Breastfeeding challenges experienced by postpartum nurses after maternity leave: a qualitative systematic review

Abstract

Background

With the continuous progress of global breastfeeding promotion, breastfeeding for postpartum returning nurses has become an important topic of medical human resource management. Nurses have always assumed a caregiver role, but postpartum nurses are seen as a particularly vulnerable and care-recipient role. Paying attention to the breastfeeding experience of postpartum returning nurses is helpful in improving the work environment of nurses and enhance the overall level of nursing service.

Objective

To systematically explore and integrate the multi-dimensional challenges of breastfeeding faced by postpartum nurses during their return to work, and to comprehensively analyze the adaptation and support needs.

Methods

We conducted a systematic search of six electronic databases including PubMed, Web of Science, Cochrane Library, Embase, Chinese National Knowledge Infrastructure and Wanfang to identify relevant qualitative studies. The search time limit was from the establishment of database to February 2025. Literature screening and data extraction were completed by two researchers independently, and the Joanna Briggs Institute criteria for qualitative research was used for evaluation. Results were reported in accordance with the Enhanced Transparency in Integrated Reporting of Qualitative Research statement. Finally, thematic analysis was used for data synthesis.

Results

A total of 19 studies were included and synthesized into three analytical themes: (i) breastfeeding attitude, (ii) breastfeeding support, and (iii) breastfeeding control. Analysis of outcomes revealed breastfeeding resilience and support are identified as facilitators, while work pressure and role conflict are identified as hindrances. In addition, breastfeeding attitude was identified as an influencer of breastfeeding.

Conclusions

In this review, the breastfeeding practice of postpartum returning nurses is complex, which affects the breastfeeding experience together with their professional identity. Breastfeeding attitude, breastfeeding support, and breastfeeding control are identified as key factors. It is suggested that health institutions should intervene in view of obstacles and improve the breastfeeding support system of postpartum returning nurses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-08593-x.

Introduction

Breastfeeding is globally recognized as the optimal method of infant feeding, with robust evidence demonstrating its significant benefits in reducing the risks of necrotizing enterocolitis, infectious diseases, and long-term metabolic disorders in neonates [1–3]. The World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) recommend exclusive breastfeeding within the first six months postpartum, followed by sustained breastfeeding through two years and beyond [4]. WHO’s Global Nutrition Targets aim to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% [5]. Nevertheless, current global progress remains suboptimal: only 44% of infants under six months are exclusively breastfed worldwide [6], and rates in high-income settings like the United States are critically low, ranging between 18.48% and 20.36% [7]. These disparities underscore an urgent need to address systemic barriers to sustained breastfeeding.

Returning to work postpartum is widely recognized as a primary factor disrupting breastfeeding continuity [8]. The transition to employment introduces multifaceted challenges, including inadequate lactation facilities, workplace reintegration difficulties, and psychological stressors, all of which may compromise mothers’ capacity to sustain breastfeeding [9–12]. Notably, postpartum nurses appear to face greater breastfeeding challenges. Nurses working in environments with long shifts, high physical workloads, and restricted rest opportunities face elevated risks of breastfeeding interruption. A recent study indicated that merely 12.5% of returning nurse mothers maintained EBF for six months, while 75% resorted to mixed feeding and 12.5% discontinued breastfeeding entirely upon resuming work [13]. Consequently, elucidating the unique breastfeeding obstacles encountered by this occupational group is essential.

Although extensive qualitative research has explored the breastfeeding experiences and dilemmas of working mothers, existing systematic reviews often aggregate heterogeneous occupational groups, potentially obscuring nuanced perspectives specific to nursing professionals [13]. This study employs a qualitative evidence synthesis methodology to holistically examine multidimensional dynamic changes experienced by postpartum nurses navigating both occupational reentry and lactation. Focusing on the obstacles and promoting factors related to breastfeeding, and further comprehensively analyze their adaptation strategies and support needs. The findings provide evidence-based insights for policymakers and healthcare institutions, so that they can develop targeted support strategies tailored to this high-risk cohort.

Methods

Study design

This study adopts a design of qualitative evidence synthesis. Thomas and Harden’s thematic synthesis, was adopted to systematically synthesize the qualitative evidence [14]. The results were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [15] (see Supplementary Material 1) and Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines (see Supplementary Material 2). The protocol was registered in PROSPERO (CRD420251027291) in April 2025.

Search strategy

PubMed, Web of Science, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI) and Wanfang databases were searched up to February 2025. Firstly, we developed the initial search formula based on the PICOs framework in PubMed. Subsequently, with the assistance of a member of the research group who is proficient in English, the search formula was adjusted and translated in different cultural contexts, thus making it applicable to the Chinese databases (CNKI and Wanfang Database). This process involved not only literal translation but also took into account common expressions and professional terms in the Chinese context. The complete, word-for-word search formulas for all databases have been included in Supplementary Material 3 to ensure the complete transparency and reproducibility of the search process.

The search terms covered breastfeeding, nurses, postpartum and qualitative research. We used the following search terms: (“nurse” OR “nurses” OR “nursing personnel” OR “registered nurse” OR “registered nurses” OR “CNS” OR “Postpartum nurses”) AND (“maternity leave” OR “return to work” OR “returning to work” OR “return-to-work” OR “back at work” OR “back to work”) AND (“breast milk OR “breastmilk” OR “human milk” OR “maternal milk” OR “mother milk” OR “breast-fed” OR “breastfed” OR “breast fed” OR “breastfeeding” OR “breast feeding” OR “milk sharing” OR “sharing milk” OR “human milk” OR “exclusive breast feeding” OR “exclusive breastfeeding”) AND (qualitative research). We did not apply language restrictions. Two reviewers independently searched all sources; the references of the articles to ensure that no references were missed. The complete search strategy can be found in Supplementary Material 3.

Eligibility criteria

We applied the PICOs (Population, Phenomena of Interest, Context, and study design) strategy to develop selection criteria, as shown in Table 1.

Table 1.

Inclusion and exclusion criteria

	Inclusion criteria	Exclusion criteria
Population	• Postpartum returning nurses	• Focus on individual with other healthcare, such as physicians, general administration officer, or other
Phenomena of interest	• Focus on postpartum nurses breastfeeding experience	• Focus on one or the other
Context	• Return to the clinical working environment after giving birth	/
Study design	• Qualitative research	• Studies that cannot establish qualitative data
	• Qualitative research in mixed quantitative and qualitative research	• Not peer reviewed.
	• Data were obtained through semi-structured interviews, participant observations, file notes, open-ended questions in surveys.

Inclusion criteria: (i) Population: postpartum returning nurses (who have returned to work within one year after giving birth); (ii) Phenomena of interest: focus on postpartum nurses breastfeeding experience; (iii) Context: return to the clinical working environment after giving birth; (iv) Study design: qualitative research, qualitative research in mixed quantitative and qualitative research, and Data were obtained through semi-structured interviews, participant observations, file notes, open-ended questions in surveys; (v) Original studies that have been published in English or Chinese; and (vi) The search period included material published as of February 2025.

Exclusion criteria: (i) Population: Focus on individual with other healthcare, such as physicians, general administration officer, or other; (ii) Phenomena of interest: Focus on one or the other; (iii) Context: none; (iv) Study design: studies that cannot establish qualitative data, not peer reviewed, and exclusions include studies in mixed-method research that do not independently report qualitative results.

Selection process

Before the screening process, we pilot tested the screening tool in Microsoft Excel with the review team. There were two screening stages. First, two reviewers independently screened for duplicate articles based on titles and abstracts. Secondly, following this first screened, two reviewers independently screened the full text review, excluded articles will be listed and given reasons for it. Subsequently, two reviewers independently applied the inclusion criteria using the standardized screening tool (EndNote software) to both titles, abstracts and full texts. Disagreements were resolved by consensus. Discrepancies were discussed within pairs with a third reviewer if needed. As shown in Table 2.

Table 2.

Brief data from the studies selected for the review

Author, year	Country	Sample (n of nurses)	Study Design	Aim	Data collection method	Data collection mode	Duration of the interview (min)	Data analysis	Findings (including themes)
Wu, 2008	China	10 (n= 10)	A qualitative approach	The aim of this study was to describe the experiences of ten three-shift nurses, with particular focus on how they make arrangements regarding breastfeeding in relation to their workplaces and work breaks.	Face to face	Semi-structured interview	1.5–2 h	Thematic content analysis	(i) Managing to express milk; (ii) Dealing with the conflict between work and expressing milk; iii) Viewing breastfeeding as part of life.
Chen, 2017	China	13 (n= 13)	A qualitative approach	To understand the feeding behavior choices of postpartum nurses returning to work and analyze its influencing factors.	Face to face	Semi-structured interview	30–50 min	Interpretative phenomenological analysis	(i) Lack of knowledge; (ii) Environmental stress; (iii) Social support; iv) Policy system.
Riaza, 2018	Pakistan	7 (n = 7)	A qualitative descriptive approach	To describe the attitudes and experiences of breastfeeding mothers returning to full-time work as nurses in a tertiary hospital in Pakistan.	Face to face	Semi-structured interview	Lasted for an average of 50 min	The data was analyzed by following the iterative approach used by Pollio, Henlay and Thompson	(i) Belief in a child’s right to breastfeed (ii) Conflict with institutional power (iii) The importance of family support in maintaining breastfeeding.
Huang, 2018	China	6 (n = 6)	Phenomenology	To explore the real experience and support needs of nurses returning to work after the second child.	Face to face	Semi-structured interview	40–60 min	Qualitative data analysis	(i) work experience (concerns about child feeding, difficulties in adaptation and self-adjustment, positive emotional experience and expression, strong physical and mental fatigue, work-family conflict) (ii) Support needs (scheduling support, hope for adaptation period, colleague support)
Rainbow, 2021	USA	20 (n = 20)	A qualitative descriptive design	To describe registered nurses’ (RNs’) experiences of working while pregnant and returning to work postpartum. Specifically, their experiences related to the work environment and work-related haz- ards.	A semi-structured interview guide	Semi-structured interview	18–48 min	Content analysis was conducted using both a deductive and inductive coding process.	(i) Support needed avoidoccupational hazards and make necessary modifications (ii) Desire to be ‘supernurses’ (iii) Put the patient first even when it meant taking risks for our health and that of their child; (iv) Fear of the consequences of occupational hazards and exposures
Moulton, 2021	USA	60 (n = 3)	Constructivist grounded theory	To explore the social and environmental conditions in emergency departments that contribute to perceived barriers and supports for workplace lactation among individuals working in emergency medicine.	Unknown	Semi-structured interview	15–102 min	Constant comparative inductive methods	(i) Emergency medicine culture (ii) Workplace lactation policies (iii) Supports for workplace lactation
Li, 2021	China	15 (n = 15)	A qualitative descriptive approach	Understand the factors that prevent nurses in the lactation period after returning to work for the second child from continuing breastfeeding	Face to face	Semi-structured interview	Unknown	Interpretative phenomenological analysis	(i) “Empiricism” leads toa lack of knowledge and skills in breastfeeding (ii) Personal factors affect the confidence and attitude of nurses returning to work after giving birth to their second child regarding breastfeeding iii) Influence family and work factors of continuous breastfeeding
Hill, 2022	USA	19 (n = 19)	A qualitative descriptive study	To understand the experiences of emergency nurses who have returned to work after parental leave, specifically relating to the return to work transition, work-life balance, work engagement, and opportunities to continue human milk	Structured interview guides one-on-one interviews and focus groups	Semi-structured interview	30–60 min	Data analysis using Braun and Clarke’s qualitative thematic analysis 6-phase framework	(i) Work engagement (ii) Lactation (iii) Childcare
Wu, 2022	China (Taiwan)	10 (n = 10)	A qualitative study	This qualitative study explored the perception of intensive care unit nurses in relation to their motherhood experiences and coping strategies.	Face to face	Semi-structured interview	60–90 min	Ddopted the content analysis method to systematically analyze and code the interview text.	(i) Challenges and conflicts of motherhood (ii) Dilemma in life and work balance (iii) Maternal engagement
Jiravisitkul, 2022	Thailand	11 (n = 2)	A mixed methods study	The study aimed to identify supporting factors and obstacles to sustaining breastfeeding in hospital-type workplaces.	Focus group discussion ( Google Meet)	Semi-structured interview	Approximately 90 min	Thematic coding analysis	(i) Personal–social factors: supporting factors and structural barriers (ii) Other personal–social factors iii)Workplace–social factors: supporting factors and structural barriers iv) Other Workplace–associated factors
Nunes Almeida, 2023	Brasil	42 (n = 42)	Descriptive exploratory qualitative study	To describe feelings, challenges and strategies related to the continuity of breastfeeding after returning to work in the perception of lactating nurses.	Unknown	Semi-structured interview	Unknown	Similitude analysis	Fear, missing the child, anguish, and pleasure in returning to work
Li, 2023	China	15 (n = 15)	A qualitative study	To explore the lactating nurses’ experiences of return to work after lifting COVID-19 lockdown.	Semi-structured video interviews	Semi-structured interview	Unknown	Empirical phenomenology method	(i) Preparation for return to work (ii) Experiences of return to work (iii) Experiences of infection
Tseng, 2023	China (Taiwan)	13 (n = 13)	A qualitative design	This study aimed to understand the experience journey of nurses in Taiwan from considering applying for parental leave to returning to work.	Face to face in-depth interviews	Semi-structured interview	40–60 min	Content analysis method and the Graneheim and Lundman data processing	(i) Considerations for taking parental leave (ii) Support received from other parties (iii) Life experience during parental leave (iv) Concerns regarding the return to the workplace (v) Preparations for the return to the workplace
Liu, 2024	China	12 (n = 12)	A descriptive phenomenological approach	To analyse experience in postnatal nurses returning to work within 3 months following the delivery of a second or third child and recommend appropriate measures to relieve pressure and enhance work engagement among this group	Face to face individual in-depth interviews	Semi-structured interview	30–60 min	Using the Colaizzi method	(i) Postnatal Physical Decline (ii) Postnatal Psychological Maladjustment (iii) Lack of Clear Career Planning
McCardel, 2024	USA	26 (n = 3)	A sequential, mixed methods design	This study aimed to examine working mothers’ experiences with returning to work after giving birth, work-family conflict, breastfeeding, and mental health.	Face to face	Semi-structured interview	Unknown	Using the narrative inquiry framework to conduct a thematic analysis	(i) Captured the context of participants’ work environments (ii) Types of work-family conflict (iii) Factors that alleviated work-family conflict
Zhou, 2024	China	16 (n = 16)	A qualitative study with descriptive phenomenological approach	This study aimed to explore the adaptation experiences of postpartum nurses returning to work.	Face to face	Semi-structured interview	30–45 min	Using Colaizzi’s 7-step method	(i) Changes and challenges of multiple roles (ii) Self-coping and social support (iii) Further needs after returning to work
Wan, 2024	China	8 (n = 8)	A qualitative descriptive design	This study aims to describe the work experience of breastfeeding nurses returning to work after maternity leave.	Face to face	Semi-structured interview	30–60 min	Braun and Clarke’s thematic analysis	i)Changes in nurses ii) Needs for an improving work environment iii) Support for breastfeeding nurses
Yang, 2024	China	15 (n = 15)	A qualitative study with phenomenological approach	To explore the physical and psychological stress and influencing factors of postpartum return-to-work nurses in pediatric emergency departments, and to propose corresponding measures to alleviate the stress of postpartum return-to-work nurses in pediatric emergency departments	Face to face	Semi-structured interview	20–30 min	Using Colaizzi’s 7-step method	(i) Difficulties in life and work of postpartum nurses returning to work in pediatric emergency department (ii) Psychological changes occurred after returning to work (iii) Role conflict v) Hope to obtain support from the workplace and family
Novintan, 2025	UK	8 (n = 2)	A qualitative research study	To examine the challenges encountered during the RTW process and investigates perspectives on the formation of an ideal RTW scheme	Face to face	Semi-structured interview	Unknown	Reflexive thematic analysis	(i) Maternity Leave (ii) Returning to Work (iii) Ideal Returning to Work Scheme

Methodological quality

A standardized data extraction form was developed with reference from JBI Critical Appraisal Checklist for Qualitative Research (JBI-QARI) checklist (see Supplementary Material 4). The tool has a total of 10 items, each of which is scored as “yes” (1 point), “no”, “unclear” or “not applicable” (0 points for each), for a total of 10 points. The scores were scored by two reviewers independently, and if there was any disagreement, the consensus was reached by consultation. In cases of disagreement, adjudication was performed by a third investigator or group discussion. This study does not exclude low quality literature [16], but systematically presents the quality of evidence through standardized evaluation process [16].

Data extraction and analysis

The team possessed specialized knowledge in breastfeeding and qualitative research. We consciously reflected on our presupposition regarding the primacy of social support and the potential variability of professional advice. To ensure rigor, bias was mitigated through triangulation and peer debriefing. An audit trail was maintained to document analytical decisions.

The researchers extracted data on authors, publication year, country, study design, study objective, interview location, sample size, methods of data collection and analysis, interview duration, and key findings were systematically extracted and entered into Microsoft office 2016. The process for extracting relevant data includes: (i) firstly, two researchers independently extracted the data; (ii) the third researchers checked the data for accuracy; and (iii) finally, research Group discuss based on the content of the extracted data. If there are any disagreement, they continue to discuss until a consensus is reached.

Data analysis employed the thematic synthesis method proposed by Thomas and Harden [14]. This process consists of three recursive stages: (i) encode the original data line by line; (ii) compare the similarities and differences in coding, and categorize them to form descriptive themes; and (iii) through repeated discussions and interpretive synthesis by the research team, analytical themes that could go beyond individual original studies and reveal the essence of the phenomenon were further developed. Any disagreements during the process were resolved through team discussions until consensus was reached.

Data synthesis

Where possible, qualitative research findings were pooled using Microsoft Excel 2016 and a thematic synthesis approach was applied, owing to it is the most closely aligned with the research objective. This method is suitable for conducting inductive and explanatory exploration of phenomena, and can directly answer research questions by generating new themes. In contrast, meta-ethnography focuses on theoretical construction, while meta-aggregation aims to produce quantifiable practical suggestions. This study aims to deeply understand the phenomenon itself, rather than developing theories or proposing specific measures.

Confidence analysis

The Confidence in the Evidence from Reviews of Qualitative Research tool (CERQual) was used to comprehensively evaluate the credibility of evidence from the four dimensions of methodological limitations, topic relevance, result coherence and adequacy of data, the evidence level of the systematic review is represented by four grades (high, moderate, low and very low) [17]. The assessment results will serve as one of the direct bases for downgrading or upgrading the confidence level of the research findings. The summary of findings and CERQual assessments in Table 3.

Table 3.

Results of the critical appraisal of the studies included

Author, year	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10
Wu, 2008	U	Yes	Yes	Yes	Yes	No	No	Yes	Yes	Yes
Chen, 2017	U	Yes	Yes	Yes	Yes	No	No	Yes	No	Yes
Riaza, 2018	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Huang, 2018	U	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes
Rainbow, 2021	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Moulton, 2021	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Li, 2021	U	Yes	Yes	Yes	Yes	No	No	Yes	No	Yes
Hill, 2022	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes
Wu, 2022	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Jiravisitkul, 2022	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Nunes Almeida, 2023	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Li, 2023	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Tseng, 2023	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Liu, 2024	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
McCardel, 2024	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Zhou, 2024	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Wan, 2024	U	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Yang, 2024	U	Yes	Yes	Yes	Yes	Yes	No	Yes	No	Yes
Novintan, 2025	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes

U unclear

Q 1. Is there congruity between the stated philosophical perspective and the research methodology?

Q 2. ls there congruity between the research methodology and the research question or objectives?

Q 3. ls there congruity between the research methodology and the methods used to collect data?

Q 4. Is there congruity between the research methodology and the representation and analysis of data?

Q 5. ls there congruity between the research methodology and the interpretation of results?

Q 6. Is there a statement locating the researcher culturally or theoretically?

Q 7. ls the influence of the researcher on the research, and vice- versa, addressed?

Q 8. Are participants, and their voices, adequately represented?

Q 9. ls the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?

Q 10. Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Results

Study selection

A total of 2552 articles were retrieved. After duplicates were removed and titles/abstracts were screened using EndNote 12 software, 85 articles advanced to the full texts review by researchers. 19 studies met al.l the inclusion criteria (Fig. 1) [18–36]. These studies were conducted in China (N = 11), USA (N = 4), Pakistan (N = 1), Thailand (N = 1), UK (N = 1), and Brazil (N = 1), and were qualitative studies featuring interviews with 286 females, 231 of whom were postpartum nurses returning to work.

Fig. 1.

Search flow diagram

The remaining 55 participants come from diverse professional backgrounds, including other medical professionals (such as physicians, dentists, pharmacists, etc., totaling 25 people) and non-medical industry workers (such as those in fields like education, administration, finance, etc., totaling 30 people). Study characteristics are reported in Table 2.

Methodological quality

Results of the critical appraisal of the studies using the JBI-QARI checklist included in Table 3. The quality scores of the included studies ranged from 5 to 9, indicating that the overall methodological quality was moderate to good level. Ten articles that do not clearly indicate whether congruity between the stated philosophical perspective and the research methodology. This may result in the original studies lacking theoretical support and guidance, and causing the research process to be lacking in organization and systematisms. Three articles that do not clearly a statement locating the researcher culturally or theoretically. This may lead to hidden biases in the research, thereby affecting the objectivity and fairness of the research results. Most studies (n = 19) failed to describe the researcher’s cultural or theoretical background, nor did they identify the researcher’s influence on the research. Five articles that do not explicitly indicate that they have received ethical approval from relevant institutions. This may lead to ethical and legal risks in the original research, affecting the legitimacy and acceptability of the results.

Confidence in the findings

The credibility of the results was evaluated using the CERQual method. Five themes received a high credibility rating, while four themes were rated as medium credibility and low credibility (Table 4).

Table 4.

Summary of findings and cerqual assessments

Summary of review finding	Studies contributing to the review finding	Assessment of methodological limitations	Assessment of relevance	Assessment of coherence	Assessment of adequacy	Overall CERQual assessment of confidence	Explanation of CERQual assessment
Breastfeeding attitudes
Active Breastfeeding	(Chao-Hua Wu, 2008), (Saadia, 2018)	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from two countries: China and Pakistan)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (two studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Breastfeeding as an accomplishment
Viewing breastfeeding as part of life
Belief in a child’s right to breastfeed
Cessation of breastfeeding
High work pressure leads to decrease in milk secretion	(Chu Chen, 2017), (Paveewan, 2022)	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from two countries: China and Thailand)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (only two studies, both offering thin data)	Low confidence	This finding was graded as low confidence because of substantial concerns regarding adequacy of data.
Conflicts between work and expressing milk	(Chao-Hua Wu, 2008), (Jessica, 2021), (Paveewan, 2022), (Meng Liu, 2024), (Xin-li, 2024), (Liu yang, 2024), Shonnelly, 2025), (Shonnelly, 2025)	Minor methodological limitations (four studies had minor methodological limitations)	Minor concerns about relevance (studies from four countries: China, USA, Thailand, and the UK)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (seven studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Institutional power	(Hualing Huang, 2018), (Rachel, 2024)	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from two countries: China and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (only two studies, both offering thin data)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Breastfeeding support
Family support	(Chu Chen, 2017), (Saadia, 2018), (Jessica, 2021), (Paveewan, 2022), (Ya-Hui, 2023)	Minor methodological limitations (three studies with minor and one study with moderate methodological limitations)	Moderate concerns about relevance (partial relevance, as the studies were from six continents: China, Thailand, Brasil, and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Substantial concerns about adequacy (six studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Work environment	(Chu Chen, 2017), (Emily K, 2022), (Paveewan, 2022) (Ya-Hui, 2023), (Xin-li, 2024)	Minor methodological limitations (one studies with minor and one study with moderate methodological limitations)	Minor concerns about relevance (studies from three continents: China, Thailand and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (five studies that together offered moderately rich data overall)	Moderate confidence	This finding was graded as moderate confidence because of moderate concerns regarding adequacy.
Colleagues support	(Jessica, 2021), (Paveewan, 2022), (Xin-li, 2024)	Minor methodological limitations (one studies with minor and one study with moderate methodological limitations)	Minor concerns about relevance (studies from three continents: China, Thailand and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (three studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Policy support	(Chu Chen, 2017), (Jessica, 2021), (Kimberly, 2021), (Paveewan, 2022),11	Minor methodological limitations (three studies with minor and one study with moderate methodological limitations)	Minor concerns about relevance (studies from four continents: China, Thailand, Brasil, and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (five studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
Breastfeeding Control
“Application”: Breastfeeding knowledge	(Chao-Hua Wu, 2008), (Hualing Huang, 2018), (Xijuan Li, 2021), (Paveewan, 2022)	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from two continents: China and Thailand)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Moderate concerns about adequacy (only four studies, both offering thin data)	Moderate confidence	This finding was graded as moderate confidence because of moderate concerns regarding adequacy.
“Debugging”: mental adaptation	(Hualing Huang, 2018), (Jessica, 2021), (Xijuan Li, 2021), (Paveewan, 2022), (Meng Liu, 2024), (Xin-li, 2024)	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from three continents: China, Thailand, Brasil, and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (six studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
“Lactation”: feeding behavior	(Hui-Chuan, 2022), (Paveewan, 2022), (Lourdes, 2023), (Tianji, 2024), (Xin-li, 2024)	Minor methodological limitations (four studies with minor and one study with moderate methodological limitations)	Minor concerns about relevance (studies from three continents: China, Brasil, and USA)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (five studies that together offered moderately rich data overall)	High confidence	This finding was graded as high confidence because of minor concerns regarding methodological limitations, relevance, coherence, and adequacy.
“Management”: Physical condition	(Hualing Huang, 2018) (Meng Liu, 2024	Minor methodological limitations (both studies had minor methodological limitations)	Minor concerns about relevance (studies from one continent: China)	Minor concerns about coherence (data reasonably consistent within and across all studies)	Minor concerns about adequacy (only two studies, both offering thin data)	Low confidence	This finding was graded as low confidence because of substantial concerns regarding adequacy of data.

Results of the qualitative synthesis

A total of three themes were synthesized: breastfeeding attitudes, breastfeeding support, and breastfeeding control. The first theme is based on mothers’ cognition and emotion on breastfeeding to express their attitudes towards breastfeeding and reflect their expectations for an ideal feeding pattern. The second theme highlighted the family, healthcare system and social support and barriers to breastfeeding. Finally, the third theme explored mothers’ sense of autonomy and control during breastfeeding and the influence of external factors on feeding decisions. (Themes overview is shown in Fig. 2, Dynamics of feeding experience is shown in Fig. 3).

Fig. 2.

Overview of the findings

Fig. 3.

Continuous breastfeeding experiences

Breastfeeding attitudes

The theme “postpartum returning nurses” attitudes and emotions toward breastfeeding” focused on their two contradictory attitudes towards breastfeeding and a professional reality conflict. On the one hand, as a group with professional medical knowledge, they recognize the clinical benefits of breastfeeding and tend to adopt a scientific and positive attitude to deal with feeding challenges [18, 20]. On the other hand, limited by the work intensity, shift system, and work pressure, they are often frustrated because they cannot balance breastfeeding and work, and are even forced to stop breastfeeding early [19, 27]. In both cases, all the mothers expressed their idealized expectations for “perfect breastfeeding”.

Active breastfeeding

The positive attitudes of postpartum returning nurses towards breastfeeding were mainly reflected in “Maternal identity in breastfeeding” aspects: (i) breastfeeding as an accomplishment. They regarded breastfeeding as a proud achievement, the most precious gift mothers gave their children, and the successful practice of professional nursing knowledge [18]; (ii) viewing breastfeeding as part of life. They strive to integrate breastfeeding naturally into their daily lives and make it an integral part of their lives through proper time management and workplace support [20]; and (iii) belief in a child’s right to breastfeed. Most importantly, they have a strong belief in the right of every child to breastfeed, which supports them to overcome the difficulties of returning to work and seek a balance between work and parenting [27].

Passive breastfeeding

However, another group of postpartum returning nurses adopts the opposite view of breastfeeding, viewing that returned to work after delivery will inevitably lead to the interruption of lactation [22, 23, 33]. Firstly, high work pressure leads to decrease in milk secretion. Secondly, conflicts between work and expressing milk. The non-interlacing nature of clinical work is in direct conflict with the need for scheduled breastfeeding. Finally, institutional power. There is a general lack of perfect lactation support system in medical institutions, strict attendance system, insufficient time and place for breastfeeding and other institutional pressures, which make returning nurses in a dilemma between maintaining the willingness to breastfeed and practical feasibility.

Breastfeeding support

Throughout the postpartum return to work process, breastfeeding, as a key turning point, has a profound impact on the dual roles of nurses at work and as mothers, and the relationship between the two identities is reconstructed. The theme “Breastfeeding support” describes the adaptation experience of four breastfeeding support in postpartum returning nurses, achieving the ideal state of “balance between work and lactation”.

Family support

When the mother goes back to work, an active support network takes on an essential role. Family support is one of the biggest drivers for postpartum nurses returning to continue breastfeeding. Despite the stress and exhaustion of the work, it is at its core to always see maternal and child health as “our shared responsibility”, which is reflected in everyday care and action. The first comes from the love and commitment that family bonds provide [19, 22]. Although work changes the pace of life, the deep emotions and common expectations built during pregnancy translate into the motivation for continued support: “Even though the work is busy, I want to do my best to share when I see her insistence on breastfeeding, because it is our family’s business.” Secondly, family members viewed sharing parenting and housework as a kind of love feedback to express their understanding and support for the long-term hard work of postpartum nurses [20]. This situation is particularly evident in families where nurses have less household responsibilities for a long time due to their busy work. In addition, maintaining the dignity of the nursing mother is an important motivator for family support [27, 29, 31]. They avoid questioning or belittling the nurse’s breastfeeding efforts in front of others, thereby preventing the mother from becoming frustrated. This support was reflected in respecting nurses’ feeding choices, helping them to remain confident, and offering to assist with practical difficulties during breastfeeding.

Work environment

With the adaptation of postpartum transition back to work, the breastfeeding status of nurses gradually tends to be stable. In the face of the double pressure of work and lactation, nurses changed from the initial anxiety to calmly cope, and coordinated the needs of workplace and lactation with a professional attitude [19, 25]. In addition to independently managing time conflicts between work and milking, nurses also began to take the initiative to utilize lactation support resources in the workplace and gradually establish a sustainable lactation rhythm [27, 28, 31]. This adaptation process is often accompanied by the professional growth of nurses, including the accumulation of lactation knowledge in addition to improving time management skills, which is derived from the identification of the value of breastfeeding, more effectively promoting healthier lactation mechanisms and more tenacity of lactation confidence.

I’m finding my rhythm, learning more about breastfeeding techniques, reaching out for help, and most importantly, accepting that I can work and breastfeed at the same time. I can’t change the nature of my work, but I can optimize the breastfeeding experience.

Collegial support

Colleagues of postpartum returning nurses defined “breastfeeding supporters” as helpers who assisted nurses to complete breast-feeding related needs and coordinate work arrangements. This situation often leads colleagues to extend the role of “work partner” to that of “breastfeeding supporter”: “She was not just a colleague, but a partner who needed my help to keep breastfeeding [22].” In addition, colleagues also assume a variety of supporting roles [27]. In order to create a nursing-friendly environment, they often play the role of “coordinator”, which includes specific functions such as “time scheduler” and “work sharer”. Some colleagues identified themselves as “advocates,” in part because of empathy for the plight of breastfeeding in the workplace, prompting them to view supporting actions as defending women’s rights. On the other hand, because postpartum returning nurses may view supporting their colleagues as an important emotional lean on, colleagues need to adjust the way they interact to maintain nurses ’breastfeeding confidence [28].

However, not all colleagues share this “breastfeeding supporter” identity. They are more committed to a purely “colleague relationship,” viewing breastfeeding support as part of workplace mutual support rather than as an added responsibility. This group equated breastfeeding support with “professional nursing duties” and believed that excessive involvement could affect working relationships.

Policy support

Facing the dual pressure of breastfeeding and work after returning to work, some nurses chose to take the initiative to cope with it and began to seek institutional support [19, 22, 23, 27]. Health institutions have implemented flexible work schedules to alleviate breastfeeding conflicts by adjusting scheduling. In units where conditions permit, postpartum returning nurses used the policy-guaranteed lactation time for milking to obtain the necessary physiological adjustment. However, some postpartum returning nurses were afraid to make full use of the breastfeeding policy rights and interests for fear of affecting their career development, and continued to bear physical and mental pressure. Ultimately, this dilemma may lead to the interruption of lactation plans, and under pressure from work, nurses may choose to terminate breastfeeding early.

Breastfeeding control

The theme “breastfeeding control” showed totally different breastfeeding outcomes of returning nurses. “Breastfeeding control” mainly refers to the nurses’ breastfeeding was not significantly affected by work after returning to work, or the nurses had lactation difficulties in the early stage of returning to work but established the law after adjustment. The key to achieving this state is time management skills and workplace adaptability. In this process, nurses always regarded breastfeeding as a “manageable challenge”, and maintained feeding continuity by scientifically planning breastfeeding time and optimizing work efficiency.

Application of breastfeeding knowledge

In response to a heavy clinical nursing work, some postpartum returning nurses choose to temporarily suspend breastfeeding plans and seek external support [18, 21, 24, 27]. Some nurses chose to use the rest room provided by the hospital and appropriate lactation time to alleviate the role conflict between work and lactation. Where financial conditions permit them to do so, nurses-maintained lactation by hiring a professional nurser or purchasing smart lactation equipment to complete milk storage during work intervals. Some nurses seek professional guidance from obstetric colleagues or breastfeeding support groups to cope with feeding challenges. These “obstetric colleagues” usually refer to working in the obstetrics department and with more extensive clinical experience or specific expertise mainly include senior nurses, head nurses, midwives, and obstetricians. Professional support from the hospital lactation and feeding clinic can improve the success rate of feeding, but sometimes it may make nurses feel guilty for “relying on others”. However, some nurses chose early weaning due to work pressure, failed to adhere to the scientific feeding plan, and continued to suffer from the anxiety of mother-infant separation.

Debugging of mental adaptation

Faced with high work pressure, some postpartum returning nurses fell into anxiety because they could not consider breastfeeding and began to actively seek psychological adjustment methods. Some nurses chose psychological counseling services provided by the hospital to alleviate the conflict between their professional roles and motherhood [21]. When conditions permit, nurses obtain a “psychological buffer period” by adjusting their schedules or applying for lactation leave, and use this breathing time to adjust their emotions or restore their physical and mental balance. Some nurses confine themselves to their mothers or nursing colleagues, who are also health care workers, for empathy and support. However, there are also some nurses who avoid problems and are unwilling to face up to the nursing dilemma, and continue to be in the double consumption of work and parenting [22]. Ultimately, long-term psychological stress may lead to job burnout, and individual nurses may even be forced to choose between continuing to breastfeed or focusing on their work to reduce their mental load by weaning early [24, 27].

Attitude of breastfeeding behavior

With the transition of postpartum job adaptation, the breastfeeding behavior of nurses gradually tends to be stable. Faced with the double pressure of work and lactation, nurses changed from the initial anxiety to active adjustment, and insisted on breastfeeding in a more scientific way [26, 27]. In addition to independently coping with daily challenges such as milking and milk storage, they also began to rationally use the hospital’s lactation room and lactation equipment, and gradually established a work-lactation balance pattern [28, 29, 34]. This adaptation process is often accompanied by the improvement of professional nursing skills, including not only a skilled grasp of breastfeeding knowledge, but also the enhancement of self-efficacy. This internal motivation stems from the responsibility for the health of mother and child, and also promotes the development of stronger time management skills and psychological resilience.

I found my own pace, learned about the science of breastfeeding, reached out for help, and most importantly, I took on the challenge of returning to work to breastfeed-I couldn’t completely avoid the difficulties, but I was better prepared to do so.

Navigating physical challenges of breastfeeding

Postpartum returning nurses have different cognition on the physical condition management of breastfeeding, which directly affects their management behavior and adherence [21, 32]. Some nurses held a positive and scientific attitude, believing that postpartum body changes were a normal physiological process, and that lactation function could be effectively maintained and physical recovery could be promoted through reasonable nutritional supplementation, regular milk arrangement and moderate exercise. Although returning to work will increase the difficulty of breastfeeding, as long as appropriate management measures are taken, they can still maintain a good physical and mental state. However, other nurses held a more negative view, believing that work pressure would inevitably lead to a decrease in lactation volume and physical fatigue. They viewed breastfeeding after returning to work as an additional burden on the body and worried that long-term breastfeeding would affect job performance and career development. Faced with the dual pressures of work and breastfeeding, these nurses often regard maintaining breastfeeding as a difficult challenge.

Discussion

This review synthesizes findings from 19 qualitative studies, revealing three themes within the framework of breastfeeding resilience theory: attitude, support, and control. The findings indicate that resilience is a critical determinant of breastfeeding adherence. Despite the pressures and challenges faced by returning postpartum nurses, such adversity can activate heightened resilience traits. The dynamic interplay between these traits and environmental factors prompts adaptive responses, ultimately shaping distinct breastfeeding outcomes.

Attitude refers to an individual’s evaluation and behavioral tendency towards a certain object; while breastfeeding attitude refers to people’s views and beliefs about the methods and consequences of breastfeeding for infants [37]. Two distinct breastfeeding attitudes identified in this study are consistent with the breastfeeding resilience theoretical framework [38]. Nurses returning to work, which leads to the external pressure and internal psychological factors work together to lead individuals to show different adaptation strategies in the binary relationship of “work-breastfeeding”. At this time, their resilience traits are enhanced, and then affect the continuity and quality of lactation [18, 20]. This finding is consistent with the conclusions of previous studies, as the adaptation to returning to work after childbirth is a dynamic process, often accompanied by contradictions and differentiations in cognition and behavior [39]. When postpartum returning nurses struggle to maintain their status as caregivers while coping with job demands, role conflicts can arise [22, 27, 32, 35, 36]. However, the postpartum returning nurses’ cognition and attitude towards breastfeeding are not static but evolve dynamically along with the extension of their return to work and the balance between work and family [40]. In the future, the different association should be further discussed, and our understanding of its influencing factors should be continuously enhanced.

The nature of the positions of postpartum nurses returning to work has been claimed to potentially affect their experience of breastfeeding support, and this view was confirmed by the findings of this study [41]. Studies have shown that postpartum nurses face greater breastfeeding difficulties to adapt to the care recipient role. This difference may be related to the operational characteristics of medical institutions [42]. Compared with the previous studies, the findings of this review are that institutional support and collegial support is as critical as family support, and both of them together build the confidence foundation for adherence to breastfeeding [22, 27, 28]. Although this study found that there were differences in breastfeeding support among postpartum nurses in different departments, these differences were currently only described by surface factors such as “work intensity” and “scheduling flexibility”. Whether this finding implies that postpartum nurses in different departments have differentiated support needs is unclear. In the future, further explore the deep mechanisms that affect breastfeeding support and establish a unified analysis framework.

Behavioral control refers to the individual’s perceived ability to carry out the behavior, so breastfeeding control refers to the mother’s perceived difficulty in carrying out the behavior of breastfeeding [43]. In this review, breastfeeding control included breastfeeding knowledge, mental adaptation, feeding behavior and physical condition. With the birth policy adjustment, postpartum nurses who have two or three children face a particularly prominent dilemma. Different from the previous studies [44–46], which mainly focuses on the physiological recovery and economic pressure of ordinary mothers, this review highlights the special pressure of this subgroup under multiple roles [22, 28, 30, 34, 35]. In addition, we also found that postpartum nurses with strong psychological and adaptability can effectively cope with the social prejudice of breastfeeding, maintain a positive attitude and internal control, so as to improve their breastfeeding control. Future research should continue to explore the identity of postpartum returning nurses and focus more specifically on breastfeeding caregivers to provide them with more comprehensive social support.

Strengths and limitations

This review systematically integrates evidence to provide an in-depth exploration of the breastfeeding challenges experienced by postpartum nurses during their return to the work. However, there are still some limitations: (i) the included studies exhibited heterogeneity in their methodological design and cultural background; (ii) the numbers of included studies and postpartum nurses are small; and (iii) the included studies originated from various countries. These contextual factors may profoundly influence the experiences of mothers, leading to the heterogeneity of the research findings and limiting the direct cross-cultural applicability of its conclusions. More importantly, although the secondary interpretation of qualitative data inevitably involves certain subjectivity, the research team effectively reduced the influence of personal biases through continuous reflexive thinking and a mechanism for discussing differences.

Recommendations

Healthcare providers should consider relevant emotional and social support for postpartum returning nurses, so as to alleviate the pressure they face to continue breastfeeding in the workplace. In view of the differences in feeding needs and situation of nurses, it is recommended that providers customize targeted support programs for them based on personalized assessment. Additionally, policymakers and nursing managers should consider a hospital-based support program for postpartum returning nurses as a means of helping them cope with the challenges of breastfeeding.

Conclusion

This systematic review systematically addressed the breastfeeding challenges faced by postpartum nurses regarding the dynamic changes, adaptation strategies, and support needs of postpartum nurses after returning to work. The results indicate that professional knowledge and psychological resilience of postpartum nurses are the internal facilitating factors, while the prevalent work pressure and role conflicts are the core obstacles. Furthermore, postpartum nurses experienced breastfeeding with seeking knowledge, managing lactation through the body, and coordinating external relationships, but their effectiveness highly depends on the structural support from the workplace and family. Overall, the results of this review provide insight into a range of experiences associated with social support in pregnancy. Overall, the results of this review provide insights into the variety of breastfeeding experiences of postpartum nurses returning to work.

Author’ contributions

KL and SL co-performed data collection and analysis of this study and drafted the manuscript. MY and YW performed data analysis and interpreted the results. YL contributed to define the research theme, revise the manuscript, and responsible for the layout and use of funds. All authors read and approved the final manuscript.

Funding

This work was supported by Hospital fund of Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science and Technology (2024C06 and 2023D39). The funder contributed to define the research theme (namely focusing on breastfeeding challenges experienced by postpartum nurses after maternity leave), be fully accountable for ensuring the integrity and accuracy of the work, analyzing the data and interpreting the results.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study has been approved by the Ethics committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB202503043). Consent to participate was not required since the study was a systematic review of published articles.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.