The Psychosocial and Emotional Experience of Breastfeeding

Abstract

Breastfeeding is acknowledged as optimal infant nutrition, yet despite high initiation rates, early cessation remains common. To understand why, we asked mothers in Western Canada how they felt about their breastfeeding experience. A total of 191 women (response rate 35%) responded to a survey distributed by public health nurses. While many women felt positive about their overall breastfeeding experience, others shared mixed or negative emotions. Several themes were evident: (a) Most women reported a variety of positive aspects beyond the health benefits, (b) lactation difficulties were commonly reported, and (c) diversity among the reflections highlights the uniqueness of each breastfeeding journey. The findings reaffirm the need for breastfeeding programs to holistically promote the range of positive aspects while providing realistic information on common challenges and strategies to overcome these. Mothers require individualized support that assesses psychosocial and emotional needs and offers encouragement, reassurance, and acknowledgment of the range of experiences.

Background

Breastfeeding is promoted as the optimal mode of infant nutrition, with extensive evidence supporting a multitude of positive infant and maternal health outcomes (Horta, Bahl, Martines, & Victora, 2007; Ip et al., 2007). Yet, in many regions such as the United Kingdom, Canada, and the United States, although the vast majority of women initiate breastfeeding, most do not exclusively breastfeed for the first 6 months as recommended by the World Health Organization (Gionet, 2013; McAndrew et al., 2012; National Center for Chronic Disease Prevention & Health Promotion, 2013; World Health Organization, 2014). Research reveals that many women discontinued breastfeeding earlier than they originally intended, stating in retrospect their preference to have breastfed for a longer period (McLeod, Pullon, & Cookson, 2002; Odom, Li, Scanlon, Perrine, & Grummer-Strawn, 2013).

There is a strong case for improving interventions that support mothers in their breastfeeding efforts, thereby significantly reducing health care costs. One analysis determined the impact if 90% of mothers in the United States exclusively breastfed for the first 6 months, finding potential health care savings of US$13 billion annually and the prevention of 911 excess deaths (Bartick & Reinhold, 2010). Renfrew, Pokhrel, et al. (2012) determined if 45% of U.K. women exclusively breastfed for 4 months and if 75% of infants in neonatal units were breastfeeding on discharge, more than 17 million GBP would be saved annually due to reduced need for treatment of four acute infant diseases. The authors also estimated additional potential health care savings from improved maternal health outcomes if more women breastfed for an extended period.

Women frequently encounter some difficulties as part of their breastfeeding experience, with the first 4 weeks being a particularly vulnerable period (Gerd, Bergman, Dahlgren, Roswall, & Alm, 2012; Williamson, Leeming, Lyttle, & Johnson, 2012). In an American study, the majority of low-income women reported at least one breastfeeding problem during the first month following birth, decreasing to 45% at 3 months and 29% at 5 months (McCann, Baydar, & Williams, 2007). At least some of these challenges could be mitigated by effective breastfeeding support. A Cochrane review found that extra breastfeeding support, both lay and professional, positively affects breastfeeding duration rates (Renfrew, McCormick, Wade, Quinn, & Dowswell, 2012).

A large body of knowledge exists focused on the biomedical aspects of lactation, including initiation and cessation rates, risk factors for early cessation, and the maternal and infant health benefits. Less has been written about the unique experiences of breastfeeding women and how these might be considered when developing breastfeeding programs and offering individualized supports. Spencer (2008) found that while there is extensive biomedical research focused on the epistemological knowledge of breastfeeding, there is a lack of ontological inquiry that explores women’s lived experiences. Regan and Ball (2013) reviewed existing qualitative breastfeeding research and concluded much of it is dominated by a technological narrative that views women’s bodies as unpredictable and requiring the management of health care professionals (HCPs). They highlighted the need for HCPs to more deeply appreciate the complexity of women’s breastfeeding experiences. Powell, Davis, and Anderson (2014) explored the breastfeeding experiences of 21 women in the United States and found that women desired increased breastfeeding support including the provision of more honest and consistent breastfeeding information. The researchers highlighted the need for additional research exploring the breastfeeding experiences of a more diverse population (Powell et al., 2014).

Effective breastfeeding promotion and support initiatives must be realistic and acknowledge the uniqueness of the breastfeeding journey, including the very personal and emotional nature of this experience for many women. With this goal in mind, we asked mothers to describe in their own words how they felt about their breastfeeding experience to capture their reflections and insights.

Method

Our research explored infant feeding practices during the first 6 months and the perspectives of mothers to inform breastfeeding support programs. To capture both the details of feeding practices and the mothers’ thoughts, ideas, and recommendations, a survey was designed containing both categorical and open-ended comment questions. To ensure that a sufficient number and diversity of mothers were invited to participate in this research, the survey was distributed by public health nurses (PHNs) in a Western Canadian health region for a 6-month period beginning in January 2012.

This study used purposive sampling to recruit women who had experience with the study phenomenon (Neergaard, Olesen, Andersen, & Sondergaard, 2009; Thorne, 2008). The eligible population was women who had initiated breastfeeding and whose infant was between 6 and <12 months of age at the time of the survey. This age range was chosen because these infants were due for at least one routine immunization during the study period. This timeline also reduced recall bias by seeking information regarding feeding practices and perceptions during the first 6 months of life, while the experiences would be fresh in participants’ minds. In this health region, childhood immunization is almost exclusively administered by PHNs, thus recruitment of participants during immunization clinics at public health offices allowed access to the majority of eligible mothers.

Recruitment envelopes were offered to eligible mothers by PHNs when infants were brought into all public health offices across the health region for immunization. Recruitment envelopes were also available for mothers to take from a poster displayed in the waiting room. The envelopes contained an information pamphlet, a consent form, the survey, and a postage-paid envelope for submitting the survey. Participants had the option of completing the paper survey or an online version. They could also opt to enter a contest for one of five CAD$100 gift certificates as an incentive. To ensure confidentiality, mothers were not given the opportunity to complete the survey in front of the PHN but rather were asked to take the envelope home. Ethics approval was received from both the respective health region and university research ethics boards.

Surveys were distributed to 551 mothers with 191 participants ultimately submitting a survey for a 35% response rate. This response rate is typical for similar voluntary internet and mail-in surveys (Shih & Fan, 2008; Sinclair, O’Toole, Malawaraarachchi, & Leder, 2012). Participants were most commonly 26 to 35 years of age and were evenly distributed between primiparous and multiparous. The women had higher incomes and education than the general population in this Canadian region (Government of Canada, 2014). The majority of participants (72%) chose to mail in the paper survey version.

The 26 survey questions had both quantitative and qualitative components. The answers to the categorical questions, focused on demographic characteristics and infant feeding practices, were analyzed quantitatively using SPSS™ software. Answers to the open-ended questions, designed to capture mothers’ opinions, rationales, and reflections related to their choice of feeding method, their personal experiences, and their recommendations for breastfeeding support, were analyzed qualitatively. The findings from other survey questions are reported elsewhere (Dietrich Leurer & Misskey, 2015; Misskey, Dietrich Leurer, Bell, & Kramer, 2013). This article focuses on narrative responses to one open-ended question: “How do you feel about your experience breastfeeding your baby?” There was no limit to the length of written answers permitted to the open-ended questions. While the written narrative responses to this survey question did not provide the depth and richness of extended narratives from more interactive and engaged qualitative data collection methods, many mothers shared sincere and emotional sentiments in their answers.

Our analysis of the participants’ narrative responses was based on qualitative description (QD), a naturalistic method that is appropriate for investigating the perspectives of health care consumers (Neergaard et al., 2009). In QD analysis, the researchers stay close to the data, and although interpretation is inherent in the process, the interpretation is not as highly conceptual as compared with other qualitative methods (Sandelowski, 2000, 2010). The final product is a rich but low-inference description of the experience, such that most researchers assessing the same data would agree on the participants’ meaning (Neergaard et al., 2009). Findings are typically reported as a descriptive summary of the data content, organized in a manner that best reflects the data and is accessible to the target audience for the findings (Sandelowski, 2000).

Marie Dietrich Leurer (a nurse educator with qualitative research experience who previously offered breastfeeding support as a PHN) conducted the initial categorization. Eunice Misskey (a public health nutritionist specialized in infant nutrition) then reviewed the organization and naming of the categories identified until agreement was reached on final placements. Using qualitative content analysis (Mayring, 2000), the narrative answers were first grouped into categories according to whether the overall statement might be interpreted as mainly positive, mixed, or negative descriptions of their breastfeeding experience. This determination was guided by the emotional adjectives expressed in the narratives. Quotes in each category were then further moved into subcategories based on common experiences/emotions expressed using an iterative process of combining and subdividing apparent groupings of quotations as patterns emerged until subcategories were finalized.

Findings

Mothers described a variety of sentiments and emotions when reflecting on their breastfeeding experience, reiterating the highly personal nature of this life event. Despite the written survey data collection mode, the answers highlighted the depth of the heartfelt views held by many women.

Positive Experience

The majority of mothers had an overall positive experience with many describing how they appreciated particular aspects of breastfeeding. Some mothers used adjectives such as loved, great, awesome, and amazing that suggest they did not just think breastfeeding had gone well but were delighted with their experience:

Amazing. I had planned to formula feed from birth. But after the very first time breast-feeding, I loved it. I wish I could have breastfed longer.

I’m glad I did it, and was proud and happy to have carried on as long as I did. This was the longest breastfeeding relationship of my three.

Mothers sometimes linked their positive experience to how easy they found breastfeeding and the fact that they had not had any problems. Some answers showed awareness that breastfeeding can be difficult, mentioning latch and milk supply in particular. They appreciated that they themselves had not faced such challenges:

My baby latched perfectly every time and I had lots of milk so it made my experience nothing but positive.

Wonderful experience. My baby latched on right away and we have been in sync ever since.

I think I had a very abnormal breastfeeding experience because it was so easy for me and the babies.

Other mothers shared that they had faced some difficulties but generally felt positive about their breastfeeding experience. The word proud was sometimes used to describe their sense of accomplishment in continuing to breastfeeding despite some challenges:

I have really enjoyed it. I feel proud that I was able to get through tougher times and continue to breast feed. I have almost given up 5 times but with support “we stayed with it.”

We had a rough start but I’m proud to say that I’ve nursed for as long as I did—many of the hospital staff were quite surprised that I planned on nursing. It seems not many mothers my age want to try nursing for whatever reason.

At the beginning it was hard. It was a fight to get him to latch, people tried to help by pushing formula. Now it’s awesome. Easy to travel, work around my schedule. Zero bottles to make/buy etc.

Mothers commonly described how much they appreciated what they saw as the unique aspects of breastfeeding, particularly the bonding time inherent in the breastfeeding experience. Their responses implied that breastfeeding is a truly unique mother–infant emotional connection that might not have been the same if they had formula fed. Mothers also highlighted the ease and convenience of breastfeeding. Their comments frequently suggested several attributes simultaneously:

I enjoyed the closeness of it . . . some of the most precious moments of my life in fact. I’ll never forget this special time. Hopefully she has gained something other than nutrition from it as well.

The first few weeks felt like such a battle, both physically and emotionally. It was hard to enjoy or even think about. After everything got settled it was such a wonderful, gentle, bonding experience. It’s truly special to nurture a baby that way and I treat breastfeeding as a little relax time for us both.

I adore it. It is so very easy (I can’t imagine always having to worry about having formula on hand and all the “gear” required for it). The bond is beautiful; it is nature’s way—we were designed to nourish our babies in this way.

Some mothers made it clear that they understood breast milk is the optimal infant food and expressed pride and pleasure in being able to provide it to their baby. For these mothers, the experience seemed to increase their confidence in their ability to care for their baby:

Wonderful! I love that I am/was able to give him all the nutrients he needed. I love bonding with him in such a way that only a momma and new baby can bond.

I relish the quiet moments we spend together when he is nursing. I love holding him and taking advantage of the natural opportunity for face to face time. I feel important and happy that I am able to offer him the health benefits of nursing.

I am enjoying my time breastfeeding my child. I was so upset when he wasn’t gaining weight and my family doctor pushed a can of formula on me to start supplementing. I feel like I am successfully contributing to my child’s nutrition, as “breast milk is best” promotion from doctors/nurses/medical practitioners.

Mixed Emotions

Other mothers expressed that they liked certain aspects of breastfeeding but disliked others with somewhat conflicting emotions about their breastfeeding experience. For some, negative aspects were related to the nature of breastfeeding and not necessarily because of experiencing common breastfeeding difficulties. For example, uncertainty regarding milk supply was sometimes cited with moms lacking confidence that they could produce sufficient milk for their baby or at least seeking reassurance that they could:

It’s definitely challenging, worrisome, and stressful, because I’m not sure if my baby’s eating enough and especially if your baby’s not gaining enough weight. But it definitely gives you great opportunity to observe and bond with the baby.

I love it! Some days I get frustrated because I just want to be physically left alone and not bitten but I still feel like it is a blessing we never had any major issues and that he will only be a baby for so long.

I have mixed emotions. I would have loved it if I could have gotten over some of my control issues and relaxed enough to believe that my baby was getting what he needed from me, but that wasn’t possible given everything else that was going on.

Negative Experience

Although the majority of mothers enjoyed their breastfeeding experience, there were some who found their experience challenging for a variety of reasons. “Frustrating” and “difficult” were two descriptors commonly used to label more negative perceptions:

It was a lot of work. I also felt that my relationship with my new baby was damaged during the first few weeks, because I was so frustrated with breastfeeding and how she seemed hungry even after she would have nursed for an hour. I was going crazy with breastfeeding a baby that just wanted food to come easy.

I did not feel comfortable with breastfeeding until my baby was about 4-5 months. I kept thinking how could something so natural be so difficult? I also felt restricted to home as my baby did not like to be covered when breastfeeding plus she was so wild pulling off and on at times during a feed. I would be leaking milk all over the place. However I love the bonding and natural soothing that breastfeeding provides, but it was definitely difficult.

Some mothers shared that they found breastfeeding physically uncomfortable and/or painful. This was often identified as occurring in the first week or two; however for a few mothers, this discomfort continued for extended periods. In some instances, mothers reported quitting because of the discomfort, whereas others continued despite this challenge:

I do it because I feel it is best for my baby’s health. The first 2½ months were very painful and I did not enjoy the experience.

It was painful for me and never got any better. I stuck with it for 4 weeks, was exhausted and frustrated the whole time. Glad I stopped and switched to formula.

I loved that alone time and bonding I got but the mastitis, it made me dread it because it was so painful. I was still sad when I quit because I felt it was way too early.

In contrast to the majority of mothers who enjoyed breastfeeding, a few mothers were honest in sharing that they disliked the experience. These mothers often continued to breastfeed for the health benefits despite not enjoying it:

Awful, I hated it! I really wanted to do it until six months (at least) but couldn’t.

To be 100% honest, I really don’t like breastfeeding. I know it’s the best option and it’s only for a year.

I actually found a group of moms and we found comfort and support in one another. It’s okay to not “love” nursing your child was what we had in common. We were happy to do it for the best health of our children, but didn’t necessarily love doing it.

I feel I did well to last even 4 months as it wasn’t something I enjoyed.

Some mothers felt that breastfeeding tied them down and restricted their ability to go out or participate in other activities. Their comments suggested that they felt some of the time spent breastfeeding could have been better devoted to other aspects of their life:

I had a good experience. I just didn’t like being in one place for that long. I felt when I needed a break he wouldn’t be fed properly or enough.

It is a chore. Neither of my babies would ever take a bottle because of undue pressure on me not to offer one by the health region. I can never go out or leave the baby with anyone and it makes me feel resentful.

I felt like all I was doing was breast feeding. I have a four year old and felt like I was neglecting him . . . Honestly I felt tied down a lot. I always felt like I was breastfeeding. I bottlefed my first child and found that my husband could help. This time around I felt that my child wanted nothing to do with her father. There was a lot of mommy time.

A few mothers felt embarrassed to breastfeed, particularly in public. There was also reluctance to have others observe breastfeeding, including HCPs and in the hospital setting.

I didn’t want to anymore and I found it to be a long process and was too embarrassed to do it in public but again was bad choice and will definitely breastfeed next time.

Knocking on mother/baby ward. Less visitors—i.e., getting rid of the photo lady. I was wary of when I breastfed because of getting interrupted (didn’t want to show my breasts to strangers).

Also I am a heavier girl and my baby was active and would remove our cover. I was uncomfortable in public places.

Strong emotions surrounding the breastfeeding experience were evident when mothers shared their feelings of regret, sadness, or guilt if they wished they had been able to breastfeed their baby longer. Often these mothers felt that they had to quit because of unresolved problems but expressed regret and hope that they would be able to breastfeed longer with a subsequent baby. Their narratives are emotional and in stark contrast to the mothers who had expressed such joy and pride in their ability to breastfeed their baby:

I had a difficult time getting milk. I tried lots of tricks the nurse suggested, but nothing seemed to work. Baby and I both became frustrated. I found pumping my milk worked better however I would only get 1-2 ounces and would therefore have to supplement. This was very saddening to me.

Feel very let down, feel guilty I could not feed my baby.

I feel disappointed in myself for not trying harder. Both deliveries were stressful. First was a surprise c-section and the second I gave birth naturally but had a 3rd degree tear so recovery was long. I should have not given in so easily. We are talking about having a third. Maybe I’ll get lucky with this one :)

I feel let down. I feel like I let my baby down because I didn’t breastfeed after 2 months. She still got breast milk until she was 5 months because I pumped up to six times a day.

Several themes were evident across the narratives from mothers. First, the majority of women found breastfeeding overall to be very enjoyable, even many who had experienced some difficulties. Second, many women reported dealing with lactation problems at some stage with varying degrees of success. Third, the diversity of experiences and the accompanying emotional descriptions highlight the uniqueness of each breastfeeding journey and debunk any assumptions that breastfeeding is an easy and natural endeavor that is universally pleasant.

Discussion

Positive, Holistic Experience for the Majority of Women

The finding that the majority of mothers were very positive as they reflected on their time breastfeeding is consistent with other research. Forster and McLachlan (2010) found that 53% of Australian women interviewed at 6 months postpartum expressed only positive feelings about breastfeeding, with the remainder reporting mixed or negative emotions. The practice implications of such findings point to the need for expanded messaging in breastfeeding promotion campaigns that reflect the holistic nature of women’s positive lactation experiences, rather than a narrow focus on infant and maternal physical health benefits. Mothers’ awareness of “breast is best” messaging is evident in our research. An increase in social marketing efforts beyond the traditional emphasis on health outcomes (Canadian Paediatric Society, 2014) might highlight other positive aspects of breastfeeding appreciated by mothers such as the ease, convenience, and opportunity for emotional bonding. Hamilton (2015) found that mothers interviewed in the United Stated recommended breastfeeding campaign messages could emphasize benefits such as the environmentally friendly nature of breastfeeding as well as emotional wellness and health benefits in an effort to encourage longer duration rates.

Lactation Difficulties Are Common

Breastfeeding messaging can be contradictory for women with two competing discourses, suggesting both the idea that breastfeeding is an easy and natural experience, and a learned skill (Locke, 2009). Despite the evolutionary roots of lactation, many mothers experience problems as they acquire the skills and experiences to successfully breastfeed. Williamson et al. (2012) found women struggled with the perceived cultural expectation that breastfeeding is easy and natural versus the difficulties they experienced breastfeeding. Mothers’ narratives in our research often referred to the presence of breastfeeding difficulties as part of their lactation experience. These descriptions are supported by research that has quantified the extent of problems. In one American study, 70% of women reported at least one problem during the first month of breastfeeding (McCann et al., 2007). Research in Australia found that 83% of breastfeeding mothers experienced problems while still in hospital, with the incidence reduced but not eliminated at later stages, with problem rates of 23% at 6 weeks and 13% at 24 weeks postpartum (Binns & Scott, 2002).

Previous research suggests that many women who encounter challenges believe that they receive inadequate support, with the problems often a factor in earlier than desired cessation. McLeod et al. (2002) found that 80% of women surveyed in New Zealand who had experienced problems believed that they had not received a sufficient level of advice and support to successfully breastfeed their infant. In addition, the authors found that most women who had stopped breastfeeding would have preferred to have breastfed longer, but ceased because of reasons such as perceived milk supply issues and infant discontent. Odom et al. (2013) also reported that approximately 60% of mothers who had ceased breastfeeding did so earlier than desired with lactation difficulties commonly identified as a reason.

Breastfeeding problems can adversely affect mothers’ breastfeeding self-efficacy if they perceive that they are “failing” as breastfeeding mothers, in some cases resulting in early cessation and feelings of guilt and/or regret. Many mothers anticipate that breastfeeding will be an easy and natural experience, only to worry when they encounter problems. Binns and Scott (2002) found that only 31% of women expected prenatally that they would have difficulties breastfeeding, yet the vast majority went on to experience problems at some stage. Powell et al. (2014) found that American women felt HCPs are not always honest about the possibility of breastfeeding problems in their breastfeeding promotion and desired better forewarning regarding common difficulties that could arise. The participants suggested that having such knowledge ahead of time would have better prepared and empowered them to deal with common challenges (Powell et al., 2014). Breastfeeding promotion efforts should normalize the likelihood of difficulties while equipping women with the strategies, resources, and support to problem solve as necessary. Based on the findings in our research, breastfeeding education should address common problems by including content such as strategies to prevent/reduce discomfort and manage milk supply, coping mechanisms for those who feel tied down, and campaigns to change societal attitudes that make women feel uncomfortable or embarrassed in public places.

Recognition of the Uniqueness of the Breastfeeding Experience

Mothers in this research reported quite diverse descriptions of their breastfeeding experiences from “awesome” and “wonderful” to “uncomfortable” and “awful.” The findings highlight the need for those who offer breastfeeding support to recognize the personal nature of each mother–infant breastfeeding relationship and to tailor advice and support accordingly. It should not be assumed that breastfeeding will be a positive endeavor for all mothers. Backstrom, Hertfelt Wahn, and Ekstrom (2010) interviewed midwives and mothers, uncovering differing perspectives among the two groups. Some mothers sought more recognition of their uniqueness based on the support they received, and confirmation that their experience was normal to improve their self-confidence. Women who felt that the support they received lacked such confirmation and individualization had increased uncertainty in their ability to breastfeed. In contrast, midwives in the study perceived that they were already providing individualized support based on the unique needs of each woman (Backstrom et al., 2010). Powell et al. (2014) also found that women felt the information they received from HCPs was too general and was not adapted to meet their individual situation.

The nature of the interpersonal interaction between mothers and HCPs offering lactation support is also critical. A metasynthesis of women’s perceptions of breastfeeding support emphasized the importance of those offering support having person-centered communication skills and an authentic presence (Schmied, Beake, Sheehan, McCourt, & Dykes, 2011). The metasynthesis recommended a balanced approach to breastfeeding support that is “positive but realistic, not over idealistic; encouraging, proactive, and focused on the benefits, but not creating pressure on women to breastfeed and making them feel inadequate or failing if they do not” (Schmied et al., 2011, p. 58). Analysis of a questionnaire in New Zealand called for those offering breastfeeding support to have effective communication skills, including sensitivity to the uniqueness of women’s breastfeeding experiences (Manhire et al., 2007).

The provision of non-judgmental, caring, and encouraging support requires acknowledgment of the diversity of feelings among breastfeeding mothers. Marshall, Godfrey, and Renfrew (2007) interviewed mothers and their HCPs in England and found that it was easier for mothers to see breastfeeding as synonymous with being a “good mother” if they felt things were going well and their baby was happy and healthy. However, if the baby was not content, happy, and/or gaining weight as expected, the women’s confidence was undermined and they felt open to being judged as bad mothers by others. The authors suggested that HCPs should not medicalize breastfeeding, but rather offer support that recognizes individual contextual situations and provides emotional reassurance in addition to the technical skills required for successful breastfeeding.

Emotional support is not just required during the lactation period but afterward, especially for those mothers whose breastfeeding expectations were not met. Feelings of guilt, regret, and inadequacy are evident in the narratives of mothers in our research when breastfeeding did not go as hoped. Given the extensive “breast is best” health promotion marketing of breastfeeding, it is not surprising that mothers might believe they have failed their baby when weaning occurs earlier than hoped or recommended. Wambach and Cohen (2009) also found that adolescent mothers in their American study expressed regret and sadness if they had weaned earlier than planned. A metaethnographic synthesis of existing qualitative research into women’s breastfeeding experiences concluded that current societal and HCP discourses contribute to a sense of failure, guilt, and disillusionment for some mothers (Burns, Schmied, Sheehan, & Fenwick, 2010). The authors found that breastfeeding was equated with being a “good mother” and, similar to some descriptions in our research, acted to motivate some mothers to persevere in the face of difficulties. However, this discourse adversely affected the self-confidence of mothers who ceased breastfeeding earlier than intended with self-blame and a sense of failure commonly reported in many of the studies reviewed (Burns et al., 2010).

Mothers in our study were candid about their mixed or negative emotions despite health care and societal messaging that breastfeeding is a positive maternal act of giving. Some women seemed torn between the breastfeeding promotion messages and the psychosocial realities of breastfeeding. Other research found similar perceptions. As part of a qualitative study in Scotland, women were interviewed to investigate their infant feeding experiences from late pregnancy until 6 months postpartum (Hoddinott, Craig, Britten, & McInnes, 2012). The findings revealed a clash between idealism and realism, with real-life family situations and values sometimes perceived to be at odds with the ideal infant nutrition recommendation of exclusive breastfeeding for the first 6 months. The researchers proposed that this recommendation is seen as unrealistic by many families who feel compelled to deviate from recommended infant feeding practices to restore family well-being. The decision to switch to infant formula leaves parents open to being judged as failures and the possibility of internalizing the feelings of having failed their infant because of their perceived inability to meet the nutritional ideal. Hoddinott et al. (2012) called for increased recognition that the emotional well-being of families should also be seen as an important health outcome when offering support to new parents.

Based on the guilt/regret expressed by mothers in our study, it is important for HCPs to balance breastfeeding promotion with the need to provide emotional support and reassurance to women when the breastfeeding experience does not go well. Routine breastfeeding support should include an assessment of the mother’s emotions regarding her experience and individualized support that acknowledges and respects the diversity of maternal psychosocial responses, including recognition that not everyone loves breastfeeding.

This research has several limitations. First, voluntary surveys are only representative of those who choose to participate, and typically participant characteristics differ from those who choose not to complete a survey. In this instance, the respondents were a fairly homogeneous group with higher education and income levels than the general population. The health region’s Aboriginal population was underrepresented, and it is expected that other ethnic minorities and those with lower literacy and English-proficiency levels were also underrepresented as these characteristics were not captured by survey questions. Second, the narratives of the mothers might be narrowly reflective of the breastfeeding support services offered in this particular region and the general societal views of breastfeeding in this part of Canada. Finally, the data were derived from a written survey, which limits the possibility of extended narratives and does not allow for the clarification probes inherent in other qualitative data collection modes that result in richer, more detailed experiential accounts.

Future research could explore the effectiveness of social marketing messages that more holistically portray the aspects of breastfeeding that mothers enjoy as compared with those that focus exclusively on health benefits. Other areas for further exploration include examining the best way to provide mothers with a realistic portrayal of common breastfeeding challenges as part of breastfeeding education and promotion efforts, and investigating the optimal balance between promoting universal breastfeeding while recognizing the realities for women when lactation does not go well.

Conclusion

This research describes the holistic and unique nature of the breastfeeding experience from the perspective of mothers. The findings emphasize that breastfeeding cannot be narrowly viewed as a biological event that requires only the dissemination of a specific knowledge base and skill set to mothers. Rather, breastfeeding supports must incorporate the psychosocial and emotional aspects including the need to provide encouragement and reassurance to mothers in addition to the requisite knowledge. Mothers need to be aware of common breastfeeding challenges when the realities of breastfeeding do not meet personal and societal expectations, reassurance that difficulties are common but can be overcome and the resources to problem solve issues as they arise. Those developing breastfeeding promotion campaigns and offering individual support must recognize that not everyone finds breastfeeding easy and enjoyable, and must tailor messaging and support accordingly to acknowledge the range of experiences. Finally, emotional support and reassurance should be provided for those who are saddened or feel guilty about their breastfeeding experience. Psychosocial and emotional aspects must be addressed as part of universal breastfeeding supports as health care systems strive to increase duration rates.

Author Biographies

Marie Dietrich Leurer, RN, PhD, is an assistant professor in the College of Nursing (South Saskatchewan Campus), University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Eunice Misskey, RD, MCEd, is a freelance public health nutrition consultant previously with the Regina Qu’Appelle Health Region and Saskatchewan Ministry of Health, Regina, Saskatchewan, Canada.