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A qualitative look into mother's breastfeeding experiences
Journal of Neonatal Nursing (2014) xxx, xxxexxx
www.elsevier.com/jneo
ORIGINAL ARTICLE
A qualitative look into mother’s breastfeeding experiences Rachel Powell, MPH, CPH, CHES, PhD Research Assistanta,*, Marsha Davis, PhD, Associate Dean for Outreach and Engagementa, Alex Kojo Anderson, PhD, Associate Professorb a
University of Georgia College of Public Health, 116 Rhodes Hall, Health Sciences Campus, Athens, GA 30602, USA b 100 Barrow Hall, 115 DW Brooks Dr., Athens, GA 30602, USA Available online - - -
KEYWORDS Breastfeeding; Mothers; Clinicians; Peer counselors; Lactation consultants; Nursing; Education
Abstract The objective of the project was to gain a holistic understanding of the current breastfeeding experiences of mothers, while identifying resources and support for breastfeeding in the Athens-Clarke County and surrounding areas. This was an exploratory qualitative study of in-depth interviews with a total of 21 mothers (12 from WIC; 9 from Full Bloom) from Athens-Clarke County and surrounding areas. The inclusion criteria of the participants were mothers of infants who were 12 months old or younger who delivered in Athens. The mothers were individually interviewed. Informants attributed their success, or lack of, to the presence of a breastfeeding role model. Successful mothers shared how important it is to have peers who breastfed and/or are supportive of breastfeeding. While some reported positive support, others reported negative reaction from their work environment. About 75% of the mothers reported negative or no support from their clinician or staff of the hospital. Some informants reported a perceived lack of honesty on the clinician’s part about the possible difficulties and possible problems. It is important that clinicians provide honest and consistent breastfeeding information to prepare mothers for potential challenges that may arise during the course of breastfeeding. ª 2014 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Tel.: þ1 404 682 5963; fax: þ1 925 364 3615. E-mail address: [email protected] (R. Powell).
Breastfeeding provides numerous health benefits to both the mother and the nursing child. The
http://dx.doi.org/10.1016/j.jnn.2014.04.001 1355-1841/ª 2014 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
2 American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Academy of Family Physicians all acknowledge breastfeeding as the preferred method of feeding for newborns and infants (American College of Obstretricians and Gyngecologists, 2007; Gartner et al., 2005; AAFP, 2008). Acknowledging the importance of breastfeeding for the future health of the newborn and mother, and bridging the health disparity gaps between racial and ethnic groups, the Healthy People 2020 document includes breastfeeding objectives. Even though all of the Healthy People 2010 objectives for breastfeeding were not met, the Healthy People committee further challenges mothers, healthcare providers, and the nation by increasing the breastfeeding goals for 2020 from that of 2010, and for the first time, including a target for exclusive breastfeeding at 6 months postpartum (U.S. Department of Health and Human Services, 2010). The objectives for 2020 include an increase in the proportion of mothers who initiate breastfeeding from 75% to 81.9%, 60.6% continue breastfeeding at 6 months from the previous 50% and at 1 year from 25% to 34.1%, and exclusively breastfeeding at 3 months from 33.6% to 46.2% (U.S. Department of Health and Human Services, 2010). The Healthy People 2020 goals for exclusively breastfeeding at 6 months is 25.5% (U.S. Department of Health and Human Services, 2010) in conformation to estimates by UNICEF that exclusively breastfeeding to 6 months postpartum could save about 1.5 million infant deaths (UNICEF, 1990). While breastfeeding has health benefits for the baby and mother, it is necessary to have the support of others to help mothers reach their personal breastfeeding goals, as well as, meeting national goals. The support can come from two sources: clinical, social or both. Clinical support includes support via education, conversations, or instructions from clinical staff, which can be but not limited to: obstetricians, gynecologist, pediatricians, nurses, lactation consultants, midwives, peer counselors, and other professionals within the healthcare system. In the breastfeeding field, social support is identified as support from the baby’s father, partner, peers, friends, family, coworkers, community members, and others that the mother identifies as having a personal relationship with. Social support from peers is reported as being beneficial because they share their experience and “are there for the mother” (Schmied et al., 2011). A study conducted in the UK showed that while clinical support is very important, mothers will not be able to successfully
R. Powell et al. breastfeed if it is not accepted by people in their social circles, which includes family and friends (Brown et al., 2011). The support given by clinical staff to mothers can be very helpful in increasing confidence of the breastfeeding mothers, yet can also be a negative influence to the mother’s confidence to breastfeed if she is not receiving positive or helpful support from a clinician (Brown et al., 2011; Sheehan et al., 2009). It is important to understand how both social and clinical support collectively influences American mothers decision to initiate and continue breastfeeding. The purpose of the research project was to gain a holistic understanding of the breastfeeding experience of mothers, while identifying breastfeeding resources and support in the Athens-Clarke County and surrounding areas.
Study design and methods Study design This was a qualitative study that employed indepth interviews for data collection. The interviews were done from a phenomenological framework, which are to elicit the direct description of a particular situation or event as it is lived through without offering causal explanations or interpretive generalizations (Roulston, 2010). The study was conducted between December 2011 and June 2012 by a collaborative team of researchers from the University of Georgia, Northeast Georgia Health District WIC office, and Full Bloom Pregnancy and Early Parenting Center, which are all located in the United States. The Institutional Review Board of the University of Georgia approved the study and all participants provided written informed consent before their participation. The study included mothers of infants 12 months old or younger, who delivered in Athens and reside in Athens-Clarke County and surrounding towns. Participants included 3 groups of mothers 1) exclusively breastfed, 2) successful at breastfeeding (i.e., breastfed for more than 2 months), and 3) not successful at breastfeeding or did not breastfeed. To use phenomenological interviews effectively, it is essential that the interviewer identify participants who have both experienced, and are able to talk about the particular lived experience under examination (Roulston, 2010). Participants were recruited from the East Athens WIC Office and Full Bloom Pregnancy and Early Parenting Center in the AthensClarke Country of the State of Georgia.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences Recruitment was done through word of mouth and flyers posted at both the Full Bloom and WIC office. Once a mother indicated an interest to participate in the study, she was then screened. The mothers were screened and selected to participate in the study based on the following inclusion criteria: having delivered a newborn within the past year and was HIV negative. Additional screening questions included: mother’s age, mother’s self-identified race, mother’s selfreported socioeconomic status of household, baby’s date of birth, hospital where baby was born, how the baby was fed, and preference of place and time to be interviewed. The research team attempted to recruit mothers from different race/ethnic groups in order to ascertain a wellrounded knowledge of breastfeeding experiences across race/ethnicity within the Athens community. A total of 21 mothers (12 from WIC and 9 from Full Bloom) participated in the study.
Data collection Graduate research assistants from the University of Georgia, who were trained in qualitative data collection, used the individual in-depth interview guide for data collection. An interview guide developed and pre-tested by the research team and approved by the IRB of the University of Georgia was used for all the interviews. The interview guide, made up of open-ended questions, which allowed mothers the opportunity to answer the questions and for the interviewers to probe participants’ responses. Participants responded to questions about their experiences with clinical and hospital staff before, during, and after the birth of the index child (less than 12 months old). Other questions in the interview guide included mother’s perception of breastfeeding support and resources in the Athens-Clarke County and surrounding communities. All the indepth interviews were audio recorded, while a note-taker wrote down important points expressed by the participant, which were compiled into field notes. The interviewer and another research assistant who did not participate in any of the in-depth interviews transcribed all the audio-recorded interviews verbatim. This was to ensure validity and decrease researcher bias. All the transcripts were reviewed and any differences reconciled by one of the lead researchers responsible for the data collection by reviewing the original recorded interview and corrections made. Transcripts of the interviews were manually coded and grouped into themes. These themes were developed
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independently by two of the lead researchers and further discussions were held to resolve discrepancies in the themes. All the interviews were conducted at the East Athens WIC Office and the Full Bloom Pregnancy and Early Parenting Center or another location, based on the participant’s choice. Duration of the interview ranged from 20 to 60 min. Mothers who were WIC recipients received $25 gift cards to either Wal-mart or Target for their time and contribution, while participants from Full Bloom participated without any incentive other than to share their breastfeeding story/experience.
Results A total of 21 mothers participated in the in-depth interviews. Twelve (12) of them were WIC recipients and recruited from the East Athens WIC Clinic, while the remaining nine were recruited from the Full Bloom Pregnancy and Early Parenting Center in Athens, Georgia. The average age of the informants from WIC was 26.8 (range: 22e40) years compared to an average age of 31.9 (range: 23e36) years for their Full Bloom counterparts. All nine mothers from Full Bloom had college education or higher while only three of WIC mothers had college education or higher. For the remaining WIC mothers, four had less than high school education and five were high school graduates or GED holders. There was more racial diversity within the WIC mothers with seven (7) of them selfidentifying as White/Caucasian, three (3) as Hispanic, and two (2) as Black, respectively. Eight (8) of the Full Bloom mothers identified themselves as White/Caucasian and the remaining one identified herself as mixed race. Majority of the mothers, both WIC and Full Bloom, reported their household socioeconomic status as middle-income (64% vs. 78%, respectively). Five WIC mothers reported exclusively breastfeeding their infant for the first six months compared to six Full Bloom mothers. The remaining mothers (seven from WIC and three from Full Bloom) reported mixed feeding their infants both breast milk and infant formula for the first 6 months. Our analysis of the interview transcripts identified four major themes regarding breastfeeding promotion, support and education perceived by mothers within the community or clinical environment that hindered or promoted successful breastfeeding. The themes were as follows: 1) social influence (role models and positive deviants, 2) work environment, 3) honesty/guilt, 4) hospital and clinical practice.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
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R. Powell et al.
Social influence on the success of breastfeeding In human behavior, there is the understanding of the importance of various levels of societies and communities, and the influence they have on learning and participating in behaviors such as childcare and breastfeeding (Declercq et al., 2009; Schmied et al., 2011). Informants generally attributed their success, or lack of success, at breastfeeding to either having or not having a role model when it comes to breastfeeding. It was common for informants who exclusively breastfed or breastfed their infants for more than 6 months to attribute their success to having people in their lives who both encouraged and supported their decision to breastfed or who have successfully breastfed their own child or children. This is how one informant puts it: “Whatever you believe in you should have women who have done or been through it to support you.” Another informant who was successful at breastfeeding her newborn said: “Seeing siblings and friends breastfeed made me want to breastfeed and go all out.” An informant recruited from WIC had this to say: “My mom breastfed us and I know breast is best.” “I had a friend who had a baby right around the time I had [my son] and we pump together at lunch. It’s like a sisterhood of finding a woman who values breastfeeding and going through it together.” Informants who were successful at breastfeeding shared how important it is to have friends and peers who breastfeed and are supportive of breastfeeding. Through these relationships, breastfeeding mothers are able to depend on each other for support, share their struggles, and find common ways to make breastfeeding work. Other informants mentioned knowing people who have breastfed before or are currently breastfeeding allows the mothers to have a conversation with them about breastfeeding even before one is pregnant or has children. These conversations are helpful because it allowed the mother to think about infant feeding. One of the informants specifically reported that it helped her prepare and gain knowledge about breastfeeding, which contributed to a successful breastfeeding experience. Other informants attributed their unsuccessful breastfeeding experience to the lack of
breastfeeding role models in their life. Some reported their mothers did not breastfeed them or their siblings and that they were not very supportive of breastfeeding. Others also mentioned the lack of encouragement to breastfeed among their circle of friends. An informant shared her struggle with breastfeeding but hopeful to succeed the next time round. “It was rough. It was really rough and I was hurting a lot. He (the baby) was not latching on right, so it wasn’t that great of an experience at all. I hope with another child that it would work a lot better. I still want to try it with my next child.”
Influence of work environment on breastfeeding Informants had mixed reports on how the work environment impacted on their breastfeeding experience. While some reported positive support from the work environment, others reported to have received a negative reaction from their work environment towards their effort to breastfeed. Overall, there were more negative work environment reports than positive work environments reported by informants who worked outside the home. These are examples of the frustrations some of the informants shared with the research team regarding their breastfeeding experience at the work place: “At one point my boss came to me and was like you are pumping too much, which kind of irritated me. I was pretty offended.” Another informant said: “I work with a bunch of women. They were like it’s hard and like you’re not going to be able to do it. They were really down and I guess that kind of made me want to do it more just to prove to them.” One informant, who is also a nurse, reported that her boss came to her one day telling her that her pumping was getting in the way of her work. This was a unique comment because of the obvious contradiction that this is. The remark made by the nurse’s supervisor presents problem because of the natural contradiction it is to the quest of hospitals and healthcare professionals to promote and support breastfeeding.
Honesty and guilt in breastfeeding All of the participants mentioned the need for clinicians, lactation consultants, and counselors to
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences be honest about the expectations of breastfeeding. Prenatal and postpartum clinic visits is a time for clinicians to educate mothers on breastfeeding and support them. An informant likened this to childbirth classes and had this to say: “We prepare for childbirth and know that it will be painful but they don’t prepare you for breastfeeding. Even this last time, I can see why people stop breastfeeding. It’s rough, but when you get past it is fabulous.” Some informants shared a perceived lack of honesty on the clinician’s part about the possible difficulties and problems that could come up during breastfeeding. A number of the informants explained that during childbirth classes, they are made to understand the difficulties of childbirth during labor and some of the potential problems to expect. Being equipped with similar information on possible breastfeeding problem during clinician visits or educational classes would lead to better prepared and empowered mothers. In the case of breastfeeding, the informants reported providers are not totally honest about it and only explain and present the benefits of breastfeeding. An informant had this to say: “I just wanted more of the specifics of what to expect.” Another informant had this to say: “Some doctors tell you breastfeeding is best, but then they push formula feeding and threaten that if the baby does not gain weight they would put the baby on formula” This mother shared that the doctors used scare tactics on her by threatening to push formula feeding if the baby did not gain enough weight, yet did not fully explain the logistics and information on breastfeeding to the mother. Some of the informants also complained about most of the information and support they received from their providers as being too general and not tailored to their specific individual needs or situation. This finding is similar to the report by Hoddinott and Pill (2000).
Influence of hospital and clinician practice on breastfeeding In this study, 15 of the 21 informants reported negative or no support from their clinicians or the hospital where they delivered, while the remaining six reported positive support for breastfeeding in the Athens community. Most of the positive
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breastfeeding support was reported to come from WIC breastfeeding peer counselors and lactation counselors at the Full Bloom Pregnancy and Early Parenting Center with hardly any mention of an obstetrician or pediatrician in this community. There was mixed reports on the kind of breastfeeding support provided by the nursing and other clinical staff during the mother-infant dyad hospital stay after delivery. One of the informants had this to say: “Nursing staff did not provide any breastfeeding support until the last day when they asked which infant formula I wanted” Another informant shared: “After he was born, in the NICU they had a lactation consultant come in for her (the baby) and she was kind of rough and kind of pushy. And I think it freaked the baby’s father out a little.” The first quote from this theme shows that this mother associated a nurse asking her which kind of formula she wanted as breastfeeding support. This message is conflicting and can lead to confusion among mothers. It is the responsibility of clinicians to adequately educate mothers on the differences in infant feeding so that they are educated and empowered to make informed infant feeding decisions. Clinicians are expected to be knowledgeable and helpful in all aspects of the pregnancy and birth process, including breastfeeding. It is important to recognize the mother’s opinions of the care and information that they receive from clinicians in order to properly identify areas of improvement.
Clinical nursing implications The mothers from the Athens-Clarke County area, both WIC and Full Bloom, shared valuable information that allows researchers and practitioners to identify the strengths and weaknesses of both social and clinical support systems/resources when it comes to breastfeeding promotion, support and protection. The findings from this study are important, in that understanding mothers’ perspectives on the breastfeeding education, advice, and support that they either receive or do not receive from clinicians, family, friends, and peers are the cornerstone to successful breastfeeding practice. It is important for practitioners to support and encourage the involvement of members of a mother’s social circle in breastfeeding education during clinical visits. Whether it is the baby’s father, a partner, friend, family member, grandmother of
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
6 the baby, or other, it is important for the mother to have someone who will be there for her participate in the breastfeeding education with her so they can be a source of positive support and encouragement throughout the breastfeeding experience. Another important context of the mother’s breastfeeding experience is the level of support that her work environment provides for her to be able to continue breastfeeding once she returns to work. As we observed from the interviews, some work environments are supportive and others are not. It is important for mothers to be educated and empowered on their rights to take breastfeeding breaks to pump their milk, as well as employers and supervisors sensitized in this area. In the Affordable Care Act that was signed into law on March 23, 2010, there is an amendment (Section 4207) that requires employers to provide reasonable break time to private, non-bathroom areas for nursing mothers to express their breast milk during the workday for up to one year after the child’s birth (United States Breastfeeding Committee, 2010). This, most mothers are not aware of including other state specific breastfeeding laws/ regulations and needed to be discussed during breastfeeding education and support sessions. If women are educated about their rights as nursing mothers, then they will be able to advocate for themselves in the workplace. It is important that education on the new federal laws about breastfeeding be a part of the standard breastfeeding education that all mothers receive. The third theme, which deals with honesty and guilt in breastfeeding, is an important one for all who promote and support breastfeeding. The mothers shared their perspective and skepticism of the level of honesty in the area of breastfeeding education. It is important for those who promote and support breastfeeding to use breastfeeding education as a tool to teach and prepare mothers for potential breastfeeding problems that could come up and way to overcome them. Since every mother’s breastfeeding experience is individualized, it is important that clinicians find a balance during breastfeeding education and support without scaring mothers. Mothers shared that they are prepared for the potential issues of childbirth because they are made aware of them, so if this practice is applied to breastfeeding, there will potentially be more successful mothers who breastfeed. It is also important that each clinician that comes in contact with a mother ascertain their infant feeding plans to be able to appropriately support her. On the role of hospital and clinical staff on the mother’s breastfeeding practice, majority of the
R. Powell et al. mothers reported negative or no support from the hospital or clinical staff. This is a potentially contradictory message being sent to mothers since clinicians educate the mothers on breastfeeding yet do not offer support of it. Some mothers are dependent on clinicians’ advice and education so it is crucial that clinicians are giving a high standard of education to every patient at the initial meeting, no matter educational background, race, or age of the mother. Assumptions cannot be made about what the mother already knows otherwise there will be many missed opportunities, for breastfeeding promotion among, new mothers. Findings from the project is consistent with past research that emphasizes that social support is important for women (Schmied et al., 2011) as well as clinician support (Brown et al., 2011) are important for women. Again our findings are in agreement with a review of the literature that showed that either type of support was beneficial for breastfeeding, especially exclusive breastfeeding (Britton et al., 2007). While this research project has identified some of the challenges mothers face when it comes to breastfeeding education and support in the study community, there are a few limitations. The first limitation is that, there was a lack of diversity in race/ethnicity among the mothers that were interviewed. Even though the study was introduced as an infant feeding study, not just a breastfeeding study, there were not many formula-feeding mothers. Both settings where mothers were recruited, Full Bloom and WIC, promote breastfeeding, which could have contributed to most of the mothers in the study breastfeeding. Due to these limitations, the results may not be generalizable to other populations or settings. Future research should consider replicating this study with a more diverse population. Other areas of future research include examining mothers who formula feed their infants to understand their perspectives and opinions on breastfeeding, and how collectively breastfeeding can become more accepted and promoted within the community.
Conflict of interest There are no conflicts of interest to report.
Funding Funding for this work was provided by the Community Breastfeeding Coalition of Athens, Georgia.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences
References American College of Obstretricians and Gyngecologists, 2007. Breastfeeding: maternal and infant aspects. ACOG Clin. Rev. 12 (Supp 1), 1Se16S. Britton, C., McCormick, F.M., Renfrew, M.J., Wade, A., King, S. E., 2007. Support for breastfeeding mothers. Cochrane Database System. Rev. 1. http://dx.doi.org/10.1002/ 14651858.CD001141.pub3. Brown, A., Raynor, P., Lee, M., 2011. Healthcare professionals’ and mothers’ perceptions of factors that influence decisions to breastfeed or formula feed infants: a comparative study. J. Adv. Nurs. 67 (9), 1993e2003. http://dx.doi.org/10.1111/ j.1365-2648.2011.05647.x. Declercq, E., Labbok, M.H., Sakala, C., O’Hara, M., 2009. Hospital practices and women’s likelihood of fulfilling their intention to exclusively breastfeed. Am. J. Public Health 99 (5), 929e935. http://dx.doi.org/10.2105/ajph.2008. 135236. Gartner, L., Morton, J., Lawrence, R., Naylor, A., O’Hare, D., Schanler, R., 2005. Breastfeeding and the use of human milk. Pediatrics 115, 496e506.
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Hoddinott, P., Pill, R., 2000. A qualitative study of women’s views about how health professionals communicate about infant feeding. J. Health Expect. 3, 224e233. Roulston, K., 2010. Reflective Interviewing: a Guide to Theory & Practice. SAGE, Thousand Oaks, California. Schmied, V., Beake, S., Sheenan, A., McCourt, C., Dykes, F., 2011. Women’s perceptions and experiences of breastfeeding support: a metasynthesis. Birth: Iss. Perinantal Care 38 (1), 49e60. Sheehan, A., Schmied, V., Barclay, L., 2009. Women’s experiences of infant feeding support in the first 6 weeks postbirth. Maternal Child Nutri. 5 (2), 138e150. http://dx.doi. org/10.1111/j.1740-8709.2008.00163.x. U.S. Department of Health and Human Services, 2010. Healthy People 2020-Maternal, Infant, and Child Health from. http://www.healthypeople.gov/2020/topicsobjectives2020 /objectiveslist.aspx?topicId¼26. UNICEF, 1990. The breastfeeding initiatives exchange. In: Paper presented at the Breastfeeding in the 1990s. A Global Initiatve Florence, Italy. United States Breastfeeding Committee, 2010. Workplace Support in Federal Law from. http://www.usbreastfeeding.org/ Workplace/WorkplaceSupport/WorkplaceSupportinHealthC areReform/tabid/175/Default.aspx.
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Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
www.elsevier.com/jneo
ORIGINAL ARTICLE
A qualitative look into mother’s breastfeeding experiences Rachel Powell, MPH, CPH, CHES, PhD Research Assistanta,*, Marsha Davis, PhD, Associate Dean for Outreach and Engagementa, Alex Kojo Anderson, PhD, Associate Professorb a
University of Georgia College of Public Health, 116 Rhodes Hall, Health Sciences Campus, Athens, GA 30602, USA b 100 Barrow Hall, 115 DW Brooks Dr., Athens, GA 30602, USA Available online - - -
KEYWORDS Breastfeeding; Mothers; Clinicians; Peer counselors; Lactation consultants; Nursing; Education
Abstract The objective of the project was to gain a holistic understanding of the current breastfeeding experiences of mothers, while identifying resources and support for breastfeeding in the Athens-Clarke County and surrounding areas. This was an exploratory qualitative study of in-depth interviews with a total of 21 mothers (12 from WIC; 9 from Full Bloom) from Athens-Clarke County and surrounding areas. The inclusion criteria of the participants were mothers of infants who were 12 months old or younger who delivered in Athens. The mothers were individually interviewed. Informants attributed their success, or lack of, to the presence of a breastfeeding role model. Successful mothers shared how important it is to have peers who breastfed and/or are supportive of breastfeeding. While some reported positive support, others reported negative reaction from their work environment. About 75% of the mothers reported negative or no support from their clinician or staff of the hospital. Some informants reported a perceived lack of honesty on the clinician’s part about the possible difficulties and possible problems. It is important that clinicians provide honest and consistent breastfeeding information to prepare mothers for potential challenges that may arise during the course of breastfeeding. ª 2014 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Tel.: þ1 404 682 5963; fax: þ1 925 364 3615. E-mail address: [email protected] (R. Powell).
Breastfeeding provides numerous health benefits to both the mother and the nursing child. The
http://dx.doi.org/10.1016/j.jnn.2014.04.001 1355-1841/ª 2014 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
2 American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the American Academy of Family Physicians all acknowledge breastfeeding as the preferred method of feeding for newborns and infants (American College of Obstretricians and Gyngecologists, 2007; Gartner et al., 2005; AAFP, 2008). Acknowledging the importance of breastfeeding for the future health of the newborn and mother, and bridging the health disparity gaps between racial and ethnic groups, the Healthy People 2020 document includes breastfeeding objectives. Even though all of the Healthy People 2010 objectives for breastfeeding were not met, the Healthy People committee further challenges mothers, healthcare providers, and the nation by increasing the breastfeeding goals for 2020 from that of 2010, and for the first time, including a target for exclusive breastfeeding at 6 months postpartum (U.S. Department of Health and Human Services, 2010). The objectives for 2020 include an increase in the proportion of mothers who initiate breastfeeding from 75% to 81.9%, 60.6% continue breastfeeding at 6 months from the previous 50% and at 1 year from 25% to 34.1%, and exclusively breastfeeding at 3 months from 33.6% to 46.2% (U.S. Department of Health and Human Services, 2010). The Healthy People 2020 goals for exclusively breastfeeding at 6 months is 25.5% (U.S. Department of Health and Human Services, 2010) in conformation to estimates by UNICEF that exclusively breastfeeding to 6 months postpartum could save about 1.5 million infant deaths (UNICEF, 1990). While breastfeeding has health benefits for the baby and mother, it is necessary to have the support of others to help mothers reach their personal breastfeeding goals, as well as, meeting national goals. The support can come from two sources: clinical, social or both. Clinical support includes support via education, conversations, or instructions from clinical staff, which can be but not limited to: obstetricians, gynecologist, pediatricians, nurses, lactation consultants, midwives, peer counselors, and other professionals within the healthcare system. In the breastfeeding field, social support is identified as support from the baby’s father, partner, peers, friends, family, coworkers, community members, and others that the mother identifies as having a personal relationship with. Social support from peers is reported as being beneficial because they share their experience and “are there for the mother” (Schmied et al., 2011). A study conducted in the UK showed that while clinical support is very important, mothers will not be able to successfully
R. Powell et al. breastfeed if it is not accepted by people in their social circles, which includes family and friends (Brown et al., 2011). The support given by clinical staff to mothers can be very helpful in increasing confidence of the breastfeeding mothers, yet can also be a negative influence to the mother’s confidence to breastfeed if she is not receiving positive or helpful support from a clinician (Brown et al., 2011; Sheehan et al., 2009). It is important to understand how both social and clinical support collectively influences American mothers decision to initiate and continue breastfeeding. The purpose of the research project was to gain a holistic understanding of the breastfeeding experience of mothers, while identifying breastfeeding resources and support in the Athens-Clarke County and surrounding areas.
Study design and methods Study design This was a qualitative study that employed indepth interviews for data collection. The interviews were done from a phenomenological framework, which are to elicit the direct description of a particular situation or event as it is lived through without offering causal explanations or interpretive generalizations (Roulston, 2010). The study was conducted between December 2011 and June 2012 by a collaborative team of researchers from the University of Georgia, Northeast Georgia Health District WIC office, and Full Bloom Pregnancy and Early Parenting Center, which are all located in the United States. The Institutional Review Board of the University of Georgia approved the study and all participants provided written informed consent before their participation. The study included mothers of infants 12 months old or younger, who delivered in Athens and reside in Athens-Clarke County and surrounding towns. Participants included 3 groups of mothers 1) exclusively breastfed, 2) successful at breastfeeding (i.e., breastfed for more than 2 months), and 3) not successful at breastfeeding or did not breastfeed. To use phenomenological interviews effectively, it is essential that the interviewer identify participants who have both experienced, and are able to talk about the particular lived experience under examination (Roulston, 2010). Participants were recruited from the East Athens WIC Office and Full Bloom Pregnancy and Early Parenting Center in the AthensClarke Country of the State of Georgia.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences Recruitment was done through word of mouth and flyers posted at both the Full Bloom and WIC office. Once a mother indicated an interest to participate in the study, she was then screened. The mothers were screened and selected to participate in the study based on the following inclusion criteria: having delivered a newborn within the past year and was HIV negative. Additional screening questions included: mother’s age, mother’s self-identified race, mother’s selfreported socioeconomic status of household, baby’s date of birth, hospital where baby was born, how the baby was fed, and preference of place and time to be interviewed. The research team attempted to recruit mothers from different race/ethnic groups in order to ascertain a wellrounded knowledge of breastfeeding experiences across race/ethnicity within the Athens community. A total of 21 mothers (12 from WIC and 9 from Full Bloom) participated in the study.
Data collection Graduate research assistants from the University of Georgia, who were trained in qualitative data collection, used the individual in-depth interview guide for data collection. An interview guide developed and pre-tested by the research team and approved by the IRB of the University of Georgia was used for all the interviews. The interview guide, made up of open-ended questions, which allowed mothers the opportunity to answer the questions and for the interviewers to probe participants’ responses. Participants responded to questions about their experiences with clinical and hospital staff before, during, and after the birth of the index child (less than 12 months old). Other questions in the interview guide included mother’s perception of breastfeeding support and resources in the Athens-Clarke County and surrounding communities. All the indepth interviews were audio recorded, while a note-taker wrote down important points expressed by the participant, which were compiled into field notes. The interviewer and another research assistant who did not participate in any of the in-depth interviews transcribed all the audio-recorded interviews verbatim. This was to ensure validity and decrease researcher bias. All the transcripts were reviewed and any differences reconciled by one of the lead researchers responsible for the data collection by reviewing the original recorded interview and corrections made. Transcripts of the interviews were manually coded and grouped into themes. These themes were developed
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independently by two of the lead researchers and further discussions were held to resolve discrepancies in the themes. All the interviews were conducted at the East Athens WIC Office and the Full Bloom Pregnancy and Early Parenting Center or another location, based on the participant’s choice. Duration of the interview ranged from 20 to 60 min. Mothers who were WIC recipients received $25 gift cards to either Wal-mart or Target for their time and contribution, while participants from Full Bloom participated without any incentive other than to share their breastfeeding story/experience.
Results A total of 21 mothers participated in the in-depth interviews. Twelve (12) of them were WIC recipients and recruited from the East Athens WIC Clinic, while the remaining nine were recruited from the Full Bloom Pregnancy and Early Parenting Center in Athens, Georgia. The average age of the informants from WIC was 26.8 (range: 22e40) years compared to an average age of 31.9 (range: 23e36) years for their Full Bloom counterparts. All nine mothers from Full Bloom had college education or higher while only three of WIC mothers had college education or higher. For the remaining WIC mothers, four had less than high school education and five were high school graduates or GED holders. There was more racial diversity within the WIC mothers with seven (7) of them selfidentifying as White/Caucasian, three (3) as Hispanic, and two (2) as Black, respectively. Eight (8) of the Full Bloom mothers identified themselves as White/Caucasian and the remaining one identified herself as mixed race. Majority of the mothers, both WIC and Full Bloom, reported their household socioeconomic status as middle-income (64% vs. 78%, respectively). Five WIC mothers reported exclusively breastfeeding their infant for the first six months compared to six Full Bloom mothers. The remaining mothers (seven from WIC and three from Full Bloom) reported mixed feeding their infants both breast milk and infant formula for the first 6 months. Our analysis of the interview transcripts identified four major themes regarding breastfeeding promotion, support and education perceived by mothers within the community or clinical environment that hindered or promoted successful breastfeeding. The themes were as follows: 1) social influence (role models and positive deviants, 2) work environment, 3) honesty/guilt, 4) hospital and clinical practice.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
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R. Powell et al.
Social influence on the success of breastfeeding In human behavior, there is the understanding of the importance of various levels of societies and communities, and the influence they have on learning and participating in behaviors such as childcare and breastfeeding (Declercq et al., 2009; Schmied et al., 2011). Informants generally attributed their success, or lack of success, at breastfeeding to either having or not having a role model when it comes to breastfeeding. It was common for informants who exclusively breastfed or breastfed their infants for more than 6 months to attribute their success to having people in their lives who both encouraged and supported their decision to breastfed or who have successfully breastfed their own child or children. This is how one informant puts it: “Whatever you believe in you should have women who have done or been through it to support you.” Another informant who was successful at breastfeeding her newborn said: “Seeing siblings and friends breastfeed made me want to breastfeed and go all out.” An informant recruited from WIC had this to say: “My mom breastfed us and I know breast is best.” “I had a friend who had a baby right around the time I had [my son] and we pump together at lunch. It’s like a sisterhood of finding a woman who values breastfeeding and going through it together.” Informants who were successful at breastfeeding shared how important it is to have friends and peers who breastfeed and are supportive of breastfeeding. Through these relationships, breastfeeding mothers are able to depend on each other for support, share their struggles, and find common ways to make breastfeeding work. Other informants mentioned knowing people who have breastfed before or are currently breastfeeding allows the mothers to have a conversation with them about breastfeeding even before one is pregnant or has children. These conversations are helpful because it allowed the mother to think about infant feeding. One of the informants specifically reported that it helped her prepare and gain knowledge about breastfeeding, which contributed to a successful breastfeeding experience. Other informants attributed their unsuccessful breastfeeding experience to the lack of
breastfeeding role models in their life. Some reported their mothers did not breastfeed them or their siblings and that they were not very supportive of breastfeeding. Others also mentioned the lack of encouragement to breastfeed among their circle of friends. An informant shared her struggle with breastfeeding but hopeful to succeed the next time round. “It was rough. It was really rough and I was hurting a lot. He (the baby) was not latching on right, so it wasn’t that great of an experience at all. I hope with another child that it would work a lot better. I still want to try it with my next child.”
Influence of work environment on breastfeeding Informants had mixed reports on how the work environment impacted on their breastfeeding experience. While some reported positive support from the work environment, others reported to have received a negative reaction from their work environment towards their effort to breastfeed. Overall, there were more negative work environment reports than positive work environments reported by informants who worked outside the home. These are examples of the frustrations some of the informants shared with the research team regarding their breastfeeding experience at the work place: “At one point my boss came to me and was like you are pumping too much, which kind of irritated me. I was pretty offended.” Another informant said: “I work with a bunch of women. They were like it’s hard and like you’re not going to be able to do it. They were really down and I guess that kind of made me want to do it more just to prove to them.” One informant, who is also a nurse, reported that her boss came to her one day telling her that her pumping was getting in the way of her work. This was a unique comment because of the obvious contradiction that this is. The remark made by the nurse’s supervisor presents problem because of the natural contradiction it is to the quest of hospitals and healthcare professionals to promote and support breastfeeding.
Honesty and guilt in breastfeeding All of the participants mentioned the need for clinicians, lactation consultants, and counselors to
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences be honest about the expectations of breastfeeding. Prenatal and postpartum clinic visits is a time for clinicians to educate mothers on breastfeeding and support them. An informant likened this to childbirth classes and had this to say: “We prepare for childbirth and know that it will be painful but they don’t prepare you for breastfeeding. Even this last time, I can see why people stop breastfeeding. It’s rough, but when you get past it is fabulous.” Some informants shared a perceived lack of honesty on the clinician’s part about the possible difficulties and problems that could come up during breastfeeding. A number of the informants explained that during childbirth classes, they are made to understand the difficulties of childbirth during labor and some of the potential problems to expect. Being equipped with similar information on possible breastfeeding problem during clinician visits or educational classes would lead to better prepared and empowered mothers. In the case of breastfeeding, the informants reported providers are not totally honest about it and only explain and present the benefits of breastfeeding. An informant had this to say: “I just wanted more of the specifics of what to expect.” Another informant had this to say: “Some doctors tell you breastfeeding is best, but then they push formula feeding and threaten that if the baby does not gain weight they would put the baby on formula” This mother shared that the doctors used scare tactics on her by threatening to push formula feeding if the baby did not gain enough weight, yet did not fully explain the logistics and information on breastfeeding to the mother. Some of the informants also complained about most of the information and support they received from their providers as being too general and not tailored to their specific individual needs or situation. This finding is similar to the report by Hoddinott and Pill (2000).
Influence of hospital and clinician practice on breastfeeding In this study, 15 of the 21 informants reported negative or no support from their clinicians or the hospital where they delivered, while the remaining six reported positive support for breastfeeding in the Athens community. Most of the positive
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breastfeeding support was reported to come from WIC breastfeeding peer counselors and lactation counselors at the Full Bloom Pregnancy and Early Parenting Center with hardly any mention of an obstetrician or pediatrician in this community. There was mixed reports on the kind of breastfeeding support provided by the nursing and other clinical staff during the mother-infant dyad hospital stay after delivery. One of the informants had this to say: “Nursing staff did not provide any breastfeeding support until the last day when they asked which infant formula I wanted” Another informant shared: “After he was born, in the NICU they had a lactation consultant come in for her (the baby) and she was kind of rough and kind of pushy. And I think it freaked the baby’s father out a little.” The first quote from this theme shows that this mother associated a nurse asking her which kind of formula she wanted as breastfeeding support. This message is conflicting and can lead to confusion among mothers. It is the responsibility of clinicians to adequately educate mothers on the differences in infant feeding so that they are educated and empowered to make informed infant feeding decisions. Clinicians are expected to be knowledgeable and helpful in all aspects of the pregnancy and birth process, including breastfeeding. It is important to recognize the mother’s opinions of the care and information that they receive from clinicians in order to properly identify areas of improvement.
Clinical nursing implications The mothers from the Athens-Clarke County area, both WIC and Full Bloom, shared valuable information that allows researchers and practitioners to identify the strengths and weaknesses of both social and clinical support systems/resources when it comes to breastfeeding promotion, support and protection. The findings from this study are important, in that understanding mothers’ perspectives on the breastfeeding education, advice, and support that they either receive or do not receive from clinicians, family, friends, and peers are the cornerstone to successful breastfeeding practice. It is important for practitioners to support and encourage the involvement of members of a mother’s social circle in breastfeeding education during clinical visits. Whether it is the baby’s father, a partner, friend, family member, grandmother of
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
6 the baby, or other, it is important for the mother to have someone who will be there for her participate in the breastfeeding education with her so they can be a source of positive support and encouragement throughout the breastfeeding experience. Another important context of the mother’s breastfeeding experience is the level of support that her work environment provides for her to be able to continue breastfeeding once she returns to work. As we observed from the interviews, some work environments are supportive and others are not. It is important for mothers to be educated and empowered on their rights to take breastfeeding breaks to pump their milk, as well as employers and supervisors sensitized in this area. In the Affordable Care Act that was signed into law on March 23, 2010, there is an amendment (Section 4207) that requires employers to provide reasonable break time to private, non-bathroom areas for nursing mothers to express their breast milk during the workday for up to one year after the child’s birth (United States Breastfeeding Committee, 2010). This, most mothers are not aware of including other state specific breastfeeding laws/ regulations and needed to be discussed during breastfeeding education and support sessions. If women are educated about their rights as nursing mothers, then they will be able to advocate for themselves in the workplace. It is important that education on the new federal laws about breastfeeding be a part of the standard breastfeeding education that all mothers receive. The third theme, which deals with honesty and guilt in breastfeeding, is an important one for all who promote and support breastfeeding. The mothers shared their perspective and skepticism of the level of honesty in the area of breastfeeding education. It is important for those who promote and support breastfeeding to use breastfeeding education as a tool to teach and prepare mothers for potential breastfeeding problems that could come up and way to overcome them. Since every mother’s breastfeeding experience is individualized, it is important that clinicians find a balance during breastfeeding education and support without scaring mothers. Mothers shared that they are prepared for the potential issues of childbirth because they are made aware of them, so if this practice is applied to breastfeeding, there will potentially be more successful mothers who breastfeed. It is also important that each clinician that comes in contact with a mother ascertain their infant feeding plans to be able to appropriately support her. On the role of hospital and clinical staff on the mother’s breastfeeding practice, majority of the
R. Powell et al. mothers reported negative or no support from the hospital or clinical staff. This is a potentially contradictory message being sent to mothers since clinicians educate the mothers on breastfeeding yet do not offer support of it. Some mothers are dependent on clinicians’ advice and education so it is crucial that clinicians are giving a high standard of education to every patient at the initial meeting, no matter educational background, race, or age of the mother. Assumptions cannot be made about what the mother already knows otherwise there will be many missed opportunities, for breastfeeding promotion among, new mothers. Findings from the project is consistent with past research that emphasizes that social support is important for women (Schmied et al., 2011) as well as clinician support (Brown et al., 2011) are important for women. Again our findings are in agreement with a review of the literature that showed that either type of support was beneficial for breastfeeding, especially exclusive breastfeeding (Britton et al., 2007). While this research project has identified some of the challenges mothers face when it comes to breastfeeding education and support in the study community, there are a few limitations. The first limitation is that, there was a lack of diversity in race/ethnicity among the mothers that were interviewed. Even though the study was introduced as an infant feeding study, not just a breastfeeding study, there were not many formula-feeding mothers. Both settings where mothers were recruited, Full Bloom and WIC, promote breastfeeding, which could have contributed to most of the mothers in the study breastfeeding. Due to these limitations, the results may not be generalizable to other populations or settings. Future research should consider replicating this study with a more diverse population. Other areas of future research include examining mothers who formula feed their infants to understand their perspectives and opinions on breastfeeding, and how collectively breastfeeding can become more accepted and promoted within the community.
Conflict of interest There are no conflicts of interest to report.
Funding Funding for this work was provided by the Community Breastfeeding Coalition of Athens, Georgia.
Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001
A qualitative look into mother’s breastfeeding experiences
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Please cite this article in press as: Powell, R., et al., A qualitative look into mother’s breastfeeding experiences, Journal of Neonatal Nursing (2014), http://dx.doi.org/10.1016/j.jnn.2014.04.001