Use of the Theory of Planned Behavior Framework to Understand Breastfeeding Decision-Making Among Mothers of Preterm Infants

Introduction

Provision of mother's breast milk is recommended for preterm infants through the first corrected year of life or more because of an array of known health benefits, ¹ including reduction of necrotizing enterocolitis and bloodstream infections^2,3 and improvements in later childhood neurodevelopment. ⁴ Benefits to infants are dose dependent,^4,5 emphasizing the importance of supporting mothers in maximizing their milk production over time. Mothers of preterm infants have similar breastfeeding intent and higher rates of initiation of mother's milk production when compared to mothers of term infants. ⁶ However, mothers of preterm infants experience tremendous barriers to ongoing milk production while their infants are hospitalized, including higher risks of complicated deliveries ⁷ and comorbid health conditions that can impact milk production, such as obesity, ⁸ need for prolonged pumping rather than oral feedings at the breast, and prolonged mother-infant separation. Due to these challenges, approximately half of mothers of very low birth weight infants (≤1,500 g) in the United States stop producing milk before hospital discharge. ⁹

Among mothers who continue to produce mother's milk after infant discharge, challenges continue when transitioning to the home environment. Many preterm infants continue to have immature feeding skills and/or receive fortified mother's milk or formula in bottles, which reduce ongoing opportunities for breastfeeding. Furthermore, mother-infant separation continues after infant discharge home, as many mothers of preterm infants have returned to work or have competing demands of their time.

In short, the rate of breastfeeding continuation among mothers of preterm infants in the United States is considerably lower than the recommended standard, signifying the need to continue to elucidate novel, effective interventions to support mothers of preterm infants in reaching their lactation goals. The Theory of Planned Behavior (TPB) is a well-recognized theoretical framework to understand human behavior. ¹⁰ The premise of the TPB is that intention to perform a behavior is closely related to the actual performance of the behavior. There are three main determinants of intention, which include (1) attitudes about the behavior, (2) perceived control (a combination of self-efficacy, the belief in one's ability and control to actually perform a behavior), and (3) perceived social norms (what someone believes others think about the behavior). While this framework has been used extensively as a construct to understand parent behaviors regarding infant care practices, including breastfeeding in the full-term infant,^11–13 the factors that comprise the TPB domains among breastfeeding mothers of preterm infants are unclear. Previous studies examining TPB among mothers of healthy term infants cannot be generalized to mothers of preterm infants because of the unique experiences of this high-risk population. Therefore, the objective of this study was to determine the array of factors that comprise the domains of the TPB, attitudes, perceived control, and perceived subjective norms, related to breastfeeding among mothers of preterm infants. Our greater goal was to ascertain potential intervention targets that may inform development of a future trial to promote breastfeeding continuation among mothers of preterm infants.

Materials and Methods

Results

Characteristics of the mothers we interviewed are shown in Table 1. Regarding intention to breastfeed and actual breastfeeding, many mothers reported that they developed decisions to breastfeed during the prenatal period or even earlier. However, mothers noted that the process of breastfeeding was often much different than what they had envisioned when they delivered preterm. For example, one mother stated, “A lot of women have [a] plan for how they want things to go and then, all of a sudden, your baby comes early and the baby can't eat for whatever reason … and then they can't breastfeed, so, I think that's just a really hard concept to come to terms with.” Mothers imagined directly breastfeeding their infants after birth, and, instead, needed to exclusively pump, add fortifiers to their milk, and/or use bottles. Nearly all the mothers we interviewed initiated milk production, but mothers varied widely how long they made breast milk and whether they were able to directly breastfeed.

Regarding TPB domains, we found positive and negative factors within each domain (Table 2). With respect to maternal attitudes, we found that most mothers reported that breastfeeding was comforting and a source of bonding; however, one mother reported that she did not want to directly breastfeed because breastfed infants become too “clingy,” and she preferred pumping and giving bottled breast milk. Several mothers commented on the health benefits and protective effects of breast milk for preterm infants, particularly due to the vulnerability. Others reported that breast milk was better than formula because it was easier to digest and reduced reflux, two common issues among preterm infants. Some mothers feared that breastfeeding could negatively impact the infant's growth and development, because infants might not get enough milk. Other mothers worried about the inadequate nutritional content of mother's breast milk for a preterm infant. Mothers stated that the breast milk was too “thin,” or lacked nutritional content. Some mothers preferred formula because they felt it had better nutrition for a growing preterm infant.

Regarding perceived control, mothers reported that family members improved their sense of perceived control over their capacity to make milk by cleaning bottles, helping with milk storage, and bottle feeding, as well as nonfeeding tasks, such as childcare, cleaning, and meal preparation. Not only did mothers report that relief from these activities gave them more time to spend on actual breastfeeding and pumping but also this help gave mothers more time to rest and reduce their stress. Mothers also reported that medical providers played an important role in increasing their perceived control with breastfeeding. Mothers mentioned that medical providers helped them obtain pumping supplies and scales for weighing, and taught technical aspects of using breast pumps and storing milk.

A substantial part of every interview was devoted to mothers' narratives of various factors that limited mothers' sense of control in achieving mothers' breastfeeding goals. Mothers' felt limited by the infant's immaturity and clinical feeding processes in the NICU. Mothers reported that difficulty latching and/or coordination of sucking and swallowing, which are typical of preterm infants, made establishment of breastfeeding more difficult. Preterm infants had difficulty sucking at the breast because of their immature feeding skills, which was frustrating to mothers. Several mothers commented that feeding immaturity led to more bottle feeding by staff and consequent infant preference for bottle feeding over direct breastfeeding; this influenced several mothers' decisions to stop pumping and switch exclusively to formula. Mothers also reported that using bottles to establish oral feeding skills or to give extra fortification was a faster way to get out of the NICU and therefore a necessary practice, although this differed from mothers' initial goal to breastfeed directly.

Mothers also remarked that their lack of perceived control stemmed from lack of experience breastfeeding a premature infant and low milk supply. Low milk supply was reported by nearly all of the mothers we interviewed and was a tremendous source of stress. Some mothers felt that they could not produce enough milk for their infants, even with frequent pumping, and others were frustrated because they could not pump as often as desired to maintain a milk supply. A multitude of competing priorities impacted mothers' ability to pump or visit the NICU to feed their infants, including child care, work, household tasks, and managing visits back and forth to the NICU. One mother noted, “I ended up eventually just letting go of the breastfeeding.” Mothers of multiples acknowledged that issues with milk supply and managing the feeding schedules of two infants were even more challenging, and made mothers feel even less in control.

Regarding social norms, mothers mentioned several sources of information or advice regarding breastfeeding, including medical providers, family, friends, Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC), and the media. These sources of information were mixed regarding their support for breastfeeding. Many mothers reported that medical providers in the NICU were very supportive of breast milk for preterm infants. However, some mothers mentioned that many providers were less supportive of the process to establish actual direct breastfeeding during the NICU period. Mothers stated that direct breastfeeding required more time and practice and this need was at odds with medical providers' pressure to discharge infants' home sooner on bottles. Mothers felt that hospital providers perceived that opportunities to practice breastfeeding could be better achieved at home. Mothers also stated that some medical providers favored formula over breast milk for faster growth. Finally, mothers reported varied support for breastfeeding among family and friends. For example, some mothers acknowledged that breastfeeding was part of their culture, and for others, they were the first ones in their family to breastfeed.

Discussion

The premise of our study was to explore the array of factors comprising attitudes, perceived control, and social norms that influence breastfeeding among mothers of preterm infants. We found positive and negative factors among all domains. With respect to attitudes, mothers felt that breastfeeding was a way to connect or bond, that feeding a preterm infant breast milk was a healthy and protective measure, and that breast milk alone may be insufficient for a growing preterm infant. Regarding perceived control, mothers felt a lack of control due to the immature feeding skills of their preterm infants, need for supplementation through bottles, low milk supply, and competing priorities that limited frequent pumping. Mothers felt empowered to breastfeed with support from family and hospital staff. Regarding social norms, family, friends, hospital providers, WIC, and the media were reported by mothers as having varying support for breastfeeding.

Development of effective interventions that maximize provision of mother's breast milk among mothers of preterm infants is a public health priority because breastfeeding is a modifiable practice that can reduce the risk of short- and long-term prematurity morbidities. Because many of the unique challenges faced by mothers of preterm infants occur during the first weeks or months of hospitalization, multiple interventions to support mothers of preterm infants have occurred within the confines of the hospital setting. These efforts, however, have focused predominately on practices that occur early in the hospital period, such as early initiation of mother's milk production, prenatal and early postnatal education, and skin-to-skin care.^16–18 As the trend for provision of mother's milk at the point of hospital discharge has increased in the past decade, ⁹ developing interventions that focus on the challenges faced by mothers of preterm infants later in the hospital stay and post-discharge has become more relevant.

Because we interviewed mothers after their preterm infants' discharge home, we were able to explore several factors that occur later in the hospitalization and after discharge that prevent mothers of preterm infants from achieving their breastfeeding goals. Several mothers described a tension between wanting to directly breastfeed before infant discharge in the NICU and feeling like this process was holding back their infants' more rapid discharge home. Mothers stated that NICU providers directly told them that establishment of breastfeeding could occur better in the home setting. This advice contradicts previous literature that oral feedings at the breast, more frequent breastfeeding episodes, and early gestational age at the time of first breastfeeding attempt in the NICU setting are associated with longer duration of breastfeeding during the hospital and post-discharge periods.^19–23 Furthermore, lactation support in the home environment among mothers of preterm infants is not consistent and lactation consultants in the community generally do not have the same expertise with the unique issues of mother-preterm infant dyads as NICU-specific lactation consultants. Considering that many mothers of preterm infants stop breastfeeding in the weeks after discharge, interventions that address barriers to directly breastfeeding in the NICU time period may represent a pathway toward supporting mothers in prolonging lactation.

Mothers in our study mentioned several important barriers toward prolonged lactation that fit within the TPB framework. Mothers' beliefs that breast milk was insufficient for a growing preterm infant represented a negative attitude toward breastfeeding, which was enforced by negative social norms from hospital providers who recommended fortification through bottles or formula after discharge to maximize growth. Fortification of mother's milk is recommended for preterm infants during the NICU time period, as faster growth during the NICU time period is associated with improved neurodevelopment.^24,25 However, current evidence supporting the use of fortification after discharge among mother's own milk fed very low birth weight infants is limited. The small studies that have examined use of fortification among very low birth weight infants post-discharge have not shown improvements in neurodevelopment.^26,27 Despite the uncertainty of the benefit of post-discharge fortification among very low birth weight infants, fortification with use of formula or fortifiers for some or all feedings at infant discharge is extremely common in U.S. NICUs. ²⁸ Potential intervention strategies may focus on educating mothers and hospital staff on the difference between the known benefits of fortification early in the hospitalization period versus post-discharge to increase recognition that the need for fortification after discharge is not well established, and perhaps may be considered on a case-by-case basis. ²⁹ In instances where staff advise fortification after discharge to maintain growth, fortification strategies may be adjusted to optimally support mothers' lactation goals. For example, if a mother desires direct breastfeeding, a limited number of bottles with higher caloric density (e.g., 28 or 30 kcal/oz) could provide more opportunities for breastfeeding than all or most feedings by bottle with fortifier to 24 kcal/oz. Finally, another potential intervention to support prolonged lactation among mothers of preterm infants may include communication of clear plans for lactation and criteria to wean fortification to post-discharge providers.

Within the TPB framework, mothers also stressed the lack of control they felt in directly breastfeeding due to the immaturity of infant oromotor skills. This may be addressed by educating and supporting mothers in non-nutritive sucking, which can improve oromotor readiness and provide comfort to mothers, and has been performed as early as 31 to 33 weeks of corrected gestational age.^19,20,23,30 Furthermore, mothers in our study stated that infants “got used to bottles,” and therefore preferred bottles over the breast when they were beginning to learn to feed, presumably because that was the most frequent practice in their NICUs. Typically, assessment of oromotor skills by trained professionals in the NICU occurs with bottle feeding, not breastfeeding; thus, hospital teams become accustomed to the need to frequently assess oral feeding skills with bottles. This could be addressed by bolstering lactation training among speech and language or occupational therapists, which assesses preterm infant feeding, or, conversely, by bolstering oromotor skill assessment among lactation consultants and nurses. Perhaps the biggest barrier to more frequent episodes of direct breastfeeding in the NICU period, as mentioned by many mothers in our study, is mother-infant separation and mothers' difficulty actually visiting the NICU with their many competing priorities. At a local level, this could be addressed by providing assistance with parking, transportation, child care, or meals, which may help mothers visit the NICU more frequently. At a larger level, state policies that support paid maternity leave and breastfeeding in the workplace have been associated with higher rates of breastfeeding among preterm infants, compared to states without such policies. ³¹

Other factors we identified that comprised domains of the TPB have been previously described among mothers of preterm infants.^32–36 These include mothers' beliefs that breast milk is healthy and protective, that feeding the infant at the breast is a source of bonding, and that hospital staff can be an incredible source of support. Barriers that mothers in our study reported, such as logistical challenges, low milk supply, exhaustion, and stress of milk production have also been described previously.^32–36

Strengths of our study are the use of an established framework to understand health behaviors and inform development of interventions to change health behaviors, and inclusion of mothers across three NICUs in three states with diverse perspectives and exposures to hospital lactation practices. However, it is possible that different perspectives may have emerged if we interviewed mothers from different NICUs or if we focused our analysis on mothers with a specific subgroup of preterm infants, such as very low birth weight or late preterm infants. A limitation of our study is that mothers may have been reluctant to criticize the support from NICU providers or speak negatively about their experiences producing milk. We tried to minimize this by using interviewers who did not work in the NICU setting and by reviewing with mothers during recruitment that their responses were anonymous. Researcher bias is a possibility in qualitative research; we minimized this by using three coders, discussing discrepancies, and investigator triangulation.

Conclusion

Developing interventions that maximize longer duration of breastfeeding continues to be a crucial need to optimize the health and development of preterm infants. Addressing barriers to transitioning to direct breastfeeding in the NICU time period represents a promising pathway toward maximize breastfeeding support of mothers after NICU discharge. Intervention targets may include education on the benefits of direct breastfeeding to mothers and staff, supporting mothers in more frequent NICU visitation, and assessment of oral feeding skills while breastfeeding. Effective interventions may also incorporate mothers' post-discharge lactation goals, provide post-discharge lactation support with personnel who have expertise in the unique needs of mother-preterm infant dyads, and communicate feeding plans to post-discharge care providers who maximize opportunities for breastfeeding.