Nourishing tomorrow: Tackling structural influences on infant feeding practices – insights from the German healthcare context

In Germany, a gap persists between infant feeding recommendations and actual practices, highlighting the need for systemic action. In this qualitative study, eleven semi-structured interviews were conducted with participants from diverse healthcare backgrounds and varying levels of experience in infant feeding. Interview data were analysed using codebook thematic analysis, guided by a political economy lens to examine underlying systemic conditions and a visioning approach to explore participants' views on strategic and transformative pathways for improvement. Findings were organised into a system framework including six key themes: worldviews and sociocultural norms, institutions and policy, social network, work and care dynamics, healthcare, and commerce. Proposed strategic actions included stronger healthcare services and trustworthy information, while transformative visions emphasised valuing care work, prevention, and gender-equitable careers. Six intersecting key challenges were identified including insufficient financing, weak policy implementation, lacking political attention, conflicting commercial interests, staff shortages, and gendered power dynamics. A key finding was a tension between participants' awareness of systemic influences on infant feeding and their tendency to explain feeding outcomes based on individual knowledge and choice, with education and awareness as frequently proposed solutions. However, participants’ accounts suggest that instead of aiming for more or better knowledge in the infant care unit, improving infant feeding practices requires a systems approach that promotes breastfeeding-friendly environments across healthcare, society, politics, economy, and labour markets.