The major finding of our study was that mothers’ strategies for creating positive breastfeeding experiences generally included being calm and close to the child and being present in the breastfeeding moment. Lowering demands was also described as an important factor for positive breastfeeding experiences. To facilitate breastfeeding, mothers additionally recommended baby-led breastfeeding with correct techniques, and they suggested reading about breastfeeding in order to acquire knowledge about the activity and to ask for support if needed. Taking care of oneself and one’s body, using aids if necessary, as well as having a positive view and a strong desire to breastfeed, were also described as important factors of positive breastfeeding experiences.
Above all, participating mothers described that being calm and in closeness with their children was pivotal for creating positive breastfeeding experiences. Strategies to that end included maintaining skin-to-skin contact, making eye contact, caressing the child and talking to the child in a soft voice. Skin-to-skin contact and touch increase oxytocin secretion, which alleviates stress and pain, contributes to a sense of well-being and calmness, is linked to increased social interaction and, in the context of breastfeeding, induces milk ejection [21].
Such mother–child interaction during breastfeeding is important for establishing eating habits and attachment, and, indeed, physical presence and eye contact are central to what is called responsive feeding.
According to Silva, Costa and Giugliani [22], responsive breastfeeding involves being sensitive to the child’s signals and feeding slowly and patiently according to the child’s cues. This is because breastfeeding is an opportunity to learn from, love and talk to children, maintaining eye contact contributes to positive breastfeeding experiences that encourage children to eat without stress or distractions [22]. Eye contact and gazing are non-verbal cues that play a central role in communication; for example, an infant’s gaze can indicate hunger, hence the need for food, or satiation. Sensitivity to a child’s signals promotes responsive feeding and is essential to baby-led feeding [23]. The mothers in our study additionally highlighted that because infants are also new to breastfeeding, succeeding with breastfeeding was a team effort. That notion aligns with the concept described by Burns, Fenwick, Sheehan and Schmied that breastfeeding is a relationship between the mother and child [24].
To foster positive breastfeeding experiences, the mothers also emphasised the importance of lowering demands. Such demands could relate to housekeeping, for example, which the mothers advised taking a relaxed attitude towards while regularly engaging in breastfeeding. The mothers also highlighted the importance of keeping an effortless mindset about breastfeeding to avoid feeling a pressure to breastfeed. The mothers reported that fear of being unable to breastfeed could cause feelings of uncertainty that were liable to inhibit breastfeeding and by lowering demands that breastfeeding “must work” they felt more relaxed which in turn had a positive effect on breastfeeding. Personal, cultural and ideological views on feeding methods influence not only breastfeeding experiences but also perceptions of what constitutes so-called “good motherhood”.
Motherhood and breastfeeding are intimately intertwined such that performance and experiences in one will profoundly affect performance and experiences in the other [25]. In past work, Larsen et al. found that when mothers experienced breastfeeding as a duty and a personal responsibility, their confidence in their abilities as mothers was affected when problems with breastfeeding arose [26]. The expectation that breastfeeding is a natural process becomes replaced with the experience that breastfeeding is difficult and giving up on breastfeeding is often described by mothers as an experience of mixed feelings of failure and guilt [26]. Feelings of inadequacy can contribute to negative experiences with breastfeeding, which can consequently influence future breastfeeding initiation and duration.
Against that trend, Thomson, Ebisch-Burton and Flacking have posited that devising personal definitions of “good motherhood” can prevent feelings of failure, shame and judgement when breastfeeding fails [27]. For their part, as Cato, Sylvén, Henriksson and Rubertsson have argued, healthcare professionals should adopt more flexible stances on exclusive breastfeeding in order to not only reduce pressure to breastfeed among mothers who choose formula feeding but also reduce feelings of shame and guilt among ones who cannot or do not want to breastfeed [28]. Overall, participating mothers in our study expressed tremendous compassion towards other mothers, whether or not they had ever breastfed their children. By extension, participants stressed the importance of not feeling guilty if breastfeeding failed and of knowing, that giving up on breastfeeding does not mean that one is a bad mother.
The mothers in our study described having knowledge about breastfeeding as being important for having positive breastfeeding experiences. They reported that acquiring knowledge about breastfeeding techniques, what to expect of breastfeeding and what to do when breastfeeding-related problems occurred from not only reading and maternity education but also from discussions with midwives, nurses, partners and other mothers was helpful. The mothers also highlighted the importance of having support from midwifes, nurses, partners and family when initiating breastfeeding and to seek support elsewhere if receiving unhelpful and contradictory advice. It is well documented that support, in particular from trained professionals, can increase both duration and exclusivity of breastfeeding [29]. Several studies and meta-analysis have shown that women do not seem to get the support they need from healthcare professionals [30, 31]. Women with breastfeeding-related problems not finding skilled breastfeeding support are most likely to stop breastfeeding sooner than they had desired [32, 33].
Despite the importance of breastfeeding support, breastfeeding care is often fragmented leaving women with inadequate support [34, 35]. With increasingly short postnatal stays, the continuity of care regarding breastfeeding support needs to be improved and available for mothers to increase breastfeeding rates [36]. To the same end, it is essential for women to feel supported in creating positive breastfeeding experiences as a means to promote their motivation and intention to breastfeed in the future [15]. For healthcare professionals, providing individualised breastfeeding support can be a complex task, although following scientific evidence and the WHO’s recommendations should be viewed as a minimum.
The women in the study conducted by Blixt et al. wanted healthcare professionals to describe all options before advising which to follow, because options enable women to make informed decisions that align with their feelings and desires [13]. Although parents predominantly agree that breastfeeding is the best way to feed infants they desire and expect that they will be offered factual information related to their personal infant feeding choices, provided in a sensitive and non-judgemental manner [31]. At the same time, providing options can cause dilemmas for the primary healthcare nurse or midwife because by doing so the effort to promote exclusive breastfeeding and breastfeeding duration as recommended by the WHO [3] can be undermined, especially because breastfeeding is an important predictor of health for both mothers and children [6, 8, 10].
In fact, our study revealed that some mothers who perceived formula as an acceptable alternative to breastfeeding experienced reduced stress and pressure, which increased their likelihood of having positive breastfeeding experiences. After all, some women may fear that their breastmilk is insufficient nutrition and that their children may starve, largely because ensuring that children are not hungry is deeply ingrained in humans and can cause stress for mothers even when problems do not arise in feeding. As an antidote, supplementation with formula can heighten their sense of control over their children’s nutritional intake and assure them that their children are not hungry or starving.
In contrast to the other strategies, the mothers in our study had to create positive breastfeeding experiences; furthermore, the strategy to introduce formula as an alternative to increase the possibility of having a positive breastfeeding experience also poses some negative implications. Introducing formula at any age before 12 months is strongly, negatively associated with breastfeeding at 12 months [37]. Among other negative consequences of keeping formula as an option, in-hospital formula supplementation without medical cause and combining breastfeeding with formula both reduce the frequency and duration of breastfeeding [38, 39]. Thus, although reduced pressure to breastfeed can be perceived to promote positive breastfeeding experiences, introducing formula can reduce breastfeeding and therefore be counter-productive to the WHO’s recommendations [3]. Beyond that, in their study, Hvatum and Glavin [25] found that encouraging breastfeeding can also become or be misconstrued as pressure to breastfeed. Indeed, some mothers in their sample described feeling as though they were breaking the law if they could not or did not want to breastfeed. Likewise, Larsen et al. [26] have described how support for breastfeeding can become so focused on breastfeeding as the only correct method “that it actually works counter to the good intentions about supporting mothers to breastfeed”.
For an alternative source of encouragement, the mothers in our study stressed the importance of having a positive view and a strong desire to breastfeed. Support from healthcare professionals can influence women’s personal confidence in breastfeeding. In a metasynthesis by Schmied et al. [40], the result showed that if the intended support was perceived as supportive, women felt they were listened to and given realistic information, which increased confidence and sense of control. Those findings corroborate Blixt et al.’s [13] advice for healthcare professionals to provide breastfeeding support to women that is sensitive and individualised enough to strengthen their self-confidence, including by enabling individual decision-making and both supporting and respecting their breastfeeding goals and decisions.
In that light, the notion that breastfeeding is not only a natural process but also a competency that can be learned is central to the dynamic view on breastfeeding as a set of ability that can be developed and strengthened with the right help and appropriate knowledge [24]. That dynamic view on breastfeeding is also characterised by a less categorical approach in which breastfeeding is not only “exclusive”, “in part” or “not at all”. Instead, breastfeeding could be seen as operating on a scale from no breastfeeding to exclusive breastfeeding. Knowledge of the strategies that women themselves propose to create positive breastfeeding experiences may be important to provide individually tailored support and thus enable the mother to reach the higher end of the breastfeeding scale, if that is her goal. Asking mothers to formulate what strategies they find helpful could also be a part of facilitating more conscious and visible approaches to breastfeeding.
Strengths and limitations
This descriptive study, designed to capture the strategies that mothers use to generate positive breastfeeding experiences, has limitations. For one, although generalisation is not typically the principal objective of qualitative studies, the non-probability convenience sample of the qualitative methodology limits the generalisability of the study’s results. For another, even though 176 mothers answered the survey, and 340 critical incidents were identified, the response rate was low given that the group had approximately 5000 members at the time of the survey. It also remains uncertain whether all members were active and in fact saw the announcement posted in the group or why some group members did not want to participate. Although we do not know whether mothers who chose not to participate would have proposed different strategies, the number of critical incidents that we collected indicates that data saturation was achieved. Among other limitations, data in our study were collected with an online survey, because we wanted strategies from a broad group of mothers with different backgrounds and experiences. Whereas Flanagan [19] has claimed that using questionnaires to collect data is suitable in large samples and that data for the CIT collected via questionnaires do not essentially differ from data acquired via interviews, using interviews could also have raised the risk of social desirability bias, because motherhood and breastfeeding are associated with stigma if the strategies used are not considered to be socially acceptable.
Data extraction was performed by two authors independently, and extracted data were compared and discussed until consensus was reached. The process of analysis was performed by all authors and critically reviewed and discussed in various steps to ensure triangulation and peer scrutiny. Final categories are illustrated with participants’ quotations to illustrate the analysis of data. The data collected was concisely worded and required a low level of interpretation. Participants did not have any established relationship with any of the researchers, and member checks were not performed, because all data were collected anonymously. Iterative questioning was used by requesting summaries, and the data collected indicated internal consistency. The study’s findings are in agreement with literature in the field and are reported in accordance with COREQ guidelines [20] to ensure the description of the context and methods of the study.
