Women's Experiences With Early Breastfeeding After Gestational Diabetes

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Women’s Experiences With Early Breastfeeding After Gestational Diabetes Karen P. Jagiello and Ilana R. Azulay Chertok

Correspondence Karen P. Jagiello, MSN, RNC, James Madison University, 820 Madison Drive MSC 4305, Harrisonburg, VA 22807. [email protected] Keywords gestational diabetes mellitus breastfeeding lactation phenomenology

ABSTRACT Objective: To explore the lived experience of early breastfeeding for postpartum women who had gestational diabetes mellitus (GDM) in pregnancy. Design: A qualitative phenomenological research design. Setting: Participants were recruited from community hospitals, postpartum clinics, and lactation clinics in rural and urban facilities in the Midwest and Atlantic Regions of the United States. Participants: A purposive sample of 27 women who had been diagnosed with GDM and who had initiated breastfeeding following delivery. Methods: Questions were used as prompts to initiate conversation and to provide structure for focus group discussions and interviews. Data were analyzed independently and then collaboratively with the researchers and experts to compare findings, including interpretations and concerns before revisions were made in preparation of the final, composite description. Results: Three themes emerged from the data reflecting the participants’ interpreted experience: Breastfeeding Challenges and Breastfeeding Support, Milk Supply Challenges, and Concern for Infant Health. Delayed lactogenesis II was reported by 30% of the women, and 44% perceived decreased milk supply. Conclusions: Participants identified breastfeeding facilitators and barriers, many of which could have been modified. The women expressed a need for consistent lactation advice, education, assistance, and strategies to address breastfeeding challenges and milk supply issues.

JOGNN, 44, 500-509; 2015. DOI: 10.1111/1552-6909.12658 Accepted March 2015

Karen P. Jagiello, MSN, RNC, is an assistant professor of nursing, James Madison University, Harrisonburg, VA and a doctoral student, West Virginia University, Morgantown, WV. Ilana R. Azulay Chertok, PhD, MSN, RN, IBCLC, is a professor in the School of Nursing, West Virginia University, Morgantown, WV and Affiliate Faculty College of Nursing, University of Illinois at Chicago, Chicago, IL.

Supported by the West Virginia March of Dimes and the James Madison University Department of Nursing.

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reastfeeding is considered the most complete form of nutrition for infants and provides health, growth, development, and immunity benefits (American Academy of Pediatrics, 2012), yet many women do not breastfeed. Specifically for women with gestational diabetes mellitus (GDM) or preexisting diabetes, breastfeeding is recommended to promote maternal and infant metabolic health (American Diabetes Association [ADA], 2012; Metzger et al., 2007). However, some researchers have found that women with diabetes in pregnancy have lower rates of breastfeeding initiation (Finkelstein et al., 2013). Similarly, breastfeeding duration rates have been noted to be shorter among breastfeeding women with diabetes compared to women without diabetes (Dewey, Nommsen-Rivers, Heinig, & Cohen, 2003; Soltani & Scott 2012). With an increasing trend in the number of women diagnosed with

B

GDM (Hunt & Schuller, 2007), the need to address issues associated with breastfeeding by women with GDM is critical.

Background Limited research has been published on the breastfeeding challenges faced by women with diabetes. Much of the research on the effect of diabetes on the breastfeeding process has focused on women with type I diabetes mellitus (T1DM) (Berg & Sparud-Lundin, 2009; Stenhouse, Letherby, & Stephen, 2013), even though type II diabetes (T2DM) and GDM are more common during pregnancy and differ in nature from T1DM. The treatment for each is not necessarily insulin dependent. Furthermore, qualitative researchers focused on women with GDM and evaluated the experience of having diabetes in pregnancy

 C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

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Jagiello, K. P., and Azulay Chertok, I. R.

without exploring the perception of the breastfeeding process (Berg, Erlandsson, & Sparud-Lundin, 2012; Carolan, Gill, & Steele, 2012; Hjelm, Bard, & Apelqvist, 2012; Nolan, McCrone, & Chertok, 2011; Sparud-Lundin & Berg, 2011). Women with GDM who participated in a qualitative study in Vietnam regarding health attitudes and behaviors expressed fear of transmitting diabetes to their infants through breastfeeding (Hirst et al., 2012), which indicates a need for evidence-based information about breastfeeding and GDM. Among the limited research conducted on breastfeeding in the GDM population, one area of examination has been perceived milk supply and its effect on infant feeding practices. Various factors have been associated with no or limited breastfeeding among women with GDM, including perceived inadequate milk supply or delayed onset of copious milk production with lactogenesis II (Brownell, Howard, Lawrence, & Dozier, 2012; Dewey et al., 2003; Matias, Dewey, Quesenberry, & Gunderson, 2014; Trout, Averbuch, & Barowski, 2011). Additionally, insulin treatment, obesity, increased maternal age, and relatively low breastfeeding assessment scores were significant factors in delayed lactogenesis II (DL2) among women with a history of GDM when comparing the timing of lactogenesis II to the expected time of 72 hours postpartum (Matias et al., 2014). Women who feel that their infants are unsatisfied after nursing are more likely to supplement with formula and to cease breastfeeding (Brownell et al., 2012; Gatti, 2008). However, the use of formula supplementation may contribute to a further reduction of milk supply and sabotage breastfeeding efforts (DaMota, Banuelos, Goldbronn, Vera-Beccera, & Heinig, 2012). Additional factors identified as associated with DL2 in women who had diabetes during pregnancy (T1DM, T2DM, or GDM) included delayed breastfeeding initiation following delivery, failure to breastfeed for first feed, elevated maternal Body Mass Index (BMI), and maternal insulin treatment during pregnancy (Matias et al., 2014). cesarean birth has also been associated with DL2 in women with T1DM (Sorkio et al., 2010). The purpose of this qualitative study was to gain insight into the breastfeeding challenges that women with GDM face in the early postpartum period. The research question was “What is the structure of meaning of the lived experience of early breastfeeding for postpartum women who had GDM?”

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Limited research has been conducted on the breastfeeding experiences of women with gestational diabetes.

Methods A qualitative, phenomenological approach using focus groups and interviews was employed to elicit the experience of women who had been diagnosed with GDM and who had initiated breastfeeding. Early breastfeeding was defined as any attempt to breastfeed in the first week postpartum. Questions were used as prompts to initiate conversation and to provide structure for focus group discussions and interviews. The participants completed brief demographic surveys at the start of each session. The focus groups and interview sessions were audio-recorded using a digital recorder with permission from participants. Additionally, notes were taken by a member of the research team for data checking. Transcripts of the audio recordings were compared with the notes and were deidentified for analysis. Prior to initiating the study, ethical approval was obtained from the researchers’ institutions.

Setting and Participants Using a purposive sampling method, women who had been diagnosed with GDM and had initiated breastfeeding following birth were identified by the lactation consultant, medical, or nursing staff member in the hospital during postpartum visits or at the lactation clinic visits. The health care professionals provided the interested women with the research team’s contact information. Additionally, flyers were posted at the postpartum clinics. Women who were interested contacted the research team and received an explanation of the study procedures, including the audio recording of the sessions and signed informed consent prior to participation. The study took place over a 3- month period, from October 2013 to January 2014, in rural and urban facilities in the Midwest and Atlantic regions of the United States. Inclusion criteria were women who delivered term infants without serious health problems or anomalies diagnosed at birth, maternal history of GDM during pregnancy within the past year (9 months), any attempt to breastfeed in the first week postpartum, maternal age ࣙ18 years, fluency in English, and willing to participate in the focus groups. Participants were invited to join one of the focus groups scheduled in their regions, located in private conference or meeting rooms at a clinic

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or hospital. Women who expressed interest but were unable to attend the focus groups were invited to participate through individual in-person or telephone interviews. Twenty women participated in one of seven focus groups conducted in four states, and seven additional women participated in individual interviews to validate the findings of the focus groups for a total of 27 women. Following completion of study participation, the women were offered a $10 gift card.

Data Analysis The audio-recorded focus groups and interviews were transcribed verbatim. The deidentified qualitative data were analyzed for themes using Van Manen’s selective approach in which researchers discover the participants’ experiences through reading and rereading the transcripts, highlighting statements and phrases that capture the meaning and intent, clustering the emergent statements into categories and subcategories, and formulating themes (Creswell, 2007; Van Manen, 1990). This method of inquiry is used to investigate a phenomenon as the individual lives the experience as a unique story and to focus on the essence of each element as it is reported. In this inquiry, the researchers’ own interests are acknowledged to determine the original question but put aside to allow the participants’ voices to prevail (Van Manen, 1990). Transcripts were organized and content analyzed using NVivo 10 computer program to compare and validate themes. Descriptive data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 21 using univariate statistics to describe the group characteristics of the participants.

Validity and Rigor The primary question of interest was the women’s breastfeeding experience in the early postpartum period following their pregnancies with GDM. Additional prompting questions were used to enhance the discussion when needed, including questions about their perception of support, barriers, and facilitators to breastfeeding. We maximized credibility and rigor using three different methods: prolonged engagement, peer debriefing, and member checking (Koch, 1994). As recommended by Koch (1994), prolonged engagement was accomplished using the process of care, accountability, and open communication throughout each focus group and interview session. The transcription process allowed us

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greater immersion into the data. Member checking was accomplished by having focus group and interview participants review the transcripts for accuracy (Sandelowski, 1986). Peer debriefing was accomplished by requesting a review of the transcripts by experts in the field including two international board-certified lactation consultants and a registered dietician who specializes in women with diabetes (Creswell, 2007). Following review of the transcripts with independent interpretation, the experts compared and discussed findings including interpretations and concerns. Revisions were made in preparation of the final, composite description.

Results Descriptive characteristics of the 27 participants are presented in Tables 1 and 2. Three primary themes emerged from the narratives regarding breastfeeding experiences of women with GDM: Breastfeeding Challenges and Breastfeeding Support, Milk Supply Challenges, and Concern for Infant Health.

Breastfeeding Challenges and Breastfeeding Support The sample consisted of women who intended to and initiated breastfeeding, which indicated in general that the women were motivated to breastfeed. Overall, the women felt that they received support and encouragement to breastfeed from their partners, family, and friends, especially those with previous breastfeeding experience. Encouragement for breastfeeding included messages about the healthful outcomes associated with breastfeeding for the mother and her infant: “My husband’s awesome . . . he’s like, [you should breastfeed] because it’s healthier for him and it’s healthier for you.” Another said, “I think what was most helpful was some family and friends of mine who nursed their children or currently are. I learned [from them].” A few participants experienced a lack of early breastfeeding support by family members and health care providers with suggestions to terminate breastfeeding and/or supplement with formula: “and people are . . . like you should just stop, you should just pump, you should just use formula, why are you doing this?” These suggestions usually followed breastfeeding challenges such as delayed or decreased milk production, inability to achieve latch, or other

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Table 1: Descriptive Characteristics of Maternal/Infant Dyad Participants Affected by Gestational Diabetes Mellitus (GDM) (n = 27, except where indicated) Categorical Independent Variable

Frequency

Percent

Ethnicity White

26

96.3

Other

1

3.7

Married No

1

3.7

Yes

26

96.3

Education High school/GED

3

11.1

Some college

6

22.2

Graduated college

9

33.3

Graduate school

9

33.3

Multipara

14

51.9

Primipara

13

48.1

Parity

Maternal BMI ࣙ 25 kg/m2 Yes

21

77.5

No

6

22.5

14

51.9

Instrumental vaginal

3

11.1

Cesarean planned

5

18.5

Cesarean unplanned

5

18.5

No

2

7.4

Yes

25

92.6

Male

15

55.6

Female

12

44.4

No

23

85.2

Yes

4

14.8

No

25

92.6

Yes

2

7.4

Mode of delivery Vaginal

Anesthesia during delivery

Infant gender

Infant hypoglycemia

Infant NICU admission

(Continued)

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Table 1: Continued Categorical Independent Variable

Frequency

Percent

Stopped breastfeeding No

21

77.8

Yes

6

22.2

No

14

53.8

Yes

12

46.2

No

1

7.1

Yes

13

92.9

No

6

54.5

Yes

5

45.5

Formula supplementation (n = 26)

Breastfed previous children (n = 14)

Previous GDM (n = 14)

Note. GED = Graduate Equivalency Diploma; BMI = body mass index; NICU = neonatal intensive care unit; GDM = gestational diabetes mellitus.

difficulty in getting the infant to nurse. The lack of success could be partially explained by the new skills required for breastfeeding; however, these women are potentially at increased risk for problems associated with GDM that may negatively affect milk production. Furthermore, the relatively high rate of instrumental or cesarean births (48.1%, n = 13) and infant health issues such as neonatal hypoglycemia (14.8%, n = 4) and jaundice (7.4%, n = 2) may have contributed to extended maternal/infant separation and challenges with breastfeeding positioning. One woman who gave birth by cesarean said, “After my C-section . . . I remember the nurse had got and brought him over, helped get him latched.” Another participant voiced concern, “She was jaundiced for a long time . . . she was just tired, she didn’t want to nurse.” Some women received breastfeeding support, guidance, and assistance from lactation consultants, in person or by phone, while in the hospital or following discharge, “[She] changed everything for me. When she came . . . and my mom was like . . . she’s worth her weight in gold.” The women used their support persons and resources to seek information and help to improve the breastfeeding process. Some women reported using breastfeeding accessories and pumping to facilitate feeding their infants breast milk. Even with assistance, 44% (n = 12) of the women used formula as a

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Women with gestational diabetes face challenges that can affect breastfeeding, including delayed lactogenesis II, insufficient milk supply, infant hypoglycemia, and infant macrosomia.

supplement or in place of breastfeeding. Their frustration was apparent: I spoke with the lactation consultant over the phone a couple times, and she just kept telling me that I was doing everything right that she would eventually take and that’s when I drew the line, that last week . . . and I couldn’t, I just felt like I was starving her. There were positive and negative descriptions of the assistance received from health care providers while in the hospital. Some participants praised the staff, particularly the nurses: This nurse comes in . . . She said, listen, it doesn’t matter if you breastfeed your baby after two hours or after 24 hours. They will learn to do it. He will be fine, just keep pumping . . . in the morning he just latched right on. However, others reported that they felt that the information and help that they received in the hospital were insufficient. The participants reported inconsistent messages, incorrect information, or insufficient support from staff: So people were trying, I think desperately to help us, but the information wasn’t the same. And it caused us to really have a lot of questions and not know what was the correct way [to breastfeed] . . . it was re-

ally frustrating that the information wasn’t the same. The women also noted that health care providers encouraged formula supplementation. Seven participants felt that the supplementation was not needed and subsequently sabotaged their breastfeeding efforts, “the nurses in the hospital insisted on giving formula. Now the baby is not satisfied with breastfeeding and I am not sure that I have enough milk so I start with breastfeeding and then give formula.” Another noted, “I was pretty traumatized at day four when I went to the pediatrician and they threw some formula at me and said . . . put your baby on formula because you’re not giving him enough.” Participants reported a positive experience in seeking advice and support through web-based sources. This additional source of support was mentioned by four participants who received help using online websites or support groups for women with diabetes in pregnancy. They sought health and breastfeeding information specific to their GDM status: “I found an online support group for moms with diabetes and that helped a lot because I found out that a lot of other people felt the exactly same way.”

Milk Supply Challenges Maternal milk supply was considered a barrier to breastfeeding. Eleven (40.7%) of the women reported a delay in their milk coming in following birth, and 12 (44.44%) expressed the perception that they had inadequate milk supplies. These challenges may have been related to the women’s diabetic status as supported by the rate of DL2, perception of insufficient milk supply, efforts to increase milk production, and use of formula. One woman reported, “My milk never really came. I

Table 2: Mean Descriptive Characteristics of Maternal/Infant Dyads Affected by GDM (N = 27) Characteristic

Mean (SD)

Range

Maternal age (years)

33.74 (6.29)

20.0–43.0

Infant age (weeks)

11.24 (8.08)

1.0–31.0

Gestational age (weeks)

39.15 (1.07)

37.0–41.0

Infant birth weight (kg)

3.588 (0.65)

2.580–5.620

32.05 (9.02)

21.0–54.9

31.96 (8.17)

21.4–54.7

Maternal pre-pregnancy BMI (kg/m2 ) 2

Maternal postpartum BMI (kg/m ) Note. BMI = body mass index.

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never felt full and could only get a few drops, but I was determined to keep trying.” This perception of milk insufficiency contributed to feelings of frustration and/or failure among the women who believed that they were depriving their infants of nourishment, “I definitely failed here . . . . And I felt so guilty because he was crying so much and the whole time I’m like . . . I was starving you and I didn’t realize it.” The assessment of maternal milk supply was often measured through the infant’s weight loss, “by the time we were being discharged from the hospital he had lost a significant amount of weight, almost a pound. And they started to supplement him with formula in the hospital with a syringe.” The participants reported that they attempted various strategies to increase their milk supplies including pumping, frequent feedings, and the use of medications or herbal remedies. One woman said, “I was taking a number of supplements, fenugreek . . . things like that to kind of boost [my milk supply] as well as pumping right after I nursed.” Another stated, “I tried [medication] for a month and pumping. . . . It bumped up my production.” The women experienced mixed results from the strategies they used to increase their milk supplies; 12 women (46.0%) used formula supplementation. Many women (55.6%, n = 15) augmented their milk production through various efforts, whereas six women (22%) completely ceased breastfeeding, “The only reason I stopped breastfeeding is because I dried up. So I didn’t just stop because I wanted to stop, I stopped because there was nothing.” Another said, “I knew he wasn’t getting enough and I had concerns, but I did as much as I could before I had to go to formula. And then I cried for weeks.” On the other hand, fewer women (33.3%, n = 9) reported that their milk supplies were sufficient, “That morning whenever I woke up . . . it was there [milk supply] . . . she was able to nurse and I started nursing her then and she’s nursed ever since.”

Concern for Infant Health The respondents expressed concern for their infants’ health following birth. Among the infants, 33.3% (n = 9) experienced complications including hypoglycemia (14.8%, n = 4). Additionally, infants born to mothers with GDM were monitored for hypoglycemia following birth that caused concern and focus on the infants’ blood glucose levels. One mother noted, “I wanted to breastfeed her

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right away knowing that . . . she might throw a low blood sugar and I wanted to get her latched right away.” Health problems among the infants affected breastfeeding, and problems such as infant hypoglycemia and weight loss were often treated with feeding the infant formula. “He lost a lot of weight . . . he was very dehydrated because I wasn’t making enough [milk].” Even among women who had sufficient milk supply and those who were expressing milk, health providers insisted on using formula. One woman reported, “my milk was flowing by the third day, but because of her hypoglycemia . . . the nurses in the hospital insisted on giving formula.” Another issue reported was maternal/infant separation following birth, which the mothers felt affected breastfeeding, milk supply, and bonding, “They let me see him for just a second and then they said that he needed to go to the nursery for monitoring. . . . I didn’t get him skin to skin for hours” reported one mother, whereas another said “when her sugars were in the low stage I couldn’t even touch her so breastfeeding was problematic.”

Discussion The purpose of this study was to gain a better understanding of the lived experience of early breastfeeding for women who had GDM. Many women feel emotionally burdened by having GDM in pregnancy (Bandyopadhyay et al., 2011), and experiencing challenges with breastfeeding may be perceived as yet another difficulty. Despite the different geographic locations of the participants, the women shared many similar experiences and concerns regarding GDM in pregnancy and early breastfeeding. The essence of the participants’ experiences can be summarized as needing tailored support and assistance to successfully breastfeed. This overall finding is derived from three themes that emerged from the data reflecting the participants’ interpreted experience: Breastfeeding Challenges and Breastfeeding Support, Milk Supply Challenges, and Concern for Infant Health. The first theme highlighted the need for early breastfeeding assistance after birth and during the following weeks, which is substantiated by the literature (Cross-Barnet, Augustyn, Gross, Resnik, & Paige, 2012). Emotional support and technical assistance in managing common lactation

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difficulties have been associated with greater rates of exclusive breastfeeding at 6 months (Pisacane, Continisio, Aldinucci, D’Amora, & Continisio, 2005). The participants reported support from partners, family, friends, and lactation consultants. In contrast, they found breastfeeding support from health care providers to be lacking and inconsistent, which has been reported in other studies (Cross-Barnet et al., 2012). Some of the women felt that they were “pushed” to supplement with formula by the hospital staff. Compared to women without diabetes, breastfeeding initiation rates for women with any type of diabetes are less or initially similar but decrease over time (Finkelstein et al., 2013). As such, early postpartum support and encouragement while in the hospital for women with diabetes in pregnancy is critical to successful breastfeeding (Finkelstein et al., 2013). Another method of support that emerged from the narrative was web-based support for breastfeeding. Some of the participants sought peer support from web-based groups having identified other women with similar experiences. Women who employed the web-based approach to support described their experiences as positive and recommended it for other women facing similar issues. They also used the Internet to seek information and approaches to care. In industrialized nations, young women are using social media to seek information on the topics of pregnancy, birth, and breastfeeding, including women with diabetes (McCann & McCulloch, 2012; Sparud-Lundin, Ranerup, & Berg, 2011). This developing area of support is one that can be judiciously utilized to promote breastfeeding for mothers who are experiencing challenges. Other lactation challenges outside of milk supply included difficulty with latching and positioning as well as nipple pain with breastfeeding. Difficulty with positioning has been found to be a common problem in obese mothers (Donath & Amir, 2008), and a majority of the mothers (77.5%, n = 21) in this study were overweight or obese. Obese women were also found to be more likely to experience difficulty with latching their infants and discontinued breastfeeding earlier than women with normal weight (Oddy et al., 2006). A poor latch can cause pain with breastfeeding and inhibit a woman’s desire or ability to continue breastfeeding. This was the case in our study, and one participant abandoned breastfeeding due to nipple pain (Buck, Amir, Cullinane, & Donath, 2014).

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A second theme that emerged was related to milk supply. Women’s perceptions of insufficient milk supply was reported by other researchers (Nommsen-Rivers, Chantry, Peerson, Cohen, & Dewey, 2010), and this is a commonly reported reason for breastfeeding cessation among women who are nondiabetic (Gatti, 2008). Women with diabetes have an increased risk for impeded milk supply and reduced breastfeeding rates associated with factors such as obesity, operative vaginal birth, cesarean, and separation from the infant following birth (Brownell et al., 2012; Chapman, 2014). Additionally, their infants have higher rates of macrosomia, hypoglycemia, and admission to the neonatal intensive care unit (NICU) (Hawdon, 2011; Soltani & Arden, 2009). These various factors are associated with maternal/infant separation in the early postpartum period, a time when the initiation of bonding and first feeding can positively influence breastfeeding success. In addition to insufficient milk supply, women with GDM reported DL2, a delay in their milk “coming in,” which has been found by other researchers (Matias et al., 2014). DL2 has been defined as a delay in copious milk production greater than 72 hours after delivery (Dewey et al., 2003). More than one fourth of the participants reported that their milk did not come in until 5 or more days postpartum. This delay can affect the mothers’ perception of milk supply and can increase feelings of frustration and failure at the breastfeeding effort (Brownell et al., 2012). Participants in this study perceived that they were “starving” their infants. Pumping from early postpartum may be indicated for these women as introduction of formula supplements in the hospital is associated with early cessation of breastfeeding (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014). The delay in maternal initiation of breastfeeding has been found to affect milk supply by decreasing the stimulation needed for milk production (DaMota et al., 2012). The perception of insufficient milk supply induces some women to implement methods to stimulate milk production such as pumping (Becker, Cooney, & Smith, 2011). Participants in this study reported various means of attempting to increase their milk supply, including pumping and use of galactogogue medications or herbal remedies, though there is mixed evidence to demonstrate effectiveness (Fife et al., 2011; Hansen, McAndrew, Harris, & Zimmerman, 2005).

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The third theme that emerged from the narratives was concern for the infant’s health. The issues most commonly discussed were hypoglycemia, infant weight loss, infant monitoring and treatment, and separation of the mother from her infant. Infants of mothers with diabetes during pregnancy are more likely to experience hypoglycemia in the first 24 hours following delivery (Maayan-Metzger, Lubin, & Kuint, 2009) which increases their risk for NICU admission. There is an increased risk of macrosomia for infants of diabetic mothers, especially for those with poor maternal glucose control (Meur & Mann, 2007). Furthermore, macrosomic infants of mothers with GDM had higher rates of hypoglycemia than average for gestational age infants of mothers with GDM who were of normal weight (Esakoff, Cheng, Sparks, & Caughey, 2009). Monitoring early infant blood glucose levels can identify and prevent neonatal hypoglycemia. The women in this study reported that formula supplementation for prevention and treatment of neonatal hypoglycemia, maternal/infant separation, and admission to the NICU were employed during the first hours following delivery. Yet early infant breastfeeding can help prevent neonatal hypoglycemia and promote glucose stability (Chertok, Raz, Shoham, Haddad, & Wiznitzer, 2003). These findings suggest that initiating early breastfeeding within the first hour following delivery and monitoring of infant blood glucose while keeping the infant with the mother will promote neonatal glucose stability and limit maternal/infant separation. When supplementation is indicated, infants’ own mother’s milk should be used. Women voiced concern about their infants’ weight loss in the first week postpartum. Weight loss following birth is common, however, Renault et al. (2011) found that breastfed infants were more likely to lose weight than those who were bottle fed, independent of maternal BMI. Additionally, infants of mothers with GDM or obesity lost significantly more weight by the third day compared to infants of mothers who were nondiabetic or nonobese (Renault et al., 2011). This may have been a confounding factor for these women with GDM as more than 77% of them were overweight or obese. Dewey et al. (2003) also found a significant relationship between maternal BMI greater than 27 kg/m2 and excess infant weight loss as well as an association between DL2 and infant weight loss.

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Women with gestational diabetes expressed the need for consistent and accurate breastfeeding guidance and education to help them address the challenges they faced in early breastfeeding.

Implications for practice that may be drawn from the study include developing tailored breastfeeding support and accurate, evidence-based information for women with GDM who intend to breastfeed. Web-based resources should also provide evidence-based education and serve as a medium of socialization for pregnant and postpartum women with GDM seeking advice and peer support. Increasing breastfeeding success begins during the antenatal period with breastfeeding promotion and education that includes potential barriers during the early postpartum period. Anticipatory guidance can minimize the emotional trauma caused by lack of understanding of the lactation process during the transition period. Antenatal breastfeeding education classes geared toward women with GDM would also provide specialized information related to maternal issues such as positioning challenges related to maternal weight and mode of delivery and infant issues such as blood-glucose monitoring. Obstetric and neonatal practitioners could discuss possible health issues that may affect the infant to decrease the lack of knowledge, fear, and anxiety experienced by mothers of infants who require medical attention following delivery. Early postpartum referral to a lactation expert is important to address challenges. Strategies such as increasing milk expression frequency in the first weeks postpartum, especially in situations of maternal/infant separation, can stimulate lactation and help reduce the risk of insufficient milk supply or DL2. Health care providers should be trained in providing consistent provision of evidence-based education and strategies to help women through breastfeeding challenges. Limitations of the study include the small study sample size, which possibly limits the transferability of the study findings, though transferability is not necessarily a goal of phenomenological studies. Recommendations for future research regarding GDM women’s early breastfeeding experience and practices include exploring the specific factors affecting breastfeeding initiation and the timing of transition to lactogenesis II. Furthermore,

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specific to women with GDM, there is a lack of research on antenatal breastfeeding education. The high frequency of prenatal visits for women with diabetes in pregnancy offers the opportunity to educate and positively affect women’s decision to breastfeed during the prenatal period. Evaluation of the effectiveness of antenatal breastfeeding education tailored to GDM women can help inform the development of an appropriate approach to supporting this population with their breastfeeding efforts.

Berg, M., & Sparud-Lundin, C. (2009). Experiences of professional support during pregnancy and childbirth – a qualitative study of women with type I diabetes. BMC Pregnancy and Childbirth, 9(27), 1–8. doi:10.1186/1471-2393-9-27 Brownell, D., Howard, D. R., Lawrence, R. A., & Dozier, A. M. (2012). Delayed onset lactogenesis II predicts the cessation of any or exclusive breastfeeding. Journal of Pediatrics, 161(4), 608–614. doi:10.1016/j.peds.2012.03.035 Buck, M. L., Armir, L. H., Culliane, M., & Donath, S. M. (2014). Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeeding Medicine, 9(2), 56–62. doi:10.1089/bfm.2013.0106 Carolan, M., Gill, G. K., & Steele, C. (2012). Women’s experiences of factors that facilitate or inhibit gestational diabetes self-

Conclusion Findings from the study highlight some of the breastfeeding challenges and facilitators that women with GDM experience. Early breastfeeding initiation is important for the promotion of glucose stability in infants born to women with GDM. Some women with GDM face challenges and barriers that can affect breastfeeding such as DL2, insufficient milk supply, problems with latch and positioning, infant hypoglycemia, and infant macrosomia. Early and consistent evidencebased breastfeeding support and assistance can help mitigate the breastfeeding difficulties and facilitate the breastfeeding process. Women with GDM expressed the need for consistent and accurate breastfeeding guidance and education by health care providers to help them address the challenges they face in early breastfeeding. Health care providers should utilize the responses of the women to inform them of the need to develop an evidence-based approach to providing breastfeeding support for maternal/infant dyads faced with diabetes in pregnancy.

management. BMC Pregnancy and Childbirth, 12(1), 99–111. doi:10.1186/1471-2393-12-99 Chantry, C. J., Dewey, K. G., Peerson, J. M., Wagner, M. S., & Nommsen-Rivers, L. A. (2014). In-hospital formula use increases early breastfeeding cessation among firsttime mothers intending to exclusively breastfeed. Journal

of

Pediatrics,

164(6),

1349–1345.

Retrieved

from

http://dx.doi.org/10.1016/j.jpeds.2013.12.035 Chapman, D. J. (2014). Risk factors for delayed lactogenesis among women with gestational diabetes mellitus. Journal of Human Lactation, 30(2), 134–135. doi:10.1177/0890334414525566 Chertok, I. R., Raz, I., Shoham, I., Haddad, H., & Wiznitzer, A. (2003). Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Journal of Human Nutrition and Dietetics, 22, 166–169. doi:10.1111/j.1365277X.2008.00921.x Creswell, J. W. (2007). Five qualitative approaches to inquiry. Qualitative inquiry & research design choosing among five approaches (2nd ed., pp. 85–100). Thousand Oaks, CA: Sage Publications. Cross-Barnet, C., Augustyn, M., Gross, S., Resnik, A., & Paige, D. (2012). Long-term breastfeeding support: Failing mothers in need. Journal of Maternal Child Health, 16, 1926–1932. doi:10.1007/s10995-011-0939-x DaMota, K., Banuelos, J., Goldbronn, J., Vera-Beccera, L. E., & Heinig, M. J. (2012). Maternal request for in-hospital supplementation of healthy breastfed infants among lowincome women. Journal of Human Lactation, 28, 476–482. doi:10.1177/0890334412445299 Dewey, K. G., Nommsen-Rivers, L. A., Heinig, M. J., & Cohen,

REFERENCES

R. J. (2003). Risk factors for suboptimal infant breast-

American Academy of Pediatrics. (2012). Breastfeeding and

feeding behavior, delayed onset of lactation, and excess

the use of human milk. Pediatrics, 129(3), e827–e841.

neonatal weight loss. Pediatrics, 112(3), 607–620. Retrieved

doi:10.1542/peds.2011-3552

from

American Diabetes Association (ADA). (2012). Standards of medical care in diabetes–2012. Diabetes Care, 35(Suppl 1), 11–63. doi:10.2337/dc12-s011 Bandyopadhyay, M., Small, R., Davey, M. A., Oats, J. J., Forster, D. A., & Aylward, A. (2011). Lived experience of gestational diabetes

Donath, S. M., & Amir, L. H. (2008). Maternal obesity and initiation and duration of breastfeeding: Data from the longitudinal study of Australian children. Maternal & Child Nutrition, 4(3), 163–170. doi:10.1111/j.1740-8709.2008.00134.x

mellitus among immigrant South Asian women in Australia. Aus-

Esakoff, T. F., Cheng, Y. W., Sparks, T. N., & Caughey, A. B. (2009). The

tralian and New Zealand Journal of Obstetrics and Gynaecology,

association between birthweight 4000 g or greater and perina-

51, 360–364. doi:10.1111/j.1479-828X.2011.01322.x

tal outcomes in patients with and without gestational diabetes

Becker, G. E., Cooney, F., & Smith, H. A. (2011). Methods of milk expression for lactating women. Cochrane Database Systematic

508

http://pediatrics.aappublications.org/content/112/3/607.

full.html

mellitus. American Journal of Obstetrics & Gynecology, 200(6), e1–4. doi:10.1016/j.ajog.2009.02.035

Review, 12, CD006170. doi:10.1002/14651858.CD006170.pub3

Fife, S., Gill, P., Hopkins, M., Angello, C., Boswell, S., & Nelson, K. M.

Berg, M., Erlandsson, L. K., & Sparud-Lundin, C. (2012). Breastfeeding

(2011). Metoclopramide to augment lactation, does it work? A

and its impact on daily life in women with type 1 diabetes during

randomized trial. Journal of Maternal-Fetal & Neonatal Medicine,

the first six months after childbirth: A prospective cohort study.

24(11), 1317–1320. doi:10.3109/14767058.2010.549255

International Breastfeeding Journal, 7(20), 1–7. Retrieved from

Finkelstein, S. A., Keely, E., Feig, D. S., Tu, X., Yasseen, A. S., & Walker,

http://www.internationalbreastfeedingjournal.com/content/7/1/20

M. (2013). Breastfeeding in women with diabetes: Lower rates

JOGNN, 44, 500-509; 2015. DOI: 10.1111/1552-6909.12658

http://jognn.awhonn.org

RESEARCH

Jagiello, K. P., and Azulay Chertok, I. R.

despite greater rewards. A population-based study. Diabetic Medicine, 30(9), 1094–1110. doi:10.1111/dme.12238

Nommsen-Rivers, L., Chantry, C. J., Peerson, J. P., Cohen, R. J., & Dewey, K. G. (2010). Delayed onset of lactogenesis among first-

Gatti, L. (2008). Maternal perceptions of insufficient milk supply in

time mothers is related to maternal obesity and factors associ-

breastfeeding. Journal of Nursing Scholarship, 40(4), 355–363.

ated with ineffective breastfeeding. American Journal of Clinical

doi:10.1111/j.1547-5069.2008.00234.x

Nutrition, 92, 574–584. doi:10.3945/ajcn.2010.29192

Hansen, W. F., McAndrew, S., Harris, K., & Zimmerman, M. B. (2005).

Oddy, W. H., Li, J., Landsborough, L., Kendall, G. E., Henderson, S., &

Metoclopramide effect on breastfeeding the preterm infant: A

Downie, J. (2006). The association of maternal overweight and

randomized trial. Obstetrics & Gynecology, 105(2), 383–389.

obesity with breastfeeding duration. The Journal of Pediatrics,

doi:10.1097/01.AOG.0000151113.33698.a8

149(2), 185–191. doi:10.1016/j.jpeds.2006.04.00

Hawdon, J. M. (2011). Babies born after diabetes in pregnancy: What

Pisacane, A., Continisio, G. I., Aldinucci, M., D’Amora, S., & Continisio,

are the short- and long-term risks and how can we minimize

P. (2005). A controlled trial of the father’s role in breastfeeding

them? Best Practice & Research Clinical Obstetrics & Gynaecology, 25(1), 91–104. doi:10.1016/j.bpobgyn.2010.10.005

promotion. Pediatrics, 116, e494. doi:10.1542/peds.2005-0479 Renault, N., Botton, J., Blanc, L., Hankard, R., Forhan, A., Goua, V., . . .

Hirst, J. E., Tran, T. S., Do, M. A., Rowena, F., Morris, J. M., & Jeffery, H.

The EDEN Mother-Child Cohort Study Group. (2011). Determi-

E. (2012). Women with gestational diabetes in Vietnam: A quali-

nants of neonatal weight loss in term-infants: Specific associa-

tative study to determine attitudes and health behaviours. BMD

tion with pre-pregnancy maternal body mass index and feeding

Pregnancy & Childbirth, 12, 81–91. doi:10.1186/1471-2393-12-

mode. Archives of Disease in Childhood, Fetal Neonatal Edition,

81 Hjelm, K., Bard, K., & Apelqvist, J. (2012). Gestational diabetes: Prospective interview-study of the developing beliefs about

96(3), F217–F222. doi:10.1136/adc.2010.185546 Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science 8, 27–37.

health, illness and health care in migrant women. Jour-

Soltani, H., & Arden, M. (2009). Factors associated with breastfeeding

nal of Clinical Nursing, 21, 3244–3256. doi:10.1111/j.1365-

up to 6 months postpartum in mothers with diabetes. Journal

2702.2012.04069.x Hunt, K. J., & Schuller, K. L. (2007). The increasing prevalence of diabetes in pregnancy. Obstetrics and Gynecology Clinics of North America, 34, 173–199. doi:10.1016/j.ogc.2007.03.002 Koch, T. (1994). Establishing rigour in qualitative research: The decision trail. Journal of Advanced Nursing, 19, 976–978. doi:10.1111/j.1365-2648.2006.03681.x

of Obstetric, Gynecologic and Neonatal Nursing, 38, 586–594. doi:10.1111/j.1552-6909.2009.01052.x Soltani, H., & Scott, A. M. (2012). Antenatal breast expression in women with diabetes: Outcomes from a retrospective cohort study. International Breastfeeding Journal, 7(18), 1–5. doi:10.1186/17464358-7-18 Sorkio, S., Cuthbertson, D., Barlund, S., Reunanen, A., Nucci, A. M.,

Matias, S. L., Dewey, K. G., Quesenberry, C. P., & Gunderson, E. P.

Berseth, C. L., . . . TRIGR Study Group. (2010). Breastfeeding

(2014). Maternal prepregnancy obesity and insulin treatment

patterns of mothers with type 1 diabetes: results from an infant

during pregnancy are independently associated with delayed

feeding trial. Diabetes/Metabolism Research and Reviews, 26,

lactogenesis in women with recent gestational diabetes mellitus. American Journal of Clinical Nutrition, 99(1), 115–121. doi:10.3945/ajcn.113.073049 Maayan-Metzger, A., Lubin, D., & Kuint, J. (2009). Hypoglycemia rates in the first days of life among term infants born to diabetic mothers. Neonatology, 96, 80–85. doi:10.1159/000203337

206–211. doi:10.1002/dmrr.1074 Sparud-Lundin, C., & Berg, M. (2011). Extraordinary exposed in early motherhood-a qualitative study exploring experiences of mothers with type 1 diabetes. BMC Women’s Health, 11(10), 1–8. Retrieved from http://www.biomedcentral.com/1472-6874/11/10 Sparud-Lundin, C., Ranerup, A., & Berg, M. (2011). Internet use, needs

McCann, A. D., & McCulloch, J. E. (2012). Establishing an online and

and expectations of web-based information and communica-

social media presence for your IBCLC practice. Journal of Hu-

tion in childbearing women with type 1 diabetes. BMC Medical

man Lactation, 28(4), 450–454. doi:10.1177/0890334412461304

Informatics & Decision Making, 11:49. doi:10.1186/1472-6947-

Meur, S., & Mann, N. P. (2007). Infant outcomes following diabetic pregnancies. Paediatrics and Child Health, 17(6), 217–222. doi:10.1016/j.paed.2007.03.004 Metzger, B. E., Buchanan, T. A., Coustan, D. R., deLeiva, A., Dunger, D. B., Hadden, D. R., . . . Zoupas, C. (2007). Summary and

11-49 Stenhouse, E., Letherby, G., & Stephen, N. (2013). Women with pre-existing diabetes and their experiences of maternity care services. Midwifery, 29, 148–153. doi:10.1016/j.midw.2011.12. 007

recommendations of the fifth international workshop-conference

Trout, K. K., Averbuch, T., & Barowski, M. (2011). Promoting breast-

on gestational diabetes mellitus. Diabetes Care, 30(2), S251–

feeding among obese women and women with gestational

S260. doi:10.2337/dco75225

diabetes mellitus. Current Diabetes Reports, 11(1), 7–12.

Nolan, J. A., McCrone, S., & Chertok, I. R. (2011). The mater-

doi:10.1007/s11892-010-0159-6

nal experience of having diabetes in pregnancy. Journal of

Van Manen, M. (1990). Researching lived experience: Human science

the American Academy of Nurse Practitioners, 23, 611–618.

for an action sensitive pedagogy. Albany, NY: State University

doi:10.1111/j.1745-7599.2011.00646.x

of New York Press.

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