“Be positive as well as realistic”: a qualitative description analysis of information gaps experienced by breastfeeding mothers

Mothers in this research identified not only the helpful information they had received but also information they felt had not been provided but which they would have found helpful. There were similarities between the helpful information received by some women and not by others. Given that women commonly experience some challenges as part of their breastfeeding experience, it is critical that this content is conveyed and reinforced to all mothers so they are equipped to deal with issues should they arise. While this survey found 43% of women reported they had a major breastfeeding problem or issue, McCann, Baydar and Williams found 70% of women reported at least one breastfeeding problem within the first month with this percentage decreasing to 45% and 29% at three and five months respectively [36]. The desire expressed by mothers in this research for guidance on breastfeeding frequency and duration, milk supply, latch and feedings positions, and nipple care is consistent with other research showing these are common breastfeeding challenges [36,37].

According to a Cochrane review, all forms of breastfeeding support increase breastfeeding duration with the authors concluding all women should universally be offered such support with proactive support more effective than reactive (women initiated contact) [22]. There is a need to ensure universal delivery of information to all breastfeeding mothers, particularly the key content areas identified by mothers in this study. Specifically, information must include an understanding of the basics of milk production and milk supply management, practical guidance that facilitates development of breastfeeding skills related to latch and positioning, realistic expectations regarding the benefits and challenges of breastfeeding, instruction on hand expression and introduction of other nutritional sources, and individualized instruction on pumping techniques as required.

A cause for concern is the similarities between many of the information deficits reported in this research and frequently cited reasons for breastfeeding cessation. Perceived insufficient milk supply is the most common reason for breastfeeding cessation [9,13,15,38]. Mothers seek guidance regarding how to manage their milk supply, and related to this, issues of frequency and duration of feedings particularly in the early days. Li, Fein, Chen and Grummer-Strawn found difficulties with latch and milk supply were the main factors in breastfeeding cessation within the first two months [39]. Other information needs identified (latch and feeding position, and nipple discomfort/care) are also prominent in the literature as factors in early breastfeeding cessation [14,15]. Once breastfeeding is well established, the desire for more information on other nutrition sources may impact the low rates of exclusive breastfeeding for six months if early introduction of complementary foods is related to a lack of knowledge regarding current recommendations and the rationale behind them. Thus, HCPs need to tailor the timing of information provided to coincide with the breastfeeding stage and unique needs of each mother with a recognition that mothers have evolving information needs throughout their lactation experience.

Some of the quotes from mothers allude to inconsistencies in the advice received such as conflicting advice regarding length and frequency of feeds, and strategies to increase milk supply. This finding corroborates with other research reporting incorrect or conflicting breastfeeding advice being offered with mothers desiring accurate and consistent messages [23,40]. Montalto, Borg, Buttigieg-Said and Clemmer found incorrect advice from HCPs to be a major factor in early breastfeeding cessation [41]. Such reports suggest the need to ensure HCPs working with lactating women have sufficient evidence-based knowledge and training to provide effective breastfeeding support.

One information gap identified, that was not mentioned by mothers who felt their information needs were met, related to a desire for more realistic information about common breastfeeding challenges and how to overcome these. Mothers felt breastfeeding education and promotion should normalize common challenges in order to help mothers anticipate and adjust to these challenges without feeling like a failure. These perceptions are supported in other literature reporting a clash between breastfeeding ideals and the realities of breastfeeding experienced by mothers [42]. Williamson, Leeming, Lyttle and Johnson found there was a tension between women’s actual breastfeeding experiences and the message that breastfeeding is easy and natural [43]. The researchers recommended “greater awareness and understanding of breastfeeding difficulties so that breastfeeding women are less likely to interpret these as a personal shortcoming in a manner which disempowers them” ([43] p. 434). Kelleher found women who experienced pain and discomfort were often surprised and anxious about this occurrence, with the physical impact of these having a negative effect on their desire to continue breastfeeding [44]. Breastfeeding promotion efforts and counselling could normalize common challenges in order to help mothers anticipate issues and enhance confidence in their ability to overcome such challenges.

Dennis described breastfeeding self-efficacy as a mother’s confidence in her breastfeeding ability with self-efficacy determining the amount of effort, perseverance and resiliency a mother exhibits, particularly when encountering challenges [45]. Other research has supported self-efficacy as an important and modifiable influence on breastfeeding duration [46,47]. Several of the information gaps identified in this research provide direction to HCPs by describing opportunities consistent with confidence-enhancing strategies outlined by Dennis [45]. First, HCPs can reinforce and provide encouragement for breastfeeding successes seen in their clients. This could include observing mothers practicing skills such as latching baby properly in order to provide reassurance that they are developing the necessary breastfeeding skills and capabilities. Second, given the inconsistencies in some of the advice offered to mothers as indicated in the quotes from this research, HCPs should strive to provide consistent, evidence-based advice. Third, HCPs should provide anticipatory guidance that normalizes the typical breastfeeding experience including advice on common challenges and strategies to address these. Such anticipation and acknowledgement that mothers often have to overcome breastfeeding challenges would help reduce anxiety and promote critical thinking to search for solutions to problems as part of a normal breastfeeding experience. Finally, although this paper is focused on key content areas, the manner in which this information is provided also matters. HCPs should provide information in an encouraging and supportive manner that provides reassurance and builds confidence.

Mothers also identified a desire for more information about expression or pumping. According to research conducted in the USA, there is a trend toward increased prevalence of milk expression with 85% of breastfeeding mothers with infants 1.5 to 4.5 months of age having expressed milk, and approximately one quarter of mothers of infants 1.5 to 9.5 months regularly expressing milk [48]. Reasons commonly cited for expression include poor latch or sucking in the early postpartum period, mother’s comfort, to increase milk supply, and to obtain breast milk for someone else to feed, either to involve the father in feeding or to continue breastfeeding upon return to employment [25,48,49]. The findings of this research are consistent with other research showing mothers feel clinicians provide insufficient information on pumping, breast milk storage and maintenance of milk supply, particularly when resuming employment [25]. While more research is needed to assess the overall health benefits and challenges to mothers and infants related to this increased milk expression [49,50], it is clear that since many mothers are expressing breast milk there is a need to routinely assess for this practice and offer guidance on correct techniques, including hand expression, as part of breastfeeding counselling.

The finding that a significant number of mothers perceive their breastfeeding information needs are not being met is supported by previous research [25,51,52]. Such findings not only provide direction for HCPs who work at an individual level with breastfeeding mothers but also for those responsible for healthcare system level delivery of breastfeeding programs. To deliver effective breastfeeding support, HCPs not only must have the necessary training to provide consistent and evidence-based breastfeeding information, but must communicate with one another and follow established breastfeeding guidelines [52]. Healthcare delivery systems should ensure HCPs have the time and support necessary to receive adequate training and have networks that facilitate communication regarding implementation of breastfeeding guidelines. It should also be acknowledged that HCPs provide breastfeeding support within the context of other broad sociocultural factors that also impact a mother’s breastfeeding experience.

Breastfeeding support should be offered throughout the continuum from the prenatal period until weaning to all mothers with particular content emphasized at critical times. Researchers found mothers who received individual counselling prenatally were 55% less likely to cease breastfeeding before 6 month [53]. Similarly McLeod, Pullon and Cookson found shorter breastfeeding duration was associated with women who felt they received insufficient breastfeeding information during the prenatal period [51]. The first few weeks postnatal is a particularly critical time. Researchers found assistance breastfeeding within 30 minutes of birth had a positive impact on continued breastfeeding at 24 hours and two weeks [54]. Women who received instruction on positioning and latch in the immediate postpartum period were 30% less likely to stop breastfeeding before six months [53].

Continued support following hospital discharge until weaning should be included as part of a seamless program of support. Lewallen et al. found 35% of those who had initiated breastfeeding had stopped by eight weeks with insufficient milk cited as the most common reason [15], illustrating that the first two months is a critical time to provide and reinforce information related to milk production, responding to infant cues, and assessing infant growth. In some instances breastfeeding support following hospital discharge is not offered to all mothers [15]. Even beyond the first two months, women have ongoing information needs. Women in this research identified learning needs common after breastfeeding is well established including more information related to the introduction of other nutrition sources and expression/pumping. Taveras et al. found women felt they were not provided with sufficient information regarding how to continue breastfeeding when they returned to work [25].

Limitations of this research firstly relates to the data being drawn from a written survey and thus lacking the rich detail of other data collection formats which provide an opportunity to ask further probing and clarifying questions. Second, given the self-selected nature of this survey, the respondents’ views may not reflect those of all women in the region. For example, the respondents in this sample had higher income and education levels than the population of the region in which the study was conducted. The results therefore may not reflect the experiences of more diverse and/or disadvantaged populations, including the significant Aboriginal population in the health region, which was underrepresented. Finally, the responses are specific to the services as experienced by mothers of this particular health region and may not reflect the breadth of lactation support services in other areas.

Further research might explore what systemic strategies are successful in ensuring universal delivery of key breastfeeding information to all new mothers. It might also investigate the variety of information sources available to new mothers and their preferred communication channels for receiving critical information. Such enquiry may highlight the preferences of new mothers for face-to-face guidance versus less personal, but potentially more timely and accessible information sources, such as telephone hotlines and the internet. Finally, further exploration into the factors behind the increased prevalence of milk expression/pumping may provide guidance regarding the information needs of those mothers.