title: How UK internet websites portray breast milk expression and breast pumps: a qualitative study of content.
abstract: BACKGROUND
  Exclusive breastfeeding for six months is recommended but few parents achieve this; particularly younger and less well-educated mothers. Many parents introduce infant formula milk to manage feeding but describe a desire to express breastmilk alongside a lack of support or information. The Internet is highlighted as a key resource. This study aimed to examine UK websites on expressing breastmilk to identify key messages and how information is provided.
  
  
  METHODS
  We used search terms in Google to identify websites with information rich content on expressing breastmilk and breast pumps. Ten sites were purposively selected at two time points in 2013 and 2014 to represent 3 categories: commercial, NHS or 3(rd) sector (voluntary or not for profit). Each site was reviewed by two researchers, data and reflective analytical notes were uploaded into NVivo and thematic data analysis undertaken.
  
  
  RESULTS
  Sites varied considerably in their design, use of images, videos, audio files, product placement and marketing opportunities. Three key themes emerged: depiction of expressing; reasons to express; and recommendations about expressing. Inconsistent and conflicting information was common within and between sites. Expressing was portrayed as similar to, but easier than, breastfeeding although at the same time difficult and requiring to be learned. Expressed breastmilk is promoted by mainly commercial sites as immediately available, although pumps were also presented as needing to be concealed, not heard or seen. Health benefits were the overarching reason for expressing. Although predicated on separation from the baby, commercial sites identified this as a positive choice while other sites focused on separation due to circumstance. Commercial sites emphasised restrictions related to breastfeeding, lack of sleep and bonding with the father and wider family. Non-commercial sites emphasised hand expression, with some not mentioning breast pumps. Practical information about starting expressing in relation to infant age or duration of breastfeeding was conflicting.
  
  
  CONCLUSIONS
  Internet information about expressing breastmilk is inconsistent, incomplete and not evidence informed. The lack of research evidence on the relationship between expressing and feeding outcomes has provided opportunities for commercial companies, which have the potential to further exacerbate observed health inequalities. Access to good quality information based on robust evidence is urgently required.
authors.affiliation: School of Health Sciences, University of Stirling, Stirling, FK9 4LA, UK. r.j.mcinnes@stir.ac.uk.
authors.forename: Rhona J
authors.initials: RJ
authors.lastname: McInnes
authors.affiliation: Master of Health Research (MRes) programme, School of Health Sciences, University of Stirling, Stirling, FK9 4LA, UK. alix.arbuckle@nhslothian.scot.nhs.uk.
authors.forename: Alix
authors.initials: A
authors.lastname: Arbuckle
authors.affiliation: Nursing Midwifery and Allied Health Professions Research Unit, School of Health Sciences, University of Stirling, Stirling, FK9 4LA, UK. p.m.hoddinott@stir.ac.uk.
authors.forename: Pat
authors.initials: P
authors.lastname: Hoddinott
mesh_terms: D000367:Age Factors; D001942:Breast Feeding; D061186:Breast Milk Expression / Q000295:instrumentation; D054626:Consumer Health Information; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D020407:Internet; D040541:Marketing; D009034:Mother-Child Relations; D036301:Qualitative Research; D006113:United Kingdom