase I that non-breastfeeding mothers enrolled in the WIC program were spending on average $50 per month on extra cans of formula by the time their children were 4 months of age. This cost was perceived by majority of participating mothers as high. However, for mothers that intended to formula feed, information on cost did not appear to influence their decision to breastfeed. For breastfeeding mothers, the cost information was considered to be motivating. Medical issues, pain, physical appearance, employment constraints, comfort level, and inconvenience were reasons given by mothers for choosing to bottle feed. Information on supplemental formula cost could be provided in breastfeeding support materials used in WIC programs prenatally and post-partum as an additional motivational tool to women that intend to breastfeed. Further research could investigate if this information would support breastfeeding initiation and increase duration among WIC mothers. Future qualitative work should be done to explore ways of incorporating breastfeeding into the lifestyle of mothers that intend to bottle feed, to demystify pre-conceptualized ideas about breastfeeding, and investigate if incorporating this information into educational materials would increase breastfeeding initiation among WIC mothers.

would influence their decision to breastfeed. This research utilized a two-phase descriptive design. A total of 30 nonbreastfeeding WIC mothers were asked to take a survey in Phase I, to assess their cost buying extra cans of formula, and total of 14 pregnant WIC women were interviewed in Phase II to assess their perceptions about the cost and opinions about breastfeeding educational material.
It was found in Phase I that non-breastfeeding mothers enrolled in the WIC program were spending on average $50 per month on extra cans of formula by the time their children were 4 months of age. This cost was perceived by majority of participating mothers as high. However, for mothers that intended to formula feed, information on cost did not appear to influence their decision to breastfeed. For breastfeeding mothers, the cost information was considered to be motivating.
Medical issues, pain, physical appearance, employment constraints, comfort level, and inconvenience were reasons given by mothers for choosing to bottle feed.
Information on supplemental formula cost could be provided in breastfeeding support materials used in WIC programs prenatally and post-partum as an additional motivational tool to women that intend to breastfeed. Further research could investigate if this information would support breastfeeding initiation and increase duration among WIC mothers. Future qualitative work should be done to explore ways of incorporating breastfeeding into the lifestyle of mothers that intend to bottle feed, to demystify pre-conceptualized ideas about breastfeeding, and investigate if incorporating this information into educational materials would increase breastfeeding initiation among WIC mothers. iv   Infants, and Children (WIC) are less likely to breastfeed compared with nonparticipants of WIC program (1,2,3,4). Breastfeeding infants are provided with numerous immunologic, psychologic, social, economic, and environmental benefits that extend beyond infancy and also improve maternal health. Given that a mother's intention to breastfeed and initiation of breastfeeding increases after prenatal education (5), reaching women during the prenatal period may be a crucial opportunity to provide breastfeeding education and help mothers be more knowledgeable about infant feeding practices. Therefore the WIC population could benefit from breastfeeding education.
Qualitative research is needed to develop needs based breastfeeding educational materials (5). Knowing what influences a mother's infant feeding decision and what motivates them to breastfeed will help health professionals focus on information that the mothers consider relevant. Researchers have investigated the multi-factorial components that have an impact on a mother's decisions to breastfeed (6,7,8,9,10,11), have evaluated breastfeeding promotion interventions (12,13,14,15), have studied the effects of interventions on WIC breastfeeding rates (2,3,16,17,18), as well as investigated the economic issues of infant feeding choices (19,20,21), but no previous study has investigated cost of formula feeding for WIC mothers nor explored the effects of this information. WIC's definition of a breastfeeding woman is the practice of feeding a mother's breast milk to her infant on the average of at least once a day (30).Trends in breastfeeding from 1978 to 2003 have shown that rates for the initiation of breastfeeding among WIC participants lagged behind those of mothers who did not participate in the WIC program by an average of 23.6 ± 4.4%, with 76.1% of non-WIC women initiating breastfeeding compared with only 54% of WIC women (1). Rates of breastfeeding at six months of age differed between WIC participants and non-WIC mothers by an average of 16.3 ± 3.1% (1), with non-WIC women more likely to breastfeed (42.7%) than WIC women (21%) (1).
A more recent look at the breastfeeding rates among WIC participants, shows that nationally, women in the WIC program, were divided into pregnant (10.1 percent), breastfeeding (6.6 percent), and postpartum (6.8 percent) (31). The women classified as breastfeeding rose steadily from 3.6 percent in 1992 to 6.9 percent in 2008, but has slightly declined to 6.6 percent in 2010, which may have been affected by the major changes in the WIC food packages (31).
Breastfeeding rates of all WIC programs in Rhode Island, for babies born between January 1, 2010 and June 2010 were as follows: When all Rhode Island WIC programs were combined, the average for initiation was 58%, breastfeeding at three months was 11.14%, breastfeeding at six months 3.88%; the proportion fully breastfeeding through three months was 4.37%, and fully breastfeeding through six months was 1.46%. It appears, the breastfeeding rates for the Rhode Island WIC programs fall short of Healthy People 2020 objectives in early postpartum period (initiation) (81.9%); at six months (60.6%); exclusively breastfeeding through three months (46.2%); and exclusively through six months (25.5%) (32). Accordingly to the 2010 CDC breastfeeding report card, the state of Rhode Island had an initiation rate of 70.8%, breastfeeding at six months rate of 45.1%, breastfeeding at 12 months 22.7%, fully breastfeeding through three months 29.0%, and fully breastfeeding through six months a rate of 12.1% (33). These data supports the hypothesis that the Rhode Island WIC breastfeeding rates are lower than the general population's rate and of Healthy People 2020 objectives.
Studies have explored the idea that WIC's lower breastfeeding rates may be a reflection of participant's characteristics rather than the effect of the program per se (18). Mothers who choose to participate in WIC are socio-economically disadvantaged and likely to be different than mothers who do not participate, a selection issue, in which the program is more attractive to mothers who choose not to breastfeed and who might not have breastfed even in the absence of the program (17).

The Benefits of Breastfeeding
The benefits of breastfeeding on children and mothers are well documented (34). Breastmilk provides infants with numerous immunological benefits (35,36,37).
The protection against infection attributed to breastfed infants appear to occur due to a variety of complementary acquired and innate defense factors in human milk (38). The conjugated and unconjugated forms of oligossacharides, classified as glycans, found in human milk constitute the third most common solid component of human milk after lactose and lipids (39). Human-milk glycans are able to resist digestion (40) and are largely found intact in infant feces. The resistance to digestion allows them to remain available to protect the mucosal surface of the gastrointestinal tract (38). In addition to the accepted function as immunologic or anti-infective agents, a study on human-milk glycans describes their important role as innate anti-adhesion agents that protect the breastfed child by preventing pathogens from adhering to host ligands; this protection is associated with significant protection from diarrhea in breastfed infants (38). As diarrhea remains the leading cause of morbidity and mortality in developing countries (41) breastfeeding can provide significant protection in infancy and early childhood, as one of the most costeffective strategies known to medicine and public health for the prevention of infancy mortality (41). Immunological protection is demonstrated by reduced rates of gastrointestinal infections (42,43,44,45,46), as well as in reduced rates of ear infections (42,47,48) respiratory-tract illnesses (42,43,49), and allergy-related problems, such as asthma, atopic dermatitis, and allergic rhinitis (36,46,50,51).
Breastfeeding is therefore recommended as the optimal method of feeding newborns and young infants due to the numerous immunologic, psychologic, social, economic and environmental benefits (35). Weimer (2001), conducted a study on the economic benefits of breastfeeding for three diseases: necrotizing enterocolitis, otitis media, and gastroenteritis and concluded that $3.6 billion would potentially be saved if breastfeeding rates were increased from the Healthy People 2000 to 2010 objectives for initiation and sixmonth duration (76). In 2010, a study using updated data from Weimer's study along with more recent data on breastfeeding rates, disease incidence and cost was conducted and concluded that if 90% of United States (US) families could comply with the medical recommendations to breastfeed exclusively for six months, the US could save $13 billion/year and prevent an excess of 911 deaths annually, 95% of which would be infants. With 80% compliance, savings would be approximately $10.5 billion, with 142 deaths prevented (77).

Infant Feeding Breastfeeding Recommendations
The Rhode Island Breastfeeding Coalition recognizes breastfeeding as the optimal method of feeding (78) and The World Health Organization (WHO) states that optimal nutrition is exclusive breastfeeding (breast milk with no other liquids and/or foods) for six months and continued breast feeding for two years (79). The American Academy of Pediatrics (AAP) also recommends exclusive breastfeeding during the infant's first six months of life (28). Appropriate complementary foods should be introduced, while breastfeeding continued up to two years of age or for as long as mutually desired by mother and child (15). Nevertheless, exclusive breastfeeding remains uncommon in most countries, even in countries with high rates of breastfeeding initiation (80).

Introduction of Complementary Foods
As previously mentioned, the WHO recommends that infants should be exclusively breastfed for the first six months of life, and safe and properly nutritious foods should be introduced afterwards while breastfeeding continues up to two years of age or longer. Studies have shown that introduction of complementary foods before four to six months of age and cow's milk before age of 12 months are associated with several health risks (81). Due to the immaturity of the gastrointestinal, renal, and neurophysiological systems in infants younger than six months of age (82), the timing of introduction of foods is particularly important since is associated with excessive protein (83), excessive total energy intake (84), excessive infant weight gain (85), elevated body fat and body mass index, and respiratory illnesses (86), allergies (87), iron deficiency and anemia (88). And unlike breastmilk, unmodified cow's milk is not properly balanced for a child younger than 12 months, it contains levels of protein, sodium, potassium, phosphorus, and calcium that are higher that the requirements for infants, and it contains insufficient levels of iron, vitamin C, and linoleic acid (89,90,91). These nutritional characteristics of unmodified milk, when introduced prematurely can lead to increased renal solute load, blood loss from the gastrointestinal tract which contributes to iron deficiency and anemia, chronic constipation and anal fissures, and an increased risk for type 1 and type 2 diabetes (89,90,91).
Although the AAP (92) recommendations are to avoid early introduction of complementary food before six months and exposure to cow's milk before 12 months, about one-third of the US infants are introduced to unmodified cow's milk before that age and are offered complementary foods before four months of age(93).
The determinants for these feeding practices were investigated in a systematic review which identified six determinants for early weaning (early introduction of complementary foods): young maternal age, low maternal education, low socioeconomic status, absence or short duration of breastfeeding, maternal smoking, and lack of information or advice from health providers (81). Another study that assessed the association between the timing of prenatal participation in WIC and various infant feeding practices, including early introduction of cow's milk and solid foods suggested that entry into the WIC program prenatally is associated with early cow's milk introduction (94). In concordance with that, another study that focused on WIC participation and infant's consumption of cow's milk found that WIC infants between ages four and six months were more likely to have been fed cow's milk than non-WIC infants (95). Given the health implications of early introduction of cow's milk, this finding is important if low-income women who do not breastfeed substitute cow's milk for breast milk or formula (94).

Infant Formula
The AAP recommends parents and care givers follow the baby's feeding cues and feed on demand, and suggests that most babies are satisfied with three to four ounces (90 -120 ml) per feeding during the first month and increase that amount by one ounce (30 ml) per month until they reach a maximum of about seven to eight ounces (210-240), with a schedule of about every four hours (96). By the end of the first month, infants receiving the lower limit of three ounces every four hours (six feedings in twenty-four hours), will have a formula intake of 18 ounces a day.

Formula Preparation:
Another important aspect of formula feeding is the issue of formula preparation, such as concentrating formula (97). Bottle feeding requires a mother to think in ounces, to adopt ounces as the standard unit of measurement, and to follow formula preparation recipes (96). A study assessing the extent to which mothers learn about proper handling of infant formula from health professionals and package labels concluded that the majority of formula-feeding mothers did not receive adequate instruction about formula preparation (77%) or storage (73%) from a health professional and thirty percent did not read some of the safe-use directions on the formula package label (97).

Reasons Why Women do not Initiate or Continue to Breastfeed
American women are restricted in their ability to choose breastfeeding.
Demands of work outside the home and lack of societal support for new mothers are problematic. Although in the US, more new mothers are part of the work force than ever before, there is little evidence of employers accommodating lactating employees. This leaves the vast majority of women without access to a private place to pump milk, a refrigerator to store milk, or breastfeeding breaks to nurse a nearby infant (98) Other barriers associated to breastfeeding were the pain related to nursing, the dietary changes mothers would have to make, and anxiety about quality and quantity of breastmilk. These mothers also lacked self-efficacy as potential breastfeeders and a lack of support from relatives, friends, and some health providers (9).
A more recent study investigated common barriers for breastfeeding initiation and continuation. The study used a combination of methods, consisting of a longitudinal cohort (1,292 families) and an ethnographic study (30 families) of lowincome families in North Carolina (NC) and Pennsylvania (PA) to identify reasons women don't initiate breastfeeding or continue breastfeeding. This study found women that resided in PA were more educated, were married, or who had a firstborn child were more likely to breastfeed. Women who were working when their infants were two months old had a decreased likelihood of initiating breastfeeding.
Women who did not receive WIC and were not employed were most likely to breastfeed. Of the 30 women in the ethnographic study, 18 initiated breastfeeding.
Five had never considered breastfeeding and stated: "I'm not open to breastfeeding".
The other seven participants who did not breastfeed considered it, but stated that they were not comfortable with breastfeeding for multiple reasons, which included the pain associated with breastfeeding, return to work or school, embarrassment (public feeding), and that breastfeeding is not socially accepted. Other reasons included smoking and lack of assistance or support (101).
Several other studies have found women don't initiate or continue breastfeeding for reasons such as personal preference, having an unsupportive partner, feeling embarrassed, concerns about pain, physical/mental problems (7,12,102,103,104,105,106), maternal smoking, whether the pregnancy was intended (102) and mode of delivery (7,102). Hospital support characteristics include breastfeeding support from hospital delivery nurses, lactation specialists or peer counselors, or receipt of free formula packets in the hospital (8,12,104,107). In addition, mother's prenatal care and the influence of her health professionals, her perception of the father's views on breastfeeding, and her fear of lack an adequate milk supply for the infant have also been described as important influences on women's breastfeeding decisions (9,10).

Breastfeeding Interventions
A review conducted to evaluate the effectiveness of interventions aimed at encouraging women of different ethnicities to breastfeed found that breastfeeding education increased breastfeeding rates compared to just providing routine care. In addition peer counselor support, needs based, one-to-one, informal education and support sessions delivered either before or after the birth by a trained breastfeeding professional or peer counselor increased breastfeeding rates (13). WIC instituted a number of changes, beginning in the late 1980s, to attempt to increase the breastfeeding rates among its recipients (108), which includes an extensive use of peer counseling, use of social marketing, motivational videos, personalized education, and continuing education opportunities to WIC staff members (109).
The WIC food package was revised and became effective on October 1, 2008.
The revision aimed to encourage positive changes in participant's behaviors and outcomes, to better promote and support the establishment of successful long term breastfeeding among women who choose that feeding method, to address developmental needs of infants and to bring the infant food packages in line with current infant feeding practice guidelines from the AAP (17, 110). The approach focuses on the market value of the package for the mother/infant pair for the first year after birth (17, 110), addresses differences in supplementary nutrition needs of breastfed and formula fed infants, and considers how to minimize early supplementation with infant formula through continued or increased efforts to promote and support breastfeeding (110).
Since the amount of milk a breastfeeding woman produces depends directly on how often and how long she nurses, early supplementation can interfere with the establishment of breastfeeding and may contribute to a short duration (11,110 The food package for fully breastfeeding women provides the most foodenergy and nutrients and the package for fully formula-feeding women provides the least (110) which increases the market value of the food packages for fully breastfeeding infant/mother pair (17). Although there is some evidence that attractive food packages for the fully breastfeeding mother/infant pair might increase the mother's incentive to breastfeed (112), a study designed to explore reasons for high rates of formula supplementation in WIC and the limited use of the expanded food package concluded that the mothers were either unaware of the expanded food package or uninterested in it because it was unappealing or contained food that were difficult or time-consuming to prepare. Conversely, infant formula was highly valued, even by breastfeeding mothers, because it was perceived as an expensive item (11). Using 2002 prices, the IOM estimated that the average annual cost to WIC of foods benefits for the fully breastfeeding infant/mother pair increased from $ 668 in the old food package to $ 1,027 in the new package, which was 75%, of the value of the food package for fully formula-fed infant/mother pair (113).
Other methods found to help improve breastfeeding rates were the implementation of baby friendly initiatives in hospitals, compliance with the International Code of Marketing of Breast-milk Substitutes (114), scheduled home visits in the first week after delivery, assessment of postpartum mothers for breastfeeding techniques, provision of counseling and hands on support (14).

Demographic Information
United

Qualitative Research
Qualitative research is a type of scientific research that consists of an investigation that focusing on words rather than numbers and includes the following: seeks answers to a question, uses a predefined set of procedures to answer the question, collects evidence, and produces findings that were not determined in advance. It seeks to understand a given research problem from the point of view of the participants (112) and studies people in their natural settings rather than in artificial or experimental ones (116). When detailed rich descriptions of human behaviors, beliefs, opinions, emotions, and relationships of individuals are desired, qualitative research method is appropriate (112). It is both feasible and legitimate to analyze certain types of qualitative data quantitatively (116, 117) and when both methods are combined it can provide information to interpret and understand the complexity of the topic in question (112). Qualitative research often deals with words rather than numbers and its measurement is usually concern with taxonomy (116).
The methods used in qualitative research include direct observation, interviews, the analysis of texts or documents and the analysis of recorded speech or behavior using audio or video tapes (116). Qualitative researchers use conversation, in the form of interviews, to collect data about people's views and experiences (116, 117) Interviews can be conducted individually or in groups (focus groups) . Semistructured interviews have attracted interest because interview subjects' view-points are more likely to be expressed in a relatively openly designed interview situation than in a standardized interview or questionnaire

Decision Making
Consumers are continually making choices among products and many factors are involved in the decision making process. A study providing information about consumer behavior that focused on price and quality of a product found that consumers lack full information about the prices of goods and information about the quality of products they intend to purchase. For any purchasable item, the consumer has a choice between searching for information regarding that item's quality or experimenting with it to obtain the information; however, the cost of experimenting may be more than the cost of searching and more than what a person is willing to pay (118). Another study on decision making in the area of behavioral economics mapped many factors in decision making onto a single variable: value. However, several aspects of value, including emotional content, not only money and quantity, affect decision making. The emotional content is difficult to quantify and presents significant individual variability (119).
Traditional economic thinking assumes that consumers who understand the value between diet and health will rationally respond by choosing to eat a healthful diet. However, behavioral economics research finds that people regularly and predictably behave in ways that contradicts this assumption. Long-term thinking may not always prevail; people may not always make decisions that would follow from 24 strict expectations of economic rationality, and they may be influenced by factors such as package size and shape (120).
The investigator in this study was a WIC nutritionist and observed that WIC mothers were often surprised that they had to purchase extra cans of formula and information on cost seemed to be important.

Conclusion
A review of the literature suggests that although the WIC program has promoted breastfeeding to all pregnant women as the optimal infant feeding method, mother's participation in the program is associated with lower rates of breastfeeding. Breastfeeding education and support focus has been in multiple areas with the use of social marketing, motivational videos, peer counseling, revisions in the food package, and education to WIC staff. Incorporating new, personalized, information into educational materials for pregnant women participating in the WIC program may prove to be influential in promoting breastfeeding.

Overview
This is a descriptive study conducted in two phases. Phase I utilized a survey (Appendix A) which was developed and designed for WIC participants. It was conducted in three WIC sites in the state of Rhode Island during the participant's routine appointment at the WIC office.
This phase of the research study was designed to: 1. Assess information about the amount spent monthly for the purchase of extra cans of formula by non-breastfeeding mothers enrolled in the WIC program in Rhode Island.
Phase II utilized in-depth interviews which were structured for WIC participants (Appendix C).
This phase of the research was designed to: 1. Identify prenatal maternal intent to breastfeed.
2. Assess the mothers' reasons for choosing formula feeding or breastfeeding.
3. Assess mother's perceptions of significant other's support for infant feeding choices.
4. Assess the mothers' perceptions on the cost for the purchase of formula.
5. Assess the mothers' opinions on breastfeeding educational materials.
6. Assess factors that motivate women to breastfeed.

Study Design
Phase I of this study was conducted at the Rhode Island WIC offices in Woonsocket, Johnston, and Providence. Participants were enrolled over a period of five months, from February 2011 to July 2011. In Phase I, WIC participants were asked by the researcher on a one-on-one basis to complete a brief survey (Appendix A). Three cognitive interviews were conducted to assist in developing the survey before the initiation of data collection.

Subjects
Phase I consisted of a sample of women enrolled in the three participating WIC agencies who were recruited in person by the researcher while attending a routine appointment at the WIC offices. Eligibility criteria included: WIC recipient, non-breastfeeding biological mothers of infants from one to four months of age, and ability to understand and speak either English, Spanish or Portuguese. Verbal consent to participate from the participants was obtained and a copy of the consent form was given to all participants (Appendix B). Participants received a pedometer as an incentive upon survey completion. A total of 30 women completed phase I.

Data Collection
The Survey The survey contained the following questions: Two WIC sites in the state of Rhode Island participated. A total of seventeen mothers were screened by the WIC staff. Seven women out of the seventeen were from WIC site A, five completed the interview, one was under age and didn't qualify, and one interview was discarded due to malfunction in the tape recording equipment. Ten women out of the seventeen were from WIC site B, nine completed the interview and one woman didn't show for the appointment.

Qualitative Data Collection: In-depth Interviews
After a participant agreed to take part in the study, the researcher and the mother moved from the reception area to a semi-private room. The researcher explained the project in detail. All mothers read and signed the consent form and were asked if they had any questions prior to beginning the interview. At this point, the researcher started the tape recording. The interview process was semistructured, a list of questions and probes were utilized but the conversation was open and moved in the direction of interest (Appendix C).The interview consisted of one ice-breaker question which was used to help develop rapport and seven additional questions which were designed to evaluate breastfeeding intentions and educational materials. The length of each interview differed depending on the amount of conversation but all interviews lasted between 15 and 20 minutes and averaged 16 minutes. During the discussion, the researcher would ask a new question when she felt that the participant had been given enough time to answer and was ready to move on to the next question. After the interview was completed the participants received a $20.00 gift certificate for a local grocery store.

Each interview was transcribed by a researcher at the Nutrition and Food
Science (NFS) department at University of Rhode Island (URI). Another researcher from the NFS department verified the accuracy of the transcripts. Inconsistencies were reviewed until both researchers agreed on the content. The investigator edited each transcript to preserve confidentiality by deleting any identifiers.

Qualitative Analysis
Overview Data analysis used the methodology of Miles and Huberman (52). Deidentified verified transcripts were printed. Participants were divided into two 32 categories: 1) mothers intending to formula feed (N=9) and 2) mothers intending to breastfeed (N=5).
The initial matrix consisted of raw data organized by the seven questions. All text from each transcript related to the question (answer) was listed for the seven questions. Each answer was read twice by the investigator and quotes were highlighted. Each quote was abstracted along with the context in which occurred.
The transcripts were coded independently by a second investigator; disagreements were discussed with a third investigator until consensus was obtained. Concordance between the two investigators were 84.7%. The second matrix condensed data.
Quotes that were similar were merged and themes were generated. The third matrix compared themes by intent to breastfeed. Quantitative demographic data were tallied.

Institutional Review
The University of Rhode Island Institutional Review Board on the Protection of Human Subjects (IRB) approved this project.

Results Phase I
The objective of phase one of this study was to assess information about the amount of money spent monthly on the purchase of extra cans of formula by nonbreastfeeding mothers enrolled in the WIC program in Rhode Island.

Sampling
A total of 30 non-breastfeeding biological mothers with infants from one to

Type of can purchased by the participants
Out of 30 participants, 3 (10%) reported buying small cans of powder infant formula, 24 (80%) reported buying large cans of powder formula, 3 (10%) reported to buy liquid concentrate, and none reported to buy ready to feed formula.

How participants purchased infant formula
Out of 30 participants, 15 (50%) purchased formula with cash, 13 (43%) purchased with SNAP benefits and two (7%) purchased using other sources. For the ready-to-use formula the average price was $6.79. initiated breastfeeding (48%), seven were breastfeeding at three months (9.33%), three were breastfeeding at six months (4.00%), two were fully breastfeeding through three months (2.67%), and one was fully breastfeeding through six months (1.33%) ( Tables 5a and 5b).

Results Phase II Participants
Fourteen individual interviews were completed. Six mothers (43%) were in their third trimester of pregnancy, seven (50%) were in their second trimester, and one (7%) was in her first trimester. The women were either single (93%) or divorced (7%). Sixty percent had completed high school, the average age was 22.4 years old and most had a pre pregnancy BMI of 26, indicating they were overweight. Nine (64%) stated their intent was to bottle feed with formula and five mothers (36%) stated that their intent was to breastfeed. Table 6 presents demographic characteristics of participants.

Interview results
The data collected during the interviews was divided into two groups of participants according to their choice of feeding methods: Those who intended to breastfeed and those who intended to formula feed their babies.
Interview question one was designed to identify prenatal maternal intent to breastfeed. The following question was asked: Question 1: There are many ways of feeding an infant. There is breastfeeding, formula feeding, pumping breast milk, and both breast feeding and formula feeding.
You may not have made up your mind how you are planning on feeding your baby, but right now, how do you think you want to feed your baby?
Five women (36%) stated that their intent is to breastfeed. Nine women (64%) stated their intent is to bottle feed formula.
Interview question two was designed to assess the mother's reasons for choosing formula feeding or breastfeeding. The following question was asked: Question 2: Tell me some of the reasons you choose (breastfeeding or formula feeding)?
Despite a diversity of personal perspectives, several common themes are apparent across the participants. Key findings are presented within six major categories that define some of the reasons mothers choose either formula or breastfeeding: 1. Physical (pertaining to the body, such as medical issues, physical pain, or appearance) 2. Financial (pertaining to money matters and employment constraints), 3. Psychological (pertaining to, dealing with, or affecting the mind, as a function of feeling or motivation), 4. Educational (pertaining to acquiring knowledge), 5. Social (pertaining to constrains of physical and emotional attachment of the infant to the mother, mothers' enjoying the companionship of others, need for others to care for the baby, time and effort involved in pumping, and discomfort of self and others with mother's milk), and 6. Health (pertaining to health benefits of breastfeeding). For the formula feeding group items related to the mother's social life were accounted as their main reason for choosing formula feeding. Aspects such as inconvenience of breastfeeding, included the weaning off of breastfeeding, infant's attachment to the mother, and pumping breast milk; the convenience of formula feeding, such as the easy and fast preparation of bottles and allowance of other to care for the infant. The second main reason for formula feeders was psychological, such as not being comfortable with the overall idea of breastfeeding and having a "mind set" on formula feeding were common. The main reason for mothers to choose breastfeeding was the health benefits for the infant; other reasons included professional support, maternal weight loss, financial advantage, and simplicity of breastfeeding.
1. Physical a. Medical issues One mother stated that breastfeeding would be difficult since she has inverted nipples. A sense of embarrassment was observed by the investigator when the mother avoided eye contact with the investigator while talking about the issue.
"I have inverted nipples, that is going to be more difficult." One mothers openly talked about her breast reduction and surgery to remove loose skin and excess residual fat caused by losing weight after a bariatric surgery.
She was told that her chances of breastfeeding would be slim or that she wouldn't be able to breastfeed.
"As of right now, I plan on bottle feeding only because I had a breast reduction and they took so much out that they don't think that I would be able to breastfeed or that the chances of it would be slim. So I'm just going to stick to bottle feeding". b. Pain One mother's given reason to bottle feed was her belief that breastfeeding would hurt.
"Because that hurts, so I rather do formula".

c. Physical Appearance
A feeling of awkwardness about breastfeeding was recognized while a mother reported that she wouldn't appreciate changes in her breast's appearance if they ever happen to be uneven in sizes due to breastfeeding.
"My sister-in-law, both babies were only attached to one boob so she's got like a C and a D and I'm like "I'm good with that". I like to keep them the way they are. I don't want to be all lopsided. It's kind of silly but I kind of think about that too so I'm like "m-m" she can't find a bra, ever."

Financial d. Going back to work
Mothers discussed going back to work as a reason to bottle feed. One added not having paid maternity leave and bottle feeding would make going back to work easier.
"I don't get a paid maternity leave so I need to go back to work very quickly and it's going to make it easier." "Well, I mean, I plan on going back to work within two months." 3. Psychological e. Comfortable bottle feeding formula Many discussed being more comfortable formula feeding than breastfeeding, pumping, or breastfeeding in public.
"I'm just not really comfortable with the idea of breastfeeding".
A clear sense of dislike was identified while one of the mothers talked about her idea of breastfeeding in public and the inconvenience of having to pump.
"…you have to take time to pump or you just have to just do it in public, which is really weird. I would never do that." Another mother shared the same feeling of being uncomfortable breastfeeding in public and her dislike about pumping.
"…I'm going to feed her by bottle feeding, I think. I don't feel comfortable in public with the baby here, so bottle feeding is the way we are going to go. If it was in the privacy of my home that would be fine but just in public, I am not a big fan about it. It doesn't bother me seeing somebody else doing it because it is life, but I couldn't do it".
"Just sticking a pump there and having it there and…eh…it's not for me! One talked about her experience raising other children via bottle and being comfortable with using formula.
"Because I was used to feeding with the bottle and not by the breast, like I raised my sister's kids with her and I am used to the bottle, so I feel more comfortable with a bottle than with breastfeeding." f. Mind set on bottle feeding A common comment among mothers was also having a "mind set" on bottle feeding, which was used by some with the intent of closing the conversation about breastfeeding. "My grandmother is going to be watching the baby so it will be a lot easier for me, instead of me trying to wean the baby off of breastfeeding so early…" i. Attachment Mothers discussed the difficulty of having the child attached to them if they breastfeed. One mother strongly demonstrated her opposition to having the child attached to her.
"My cousin, her children were very attached to her. They wouldn't really go to anyone else because they were constantly with her because she was breastfeeding and I don't want to do that. I want to be able to say: -Oh, you want to watch the baby for a little while, here you go." "I don't want my child to be stuck all the time with me…" j. Easier and quicker A number of moms mentioned that formula feeding would be easier and/or quicker than breastfeeding or pumping. Pumping was referenced as inconvenient and a burden.
"It is easier to do. Like preparing it and all that. Like preparing it is easier, like you are done right away instead of like breastfeeding." "Yeah, it's easier and quicker".
"Breastfeeding, I think it is really inconvenient because you have to take time to pump. I've known people that breastfed and sometimes it takes them a while to pump." "Bottles are easy, you can just put them in the bottle and heat it up and give it to the baby. And if someone is babysitting you don't have to worry about pumping, you just say: here are the bottles." "She [cousin] even said it was more like a burden [breastfeeding] a lot of times because she was constantly pumping or feeding or something like that, so I mean, overall, I think bottle feeding is a lot easier." One mother talked about how formula would make it easier for the partner to feed the infant, as he wouldn't have to hold the bags of breast milk, which he didn't feel comfortable doing and refused to do it.
"He is a little awkward about the pumping, he was like "Well" and I was like "it is life, it is just milk, you are not touching it, you are not handling it, it's going from a bag to a bottle, to the baby, you are just holding the bottle", and he was like "No, I can't knowing something came out of somebody else and going into somebody." He was like "No, I can't! I can't handle it! I can't touch it", and I was like "OK". "It makes it easier for him too because he doesn't want to sit there and hold the little packages of breast milk." Reasons for mothers to choose formula feeding was multi factorial, and included physical, financial, psychological, and educational.

a. Weight loss
Mother's weight loss was enthusiastically reported as one of the reasons for breastfeeding.
"First of all because of the health benefits for the baby and secondly, honestly, to lose the weight. I know that that will help me go back to my pre pregnancy but also obviously the health benefits. And I have seen the difference with friends of mine that have breastfed versus bottle fed and I do see a healthier child with the breastfed children."

Financial b. Breastfeeding is cheaper
One mentioned the financial aspect of breastfeeding and reported knowing that it's cheaper than formula feeding.
"Actually I read that I guess it's healthier, it's cheaper, and yeah it's like better for the baby, they get less sick, it's just a lot better, I've read."

Psychological c) Overwhelmed by formula products
Emotionally one of the mothers talked about the overwhelming experience of selecting the right kind of formula would be opposed to the confident feeling that breastfeeding gives her that she would be selecting the right kind of milk.
"And I don't know, and for the formula that you buy you don't know what kind of formula because there are so many kinds and you know that your breastfeeding it's like the right kind of milk and it's giving off all the right nutrition and everything, you don't know what kind of formula does that and everything else." "Being pregnant is just overwhelming in general." 3. Health

d. Overall health benefits
All mothers reported infant's health as their main reason for breastfeeding.
"You build up immunities from the breast milk that the parent already has built up so it helps the child work with illnesses, there's brain development, eye function, everything, it comes right from there. So by not doing that you're taking key things away". "That's what I want to do so I'm going to try and do that." "Probably the healthiest way which would be breastfeeding." "Have a healthy baby, you have to do whatever what's best for them and everyone says breastfeeding is one of the healthiest things for your child."

Social e) Support
A mother simply defined one of her reasons for breastfeeding as encouragement from her doctor.
"Basically overall, even like my doctor encourages it, and it's healthier for the baby." Interview question two contained a probe that was designed to assess family member's perceptions of mother's infant feeding choices. The following question was asked: Probe of question 2: How does your family feel about __________? Specifically assess mother, grandmother, sister and find out how the father of the baby &/or her current partner feels about _____________.

Formula feeding group
The majority of the mothers in this group strongly felt that choosing the infant's feeding method was their decision, regardless of their families or partner's position on the subject. The families and partners were either supportive or apathetic of mother's decision. People had different reasons to be supportive of mothers and were grouped into four themes: a) Family member formula fed, b) Infant feeding method is a mother's choice, c) Belief that formula is easier for the mother, and d) Empathetic.
1. Supportive a) Family member formula fed.
Mothers comfortably commented on receiving support from family members that had also chosen to bottle feed their children.
"My sister just had two kids and she bottle fed with formula for both of them.
Actually my mom did too, so they are both supportive…" "They're fine, because my auntie and my mom they didn't breast feed for either child.
b) Infant feeding choice is a mother's decision.
Mothers discussed that the baby's father and family members supported their decision because they either accepted or understood that it was their decision on how they would be feeding the infant.
"He (baby's father) was breastfed, but he said it's my choice because he understands it's not him that has to do it".
"He (baby's father) wanted me to (breastfeed) but when I told him no I was pretty much "tough luck" and he was like "okay fine". He was okay with it." "My aunt thinks I should breast feed because it is healthier for the baby. I told her I was like yeah I'll think about that, but I was like I don't know. I've been thinking about bottle feeding." c) Belief that formula feeding would be easier Some family members and partners supported mother's decision to bottle feeding because they believed it would be easier for the mother and/or for them.
"my cousin breastfed all three of her kids, but my mother bottle fed me and she said it was so much easier, it was a combination of whoever was around who was able to feed the baby, it wasn't just strictly you at that point so it was more helpful." "They think it is easier for me to do instead of breast feeding…the baby's father, my mother, father and some other people…" "He (baby's father) supports it any way too. It makes it easier for him too because he doesn't have to sit there and hold the little packages of breast milk. He was a little uncomfortable with that."

d) Empathetic
Some comfortably talked about their families and partners being supportive of them regardless of their decision on infant feeding.
"They were very supportive of whatever I choose." "They tell me that any decision I make they are going to support it. My mom had three kids, my aunt had a million kids, some breast fed and some bottle fed, some say bottle feeding is better, some say breast feeding and they say whatever you decide we are going to support you anyways."

Apathetic family
Mothers talked about her family's position on infant feeding.
"It's just mine I mean they don't really care. They don't care it's whatever I want to do." "They don't really mind. It's like my decision."

Breastfeeding Group
The mothers that intended to breastfeed also expressed their opinion in regards to the family's support. Being: 1) Supportive or 2) Apathetic. Those who were supportive of mother's decision believed that a) Infant feeding method is a mother's choice, or b) They were empathetic.
1. Supportive a) Infant feeding method is a mother's choice One mother discussed that although the boyfriend suggested her to formula feed, after she explained him the benefits of breastfeeding he was supportive of her after all.
"Actually, my boyfriend he is more "oh just do formula" but I am more "Oh but I want to do breastfeeding" so. He's fine with it. He just thinks it's going to take longer with pumping and everything like that but I explained to him why I'm choosing to breast feed so he is fine with it but it's funny, you know with a guy's perspective, he's like "oh let's just do formula that'll be easier" One mother mentioned having a supportive boyfriend but a mother in law that is skeptical of her breastfeeding. Regardless of mother-in-law's position, mother confidently stated that her opinion doesn't affect her decision to breastfeed.
"He is very supportive with everything that I do so he knows that I have only the best intentions. I have the final say in everything, it's amazing, I love it! But his mom is skeptical about me doing that. She never breast fed any of her kids because she claims that it ruins your boobs, and she is all about her appearance and everything, but she doesn't count." A mother mentioned that her family was somewhat shocked by her decision to breastfeed, due to her young age, but were supportive of her decision.
"Actually, they were shocked a little bit because not a lot of people my age does breastfeeding so they were a little bit shocked." b) Empathetic One mother stated that the baby's father was supportive of her decision and wanted her to breastfeed.
"The baby's father is a hundred percent supportive, it is the way he me wanted to go but he kept his opinion to himself until I came out and said it.
And then he said "oh thank god I am so glad you said that". My mother looks at it as more of a bonding experience than health benefits. So she told me if I am comfortable with it that's fine and if I'm not comfortable with it that's fine, she's pretty neutral. My friends have breastfed so that's just the natural choice."

Apathetic
A mother strongly defended the idea that it was her decision of how she would feed the baby.
"None of them really had an opinion or cared. It's my decision, not theirs so they don't really have a say." Majority of mothers mentioned having support from family and partners and shared the same idea that the mothers is entitle of choosing the method of feeding.
Few reported having an apathetic family.
Question number three was developed to assess mothers' knowledge about the cost of formula.

Formula feeding group
None of the mothers, from both groups, knew the cost of formula. The mothers estimated cost varied largely from a range of $40 to $100 or more per month. Only one mother with experience in formula retail was able to estimate the cost of formula correctly.
The mothers that intended to formula feed had various answers and they were grouped into three common themes: 1. Don't know, 2. It depends on the infant's feeding demands, 3. $100 or more.

Don't know
Some mothers simply mentioned not knowing the cost of extra cans of formula. Some that also reported not knowing believed the cost would be a lot.
"I have no idea. I am kind of lost out of the blue when it comes to any of this stuff. I don't really know. My friend's littlest one she is still kind of breast feeding and she has a two year old and I never asked her what she did. And then my sister-in-law she got a 10 and a 7 year old so she probably don't even remember, so I'm a little lost in that situation".
"A lot! Hum…I really don't know the roundabout figure but I do know it is expensive, but I mean, I have the help so I am hoping that it will work, but I'm not really sure exactly how much it would be in addition." "A lot, because my friend spent over 200 dollars on formula".
2. It depends on the infant's feeding demands.
One mother didn't answer the question directly because she believed the cost would depend on how much the baby demands of formula, which would determine how much the mother has to buy it. The same mother overestimated the price of a can of formula.
"Well it depends on how much they would need because one can is like 30 dollars and that is a lot…for one can that lasts you like a week, if that. So I don't really know just depends on how much they would have to buy." 3. $100 or more Some mothers estimated that the cost would be hundred dollars or more.
One guessed a couple of hundred dollars but expanded her answer by stating that it would depend on the baby's size.
"Maybe a couple of hundred, a few hundred dollars. It depends on how big the baby is. I mean…You got to feed it more." One mother's answer was based on her cousin's experience of buying extra cans of non-standard formula each month.
"Well she had to have a special kind of formula because she was allergic to the other ones so she spent somewhere, each can was like somewhere in between 20-25 dollars a can so she was pretty much spending close to over a hundred dollars with the checks."

Breastfeeding group
The groups of mothers that reported intent to breastfeed had their answers grouped into themes: 1. Don't know, but a) estimated $100 or more, b) estimated $40 TO $50, c) a lot; 2) $80 to $100; and 3) $65 to $80. Cost of formula was perceived as high by most mothers from both groups. For only a few the cost was not perceived as a lot. All mentioned the fact that breastfeeding is cheaper than formula and the increasing cost of formula as the baby gets older.
Examples of answers from the formula feeding group are quoted below. The answers were grouped into themes: 1. Breastfeeding is cheaper, 2. Cost of formula feeding increases each month, 3. Formula is costly, and 4. Cost doesn't seem to be a lot.

Breastfeeding is cheaper.
Mother's description of Brochure A included that it's cheaper to breastfeed.
"It basically means that it doesn't cost money for breast feed and it costs money for formula".
"Breastfeeding is cheaper, obviously." "Obviously it doesn't cost much to feed by breast feeding." "I mean obviously formula feeding is going to cost more than breastfeeding, it's obvious to me…" 2. The cost of formula feeding increases each month.
Mothers reported noticing that the cost increases monthly as the infant gets older.
"Well it definitely goes up because they need to eat more". "It doubles every month pretty much".
Mothers discussed that formula is costly but generally either expected the cost or thought it was worth it to return to work.
"Well it's definitely costly. But I knew it was going to get expensive anyways so I kind of expected it." "Expensive." "It's taking money out of your pocket and you can't get other things." "It's a lot. It's just a lot of money…" It's expensive. It's definitely going to be expensive but it will allow me to go back to work so it will even out each other." 4. Cost doesn't seem to be a lot.
Some mentioned the cost of buying extra cans didn't seem to be a high.
"Well, I would still do this [buy extra cans of formula] but it doesn't seem like it would be a lot.

Breastfeeding group
The breastfeeding group also had their opinions on the cost of formula. The answers were separated into four themes: 1. Cost doesn't seem to be a lot, 2. Cost increases each month, 3. Formula is costly, and 4. Breastfeeding is cheaper 1. Cost doesn't seem to be a lot.
One mother acknowledged the cost difference between formula feeding and breastfeeding but she reported not finding the cost of formula feeding outrageous.
"…I mean obviously there is a difference from nothing to something but I really don't think it is extremely that outrageous, the price you know?
2. The cost of formula increases each month.
Mothers discuss the increasing cost of formula each month.
"It definitely jumps, I mean from like month 2 to month 4 there is definitely a huge difference." 3. Formula is costly.
One strongly described the cost of formula feeding as unfortunate, very expensive, and inevitable for some mothers that would eventually need to purchase formula. One mother stated that seeing that breastfeeding is free while the cost of formula feeding increases is comforting.
"WOW, so by the fourth month they were at the 50?" And still zero for the breast fed moms! That's good. That makes me feel more comfortable!" In summary, the cost of formula was perceived as high by the majority of the participating from both group of mothers, but for a few the cost was not perceived as a lot. All mentioned breastfeeding was cheaper than formula and that the cost of formula increases as the baby gets older.
Question four probe was asked to assess how the information about cost would influence mothers' breastfeeding intent. "Not really, no." "I really want to bottle feed and not breast feed".
"Um, I still wouldn't breastfeed, I just feel like I wouldn't."

Financial b) Going back to work
One mentioned that cost wouldn't influence her decision to bottle feed since she is going back to work and breastfeeding would not be a possibility.
"Especially since by 4 months breast feeding probably wouldn't be much of an option when I am back to work and stuff like that".
c) Prepared to pay the price of formula For some, the cost of formula is not surprising; therefore information on cost doesn't make a difference in their decision. One mother seemed frustrated with the investigator's question and stated that mothers should know that having a baby will cost money.
"I guess you know when you are having a baby that is going to cost money. So I feel like it shouldn't be a problem because you are getting so much help from WIC that it shouldn't be an issue to buy two cans of it." "Not really influencing me much, like I said I kind of expected it. I knew breast feeding is like no money at all". d) Cost may be inevitable One mother mentioned that the cost on formula may be inevitable and expressed concern about not being able to breastfeed even if she chooses to do it.
"Personally, it probably wouldn't affect it because I know that even if I do choose breastfeeding, I may not be able to, so it may be inevitable that I have to pay and I think just keeping an open mind is the best way to go." e) Additional help from family and friends One comfortably talked about money not being a concern since she has support from family and friends.
"I know that family is there if I ever need them, I have a lot of people that will help, we have a lot of family friends that have babies and stuff like that."

Health
A mother mentioned that cost wouldn't influence her decision because she feels that her child would be just as healthy with formula as with breastfeeding.
"It really doesn't have that effect because I know that either way I go, she is going to be health." It appears that information on cost of formula was not considered influential on their decision to formula feed.

Breastfeeding group
For the whole group of breastfeeding mothers, the information on cost of formula feeding would have a positive influence on their decision on breastfeeding but it wouldn't determine their choice. They found the information: 1) Motivational, 2) Financially beneficial, and 3) Educational.

Motivational
Information on cost would be another reason to choose breastfeeding but the health benefits of breastfeeding were the main reason for choosing to breastfeed.
"Yeah that would be another reason, but it wouldn't be a top reason because of the money. For me, it would be health reasons but that wouldn't be my ultimate decision".
"It makes me want to breastfeed more."

Financially beneficial
One mother stated her decision to breastfeed didn't change after knowing the cost but it helped her want to breastfeed more and she stated that she would pump breast milk if feeding on the breast didn't work since she couldn't afford the cost of formula.
"My decision hasn't really changed especially because of cost wise, definitely makes me want to do it more. And if actually feeding doesn't work I would rather do the pumping for a long as possible because frankly, I can't afford that." Another mother stated that saving money by breastfeeding is great, but she never thought of that, and she would actually pay to breastfeed if that was necessary.
"Even if I had to pay to breastfed, like if I had to give an amount to the government say if because you know if they weren't getting my taxes, I would still breastfeed. Yes, the cost is great but to be honest the cost never crossed my mind, it never did. I don't know why."

Educational
One woman reported that having information on the health benefits of breastfeeding combined with information on cost is mind opening.
"Yeah, it's just so smart and easy. It's the right decision, because you have no idea, and you get all this information and you know everything, it's just so mind opening." In summary, for breastfeeding mothers the information on cost was found to be motivating but not to influence their decision.
Question four probe c was developed to assess mothers' opinion about how other pregnant women would respond to information about cost of formula feeding.

Question 4 Probe c) How do you think other moms would respond to this information?
Majority of the mothers from both groups reported finding the information about cost beneficial for other mothers, especially for those who are in an unfavorable financial situation.

Formula feeding group
Information on cost was found to be Influential or not influential.

Influential a) Financially beneficial
Some discussed that other mothers would consider breastfeeding after learning about the cost of formula because breastfeeding is cheaper and they would save money.
"I think that they probably start considering breast feeding more. Obviously, it is cheaper".
"Um, for them I think they would probably breast feed instead of bottle feed because I guess they will save their money".
Some discussed that information on cost could influence mothers that are not working or don't have help from others.
"Well, if they don't have any money and they don't work, to breastfeed." "It would be hard especially if they are not working full time or not having someone there to help them, but I have my family who is willing to help me with this. I could see where it would be difficult and they would probably choose to breastfeed if they could over formula." It was discussed that information on cost of formula for mothers who are not prepared or not willing to pay the price of formula, as well as for those who cannot afford it, could have an influence on their decision.
"Well I think for some people it definitely makes a difference if they're not prepared or willing to pay what they need to pay for formula." "Yeah it's cheaper and some moms might go that way because they can't afford it and they don't have the option, they have to [breastfeed].

b) Educational
One stated that knowing the cost would give other mothers the opportunity to make an informed decision between formula feeding and breastfeeding, she mentions that the cost could be an eye opener for some mothers.
"Yeah it's cheaper and some moms might go that way because they can't afford it and they don't have the option, they have to [breastfeed]. But the mothers that have the option will sit here and look at you and be like "well I know this is free, but I have two options in front of me and I want to give this one [breastfeeding] a try, if it doesn't work then I will switch over [to formula]…" "…Okay, now she [the mother] knows that breastfeeding is for free but she still has the option of formula feeding and for some moms, it might be an eye opener and say "I can't afford this."

Not influential
Others reported that the information on cost would not influence other mother's decision to breastfeed. Discussed reasons were separated into two themes: a) Psychological and b) Financial.

a) Psychological
It was reported that the cost of formula would influence a mother to breastfeed only if she was comfortable with the overall idea of breastfeeding. One mother states that cost would not influence her since she clearly dislikes breastfeeding.
"I mean It really only depends on how the person is with the breastfeeding.
I'm not really comfortable with having a baby attached to my boob."

b) Financial
Participant strongly defended her idea that having a baby is expensive and the price of formula feeding should be accounted by the mother before making the decision of having a child.
"Well if they already have babies I would assume they would think the same way as me [that babies are expensive]. Because, if you don't know the baby is going to be expensive you should have thought about that before.
One discussed having friends on WIC that don't have to purchase extra cans of formula, therefore, she believes that extra formula may not be necessary.
"Well, all of the people that I do know that just had their babies none of them breastfed." "My friend has WIC, and she says that she is fine. She doesn't have to get any extra."

Breastfeeding group
The answers from the group of breastfeeding mothers were also divided into: 1. Influential and 2. Not influential.

Influential a) Financial
Information could have a positive impact on mother's decision to breastfeed if they were in an unfavorable financial situation. One mentioned that the decision to breastfeed would depend on how comfortable the mother is with breastfeeding, and the comfort level would determine if the mom would mind paying the cost of formula or not.
"…depend on how they feel about breastfeeding, I guess. If they don't really like breastfeeding, they wouldn't mind paying that much." 2. Not influential c) Mind set on formula feeding One mother doesn't believe that the information would be sufficient to change the behavior. She reported that although some would look at the information and say that they would breastfeed, they wouldn't actually do it, they would spend the money on formula instead.
"They would probably look at it and go: -oh yeah I will do breastfeeding, but in reality they will just be spending the money, they will do it the easier way.
Everybody takes the easier way out of everything." In summary majority of participants believed that information on cost would be beneficial for other mothers, especially if they were in an unfavorable financial situation. However, mother's comfort level with breastfeeding would determine if she would breastfeed, not the available information on cost.
Question five was designed to assess mothers' opinion on breastfeeding educational material. "Numbers are definitely a better way to show what it will really cost because it's more accurate rather than just the projection itself…" "I just think that cut and dry is the best way to prepare you." One mother preferred brochure B than A or C. She reported that for her, the point is that the cost of formula feeding increases as the baby gets older, and that every baby is different and will demand different amounts of formula and, therefore, the cost of formula could be a lot more that the cost shown on the brochure. Three mothers stated that they preferred brochure C because they liked to see how many cans WIC provides and how many can they would possibly have to buy, instead of just showing the cost of formula feeding as shown on brochure A and B.
"[Brochure C] Because it shows you how many cans".
"I kind of liked C because it shows you how many cans and it shows you how many cans you will be going through, or how many you have to buy…"

Breastfeeding group
Four mothers preferred brochure A because they liked to see the actual dollar amount associated with the cost, one reported that brochure A gets the point across, two stated that seeing the actual price is more shocking than seeing the image of the two cans of extra formula or just the projection of cost. which doesn't seem that much." One mother reported that she preferred brochure C because it shows how much WIC provides but it also shows that the mother still has to buy extra cans, and seeing information about the amount needed to purchase is clearer than just showing the cost.
"Brochure C shows you how much you get, you get all these, but yet you still have to buy more. It's like kind of more clear, seeing what you are buying right in front of you is easier than money wise, than just a number." In sum, majority of the mothers from both groups preferred brochure A because it provides direct information on cost.
Question six was designed to assess factors that would motivate mothers to breastfeed. Two mothers mentioned that nothing would motivate them to breastfeed.
Mothers that answered nothing demonstrated strong dislike about breastfeeding and seemed ready for closing the interview.
"Personally me, no, nothing is probably going to motivate me to breast feed I am really stuck on that. It's difficult trying to wean the baby off, you know?
Because then you are the one that's stuck constantly, you can't really do much so. Yeah, breastfeeding is just, for me it was never pretty much an option."

Differences in methods
One mother mentioned that she didn't know if anything would motivate her since she believes that breastfeeding is very inconvenient. However, she mentioned that she would like to see a brochure that shows the benefits, advantages and disadvantages of both methods of infant feeding.
"I don't really know. I would make a chart of why you shouldn't breast feed…Benefits of formula and disadvantages of breastfeeding. Well there are benefits for both but I would never breast feed. There are two benefits of breast feeding, it's good for your baby and it makes you lose weight faster.
It's so inconvenient, like if I wanted you to babysit, oh wait, I would just be like I have to pump first and that is just so time consuming." This theme was common and many mothers mentioned a brochure that would explain in details the existing differences between formula and breast milk, including which method is healthier, what are the benefits of both methods of feeding for the mother and baby, the difference in content between breast milk and formula, and advantages and disadvantages of both methods.
"Health, exactly. Like which one is actually healthier or if there is a difference, especially since formula has changed now since years ago, if there is still any health changes, which one is healthier for the baby and things like that." "The benefits of both ways of feeding".
"I would want to say, probably like a list of some type of positives and

Cost of formula
For some mothers, information on the cost of formula feeding combined with comparison chart of the pros and cons of both feeding methods should be included.
"The average cost, definitely a big factor". "[cost] of formula or baby food in general and then the out-weighing the good and the bad, versus the pros and cons of breastfeeding versus bottle feeding." "[the cost] it's definitely a disadvantage to bottle feeding but again, it's important because it may be the reality for some people, so I think you know seeing both views, the benefits and maybe not so beneficial things, because that's important too."

Comfort level
One mother mentioned a brochure containing a picture of a mother breastfeeding side by side with a mother bottle feeding in public.
"Maybe having like a mother sitting down with a bottle versus another sitting down with a baby so they could visually see the difference: -Am I going to be comfortable sitting in public?"

Breastfeeding initiation
One mentioned information on breastfeeding initiation at the hospital.
"I was thinking when I am in the delivery room I was going to try and see how I liked it"

Breastfeeding group
For the group of breastfeeding mothers, information that would motivate them to breastfeed included the themes: 1. Differences in methods, 2) Financial, and 3. Future planning.

Differences in methods
Mothers mentioned listing the pros and cons of both methods of infant feeding, including the health benefits for the mother and child, time required for both methods, and cost. One strongly believed that cost should be included since many may not be aware of high cost of formula.
"I mean besides the cost difference you know, the health benefits because I don't think a lot of people get that". "I think most people don't really realize how expensive it actually is. That's why all those girls are getting 16 and pregnant...well it is, because they see it on TV and they think it's going to be a free ride and it's not." 3. Future planning.
One mother mentioned a list of exciting things that she could look forward to in the future if she chooses to breastfeed, as for example saving money to do fun things with the child.
"I would put things down that you can look forward to in the future, like if you choose to do breastfeeding you would save a lot of money so you can put down like things that you would want to do in the future with your kid or even like saving money to get a decent size house, just like show like things that will inspire you to continue to go with that goal and everything else." In addition to the infant needs, the incorrect handling of formula may increase the need for additional formula. Bottle feeding preparation requires that the mother thinks in ounces and uses it as the standard unit of measurement, and that she follows a formula preparation (96). Fein & Falci found that the majority of formula-feeding mothers did not receive instruction on formula preparation (77%) or storage (73%) from a health professional and thirty percent did not read some of the safe-use directions on the formula package label (97). Therefore, it is possible that some of the participating mothers were handling formula preparation improperly.

DISCUSSION
By month three, the majority of the mothers (73%) were buying two cans of infant formula a month. However, if the babies are indeed drinking on average 33 ounces of formula, seven ounces more per day than the averaged 26 ounces provided by the WIC program, a minimum of 2.5 cans would need to be purchased by the mothers to cover the infant demands. Therefore, it would be interesting to investigate how mothers are filling the gap between the available amount of formula and the infant's demand. Previous research shows that early introduction of complementary foods (weaning) was strongly associated with young maternal age, low maternal education, low socioeconomic status, absence or short duration of breastfeeding, maternal smoking, and lack of information or advice from health care providers. Early introduction of cow's milk had two determinants: low maternal education and low socioeconomic status (81). Since these demographic characteristics are similar to those who participated in this study and it is known that about one third of American infants are exposed to unmodified milk before 12 months of age and the same proportion is introduced complementary foods before four months of age (93) it is reasonable to assume that some of these mothers were likely to be supplementing their infants with complementary foods and/or unmodified cow's milk and other liquids.

Overview and recommendations
Objectives of phase II included assessing mother's prenatal breastfeeding intent, barriers, and motivators. The present study provides some of the answers why women in WIC are not breastfeeding that are similar to other studies: discomfort, embarrassment, infant's attachment to the mother (need for others to care for baby), lack of supportive work environment, time and effort involved in pumping and discomfort of self and others with handling mother's milk. These factors were considered by the mothers as barriers to breastfeeding and could be perceived as "costs" of breastfeeding. It appears that the mothers' decision to breastfeed or formula feed was based on the value that each of the feeding options had for the mother. For the mothers that intended to formula feed, breastfeeding value (the health benefits for the infant and mother's weight loss), was lower than the perceived value of formula feeding, which was perceived as high since that could provide the mother "freedom" from the breastfeeding barriers (Figure1). Therefore, if the "cost" of breastfeeding outweighs the perceived value of formula feeding, regardless of the method utilized to try to motivate mothers to breastfeed, including information on cost of formula, breastfeeding may not occur. Value, has been accounted as the key factor in decision making on a study on decision making in behavioral economics, which mapped factors in decision making onto a single variable: value (119). One mother states that during the interview: "Well, there are benefits for both but I would never breastfeed. There are two benefits of breastfeeding, it's good for your baby and it makes you lose weight faster. It is so inconvenient, like if I wanted you to babysit, Oh wait, I would just be like I have to pump first and that is just so time consuming." Although the cost of purchasing formula was found to be high by all the participants, for breastfeeding mothers the long-term health benefits of breastfeeding was their number one reason to breastfeed and cost of formula was seen as a "bonus" that comes with the health benefits. It is possible that mothers that intend to formula feed focused on their short-term objectives, which for most participants of this study would be to maintain their lifestyles and not changing it to accommodate breastfeeding, even when the long term benefits of breastfeeding would outweigh the short-term formula advantages. One study refers to the lack of sense of urgency regarding future health that may make nutrition a low concern and the challenge of helping people incorporate healthy eating into their lifestyle (120).
This is an issue that could be projected to breastfeeding, since incorporating a healthier feeding method into a mother's lifestyle seems to be also a challenge (120).
If breastfeeding cost has a higher value for the mother at that point and time than the long-term health benefits and savings on cost, addressing the health benefits of breastfeeding and its economic value would not have a positive influence on mother's decision to breastfeed, this was demonstrated in this study. Ways of incorporating breastfeeding into the mother's lifestyle should be further investigated.
An interesting fact about the participants of this study that differ from other studies is that all of the women were pregnant and single and were interviewed in their second or third trimester. It was possible that breastfeeding intent, barriers,  In a large scale, a future breastfeeding intervention, would initiate with a prenatal breastfeeding intent assessment, where the professional would ask the mother sensitive questions and probes in order to obtain information about her breastfeeding intent, barriers and motivators. Utilizing information learned from this assessment, the professional would be able to identify the problem (what is impeding her from breastfeeding, why, and what could possibly motivate her to try breastfeeding) and refer the mother to professional (certified lactation counselor, midwife, dietitian, social worker, etc.). This specialist would be able to use the personal information obtained from the mother to tailor the consultations accordingly to her needs. The counseling sessions should be personalized and focused on addressing the specific barriers to that one mother. Starting early in the pregnancy would give the professional an opportunity to build rapport with the mother and to slowly work on key factors that are specific for each mother (Figure 3). In a smaller scale, since the WIC program doesn't have an independent researcher or professional to conduct the initial assessments, or a multidisciplinary team to refer mothers, it would be interesting to explore the idea of having the WIC nutritionists conducting an initial breastfeeding prenatal assessment and having all the mothers referred to a peer counselor, as early as possible in the pregnancy, despite of their breastfeeding intent. This intervention would require nutritionists to be involved in supporting the breastfeeding peer counselor program and for the peer counselors to contact mothers before their third trimester.
Parallel to this intervention, an investigation of how breastfeeding could be included into mother's lifestyle, ways to demystify breastfeeding, and communicate with the mothers is needed. The fact that WIC mothers were all single should be taken into consideration while working with the mothers. The finding that mothers felt they were in charge of the decision of how they would feed their babies could be attributed to the fact that they were single and felt that they own the right of deciding, which is a strong factor that should included in future interventions. The idea of a breastfeeding intervention titled "It's your decision" should have potential to bring the attention to the mothers that believe in fact that it's their decision how they will feed their babies.

Information about cost
It was found during Phase I that the mean cost of buying extra cans of formula was $50 per month for the participant in the fourth month. The material was presented to a group of prenatal women enrolled in the WIC program. It was found that the majority of the mothers considered the cost of buying extra formula high; clear adjectives such as costly and expensive were used to describe the cost. There was no difference between the breastfeeding and formula feeding group in regards to finding this cost high. Both groups were able to notice the increase in the cost of formula as the child gets older, and similar to another study (121), breastfeeding was noted as cheaper than formula feeding by WIC participants.
Although some mothers stated not finding the high cost of formula surprising and about what they expected it to be, when they were asked to estimate the amount spent on formula, none of them knew the cost of formula, except for one mother which worked at a grocery store. Many participants stated not having an idea of the cost, concluding that the groups were not up to date with information regarding the cost of formula, an item that it was perceived as expensive, and for formula feeding mothers indispensable. A study on consumer behavior talks about consumers lacking full information on prices and quality of items they intend to purchase (118).
Information on cost of formula should be included in prenatal counseling in order to educate mothers about formula cost. These costs should be updated periodically to follow the changes in market prices. Since participation in the program has been linked to early introduction of solids and cow's milk, WIC nutritionists may pay attention to formula feeding post-partum mothers during their WIC visits to ensure that mothers are not replacing the formula with solids or milk when the amount of formula given by the program is insufficient to cover infant's feeding demands. Education about proper mixing of formula, infant's feeding demands and cues, along with information on how to read recipes that utilize ounces should be ensured to be given to all participants. Mothers that report being in an unfavorable economic situation, maybe "red flagged" by WIC nutritionists and followed up at each visit in regards to infant feeding practices.

WIC characteristics
Mothers that reported intent to breastfeed belonged to the same WIC site, B.
Although breastfeeding initiation rate for babies born in 2010 participating in this site was below Healthy People 2020 goals, only 53%, it was superior to the breastfeeding initiation rate of WIC site A (37%). Considering that only WIC site B had participants intending to breastfeed it would be interesting to further investigate how both WIC programs differ from each other in their breastfeeding approaches. Since breastfeeding support from nurses, lactation specialist or peer counselors are an important influence on women's decision to breastfeed (8,12,104,107), it is possible that the intent of breastfeeding from WIC site B partially came from their staff's approach to breastfeeding. The group of breastfeeding mothers was older than the group of bottle feeding mothers and they also had a higher level of education, this pattern is confirmed by previous studies that documented that older and more educated mothers are more likely to breastfeed than younger and less educated mothers (1, 26). Therefore breastfeeding intent could be attributed to participant's characteristics.

Educational materials
The second objective of phase II of this research was to evaluate nutrition education materials through in-depth interviews. It was found that the majority of participants, including mothers from both groups -breastfeeding and formula feeding, liked brochure A better than brochures B and C. These mothers seemed to appreciate learning the actual cost of formula per month. They found having the price displayed on the brochure a simpler and easier way to understand the information, informative and direct to the point. Brochure B was not very popular when compared to brochure A or C, with only one mother preferring its style.
Brochure B didn't contain the actual cost of formula, and it was elaborated with the intention of showing graphically to mothers that breastfeeding is free and formula feeding, conversely, has a cost associated to it that increases along with the infant's growth. Some of the issues with brochure C included the use of images of cans of formula to compare the amount of formula given to the amount that would need to be purchase by the participants (two large cans). Since WIC provides majority of the cans, the images of two large cans gave the impression to some of the mothers that the cost of formula feeding may not be high. Therefore, brochure C had the opposite effect desired by the researcher. An example of that opinion is quoted below: "…this actually makes it look not that bad. Because I mean the way they have it shown its only two extra cans".
Interestingly, reasons why some formula feeding mothers liked brochure C were that it showed how many cans they would receive from WIC, which was perceived as positive, versus the other two brochures A and B that only showed the negative side of formula feeding, the cost for the participant. It could be assumed these mothers were focusing on how much they would receive (highly valued) instead of how much they would be spending. Conversely, the reason why a breastfeeding mother liked brochure C was because it informs mothers that WIC provides formula, however, the amount is not sufficient and the mother will have to buy extra cans. From a breastfeeding point of view, the mother's focus was on how many cans she would have to purchase instead of how many she would receive.

Summary
When mothers were asked about factors that would motivate them to breastfeed, many mentioned the main differences between formula and breastfeeding, including differences in nutritional content and health benefits of breastfeeding. However, some of this information is available to WIC participants at the participating sites. Therefore it is possible that mothers may not be reading information that is provided (and reasons why they are not reading it should be investigated) or it is possible that the information is not being given to the participant. Effective ways of communicating information to mothers should be prioritized when promoting breastfeeding. Mothers' language (their own words) should be used in educational materials to address their needs objectively. This research could be utilized to identify common language used by the participants when talking about breastfeeding. The use of images could be explored as way of communicating with mothers, especially if they are not taking the time to read materials or interested in listening to other people.
Finally, this study found that information on cost may not be effective in influencing mothers that intend to formula feed to breastfeed but motivational to mothers that intent to breastfeed. This cost was found to be important and should be included into educational materials. Multi-factorial reasons are involved in mothers' choice to bottle feed. These reasons, which seemed to be directly associated to their lifestyle and myths associated to breastfeeding, should be explored and ways of incorporating breastfeeding into mother's lifestyle and demystifying breastfeeding should be added to educational materials.

Limitations:
Considering that 87% of Hispanics in Rhode Island and 20% nationally spoke other language than English in 2009 according to U.S. Census Bureau (48), the fact that 86% of the subjects were non-Hispanic of white race, the lack of diversity was a limitation. While a trilingual researcher was available in the WIC sites, Spanish or Portuguese clients were either not recruited or not available for recruitment.

Future Research
Future qualitative research should intend to investigate ways of incorporating breastfeeding into mother's lifestyle. Followed by an investigation of how this could be incorporated into WIC breastfeeding materials that would help mother's achieve their goals (social, economic, personal, physical, and etc) without sacrificing breastfeeding.
An investigation of how to effectively demystify breastfeeding should be conducted. The use of images may be explored as way of quickly addressing some of the perceived "costs" of breastfeeding. Picture of a mother breastfeeding discretely in public versus a mother bottle feeding; a mother shopping freely (carrying only the baby and a hand bag) versus a mother carrying a large bag with water, bottles, formula, bottle warmers, bottle sanitizers, and etc); a mother breastfeeding in a comfortable rocking chair versus a mother getting up to prepare a bottle in the middle of the night, and many other possible images. It would be interesting to learn how mothers respond to these emotional images that are directly related to their lifestyle and perceptions of breastfeeding.

IMPLICATION FOR RESEARCH AND PRACTICE
This paper provides several contributions to our understanding of infant feeding decisions among WIC participants. It provides information on cost of formula feeding for non-breastfeeding WIC mothers in Rhode Island, which wasn't available.
It also provides information on how and why information on cost doesn't influence mothers that intent to formula feed to breastfeed, but motivates mothers that intent to breastfeed, and provides factors that mothers perceived as motivators or deterrents of breastfeeding.

LIST OF REFERENCES
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Title of Project: Increasing Breastfeeding in WIC Participants
Dear Participant: You have been invited to take part in the research project described below. If you have any questions, please feel free to contact Viviane Donahue or Geoffrey Greene, the people mainly responsible for this study.
The purpose of this study is to develop and evaluate educational materials to be used as part of WIC prenatal breastfeeding educational classes. Responses to these items will be collected by a WIC staff member or by the researcher. This is an anonymous survey, your name is not recorded and all information will be confidential.
YOU MUST BE AT LEAST 18 YEARS OLD to be in this research project.
If you decide to take part in this study, your participation will involve filling out a survey about use of infant formula. You will receive an incentive upon completion of the survey.
The possible risks or discomforts of the study are minimal.
Although there are no direct benefits of the study to you, if we develop material that helps encourage breastfeeding this is likely to benefit both mothers and children. If the program is found to be effective it could be used in other WIC programs and could improve the health of children in America.
Your part in this study is anonymous. That means that your answers to all questions are private. No one else can know if you participated in this study and no one else can find out what your answers were. Scientific reports will be based on group data and will not identify you or any individual as being in this project.
The decision to participate in this research project is up to you. You do not have to participate and you can refuse to answer any question. tell her that the interview is about her and her plans but you will tell her when the interview is over). Tell her about the topic of the interview, as described on the consent form, explain that answers are used for research only and that her name will remain confidential. Tell her what to expect during the interview, how long it will take, what she will receive as an incentive and that she will receive her incentive as soon as the interview is completed. Remind her the interview will be tape recorded.
Review the consent form and ask if she has any questions. Both of must sign the consent form and you must give her a copy. Ask if she knows whether the baby is a boy or girl and note the gender so you can refer to the baby as he or she later in the interview then ask the introductory, "ice breaker" question about their favorite television show. This introductory process will help form rapport, to build a relationship, and to gain trust and confidence.

Interview Questions
The interviewing process is unstructured. Although a list with questions and probes will be provided, the conversation will be open, moving in any direction of interest. The list of questions presented below should be asked of each participant if topics are not covered. If further explanation is needed, use the probes.
1. There are many ways of feeding an infant. There is breastfeeding, formula feeding, pumping breast milk, and both breast feeding and formula feeding.

Final thoughts
Summarize key points and ask if this is correct. Do you have any questions or comments or anything else you want to say? If they wanted to know about your breastfeeding you can respond now. They will be informed the interview has been completed. An incentive will be given in appreciation of subject's participation in the study. Have them sign acknowledgement of incentive receipt. Thank them for helping develop materials that could help other WIC moms. You have been invited to take part in a research project described below. Viviane Donahue, the researcher, will explain the project to you in detail. You should feel free to ask questions. If you have more questions later, Geoffrey Greene, the person mainly responsible for this study, 401-874-4028, will discuss them with you. You must be at least 18 years old to be in this research project.

Description of the project:
The purpose of this study is to access the acceptability of breastfeeding support materials. What do you think and how do you feel about the information presented to you during the interview.

What will be done:
If you decide to take part in this study, you will participate in a 15-minute interview where questions will be asked about your infant feeding choice and your opinion about educational materials. Interviews will be held in private at the WIC office. This interview will be taperecorded and a transcript of the interview will be prepared. All identifying information will be removed from the transcript to preserve confidentiality. After the interview, you will be asked to read a summary of the interview to confirm accuracy. If you would like to make changes to your interview results, you can schedule an in-person meeting or a telephone call to do so. You will receive an incentive upon completion of interview. After three years, the tape recordings and transcripts will be destroyed.

Risks or discomfort:
No risks are anticipated by participating in this study.

Benefits of this study:
Although there are no direct benefits of the study to you, if we develop material that helps encourage breastfeeding this is likely to benefit both mother and children. If the material is found to be effective it could be used in other WIC programs and could improve the health of children in America.

Confidentiality:
Your part in this study is confidential. None of the information will identify you by name. That means that no one else can know if you participated in this study and no one else can find out what your answers were. All records will be secured in a password-protected computer that is only used by Viviane Donahue, locked when not in use and stored in a locked room at 80 Washington Street Room 300. Providence, RI. Confidentiality will be preserved through the use of pseudonyms and publishing of the results using these pseudonyms. Only the interviewer, Viviane Donahue, will retain the link between the pseudonym and your identity.

Decision to quit at any time:
The decision to take part in this study is up to you. You do not have to participate. If you decide to take part in the study, you may quit at any time. Whatever you decide will in no way penalize you.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with Geoffrey Greene (    "Right now we are planning on bottle feeding but I still trying to keep an open mind about breastfeeding probably something I will try in the hospital but right now I'm pretty much set on bottle feeding." "[bottle feeding] Formula, yeah, I am not pumping. 2 "Bottle feeding." "Formula" 3 "Bottle feeding." "Formula" 4 "Probably formula" 5 "I like the bottle" "Formula" 6 "Not going to breastfeed" 7 "As of right now, I plan on bottle feeding only because I had a breast reduction and they took so much out that they don't think that I would be able to breastfeed or that the chances of it would be slim. So I'm just going to stick to bottle feeding" 8 "I'm not really sure, I'm not really educated on breast feeding so I'll probably like to try doing it you know like maybe at night or something, not consistent, I'd like to bottle feed as well." "Um, probably bottle feeding only because that's really what I know more about and what I would be more comfortable with." 9 I'm going to feed her by bottle feeding, I think, I don't feel comfortable in public with the baby here, so bottle feeding is the way we are going to go!" 10 "I have plans on breastfeeding." "Pumping also." 11 "Breast feeding" 12 "Probably the healthiest way which would be breastfeeding; it's a nerve wrecking thing that you don't even know what's right or wrong. But if I had to choose I would probably say breastfeeding right now. That would be my decision today." 13 "We are going to breastfeed but I am going to pump also. More so to have an adequate supply of milk, moms that I have known have said that had really helped them make sure that they had enough so they could continue to breast feed." Initial Matrix for Question Two Table 10.2 List of responses to question 2, tell me some of the reasons you choose___?

Participants
Participant Responses 1 "I'm just not really comfortable with the idea of breastfeeding. Also, I have inverted nipples, that's going to be more difficult so. Also, I don't get a paid maternity leave so I need to go back to work very quickly and it's going to make it easier." "Yeah, I kind of have my mind pretty much set so." 2 "Because I was used to feeding with the bottle and to by the breast, like I raised my sister's kid with her and I am used to the bottle so I feel more comfortable with a bottle than with breastfeeding." "I just choose it on my own because I don't feel comfortable with it." 3 "I know a lot of people who have been having lots of trouble weaning the baby off of breastfeeding. So I don't want to have too much [trouble]. My friend Gina had to bring my niece to my baby shower because she doesn't want to switch and it's kind of hard for her to do a lot of things and what not, so that's one of the main reasons." "It's probably a silly one [reason], but my sister-in-law, both babies were only attached to one boob so she's got like a C and a D and I'm like "I'm good with that" I like to keep them the way they are. I don't want to be all lopsided. It's kind of silly but I kind of think about that too so I'm like "m-m" she can't find a bra, ever." "I have always been on the mind set of bottle feeding." 4 "Because that hurts, so I just rather do formula" 5 "It is easier to do". "Like preparing it and all that. Like preparing it is like easier, like you are done right away instead of like breast feeding. "Yeah it's quicker and better".
6 "I just think it's weird". "Breastfeeding I think is really inconvenient because you have to take time to pump or you have to just do it in public, which is really weird. I would never do that." "I've known people that breastfeed and sometimes it takes them a while to pump, sometimes it's quick, sometimes you just can't, I don't know." "Bottles are easy, you can just put them in the bottle and heat it up and give to the baby. And if someone is babysitting, you don't have to worry about pumping, you just say: here are bottles." 7 "As of right now, I plan on bottle feeding only because I had a breast reduction and they took so much out that they don't think that I would be able to breastfeed or that the chances of it would be slim. So I'm just going to stick to bottle feeding." "Well, I mean, I plan on going back to work within 2 months; my grandmother is going to be watching the baby so it'll be a lot easier for me, instead of me trying to wean the baby off of breastfeeding so early, just go and just bottle feed." "My cousin, her children were very attached to her. They wouldn't really go to anyone else because they were constantly with her because she was breast feeding and I don't want that. I want to be able to say: "Oh you want to watch the baby for a little while, here you go". I don't want my child to be stuck all the time with me if someone wants to take the baby out for a little while especially my family because they don't get to see me often." "It was more like she [cousin] even said it was more like a burden a lot of times because she was constantly pumping or feeding or something like that so I mean, overall, I think bottle feeding is a lot easier." "Most likely probably my surgery and the sensitivity that I have and things like that." 8 "I'm not really sure, I'm not really educated on breast feeding so I'll probably like to try doing it you know like maybe at night or something, not consistent, I'd like to bottle feed as well." "Um, probably bottle feeding only because that's really what I know more about and what I would be more comfortable with." 9 "I am not comfortable in public with the baby there, if it was in the privacy of my own home that would be fine. But just in public I am not a big fan about it. It doesn't bother me seeing somebody else doing it because its life but I couldn't do it." "I think it's just the whole feeling and the whole concept of it. Just sticking a pump there and having it there and eh…it's not for me!" "It makes it easier for him too because he doesn't have to sit there and hold the little packages of breast milk. He was a little uncomfortable with that too so I was like well okay, I was like, "Well then I'll go with the bottle because she is going to be going from my house to your house, not right away, but from my house to your house and I'm pretty sure you're not going to sit there and pump yours and I'm not going to be there so" and he was like, "Alright, the bottle is fine with me". So I was like "Okay"! "He [baby's father] is a little awkward about the pumping, he was like "Well" and I was like "it is life, it is just milk, you're not touching it, you're not handling it, it's going from a bag to a bottle, to the baby, you're just holding the bottle" and he was like "No I can't, knowing something came out of somebody else and going into somebody." He was like "No, I can't! I can't handle it! I can't touch it." And I was like "OK". So we just went to the formula." "It didn't affect [his opinion] me at all because I kind of figured, he is a man and they do the grossest things but the littlest things freak them out. So I was like we will just go with the formula." "We might have given it [breastfeeding] a try but he wasn't comfortable with it and I was like well he is not living with me so I can't have it there so I was like we can just do the formula if it makes it easier on you, less stressful for me. And then we will put so many at your house, I'll have so many at mine so then we don't have to worry about "Oh did you grab this? Do you have enough of this?" So we made it work out that way too." 10 "Basically overall, even like my doctor encourages it and it's healthier for the baby." "Probably just health factors right now." 11 "Because you are doing an extreme disservice to your child if you're not" "You build up immunities from the breast milk that the parent already has built up so it helps the child work with illnesses, there's brain development, eye function, everything, it comes right from there. So by not doing that you're taking key things away." "I guess it's beneficial for both but I would say mostly for the baby because from what I hear it is pretty painful so…" "That's what I want to do so I'm going to try and do that." 12 "Have a healthy baby, you have to do whatever what's best for them and everyone says breast feeding is one of the healthiest things for your child and obviously for your kid you want to have the best thing for them so that's probably why I would" "Just the whole healthiness and it's kind of what you have to do. And I don't know, and for the formula that you buy you don't know what kind of formula because there are so many kinds and you know that your breastfeeding it's like the right kind of milk and it's giving off all the right nutrition and everything you don't know what kind of formula does that and anything else." "Being pregnant is just overwhelming in general; it's one of the most overwhelming things I am going through right now!" 13 "First of all because of the health benefits, for the baby and secondly, honestly, to lose the weight. I know that that will help me go back to my pre pregnancy but also obviously the health benefits. And I have seen the difference with friends of mine that have breastfed versus bottle fed and I do see a healthier child with the breastfed children." Yes, everyone has said to me "oh don't worry, the weight will fall off if you plan to breastfeed", so I'm hoping they're right." 14 "Actually I read that I guess it's healthier, it's cheaper and yeah it's like better for the baby, they get less sick, it's just a lot better, I've read." Initial Matrix for Question Two Probe Table 10.2 List of responses to question 2-probe, how does your family feel about__? Specifically assess mother, grandmother, sister and find out how the father of the baby &/or her current partner feels about__.

Participants
Participant Responses 1 "My sister just had two kids and she bottle fed with formula for both of them. Actually my mom did too so they are both supportive, It was pretty much my choice and same with my boyfriend." He was breastfed, but he said it's my choice because he understands it's not him that has to do it". 2 "They were fine with it" 3 "They're fine, because my auntie and my mom they didn't breast feed for either child. "He [baby's father] wanted me to [breastfeed] but when I told him no I was pretty much "tough luck" and he was like "okay, fine". He was okay with it." 4 "It's just mine [decision]. I mean, they don't really care. They don't care, it's whatever I want to do.

5
"They think it is easier for me to do instead of breast feeding…the baby's father, my mother, father, and some other people. My aunt thinks I should breastfeed because it is healthier for the baby. I told her I was like yeah I'll think about that, but I was like I don't know. I've been thinking about bottle feeding." 6 "They don't really mind. It's like my decision." 7 "I mean my cousin breastfed all three of her kids, but my mother bottle fed me and she said it was so much easier, it was a combination of whoever was around who was able to feed the baby, it wasn't just strictly you at that point so it was more helpful." "My cousin, her children were very attached to her. They wouldn't really go to anyone else because they were constantly with her because she was breast feeding and I don't want that. I want to be able to say: "Oh you want to watch the baby for a little while, here you go". I don't want my child to be stuck all the time with me if someone wants to take the baby out for a little while especially my family because they don't get to see me often. "It was more like she [cousin] even said it was more like a burden a lot of times because she was constantly pumping or feeding or something like that so I mean, overall, I think bottle feeding is a lot easier." 8 "That it's my own decision, nobody was pushy." "They are very supportive of whatever I chose." 9 "They tell me that any decision I make they are going to support it. My mom had three kids, my aunt had a million kids, some breastfed and some bottle fed, some say bottle feeding is better, some say breastfeeding and they say whatever you decide we are going to support you anyways." "He [baby's father] supports it any way too. It makes it easier for him too because he doesn't have to sit there and hold the little packages of breast milk. He was a little uncomfortable with that too so I was like well okay, I was like: "Well then I'll go with the bottle because she is going to be going from my house to your house, not right away, but from my house to your house and I'm pretty sure you're not going to sit there and pump yours and I'm not going to be there so" and he was like, "Alright, the bottle is fine with me". So I was like: "Okay"." "He's a little awkward about the pumping, he was like "Well…." and I was like "its life, it's just milk, you're not touching it, you're not handling it, it's going from a bag to a bottle, to the baby, you're just holding the bottle" and he was like "No I can't, knowing something came out of somebody else and going into somebody." He was like "No, I can't! I can't handle it! I can't touch it." And I was like "OK". So we just went to the formula. "[Baby's father opinion] It didn't affect me at all because I kind of figured, he is a man and they do the grossest things but the littlest things freak them out. So I was like we will just go with the formula." "We might have given it [breastfeeding] a try but he wasn't comfortable with it and I was like well he is not living with me so I can't have it there so I was like we can just do the formula if it makes it easier on you, less stressful for me. And then we will put so many at your house, I'll have so many at mine so then we don't have to worry about "Oh did you grab this? Do you have enough of this?" So we made it work out that way too." 10 "Um actually, my boyfriend he is more "oh just do formula" but I am more "Oh but I want to do breast feeding" so. He's fine with it. He just thinks it's going to take longer with pumping and everything like that but I explained to him why I'm choosing to breast feed so he is find with it but it's funny, you know with a guys perspective, he's like "oh let's just do formula that'll be easier" "Oh yeah, once I explained why and everything "The baby's father is a hundred percent supportive, it is the way he me wanted to go but he kept his opinion to himself until I came out and said it. And then he said "oh thank god I am so glad you said that". My mother looks at it as more of a bonding experience than health benefits. So she told me if I am comfortable with it that's fine and if I'm not comfortable with it that's fine, she's pretty neutral. My friends have breastfed so that's just the natural choice; they never even considered a bottle fed baby. And the ones that did, pushed for the bottle feeding. And they say it's much easier and convenient and you can share. My fiancé, he does want to be able to take part in feeding the baby, so once we get to the pumping he will be able to do that. So he is anxious for the pumping part. Well he says that now, we will see when it actually happens when it's 2 in the morning and I'm like "there you go!" "Well, I can tell you my mother  3 "I have no idea. I am kind of lost out of the blue when it comes to any of this stuff. I don't really know. My friend's littlest one she is still kind of breastfeeding and she has a two year old and I never asked her what she did. And then my sister-in-law she got a 10 and a 7 year old so she probably don't even remember, so I'm a little lost in that situation".

4
"Maybe a couple of hundred, a few hundred dollars." "It depends on how big the baby is I mean, you got to feed it more." 5 "A lot, because my friend spent over $200 on formula." 6 "Well it depends on how much they would need because one can is like 30 dollars and that is a lot for one can that lasts you like a week, if that. So I don't really know just depends on how much they would have to buy." 7 "A lot! Um I really don't know the roundabout figure but I do know it is expensive but I mean I have the help so I am hoping that it'll work but not really sure exactly how much it would be in addition." "No idea" 8 "Maybe $100" 9 "She [cousin] constantly had to do that [buy formula]." "She had to do that, she'd have so many cans and she would just run through them before her checks were due again, she had to go out and buy at least another two or three cans just to have them because she always ran out." "Well she [cousin] had to have a special kind of formula because she was allergic to the other ones, so she spent somewhere…each can was like somewhere in between $20 -$25 a can so she was pretty much spending close to over a hundred dollars with the checks too plus the extras so she was spending quite some money. But she did it the smart way, she put money aside for the baby, can't touch it, strictly for this so she planned ahead so that's what we're doing. We are starting to save money already, we already have at least 1300 dollars put aside for her, and we are not touching it, it is for her. So between the diapers, the formula, medicine, everything, that's where that money comes in."  "That is a lot cheaper to breastfeed". "Well, it definitely goes up because they need to eat more." "It doubles every month pretty much".
2 "It basically means that I don't cost money for breastfeed and it costs money for formula." "Well, I would still do this [formula] but it don't seem like it would be a lot." 3 "Well it's definitely costly. But I knew it was going to get expensive anyways so I kind of expected it". "I expected it to be expensive from formula to breastfeeding because breast feeding is right there and formula is not so I do kind of expect it to be on the pricey side. Yeah so I am definitely not shocked. I know babies are expensive so that one [information on cost] is not too bad." "I mean, I knew it was going to go up as the baby got bigger, more and more. So, yeah, kind of about what I expected". 4 "I think that it's a lot more. The baby is one month old; they are telling me I'm going to only have to pay $7.50? No way, no [Mother's perception on cost at 1 month]." "[mother's perception on cost at month 4] Expensive." "Well, it's taking money out of your pocket and you can't get other things." 5 "Looks cheap." "Not cheap cheap but." "Yeah, higher and higher [referring to the increase on cost ever the months]." 6 "Breast feeding is cheaper obviously" "It's a lot. It's just a lot of money, well is that 7.50 for one month? "Um, I still wouldn't breast feed, I just feel like I wouldn't.
[mother's comment after learning about the cost at 4 months old]" I guess you know when you're having a baby that it's going to cost money. So I feel like it shouldn't be a problem especially because you're getting so much help from WIC that it shouldn't be an issue to buy two cans of it." 7 "It's expensive. It's definitely going to be expensive but it'll allow me to go back to work so it'll out way each other." "Well, I mean I understand that obviously, as they get older they are going to eat more so obviously it would go up but I mean nothing major.  ] jumps with everything at most, like gas prices jump, so the food prices jump, everything else is going to jump, so I know I'm not the only one paying the same amount of money for it. And I know that eventually when prices start coming down, so will the price of formula. So I am okay with spending the extra money on that because eventually it will come back down and we won't be paying so much for it." 10 "This is in addition to the WIC, right,?" "I mean I don't think it's that, I mean obviously there is a difference from nothing to something but I really don't think it is extremely that outrageous, the price you know? "Yeah, no, it definitely jumps [the cost], I mean from like month 2 to month 4 there is definitely a huge difference, absolutely."

11
"That sucks" "The actual amount of money that you have to end up spending that's unfortunate. It shouldn't cost that much for that kind of stuff, like it's a necessity eventually at some point." "Yeah, I mean you can't breast feed forever eventually you're going to have to wean them off at some point. And there are some women that can't even at all, they try, they can't. So there are really only a couple routes they can go. And if formula is one of them that's just really expensive. " 12 "That's nuts. It is! Money goes so fast that's all I can to say! Babies are expensive! "Well it just shows how in between two months, like twenty dollars, just saying, that is just an estimating of money just adds up so fast, and then you have this [breastfeeding] it costs nothing, if you're doing the formula, it's just throwing the money away basically, it's a money waster of hecticness its nuts, it's crazy to think that money can just add up in a matter of a month on how much money can really happen." "Yeah like month one you're at 7.50 and then all of a sudden 3 months later you're at 50 dollars spending it, it's crazy!" 13 "Wow, so by the fourth month they were at the $50?" "And still zero for the breastfed moms! That's good. That makes me more comfortable." 14 "At first I thought it was a lot cheaper for the first month but then it got a lot more expensive." 4 "Well, if they don't have any money and they don't work, to breastfeed." 5 "Um, for them I think they would probably breastfeed instead of bottle feed because I guess they will save their money". 6 "Well, all of the people that I do know that just had babies none of them breast feed." "My friend Chelsea has WIC, and she says that she is fine. She doesn't have to get any extra." 7 "It would be hard especially if they're not working full time or not having someone there to help them but I have my family who is willing to help me with this. I could see where it would be difficult and they would probably choose to breast feed if they could over formula." 8 "Well I think for some people it definitely makes a difference if they're not prepared or willing to pay what they need to pay for formula then they may already have their decision made." 9 "They might appreciate it and some just might say that they will go the extra mile and pay it [for formula] anyways, some might not have a care in the world and some just might be like "well, mom and dad said they will help" and I was like, okay, but well…mom and dad aren't going to be there forever, you'll have to do it on your own and they're like, well…we will worry about it when the time comes. And you can't do that, you have to worry about it now." "Yeah because they [other mothers] might know [the cost] and then be like well we can't do it, how can we get help, how can we get some support? And by them knowing the information and help them out and then maybe they will figure, alright I can do this and they might actually go the extra mile." "Yeah it's cheaper [breastfeed] and some moms might go that way because they can't afford it and they don't have the option, they have to. But the mothers that have the option will sit here and look at you and be like "well I know this is free, but I have two options in front of me and I want to give this one a try, if it doesn't work then I will switch over and if it has an affect then we will have no choice but to go back or what can I do, and some are just like no, we are just going to pay the money and just go from there, they don't want to hear it." "So maybe I [referring to other mothers] have to go this way [breastfeeding] whether I like it or not because I can't afford to do it this way. You can't starve a child so you have to go one way or the other." 10 "Yeah I think it would absolutely maybe impact their decision on going to breast feed instead of formula, if they weren't expecting those prices and if they are budgeting and all the other costs for having a baby, you have diapers and everything else. I think that definitely could persuade someone to do; or half and half, half breast feed, half formula, try to do breast feeding more, absolutely." 11 "I mean, the moms that I know they all breast feed or breast pump. Formula was the last option. Any of my other friends that don't have children and if they did have them I would hope that they would breast feed, but I mean if they saw that maybe it would change their mind, but I don't really know at the end of the day I am not in their financial position so it would be different for them and I can't judge so." 12 "Well my cousin just had a baby last year in July, she didn't do breastfeeding and she's still doing the whole formula thing. I can see her struggling because she is my age well she is two years older but she was my age when she got pregnant. And she struggled and a lot of my friends would probably do the formula thing too because a lot of people that I know are just very full of themselves and don't really think about anyone else but themselves. So they would probably look at it and go oh yeah I'll do breast feeding but in reality they will just be spending the money, they will do it the easier way. Everybody takes the easier way out of everything." 13 "I'm sure if you have any financial difficulty, this would be a factor. I mean if you can save fifty dollars a month, that's a lot of money especially if you are in a situation where, you know, fifty dollars is a lot of money." "I think that could. If I were going to formula feed my baby and I didn't have that extra fifty dollars and I think it would make me look again at breastfeeding. Maybe not make the decision to do it if you're not comfortable with it but definitely get some more information to see if I could. I would think so anyway." 14 "It depends how they feel about breastfeeding, I guess. If they don't really like it then I don't think they would mind paying that much." *Mother was probed: Do you think that it would influence them in any way? Initial Matrix for Question Five Table 10.5 List of responses to question 5, we developed two other brochures, they contain the same information but in a different format, which of these two do you like best? What are some reasons you like (brochure name) better than (brochure name)? Show all three and ask for preference then ask for reasons specifying brochure name. "I kind of liked C because it shows you how many cans and it shows you how many cans you will be going through or how many you have to buy and then pricing them and they could add up the prices too and be like okay well this is the one that I'm on, this is expensive, why am I paying so much, is there something else I can get, but the other ones just show them like the money too so I would have to go with C." "Because it physically shows you the cans. It shows you how many you would go through or how many of these and price it out. I think it gives everyone more grasp on how much they are going to be spending." "Because it gives you a visual like the people that aren't very good with just seeing money, they actual see the cans and they're like okay well this is why it's so much, can I do this and this, will it make it cheaper, they can visually see how many cans, where on these you just see the amounts and some get confused when you through money at them."  3 "Personally me, no. Nothing is probably going to motivate me to breastfeed I am really stuck on that. It is difficult trying to wean the baby off, you know? Because then you are the one that's stuck constantly, you can't really do much so. Yeah, breast feeding is just, for me it was never pretty much an option." 4 "The money and the cans, and the powder." "There are things in breast that isn't in this formula so that's why, you know, I would do that if I chose that." "When you breastfeed, there is things in the milk that there isn't in the powder." 5 "I was thinking when I am in the delivery room, I was going to try and see how I liked it." 6 "I don't really know. I would make a chart of why you shouldn't breast feed." "Because it's awkward." "Benefits of formula and disadvantages of breast feeding. Well there are benefits for both but I would never breast feed. There are two benefits of breast feeding, it's good for your baby and it makes you lose weight faster. It's so inconvenient, like if I wanted you to babysit, oh wait, I would just be like I have to pump first and that is just so time consuming. I don't know." 7 "The average costs definitely a big factor." "[Average cost] of formula or baby food in general and then the outweighing the good and the bad versus the pros and cons of breastfeeding versus bottle feeding." "Health, exactly. Like which one is actually healthier or if there is a difference, especially since formula has changed now since years ago, if there is still any health changes, which one is healthier for the baby and things like that." 8 "Benefits of both ways of feeding probably." "I mean physical, health for both the mother and child." "[cost]I mean it's definitely a disadvantage to bottle feeding but again, it's important because it may be the reality for some people so I think you know seeing both views and benefits and maybe not so beneficial things because that's important too. 9 Maybe having like a mother sitting down with a bottle versus another sitting down with a baby so they could visually see the difference; am I going to be comfortable sitting in public having a mother hold her here or am I going to be comfortable sitting here and being able to walk around and move and stuff and not have people stare at you. Some people are self conscious and think everybody is staring at them and they're not and they think that the bottle is the better way to go. Some mothers are just like, there are staring at me because I am doing something weird but it's to help my baby so I don't care. So If I were to do a brochure I would do split it down the middle, I would have a mother feeding her baby with a bottle and then have a mother breastfeeding and go through and put some information of yeah if you feed your child with formula you could have some defects, there are some good but it could also happen if you breastfeed too. So either way you go, you have a 50/50 chance of having something wrong or not having something wrong but you're not going to know until you go down the road. So you just put two visuals up and just go from there. "In public somewhere and you could also have a mother and show them why breast feeding is uncomfortable and in the privacy of their own home versus being in public and the bottle public or anything, it's more as you would say people friendly to feed a baby with a bottle because they're used to seeing it, feeding with a bottle and having a mother just holding here. It's more common." 10 "I would want to say, probably like a list of some type of positives and negatives for breastfeeding versus formula, that's what I would want to see. A chart basically spelled out what the pros and cons are." "Even cost, everything. Even health benefits for the mother as well." "Double the work, you are pumping, you are also feeding the baby after too. You are taking double the time, but again you are weighing out, what's the best for the baby, you know?" 11 "I mean besides the cost difference you know, the health benefits because I don't think a lot of people get that." "Yeah because I think most people don't really realize how expensive than it actually is. That's why all those girls are getting 16 and pregnant." "Well it is, because they see it on TV and they think it's going to be a free ride and it's not." 12 "I would put things down that you can look forward to in the future, like if you choose to do breastfeeding you would save a lot of money so you can put down like things that you would want to do in the future with your kid or even like saving money to get a decent size house, just show like things that will inspire you to continue to go with that goal and everything else." "I have inverted nipples, that's going to be more difficult" "I had a breast reduction and they took so much out that they don't think that I would be able to breastfeed or that the chances of it would be slim."

13
"Because that hurts, so I just rather do formula" "…both babies were only attached to one boob so she's got like a C and a D and I'm like "I'm good with that" I like to keep them the way they are. I don't want to be all lopsided. It's kind of silly but I kind of think about that too so I'm like "m-m" she can't find a bra, ever." "First of all because of the health benefits, for the baby and secondly, honestly, to lose the weight." 158 2. Financial e) Going back to work f) Breastfeeding is cheaper "I don't get a paid maternity leave so I need to go back to work very quickly and it's going to make it easier." "Actually I read that I guess it's healthier, it's cheaper and yeah it's like better for the baby…" 3. Psychological g) Comfortable bottle feeding h) Mind set on bottle "Because I was used to feeding with the bottle and to by the breast, like I raised my sister's kid with her and I am used to the bottle so I feel more comfortable with a bottle than with breastfeeding." "I'm just not really comfortable with the idea of breastfeeding." "I'm not comfortable with the baby there, if it was in the privacy of my own home that would be fine…" "…or you just have to do it in public, which is really weird. I would never do that." "Just sticking a pump there and having it there and eh…it's not for me!" "I have always been on the mind set of feeding i) Overwhelmed by options of formula products bottle feeding." "And I don't know, and for the formula that you buy you don't know what kind of formula because there are so many kinds and you know that your breastfeeding it's like the right kind of milk and it's giving off all the right nutrition and everything you don't know what kind of formula does that and anything else." "Being pregnant is just overwhelming in general…" 4. Educational j) Not educated on breastfeeding "I'm not really sure, I'm not really educated on breast feeding so I'll probably like to try doing it you know like maybe at night or something, not consistent, I'd like to bottle feed as well." "Um, probably bottle feeding only because that's really what I know more about and what I would be more comfortable with." 5. Social inconvenience/Convenience k) Wean baby off of breastfeeding "I know a lot of people who have been having lots of trouble weaning the baby off of breastfeeding. So I don't want to have too much [trouble]." "My grandmother is going to be watching the baby so it'll be a lot easier for me, instead of me trying to wean the baby off of l) Attachment m) Easier and quicker breastfeeding so early, just go and just bottle feed." "My cousin, her children were very attached to her. They wouldn't really go to anyone else because they were constantly with her because she was breast feeding and I don't want that." "Bottles are easy, you can just put them in the bottle and heat it up and give to the baby. And if someone is babysitting, you don't have to worry about pumping, you just say: here are bottles." "My grandmother is going to be watching the baby so it'll be a lot easier for me, instead of me trying to wean the baby off of breastfeeding so early, just go and just bottle feed." "It's easier to do" Like, preparing it and all that. Like preparing it is easier, like you are done right away instead of breastfeeding. "Yeah, it's quicker and better." "It makes it easier for him too because he doesn't have to sit there and hold the little packages of breast milk. He was a little uncomfortable with that too so I was like well okay, I was like, "Well then I'll go with n) support the bottle because she is going to be going from my house to your house, not right away, but from my house to your house and I'm pretty sure you're not going to sit there and pump yours and I'm not going to be there so" and he was like, "Alright, the bottle is fine with me". So I was like "Okay"!" "Basically overall, even like my doctor encourages it and it's healthier for the baby." 6. Health o) Overall health benefits "You build up immunities from the breast milk that the parent already has built up so it helps the child work with illnesses, there's brain development, eye function, everything, it comes right from there. So by not doing that you're taking key things away." "Have a healthy baby, you have to do whatever what's best for them and everyone says breastfeeding is one of the healthiest things for your child…" Second Matrix for Question Two Probe Table 11.2 a List of themes generated from question 2-probe, how does your family feel about__? Specifically assess mother, grandmother, sister and find out how the father of the baby &/or her current partner feels about__.
Themes Formula Feeding Responses Breastfeeding Responses 1. Supportive a. Family member formula fed b. Infant feeding method is a mother's choice c. Belief formula is easier for the mother d. Empathetic "My sister just had two kids and she bottle fed with formula for both of them. Actually my mom did too so they are both supportive…" "He [baby's father] wanted me to [breastfeed] but when I told him no I was pretty much "tough luck" and he was like "okay, fine". He was okay with it." "They think it is easier for me to do instead of breast feeding…the baby's father, my mother, father, and some other people." "They tell me that any decision I make they are going to support it." "They are very supportive of whatever I chose." "It's my decision, not theirs so they don't really have a say." "The baby's father is a hundred percent supportive, it is the way he me wanted to go but he kept his opinion to himself until I came out and said it." 2. Apathetic "I mean, they don't really care. They don't care, it's whatever I want to do." "None of them really had an opinion or cared." Second Matrix for Question Three "I mean obviously there is a difference from nothing to something but I really don't think it is extremely that outrageous, the price you know? 2. The cost of formula increases each month "It doubles every month pretty much".
"Yeah like month one you're at 7.50 and then all of a sudden 3 months later you're at 50 dollars spending it, it's crazy!" 3. Formula is costly "Well it's definitely costly." "That sucks" "The actual amount of money that you have to end up spending that's unfortunate. It shouldn't cost that much for that kind of stuff.""… that's just really expensive." 4. Cost doesn't seem to be a lot "Looks cheap." "Not cheap cheap but." "Wow, so by the fourth month they were at the $50?" "And still zero for the breastfed moms! That's good." "…Especially since by 4 months breastfeeding probably wouldn't be much of an option when I am back to work…" "…like I said, I kind of expected it. I knew breastfeeding is like no money at all." "Personally, it probably wouldn't affect it because I know that even if I do choose breast feeding, I may not be able to so it may be inevitable that I have to pay and I think just keeping an open mind is the best way to go." "I know that family is there if I ever need them, I have a lot of people that will help, we have a lot of family friends that have babies and stuff like that." 3. Health "It really doesn't have that affect because I know that either way I go, she is going to be healthy…" "Even if I had to pay to breastfeed, like if I had to give an amount to the government say if because you know if they weren't getting my taxes, I would still breastfeed. Yes, the cost is great but to be honest the cost never crossed my mind, it never did. I don't know why." INFLUENTIAL 1. Motivational "…definitely makes me want to breastfeed more…" "Yeah, that would be another reason, but it wouldn't be the top reason…" 2. Financially beneficial "Money saving, you would save so much and like that money that you would be spending on that you could use on something else that would help you out more, and the baby, and your family." 3. Educational "[nod]" "Yeah, it's just so smart and easy. It's the right decision, because you have no idea, and you get all this information and you know everything, it's just so mind opening." "…she struggled and a lot of my friends would probably do the formula thing too because a lot of people that I know are just very full of themselves and don't really think about anyone else but themselves. So they would probably look at it and go oh yeah I'll do breast feeding but in reality they will just be spending the money, they will do it the easier way. Everybody takes the easier way out of everything." 2. Financial "Well if they already have babies I would assume they would think the same way as me. Because, if you don't know the baby is going to be expensive you should have thought about that before. So I would think they would be about on the same level with me with that". "My friend Chelsea has WIC, and she says that she is fine. She doesn't have to get any extra." INFLUENTIAL 1. Financial a) Financially beneficial "I think that they probably start considering breastfeeding more. Obviously, it is cheaper." "Well, if they don't have any money and they don't work, to breastfeed." "Um, for them I think they would probably breastfeed instead of bottle feed because I guess they will save their money".
"Yeah I think it would absolutely maybe impact their decision on going to breast feed instead of formula, if they weren't expecting those prices and if they are budgeting and all the other costs for having a baby, you have diapers and everything else. "I'm sure if you have any financial difficulty, this would be a factor. I mean if you can save fifty dollars a month, that's a lot of money especially if you are in a situation where, you know, fifty dollars is a lot of money." 1. Psychological "It depends how they feel about breastfeeding, I guess. If they don't really like it then I don't think they would mind paying that much." Second Matrix for Question Five Table 11.5 List of themes generated from question five, we developed two other brochures, they contain the same information but in a different format, which of these two do you like best? What are some reasons you like (brochure name) better than (brochure name)? Show all three and ask for preference then ask for reasons specifying brochure name.

Participant Preferences
Formula Feeding Responses Breastfeeding Responses Brochure A better than B or C Effective Easier/simpler Informative Objective "Information wise, this one [A]." "It's just more informative, to see the actual price, it's just more effective." "…seems like this one [A] is more simple compared to this one [C]." "[A] I think the cost helps because it gives you an estimation. It kind of gives you a figure as to what you would need each month versus just knowing that it will go up because you don't know how much it will go up." "[Brochure C] I mean it basically just shows how much would be needed but not knowing exactly how much you would be getting until the baby is born until you start receiving your checks, it doesn't really help that much you don't know the cost of them and things like that." "I just think that cut and dry is the best way to prepare you [referring to brochure A]." "I mean if you're trying to get the point across about cost, I would do A." "I think that's why, because you're seeing a lot of cans [on brochure C]. It's not really hitting exactly like that these two are going to be like almost a hundred dollars extra every month." "I would want to see that one with the money [A] instead of this one [B] because just having these money things really explains how much because on this one it says zero dollars, but here you just see money progressing and you don't really know how much you would be spending so that's like kind of an eye-opener of how much money you would really be spending." Brochure B better than A or C "Would rather have B because you don't know how much. I mean everyone is different and it's a lot Personalized more than that [referring to the cost]." "I don't really get it [brochure C]". Brochure C better than A or B Visually appealing "So you are showing what you are getting for your money, like the money you are spending." "Well, both of them [A and C are easy to understand] but this one [C] shows more of a clear picture." "Yeah because this one [A] doesn't say what WIC gives you, and this one does. And then what the baby would need, it doesn't say that on here [A] it just says how much you would be spending." "Because it gives you a visual like the people that aren't very good with just seeing money, they actual see the cans…" Second Matrix for Question Six Table 11.5 List of themes generated from question five, we developed two other brochures, they contain the same information but in a different format, which of these two do you like best? What are some reasons you like (brochure name) better than (brochure name)? Show all three and ask for preference then ask for reasons specifying brochure name.
Themes Formula Feeding Responses Breastfeeding Responses 1. Nothing "Personally me, no. Nothing is probably going to motivate me to breastfeed. I am really stuck on that.

Differences in methods
Health, exactly. Like which one is actually healthier or if there is a difference, especially since formula has changed now since years ago, if there is still any health changes, which one is healthier for the baby and things like that." "There are things in breast that isn't in this formula…" "Benefits of both ways of feeding probably." "I mean physical, health for both the mother and child." "I would want to say, probably like a list of some type of positives and negatives for breastfeeding versus formula, that's what I would want to see. A chart basically spelled out what the pros and cons are." "Double the work, you are pumping, you are also feeding the baby after too. You are taking double the time, but again you are weighing out, what's the best for the baby, you know?" 3. Financial a) Information on cost "The average costs definitely a big factor." "Even cost, everything…" 4. Comfort Level b) Public feeding Maybe having like a mother sitting down with a bottle versus another sitting down with a baby so they could visually see the difference; am I going to be comfortable sitting in public having a mother hold her here or am I going to be comfortable sitting here and being able to walk around and move and stuff and not have people stare at you. 5. Breastfeeding Initiation "I was thinking when I am in the delivery room, I was going to try and see how I liked it." 6. Future Planning "I would put things down that you can look forward to in the future, like if you choose to do breastfeeding you would save a lot of money so you can put down like things that you would want to do in the future with your kid or even like saving money to get a decent size house, just show like things that will inspire you to continue to go with that goal and everything else." APPENDIX H -Brochures A, B, and C