The Role of Early Maternal Support in Balancing Full-Time Work and Infant Exclusive Breastfeeding: A Qualitative Study

Abstract

Introduction:

Support of others is a key factor for mothers who choose to breastfeed their infants, including those who balance work outside the home and breastfeeding. However, little research has been done to understand how maternal support during the postpartum period impacts mothers' ability to later balance work and breastfeeding, in particular full-time work and exclusive breastfeeding. The results of this qualitative study indicate that the timing of support plays a key role in mothers' ability to successfully overcome barriers during the early postpartum period, thus building maternal self-efficacy in addressing problems encountered when they return to work.

Methods:

To understand the experience of low-income women who successfully balance full-time work and exclusive breastfeeding for the recommended 6 months, interviews were conducted with women who met study criteria for income level, work status, and exclusive breastfeeding. Breastfeeding peer counselors were also interviewed as key informants. Interviews were recorded, transcribed, and coded for themes. The results of both sets of interviews were triangulated with a focused literature review to assure the soundness of the qualitative analysis.

Results:

Timing of support included acute support, such as help establishing a successful latch needed during the first 2 weeks after delivery, to deal with breastfeeding problems that mothers perceived as being mentally and emotionally overwhelming and longer-term support needed to overcome problems perceived as being less intense.

Conclusions:

The research invites further exploration into the relationship between breastfeeding support provided by mothers' support system, including healthcare professionals, during the postpartum period and rates of breastfeeding duration and exclusivity.

Introduction

The health and cost benefits of feeding infants breast milk are well established.^1–3 In addition, data from the Infant Feeding Practices Survey II indicate that mothers concur with the recommendations concerning feeding breast milk exclusively for 6 months.⁴ The World Health Organization recommends feeding breast milk only and no other foods until infant age 6 months, which is the commonly accepted definition of exclusive breastfeeding. However, in the United States, the majority of parents begin to feed their infants cereal or other solid foods at infant age 4–5 months.⁵ Despite mothers' agreement with recommendations on breastfeeding exclusivity and duration, in the United States, only 49% of infants are fed any breast milk at age 6 months and only 18% are fed breast milk exclusively at age 6 months.⁵ These rates are well below Healthy People 2020 goals of 60% and 25%, respectively.⁵ The majority of mothers in the United States return to work within 3 months after their child's birth and are more likely to wean their children sooner than women who return to work later.^1,5 Women with lower income and education levels are less likely to combine work and breastfeeding.^5,6

Support of others has consistently been shown to be a key factor among women who breastfeed, including those who balance work and breastfeeding.^7–10 The Infant Feeding Practices Survey II data on workplace support are not delineated by income; however, women in low-wage jobs are more likely to report lack of support from employers.^5,11,12 Lack of workplace support contributes to emotional stresses such as anxiety about workplace barriers and guilt over being unable to fulfill both mother and employee roles, all of which contribute to working mothers' decisions to stop feeding their infants breast milk.^13–15 Interventions using professionals and paraprofessionals who provide intensive support in the postpartum period (birth to 6 weeks) have been shown to improve rates of breastfeeding exclusivity and duration.^16–20 While empirical data show that timely interventions by professionals or paraprofessionals result in increased rates of breastfeeding exclusivity and duration, less is known about mothers' perceptions regarding how the timing or the type of support they receive impacts their ability to breastfeed exclusively as well as feed their infant breast milk for the recommended 6 months. There has been little research done to understand how breastfeeding support during the postpartum period, especially during the first 2 weeks after delivery, impacts a woman's later ability to balance work while meeting recommendations for breastfeeding duration and exclusivity.

We conducted a qualitative study with mothers who successfully balanced full-time work and exclusive breastfeeding to determine the factors that contributed to their ability to maintain a behavior that few mothers are able to achieve. For this study, exclusive breastfeeding was defined as feeding breast milk, but not formula, and with feeding solid food as acceptable.

Methods

Approach

Positive deviance was used as a framework in guiding this qualitative study to explore how low-income women succeeded in meeting recommendations for breastfeeding exclusivity and duration while also working full-time outside the home when the majority of their peers do not. Positive deviance is identified as an uncommon behavior practiced by few members of a community that results in an improved state of being for those few members when compared with the larger community.²¹ A small number of mothers engage in an uncommon behavior, working full-time and breastfeeding exclusively, with the resulting positive outcome of improved health for their infants. The mothers in this study represent cases of positive deviant behavior within the community of mothers with infants.

The narrative analysis approach of phenomenology was used as the qualitative approach because the researchers wanted to understand the experience of low-income women who meet breastfeeding recommendations for exclusivity and duration while working full-time outside the home. This behavior cannot be separated from the experience of being the mother of an infant and feeding breast milk, at least some of the time, while at the same time being employed full-time in work that requires the mother to be outside the home and away from her child.

Participants

This study used purposeful sampling to recruit women who were eligible for the USDA's Women, Infants, and Children Supplemental Nutrition Program (WIC) during the time they were breastfeeding; worked at least 32 hours outside the home; fed breast milk, but not formula; had consistently engaged in that breastfeeding behavior while the infant was less than 1 year old; spoke English; and were between the ages of 19–45. Breastfeeding peer counselors currently employed by WIC clinics were also interviewed as key informants.

Recruitment

The initial recruitment strategy included approaching directors of the WIC clinics in the state of Nebraska by e-mail to explain the purpose of the study and then follow-up with a phone call to verify receipt of the initial e-mail and provide an opportunity for further discussion of the study. The response to this initial recruitment effort was extremely low because most of the WIC clinics indicated that they had few or no mothers who met the inclusion criteria. Recruitment was expanded to include WIC clinics in western Iowa. A quasi-snowball technique was also applied to recruitment where organizations engaged in promoting and advocating for breastfeeding were contacted and asked to share information about the study with their members. Information was also posted on the breastfeeding promotion and advocacy organizations' Facebook pages. Two large medical centers in the metropolitan Omaha, Nebraska, area and several area churches and day care centers were also contacted. All declined to allow direct recruitment at their sites, although the churches agreed to post recruitment flyers in their facilities. Recruitment was conducted over a period of 1 year from November 2012 through November 2013. Recruitment was terminated when it became clear through discussions with WIC Clinic Directors and local breastfeeding advocates that all available avenues for reaching the small number of mothers who qualified for the study within the specified geographic area had been exhausted. Budget constraints limited recruitment to Nebraska and western Iowa.

When all possibilities for recruiting mothers who met the inclusion criteria were exhausted, WIC breastfeeding peer counselors were recruited to serve as key informants. The research team believed that these peer counselors could provide insight through their interactions with breastfeeding mothers and including their perspectives would strengthen the study. The breastfeeding peer counselors were recruited by WIC breastfeeding peer counselor coordinators who shared information about the study at regular peer counselor meetings within the WIC clinics.

Data collection

Study participants were interviewed either in-person or by telephone. Those interviewed in-person chose the location for the interviews. All of the mothers included in the study fed their child breast milk longer than the recommended 6 months, therefore mothers eligible for this study were incorporating solid food into their infant's diet at approximately 4–5 months.

Interviews with mothers and peer counselors were conducted using the same semistructured interview guide. The mothers interviewed ranged in age from 19 to 35 years, had from one to six children, and worked in paraprofessional capacities (Table 1). The first two mothers interviewed indicated that experiences in their adolescence played a role in their perceptions of themselves as mothers. The original interview guide did not cover this possibility, so an additional question addressing the influence of adolescent experiences on perceptions of motherhood was added to the interview guide for subsequent interviews. The WIC breastfeeding peer counselors ranged in experience from 1 year to 3 years and all had average caseloads of between 50 and 100 mothers, including pregnant women. Of the eight peer counselors interviewed, only one indicated that she had a client who was working full-time and breastfeeding exclusively.

Table 1.

Demographic Data on Study Subjects Identified by Researcher-Assigned Pseudonym

Participant pseudonym	Participant description
Abbey	30 years old with 3 children. She was not married, but living with the father of the youngest child. The two older children were from a different relationship. She breastfed the youngest two, but not the oldest. Abbey worked in a hospital.
Evelyn	26 year old and married with two children. Evelyn had breastfed both children. She worked in public health.
Irene	35 years old and married with three children. Irene breastfed all three children. She worked as a bank clerk.
Becky	28 years old. She was not married and living with her parents, but was still involved with the baby's father. She had 3 children and worked in a hospital.
Fran	22 years old and married with 2 children. Fran worked in a hospital.
Jackie	19 years old with 1 child. She was married and worked in public health.
Cathy	29 years old and married with 2 children. Cathy worked for a local government agency.
Gabby	24 years old with 1 child. Gabby was recently separated from her husband and was living with her parents. She worked in public health.
Karen	23 years old and married with 2 children. Karen worked in higher education with a state university.
Debbie	28 years old. Debbie was married with 6 children. She worked for a social services agency.
Helen	29 years old and married with 2 children. Helen worked for a large insurance agency.
Linda	21 years old and married with 2 children. Linda worked in a hospital laboratory.

Data analysis

All interviews were audiorecorded and transcribed by the lead author. Data analysis included using NVivo to conduct line-by-line coding of the mothers' interviews into categories determined by the interview questions. This work was done as a part of the lead author's dissertation research, therefore the lead author conducted all coding under the guidance of the supervisory committee chair, who had extensive experience in qualitative research. Categories were then reviewed to identify concepts. Interviews with the WIC breastfeeding peer counselors were coded in a similar manner. To establish validity of the study results, a focused literature review was conducted and the results triangulated with the results of the mother and WIC peer counselor interviews. The most significant concepts focused on the women's sense of themselves as mothers and the type and timing of support they received.

The University of Nebraska Medical Center Institutional Review Board approved this study. Verbal consent was received from mothers and peer counselors interviewed through telephone and written consent from those interviewed in-person.

Results

Interviews were conducted with 12 women who met the recruitment criteria. Efforts were made to recruit minority women; however, all of the women who agreed to be interviewed were Caucasian. The lack of diversity in the sample of mothers recruited may be an artifact of the snowball recruitment technique used or a combination of the facts that the area from which participants were drawn has a population that is primarily Caucasian, and minority women, particularly black and Hispanic women, are less likely to breastfeed exclusively for 1 year (one of the inclusion criteria for the study). Recruitment of WIC breastfeeding peer counselors resulted in eight women who agreed to be interviewed. Interviews averaged 1 hour and were conducted in-person or by phone.

Analysis of the mothers' interviews indicated a clear distinction between the type of support received and the timing of the support. Results from the WIC peer counselor interviews were consistent with the findings about support revealed in the mothers' interviews.

Mothers were asked about their experiences during the first 2 weeks after birth to assess the type of support they received as they established breastfeeding with their infant. Having breastfeeding well established was important when the mother transitioned into balancing work and breastfeeding. The support of family played a vital role because even women who were experienced mothers were undergoing the physiological changes associated with childbirth, which affect mood and energy level. Two concepts emerged during the conversations about the support the mothers received: acute need support and routine support.

Acute need support

One concept characterized the importance of having support immediately available during times of acute need, such as difficulties with latch, which occurred most often during the first 2 weeks after delivery. All of the women mentioned varying levels of difficulty during the first week after delivery, and all indicated that had immediate support not been available, they likely would have started to feed formula despite their intentions to breastfeed exclusively. All of the women described these moments of acute need as mentally and emotionally overwhelming. One woman who is also a trained breastfeeding peer counselor reported the same emotionally fraught difficulties as the other mothers despite her training and experience. Several mothers emphasized the important role that the baby's father played in helping resolve breastfeeding problems.

“I don't know what I would have done if he [husband] had not been there. When he asked me what I would do if I were counseling one of my moms [WIC breastfeeding clients], I said I'd tell her to hand express and then I just cried with relief. Just having him there to take the baby and give me a minute to calm down and think made all the difference.” (Evelyn)

“That's where [baby's father] was my biggest support. I would get so frustrated, or I would get so upset, and the baby would get so upset that nothing was coming out of me and she is screaming in my lap and he would make me go to another room. He would calm her down and then I would calm myself down, so I could feed her, or I would just go pump and he would feed her. He was my biggest support in that part because I would get so frustrated that I wouldn't stop to think about calming myself down.” (Abbey)

This support took the form of both advice and verbal encouragement or moral support.

“I had a midwife, but she left after [baby] latched when he was about 3 hours old. So, I was kind of on my own and calling friends who I knew could help me, they reminded me ‘okay go and get some cabbage leaves’, ‘okay you're going to have to go get some cold packs’ because I was really engorged each time when my milk did come in.” (Debbie)

“I knew that I could try at least because my mom and [husband's] mom are both really supportive. I remember when my milk first came in, it was horrible. I didn't know what was going on. I'm a new mom, I don't have a clue to what I'm doing, and [husband's mom] goes ‘where's your pump?’ and I was like ‘what?’ and she was like 'pump' [mother gestures to indicate how her mother-in-law mimed using a breast pump], and I'm like I don't know we got that like months ago, I'm really not sure where it is. When she had kids, she didn't have a pump, so she's like 'I don't know how to run it’ and it was a hand-me-down to me, so I didn't know how to run it because it didn't come with any instructions. So, here we are trying to figure out what we're doing. I've got such a supportive family.” (Linda)

The WIC peer counselors reported similar experiences among the mothers they counsel. If the mother had support immediately available to her during an episode of acute need, it appeared she was able to successfully resolve the problem and continue to breastfeed. They also report that if a mother was surrounded by others who tell her it is acceptable to feed formula or that attempting to breastfeed is enough, then the mother will quit more quickly. One WIC peer counselor described the role that mothers, grandmothers, or other close relatives played in the mother's decision to work through the breastfeeding problems she experienced.

“If there's a mom or grandma telling her that it's okay because not every woman can breastfeed, then the mom just gives up. What the people closest to her are saying is critical.” (WIC peer counselor with 2 years' experience)

Routine need support

The second theme involved routine supports and focused on dealing with less acute problems once the mother established a breastfeeding routine and became comfortable in her role as a nursing mother. These problems were often related to relatively minor issues that did not require an immediate resolution. The mothers interviewed for this study indicated that they relied on friends who breastfed as well as providers when they encountered more routine problems. One mother described how mothers in an online support group she frequented helped her put a name to a problem that she had experienced with all of her children.

“I went online and found some mothers' groups there. It was helpful because with all my kids, I'd experienced this weird feeling—almost like a panic attack—when my milk let down. I thought it was just me and just worked through it, but one of the women in an online group mentioned the same thing. I was relieved when I learned that it had a name and it wasn't just me.” (Debbie)

“I know my mom was really helpful with nipple confusion when we dealt with that. Um, she was really helpful just as far as being encouraging and ‘don't give up’ kind of thing. But, for specific advice on how to handle the engorgement or when it came to pumping, I went to friends who had dealt with it.” (Becky)

The impact of early support in reinforcing the mother's decision to breastfeed was also evident in how the mothers interacted with their healthcare providers when dealing with the more routine problems they encountered. The mothers who turned to providers for help in addressing routine breastfeeding issues sought out breastfeeding-friendly providers and acted as advocates in their own behalf in finding what they deemed to be acceptable care. The act of being their own advocate with healthcare providers may also build the maternal self-efficacy needed to overcome barriers or problems when the mother returns to work. One participant called the physician who had delivered her first child when the family lived in a different part of the state to get the formula for a nipple cream that she wanted to use while breastfeeding her second child.

“I'd had a nipple cream from the doctor in [previous city of residence] with my first one, but the doctor here didn't know about it. So, I called my old doctor and got the formula and gave it to the doctor here. They called it into the pharmacy then for me.” (Irene)

Another mother disagreed with her primary care provider's decision about resolving her baby's tongue-tie that was causing issues with latch. She located a breastfeeding support provider with a breastfeeding medicine expert on staff and was then referred to a different physician who was willing to treat the problem.

“My doctor told me that the reason we were having trouble with latch was that the baby was tongue-tied, but he wouldn't clip the tongue until the baby was at least 8 months old. That didn't make any sense to me, so I called [a breastfeeding support organization] and they referred me to a doctor in [city of residence]. We got his tongue clipped and everything was fine after that.” (Gabbie)

The WIC breastfeeding peer counselors reported similar experiences in working with the mothers who breastfeed for more than a few days. The WIC peer counselors were constrained, in that they could not contradict the advice of a physician, but they reported that their clients often relied on the advice of other nursing mothers.

Discussion

The literature shows that women who have support are more likely to successfully overcome the problems associated with shorter duration and exclusivity. Even if a woman stops breastfeeding exclusively, with appropriate support, they reinitiate exclusive breastfeeding and breastfeed longer.¹⁴ However, the role of support has been researched in a generalized manner based on the source of support rather than the type or timing of support.^15,22,23

A key concept that emerged from this study was the difference between the types and timing of support. Study participants identified times of acute need, such as not being able to get their hungry and crying infant to latch successfully, when the mother is feeling overwhelmed and is likely unable to articulate what kind of help she needs. The key factor appears to be having support available at the point when the mother was most tempted to give up attempts to breastfeed. The mothers' partners, close friends, and family members are most likely to form the support system that is present or more easily accessible when the mother is experiencing an episode of acute need. When their partners are included in breastfeeding education or are involved in breastfeeding decisions and provide support, especially in the early postpartum period, mothers breastfeed longer and feed breast milk exclusively for longer periods.^8,17 The support of family members and close friends is also associated with breastfeeding exclusivity and duration. Women are influenced in their breastfeeding decisions by other women within their social circles who breastfed and who these mothers see as key providers of support.^3,9,10

Participants also identified routine need for support once breastfeeding is established. In addressing these needs, mothers appear to seek help from those who have had the same experiences, which reinforces the importance of having trained peers or paraprofessionals, who have also breastfed, available to provide support for these mothers. Group support, including prenatal care provided in a group setting, is also associated with longer periods of exclusive breastfeeding.²⁴ Having a childcare provider who is supportive of the mother's breastfeeding efforts, for example, being willing to store and feed pumped milk, is also associated with exclusive breastfeeding duration.³

Limitations

This study was limited, in that all of the women interviewed were non-Hispanic Caucasian and the peer counselors interviewed were non-Hispanic Caucasian except for one who was Hispanic Caucasian. As a result, the study results may not reflect racial or ethnic differences that may exist. The study was also limited by the small number of participants and the lack of negative cases or cases where mothers described different experiences.

Conclusions

This qualitative study demonstrates the role that timing and type of support play in enhancing mothers' efforts to balance exclusive breastfeeding, including when they return to work. More work is needed to better understand the role that healthcare professionals, paraprofessionals, and families play in providing support during episodes of acute need in the early postpartum period and identifying strategies of breastfeeding support that consciously builds the mothers' long-term breastfeeding self-efficacy. The results of this qualitative study also provide support for full-time in-hospital lactation consultants who can help address breastfeeding problems beginning with the first breastfeeding session as well as full-time lactation consultants in pediatric clinics to address ongoing issues. Having lactation consultants available in these settings increases mothers' abilities to access acute need support during the early postpartum period. The results of this research also provide support for including fathers and close family members, especially mothers or grandmothers, in breastfeeding classes so that the mother's support system has the knowledge they need to provide appropriate support during times of acute need.

Footnotes

Acknowledgment

The authors would like to acknowledge the contribution of M. Patricia Leuschen, PhD (Retired), School of Allied Health, University of Nebraska Medical Center, for her guidance during this research project.

Disclosure Statement

No competing financial interests exist.

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