Views and experience of breastfeeding in public: A qualitative systematic review

Abstract Breastfeeding rates in many Global North countries are low. Qualitative research highlights that breastfeeding in public is a particular challenge, despite mothers often having the legal right to do so. To identify barriers and facilitators, we systematically searched the qualitative research from Organisation for Economic Co‐operation and Development countries relating to breastfeeding in public spaces from 2007 to 2021. Data were analysed using the Thematic Synthesis technique. The review was registered with PROSPERO (registration number: CRD42017081504). Database searching identified 3570 unique records. In total, 74 papers, theses, or book chapters, relating to 71 studies, were included, accounting for over 17,000 mothers. Overall, data quality was high. Our analysis identified that five core factors influenced mothers' thought processes and their breastfeeding in public behaviour: legal system; structural (in)equality; knowledge; beliefs and the social environment. Macro‐level factors relating to legislation and inequality urgently require redress if breastfeeding rates are to be increased. Widespread culture change is also required to enhance knowledge, change hostile beliefs and thus the social environment in which mother/infant dyads exist. In particular, the sexualisation of breasts, disgust narratives and lack of exposure among observers to baby‐led infant feeding patterns resulted in beliefs which created a stigmatising environment. In this context, many mothers felt unable to breastfeed in public; those who breastfed outside the home were usually highly self‐aware, attempting to reduce their exposure to conflict. Evidence‐based theoretically informed interventions to remove barriers to breastfeeding in public are urgently required.


| INTRODUCTION
Increasing breastfeeding rates is a public health policy objective in many developed countries (Rollins et al., 2016). Within many Organisation for Economic Co-operation and Development (OECD) countries, which we use as a proxy for Global North countries, women have a legal right to breastfeed (Brown, 2021).
In some countries, this right is explicitly included in law, for example under the UK Equality Act 2010 and the Republic of Ireland Equal Status Act 2000. In other countries, legal permission to breastfeed in public is implicit, for example, in the Basic Law for the Federal Republic of Germany which protects the rights of parents, and the Canadian Charter of Rights and Freedoms which gives equal status to men and women's freedom. However, an integrative review of evidence has shown that breastfeeding in public is challenging for those who are breastfeeding, with no safe space to breastfeed regularly reported (Hauck et al., 2021). Feeling unable to breastfeed in public spaces (de Jager et al., 2013), or perceiving the neighbourhood as unsafe for children to play in (Peregrino et al., 2018) are known barriers to breastfeeding continuation. Evidence shows that, as well as maternal embarrassment and social discomfort, partners (Andrew & Harvey, 2011) and observers (Henderson et al., 2011) find breastfeeding in public uncomfortable. Furthermore, although not all public places are staffed, where there are employees who could help to protect mothers' legal right to breastfeed, they can find it challenging to support breastfeeding mothers (Marsden & Abayomi, 2012) or may be unaware of the law (Alb et al., 2017).
Within the existing integrative review, key challenges to breastfeeding in public were drawn from 27 papers which were represented 12 countries worldwide, including China, Ghana, Romania, Singapore, and Thailand (Hauck et al., 2020). By contrast, our systematic review was restricted to qualitative research on perceptions and experiences of breastfeeding in public spaces within OECD countries, to reduce heterogeneity across findings and shape the design of future interventions aimed at reducing barriers to breastfeeding outside of the home in high-and middle-income countries. Furthermore, whilst Hauck et al. (2020) eliminated 11 of the 38 manuscripts on the basis of quality, we did not exclude articles on the basis of quality as long as their findings contained at least a paragraph of content relating to views and experiences of breastfeeding in public and were therefore felt to have value.

| Aim
To undertake a qualitative systematic review investigating barriers and facilitators to breastfeeding in public in OECD countries using the Thematic Synthesis approach (Thomas & Harden, 2008).

| Search strategy
We identified the search terms to be included in the review by hand-

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Two reviewers (AG and either Michael Robling or RE) independently reviewed all titles and abstracts identified through the searches against the inclusion and exclusion criteria. Any inconsistencies were resolved through discussion, and it was not necessary to involve a third reviewer. The full texts of potentially relevant studies were reviewed independently by two reviewers (AG and either BP or RE).

| Quality assessment
All included studies were subjected to the CASP critical appraisal checklist (Critical Appraisal Skills Programme, 2018) by one researcher (AG). A sample of 10% of included studies was independently appraised by a second reviewer (LC). Each study was provided with an overall assessment of quality using the categories 'high', 'medium' and 'low', based on the number of criteria fulfilled, an approach which has been utilised in other qualitative syntheses (Woodman et al., 2016). All studies were included in the synthesis regardless of CASP score as long as their findings were felt to be valuable (question 10 on the CASP checklist) due to the heterogeneity of methods and disciplines involved in research on breastfeeding in public. However, quality was used to interpret the relevance of the findings and CASP scores are reported in Table 2.
Alongside undertaking the CASP assessment, a data extraction sheet was developed which comprised of demographic characteristics and space for all qualitative findings relating to the review's focus (including within abstracts and appendices). This was to enable study characteristics, critical appraisal and qualitative data to be reviewed together.

| Qualitative synthesis: Thematic synthesis
We followed the Thomas and Harden (2008) thematic synthesis procedure: coding text, development of descriptive themes and analytical theme generation. Two researchers (AG and RP) with different disciplinary backgrounds (sociology/health psychology) inductively hand-coded five of the included papers and met to discuss the codes they had utilised to see if similar codes were developed.
There was considerable overlap in how data extracts had been grouped, although different names were assigned to these early codes.
Following this, each study document relating to studies from 2007 to 2017 (structured summary, CASP and qualitative findings) was added to NVivo 11 to allow for coding by AG. To reduce bias from relevant data being excluded from the coding framework, each sentence of data which related to breastfeeding in public received at least one code (line-by-line coding), and many received more than one code.
Where new codes were identified during the analysis, previously coded studies were reviewed and recoded where necessary.
A series of three data analysis meetings were held between (AG, BP, LC, RP and Michael Robling) to refine the development of descriptive themes, enabling the translation of concepts between papers. To promote analytical theme generation within the multidisciplinary team, the NVivo analysis file and a 'summary of themes' document (containing selected data extracts and a narrative presented within AG's initial thematic coding structure) was reviewed by each researcher independently, who inferred barriers and facilitators to breastfeeding from these descriptive themes, as per thematic synthesis guidance (Thomas & Harden, 2008). This included collapsing themes into a hierarchical structure with up to three layers and further subdivisions between data from mothers and other groups (i.e., observers and the family and friends of mothers). Following each of the three meetings, AG updated and circulated the draft summary of the thematic analysis and an updated NVivo file where additional coding had been undertaken. At each stage, the research team reviewed these independently and discussed in the following meeting until the final themes were agreed by all researchers. Before publication, the searches were repeated from 2017 to 2021 by DM, and the additional papers were analysed using the existing coding framework. Following two additional data analysis meetings between AG, DW and AB, it was agreed that no new codes were required. This decision was agreed by email with all authors. Two authors (AG and RP) developed the figures displaying the results, which were agreed by all researchers.

| Studies identified
Database searching identified 3570 unique records, 111 of which were fully screened against the inclusion criteria. Additionally, 1235 books were screened for inclusion and the full text of 10 books or potentially relevant chapters were reviewed. One was included in the synthesis, with a second book identified through database searching.
Unpicking systematic reviews, as well as forward and backward chaining identified additional seven eligible sources. The PRISMA flow diagram in Figure 1 illustrates this process (Moher et al., 2009).

| Included studies
Seventy-one studies were included in the review, which accounted for 74 papers as three studies had two papers published using the same data (Boyer, 2012(Boyer, , 2018Bueno-Gutierrez & Chantry, 2015;Chantry et al., 2008;Grant, 2015Grant, , 2016. The most common data sources used within the included studies were documents (i.e., a written or graphical artefact found in isolation from its author Grant, 2022), although these were often small data extracts, such as tweets or comments within forums. With the exception of documents, data overwhelmingly came from pregnant women and mothers with over 17,700 participants divided mostly between survey and interview studies. Data collection between 1995 and 2020 were stated, although in 23 of the 71 cases the year of data collection was not stated. Interviews were the most utilised research method, although more than one research method was used in 15 of the studies. There was variation in approach between studies that employed interview methods, including online interviews and emails (Dowling & Pontin, 2017), visual methods (Grant et al., 2017) and repeat interviews (Helps & Barclay, 2015). A broad range of theoretical and analytical approaches was utilised. A summary of the participants, location, and data collection and analysis methods used within the included studies can be seen in Table 1. Characteristics of each individual study are summarised in Table 2. F I G U R E 1 PRISMA flow chart of study selection

| Quality of included studies
The majority of papers were high quality according to CASP (Table 2) with few medium (n = 7) or low (n = 6) papers. However, we felt that the CASP scoring system was not always indicative of research quality. For example, Rose (2012) contained rich and interesting data but, due to limited methodological content, scored 'low'. Opposingly, Rhoden (2016) was a doctoral dissertation which appeared to be poorly executed in several aspects but was rated as 'medium' quality based on its CASP score.

| Thematic synthesis
Within the synthesis, the high-level societal contexts were inferred from small extracts of data found in multiple included studies, which were combined to develop a new theme as per the qualitative synthesis guidance (Thomas & Harden, 2008). This inference was based on a range of explicit lower-level societal discourses extracted from the data.
Findings relating to knowledge, beliefs, space and the interactions between mothers and members of the public are reported based on the data within the included papers, with little inference required. Table 3 provides a summary of themes within individual articles, and a graphical representation of our thematic synthesis can be found in Figure 2.

| High-level social contexts
Our inferred social contexts focused on two major issues that were beyond the control of the individual citizen: legal protection for breastfeeding in public spaces, and intersectional inequality, which we framed through a lens of patriarchal misogyny (such as racism) and its associated impact on individuals who were more closely observed, and sometimes stigmatised by, authority figures and members of the public ( Figure 3).

| Legal system
We inferred from the data that legal systems were generally not actively supportive of breastfeeding in public, either due to authors not reporting the legal context (seeTable 2) or stating that the law was poorly enforced.
We also noted a relative lack of discussion of the legal context by mothers (see Table 3), although in seven papers mothers' knowledge of legal protections for breastfeeding in public provided maternal confidence (Hauck et al., 2020;Isherwood et al., 2019;Marcon et al., 2019;Owens et al., 2018;Sheehan et al., 2019;Spurles & Babineau, 2011;Stevenson, 2019). Some mothers also noted that they were prepared to strongly assert their right to breastfeed in public if confronted by a stranger, although this was not explicitly linked to stating their legal right or knowledge of it (Boyer, 2011(Boyer, , 2012Charlick et al., 2017;   | 35 of 47 Grant et al., 2017;Pallotti, 2016). However, other mothers expected their right to breastfeed in public to be ignored or actively challenged (Owens et al., 2018).
Where papers' authors reported that breastfeeding in public was legal, it was noted that most observers did not know this (Grant, 2016;Leeming et al., 2013;Morris et al., 2016;Pallotti, 2016;Ware et al., 2014), or they understood that breastfeeding in public was legal, but still perceived it to be inappropriate (Grant, 2016;Morris et al., 2016). Observers displaying support for the law were in a minority (Grant, 2015;Spurles & Babineau, 2011). One grandmother expressed in a mother/grandmother dyad interview that she thought breastfeeding in public was against the law (Pallotti, 2016).

| Intersectional sexism, surveillance and stigma
The surveillance of women's bodies by strangers was regularly reported by pregnant women and mothers. All of the studies included in the analysis either explicitly reported on sexism and surveillance or contextualised their findings within an assumption of a sexist culture which used surveillance and stigma of women's bodies. Breasts were explicitly positioned as sexual, as opposed to maternal, particularly in studies reporting data from observers (Grant, 2015;Grant et al., 2017;Morris et al., 2016;Rhoden, 2016) and partners (Avery & Magnus, 2011;Bueno-Gutierrez & Chantry, 2015;Chantry et al., 2008;Furman et al., 2013;Helps & Barclay, 2015;Henderson et al., 2011;Rhoden, 2016).
In addition to general sexist surveillance, some women were further marginalised by their intersectional characteristics (see Crenshaw, 1989) and reported this in relation to their views and experiences of breastfeeding in public when compared to white middle-class women (Andrew & Harvey, 2011;Boyer, 2011Boyer, , 2012Boyer, , 2018Leahy-Warren et al., 2017;Leeming et al., 2013). In addition, midwives had additional knowledge arising from their profession which appeared to be a protective factor for some (Battersby, 2007). Racism and the perception of oneself being considered 'out of place' (as in Dowling and Pontin's [2017, p. 67] reference to breastmilk itself) was inferred in relation to Black women (Avery & Magnus, 2011;Furman et al., 2013;Owens et al., 2018;Robinson & VandeVusse, 2011;Ware et al., 2014) and their partners (Avery & Magnus, 2011;Rhoden, 2016); as well as Indigenous (Eni et al., 2014;Helps & Barclay, 2015), refugee and migrant (Chiang, 2017;Condon, 2018;Gallegos et al., 2015) women. well as their partners (Henderson et al., 2011) considered breastfeeding in public, with the act seeming more acceptable in high-income locations (Isherwood et al., 2019). Higher income also afforded individuals entry to breastfeeding-friendly locations, such as cafes (Mathews, 2018). Young mothers also experienced feelings of heightened surveillance related to their age (Chopel et al., 2019;Nesbitt et al., 2012;Pallotti, 2016), as did women in larger bodies (Charlick et al., 2018;Hauck et al., 2020;McKenzie et al., 2018;Newman & Williamson, 2018). This was also experienced by more privileged women who breastfed older infants, particularly when infants were able to ask to breastfeed or to help themselves without asking (Andrew & Harvey, 2011;Dowling & Pontin, 2017;Hauck et al., 2020;Prendergast & James, 2016;Stearns, 2011;Swigart et al., 2017). Sexual orientation and gender identity were generally not reported.

| Societal discourses
Within this section, we consider the ways in which knowledge, beliefs, and the social environment (which is further divided into observers and the physical environment) impacted the experience, or perceived experience, of breastfeeding in public. Each of the discourses identified in the data was explored from the point of view of strangers/observers, those known to the mother and the mothers themselves.

| Knowledge
In general, breastfeeding itself was viewed as good for infants' health.
However, there was evidence that demonstrated limited knowledge relating to normal infant feeding patterns and breastfeeding behaviours among observers (Grant, 2016;Rhoden, 2016), and partners (Avery & Magnus, 2011;Henderson et al., 2011). A lack of exposure to breastfeeding was associated with less knowledge among observers (Chiang, 2017;DeMaria et al., 2020;Jamie et al., 2020), whilst exposure increased comfort around breastfeeding in public for observers (DeMaria et al., 2020;Schmied et al., 2019), mothers (Chopel et al., 2019;Isherwood et al., 2019;Prendergast & James, 2016;), and fathers (Henderson et al., 2011). Examples of incorrect knowledge included observers believing that women decided when to feed a baby based on their preferences alone, and not that they responded to infants' cues (Grant, 2015;Swigart et al., 2017) and the incorrect assumption that breastfeeding needed to expose the entire breast (Cato et al., 2020;Charlick et al., 2018). A small number of mothers reported limited knowledge of breastfeeding as a result of a lack of exposure to breastfeeding (Owens et al., 2018;Stearns, 2011).
Additionally, breastmilk was viewed as a form of dangerous pollutant to be avoided at all costs by some participants, including observers, fathers, and mothers (Avery & Magnus, 2011;Grant, 2016;Morris et al., 2016;Spurles & Babineau, 2011).
In contrast to the limited knowledge of observers, many mothers used their experiential knowledge as a parent to highlight the need to respond to normal infant feeding cues to prevent infant distress (Battersby, 2007;Boyer, 2011;Brouwer et al., 2012;Charlick et al., 2017;Dyson et al., 2010;Eni et al., 2014;Grant, 2015;Leeming et al., 2013;Spurles & Babineau, 2011). In addition, in four studies (Boyer, 2012;Chiang, 2017;Gallegos et al., 2015;Grant et al., 2017) it was noted that mothers had previously lived in countries that were more supportive of breastfeeding in public spaces and that this influenced their exposure to, and knowledge of, breastfeeding before their own experience as a parent.
Attempts to increase knowledge occurred both through informal breastfeeding activism, known as lactivism (

| Societal beliefs
In every paper, we identified discourses suggesting that breastfeeding was viewed as an antisocial act to be conducted in private only; such discourses were largely related to the sexualisation of breasts. In two UK studies, breastfeeding was negatively associated with poverty and not being able to afford to purchase infant formula (Condon, 2018;Grant, 2016). However, in two studies reporting on social media content, these beliefs were contested (Lehto, 2019;Marcon et al., 2019). The most frequently reported emotional reaction arising from observing breastfeeding, within the context of it being considered an antisocial act, was discomfort (Battersby, 2007;Boyer, 2012;Grant, 2016;Henderson et al., 2011;Morris et al., 2016;Owens et al., 2018;Rhoden, 2016;Spurles & Babineau, 2011;Stearns, 2011). In two UK-based studies (Grant, 2015;Morris et al., 2016), observers stated that they were concerned about being perceived by a breastfeeding woman as though they were 'kind of perv' (Grant, 2015, p. 145) or being viewed by other people as a 'weirdo' (Morris et al., 2016, p. 476). However, another observer suggested that 'leering' was a deliberate strategy to stop women breastfeeding outside of the home (Grant, 2015, p. 145). In three studies, female observers noted that they were not uncomfortable, but were concerned that men would be (Grant, 2016;Morris et al., 2016;Spurles & Babineau, 2011). Children were also shielded by women from images of breastfeeding in the United Kingdom (Henderson et al., 2011), and from feelings of discomfort, observers suggested that discretion should be used by breastfeeding mothers in five studies (Grant, 2016;Morris et al., 2016;Rhoden, 2016;Spurles & Babineau, 2011;Ware et al., 2014), such as using a 'cover' whilst breastfeeding (Rhoden, 2016, p. 161); a 'designated room' (Spurles & Babineau, 2011, p. 134) or a 'private' space (Grant, 2016, p. 56).
Disapproval from partners was identified in 11 studies (Avery & Magnus, 2011;Brouwer et al., 2012;Carlin et al., 2019;Chantry et al., 2008;Dayton et al., 2019;Eni et al., 2014;Furman et al., 2013;Helps & Barclay, 2015;Henderson et al., 2011;Sheehan et al., 2019;Ware et al., 2014), with a complex range of concepts informing the disapproval. Occasionally, a difficulty reconciling breasts with infant feeding resulted in disgust reactions (Furman et al., 2013;Helps & Barclay, 2015) where breastfeeding was referred to as 'nasty…freaky stuff' (Furman et al., 2013, p. 62). More usually, breastfeeding itself was not the problem, but the social context whereby other men may view the individual's partner sexually led to two reactions. First, partners expressed concern over the potential for them to be involved in a confrontation with strangers (Avery & Magnus, 2011;Henderson et al., 2011). Second, male partners reported feelings of ownership over their partners' bodies (Chantry et al., 2008;Furman et al., 2013;Helps & Barclay, 2015;Henderson et al., 2011). Explicit concern regarded their partners' use of public transport coinciding with a need to breastfeed was described by young fathers (Henderson et al., 2011).
Three interactions were also reported where mothers who were breastfeeding had their personal space invaded by strangers, including one man behaving sexually towards a woman on a bus (Furman et al., 2013), a stranger masturbating near a breastfeeding woman (Lehto, 2019), and an older woman who 'ripped off' a young mothers' breastfeeding cover on a sunny day (Pallotti, 2016, p. 158). An African American woman also noted sexualised reactions when she was breastfeeding in public (Owens et al., 2018).
Occasionally it was reported that mothers were (Thomson et al., 2015), or would be (Pallotti, 2016), asked to leave the premises because they were breastfeeding, typically as a result of observers complaining to members of staff (Battersby, 2007). Staff in public spaces, such as restaurants and shops, were discussed in four papers by mothers and observers, all from the United Kingdom (Battersby, 2007;Grant, 2015;Grant et al., 2017;Morris et al., 2016).
Reports included those where staff had been awkward (Battersby, 2007) or asked intrusive questions (Grant et al., 2017), and there were media reports of instances where staff had denied women their legal right to breastfeed (Grant, 2015;Morris et al., 2016). One study (Marsden & Abayomi, 2012) reported on interviews with staff working in public spaces. In these interviews, staff recounted instances of observers displaying disapproval of breastfeeding. The authors concluded that the experience of being a parent or working in a 'baby friendly' 1 space led to staff members displaying increased confidence in supporting breastfeeding mothers.

| Social environment: Mother and baby rooms V toilets
Mother and baby rooms, generally located within shopping centres (with one room noted on a college campus in Rose, 2012) were identified both positively and negatively. They reportedly provided a 'private' space away from home (Battersby, 2007;Boyer, 2012;Brouwer et al., 2012;Charlick et al., 2017;Charlick et al., 2018;O'sullivan et al., 2020;Zhou et al., 2020), which was especially valued in the early weeks of breastfeeding (Boyer, 2012;Brouwer et al., 2012). Mother and baby rooms identified as having highquality facilities were particularly viewed positively (Hauck et al., 2020), although even low-quality facilities were sometimes viewed as better than no provision at all .

| Mothers' response to societal barriers and facilitators
In this section, we divide mothers' responses to the wider social context and societal discourses into their thoughts and behaviour, which arose in response to the social environment within which they existed.

| Mothers' thoughts
In all but 7 of the 63 studies that included the views of mothers and/or pregnant women, the societal belief that breastfeeding should be a   & Williamson, 2018;Prendergast & James, 2016;Swigart et al., 2017). This was usually tied to an understanding of hostile societal beliefs and an associated unpleasant environment in terms of the physical space and the potential for conflict from strangers. Some mothers explained their negative thought processes relating to breastfeeding in public as directly originating from family (Boyer, 2011;Eni et al., 2014;Furman et al., 2013;Helps & Barclay, 2015), friends (Boyer, 2011;Eni et al., 2014;Owens et al., 2018) and strangers (Boyer, 2012;Gallegos et al., 2015;Helps & Barclay, 2015). Mothers and pregnant women reported anticipating being disapproved of in 27 papers. Within this context, it is unsurprising that women in many papers felt embarrassed, uncomfortable, self-conscious, and exposed, as is illustrated in Table 4.
Conversely, a small minority of mothers reported feeling empowered by breastfeeding in public (Battersby, 2007;Boyer, 2012; T A B L E 4 Mothers' negative feelings relating to their own experience of breastfeeding in public Theme Subtheme Studies

| Mothers' behaviour
In 37 studies that reported women's experiences, at least some of the participants did not breastfeed in public. Conversely, participants in six papers reported that they were able to breastfeed in public without issue, with mothers in eight papers noting that they 'got used to' breastfeeding in public as they became more experienced. Participants who reported neutral or positive accounts included those who were multi-parous (Andrew & Harvey, 2011;Battersby, 2007), more experienced at breastfeeding (Battersby, 2007), had supportive partners (Alianmoghaddam et al., 2017), were from relatively privileged, white middle-class, backgrounds in the United Kingdom (Boyer, 2012;Dowling & Pontin, 2017), had been exposed to a breastfeeding in public intervention (Stevenson, 2019), or had been part of online breastfeeding groups which engendered greater confidence (Robinson et al., 2019).
Five participants responding to a survey noted 'no negative view' (Forster & McLachlan, 2010, p. 121), with a quarter of respondents in another study noting that breastfeeding facilitated socialising outside of the home, due to its greater convenience than bottle feeding (Nesbitt et al., 2012).
In the majority of studies reporting mothers' experiences of breastfeeding outside of the home (n = 49), women noted that they breastfed in a highly self-aware way to protect themselves from the hostile social environment, and also to protect observers from potential discomfort; we termed this 'doing it anyway'. This involved actualising the need to be 'discrete (sic)' through a range of strategies  (Battersby, 2007;Charlick et al., 2017;Furman et al., 2013;Gallegos et al., 2015;Grant et al., 2017;Robinson & VandeVusse, 2011;West et al., 2017) or specific breastfeeding covers (Charlick et al., 2018;DeMaria et al., 2020;Eni et al., 2014;Hauck et al., 2020;McKenzie et al., 2018;Owens et al., 2018;Pallotti, 2016;Schindler-Ruwisch et al., 2019;Schmied et al., 2019;Sheehan et al., 2019;Swigart et al., 2017) to hide the maternal breast. Two mothers noted panicking when their chosen shawl/cover had been left at home and their baby needed feeding in public; both noted the support of their partners during this single feed (Grant et al., 2017;Owens et al., 2018).
Only one mother reported that she refused to use a cover, due to it being hot and reducing the visibility of her baby (Owens et al., 2018).
Having large breasts (Battersby, 2007;Grant et al., 2017), an excess milk supply leading to leakage (Leeming et al., 2013), or being inexperienced in the mechanics of breastfeeding (Boyer, 2011;Brouwer et al., 2012), were all identified as additional challenges in hiding breastfeeding. Infants could also contribute to making breastfeeding more visible, including a baby who was 'off and on' the breast (Leeming et al., 2013, p. 463;Owens et al., 2018) or noisy during feeding. One mother noted avoiding making eye contact with strangers to prevent inadvertently opening an opportunity for interaction (Dowling & Pontin, 2017), whilst others moved themselves into a more private area (Charlick et al., 2017). Despite many women's self-conscious behaviour and attempts for discretion, experiencing negative feedback from observers resulted in some women never attempting to breastfeed in public again (Helps & Barclay, 2015;Pallotti, 2016). As a consequence, some women therefore reported providing their infants with infant formula (Andrew & Harvey, 2011;Eni et al., 2014;Forster & McLachlan, 2010;Grant et al., 2017;Leeming et al., 2013;Owens et al., 2018;Robinson & VandeVusse, 2011) or expressed breastmilk (Grant et al., 2017;Leeming et al., 2013), or undisclosed 'milk' from a bottle (Battersby, 2007;Boyer, 2012;Dyson et al., 2010;Helps & Barclay, 2015;Nesbitt et al., 2012;Pallotti, 2016) in public spaces. In one case, a woman noted that negative feedback from breastfeeding in public was the reason for her stopping breastfeeding earlier than she wanted to, when her baby was 3 weeks old (Boyer, 2012). By contrast, lockdowns associated with the COVID-19 pandemic in the United Kingdom were associated with providing more privacy which enabled women to avoid public breastfeeding, but also resulted in some mothers lacking the skills and confidence to breastfeed in public once lockdowns were removed (Brown & Shenker, 2021).
Other mothers who continued breastfeeding moved to only using a 'private' or semi-private space (Nesbitt et al., 2012;Owens et al., 2018;Shortt et al., 2013;Thomson et al., 2015) where available, including mother and baby rooms (Battersby, 2007;Boyer, 2012;Brouwer et al., 2012;Charlick et al., 2017 Leeming et al., 2013;Robinson & VandeVusse, 2011;Shortt et al., 2013;Spurles & Babineau, 2011;West et al., 2017). This was not reported to be a satisfactory solution in any of the papers, and it was explicitly stated that this was unpleasant or inconvenient in several instances (Furman et al., 2013;Shortt et al., 2013;West et al., 2017). A further protective strategy adopted by a minority of mothers was to only breastfeed in public in the company of other breastfeeding mothers (Charlick et al., 2018;Isherwood et al., 2019;Newman & Williamson, 2018;Stav, 2019) or on days when they felt able to cope with a potential confrontation (Mathews, 2018). In very rare instances, women confronted those who responded negatively to their breastfeeding, including one woman whose neighbour criticised her breastfeeding in front of her (Leahy-Warren et al., 2017).

| DISCUSSION
Our thematic synthesis of 71 studies, reported in a total of 74 papers, covered over 17,000 mothers from 12 OECD countries. We identified five areas that influenced mothers' thoughts and behaviour in relation to breastfeeding in public: legal systems, intersectional inequality, knowledge, beliefs, and the social environment. Each of these themes contained barriers and facilitators, although limited attention was paid to the macro-level influences that we identifiedthe legal system and structural inequality. Furthermore, the attention of observers was firmly focused on mothers as sexualised women, rather than as caregivers to infants who needed food within the mother-baby dyad. We strongly identified anti-breastfeeding beliefs in the majority of the members of the public within the qualitative studies included in this review, which we inferred as originating from lack of knowledge of the needs of infants in relation to feeding and normal breastfeeding behaviour, alongside the sexualisation of breasts and the mistaken belief that breastmilk was a biohazard.
Partners, family and friends were sometimes supportive, but other times discouraged breastfeeding in public. Limited research had been undertaken on the views of staff working in public spaces but, within the included studies, staff did not feel fully comfortable supporting breastfeeding in their workplace.
Mothers identified that the built environment often resulted in no 'good' place to breastfeed, although places with comfortable seating and a 'safe' feeling atmosphere were identified in a minority of studies.
Additionally, mothers were mixed in their opinions regarding the value of mother and baby rooms, which could feel supportive, but were also inaccessible and unsuitable in many ways. The majority of mothers felt negatively about breastfeeding in public and anticipated conflict. Many reported negative behaviours directed towards them or other mothers they knew when breastfeeding in public including looks, tuts, negative comments and occasional touching. Positive experiences were described much less frequently. As a response, mothers avoided breastfeeding in public, or did so 'discreetly' using clothing and covers designed to minimise the view to strangers. Maternal knowledge of legal rights protecting breastfeeding appeared to be a facilitator for breastfeeding in public in a small number of studies.
Our synthesis highlighted a large range of barriers, and rather fewer facilitators, to breastfeeding in public. Within this context, mothers' avoidant and highly self-aware breastfeeding in public behaviour should be viewed as a functional and protective response to a hostile environment, in urgent need of change. Existing interventions included: peer supporters spreading knowledge (Condon et al., 2010), The Breastfeeding Welcome scheme (Stevenson, 2019), and approaches using crowd-sourced information and mapping technology to find 'supportive' (Simpson et al., 2016, p. 2) or hidden spaces for breastfeeding (Shankar et al., 2019). Based on our thematic synthesis, however, we believe that changes to the built environment alone, such as the use of pods and mother and baby rooms, may undermine breastfeeding in public in a wider sense by hiding it from public view (Battersby, 2007), and thus we do not recommend this strategy.
Accordingly, instead of directing interventions towards mothers who exist in a hostile context, the narrative around breastfeeding in public should be reframed around the needs of the baby, as facilitated by its mother, rather than as something the mother does to meet her own needs. Theoretically informed interventions should be developed to spread this narrative among the public (Skivington et al., 2021).
Core elements that should be addressed by interventions include increasing knowledge among the general public to reduce the continuing presence of negative beliefs suggesting that breastfeeding is sexual, and that breastmilk is a contamination threat. This would directly aim to reframe beliefs centred around mothers' sexuality, illuminating the importance of breastfeeding in public for babies' nutrition. Social media campaigns may be of value (Giles, 2018), as well as changes in legislation and enforcing existing rights to breastfeed contained in legislation. We hypothesise that when the social environment is more welcoming, the limitations of the built environment will have less impact on where mothers feel that they can breastfeed. It is well established that appropriately tailored face-to-face support provided to breastfeeding mothers increases breastfeeding duration and exclusivity (McFadden et al., 2017). These principles could be used in relation to building confidence to breastfeed in public, alongside more general support on how to physically breastfeed.
Feminist theories, used in several included studies, explain the social discomfort around breastfeeding in public as arising from a patriarchal society which is not appropriately set up to meet the needs of women, let alone mothers (Ahmed, 2017). This particularly affects mothers from marginalised groups, including young, Black, and Disabled women, who can be further stigmatised (Crenshaw, 1989). This discomfort has been explained using a wide range of mid-range theories, including Goffman's social interaction (Brouwer et al., 2012), liminality (Dowling & Pontin, 2017), Sara Ahmed's affect (Boyer, 2012), Foucault's heterotopian space (Rose, 2012), Lazare's shame (Thomson et al., 2015), power and poverty (Groleau et al., 2013), and Heidegger's concept of they (McBride-Henry, 2010). In addition, mothers themselves, in attempting to maintain their own 'good mother' identity, were involved in generating and sustaining stigma in relation to those who breastfed in a way that was perceived as being less modestly than they did. The phenomenon of 'othering', identified and linked to the generation of stigma more than half a century ago (Goffman, 1959), has already been considered in one paper (Brouwer et al., 2012), and is worthy of further exploration within the context of breastfeeding in public.
Collectively, this theorising highlights the importance of power and stigma in guiding infant feeding in public views and behaviours, and feminist theories may be valuable in developing new interventions.

| Strengths and weaknesses
Our analysis of 71 studies from 2007 to May 2021 followed rigorous systematic review and evidence synthesis (Thomas & Harden, 2008) procedures through a series of meetings between a team of infant feeding researchers from varying disciplinary backgrounds. The synthesis highlighted considerably more barriers to breastfeeding in public than facilitators. This may be because the majority of papers included were concentrated in three high-income counties-United Kingdom, United States and Australia-within the 38 OECD countries. Countries where breastfeeding rates are considerably higher than, for example, the United Kingdom (such as the Nordic countries) were not included in our systematic search. This could be because of the English language focus of our systematic literature search, or the lack of problematisation of breastfeeding in public in countries with higher breastfeeding rates. In addition, our restriction to only journal articles and books will likely have excluded grey literature which could have shed additional light on interventions available at national and local levels within OECD countries. Whilst research was included that focused on marginalised groups including Black, Indigenous, Fat, young and low-income women, there was very limited content identified as originating from mothers of minority sexual orientations, and no content from trans men, nonbinary, and other minority gender identities for whom breastfeeding (or chestfeeding) in public may be further stigmatised. Finally, only a small amount of evidence was included based on perceptions of 'safe' spaces to breastfeed, and there is an urgent need for further research into women's views and experiences of positive breastfeeding in public experiences.

| CONCLUSION
Our systematic review of experiences of women from OECD countries has identified a wide range of barriers to breastfeeding in public spaces. Mothers' thoughts and behaviour in relation to breastfeeding in public are often a functional and protective response to embarrassment, discomfort, shame, and anxiety resulting from a hostile social environment. Breastfeeding is a gendered behaviour and exists within a patriarchal culture where gendered stigma interacts with other characteristics such as racism, ageism, and classism. Less marginalised mothers are known to breastfeed for longer which may be due to them experiencing society as less stigmatising in relation to breastfeeding. Interventions to promote breastfeeding in public-particularly focused on improving legal support, increasing societal knowledge, and decreasing stigma associated with the maternal breast-may hold promise. As with much of the research related to breastfeeding, there is an urgent need for appropriately funded investment to develop and evaluate interventions that specifically target the social and physical environment, rather than focusing solely on individual-level interventions that target mothers' (rational) beliefs, knowledge and attitudes.