Table 4.

Illustration of how individual paper findings map on to synthesis theme and subthemes

Theme: Weight amplifies breastfeeding difficulties
Subthemes	Garner et al. (2014)	Garner et al. (2016)	Keely et al. (2015)	Lyons et al. (2019)	Massov (2015)
Psychological reactions to medical interventions	• Women with a BMI > 30 kg m2 have reduced stamina and mobility due to weight and caesarean sections. • Women with a BMI > 30 kg m2 have low motivation because medical interventions make breastfeeding more difficult.	• Women with a BMI > 30 kg m2 often have long, difficult labours, which may result in caesarean section and reduced mobility and infection. • Women with a BMI > 30 kg m2 had sick babies and were separated from their infants.	• Caesarean sections delay skin‐to‐skin and lead to separation from infants. • Medical interventions lead to longer hospital stays, where women with a BMI > 30 kg m2 feel uncomfortable to initiate breastfeeding due to the lack privacy.	• Many women with a BMI > 30 kg m2 experience medical intervention, which removes their sense of control over their pregnancy and breastfeeding.	—
Perception of body's ability to breastfeed	• Women with a BMI > 30 kg m2's body shape and size negatively impact on breastfeeding, and they fear smothering their infant. • Women with a BMI > 30 kg m2 worry about their body's ability to breastfeed and are self‐conscious because they struggle to breastfeed discreetly. • Positioning requires more trial and error.	• Women with a BMI > 30 kg m2 lacked confidence in their ability to breastfeed, so planned to breastfeed for shorter durations. • Women with a BMI > 30 kg m2 have difficulty with positioning and latching, and their perception of their body size and shape leads to fears of suffocating their infant. • Women with a BMI > 30 kg m2 struggle to find affordable nursing bras in the right sizes.	• Women with a BMI > 30 kg m2 lacked belief in their ability to breastfeed discreetly in public and did not want to breastfeed in front of family and friends in their home, which led to the cessation of exclusive breastfeeding. • Having a bigger body and breasts caused difficulty with latching and positioning and led women to fear suffocating their infant. • Women with a BMI > 30 kg m2 introduced formula milk early due to beliefs that they were not producing enough breast milk.	• Women with a BMI > 30 kg m2 face barriers related to their body size and shape, which reinforce the perceived lack of control over breastfeeding. • Women with a BMI > 30 kg m2 worry about their ability to produce nutritious milk.	• Women with a BMI > 30 kg m2 found breastfeeding difficult and felt unprepared. • Having difficulty latching because of larger breasts and bodies led women with a BMI > 30 kg m2 to lack belief in their ability to breastfeed and to do so discreetly and to worry about suffocating their infant. • Women with a BMI > 30 kg m2 introduced formula milk due to beliefs that they did not produce enough breast milk.
Additional need for support	• Women with a BMI > 30 kg m2 have less access to social support compared with other women. • Women with a BMI > 30 kg m2 need more support and education about breastfeeding in pregnancy.	•Women with a BMI > 30 kg m2 needed more latching support over a longer period of time but had less access to social support.	• Partner support was viewed as important when making infant feeding decisions. • Few women with a BMI > 30 kg m2 sought professional support because they misunderstood its purpose, but those that did described it as a positive experience. • Women with a BMI > 30 kg m2 wanted support at home and valued support from friends who breastfed.	• Seeking support helped women with a BMI > 30 kg m2 to overcome medical, social, and practical barriers. • Women with a BMI > 30 kg m2 wanted support beyond the initial latching stage to normalise and support maintenance.	• Women with a BMI > 30 kg m2 sometimes found professional help distressing, as they were not comfortable with health professionals touching their bodies and infant. • Women with a BMI > 30 kg m2 felt uncomfortable asking for professional help in hospital as they felt staff were too busy.

Abbreviation: BMI, body mass index.