The Experience of Breastfeeding the Late Preterm Infant: A Qualitative Study

Abstract

Background:

Breastfeeding confers several health advantages to both infants and mothers. For reasons that are multifactorial, infants born even a few weeks prematurely are less likely to initiate breastfeeding, and those who breastfeed do so for a shorter duration than term infants.

Materials and Methods:

Qualitative analysis of structured telephone interviews was used to examine the breastfeeding experience of mothers of late preterm infants.

Results:

Our study found that, among mothers of late preterm infants, breastfeeding is both a positive bonding experience and a challenging experience, fraught with physical and medical struggles and feelings of guilt and failure. When looking back at the breastfeeding experience, many mothers recount negative experiences of milk supply concerns and breast pumping and report aspiring to be able to feed at breast more and pump less with their next child.

Conclusions:

Mothers of late preterm infants reported that breastfeeding was a bonding experience for themselves and their infants, and many plan to do it again if they have future children. However, these mothers also reported that their breastfeeding experience included challenges with latching and milk supply, inadequate lactation support from providers after hospital discharge, and feelings of failure. Interventions with the potential to improve the breastfeeding experience of mothers of late preterm infants include (1) nipple shields and other devices to assist with latching, (2) hand expression or supplementation with small volumes of donor milk or formula to help limit the burden of pumping, (3) provider education to improve lactation support after hospital discharge, and (4) peer support groups.

Introduction

In the United States, about 12% of infants are born prematurely, prior to 37 weeks' gestation, and these preterm infants are at an increased risk of morbidity and mortality during the birth hospitalization.^1,2 The large majority of these are late preterm infants, those born at 34–36^6/7 weeks' gestation, who are at much higher risk of adverse health outcomes than healthy, full-term infants. Late preterm infants are much more likely to struggle with neonatal respiratory distress, hypoglycemia, temperature instability, and feeding difficulties than term infants.^1–5

Breastfeeding confers many health benefits, including decreased rates of childhood infections and allergies.⁶ Preterm infants benefit from breastfeeding even more than term infants and are especially protected by breastfeeding from the risk of necrotizing enterocolitis, yet breastfeeding rates are consistently lower among infants born prematurely.^2,7–9 There are likely many reasons for this disparity, including maternal factors that predispose to preterm birth in addition to infant feeding difficulties. There is a small but growing body of qualitative literature describing the challenges associated with breastfeeding the late preterm infant. One study discussing the meaning of breastfeeding among mothers of preterm infants in São Paulo, Brazil, recounted the challenge of balancing the health benefits of breastfeeding and the belief that breastfeeding is a part of motherhood with the fact that breastfeeding a premature infant is difficult and exhausting.¹⁰ Demirci et al.¹¹ from Pittsburgh, PA, have proposed the theoretical model of Weighing Worth Against Uncertain Work to describe this struggle of breastfeeding establishment among late preterm mother–infant dyads.

Our study builds on the existing work by using a qualitative approach to examine the overall breastfeeding experience of mothers of late preterm infants as well as the reasons for weaning prior to 1 year. Our sample of mothers is from Iowa City, IA, where, similar to the U.S. national averages, 76.5% of infants initiate breastfeeding, and 54% are still breastfeeding at 6 months.¹²

Materials and Methods

Study design

This is a qualitative study examining mothers' experiences with breastfeeding late preterm infants. The study questions discussed herein were administered as part of a prospective cohort study focused on late preterm infant breastfeeding behavior.

Participants and setting

Participants for this study were recruited by study investigators during the birth hospitalization. Sixty-four mothers of 71 infants born in 2008–2009, between 34 and 36^6/7 weeks' gestation, at the University of Iowa Hospitals and Clinics or an outside facility with transfer to the University of Iowa Hospitals and Clinics within the first 24 hours following delivery were enrolled in a prospective cohort study examining late preterm infant breastfeeding behavior. Of these 64 mothers, seven breastfed beyond a year, and 13 were lost to follow-up prior to weaning. The remaining 44 mothers from this cohort, all of whom had initiated breastfeeding and weaned prior to 1 year, became the participants for this qualitative study. The survey questions administered to these participants were as follows:

(a) “What was your overall feeling regarding your breastfeeding experience?”

(b) “Why did weaning occur?”

All 44 mothers provided a response to each of the three questions. Informed consent was obtained from all participants during the birth hospitalization. This study was approved by the Institutional Review Board at the University of Iowa.

Data collection

Mothers in this cohort were surveyed weekly while their infants were inpatient, weekly for the first 4 weeks following discharge, and monthly thereafter until 12 months or weaning, whichever occurred first. When the mother indicated that her infant had weaned, our research nurse, either in person or by telephone, asked the participant mother the three qualitative study questions about her experience with breastfeeding and weaning. The research nurse transcribed mothers' responses verbatim, by hand, on a paper script during the interview. She subsequently typed the responses into a spreadsheet.

Analysis

The responses from these interviews were then compiled into a text file for qualitative analysis. Two general pediatricians (L.R.K. and V.J.F.), neither of whom was involved in study design or data collection, coded the entire text by hand using qualitative methods based in grounded theory. Each coder cataloged her codes independently and organized them into themes. The coders were at different institutions and were initially blinded to each other's coding. Following the initial analysis, they compared codes and themes and combined results into four main themes.

Results

Demographics

Most mothers included in this study were white and married, with an average age of 28.4 years. The average gestational age of their infants was 35^3/7 weeks, and average breastfeeding duration was 3.6 months. Additional demographic details of the participants are listed in Table 1.

Table 1.

Demographics for Study Participants (n=44 Mothers)

Demographic	Value
Maternal age (years)	28.4±5.3
Primiparous	24 (53)
Twin gestations	6 (14)
Gestational age (weeks) at delivery	35^3/7±1^0/7
Mothers with at least one study infant admitted to the NICU	36 (82)
Breastfeeding duration (months)	2; 3.6±3.7^a
Infant hospital stay (days)^b	11.5; 13.7±9.3^a
Maternal race
African American	2 (4.5)
White	37 (84)
Asian	2 (4.5)
Native American or Alaska Native	2 (4.5)
White and Native American/Alaska Native	1 (2)
Marital status
Married	35 (80)
In a relationship with infant's father, not married	6 (14)
Not in a relationship	3 (7)
Maternal education
<High school	1 (2)
High school	6 (14)
Some college/associate's	18 (41)
Bachelor's	9 (20)
Master's or higher	10 (23)
Annual household income
<$15,000	4 (9)
$15,000–25,000	5 (11)
$25,000–40,000	13 (30)
$40,000–80,000	9 (20)
>$80,000	12 (27)
No response	1 (2)
Paternal involvement
Mother and father live together	39 (89)
Daily involvement of father but live separately	2 (4)
No paternal involvement	3 (7)

Data are mean±standard deviation or number (%) as indicated.

Data are median; mean±standard deviation.

Only one of each set of twins was included for calculations of infant mean and median values.

NICU, neonatal intensive care unit.

Themes

Theme I: A beautiful bonding experience

Looking back upon the experience of breastfeeding after they had weaned, mothers of late preterm infants reported that it was a “beautiful, great experience. Awesome for bonding.” Despite the difficulties, it “was nice to have that special time that was only mine to breastfeed him.” Most mothers reflected positively about breastfeeding. One mother stated she “enjoyed it, definitely a bonding experience,” and another mother stated that she “loved breastfeeding. The bond with your baby is immeasurable!”

Theme II: I failed to meet my expectations

Along with the joy of the breastfeeding experience for many mothers came the negative feeling of failing to meet their expectations. Many mothers recalled that they were “very happy, but disappointed it ended earlier than planned.” Those who struggled with low milk supply described a great deal of disappointment and feeling “like a failure because I couldn't feed my baby.” This stress is a lasting memory for these mothers, who stated while they were breastfeeding they “always had guilt that supply was not good enough.” For some “it was too hard to keep up supply. It wasn't worth it.” The theme of feeling like a failure resonates through the voice of mothers who breastfed for all different durations without meeting their personal breastfeeding goals: “I am sad. I wanted to breastfeed for two years. I feel like a failure.”

Theme III: Medical and physical struggle

The phenomenon of breastfeeding the late preterm infant carries with it a medical and physical struggle for infant and mother. Mothers recounted that it was a “hard but good experience. It was a lot to handle at once.” For many mothers “just pumping wasn't working well,” and their infants “never latched well.” Pumping was a burden for these mothers, integral to being able to feed their preterm infant breastmilk but sometimes leading to weaning. One mother recalled that she weaned because “I went out of town and forgot my pump.” Another mother described how she was so exhausted following her baby's neonatal intensive care unit (NICU) stay, she “fell asleep while pumping.”

Many mothers reported their own medical concerns led to weaning: “I was nervous about how breastfeeding affected my hormones.” Some stopped breastfeeding owing to mastitis or taking medications incompatible with breastfeeding. Mothers in our study who sought help with weaning from medical providers did not receive the help they wanted. One reported, “When I asked the doctors, they told me just to stop breastfeeding, but I became very engorged. I had to look up info myself, and pumped.”

Some reported their pediatricians recommended they supplement with formula. One mother was recommended formula at 1 week so her baby “wouldn't shut down.” Another reported that her baby had switched to a hypoallergenic formula owing to bloody stools. Others remarked that their babies were not able to latch, were biting, or were disinterested in breastfeeding, leading to “a hassle for both of us.”

Theme IV: Would do it all again

Many mothers felt that breastfeeding this child was a learning experience they would carry forward “for the next child.” Many reflected their struggles with a positive outlook. One mother said, “Next time I would rather breastfeed than just pump,” and another commented, “We never got a good schedule down due to being in the NICU. Next time I will plan better.” Overall, good and bad, most mothers who experienced breastfeeding a late preterm infant “would do it again” if they “have another one.”

Discussion

Main findings

Our qualitative data show that mothers of late preterm infants enjoy the bonding experience of breastfeeding and plan to breastfeed again if they have another child. Yet, these mothers also struggle trying to get their babies to latch as well as working to maintain a milk supply while feeding their babies pumped breastmilk. They look to outpatient providers for guidance but often do not receive the help they seek. When they discontinue breastfeeding, they feel like a failure.

Our results support the theoretical model of Weighing Worth Against Uncertain Work, proposed by Demirci et al.¹¹ to describe the interplay between the ambiguity of late preterm infant feeding cues and maternal breastfeeding motivation and breastfeeding work in the establishment of breastfeeding among late preterm dyads. By interviewing mothers after they had weaned their infants, we were able to add to the existing literature by identifying barriers to breastfeeding continuation among mothers of late preterm infants. These barriers included a lack of outpatient lactation support, inability to maintain an adequate milk supply, frustration with pumping, and maternal feelings of failure and defeat.

The positive, bonding experience of breastfeeding described by mothers in our study is a universal benefit that transcends gestational age. The negative experiences these mothers report, however, are directly related to late preterm infants' physical immaturity at birth and offer insight into areas for intervention. Late preterm infants, although not as ill and in need of medical interventions at the time of birth as extremely premature infants, are nonetheless physiologically immature at the time of birth compared with full-term newborns. Many initially struggle to latch and to feed exclusively at the breast. Mothers of these infants often express their breastmilk by pump. Some late preterm dyads are discharged from the hospital prior to maternal mature milk production, and many are discharged prior to the infant taking full feeds at the breast. These mothers rely on outpatient providers to offer ongoing infant feeding guidance.

It is interesting that in our study in a community with breastfeeding rates at the national average, mothers' recollections of interactions with outpatient physicians were universally negative, indicating a breastfeeding knowledge gap among some outpatient providers. Assistance from providers with the knowledge and skills to provide appropriate breastfeeding support would alleviate a substantial source of dissatisfaction with the experience of breastfeeding for mothers of late preterm infants. This could include follow-up with a lactation consultant or a primary care provider comfortable providing evidence-based breastfeeding support¹³ or, for those who live in more remote areas, perhaps innovative strategies, such as online breastfeeding support resources.¹⁴ Additionally, to address the feelings of failure that several of these mothers endorsed, peer counseling programs designed specifically for breastfeeding mothers of late preterm infants might prove beneficial, as these programs have proven helpful for populations with low breastfeeding self-efficacy.^15,16

Many mothers of late preterm infants in our study had negative memories of breastmilk pumping. Alternatives to long-term pumping and bottle feeding may improve the breastfeeding experience for mothers of late preterm infants and, in doing so, may improve breastfeeding duration. Possible interventions to decrease mothers' dependence on pumping include outpatient lactation support to help babies learn to latch, nipple shields to help with latch,¹⁷ hand expression during and perhaps even after the birth hospitalization,^18,19 and early limited donor milk or formula supplementation.²⁰ Additionally, a recent randomized controlled trial showed that cup feeding rather than bottle feeding significantly increased the likelihood of 32–35-week preterm infants exclusively breastfeeding at hospital discharge and 3 months following discharge.²¹

Limitations

The participants in our study were Iowans who received care at the University of Iowa Hospitals and Clinics, and as a result, African Americans and other racial and ethnic groups are underrepresented in our sample. Our population is highly educated and wealthy, so we cannot speak to the experience of mothers of late preterm infants who live in poverty. The interviews were brief and intentionally excluded mothers of late preterm infants who continued to breastfeed beyond a year. At our center, most late preterm infants are admitted to the NICU, and our sample may not be representative of late preterm infants cared for in lower-acuity nurseries. Nonetheless, this study provides insight into the lived experience of breastfeeding among mothers of late preterm infants in Iowa.

Conclusions

The experience of breastfeeding the late preterm infant is complex and dichotomous. It is both a strong positive, bonding experience that mothers would do all over again and a challenging experience, fraught with physical and medical struggles and feelings of failure. Barriers to breastfeeding continuation among this population of mothers include latching difficulties, frustration with pumping, and inadequate support and guidance from outpatient healthcare providers. For mothers of late preterm infants, feelings of guilt and failure are often a consequence of discontinuing breastfeeding earlier than planned. Future research is needed to help establish clinical best practices to maximize the breastfeeding experience and breastfeeding duration for late preterm mother–infant dyads. Interventions that may overcome barriers identified in this qualitative study include strategies to improve latching and/or decrease the need for pumping, peer support groups, and educational programs for outpatient providers.

Footnotes

Acknowledgments

This research was funded by a grant from the Children's Miracle Network. We would like to thank the Children's Miracle Network for their support and Tamara Seufferlein, MA, for her work with data collection for this study.

Disclosure Statement

No competing financial interests exist.

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