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Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition During Lactation. Washington (DC): National Academies Press (US); 1991.

Nutrition During Lactation.

• Hardcopy Version at National Academies Press

1 Summary, Conclusions, and Recommendations

During the past decade, the benefits of breastfeeding have been emphasized by many authorities and organizations in the United States. Federal agencies have set specific objectives to increase the incidence and duration of breastfeeding (DHHS, 1980, 1990), and the Surgeon General has held workshops on breastfeeding and human lactation (DHHS, 1984, 1985). At the federal and state levels, the Special Supplemental Food Program for Women, Infants, and Children (WIC) has produced materials designed to promote breastfeeding (e.g., Malone, 1980; USDA, 1988). Furthermore, the Office of Maternal and Child Health has sponsored breastfeeding projects (e.g., The Steering Committee to Promote Breastfeeding in New York City, 1986), as have state health departments and others. However, less attention has been given to two general topics: (1) the effects of breastfeeding on the nutritional status and long-term health of the mother and (2) the effects of the mother's nutritional status on the volume and composition of her milk and on the potential subsequent effects of those changes on infant health. The present report was designed to address these topics.

This summary briefly describes the origin of this effort and the process; provides key definitions; reviews what was learned about who is breastfeeding in the United States and if those women are well nourished; discusses nutritional influences on milk volume or composition; and describes how breastfeeding may affect infant growth, nutrition, and health, as well as maternal health. It then presents major conclusions, clinical recommendations, and the research recommendations most directly related to the nutrition of lactating women in the United States.

• Origin Of This Study

This study was undertaken at the request of the Maternal and Child Health Program (Title V, Social Security Act) of the Health Resources and Services Administration, U.S. Department of Health and Human Services. In response to that request, the Food and Nutrition Board's Committee on Nutritional Status During Pregnancy and Lactation and its Subcommittee on Nutrition During Lactation were asked to evaluate current scientific evidence and formulate recommendations pertaining to the nutritional needs of lactating women, giving special attention to the needs of lactating adolescents; women over age 35; and women of black, Hispanic, or Southeast Asian origin. Part of this task included consideration of the effects of maternal dietary intake and nutritional status on the volume and composition of human milk, the appropriateness of various anthropometric methods for assessing nutritional status during lactation, and the effects of lactation both on maternal and infant health and on the nutritional status of both the mother and the infant.

• Approach To The Study

The study was limited to consideration of healthy U.S. women and their healthy, full-term infants. The Subcommittee on Nutrition During Lactation conducted an extensive literature review, consulted with a variety of experts, and met as a group seven times to discuss the data and draw conclusions from them. The Committee on Nutritional Status During Pregnancy and Lactation (the advisory committee) reviewed and commented on the work of the subcommittee and helped establish appropriate linkages between this report and the reports on weight gain and nutrient supplements during pregnancy contained in Nutrition During Pregnancy —a report prepared by two other subcommittees of this advisory committee (IOM, 1990). Compared with earlier reports from the National Research Council, Nutrition During Pregnancy recommended a higher range of weight gain (11.5 to 16 kg, or 25 to 35 lb, for women of normal prepregnancy weight for height). In addition, it advised routine low-dose iron supplementation during pregnancy, but supplements of other vitamins or minerals were recommended only under special circumstances.

In examining the nutritional needs of lactating women, priority was given to energy and to those nutrients believed to be consumed in amounts lower than Recommended Dietary Allowances (RDAs) by many women in the United States. These nutrients include calcium, magnesium, iron, zinc, folate, and vitamin B 6 . Careful attention was given to the effects of lactation on various indicators of nutritional status, such as measurements of levels of biochemical compounds; functions related to specific nutrients; nutrient levels in specific body compartments; and height, weight, or other indicators of body size or adiposity. The subcommittee took into consideration that weight gain recommendations for pregnant women have been raised (see Nutrition During Pregnancy [IOM, 1990]) and that average weight gains of U.S. women during pregnancy have risen over the past two decades.

When possible, a distinction was made between exclusive breastfeeding, defined as the consumption of human milk as the sole source of energy, and partial breastfeeding, defined as the consumption of human milk in combination with formula or other foods, or both.

The nutritional demands imposed by lactation were estimated from data on volume and composition of milk produced by healthy, successfully lactating women, as done in Recommended Dietary Allowances (NRC, 1989). When it was feasible, evidence relating to possible depletion of maternal stores or to a decrease in the specific nutrient content of milk resulting from low maternal intake of the nutrient was also addressed. Because of the complex relationships between the nutrition of the mother and infant, the subcommittee examined the nutrition and growth of the breastfed infant.

The terms maternal health and infant health were interpreted in a broad sense. Consideration was given to both beneficial and adverse consequences for the health of the mother and her offspring, both during lactation and long after breastfeeding has been discontinued. For the mother, there was a search for evidence of differences in outcome related to whether or not she had breastfed. For the infant, evidence was sought for differences in outcome related to the method of feeding (breast compared with bottle). The possible influences of breastfeeding on prevention or promotion of chronic disease were addressed.

To the extent possible, this report includes detailed coverage of published evidence linking maternal nutrition, breastfeeding, and maternal and infant health. Because breastfeeding is encouraged primarily as a method for promoting the health of infants, considerable attention is also directed toward infant health even when there is no established relationship to maternal nutritional status. Recognizing the serious gaps in knowledge of nutrition during lactation, the subcommittee gave much thought to establishing directions for research.

The members of the subcommittee realized that nutrition is not the sole determinant of successful breastfeeding. A network of overlapping social factors including access to maternal leave, instructions concerning breastfeeding, availability of prenatal care, the length of hospital stay following delivery, infant care in the workplace, and the public attitudes toward breastfeeding are important. Given the goals of this report, the subcommittee did not specifically address those factors, but it recognizes that they should be considered in depth by public health groups that are attempting to improve rates of breastfeeding in this and other countries.

• What Was Learned

Who Is Breastfeeding

The incidence and duration of breastfeeding changed markedly during the twentieth century—first declining, then rising, and, from the early 1980s, declining once again. Currently, women who choose to breastfeed tend to be well educated, older, and white. Data on the incidence and duration of breastfeeding in the United States are especially limited for mothers who are economically disadvantaged and for those who are members of ethnic minority groups. The best data for any minority groups are for black women. Their rates of breastfeeding are substantially lower than those for white women, but factors that distinguish breastfeeding from nonbreastfeeding women tend to be similar among black and white women. Social, cultural, economic, and psychological factors that influence infant feeding choices by adolescent mothers are not well understood. In the United States, where few employers provide paid maternity leave, return to work outside the home is associated with a shorter duration of breastfeeding, but little else is known about when mothers discontinue either exclusive or partial breastfeeding. Such data are needed to estimate the total nutrient demands of lactation.

How Can It Be Determined Whether Lactating Women Are Well Nourished

The few lactating women who have been studied in the United States have been characterized as well nourished, but this observation cannot be generalized since these subjects were principally white women with some college education. Women from less advantaged, less well studied populations may be at higher risk of nutritional problems but tend not to breastfeed.

To determine whether women are adequately nourished, investigators use biochemical or anthropometric methods, or both. For lactating women, however, there are serious gaps and limitations in the data collected with these methods. Consequently, there is no scientific basis for determining whether poor nutritional status is a problem among certain groups of these women. To identify the nutrients likely to be consumed in inadequate amounts by lactating women, the subcommittee used an approach involving nutrient densities (nutrient intakes per 1,000 kcal) calculated from typical diets of nonlactating U.S. women. That is, they made the assumption that the average nutrient densities of the diets of lactating women would be the same as those of nonlactating women but that lactating women would have higher total energy intake (and therefore higher nutrient intake). Using this approach, the nutrients most likely to be consumed in amounts lower than the RDAs for lactating women are calcium, zinc, magnesium, vitamin B 6 , and folate.

Data for U.S. women indicate that successful lactation occurs regardless of whether a woman is thin, of normal weight, or obese. Anthropometric measurements (such as weight, weight for height, and skinfold thickness) have not been useful for predicting the success of lactation among the few U.S. women who have been studied. The predictive ability is not known for anthropometric measurements that fall outside the ranges observed in these limited samples.

Lactating women eating self-selected diets typically lose weight at the rate of 0.5 to 1.0 kg (˜1 to 2 lb) per month in the first 4 to 6 months of lactation. Such weight loss is probably physiologic. During the same period, values for subscapular and suprailiac skinfold thickness also decrease; triceps skinfold thickness does not. Not all women lose weight during lactation; studies suggest that approximately 20% may maintain or gain weight.

Biochemical data for lactating women have been obtained only from small, select samples. Such data are of limited use in the clinical situation because there are no norms for lactating women, and the norms for nonpregnant, nonlactating women may not be applicable to breastfeeding women. For example, there appear to be changes in plasma volume post partum, and there are changes in blood nutrient values over the course of lactation that are unrelated to changes in plasma volume.

Does Maternal Nutritional Status or Dietary Intake Influence Milk Volume

The mean volume of milk secreted by healthy U.S. women whose infants are exclusively breastfed during the first 4 to 6 months is approximately 750 to 800 ml/day, but there is considerable variability from woman to woman and in the same woman at different times. The standard deviation of daily milk intake by infants is about 165 ml; thus, 5% of women secrete less than 550 ml or more than 1,200 ml on a given day. The major determinant of milk production is the infant's demand for milk, which in turn may be influenced by the size, age, health, and other characteristics of the infant as well as by his or her intake of supplemental foods. The potential for milk production may be considerably higher than that actually produced, as evidenced by findings that the milk volumes produced by women nursing twins or triplets are much higher than those produced by women nursing a single infant.

Studies of healthy women in industrialized countries demonstrate that milk volume is not related to maternal weight or height or indices of fatness. In developing countries, there is conflicting evidence about whether thin women produce less milk than do women with higher weight for height.

Increased maternal energy intake has not been linked with increased milk production, at least among well-nourished women in industrialized countries. Nutritional supplementation of lactating women in developing countries where undernutrition may be a problem has generally been reported to have little or no impact on milk volume, but most studies have been too small to test the hypothesis adequately and lacked the design needed for causal inference. Studies of animals indicate that there may be a threshold below which energy intake is insufficient to support normal milk production, but it is likely that most studies in humans have been conducted on women with intakes well above this postulated threshold.

The weight loss ordinarily experienced by lactating women has no apparent deleterious effects on milk production. Although lactating women typically lose 0.5 to 1 kg (˜1 to 2 lb) per month, some women lose as much as 2 kg (˜4 lb) per month and successfully maintain milk volume. Regular exercise appears to be compatible with production of an adequate volume of milk.

The influence of maternal intake of specific nutrients on milk volume has not been investigated satisfactorily. Early studies in developing countries suggest a positive association of protein intake with milk volume, but those studies remain inconclusive. Fluids consumed in excess of thirst do not increase milk volume.

Does Maternal Nutritional Status Influence Milk Composition

The composition of human milk is distinct from the milk of other mammals and from infant formulas ordinarily derived from them. Human milk is unique in its physical structure, types and concentrations of macronutrients (protein, fat, and carbohydrate), micronutrients (vitamins and minerals), enzymes, hormones, growth factors, host resistance factors, inducers/modulators of the immune system, and anti-inflammatory agents.

A number of generalizations can be made about the effects of maternal nutrition on the composition of milk (see also Table 1-1 ):

Possible Influences of Maternal Intake on the Nutrient Composition of Human Milk and Nutrients for Which Clinical Deficiency Is Recognizable in Infants.

• Even if the usual dietary intake of a macronutrient is less than that recommended in Recommended Dietary Allowances (NRC, 1989), there will be little or no effect on the total amount of that nutrient in the milk. However, the proportions of the different fatty acids in human milk vary with maternal dietary intake.
• The concentrations of major minerals (calcium, phosphorus, magnesium, sodium, and potassium) in human milk are not affected by the diet. Maternal intakes of selenium and iodine are positively related to their concentrations in human milk, but there is no convincing evidence that the concentrations of other trace elements in human milk are affected by maternal diet.
• The vitamin content of human milk is dependent upon the mother's current vitamin intake and her vitamin stores, but the strength of the relationships varies with the vitamin. Chronically low maternal intake of vitamins may result in milk that contains low amounts of these essential nutrients.
• The content of at least some nutrients in human milk may be maintained at a satisfactory level at the expense of maternal stores. This applies particularly to folate and calcium.
• Increasing the mother's intake of a nutrient to levels above the RDA ordinarily does not result in unusually high levels of the nutrient in her milk; vitamins B 6 and D, iodine, and selenium are exceptions. Studies have not been conducted to evaluate the possibility that high levels of nutrients in milk are toxic to the infant.
• Some studies suggest that poor maternal nutrition is associated with decreased concentrations of certain host resistance factors in human milk, whereas other studies do not suggest this association.

In What Ways May Breastfeeding Affect Infant Growth and Health

Infant nutrition.

Several factors influence the nutritional status of the breastfed infant: the infant's nutrient stores (which are largely determined by the length of gestation and maternal nutrition during pregnancy), the total amount of nutrients supplied by human milk (which is influenced by the extent and duration of breastfeeding), and certain genetic and environmental factors that affect the way nutrients are absorbed and used.

Human milk is ordinarily a complete source of nutrients for the exclusively breastfed infant. However, if the infant or mother is not exposed regularly to sunlight or if the mother's intake of vitamin D is low, breastfed infants may be at risk of vitamin D deficiency. Breastfed infants are susceptible to deficiency of vitamin B 12 if the mother is a complete vegetarian—even when the mother has no symptoms of that vitamin deficiency.

The risk of hemorrhagic disease of the newborn is relatively low. Nonetheless, all infants (regardless of feeding mode or of maternal nutritional status) are at some risk for this serious disease unless they are supplemented with a single dose of vitamin K at birth.

Full-term, exclusively breastfed infants ordinarily maintain a normal iron status for their first 6 months of life, regardless of maternal iron intake. Providing solid foods may reduce the percentage of iron absorbed by the partially breastfed infant, making it important in such cases to ensure that adequate iron is provided in the diet.

Growth and Development

Breastfed infants gain weight at about the same rate as formula-fed infants during the first 2 to 3 months post partum, although breastfed infants usually ingest less milk and thus have a lower energy intake. After the first few months post partum, healthy breastfed infants gain weight more slowly than those who are formula fed. In general, this pattern is not altered by the introduction of solid foods. Differences in linear growth between breastfed and formula-fed infants are small if statistical techniques are used to control differences in size at birth.

Infant Morbidity and Mortality

Several types of health problems occur less often or appear to have less serious consequences in breastfed than in formula-fed infants. These include certain infectious diseases (especially ones involving the intestinal and respiratory tracts), food allergies, and, perhaps, certain chronic diseases. There is suggestive evidence that severe maternal malnutrition might reduce the degree of immune protection afforded by human milk, but further studies will be required to address that issue.

Few infectious agents are commonly transmitted to the infant via human milk. The most prominent ones are cytomegalovirus in all populations that have been studied and human T lymphocytotropic virus type 1 (HTLV-1) in certain Asian populations. The transmission of cytomegalovirus by breastfeeding does not result in disease; the consequences of the transmission of HTLV-1 by breastfeeding are unknown. There are some case reports that indicate that human immunodeficiency virus (HIV) can be transmitted by breastfeeding as a result of the transfusion of HIV-contaminated blood during the immediate postpartum period. The likelihood of transmitting HIV via breastfeeding by women who tested seropositive for the agent during pregnancy has not been determined. Public policy on this issue has ranged from the Centers for Disease Control's recommendation not to breastfeed under these circumstances to the World Health Organization's encouragement to breastfeed, especially among women in developing countries.

In developing countries, mortality rates are lower among breastfed infants than among those who are formula fed. It is not known whether this advantage also holds in industrialized countries, in which death rates are lower in general. It is reasonable to believe that breastfeeding will lead to lower mortality among disadvantaged groups in industrialized countries if they have higher than usual infant and child mortality rates, but this issue has not been studied.

Medications, Drugs, and Environmental Contaminants

The few prescription drugs that are contraindicated during lactation because of potential harm to the infant can usually be avoided and replaced with safer acceptable ones. For example, there are a number of safe and effective substitutes for the antibiotic chloramphenicol, which is contraindicated for lactating women. If treatment with antimetabolites or radiotherapeutics is required by the mother, breastfeeding is contraindicated.

Cigarette smoking and alcohol consumption by lactating women in excess of 0.5 g/kg of maternal weight may be harmful to the infant, partly because of potential reduction in milk volume. Furthermore, a single report (Little et al., 1989) associates heavy alcohol use by the mother with retarded psychomotor development of the infant at 1 year of age. Infrequent cigarette smoking, occasional consumption of small amounts of alcohol, and moderate ingestion of caffeine-containing products are not considered to be contraindicated during breastfeeding. Use of illicit drugs is contraindicated because of the potential for drug transfer through the milk as well as hazards to the mother. Since the limited information on the impact of these habits upon the nutrition of women in the childbearing years is reviewed in Nutrition During Pregnancy (IOM, 1990), they were not considered further by this subcommittee.

In the uncommon situation of a high risk of exposure to such environmental contaminants as organochlorinated compounds (such as dichlorodiphenyl-trichloroethane [DDT] or polychlorinated biphenyls [PCBs]) or toxic metals (such as mercury), risks must be weighed against the benefits of breastfeeding for both mother and infant on a case-by-case basis. In areas of unusually high exposure, levels of the contaminant should be measured in the mother's blood and milk.

How Does Breastfeeding Affect Maternal Nutrition and Health

Breastfeeding substantially increases the mother's requirements for most nutrients. The magnitude of the total increase is most strongly affected by the extent and duration of lactation. Adequacy of intakes of calcium, magnesium, zinc, folate, and vitamin B 6 merits special attention since average intakes may be below those recommended. The net long-term effect of lactation on bone mass is uncertain. Some data associate lactation with short-term bone loss, whereas most recent studies suggest a protective long-term effect. Those data are provocative but of such preliminary nature that no definitive conclusions may be drawn from them.

Although most lactating women lose weight gradually during lactation, some do not. The influence of lactation on long-term postpartum weight retention and maternal risk of adult-onset obesity has not been determined.

A well-documented effect of lactation is delayed return to ovulation. In addition, some recent epidemiologic evidence indicates that breastfeeding may lessen the risk that the mother will develop breast cancer, but the data are not consistent across all studies.

• Conclusions And Recommendations

The major conclusions of the report are as follows.

Women living under a wide variety of circumstances in the United States and elsewhere are capable of fully nourishing their infants by breastfeeding them. Throughout its deliberations, the subcommittee was impressed by evidence that mothers are able to produce milk of sufficient quantity and quality to support growth and promote the health of infants—even when the mother's supply of nutrients and energy is limited. With few exceptions (identified later in the summary under "Infant Growth and Nutrition"), the full-term exclusively breastfed infant will be well nourished during the first 4 to 6 months after birth.

In contrast, the lactating woman is vulnerable to depletion of nutrient stores through her milk. Measures should be taken to promote food intake during lactation that will prevent net maternal losses of nutrients, especially of calcium, magnesium, zinc, folate, and vitamin B 6 .

Breastfeeding is recommended for all infants in the United States under ordinary circumstances. Exclusive breastfeeding is the preferred method of feeding for normal full-term infants from birth to age 4 to 6 months. Breastfeeding complemented by the appropriate introduction of other foods is recommended for the remainder of the first year, or longer if desired. The subcommittee and advisory committee recognize that it is difficult for some women to follow these recommendations for social or occupational reasons. In these situations, appropriate formula feeding is an acceptable alternative.

Data are lacking for use in developing strategies to identify lactating women who are at risk of depleting their own nutrient stores. Although nutrient intake appears adequate for the small number of lactating women who have been studied in the United States, evidence from U.S. surveys of nonpregnant, nonlactating women suggests that usual dietary intake of certain nutrients by disadvantaged women is likely to be somewhat lower than that by women of higher socioeconomic status. Thus, if breastfeeding rates increase among less advantaged women as a result of efforts to promote breastfeeding, it will be important to examine more completely the nutrient intake of these women during lactation.

If lactating women follow eating patterns similar to those of the average U.S. woman in sufficient quantity to meet their energy requirements, they are likely to meet the recommended intakes of all nutrients except perhaps calcium and zinc. However, if they curb their energy intakes, their intakes of several nutrients are likely to be less than the RDA.

Recommendations for Women Who Wish To Breastfeed and for Their Care Providers

Because of serious gaps in information about nutrition assessment and nutrient requirements during lactation and about effects of maternal nutrition on the wide array of components in the milk, the following recommendations should be considered preliminary. Although they reflect the best judgment of the subcommittee and advisory committee, these recommendations are open to reconsideration as the knowledge base grows.

Diet and Vitamin-Mineral Supplementation

Lactating women should be encouraged to obtain their nutrients from a well-balanced, varied diet rather than from vitamin-mineral supplements.

• Provide women who plan to breastfeed or who are already doing so with nutrition information that is culturally appropriate (that is, information that is sensitive to the foodways, eating practices, and health beliefs and attitudes of the cultural group). To facilitate the acquisition of this information, health care providers are encouraged to make effective use of teaching opportunities during prenatal visits, hospitalization following delivery, and routine postpartum visits for maternal or pediatric care.
• Encourage lactating women to follow dietary guidelines that promote a generous intake of nutrients from fruits and vegetables, whole-grain breads and cereals, calcium-rich dairy products, and protein-rich foods such as meats, fish, and legumes. Such a diet would ordinarily supply a sufficient quantity of essential nutrients. The individual recommendations should be compatible with the woman's economic situation and food preferences. The evidence does not warrant routine vitamin-mineral supplementation of lactating women.
• If dietary evaluation suggests that the diet does not provide the recommended amounts of one or more nutrients, encourage the woman to select and consume foods that are rich in those nutrients.
• For women whose eating patterns lead to a very low intake of one or more nutrients, provide individualized diet counseling (preferred) or recommend nutrient supplementation (as described in Table 1-2 ).
• Encourage sufficient intake of fluids—especially water, juice, and milk—to alleviate natural thirst. It is not necessary to encourage fluid intakes above this level.
• The elimination of major nutrient sources (e.g., all dairy products) from the maternal diet to treat allergy or colic in the breastfed infant is not recommended unless there is evidence from oral elimination-challenge studies to determine whether the mother is sensitive or intolerant to the food or that the breastfed infant reacts to the foods ingested by the mother. If a key nutrient source is eliminated from the maternal diet, the mother should be counseled on how to achieve adequate nutrient intake by substituting other foods.

Suggested Measures for Improving Nutrient Intake of Women with Restrictive Eating Patterns.

A Defined Health Care Plan for Lactating Women

There should be a well-defined plan for the health care of the lactating woman that includes screening for nutritional problems and providing dietary guidance. Since preparation for lactation should begin during the prenatal period, the physician, midwife, nutritionist, or other member of the obstetric team should introduce general information about nutrition during lactation and should screen for possible problems related to nutrition. Ideally, more extensive evaluation and counseling should take place during hospitalization for childbirth. If that is precluded by the brevity of the hospital stay, an early visit to an appropriate health care professional by the mother or a visit to the mother's home is advisable.

To implement routine screening economically and practically, the subcommittee considers it sufficient to continue the practice of weighing women (using standard procedures as described in Nutrition During Pregnancy [IOM, 1990]) at scheduled visits and to ask a few simple questions to determine the following:

• Are calcium-rich foods eaten regularly?
• Does the diet include vitamin D-fortified milk or cereal or is there adequate exposure to ultraviolet light?
• Are fruits and vegetables eaten regularly?
• Is the mother a complete vegetarian?
• Is the mother restricting her food intake severely in an attempt to lose weight or to treat certain medical conditions?
• Are there life circumstances (e.g., poverty, or abuse of drugs or alcohol) that might interfere with an adequate diet?

It is not necessary to obtain measurements of skinfold thickness or to conduct laboratory tests as a part of the routine assessment of the nutritional status of lactating women.

The subcommittee recognizes that establishing standard health care procedures for lactating women requires expanded training of health care providers. Activities to achieve this expanded training are being initiated by the Surgeon General's workshop committee comprising representatives from the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and other professional organizations.

Breastfeeding Practices

Efforts to support lactation must consider breastfeeding practices.

• Because the early management of lactation has a strong influence on the establishment of an adequate milk supply, breastfeeding guidance should be provided prenatally and continued in the hospital after delivery and during the early postpartum period.
• All hospitals providing obstetric care should provide knowledgeable staff in the immediate postpartum period who have responsibility for providing support and guidance in initiating breastfeeding and measures to promote establishment of an ample supply of milk.
• Breastfeeding practices that are responsive to the infant's natural appetite should be promoted. In the first few weeks, infants should nurse at least 8 times per day, and some may nurse as often as 15 or more times per day. After the first month, infants fed on demand usually nurse 5 to 12 times per day.

Maternal Weight

Women who plan to breastfeed or who are breastfeeding should be given realistic, health-promoting advice about weight change during lactation.

• Advise women that it is normal to lose weight during the first 6 months of lactation. The average rate of weight loss is 0.5 to 1.0 kg (˜ 1 to 2 lb)/month after the first month post partum. However, not all women who breastfeed lose weight; some women gain weight post partum, whether or not they breastfeed. If a lactating woman is overweight, a weight loss of up to 2 kg (˜4.5 lb) per month is unlikely to adversely affect milk volume, but such women should be alert for any indications that the infant's appetite is not being satisfied. Rapid weight loss (>2 kg/month after the first month post partum) is not advisable for breastfeeding women.
• Advise women who choose to curb their energy intake to pay special attention to eating a balanced, varied diet and to including foods rich in calcium, zinc, magnesium, vitamin B 6 , and folate. Encourage energy intake of at least 1,800 kcal/day. Calcium, multivitamin-mineral supplements, or both may be advised when dietary sources are marginal and it is unlikely that appropriate dietary practices will or can be followed. Intakes below 1,500 kcal/day are not recommended at any time during lactation, although fasts lasting less than 1 day have not been shown to decrease milk volume. Liquid diets and weight loss medications are not recommended. Since the impact of curtailing maternal energy intake during the first 2 to 3 weeks post partum is unknown, dieting during this period is not recommended.

Maternal Substance Use and Abuse

The use of illicit drugs should be actively discouraged, and affected women (regardless of their mode of feeding) should be assisted to enter a rehabilitative program that makes provision for the infant. The use of certain legal substances by lactating women is also of concern, including the potential for alcohol abuse.

• There is no scientific evidence that consumption of alcoholic beverages has a beneficial impact on any aspect of lactation performance. If alcohol is used, advise the lactating woman to limit her intake to no more than 0.5 g of alcohol per kg of maternal body weight per day. Intake over this level may impair the milk ejection reflex. For a 60-kg (132-lb) woman, 0.5 g of alcohol per kg of body weight corresponds to approximately 2 to 2.5 oz of liquor, 8 oz of table wine, or 2 cans of beer.
• Actively discourage smoking among lactating women, not only because it may reduce milk volume but because of its other harmful effects on the mother and her infant.
• Discourage intake of large quantities of coffee, other caffeine-containing beverages and medications, and decaffeinated coffee. The equivalent of 1 to 2 cups of regular coffee daily is unlikely to have a deleterious effect on the nursling, although preliminary evidence suggests that maternal coffee intake may adversely influence the iron content of milk and the iron status of the infant.

Infant Growth and Nutrition

The subcommittee recommends that health care providers be informed about the differences in growth between healthy breastfed and formula-fed infants. On average, breastfed infants gain weight more slowly than those fed formula after the first 2 to 3 months. Slower weight gain, by itself, does not justify the use of supplemental formula. When in doubt, clinicians should evaluate adequacy of growth according to the guidelines described by Lawrence (1989).

Regardless of what the mother eats, the following steps should be taken to ensure adequate nutrition of breastfed infants.

• All newborns should receive a 0.5- to 1.0-mg injection or a 1.0-to 2.0-mg oral dose of vitamin K immediately after birth regardless of the type of feeding that will be offered the infant.
• If the infant's exposure to sunlight appears to be inadequate, the infant should be given a 5- to 7.5-µg supplement of vitamin D per day.
• Fluoride supplements should be provided to breastfed infants if the fluoride content of the household drinking-water supply is low (<0.3 ppm)
• When breastfeeding is complemented by other foods, and by 6 months of age in any case, the infant should be given food rich in bioavailable iron or a daily low-dose oral iron supplement.

Infant Health

Health care providers should recognize that breastfeeding is recommended to reduce the incidence and severity of certain infectious gastrointestinal and respiratory diseases and other disorders in infancy. Breastfeeding ordinarily confers health benefits to the infant, but in certain rare cases it may pose some health risks, as indicated below.

• For mothers requiring medication and desiring to breastfeed, the clinician should select the medication least likely to pass into the milk and to the infant.
• Although medications rarely pose a problem during lactation, breastfeeding is contraindicated in the case of a few. Such drugs include antineoplastic agents, therapeutic radiopharmaceuticals, some but not all antithyroid agents, and antiprotozoan agents.
• In those rare cases when there is heavy exposure to pesticides, heavy metals, or other contaminants that may pass into the milk, breastfeeding is not recommended if maternal levels are high.

Recommendations for Nutrition Monitoring

The committee recommends that the U.S. government provide a mechanism for periodically monitoring trends in lactation and developing normative indicators of nutritional status during lactation.

• Monitoring of trends . Data are needed on the incidence and duration of breastfeeding among the population as a whole, and among some particularly vulnerable subpopulations. Exclusive, partial, and minimal breastfeeding should be distinguished; and data should be collected at several ages during infancy. Current or planned surveys by such agencies as the National Center for Health Statistics or the Nutrition Monitoring Division of the U.S. Department of Agriculture could be modified to serve these goals.
• Developing normative indicators of nutritional status . There is a need for data on dietary intakes by, and nutritional status among, lactating women and their relationship to lactation performance. Identification of groups of lactating women who are at nutritional risk is a problem of public health importance.

Research Recommendations

In its deliberations, the subcommittee was well aware that many factors (such as hospital practices, social attitudes, governmental policies, and exposure to infectious agents) may have a great influence on breastfeeding rates and lactation performance and that there is a need for studies to examine approaches that hold the most promise for improving both of these. Similarly, the subcommittee recognized the great need for studies to examine the short- and long-term benefits of breastfeeding in the United States among mothers and infants in all segments of the population, but especially among disadvantaged groups, which currently have the lowest rates of breastfeeding. Research recommendations concerning several of these issues (infant mortality, growth charts for breastfed infants, possible transmission of HIV, indicators of infant nutritional status) are contained in Chapter 10 . They have been excluded from this summary, not because they are unimportant, but rather because they relate only indirectly to the nutrition of healthy U.S. women during lactation.

• Research is needed to develop indicators of nutritional status for lactating women. First, the identification of normative values for nutritional status should be based on observations of representative, healthy, lactating women in the United States. In addition, indicators are needed of both (1) risks of adverse outcomes related to the mother's dietary intake and (2) the potential of the mother or her nursing infant to benefit from interventions designed to improve their nutritional status or health.
• Research is needed to identify groups of lactating women in the United States who are at nutritional risk or who could benefit from nutrition intervention programs. In general, it has been difficult to identify groups of mothers and infants in the United States with nutritional deficits that are severe enough to have measurable functional consequences. Priority should be given to the study of lactating women in subpopulations believed to be at risk of inadequate intake of certain nutrients, such as calcium by blacks and vitamin A by low-income women. The potential influence of culture-specific food beliefs on nutrient intake of lactating women should be included in any such investigations.
• Intervention studies of improved design and technical sophistication are needed to investigate the effects of maternal diet and nutritional status on milk volume; milk composition; infant nutritional status, growth, and health; and maternal health. The nursing dyad (the mother and her infant) has seldom been the focus of studies. Thus, a key aspect of this recommendation is concurrent examination of the mother, the volume and composition of the milk, and the infant. The design of such research needs to be adequate for causal inference; thus, if possible, it should include random assignment of lactating subjects to treatment groups. Appropriate sampling and handling of milk for the valid assessment of energy density, nutrient concentration, and total milk volume are essential, as is accurate measurement of nutrient concentrations.

With regard to the energy balance of lactating women, the threshold below which energy intake is insufficient to support adequate milk production has not yet been identified. Resolution of this question will probably require supplementation studies of women in developing countries whose diets are chronically energy deficient. Although such deficient diets are not common in the United States, identification of the level of energy intake that is too low to support lactation will be useful in establishing guidelines for women who want to breastfeed but who also want to restrict their energy intake to lose weight. Although chronically low energy intakes by women in disadvantaged populations may not be completely analogous to acute energy restriction among otherwise well-nourished women, ethical considerations limit the kinds of investigations that could directly address the influence of energy restriction. In supplementation studies, measurements should be made of lactation performance and of any impact on the mother's nutritional status and health, including the period of lactation amenorrhea.

With regard to specific nutrients, the impact of relatively low intakes of folate, vitamin B 6 , calcium, zinc, and magnesium during lactation on the mother's nutritional status and health needs to be assessed in more detail. As a part of this assessment, studies of the absorption of calcium, zinc, and magnesium during lactation will be useful. There is also a need to identify a reliable indicator of vitamin B 6 status of infants and to document the relationships between this indicator, maternal vitamin B 6 intake, and vitamin B 6 content in milk. Finally, resolution of the conflicting findings concerning the impact of maternal protein intake on milk volume would be desirable.

• DHHS (Department of Health and Human Services). 1980. Promoting Health/Preventing Disease: Objectives for the Nation . Public Health Service, U.S. Department of Health and Human Services, U.S. Government Printing Office, Washington, D.C. 102 pp.
• DHHS (Department of Health and Human Services). 1984. Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation . DHHS Publ. No. HRS-D-MC 84-2. Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services, Rockville, Md. 93 pp.
• DHHS (Department of Health and Human Services). 1985. Followup Report: The Surgeon General's Workshop on Breastfeeding & Human Lactation . DHHS Publ. No. HRS-D-MC 85-2. Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services, Rockville, Md. 46 pp.
• DHHS (Department of Health and Human Services). 1990. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Conference Edition . U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary of Health, Washington, D.C. 672 pp.
• IOM (Institute of Medicine). 1990. Nutrition During Pregnancy: Weight Gain and Nutrient Supplements . Report of the Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 468 pp.
• Lawrence, R.A. 1989. Breastfeeding: A Guide for the Medical Profession , 3rd ed. C.V. Mosby, St. Louis. 652 pp.
• Little, R.E., K.W. Anderson, C.H. Ervin, B. Worthington-Roberts, and S.K. Clarren. 1989. Maternal alcohol use during breastfeeding and infant mental and motor development at one year . N. Engl. J. Med. 321:425-430. [ PubMed : 2761576 ]
• Malone, C. 1980. Breast-Feeding. Cumberland County WIC Program, People's Regional Opportunity Program, Portland, Maine . 13 pp.
• NRC (National Research Council). 1989. Recommended Dietary Allowances , 10 th ed. Report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 284 pp.
• The Steering Committee to Promote Breastfeeding in New York City. 1986. The Art and Science of Breastfeeding . Division of Maternal and Child Health, Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, U.S. Department of Health and Human Services, Washington, D.C. 74 pp.
• USDA (U.S. Department of Agriculture). 1988. Promoting Breastfeeding in WIC: A Compendium of Practical Approaches . FNS-256. Food and Nutrition Service, U.S. Department of Agriculture, Alexandria, Va. 171 pp.
• Cite this Page Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition During Lactation. Washington (DC): National Academies Press (US); 1991. 1, Summary, Conclusions, and Recommendations.
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• Published: 26 November 2021

Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature

• Bridget Beggs 1 ,
• Liza Koshy 1 &
• Elena Neiterman 1  

BMC Public Health volume  21 , Article number:  2169 ( 2021 ) Cite this article

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Despite public health efforts to promote breastfeeding, global rates of breastfeeding continue to trail behind the goals identified by the World Health Organization. While the literature exploring breastfeeding beliefs and practices is growing, it offers various and sometimes conflicting explanations regarding women’s attitudes towards and experiences of breastfeeding. This research explores existing empirical literature regarding women’s perceptions about and experiences with breastfeeding. The overall goal of this research is to identify what barriers mothers face when attempting to breastfeed and what supports they need to guide their breastfeeding choices.

This paper uses a scoping review methodology developed by Arksey and O’Malley. PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched utilizing a predetermined string of keywords. After removing duplicates, papers published in 2010–2020 in English were screened for eligibility. A literature extraction tool and thematic analysis were used to code and analyze the data.

In total, 59 papers were included in the review. Thematic analysis showed that mothers tend to assume that breastfeeding will be easy and find it difficult to cope with breastfeeding challenges. A lack of partner support and social networks, as well as advice from health care professionals, play critical roles in women’s decision to breastfeed.

While breastfeeding mothers are generally aware of the benefits of breastfeeding, they experience barriers at individual, interpersonal, and organizational levels. It is important to acknowledge that breastfeeding is associated with challenges and provide adequate supports for mothers so that their experiences can be improved, and breastfeeding rates can reach those identified by the World Health Organization.

Peer Review reports

Public health efforts to educate parents about the importance of breastfeeding can be dated back to the early twentieth century [ 1 ]. The World Health Organization is aiming to have at least half of all the mothers worldwide exclusively breastfeeding their infants in the first 6 months of life by the year 2025 [ 2 ], but it is unlikely that this goal will be achieved. Only 38% of the global infant population is exclusively breastfed between 0 and 6 months of life [ 2 ], even though breastfeeding initiation rates have shown steady growth globally [ 3 ]. The literature suggests that while many mothers intend to breastfeed and even make an attempt at initiation, they do not always maintain exclusive breastfeeding for the first 6 months of life [ 4 , 5 ]. The literature identifies various barriers, including return to paid employment [ 6 , 7 ], lack of support from health care providers and significant others [ 8 , 9 ], and physical challenges [ 9 ] as potential factors that can explain premature cessation of breastfeeding.

From a public health perspective, the health benefits of breastfeeding are paramount for both mother and infant [ 10 , 11 ]. Globally, new mothers following breastfeeding recommendations could prevent 974,956 cases of childhood obesity, 27,069 cases of mortality from breast cancer, and 13,644 deaths from ovarian cancer per year [ 11 ]. Global economic loss due to cognitive deficiencies resulting from cessation of breastfeeding has been calculated to be approximately USD $285.39 billion dollars annually [ 11 ]. Evidently, increasing exclusive breastfeeding rates is an important task for improving population health outcomes. While public health campaigns targeting pregnant women and new mothers have been successful in promoting breastfeeding, they also have been perceived as too aggressive [ 12 ] and failing to consider various structural and personal barriers that may impact women’s ability to breastfeed [ 1 ]. In some cases, public health messaging itself has been identified as a barrier due to its rigid nature and its lack of flexibility in guidelines [ 13 ]. Hence, while the literature on women’s perceptions regarding breastfeeding and their experiences with breastfeeding has been growing [ 14 , 15 , 16 ], it offers various, and sometimes contradictory, explanations on how and why women initiate and maintain breastfeeding and what role public health messaging plays in women’s decision to breastfeed.

The complex array of the barriers shaping women’s experiences of breastfeeding can be broadly categorized utilizing the socioecological model, which suggests that individuals’ health is a result of the interplay between micro (individual), meso (institutional), and macro (social) factors [ 17 ]. Although previous studies have explored barriers and supports to breastfeeding, the majority of articles focus on specific geographic areas (e.g. United States or United Kingdom), workplaces, or communities. In addition, very few articles focus on the analysis of the interplay between various micro, meso, and macro-level factors in shaping women’s experiences of breastfeeding. Synthesizing the growing literature on the experiences of breastfeeding and the factors shaping these experiences, offers researchers and public health professionals an opportunity to examine how various personal and institutional factors shape mothers’ breastfeeding decision-making. This knowledge is needed to identify what can be done to improve breastfeeding rates and make breastfeeding a more positive and meaningful experience for new mothers.

The aim of this scoping review is to synthesize evidence gathered from empirical literature on women’s perceptions about and experiences of breastfeeding. Specifically, the following questions are examined:

What does empirical literature report on women’s perceptions on breastfeeding?

What barriers do women face when they attempt to initiate or maintain breastfeeding?

What supports do women need in order to initiate and/or maintain breastfeeding?

Focusing on women’s experiences, this paper aims to contribute to our understanding of women’s decision-making and behaviours pertaining to breastfeeding. The overarching aim of this review is to translate these findings into actionable strategies that can streamline public health messaging and improve breastfeeding education and supports offered by health care providers working with new mothers.

This research utilized Arksey & O’Malley’s [ 18 ] framework to guide the scoping review process. The scoping review methodology was chosen to explore a breadth of literature on women’s perceptions about and experiences of breastfeeding. A broad research question, “What does empirical literature tell us about women’s experiences of breastfeeding?” was set to guide the literature search process.

Search methods

The review was undertaken in five steps: (1) identifying the research question, (2) identifying relevant literature, (3) iterative selection of data, (4) charting data, and (5) collating, summarizing, and reporting results. The inclusion criteria were set to empirical articles published between 2010 and 2020 in peer-reviewed journals with a specific focus on women’s self-reported experiences of breastfeeding, as well as how others see women’s experiences of breastfeeding. The focus on women’s perceptions of breastfeeding was used to capture the papers that specifically addressed their experiences and the barriers that they may encounter while breastfeeding. Only articles written in English were included in the review. The keywords utilized in the search strategy were developed in collaboration with a librarian (Table  1 ). PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched for the empirical literature, yielding a total of 2885 results.

Search outcome

The articles deemed to fit the inclusion criteria ( n  = 213) were imported into RefWorks, an online reference manager tool and further screened for eligibility (Fig.  1 ). After the removal of 61 duplicates and title/abstract screening, 152 articles were kept for full-text review. Two independent reviewers assessed the papers to evaluate if they met the inclusion criteria of having an explicit analytic focus on women’s experiences of breastfeeding.

Prisma Flow Diagram

Quality appraisal

Consistent with scoping review methodology [ 18 ], the quality of the papers included in the review was not assessed.

Data abstraction

A literature extraction tool was created in MS Excel 2016. The data extracted from each paper included: (a) authors names, (b) title of the paper, (c) year of publication, (d) study objectives, (e) method used, (f) participant demographics, (g) country where the study was conducted, and (h) key findings from the paper.

Thematic analysis was utilized to identify key topics covered by the literature. Two reviewers independently read five papers to inductively generate key themes. This process was repeated until the two reviewers reached a consensus on the coding scheme, which was subsequently applied to the remainder of the articles. Key themes were added to the literature extraction tool and each paper was assigned a key theme and sub-themes, if relevant. The themes derived from the analysis were reviewed once again by all three authors when all the papers were coded. In the results section below, the synthesized literature is summarized alongside the key themes identified during the analysis.

In total, 59 peer-reviewed articles were included in the review. Since the review focused on women’s experiences of breastfeeding, as would be expected based on the search criteria, the majority of articles ( n  = 42) included in the sample were qualitative studies, with ten utilizing a mixed method approach (Fig.  2 ). Figure  3 summarizes the distribution of articles by year of publication and Fig.  4 summarizes the geographic location of the study.

Types of Articles

Years of Publication

Countries of Focus Examined in Literature Review

Perceptions about breastfeeding

Women’s perceptions about breastfeeding were covered in 83% ( n  = 49) of the papers. Most articles ( n  = 31) suggested that women perceived breastfeeding as a positive experience and believed that breastfeeding had many benefits [ 19 , 20 ]. The phrases “breast is best” and “breastmilk is best” were repeatedly used by the participants of studies included in the reviewed literature [ 21 ]. Breastfeeding was seen as improving the emotional bond between the mother and the child [ 20 , 22 , 23 ], strengthening the child’s immune system [ 24 , 25 ], and providing a booster to the mother’s sense of self [ 1 , 26 ]. Convenience of breastfeeding (e.g., its availability and low cost) [ 19 , 27 ] and the role of breastfeeding in weight loss during the postpartum period were mentioned in the literature as other factors that positively shape mothers’ perceptions about breastfeeding [ 28 , 29 ].

The literature suggested that women’s perceptions of breastfeeding and feeding choices were also shaped by the advice of healthcare providers [ 30 , 31 ]. Paradoxically, messages about the importance and relative simplicity of breastfeeding may also contribute to misalignment between women’s expectations and the actual experiences of breastfeeding [ 32 ]. For instance, studies published in Canada and Sweden reported that women expected breastfeeding to occur “naturally”, to be easy and enjoyable [ 23 ]. Consequently, some women felt unprepared for the challenges associated with initiation or maintenance of breastfeeding [ 31 , 33 ]. The literature pointed out that mothers may feel overwhelmed by the frequency of infant feedings [ 26 ] and the amount as well as intensity of physical difficulties associated with breastfeeding initiation [ 33 ]. Researchers suggested that since many women see breastfeeding as a sign of being a “good” mother, their inability to breastfeed may trigger feelings of personal failure [ 22 , 34 ].

Women’s personal experiences with and perceptions about breastfeeding were also influenced by the cultural pressure to breastfeed. Welsh mothers interviewed in the UK, for instance, revealed that they were faced with judgement and disapproval when people around them discovered they opted out of breastfeeding [ 35 ]. Women recalled the experiences of being questioned by others, including strangers, when they were bottle feeding their infants [ 9 , 35 , 36 ].

Barriers to breastfeeding

The vast majority ( n  = 50) of the reviewed literature identified various barriers for successful breastfeeding. A sizeable proportion of literature (41%, n  = 24) explored women’s experiences with the physical aspects of breastfeeding [ 23 , 33 ]. In particular, problems with latching and the pain associated with breastfeeding were commonly cited as barriers for women to initiate breastfeeding [ 23 , 28 , 37 ]. Inadequate milk supply, both actual and perceived, was mentioned as another barrier for initiation and maintenance of breastfeeding [ 33 , 37 ]. Breastfeeding mothers were sometimes unable to determine how much milk their infants consumed (as opposed to seeing how much milk the infant had when bottle feeding), which caused them to feel anxious and uncertain about scheduling infant feedings [ 28 , 37 ]. Women’s inability to overcome these barriers was linked by some researchers to low self-efficacy among mothers, as well as feeling overwhelmed or suffering from postpartum depression [ 38 , 39 ].

In addition to personal and physical challenges experienced by mothers who were planning to breastfeed, the literature also highlighted the importance of social environment as a potential barrier to breastfeeding. Mothers’ personal networks were identified as a key factor in shaping their breastfeeding behaviours in 43 (73%) articles included in this review. In a study published in the UK, lack of role models – mothers, other female relatives, and friends who breastfeed – was cited as one of the potential barriers for breastfeeding [ 36 ]. Some family members and friends also actively discouraged breastfeeding, while openly questioning the benefits of this practice over bottle feeding [ 1 , 17 , 40 ]. Breastfeeding during family gatherings or in the presence of others was also reported as a challenge for some women from ethnic minority groups in the United Kingdom and for Black women in the United States [ 41 , 42 ].

The literature reported occasional instances where breastfeeding-related decisions created conflict in women’s relationships with significant others [ 26 ]. Some women noted they were pressured by their loved one to cease breastfeeding [ 22 ], especially when women continued to breastfeed 6 months postpartum [ 43 ]. Overall, the literature suggested that partners play a central role in women’s breastfeeding practices [ 8 ], although there was no consistency in the reviewed papers regarding the partners’ expressed level of support for breastfeeding.

Knowledge, especially practical knowledge about breastfeeding, was mentioned as a barrier in 17% ( n  = 10) of the papers included in this review. While health care providers were perceived as a primary source of information on breastfeeding, some studies reported that mothers felt the information provided was not useful and occasionally contained conflicting advice [ 1 , 17 ]. This finding was reported across various jurisdictions, including the United States, Sweden, the United Kingdom and Netherlands, where mothers reported they had no support at all from their health care providers which made it challenging to address breastfeeding problems [ 26 , 38 , 44 ].

Breastfeeding in public emerged as a key barrier from the reviewed literature and was cited in 56% ( n  = 33) of the papers. Examining the experiences of breastfeeding mothers in the United States, Spencer, Wambach, & Domain [ 45 ] suggested that some participants reported feeling “erased” from conversations while breastfeeding in public, rendering their bodies symbolically invisible. Lack of designated public spaces for breastfeeding forced many women to alter their feeding in public and to retreat to a private or a more secluded space, such as one’s personal car [ 25 ]. The oversexualization of women’s breasts was repeatedly noted as a core reason for the United States women’s negative experiences and feelings of self-consciousness about breastfeeding in front of others [ 45 ]. Studies reported women’s accounts of feeling the disapproval or disgust of others when breastfeeding in public [ 46 , 47 ], and some reported that women opted out of breastfeeding in public because they did not want to make those around them feel uncomfortable [ 25 , 40 , 48 ].

Finally, return to paid employment was noted in the literature as a significant challenge for continuation of breastfeeding [ 48 ]. Lack of supportive workplace environments [ 39 ] or inability to express milk were cited by women as barriers for continuing breastfeeding in the United States and New Zealand [ 39 , 49 ].

Supports needed to maintain breastfeeding

Due to the central role family members played in women’s experiences of breastfeeding, support from partners as well as female relatives was cited in the literature as key factors  shaping women’s breastfeeding decisions [ 1 , 9 , 48 ]. In the articles published in Canada, Australia, and the United Kingdom, supportive family members allowed women to share the responsibility of feeding and other childcare activities, which reduced the pressures associated with being a new mother [ 19 , 20 ]. Similarly, encouragement, breastfeeding advice, and validation from healthcare professionals were identified as positively impacting women’s experiences with breastfeeding [ 1 , 22 , 28 ].

Community resources, such as peer support groups, helplines, and in-home breastfeeding support provided mothers with the opportunity to access help when they need it, and hence were reported to be facilitators for breastfeeding [ 19 , 22 , 33 , 44 ]. An increase in the usage of social media platforms, such as Facebook, among breastfeeding mothers for peer support were reported in some studies [ 47 ]. Public health breastfeeding clinics, lactation specialists, antenatal and prenatal classes, as well as education groups for mothers were identified as central support structures for the initiation and maintenance of breastfeeding [ 23 , 24 , 28 , 33 , 39 , 50 ]. Based on the analysis of the reviewed literature, however, access to these services varied greatly geographically and by socio-economic status [ 33 , 51 ]. It is also important to note that local and cultural context played a significant role in shaping women’s perceptions of breastfeeding. For example, a study that explored women’s breastfeeding experiences in Iceland highlighted the importance of breastfeeding in Icelandic society [ 52 ]. Women are expected to breastfeed and the decision to forgo breastfeeding is met with disproval [ 52 ]. Cultural beliefs regarding breastfeeding were also deemed important in the study of  Szafrankska and Gallagher (2016), who noted that Polish women living in Ireland had a much higher rate of initiating breastfeeding compared to Irish women [ 53 ]. They attributed these differences to familial and societal expectations regarding breastfeeding in Poland [ 53 ].

Overall, the reviewed literature suggested that women faced socio-cultural pressure to breastfeed their infants [ 36 , 40 , 54 ]. Women reported initiating breastfeeding due to recognition of the many benefits it brings to the health of the child, even when they were reluctant to do it for personal reasons [ 8 ]. This hints at the success of public health education campaigns on the benefits of breastfeeding, which situates breastfeeding as a new cultural norm [ 24 ].

This scoping review examined the existing empirical literature on women’s perceptions about and experiences of breastfeeding to identify how public health messaging can be tailored to improve breastfeeding rates. The literature suggests that, overall, mothers are aware of the positive impacts of breastfeeding and have strong motivation to breastfeed [ 37 ]. However, women who chose to breastfeed also experience many barriers related to their social interactions with significant others and their unique socio-cultural contexts [ 25 ]. These different factors, summarized in Fig.  5 , should be considered in developing public health activities that promote breastfeeding. Breastfeeding experiences for women were very similar across the United Kingdom, United States, Canada, and Australia based on the studies included in this review. Likewise, barriers and supports to breastfeeding identified by women across the countries situated in the global north were quite similar. However, local policy context also impacted women’s experiences of breastfeeding. For example, maintaining breastfeeding while returning to paid employment has been identified as a challenge for mothers in the United States [ 39 , 45 ], a country with relatively short paid parental leave. Still, challenges with balancing breastfeeding while returning to paid employment were also noticed among women in New Zealand, despite a more generous maternity leave [ 49 ]. This suggests that while local and institutional policies might shape women’s experiences of breastfeeding, interpersonal and personal factors can also play a central role in how long they breastfeed their infants. Evidently, the importance of significant others, such as family members or friends, in providing support to breastfeeding mothers was cited as a key facilitator for breastfeeding across multiple geographic locations [ 29 , 34 , 48 ]. In addition, cultural beliefs and practices were also cited as an important component in either promoting breastfeeding or deterring women’s desire to initiate or maintain breastfeeding [ 15 , 29 , 37 ]. Societal support for breastfeeding and cultural practices can therefore partly explain the variation in breastfeeding rates across different countries [ 15 , 21 ]. Figure  5 summarizes the key barriers identified in the literature that inhibit women’s ability to breastfeed.

Barriers to Breastfeeding

At the individual level, women might experience challenges with breastfeeding stemming from various physiological and psychological problems, such as issues with latching, perceived or actual lack of breastmilk, and physical pain associated with breastfeeding. The onset of postpartum depression or other psychological problems may also impact women’s ability to breastfeed [ 54 ]. Given that many women assume that breastfeeding will happen “naturally” [ 15 , 40 ] these challenges can deter women from initiating or continuing breastfeeding. In light of these personal challenges, it is important to consider the potential challenges associated with breastfeeding that are conveyed to new mothers through the simplified message “breast is best” [ 21 ]. While breastfeeding may come easy to some women, most papers included in this review pointed to various challenges associated with initiating or maintaining breastfeeding [ 19 , 33 ]. By modifying public health messaging regarding breastfeeding to acknowledge that breastfeeding may pose a challenge and offering supports to new mothers, it might be possible to alleviate some of the guilt mothers experience when they are unable to breastfeed.

Barriers that can be experienced at the interpersonal level concern women’s communication with others regarding their breastfeeding choices and practices. The reviewed literature shows a strong impact of women’s social networks on their decision to breastfeed [ 24 , 33 ]. In particular, significant others – partners, mothers, siblings and close friends – seem to have a considerable influence over mothers’ decision to breastfeed [ 42 , 53 , 55 ]. Hence, public health messaging should target not only mothers, but also their significant others in developing breastfeeding campaigns. Social media may also be a potential medium for sharing supports and information regarding breastfeeding with new mothers and their significant others.

There is also a strong need for breastfeeding supports at the institutional and community levels. Access to lactation consultants, sound and practical advice from health care providers, and availability of physical spaces in the community and (for women who return to paid employment) in the workplace can provide more opportunities for mothers who want to breastfeed [ 18 , 33 , 44 ]. The findings from this review show, however, that access to these supports and resources vary greatly, and often the women who need them the most lack access to them [ 56 ].

While women make decisions about breastfeeding in light of their own personal circumstances, it is important to note that these circumstances are shaped by larger structural, social, and cultural factors. For instance, mothers may feel reluctant to breastfeed in public, which may stem from their familiarity with dominant cultural perspectives that label breasts as objects for sexualized pleasure [ 48 ]. The reviewed literature also showed that, despite the initial support, mothers who continue to breastfeed past the first year may be judged and scrutinized by others [ 47 ]. Tailoring public health care messaging to local communities with their own unique breastfeeding-related beliefs might help to create a larger social change in sociocultural norms regarding breastfeeding practices.

The literature included in this scoping review identified the importance of support from community services and health care providers in facilitating women’s breastfeeding behaviours [ 22 , 24 ]. Unfortunately, some mothers felt that the support and information they received was inadequate, impractical, or infused with conflicting messaging [ 28 , 44 ]. To make breastfeeding support more accessible to women across different social positions and geographic locations, it is important to acknowledge the need for the development of formal infrastructure that promotes breastfeeding. This includes training health care providers to help women struggling with breastfeeding and allocating sufficient funding for such initiatives.

Overall, this scoping review revealed the need for healthcare professionals to provide practical breastfeeding advice and realistic solutions to women encountering difficulties with breastfeeding. Public health messaging surrounding breastfeeding must re-invent breastfeeding as a “family practice” that requires collaboration between the breastfeeding mother, their partner, as well as extended family to ensure that women are supported as they breastfeed [ 8 ]. The literature also highlighted the issue of healthcare professionals easily giving up on women who encounter problems with breastfeeding and automatically recommending the initiation of formula use without further consideration towards solutions for breastfeeding difficulties [ 19 ]. While some challenges associated with breastfeeding are informed by local culture or health care policies, most of the barriers experienced by breastfeeding women are remarkably universal. Women often struggle with initiation of breastfeeding, lack of support from their significant others, and lack of appropriate places and spaces to breastfeed [ 25 , 26 , 33 , 39 ]. A change in public health messaging to a more flexible messaging that recognizes the challenges of breastfeeding is needed to help women overcome negative feelings associated with failure to breastfeed. Offering more personalized advice and support to breastfeeding mothers can improve women’s experiences and increase the rates of breastfeeding while also boosting mothers’ sense of self-efficacy.

Limitations

This scoping review has several limitations. First, the focus on “women’s experiences” rendered broad search criteria but may have resulted in the over or underrepresentation of specific findings in this review. Also, the exclusion of empirical work published in languages other than English rendered this review reliant on the papers published predominantly in English-speaking countries. Finally, consistent with Arksey and O’Malley’s [ 18 ] scoping review methodology, we did not appraise the quality of the reviewed literature. Notwithstanding these limitations, this review provides important insights into women’s experiences of breastfeeding and offers practical strategies for improving dominant public health messaging on the importance of breastfeeding.

Women who breastfeed encounter many difficulties when they initiate breastfeeding, and most women are unsuccessful in adhering to current public health breastfeeding guidelines. This scoping review highlighted the need for reconfiguring public health messaging to acknowledge the challenges many women experience with breastfeeding and include women’s social networks as a target audience for such messaging. This review also shows that breastfeeding supports and counselling are needed by all women, but there is also a need to tailor public health messaging to local social norms and culture. The role social institutions and cultural discourses have on women’s experiences of breastfeeding must also be acknowledged and leveraged by health care professionals promoting breastfeeding.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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Acknowledgements

The authors would like to acknowledge the assistance of Jackie Stapleton, the University of Waterloo librarian, for her assistance with developing the search strategy used in this review.

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BB was responsible for the formal analysis and organization of the review. LK was responsible for data curation, visualization and writing the original draft. EN was responsible for initial conceptualization and writing the original draft. BB and LK were responsible for reviewing and editing the manuscript. All authors read and approved the final manuscript.

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Beggs, B., Koshy, L. & Neiterman, E. Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature. BMC Public Health 21 , 2169 (2021). https://doi.org/10.1186/s12889-021-12216-3

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Benefits of Breastfeeding Versus Formula-Feeding Essay

Introduction, history of breastfeeding, advantages of breastfeeding over bottle-feeding, advantages of bottle-feeding over breastfeeding, importance of research.

Nowadays, one of the most challenging tasks many young mothers have to face is the necessity of choosing between breastfeeding and formula/bottle-feeding. It is easy to surf the web and find several correlational, cohort, or experimental studies where different authors defend their positions on the chosen topic. On the one hand, breastfeeding is deemed preferable due to its perfect balance of nutrients, protection against allergies and diseases, and easy digestion for babies.

On the other hand, formula-feeding is characterized by certain merits, such as the possibility for another person to feed a baby anytime, a mother’s freedom to be involved in different activities or even start working, and no dependence on the mother-child diet. Although some mothers might still choose to bottle-feed their infants with formula due to practical concerns, research shows that breastfeeding is preferable due to its impact on maternal and child health.

The history of breastfeeding is as long as the existence of life on the planet. In ancient cultures and in modern times women continued to breastfeed children to nourish them. However, some cultures did not focus on breastfeeding as an intimate link between the mother and the child. For example, while most ancient civilizations had mothers feed their children, more structurally segregated Western European countries created the role of a wet nurse – a woman whose job was to breastfeed children of royal and noblewomen.

Various cultures assigned different meanings to the process of breastfeeding and followed their sets of rules to determine how, when, and where to feed children. In ancient times, Egyptian and Greek civilizations did not treat breastfeeding as a job fit only for common folk and allowed women of all social statuses to feed their children. Nevertheless, wet nurses still had a place in the culture and were respected for their work. In Japan, breastfeeding was common but declined in popularity in the 20th century due to the interest of mothers in modern medicine and artificial feeding options. However, with a well-thought-out campaign, the government was able to elevate breastfeeding to be the primary choice of mothers in the country.

Western countries faced similar challenges earlier, during the middle ages, and then again at the beginning of the 19th century. Here, the history of breastfeeding was firmly connected to the cultural aspects of these civilizations. Countries with a rigid societal structure viewed breastfeeding as a job for lower classes and the process became plagued with many preconceptions. The combination of men’s opinions on breastfeeding and their lack of medical knowledge pressured women into declining breastfeeding. Later efforts in raising the popularity of breastfeeding emphasized health benefits for mothers and children and an establishment of an emotional connection between the parent and the child.

The breastfeeding vs. formula-feeding dilemma appears as soon as women find out that they are pregnant. They have to evaluate all the pros and cons of their pregnancy outcomes, understand if they want to take sick leave, and recognize the relationship between baby feeding and health. All circumstances have to be taken into consideration to make the best decision. Both methods, breastfeeding and bottle-feeding, have their advantages and disadvantages.

Sometimes, it is hard to make a choice, and extensive research is required. This dilemma may be considered through the prism of health, social factors, emotional stability, and personal convenience. In this paper, special attention to the works by Belfort et al. (2013), Boué et al. (2018), Fallon, Komninou, Bennett, Halford, and Harrold (2017), Horta and Victoria (2013) will be made to clarify if the benefits of breastfeeding prevail over the benefits of bottle-feeding in terms of health.

The first months after a baby is born may be defined as the period when it is necessary to choose to breastfeed over bottle-feeding and establish a strong mother-child contact. There are many short- and long-term health benefits for both participants of a process that may be enhanced through its exclusivity and duration (Fallon et al., 2017). The representatives of the World Health Organization admit that exclusive breastfeeding during the first six months can decrease morbidity from allergies and gastrointestinal diseases due to the presence of nutritional benefits in human milk (Horta & Victoria, 2013).

For example, the nutrient n-3 fatty acid docosahexaenoic acid (DHA) found in breast milk aims at improving the functions of the brain (Belfort et al., 2013). Therefore, when the advantages of breastfeeding have to be identified, this point plays an important role.

In addition to nutrients, breastfeeding is a method in terms of which infants can control their condition and take as much amount of milk as they may need. They do not take more or less, just the portion they need at that moment. Mothers should take responsibility for the quality of milk they offer to their children and follow simple hygiene rules and schedules.

Another important aspect that underlines the necessity of breastfeeding is the protection of children against diseases and other health threats. Probiotics and prebiotics, also known as important live microorganisms, protect the body and establish a gut microbiota that promotes positive health outcomes through the creation of barriers to pathogens, improvement of metabolic function, and energy salvation (Boué et al., 2018). Stomach viruses and other conditions that may cause discomfort are also significantly reduced with breastfeeding.

Allergies pose another serious threat to infants. It is hard for a mother to comprehend what product is safe for a child and what ingredients should be avoided. Breast milk is characterized by appropriate natural filters and the possibility to avoid ingesting real food until the body is properly developed. It helps babies digest food and uses the enzymes in a mother’s milk to speed up digestion and avoid complications.

Finally, breastfeeding is preferable because of the promotion of the bond between a mother and a child, and its price. This process of feeding is a unique chance for mothers to be relieved from anxiety and develop an emotional attachment to their children. Sometimes, it is not enough for mothers to talk to their children, observe their smile, and touch them. Breastfeeding is an exclusive type of contact that is not available to other people, including even the closest family members. This relationship is priceless. Indeed, when talking about the price, it is also necessary to admit that compared to bottle-feeding, which requires buying special ingredients, bottles, and hygienic goods, breastfeeding is a cheap process with no additional products except a mother and a child being present in it.

However, despite all the benefits of breastfeeding, it is wrong to believe that formula-feeding is solely negative or does not have important characteristics that breast-feeding cannot offer. Many significant aspects should be considered by mothers who still have some doubts about their choice. For example, some mothers may be challenged by poor health or inappropriate health status for breastfeeding.

Mothers may suffer from the inability to breastfeed as they are unable to produce milk or the milk is of poor quality. In these cases, mothers still want to find new ways to be close to their children and support them and formula-feeding is one option that they can rely on on under any condition. No connection between the health problems of a mother and a child is observed. Bottle-feeding creates several good opportunities for mothers to stabilize their personal and professional lives. Fallon et al. (2017) admit that the choice of the formula is usually explained by breastfeeding management, not biological issues. Therefore, the advantages of bottle-feeding over breastfeeding in terms of health care are based on the emotional aspects and mental health of mothers.

An understanding of the differences between breastfeeding and formula-feeding should be based on thorough research. For example, a study developed by Horta and Victoria (2013) asserts that formula-fed children may have serious hormonal and insulin responses to feeding and an increased number of adipocytes compared to breast-fed children. Bottles have to be cleaned and properly stored to avoid the growth of bacteria that may harm a child (Boué et al., 2018). Finally, the study by Fallon et al. (2017) shows that mothers may feel guilt and stigma in case they choose formula as the main method of feeding. All these studies prove that research is a crucial step to comprehend the benefits of breastfeeding nowadays.

In general, it is hard to neglect the existing dilemma of breastfeeding vs. bottle-feeding. Mothers have to weigh all the pros and cons of both processes and understand what method is more appropriate to them. Regarding the chosen cohort and experimental studies and past research, it is concluded that despite several positive socio-cultural and emotional outcomes of formula-feeding, breastfeeding remains the preferred method due to its effects on health, the establishment of mother-child relations, and the promotion of the cognitive development of children.

Belfort, M. B., Rifas-Shiman, S. L., Kleinman, K. P., Guthrie, L. B., Bellinger, D. C., Taveras, E. M.,… Oken, E. (2013). Infant feeding and childhood cognition at ages 3 and 7 years: Effects of breastfeeding duration and exclusivity. JAMA Pediatrics, 167 (9), 836-844.

Boué, G., Cummins, E., Guillou, S., Antignac, J. P., Le Bizec, B., & Membré, J. M. (2018). Public health risks and benefits associated with breast milk and infant formula consumption. Critical Reviews in Food Science and Nutrition, 58 (1), 126-145.

Fallon, V., Komninou, S., Bennett, K. M., Halford, J. C., & Harrold, J. A. (2017). The emotional and practical experiences of formula‐feeding mothers. Maternal & Child Nutrition, 13 (4), 1-14.

Horta, B. L., & Victoria, C. G. (2013). Long-term effects of breastfeeding: A systematic review . Geneva, Switzerland: WHO Press.

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Introduction, benefits for the child, benefits for the mother, misconceptions about breastfeeding, societal barriers.

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Breast-milk is one of the essential requirements in newborns since it contains all nutrients that an infant requires to grow healthy. For a child to obtain the nutrients from the mother, the mother should feed with nutritious food which is balanced. By this it means that the food should contain,...

Breastfeeding: The Best Food for Babies Breastfeeding is a cheap and easily accessible activity. It is absolutely necessary for both people and creatures. A first-time mother is exposed to the idea that "breastmilk is the best food" the moment she enters the obstetrician's waiting area. (Fridinger 230). Normally, she receives complete...

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New mothers and breastfeeding New mothers frequently struggle with the arduous chore of nursing their newborn (Pillitteri & Ovid Technologies, Inc., 2014). It is therefore not unusual that a mother may choose not to breastfeed her child and instead feed him or her formulas. As a registered nurse, you are responsible...

Introduction Since the collapse of man in the Garden of Eden, procreation and breastfeeding the resulting children has been important for the survival of all animals in the Animal Kingdom. It is one of the normal things that all females must be comfortable doing without shame or humiliation. However, in today's...

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Essays on Breastfeeding

Breastfeeding is an important part of a baby’s life, providing essential nutrition and forming the bond between mother and child. It has numerous benefits for both mother and baby, including physical, emotional and psychological advantages. Breast milk contains all the nutrients a baby needs to grow strong and healthy. It also helps to boost immunity by passing on antibodies from the mother. Furthermore, breastfeeding can help reduce risks of certain illnesses such as asthma, obesity and diabetes in later life. For mothers it can lower their risk of breast cancer, ovarian cancer and osteoporosis.On an emotional level, breastfeeding encourages affectionate contact between mother and baby which promotes secure attachment that will benefit them throughout their lives. Psychologically speaking breastfeeding provides comfort when babies cry or are feeling stressed due to colic or teething pain; they feel safe when being held close while nursing which releases oxytocin (the bonding hormone) into both mom’s bloodstream as well as her baby’s making them feel relaxed in each other’s presence. In addition to these many benefits there are practical considerations too: breastfed babies tend to feed more often than formula-fed babies so parents do not have to worry about preparing bottles every time the little one gets hungry ” plus breastmilk is always at just the right temperature. Finally it is worth mentioning that breastfeeding reduces healthcare costs for families with no need for purchasing costly formulas or specialist bottles/accessories – saving money over time. All in all it is clear that breastfeeding should be encouraged whenever possible due its multiple positive impacts on both mother & child alike; however this does not mean parents who choose formula feeding cannot provide loving care for their children either.

Introduction The issue of whether women should adhere more to breastfeed their babies or resort to modern feeding methods such as bottle feeding remains a controversial and contentious topic that has sparked heated debate from both divides. While other people claim that breastfeeding is the only natural mechanisms that a mother can create the special […]

Breastfeeding is very important to a mother and child, yet rates are not as high as recommendations of AAP and WHO. Investigation of why more women do not breastfeed focus on breastfeeding challenges including issues related to breastfeeding in public. There is a need to implement strategies which support public breastfeeding and change stigma surrounding […]

Breastfeeding, also referred to as nursing, is the act of feeding infants using milk from the mother’s breasts. It is widely recognized as the optimal method for nourishing babies and is often preferred by mothers. Although breastfeeding is a natural occurrence, it can be challenging in the early stages of motherhood, emphasizing the importance of […]

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• Essay on Milk

Sample Argumentative Essay On Breastfeeding In Public Lactation And The Law

Type of paper: Argumentative Essay

Topic: Milk , Law , Women , Parents , Breastfeeding , Family , Children , Nursing

Words: 1500

Published: 03/22/2020

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Essays on Breastfeeding in Public: Lactation and the Law

Introduction Breastfeeding is a natural and the most efficient way of nursing infants. However, breastfeeding in public has been taken to negatively make it impossible for mothers to feed their babies comfortably in public. In the United States, breasts have been sexualized, and used in advertisements and at multiple restaurants. Furthermore, breastfeeding in public has been taken negatively, ascetic, inappropriate, and tawdry. There are unique benefits of breastfeeding to the baby (Humphries, 2011). These benefits include advanced cognitive development, low rates of childhood obesity, and small risks of asthma among others. Companies manufacturing formula milk have developed products that resemble all the nutrients found in the breast milk. However, breastfeeding cannot be compared to formula milk. If breastfeeding is supported, mothers will be comfortable nursing their babies in public, thus providing them with the best nourishment (Humphries, 2011).

Benefits of breastfeeding to mother and child

Breast milk protects the baby from long term illnesses. Breast milk is a source of antibodies that help its body to fight diseases (Humphries, 2011). In addition, breastfeeding exclusively for at least six months gives the child maximum protection. Some infections such as meningitis, ear infection, lower respiratory diseases and many others are lesser in children who are breastfed. Furthermore, if the baby gets such illnesses, they are less severe. The breast milk changes to create more protection with time, unlike the formula milk. The protection found in formula milk is not as sufficient as the one found in breast milk. When the mother’s body responds to pathogens, the immunity is also passed to the baby in the form of antibodies. Breast milk also protects the child from allergies. When a baby is fed on formula, they are likely to get allergies from the formula milk can get contaminated during preparation. The contents of breast milk can also cause allergies to the child. Breast milk has the right composition appropriate for the child and therefore the child cannot develop allergies (Mulready-Ward & Hackett, 2014). Breast milk also has benefits to the mother. For example, the motor burns several calories, helping reducing baby fat that was gained during the pregnancy. The mother and the baby can bond (Lippitt et al., 2014). During breastfeeding, prolactin is produced, and it helps the mother to relax and focus on the baby. Oxytocin is also produced during breastfeeding, and it generates a strong connection of love and care and attachment between the mother and the child. On the other side, formula feeding does not promote bonding since these hormones are not produced (Salcedo, 2014). The bonding that is promoted through breastfeeding is another reason as to why formula cannot be as beneficial as breastfeeding. Oxytocin also has more health benefits to the mother including helping the uterus to return to its regular size more quickly (Lippitt et al., 2014). Breastfeeding also promotes higher cognitive development as compared to formula milk. Breast milk contains DHA that is an essential fatty acid that promotes cognitive development (ABC News, 2009). DHA has been added to formula milk currently, but its effects cannot be compared to that of breast milk. Research also indicates that the IQ scores and other intelligence tests were higher for those children who had prolonged and exclusive breastfeeding (Abc News, 2009). Lactation is cheaper and more efficient than formula milk. Breast milk is produced in sufficient amounts for the baby (Salcedo, 2014). On the other side, formula milk needs the mother to spend so much money, and they still have to ensure that it is prepared in the right way to prevent contamination. The breastfed baby will also not need excessive medical attention since they grow up healthier than the babies fed on formula. The preparation of formula milk also takes longer while nursing is simpler and faster. With formula milk, there is also an increase in the chances of tainting during the cleaning of the feeding equipment. When a mother is breastfeeding, they will not need to carry a bag full of feeding equipment. Through the production of Oxytocin, the mother relaxed, and this reduces the stress level, which sometimes results in postpartum depression (de Jager et al., 2014). Research indicated that mother who stopped breastfeeding early were at a greater risk of developing postpartum depression as compared to those who breastfed for longer (de Jager et al., 2014). Therefore, nursing in public should be supported to help the mother to give their babies the best nourishment. Lactation in public has been taken negatively because of the social and cultural norms that term, it indecent (Anderson, 2013). The whole issue relates to sexuality and the perception attached to various body parts in relation to the larger society (Mulready-Ward & Hackett, 2014). In encouraging breastfeeding in public, it is important to understand that breasts are not only for sex purposes. In understanding this, it is possible to make people understand that nurturing young ones are another function of breasts (Jocelyn, 2014). Since sex is taken to be a taboo, breastfeeding is associated with indecency. However, when breasts are not associated with sex, then the negativity on breastfeeding can be reduced (Anderson, 2013).

Laws protecting breastfeeding

Laws have been created to ensure nursing mothers have the freedom to breastfeed their children. However, parents have been forced to feed their babies in dirty bathrooms or uncomfortable situations (Jake 2007). It is also hypocritical to see that feeding bottle’s top is expected to resemble a nipple, but it is acceptable and real breastfeeding unacceptable. The laws that have been formulated help in making breastfeeding acceptable and showing that it is not indecency. In the U.S, there are states that have laws on breastfeeding while others do not. For example, Texas has a law allowing mothers to nurse their babies in the places they are while states such as Pennsylvania do not have any breastfeeding laws (Jake 2007). Two laws give limitations on how breastfeeding should be done in public. The state breastfeeding law says that a mother has a right to breastfeed her baby at any location in any place that she and her child have a right to be whether the breast is showing or not. In addition to this, a woman has a right to take legal action to anyone who interferes with her breastfeeding. The other provision says that a woman has a right to breastfeed in public but does not give a way in which this law is enforced. The third provision indicates that breastfeeding does not qualify as indecent exposure (Jake 2007). The woman, therefore, cannot be charged with a sex crime if found breastfeeding. In addition, in states where no law to protecting breastfeeding women has been created, harassment and discrimination on the breastfeeding basis breaks the mother’s right. The harassment can also qualify as inflicting emotional distress. A nursing mother also has the right to report such a case to the owner of the enterprise where she is harassed for breastfeeding. She can also file charges in the states that have breastfeeding laws against anyone who interferes with their breastfeeding (Jake 2007).

Nursing is a natural way of taking care of young one and therefore it should be supported. It is clear that no other form of feeding that can be as beneficial to a child as lactation. Therefore mothers should be given their space and not harassed when lactating in public. There should also be a change of attitudes towards nursing in public. The change in beliefs will help the public to be supportive to lactating mothers.

Anderson, R. (2013). Breastfeeding in public: what is and what is not "appropriate". Retrieved from http://savageminds.org/2013/09/23/breastfeeding-in-public-what-is-and-what-is-not-appropriate/ de Jager, E., Broadbent, J., Fuller-Tyszkiewicz, M., & Skouteris, H. (2014). The role of psychosocial factors in exclusive breastfeeding to six months postpartum. Midwifery, 30(6), 657-666. Humphries, J. M. (2011). Breastfeeding Promotion. AJN The American Journal of Nursing, Jake Marcus, J.D. (2007) Lactation and The Law. http://breastfeedinglaw.com/articles/lactation- and-the-law/ Jocelyn Hickenbotham. (2014). Interview with Jocelyn Hickenbotham (See other attachment) Lippitt, M., Masterson, A. R., Sierra, A., Davis, A. B., & White, M. A. (2014). An Exploration of Social Desirability Bias in Measurement of Attitudes toward Breastfeeding in Public. Journal of Human Lactation, 0890334414529020. Mulready-Ward, C., & Hackett, M. (2014). Perception and Attitudes Breastfeeding in Public in New York City. Journal of Human Lactation, 30(2), 195-200. Salcedo, E. S. (2014). Breastfeeding in the Workplace: What's Wrong with the Right?. Available at SSRN.

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• Open access
• Published: 14 May 2024

Breastfeeding mother’s experiences with breastfeeding counselling: a qualitative study

• Ingvild Lande Hamnøy 1 ,
• Marianne Kjelsvik 1 ,
• Anne Bergljot Baerug 2 &
• Berit Misund Dahl 1 , 3  

International Breastfeeding Journal volume  19 , Article number:  34 ( 2024 ) Cite this article

Metrics details

Mothers are recommended to breastfeed their children but can find it challenging and experience breastfeeding problems. Qualified breastfeeding counselling from healthcare professionals can help mothers master breastfeeding, but there is a need to explore mothers’ lived experiences with receiving breastfeeding counselling. We aimed to reveal breastfeeding mothers’ experiences with receiving breastfeeding counselling from midwives and public health nurses (PHNs) to provide a deeper insight into the phenomenon of breastfeeding counselling, which may improve breastfeeding counselling in practice.

A qualitative design with a hermeneutic phenomenological approach was used. Individual interviews of 11 breastfeeding mothers from Norway were conducted from September 2021 to 2022. Van Manen’s guided existential inquiry guided the reflective process to provide deeper insights into the phenomenon of breastfeeding counselling.

The study captured the meaning of breastfeeding mothers’ lived experiences with breastfeeding counselling. Three themes and eight sub-themes were found. Breastfeeding was at stake for the mothers because breastfeeding could be reduced or stopped, and qualified breastfeeding counselling from midwives and PHNs was essential for them to establish and continue breastfeeding. They needed to be perceived as both breastfeeding mothers and as women with their own needs to master everyday life during the breastfeeding period.

Conclusions

This study offers insights to midwives, PHNs and others offering breastfeeding counselling by facilitating an understanding of being a breastfeeding mother receiving breastfeeding counselling. Qualified breastfeeding counselling and a trusting relationship with midwives and PHNs are essential for mothers to establish and continue breastfeeding, while deficient counselling may cause breastfeeding difficulties. Mothers need to be treated as whole and competent persons to avoid objectification and fathers/partners need to be included in breastfeeding counselling. The ‘Baby-Friendly Hospital Initiative’ should be continued, and guidelines should align with the mothers’ need to incorporate breastfeeding into their daily lives during the breastfeeding period.

Mothers often find breastfeeding more challenging than expected. However, qualified breastfeeding counselling from healthcare professionals could prevent or solve many of the breastfeeding problems they experience [ 1 , 2 , 3 ].

Mothers are recommended to exclusively breastfeed their infants until they are six months old and to continue breastfeeding alongside complementary food until two years or older [ 4 ]. ‘The Baby-Friendly Hospital Initiative’ (BFHI) based on the WHO/United Nations Children’s Fund’s (UNICEF) ‘Ten Steps to Successful Breastfeeding’ contains policies and procedures for how maternity and newborn services can promote, protect, and support breastfeeding and ensure that healthcare professionals provide qualified breastfeeding counselling [ 4 , 5 ].

Mothers often feel unprepared to breastfeed, but report that qualified breastfeeding counselling and emotional support from healthcare professionals at the hospital and in the first weeks at home motivate them to master challenges associated with breastfeeding [ 6 , 7 ].

It has been reported that to help mothers become confident in their role and strengthen the family’s experience of handling the situation, healthcare professionals should include mothers’ partners in breastfeeding counselling [ 8 ].

Mothers can be unsure of their identity as breastfeeding mothers, they may experience guilt, shame, and self-doubt during interactions with healthcare professionals [ 9 ]. Although many mothers feel their feeding choices are respected, some feel pressured to breastfeed by healthcare professionals [ 2 , 10 ], while others feel pressured to introduce infant formula if the child’s weight gain does not meet expectations [ 10 ].

Mothers should be invited to a dialogue characterised by respect and support because a strong relationship with the healthcare professional marked by openness and a sense of security will enable them to seek support and help with breastfeeding when needed [ 10 , 11 ], and a screening instrument can be used to assist caring dialogues about breastfeeding based on the mothers` unique breastfeeding stories [ 11 ].

Women often find that breastfeeding is a natural part of becoming a mother, providing physical and emotional rewards for themselves and the infant [ 12 ]. Nevertheless, some mothers end breastfeeding earlier than planned for different reasons, and women who strongly wish to breastfeed but cannot, need emotional support and acceptance of their grief [ 12 , 13 ]. Common reasons for early weaning are perceiving insufficient milk supply and misinterpreting normal baby behaviours as milk insufficiency [ 14 ]. Healthcare professionals have a special responsibility to counsel mothers regarding understanding their babies’ behaviour and the signs of having enough milk to help them maintain milk production and feel confident to breastfeed exclusively [ 14 , 15 ].

Qualified breastfeeding counselling from healthcare professionals can help mothers master breastfeeding, but there is a need to explore mothers’ lived experiences with breastfeeding counselling. Against this background, we aimed to reveal breastfeeding mothers’ experiences with receiving breastfeeding counselling from midwives and PHNs to provide a deeper insight into the phenomenon of breastfeeding counselling. This may assist in improving breastfeeding counselling in practice.

A qualitative study with a hermeneutic phenomenological approach was used to explore mothers’ experiences with breastfeeding counselling. This design is suitable for exploring and reflecting on the meaning of human lived experiences to gain new insights into a phenomenon [ 16 , 17 ].

This study was conducted in Norway, where it is recommended that mothers breastfeed exclusively for the first six months, and subsequently together with complementary food until the baby is at least 12 months old [ 18 ]. Most children in the country are born at public hospitals [ 19 ]. After hospital discharge, the mothers receive breastfeeding counselling from midwives and PHNs working at community child health clinics [ 18 ].

The BFHI has been developed and adapted for integration into routine community child health services in communities in Norway to ensure the quality of breastfeeding counselling [ 20 ], and baby-friendly community health clinics have been associated with increases in the number of children exclusively breastfed for up to six months [ 3 ]. In addition to the public child health service, the mother-to-mother organisation Ammehjelpen provides breastfeeding information and counselling [ 21 ]. Norway offers paid parental leave for 12 months after childbirth; 15 weeks are reserved for each parent after birth, and 16 weeks can be used as the family prefers [ 22 ].

Recruitment and sample

To gain an in-depth understanding of the phenomenon of breastfeeding counselling, mothers with rich experiences in breastfeeding were asked to participate in the study. Leaders of baby-friendly community health clinics were contacted to ask PHNs to inform mothers about the study. Inclusion criteria were mothers who had had children within the last two years, spoke Norwegian, had a child born after the 37th week of pregnancy, and were exclusively or partly breastfeeding when leaving the hospital. Mothers who were interested in participating gave their consent to the PHNs and their contact details were given to the first author. The mothers were contacted by the first author and asked if they wanted to participate, thereafter the time and place for the interviews were arranged. Eight mothers were recruited through PHNs and three via snowball sampling. Recruitment continued until the research group included enough rich descriptions of mothers’ lived experiences with breastfeeding counselling to explore the meaning of the phenomenon [ 16 ].

Eleven breastfeeding mothers from five counties and nine child health clinics participated in the study. No participants withdrew from the study. The mothers’ ages ranged from 27 to 43 years. Nine of the mothers were breastfeeding when the interviews were carried out, while two mothers had stopped breastfeeding their child at eight to nine months of age. The children’s ages varied between four and 18 months.

Data collection

An interview guide with open-ended questions was developed by the first author in collaboration with one of the other authors [ 23 ]. The interview guide was read by two mothers with breastfeeding experience, and changes were made based on their feedback. The purpose of the questions was to gain access to the mothers’ lived experiences through concrete descriptions of the breastfeeding counselling they had received from the midwives and PHNs(Table  1 ).

Individual interviews were conducted from September 2021 to 2022 by the first author and audio-recorded. The first author strove to have an open and reflexive attitude during the interviews in line with the hermeneutic phenomenological approach [ 16 ]. Seven interviews were conducted virtually (Microsoft Teams), two were held in the mother’s home, and two in a private meeting room in a public office. The interviews lasted 45–75 min. One of the mothers sent an email with supplementary information following her interview.

Data analysis

All interviews were audio-recorded and transcribed verbatim in their entirety by the first author. The first author and two others in the research team (BMD, MK) read the transcriptions independently several times to grasp the meaning of each text as a whole, consistent with the hermeneutic phenomenological approach [ 16 , 17 ]. NVivo software was used to organise the qualitative data by naming essential phrases and paragraphs, which captured examples of the patterns related to the meaning of mothers’ lived experiences [ 16 ]. We identified preliminary themes for each interview and the preliminary themes were discussed in the research group. During further analysis, each interview was synthesised into one text, referring to the whole interview and its parts [ 17 ]. Next, the preliminary themes from all the interviews were compared and discussed in the research group before agreeing on three essential themes (see examples of the analysis in Table  2 ). In this process, Van Manen’s ‘guided existential inquiry’ of the five universal and interrelated lifeworld themes (existential) through which humans experience the world was used to assist the reflective process of finding the meaning of being a mother receiving breastfeeding counselling [ 16 , 17 ]. An example of this included how the mother experienced the relationship with the nurse when her breasts were touched harshly.

Ethical considerations

The study was conducted with the approval of Sikt (No. 784,292, 29th June 2021). All procedures were in accordance with the Declaration of Helsinki and Ethical Principles for Medical Research [ 24 ]. All participants received information about the study before the interviews and provided written informed consent. Consent forms were stored safely to protect the participants’ anonymity.

Rigour and reflexivity

The criteria of credibility, dependability, confirmability, and transferability were used to strengthen the rigour and trustworthiness of the study [ 25 ]. All the participants were informed of the first author’s background as a PHN to gain credibility. The first author’s knowledge of the field contributed to a better understanding of the mothers’ descriptions of their experiences with breastfeeding counselling, and helped gain the mothers’ trust. Conversely, knowing the field well required a reflexive attitude to the fact that the first author’s preconceptions could influence the interview and the findings. To further strengthen credibility, quotes about the mothers’ lived experiences were presented in the study, and the themes were discussed by the research team, which consisted of three RNs, two of whom are PHNs and one is a nutritionist. The aspect of dependability was ensured by using the same interview guide in all the interviews, with only minor changes during the research process, and an awareness of being open and curious during the interview [ 16 ]. To ensure confirmability, reflexive notes were made during the research process. Using the Consolidated criteria for reporting qualitative research (COREQ) guidelines [ 26 ] ensured a careful description of the research process, which contributed to the transferability of the data.

The essential themes captured the meaning of 11 breastfeeding mothers’ experiences with breastfeeding counselling. Breastfeeding was at stake for the mothers, and qualified breastfeeding counselling from midwives and PHNs was essential for them to establish and continue breastfeeding. They needed to be perceived as both breastfeeding mothers and as women with their own needs to master breastfeeding and everyday life during the breastfeeding period. The findings are presented as three essential themes with eight sub-themes (Table  3 ).

Breastfeeding at stake

Mothers had expectations that the midwives and PHNs would understand their motivation for breastfeeding. Qualified breastfeeding counselling was important to feel confident in breastfeeding, while deficient breastfeeding counselling caused breastfeeding problems and despair with a risk of breastfeeding being reduced or stopped (Table  3 ).

Expectations of being understood

Mothers wished the midwives and PHNs were interested in exploring their motivation and expectations related to breastfeeding. They described that it was good to be understood by the midwives and PHNs about their choices related to the child’s nutrition and to receive counselling adapted to their needs:

We clarified the expectations very early, and then it was getting straight to the point with counselling. (M1)

Most mothers expressed high expectations for themselves to master breastfeeding. These mothers were well-prepared and motivated for breastfeeding. They wanted the midwives and PHNs to understand that they were willing to stretch far to master breastfeeding. Other mothers had little expectation that breastfeeding would work, and some decided to combine breastfeeding with infant formula or stopped breastfeeding earlier than recommended.

Confidence or despair

Mothers described that good breastfeeding counselling helped them feel safe and confident, while a lack of quality counselling made them sad and led to a feeling of being left to fend for themselves in a new and demanding situation.

Mothers stated that it felt good when knowledgeable and competent midwives and PHNs helped them establish breastfeeding. They appreciated that the nurses took the initiative to help them, asking about breastfeeding and giving advice regarding the different aspects such as latching, pumping, and cup feeding. A mother described her experience of getting help and developing trust in the PHN:

Being taken seriously, I just felt that she was interested in helping me achieve that, and […] it was very good that it went well. Then it was so good; every time she said something, I did it and then it worked; almost became like a guru. It was like ‘oh, it actually worked’, so then you trust it even more. It became like, yes, then I do what she says. (M5)

Other mothers felt they were not met with an understanding of how challenging the first days of breastfeeding can be. Some mothers compared the process of mastering breastfeeding to taking an important exam. A mother had difficulties with breastfeeding at the start and described how difficult it was not to meet the nurses’ breastfeeding expectations. They said to her: ‘You have to try, you have to try’. Although the mother knew it was important to put her child frequently to the breast to initiate milk production, she wished the nurses had not been so reluctant to recommend infant formula and that they understood that she needed some relief in between the breastfeeding sessions.

A lack of breastfeeding counselling or poor advice in the hospital could lead to a challenging time at home. Some mothers described that the staff at the hospital were in a hurry and that they were partly left to themselves. Those mothers who experienced that the father/partner was not allowed to be at the hospital felt lonelier. It was confusing when they had to deal with many different persons providing different advice. Advice to start with bottle feeding and formula led to breastfeeding problems. If breastfeeding was interrupted for several hours because the doctor was to examine the child, it became demanding to establish breastfeeding. They felt tired, cried a lot, and did not know how to deal with the situation. A lack of information about what awaited them related to breastfeeding when they returned home made them feel little prepared and they experienced blocked milk ducts, and breast swelling without knowing how to deal with those challenges.

Owing to all these problems, mothers needed more follow-up visits to the midwives and PHNs in the child health clinic, and some of them struggled for weeks before they could breastfeed exclusively, which was their desire.

Being a breastfeeding mother and woman

Mothers hoped that midwives and PHNs would be interested in helping and supporting them, but experienced that their expectations were unmet. Concurrently, the mothers described that they wished to be seen as whole persons and treated as competent women.

Broken expectations

Mothers hoped that the midwives and PHNs were more engaged in their situation, and this was especially important in the first weeks after delivery when they felt vulnerable being in a new situation. The initial period after delivery was difficult owing to breastfeeding problems and deficient support. One mother experienced numerous breastfeeding difficulties but felt her problems were not taken seriously when the midwives and PHNs told her that the pain would pass and she would be fine. The PHN showed little interest in observing the mother while breastfeeding and did not investigate why it was so painful. The mother said she had to seek all the information by asking questions and did not receive helpful answers:

My midwife often replied: you can Google that. (M2)

This made her feel like the PHN did not understand her needs, and the mother felt she was not being cared for.

Experiencing a lack of support after returning home made the first weeks difficult for some mothers. A mother said that the family did not have a home visit from the midwife at the child health clinic because of a holiday. Six days after hospital discharge, they received counselling at a breastfeeding outpatient clinic in the hospital. Further, a PHN visited them several times at home during the first three weeks to weigh the child. These visits were not experienced by the mother as any qualified help to master breastfeeding, but only as confirmation that the baby’s weight gain was unsatisfactory. At the child health clinic, they met many different PHNs. Standing in a crowded waiting room in the queue among other mothers weighing their babies made the mother feel confused and dejected:

I remember standing and crying at the child health clinic and did not quite know what to do then. So it was a tiring time; it certainly was. (M8)

After three difficult weeks, they received qualified counselling with an experienced PHN in the child health clinic, and the mother managed to breastfeed.

In contrast, another mother described that she felt reassured when a PHN supported her to stop weighing so often and breastfeed on demand after the baby gained weight. She gained the courage to trust herself and breastfeed in line with the child’s needs.

Met as a whole person

Mothers did not feel prepared for what their bodies would feel like during the breastfeeding period and were overwhelmed by breast swelling, difficulties with connecting the child to their breasts, frequent breastfeeding, and changes in their bodies. Mothers wished the midwives and PHNs would notice their need for information and advice on caring for their vulnerable bodies, but felt they were asked little about how they felt physically.

When the midwives and PHNs were most concerned about the child and how they should be breastfed, it felt like the mothers’ pain and discomfort were not taken seriously. A mother explained how the focus on breastfeeding made her feel ignored as a person with her own need for care:

Of course, they ask how you are, but there was a lot of focus on getting your baby the food. Everything else was not unimportant but maybe it could have been a little more focused on the mother too from time to time […]. You feel a bit like you’re a milk cow then […]. You’ve just given birth to a child; that’s big for me too. (M5)

During breastfeeding counselling, some mothers experienced that midwives or PHNs touched their painful breasts in a harsh way; this made them feel that their bodies had become ‘common property’. Mothers explained that they understood that this type of breastfeeding counselling was meant to help them, but it felt uncomfortable. A mother experienced another uncomfortable situation at the child health clinic, when she was asked if a PHN could observe her breastfeeding her three-month-old baby who had gained little weight. The mother felt she was mastering breastfeeding, but the situation seemed like a test, and she felt that intimate boundaries were crossed.

In contrast, some mothers felt taken care of and seen as complete individuals when the midwives and PHNs were interested in how they felt mentally and physically and asked if they had friends or family to help. A mother described a positive experience meeting a midwife who was concerned with how she experienced her body and offered to check her wounds and stitches and assured her that her body would heal.

Treated as a competent woman

To be treated as women capable of mastering challenges and making decisions related to breastfeeding and their infant was underlined as important by the mothers. They described finding the strength to resolve difficult situations and feeling proud of mastering breastfeeding despite experiencing problems.

Mothers preferred experiences in which the dialogue with the midwives and PHNs made them feel accepted and competent. A mother described how the PHN made her feel that she could make her own choices:

The PHN has been sneaking in words like, ‘have you thought about’ or something like that to remind me a little, or nicely say, ‘now it is time for some porridge’. It is up to me to ask and decide the right thing to do. (M3)

Another mother said that she never felt pressured by the midwives and PHNs and could decide to breastfeed or stop breastfeeding, which was crucial for her to want to continue breastfeeding.

Mothers wanted to learn more about understanding their infants because they were unsure of how to interpret their child’s cues. If their baby was crying, the mothers wondered how much and how often they should breastfeed, whether their baby was hungry or full, and if they had enough milk. A mother underlined that the most important counselling she had received was gaining expertise in awareness of the baby’s cues. This made her stronger and wiser:

To become confident and aware of what cues my child sends, I think that has been the most important thing, that kind of competence. (M6)

However, mothers who had been told to breastfeed every third hour had a written breastfeeding schedule. This gave them a feeling of control over the situation, but for most, it felt demanding to use this schedule to determine when they should breastfeed instead of listening to their child and learning to understand how their body naturally regulates milk production. Mothers did not know how long they were supposed to follow these schedules, but they continued for weeks for fear they might do something wrong. This created problems with milk production and mastitis for a mother:

I sat there afterwards and was quite bitter for having been given such advice. I don’t know if I should call it hesitant advice, maybe it was right at the start, but you can’t give advice like that and then not give an end date of how long you are going to keep doing this. (M5)

Learning the natural cues of the baby gave mothers a better experience in breastfeeding and everyday life.

Mastering everyday life

Mothers said they expected qualified and individually adapted breastfeeding counselling from midwives and PHNs to enable them to master their daily lives during the breastfeeding period. Dialogue and personal support helped them to gain trust in the midwives and PHNs and felt more confident as mothers. Knowledge-based advice adapted to the child’s development, and changes in daily life were described as important to be prepared for the next steps to come.

Expectations of qualifications and individually adapted breastfeeding counselling

The need for information and breastfeeding counselling was described as important to overcome the various challenges they encountered during the breastfeeding period.

In the beginning, mothers wondered about normal issues related to breastfeeding, for example, how long the child should be attached to the breast or how the let-down reflex, which makes breast milk flow, works. Mothers who combined breastfeeding with infant formula requested information about helping the baby get used to a bottle, formula ingredients, and serving size. Other mothers produced more milk than needed and wanted information on achieving normal milk production.

Mothers appreciated meeting a midwife or PHN in person who could adapt the counselling to their specific needs, confirming what they were doing right and helping them resolve challenges:

Even though a lot is written about breastfeeding on the internet, what I have appreciated is that they invited me into the office, sat down, and talked about things […]. We have been lucky we have always had things explained. Yes, websites have been used; they have shown us where we can obtain information […], but we have also discussed the obtained information. It has been very nice. (M1)

In contrast, some mothers experienced meeting midwives and PHNs with limited knowledge. They described feeling frustrated if they did not get clear answers when they needed advice.

Including the father/partner in breastfeeding counselling was important for mothers. They used the word ‘we’ when speaking about breastfeeding and said that it was good to be treated like a family because they were a team doing this together. The father/partner was a support and discussion partner.

The father/partner helped by having an overview of when the child was fed, boiling bottles, looking after the siblings, and taking care of the child at night. For mothers, it was reassuring that both of them received information because it was demanding to process everything and easier to have two people remembering what was said.

Dialogue and personal support

A personal relationship with a competent healthcare professional, which meant meeting the midwife or PHN at the child health clinic and sitting down to have a dialogue, helped mothers feel safe and prioritised. Mothers felt accepted when they could ask questions without feeling stupid and were allowed to cry and be sensitive. Mothers appreciated when the midwives and PHNs confirmed that they were doing a good job with breastfeeding their child and should not give up, conveying that they could master this together.

Mothers described that meeting kind midwives and PHNs who wanted to help and follow up gave them a feeling of being taken care of. A mother said it felt good when the PHN was supportive and able to calm her when she felt worried:

What I felt was most important for us was the ‘breastfeeding PHN’ who helped me the most and relaxed me. She didn’t focus so much on breastfeeding. She gave me specific tips about breastfeeding, but it wasn’t that we talked most about but rather that my child was strong enough. It doesn’t matter that the child doesn’t eat all day in a way; my child was robust enough. I think that’s kind of what you need to hear. […] You are very afraid that’ I don’t have enough, I’m not good enough’, but she was very supportive. What I did was good enough, and that was nice. (M8)

A mother described how she experienced quality breastfeeding counselling and developed trust in her PHN, who was competent in and worked only with breastfeeding counselling. The PHN took the time for a conversation in her office, normalised the situation, and communicated that everything was going to be fine. The PHN supported the mother in reducing bottle feeding and increasing breastfeeding, following her child’s cues instead of a feeding schedule. The mother felt confident, and as a result of their work together, the mother was finally able to breastfeed exclusively.

Prepared for the next step

Mothers thought about the time ahead and expressed that it was important for PHNs to provide counselling concerning future changes related to combining breastfeeding with solid food.

Some mothers described meeting knowledgeable PHNs and felt well-informed about starting solid food when the child was four months old. Nevertheless, many mothers experienced a lack of knowledge among PHNs and received scant comprehensive information. Insufficient information made mothers feel frustrated and confused. A mother described how she felt when the PHN asked her about her curiosities regarding breastfeeding and solid food:

What am I wondering? I wonder about everything. Breastfeeding first or last? There was no information. There is no conclusion as she said; and it is a bit annoying that there is no conclusion, but I think she must be required to give some advice then. (M4)

Mothers explained that breastfeeding after the first six months demanded a lot from them. Nevertheless, they shared fewer experiences with breastfeeding counselling at the child health clinic after the first months and further into the second year of life, but one theme they raised was how they could combine breastfeeding with work. Long before mothers started working again, they worried about how their child would eat properly when they were not around. This led some of them to reduce breastfeeding or stop breastfeeding earlier than recommended.

The study of the meaning of mothers` lived experiences with receiving breastfeeding counselling revealed that breastfeeding was at stake for the mothers because breastfeeding could be reduced or stopped, and breastfeeding counselling from midwives and PHNs was essential if they should establish and continue breastfeeding. Midwives and PHNs had to consider mothers’ needs as both breastfeeding mothers and women if they should master everyday life with a breastfeeding child.

The participants strived to accommodate breastfeeding not only because they knew the positive health effects but also because it was associated with pleasure and connecting with their child, which Brown [ 12 ] highlights as an important motivation for women to breastfeed. Van Manen [ 16 ] claims that our identity is shaped by periods in life, in this case, the period of becoming a mother. Brown [ 12 ] and Yuen [ 13 ] point out that mastering breastfeeding can be associated with women’s identity, and women who wish to breastfeed but cannot may experience grief. Hence, it is significant to help women fulfil their breastfeeding wishes.

Mothers stated that they needed to learn to understand their babies’ cues and breastfeeding techniques and to deal with breastfeeding difficulties. This aligns with the findings of Pèrez-Escamilla et al. [ 14 ]., that mothers should be taught how to breastfeed after the cues of the baby because they misinterpret normal baby behaviours as milk insufficiency as a result infant formula is introduced. Research-based methods for how parents can learn about babies’ cues should be implemented in the child health services to help mothers breastfeed instead of starting with infant formula.

The results revealed that when mothers felt that midwives and PHNs had the competency to help them master breastfeeding and provided counselling in a caring manner, they developed trust in the healthcare professional and became open to receiving breastfeeding counselling. Similarly, Murphy et al. [ 10 ] and Gustafsson et al. [ 11 ] highlighted that a safe relationship and a respectful dialogue with openness for the mothers’ expectations and wishes related to the children’s nutrition is a prerequisite for helping mothers achieve their breastfeeding goals and experience care. Midwives and PHNs should facilitate mothers to tell their unique breastfeeding stories assisted by a screening instrument [ 11 ], but midwives and PHNs should also be sensitive listeners and use their clinical judgment to ensure that caring does not become instrumental as Hamnøy et al. [ 27 ] pointed out.

The findings reveal that qualified breastfeeding counselling made the mothers feel more confident in understanding their child and solving breastfeeding problems, meaning they felt empowered and enabled to master breastfeeding and manage their daily lives. This aligns with what the WHO [ 28 ] describes as the ‘empowerment process’—a health-promoting strategy.

Although many mothers had good experiences meeting midwives and PHNs, some felt isolated when they experienced a lack of support and were misunderstood by the midwives and PHNs. An example of this was when mothers felt their intimate boundaries were crossed by midwives or PHNs during breastfeeding counselling. Martinsen [ 29 ] claims that every conversation entails a risk of being rejected and violated by the other person. A person’s protective zone of untouchability can be crossed, integrity can be hurt, and the result can be closedness; consequently, the mother is not open to receiving counselling. Others found it difficult when midwives and PHNs seemed to care only about how the baby should be fed, without paying attention to their physical pain and suffering. This led to a feeling of not being seen and cared for as a whole person; one mother expressed that she felt like a ‘milk cow’ for the purpose of simply feeding the child. This aligns with Young’s [ 30 ] description of how women’s bodies and breasts tend to be objectified and their experiences related to normal reproductive processes are devalued by healthcare professionals. According to Martinsen [ 29 ], objectifying can be a threat to a healthy dialogue. This indicates that midwives and PHNs need to take the time to have a dialogue and listen to mothers to avoid objectifying them and inhibiting breastfeeding counselling and mothers’ mastery of breastfeeding. Further, mothers expressed that frequent weighing, a written schedule, or internet research disturbed their relationships with the midwives and PHNs and made them feel ignored or stressed. Counselling related to the use of objects without a dialogue seems to intensify negative emotions and foster a feeling of alienation, similar to how Young [ 30 ] describes that the use of instruments can contribute to objectification.

Some mothers experienced breastfeeding difficulties when the advice from midwives and PHNs did not follow the BFHI and WHO/UNICEF`s ‘Ten Steps to Successful Breastfeeding’ [ 4 ]. Examples of this were feeding the child every third hour and an early introduction of infant formula feeding without a medical reason. The findings underline the importance of continuing the work and implementation of the BFHI in hospitals and community health services to ensure that mothers receive qualified breastfeeding counselling, as Bærug et al. [ 3 ] and Pérez-Escamilla et al. [ 5 ] have demonstrated.

Mothers emphasised that they needed breastfeeding counselling throughout the breastfeeding period. Despite this, some mothers received little counselling after the first months, or the counselling was offered later than needed. Hence, the mothers searched for advice elsewhere to find solutions without discussing it with the PHNs. Qualified breastfeeding counselling can help mothers continue breastfeeding [ 1 , 15 ], but guidelines for breastfeeding counselling and midwives and PHNs’ practice should be more aligned with mothers’ need for preparing for the challenges they will meet to promote and protect continued breastfeeding.

This study shows that mothers regard breastfeeding as a family affair and highlights that midwives and PHNs should include fathers/partners in breastfeeding counselling. Hence, to understand the phenomenon of breastfeeding counselling, fathers’/partners’ perspectives on breastfeeding counselling should be further investigated.

This study revealed limited findings concerning mothers’ experiences with breastfeeding counselling after six months and after one year. To obtain more examples of mothers’ experiences with breastfeeding counselling after the first year, more mothers with children over one year of age or with previous breastfeeding experience should be recruited. Brockway and Venturato [ 31 ] emphasised that little is written about breastfeeding after one year, possibly because mothers in Western cultures conceal that they are breastfeeding to avoid negative comments from others, including healthcare professionals. More research is needed to explore mothers’ experiences with and needs from PHNs during this latter part of the breastfeeding period. Increased knowledge about this may promote and protect breastfeeding.

Limitations of the study

PHNs were asked to recruit mothers because they meet most of the mothers in the child health clinic, and therefore had a good overview of who had received breastfeeding counselling and met the inclusion criteria for the study. Nevertheless, this could be a limitation of the study because the mothers who were asked and accepted to participate could be those with a good relationship with the PHN and had positive experiences with the help they had received. The results show, however, that the mothers experienced both good and poor quality of the breastfeeding counselling.

Both primiparas and multiparas were included in the study to ensure the mothers had varied and rich experiences with breastfeeding counselling, which was considered a strength of the study.

Including mothers with languages other than Norwegian and from other cultures could have strengthened the study and given a broader perspective on the phenomenon of breastfeeding counselling and should be further investigated in other studies.

This study provides new insight into the phenomenon of breastfeeding counselling based on a sample of mothers and their experiences as mothers receiving breastfeeding counselling from midwives and PHNs. Our study reveals that mothers consider qualified breastfeeding counselling important to help them establish and continue breastfeeding, while a lack of qualified breastfeeding counselling can lead to frustration and breastfeeding difficulties. Overall, a trusting relationship with midwives and PHNs is essential for mothers to be open to receiving breastfeeding counselling and master breastfeeding. Developing trust is dependent on midwives or PHNs’ breastfeeding competence and their ability to communicate with the family. Midwives and PHNs need to engage with mothers as unique individuals, ensuring that their experiences are addressed comprehensively, treating them as whole and competent persons rather than objectifying them. Midwives, PHNs and policymakers need to continue the ‘Baby-Friendly Hospital Initiative’ in hospitals and community health services. Guidelines should align with the mothers’ need to incorporate breastfeeding into their daily lives during the breastfeeding period.

The findings provide midwives, PHNs and others who offer breastfeeding counselling with new insights into and an understanding of being a mother receiving breastfeeding counselling which may improve breastfeeding counselling in practice.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Baby-Friendly Hospital Initiative

Consolidated criteria for reporting qualitative research

Public health nurse

United Nations Children`s Fund

World Health Organization

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Acknowledgements

We are grateful to the mothers who shared their valuable experiences with receiving breastfeeding counselling.

This research was funded by the Norwegian University of Science and Technology.

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I.L.H., B.M.D. and M.K. made contributions to design the study. I.L.H collected data, transcribed the interviews and was responsible for drafting the manuscript. All authors were involved in the analysis and interpretation of data. B.M.D., M.K. and A.B.B. contributed to revising the manuscript critically. All authors read and approved the final manuscript.

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Hamnøy, I.L., Kjelsvik, M., Baerug, A.B. et al. Breastfeeding mother’s experiences with breastfeeding counselling: a qualitative study. Int Breastfeed J 19 , 34 (2024). https://doi.org/10.1186/s13006-024-00636-x

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Breastfeeding Programs at Work | Research Paper Writing Help

The health of babies and mothers is the primary concern when deciding on the return to work formula after the maternity leave lapses. Mothers’ breastfeeding their babies while at work is critical for their health and that of the babies’. The breastfeeding This is achieved by incorporating programs that ensure the mother spends ample time with the child. These programs seek to ensure that the best welfare of newborn babies and mothers can have vast positive effects on the company’s workforce. Such a program seeks to serve the interests of both parties involved. On the part of employees, it promotes office morale by allowing the mother to bond with the child. This shows concern and provides factual information to the staff that they are valued in the company. The company has offered a range of programs to ensure my smooth transition in the job post-natal. I took the liberty of researching the programs to ensure I choose the best program.

Many women leave employment after childbirth, mainly due to family structure, which ultimately impacts negatively on their career progression. This can be avoided by striking a balance between work and personal life. In the contemporary business world, there are diverse programs associated with post-natal strategies for mothers who have been recalled. The research I did was aimed at aiding choose the best course of action that would be beneficial to both the mother and child while maintaining consistency and efficiency at work. The best program would incorporate all three parties, ensuring that each of their interests is satisfied with little or no negative implication. The research incorporated programs such as; on-site care, part-time working, telecommuting, job sharing, flexible job schedules, and commuting the baby from home to work assisted by a caretaker (Stoltenburg, 2018). After analyzing the available programs, the best action plan would entail coming to work with the baby.

Implementation of the Plan

The infant at work program is created to enable eligible employees, such as new mothers and fathers to bring their baby to work. The company shows commitment to supporting parental well-being and healthy infant development. The company has spelled out the policy requirements that ensure workplace disruptions are controlled and that employees can maintain focus while improving productivity. The company’s policy regarding the infant at work program involves designing a special room for breastfeeding mothers equipped with professional caretakers. Accommodation of breastfeeding mothers in a special room is spelled out under the Affordable Care Act (Kozhimannil, Jou, Gjerdingen, and McGovern, 2016) The company hires professional nurses. They take care of the child while the employees engage in work-related programs.

The hiring of professional nurses provides a fast-access point to trained personnel who can provide the necessary care for mothers. This creates an opportunity where mothers can, from time to time, check on their babies and breastfeed them sufficiently. Professional nurses also serve as efficient substitutes to nurse the baby through the formula to ascertain the babies’ satisfaction and health (Haviland, James, Killman & Trbovich, 2015). The program creates a chance for mothers to check on their babies frequently and breastfeed them while still maintaining their productivity level. The implementation of the plan as the best-fit stems from the research using a cost-benefit analysis.

Benefits of Infant at Work Program for Mothers and the Company

On-site childcare increases bonding between the mother and the child. The bonding is achieved when the mother gets to breastfeed the baby at intervals within the day. The program enables the family to save money. The high cost of full-time infant childcare and family income reduction was the primary reason for going back to work as I would support the family financially. The company subsidizes the costs of hiring a professional caretaker by way of cost-sharing with the parents. The company benefits from employee retention as critical employees can work efficiently without the need to quit (Lisbona, Bernabé, and Palací, 2020). With the unemployment rate soaring, employers have to implement creative strategies to attract and retain talent in a competitive market. The program also improves morale among the staff, especially the mothers, due to the reduction in stress levels associated with the child being away from them for long periods. There is also improved teamwork and excellent public relations by employee satisfaction as they deem the company is committed to their needs.

Community Agencies

While at work, breastfeeding mothers have attracted community recognition due to the lack of information and training accorded to mothers during this critical time. Examples of community agencies involved in the promotion of these services include; breastfeeding support groups consisting of women who have undertaken the program successfully and the national breastfeeding helpline. Mothers who have been in employment while still nursing the baby act as the best reference for the struggles that new mothers go through each day at the office. The groups can be contacted through hospital helplines and social media tools. The groups often use referrals through the member’s friend networks. The groups offer advice to the new mothers by providing mutual support to first-time mothers and physical and psychological exercises (Dombrowski, Henderson, Leslie, Mohammed, Johnson and Allan, 2020). This is done by holding meetings where the women share their experiences, and the services are free.

Local children’s center is an agency committed to helping mothers through the breastfeeding period by sharing information and support. The agency has a dedicated hotline that operates for specific hours daily. The agency can also be contacted through its social media platforms. The agency employs mothers who have breastfed and received extensive training in breastfeeding support voluntarily. The services offered include training on how to feed the baby, breastfeeding tips on how to store expressed milk, and providing reassurances and help in overcoming common breastfeeding hurdles such as unsatisfactory milk expression. The agency relies on volunteers; thus, the services offered are free.

The on-site care package though attractive is also ridden with challenges that impact the mother and the company. Many infants at work policies state that the employee will receive less pay: salary for six hours rather than 8 hours. This reduced pay, coupled with the caretaker pay, will hurt the already dwindling family financials. The infants often are associated with distractions for the mother while in the office. The distractions are believed to lower productivity; thus, the company enacted rules to have performance reviews from the employees while on the program. Though the number of distractions may not be frequent, productivity is bound to change.

The job description is another challenge to implementing this course of action where the stress levels can hinder the expression of milk. Optimum conditions are necessary for the breastfeeding program to work as hostile conditions enhance risks to both the baby and the mother (Pounds, Fisher, Barnes-Josiah, Coleman and Lefebvre, 2017). The office environment provides challenges when the baby becomes mobile, as it becomes hard to ensure their safety. Another challenge is time management. Most of the time is taken up by the job and the child leaving the mother with few hours for personal development. This leads to sleep deprivation as one tries to fix a flexible time table to accommodate every aspect of motherhood.

The topic was chosen as I wanted to highlight the challenges that new mothers have to overcome in the contemporary business world, especially working mothers. The research conducted in this lot of life scenario was aimed at showcasing the various cracks in the healthcare system and business world concerning the transition from maternity leave back to the office premises. The research shows the need for reforms in the systems currently in use as they are draconian to the needs of the mother and the baby. The expensive healthcare costs associated with the post-natal affordability of caretakers play a significant role in career women stagnating in job development. The women are forced to quit their jobs when the company does not offer programs that favor the mother’s adjusted timetable.

The agencies responsible should push for the enacted of regulations and policies that will benefit the new mothers by cushioning them against hurdles they experience when breastfeeding, such as the extension of maternity leave or a return to work formula after a specified period taken to cater for the baby. Researching the topic has elicited positive views on parenting, where I got to know the sacrifice working mothers go through each day to cater to the child’s best upbringing. The support provided to mothers shows the concern that people have on the health of children and new mothers, a virtue that I will endeavor to spread to members of the public who are not enlightened on the hurdles the mothers go through every day.

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Why Are We Obsessed With Breasts?

After her own mastectomy, sociologist Sarah Thornton sought to answer the question.

By Alisha Haridasani Gupta

The day before her double mastectomy surgery six years ago, the author and cultural sociologist Sarah Thornton let her breasts free. She went swimming in an outdoor pool in the San Francisco Bay Area and untied her bikini top, allowing her 34Bs to sway in the water and soak up the sunshine. It was her way of saying goodbye to them, she said in a recent interview.

“I was someone who kind of dismissed them as just dumb boobs, irrelevant, not important,” she said. As a self-proclaimed feminist, she used to think that any obsession with breasts was vain and distasteful, driven by a superficial need to please the male gaze. Her own breasts were the focus of two sexual harassment incidents in her teens, and, about a decade ago, they became a source of fear: Breast cancer ran in the family and doctors discovered atypical cells. After much prodding and testing, getting rid of a part of her body that she wasn’t particularly attached to seemed like an easy precaution to take.

But months after her surgery, which included getting implants that felt like “silicone impostors” — so foreign and inanimate to her that she felt compelled to give them the names Bert and Ernie — she became “just a total muddle of emotions around what I lost and what I gained,” she said. “Bert and Ernie were really weird for me — they were larger than I’d ever had before, they were hard, I had no nipple sensation anymore.” (For our video interview, Thornton wore a crew neck T-shirt with a drawing of Bert, Ernie and other Sesame Street residents across her chest). It was then that she realized she hadn’t appreciated her breasts enough.

Thornton’s exploration into the cultural significance of breasts resulted in her new book , “Tits Up: What Sex Workers, Milk Bankers, Plastic Surgeons, Bra Designers, and Witches Tell Us About Breasts,” which will be published on May 7. “Tits,” she writes, is her preferred word; “breasts” sounds sterile and is associated with cancer and feeding, while “boobs” suggests unseriousness, like “booby prize” or “booby trap.”

Thornton wrote the book “in order to help women reappraise their chests in positive ways, and men, too,” she said. “Actually, I would really like men to read the book because so many of them think they really know about tits.”

This interview has been edited and condensed for clarity.

How do you feel about ‘Bert’ and ‘Ernie’ now, after writing this book?

After I finished the book last November, I actually had another surgery. I got rid of Bert and Ernie. And I now have Glenda and Brenda. And the good thing about Glenda and Brenda, compared to Bert and Ernie, is they’re smaller, they are much more comfortable. I like these girls now. I can wear some of my old jackets. Actually last night, I wore a jacket I hadn’t worn since before I had the first surgery.

My attitude toward this part of our bodies has been totally transformed. Studies show that most women in America are dissatisfied with this part of their body. And these days I’m like, Are you kidding me? This is the emblem of womanhood and it’s right under our face, it’s front and center.

You note in the book that much of the dissatisfaction women feel stems from the pressure to fit a specific idea of attractiveness. How did breasts become a subject of eroticism?

In the early 20th century, legs were most fetishized. You have to remember that women had been wearing long skirts throughout the 19th century and then, in the ’20s, there was a radical shift in the clothing women wore — legs started to be seen after World War I. Of course, you usually only saw them from the knee down. Betty Grable? Her legs were insured for a million dollars. That was partly a publicity stunt, but it was because her legs were her asset.

That totally shifts after World War II. There’s a shift with pinups and Hollywood and magazine publishing. But very importantly, there’s also the rise of baby formula. You don’t have the full sexualization of the breast when they’re associated with breastfeeding. There’s a correlation you can see between breast milk substitutes and the sexualization of breasts because, if a baby owns a breast, it interrupts a man’s ownership of the breast.

More recently, the sexualization of breasts has resulted in the huge popularity of breast augmentation. Are we still obsessed with big breasts?

I don’t think big is best anymore. I would say that augmentation reached a peak in 2007 — there is a sense that the really big boobs look old-fashioned.

Augmentation also skews more working class nowadays — actually, I would say conspicuous boob jobs skew working class. In one study , a segment of British working class women, for example, see fake tits as a form of consumption that gives them status and signals that they are independent women in command of the male gaze. And then similarly, a contingent of Brazilian women who began their lives in poverty want people to know they have implants as a form of financial accomplishment.

The whole notion that big breasts are the benchmark beauty ideal is particularly American and possibly runs right through the Americas. But in Asia, for example, there’s a very long history of breast binding. And actually the sexiest women had flat chests. You can see that in the costume of a geisha. In Africa — I reference a sculpture from the Dogon tribe, but you can see this in other tribal aesthetic traditions as well — this kind of dagger-like breast, a downward pointy breast, is the beauty standard and it’s absolutely related to nursing.

Peoples living in hot climates did not tend to cover their chest, male or female, and breasts were not sexualized and still are not sexualized in those cultures. Breasts are honored principally for their hydrating, nutritional and immunological functions. And their eroticization is a kind of perverse import.

In your book, you touch on the breast-related legends and symbols embedded in many major religions. Was there an idea you came across that stands out?

In south India, there’s this notion that nipples are a third eye . That I find hugely appealing, because I didn’t realize how sentient and living my nipples were until I lost all my breast tissue and the nerves to my nipples were cut off. We also know that the relationship between mother and child is absolutely a communicative one — an infant’s saliva and body temperature and everything about an infant during nursing is in a feedback loop with the mother’s body and the breast milk will accommodate, in different ways, infant nutritional need. This kind of interpersonal communication through the breast is validated by medical studies. Actually, a milk scholar that I have in the book calls this “corporeal communication.” I actually really love that term.

Alisha Haridasani Gupta is a Times reporter covering women’s health and health inequities. More about Alisha Haridasani Gupta

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