Breastfeeding Experiences in First-Time Mothers After Assisted Conception

Abstract

Objective:

The association between assisted conception and breastfeeding outcomes has been investigated, but the women's experiences have not been fully explored. This study aimed to describe and understand the breastfeeding experience of first-time mothers who conceived using assisted reproductive treatment.

Methods:

A qualitative study based on Gadamer's hermeneutic phenomenology was conducted with a sample of 27 women who conceived using assisted reproductive treatment during the last 10 years. Focus group and in-depth interviews were conducted using a semistructured interview guide. The interviews' transcriptions were coded and categorized into themes and subthemes.

Results:

Two main themes emerged from the data analysis: (1) “the transition from infertility to motherhood,” with the subthemes “infertility and decision to breastfeed,” “the impact of birth experience on breastfeeding,” and “hospital factors influencing breastfeeding practice”; and (2) “the reality of becoming a breastfeeding mother after assisted reproductive technology,” with the subthemes “I want to breastfeed my infant,” “the need for supports from others,” and “when breastfeeding lasts longer than expected.”

Conclusion:

Women who conceive by using assisted reproductive treatment experience a strong desire to breastfeed and problems such as low milk supply. Early cessation of breastfeeding provokes feelings of guilt and failure as mothers. Positive family networks and professional assistance are necessary to support breastfeeding.

Introduction

Infertility is defined as the inability of one or both partners to achieve a pregnancy after 1 year or more of regular unprotected sexual intercourse.¹ Infertility may have a negative effect on couples, affecting psychological well-being and the quality of life.² Infertile women experience higher levels of anxiety and distress probably associated with the feeling of guilt for not being able to become pregnant and not meeting the expectations of their partner and society.² During recent decades, infertility rates have suffered an increase, particularly in high-income countries.³ It is estimated that about 8–12% of couples worldwide are infertile.⁴

Approximately one million couples turn to assisted reproductive treatment (ART) to achieve conception and give birth to a healthy infant of their own.^5,6 Although the use of ART has been considered safe,⁶ adverse neonatal outcomes such as low birth weight, preterm birth,⁷ and birth defects⁸ have been associated with its use. These outcomes may be attributed, in part, to high rate of multiple gestations after ART.⁹ Furthermore, women who conceive using ART have a higher risk of hypertension,⁷ stillbirths,⁸ gestational diabetes,⁷ cesarean deliveries,¹⁰ and maternal hemorrhage.⁸ These adverse maternal and neonatal outcomes related to ART may influence the breastfeeding experience.^11,12 On the contrary, women who conceive with the help of ART may experience breastfeeding difficulties,^12,13 doing it for a shorter period than women who conceive spontaneously.¹²

We follow the theory of planned behavior (TPB) as a theoretical framework, used to explain or change health behaviors.¹⁴ This theory affirms that the intention to perform a certain type of behavior is based on individual attitudes, social normative beliefs, and perceived behavioral control.^14,15 The TPB has been used to predict breastfeeding behavior in previous research.^16,17

Several studies have examined the relationship between ART and breastfeeding outcomes although their results are inconsistent.^12,13 However, the experience of women has not been explored, and therefore, this study aimed to describe and understand the breastfeeding experience of first-time mothers who conceived using ART.

Materials and Methods

Study design

An interpretative qualitative approach guided by Gadamer's hermeneutic phenomenology was followed.¹⁸ For Gadamer, the phenomenon of understanding can only be achieved through language. Understanding a phenomenon involves the fusion between the interpreter's preunderstanding horizon and the participant's horizon of understanding.¹⁸ The steps of Gadamerian-based research were used to elaborate this study¹⁹: (1) Decide if the methodological postulate is appropriate to the research question. Breastfeeding is a phenomenon that can be explored from a hermeneutic phenomenology approach.¹⁹ (2) The researchers reflected on the preunderstanding of the object of study, derived from their clinical experience as nurses in the mother-baby care units.

Setting and participants

Participants were recruited applying a convenience sample technique among women who had conceived using ART during the last 10 years in a hospital located in the southeast of Spain. This institution promotes the exclusive use of breastfeeding, but it does not have Baby-Friendly designation. Women are informed about the benefits of breastfeeding, and a nurse instructs them on how to initiate breastfeeding in the early postpartum. Women were invited to participate in the study via a phone call from the first author. They were informed of the aim of this research and were asked if they were interested in participating in the study. Women were involved in this study if they were ≥18 years old at the time of delivery, a first-time mother, had conceived using ART, had a singleton pregnancy, and gave birth to a healthy infant at term with a weight appropriate for their gestational age. Moreover, the birth was through vaginal delivery and women decided to breastfeed during pregnancy. Women were excluded if they refused to participate in the study, had a prior pregnancy, had a multiple pregnancy, or gave birth a preterm infant or a small infant for gestational age.

Data collection

We conducted a focus group discussion (FGD) with 8 participants and 19 in-depth interviews (IDIs) between March and May 2019. The FGD, with a duration of 86 minutes, and IDIs, with an average duration of 37 minutes, were carried out in a private office in the hospital next to mother-baby care unit. First, the FGD was conducted, from which topics addressed later in the IDIs arose. The FGD was conducted by two investigators (J.D.S. and J.G.-M.) and started with a general question: “What was your experience when breastfeeding your baby?.” Although IDIs were characterized by an open approach, we used a semistructured interview guide to conduct IDIs that included themes belonging to breastfeeding attitudes and practices, experiences about using of ART, and the possible relationship between breastfeeding and ART (Table 1). IDIs were conducted by two investigators (J.D.S. and M.d.M.L.-R.). Data collection was stopped after data saturation was reached, having also collected sociodemographic data of the participants. Both, FGD and IDIs, were recorded and immediately transcribed to avoid losing any details.

Table 1.

Interview Protocol

Stage	Subject	Content and example of questions
Introduction	Reasons	Knowing their experiences could help other parents and be useful for health care professionals.
Introduction	Ethical issues	Inform about volunteering, recording, consent and possibility of leaving the study.
Beginning	Introductory question	What has been your experience about assisted conception and breastfeeding?
Development	Conversation guide	Could you tell me how fertility treatment has affected your life?
		In what ways has your life changed after the birth of your child?
		Do you think assisted conception has affected your experience with breastfeeding?
		Did you experience any difficulty with breastfeeding? How did you solve it?
		What type of support have you received from your family?
		What support you have received from your partner?
		What has been your experience in terms of the support you have received from health professionals?
Closing	Final question	Is there anything else you would like to tell me?
Closing	Appreciation	Thank you for taking part. Your testimony will be used for the research study. You will receive the study upon completion.

This study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ²⁰) and was approved by the Ethics and Research Committee of the Hospital (17/2019). All participants received written information on the purpose of the study, participated voluntarily and signed an informed consent form. Confidentiality and the anonymity of participants were guaranteed.

Data analysis

The transcriptions were analyzed using the following steps¹⁹: (1) To reach a spontaneous understanding of the subject through the conversation with the participants. New questions arose during the interviews such as “How does conception using ART affect breastfeeding?”; (2) To understand, through analysis of the text, each transcription was analyzed line by line. Data coding was developed individually by three members of the research team (I.M.F.M., C.F.S., J.M.H.-P.), who selected significant fragments of the text as citations that were assigned codes that capture their meaning. The codes were grouped into units of meaning, themes, and subthemes, after discussing the preliminary analysis. This step was performed with ATLAS.ti 8 software. (3) To establish the rigor of the study, reliability was derived from the identification of all stages of the research process. Credibility was ensured by representing all the opinions and points of view of the participants in the study. Confirmability was achieved by returning the final list of topics and subthemes to the participants to confirm the results.

Results

Demographics

A total of 34 women were invited to participate, but five refused to take part, and two were unable to discuss the subject due to family and work reasons. The study sample was made up of 27 women with an average age of 38.37 years; 59.3% of conceptions were by in vitro fertilization, and 40.7% were by artificial insemination. All participants initiated breastfeeding in the early postpartum. At 3 months postpartum, 37% of the participants were exclusively breastfeeding; 48.2% used a combination of breastfeeding and formula feeding, and the rest used only formula feeding. However, at 6 months postpartum, only half of the mothers who had exclusively breastfed continued to do. The participants' demographic data are shown in Table 2.

Table 2.

Sociodemographic Data of the Participants (N = 27)

Demographic characteristics	Value, n (%)
Age, mean (SD), years	38, 37 (4.9)
Marital status
Married	21 (77.8)
Cohabiting	6 (22.2)
Level of education
Basic	10 (37)
Medium	2 (7.4)
Higher	15 (55.6)
Type of ART
In vitro fertilization	16 (59.3)
Artificial insemination	11 (40.7)
Breastfeeding initiation during early postpartum	27 (100)
Feeding type at 3 months postpartum
Breastfeeding only	10 (37)
Breastfeeding + formula	13 (48.2)
Formula	4 (14.8)
Feeding type at 6 months postpartum
Breastfeeding only	5 (18.5)
Breastfeeding + formula	18 (66.7)
Formula	4 (14.8)

ART, assisted reproductive treatment; SD, standard deviation.

Themes

Emerging results were divided into units of meaning, main themes, and subthemes (Table 3). Collectively, they help to understand the breastfeeding experiences of women who had conceived using ART.

Table 3.

Themes, Subthemes, and Units of Meaning

Theme	Subtheme	Units of meaning
1. The transition from infertility to motherhood	1.1. Infertility and decision to breastfeed	Impact of fertility treatment
		Need to be a good mother
		Breastfeeding benefits
		Family tradition
	1.2. The impact of birth experience on breastfeeding	Fatigue
	1.2. The impact of birth experience on breastfeeding	Emotional shock
	1.3. Hospital factors influencing breastfeeding practice	Family visits
		Lack of professional support
		Lack of information
2. The reality of becoming a breastfeeding mother after artificially assisted technology	2.1. I want to breastfeed my infant	Pressure to breastfeed
		Breastfeeding difficulties
		Influence of negative comments
		Guilt
	2.2. The need for supports from others	Family support
		Emotional support
		Professional support
	2.3. When breastfeeding lasts longer than expected	Bond
		Other people's opinions
		Raising children

Theme 1: The transition from infertility to motherhood

Infertility and conception through ART have a high physical and emotional impact on women. This theme reflects the influence of fertility treatment on breastfeeding and the breastfeeding experiences during labor and early postpartum.

Subtheme 1.1: Infertility and decision to breastfeed

The performance of ART techniques involve a series of psychological effects that influence their “woman's identity.” Women felt guilty and frustrated for not having achieved a pregnancy on their own. During pregnancy, they experienced worry about the impact of ART on infant health. Previous infertility and the need to be a “good mother” influenced women's decisions to breastfeed their infants. Encouraged by the benefits of breastfeeding, women affirmed that human milk was “the best for their infants” despite the fact that many of the women had not received maternal education or information about motherhood during pregnancy.

When you decide to become a mother and use an assisted reproductive technique, as the desire is so great, you want to experience all aspects of motherhood to the full, including breastfeeding.

Those women in whose families there was a tradition of breastfeeding found their decision reinforced and defined breastfeeding as “a natural act of the human species.” The experiences of close friends also had a positive influence on the women's decision to breastfeed. Most women said that the decision to breastfeed was taken by they themselves during pregnancy, without agreeing with their partner.

My mother and sister have breastfed and I had no doubts, I had a lot of problems getting pregnant and I wanted to give my baby the best.

Subtheme 1.2: The impact of birth experience on breastfeeding

A high percentage of women had an uncomplicated eutocic delivery; however, some of women suffered a prolonged labor induced with oxytocin. These women reported that after extended labor they felt exhausted, and this fatigue had a negative influence on breastfeeding. Prolonged labor was strongly associated with ART.

I was very tired, I had not slept at all…, and I had to try to breastfeed my infant. Nurses saw me so overwhelmed that they left me a bottle in case I wanted to use it…

On seeing their infants for the first time, some women suffered a state of emotional shock and had difficulty to adapt to the new reality. They could not believe that after so much effort they could finally have their infants in their arms. Due to this state of shock, some women did not pay much attention to breastfeeding during early postpartum.

I was like in a cloud when my baby was born, after so much effort, my baby was finally here. I couldn't stop looking at my baby and it was practically impossible for me to assimilate the breastfeeding information that nurses were giving me.

Subtheme 1.3: Hospital factors influencing breastfeeding practice

After previous infertility, the women's family experienced the birth of the infant as a great family event. The visits of family and friends during the hospital stay interfered with the practice of breastfeeding. Women want to share these moments exclusively with their partner.

I had so much pain during labor that I had a mental block, I was in shock; it bothered me that someone visited me… Only when at night I was alone with my husband and my baby listening to his breathing could I relax… The first moments you want to live in privacy, without anyone bothering you….

Breastfeeding their infants was considered by women as a reward that compensated for the physical and emotional damage suffered by ART. However, women stated that insufficient professional support during the early postpartum and at the time of hospital discharge are obstacles to carrying out successful breastfeeding. Due to breastfeeding difficulties during the early postpartum, some nurses offered women the possibility of feeding with artificial formula. In this situation, women felt misunderstood.

They put him on me as soon as he was born, and he took my breast without any problems. In the room, nurses told me that I had to put him to my breast and that's all, they didn't go in depth into the subject. But as the infant cried when I put him to my breast, I gave him a little formula to keep him calm.

Theme 2: The reality of becoming a breastfeeding mother after assisted reproductive technology

This theme reflects how women experienced breastfeeding and the difficulties they had to face, as well as the influence on their emotional state.

Subtheme 2.1: I want to breastfeed my infant

Women experienced breastfeeding in a very different way than they had imagined. The majority thought that the act of breastfeeding would happen naturally and without complications. Those women who initially experienced problems with breastfeeding, despite feeding their infant with artificial formula, continued trying to breastfeed for a long period of time.

We started feeding him with formula, but, even so, I continued trying to breastfeed him for 3 or 4 months because that was what I wished, and I wanted to protect him as much as possible until I said, “This (breastfeeding) can't go on,” and I continued feeding him with formula, and that was it.

Cracks in the nipple and mastitis were some of causes of the early abandonment of breastfeeding. However, after making a considerable effort to breastfeed their infants, some women preferred to endure the pain caused by the aforementioned complications and continue breastfeeding.

The cracks hurt a lot, when I had been breastfeeding for a little, the pain went down a little bit, but I thought about stopping breastfeeding. I made the sacrifice and put up with the pain for him, and I don't regret it.

Many women experienced hypogalactia, that is, their milk production diminished after hospital discharge; nevertheless, they did not try to look for professional help because they thought their problem had no solution. The negative comments regarding the low milk supply or its poor quality, especially by the grandmothers of the infants, reinforced this belief. Women even became obsessed with the weight gain of their infants since this was an indicator of the success of breastfeeding.

Neither my mother nor my sisters have breastfed. The reason is that according to them they didn't have enough milk… They tell you “your milk doesn't nourish the baby” and you think, “Maybe it's true”… I didn't look for help because I wanted to do it for myself, and as I couldn't, I stopped it… I thought it was something genetic (FG).

The stress and guilt that women perceived because of the difficulties with breastfeeding caused them to feel that they were “bad mothers” and related it to previous infertility. Women who abandoned breastfeeding after going back to work also experienced these kinds of emotions. The feeling of guilt in those women who became pregnant again was solved by a longer breastfeeding period for the second infant.

Sometimes you think, “What a pity, I haven't been able to breastfeed.” You are disappointed for not being able to do what you wanted.

Subtheme 2.2: The need for supports from others

Breastfeeding helped them deal with the experience of ART. Breastfeeding was perceived by women as a demanding and stressful situation. Although during the first months the time and energy of women were exclusively directed toward the newborn infant, they felt insecure and they consider emotional support essential during this period. The women recognized that family and partner support are the most important parts in the process of achieving successful breastfeeding and care.

If it hadn't been for my mother, it would have been impossible to get on with the baby and breastfeeding, and then, with my job. My mother has been was my feet and my hands, she took over the housework.

Women spoke about the absence of professional support after discharge: they felt alone and did not know how to find information and professional advice, which affected the establishment of successful breastfeeding. For our participants, their infants were a precious treasure, and they experienced this lack of information and support with greater anxiety and despair. What they need was a follow-up of the breastfeeding process through home visits made by nurses for at least the first month, as well as a phone service to help with their queries. Information about breastfeeding support groups also helps women achieve successful breastfeeding.

Everybody tells you breastfeeding is the best, but nobody tells you that it has incredible complications and it is the mother who suffers it all the time. Breastfeeding makes you a slave. If everything goes well, then it' s perfect, but if I have difficulties, who can fix it?.

Subtheme 2.3: When breastfeeding lasts longer than expected

Women who were able to establish successful breastfeeding and decided to keep it up for 2 years or more related that they had made this decision, in addition to the need to protect their infants, because of the positive feelings provided by the period of breastfeeding, especially in relationship to the mother-infant bond. Women who had to cease breastfeeding and provide formula milk said that the use of the bottle had broken the bond with their infant.

It was a very beautiful time, I remember that the connection between the two, it was our moment… Although I did it thinking about the benefits it had for him, what enriched me was the connection that was generated between the two of us.

Women had to face not only the negative opinions of people around them as they overextended the period of breastfeeding but also the views and comments of strangers when they breastfed their infant in public.

As the months went by, everybody told me: When are you going to give up breastfeeding? How big he is! And my answer was: Don't tell me more because I'm going to breastfeed as long as I want to.

Regarding the upbringing of an infant conceived by ART, women who became naturally pregnant at a later age stated that there were no differences in any aspect of the upbringing between one infant and another. However, many women revealed that they felt “special mothers.”

We are not better mothers, but more special. When you want something so much, you appreciate it and take care of it with more care. I worry a little more about him because he was so longed for….

Discussion

The aim of this study was to describe and understand the breastfeeding experience of first-time mothers who had conceived by using ART. While some of the experiences of women who conceived by using ART were similar to those of other women who conceived spontaneously, this study provides information on the specific factors that influence the initiation and continuation of breastfeeding in this population.

Concurring with other studies, our results suggest that women's decisions and experiences about feeding infants are influenced by a strong desire to breastfeed.²¹ Breastfeeding has a special meaning for these women because in most cases, it is the only opportunity they had to go through this type of experience, and it could also compensate for the emotional damage caused by not having been able to conceive naturally.²² Women persevere with breastfeeding despite experiencing initial difficulties.²¹ In addition, women may adopt overprotective behaviors as a result of infertility.²³

Although breastfeeding initiation rates are similar between mothers who conceived with and without ART,²⁴ a number of studies suggest that women who have conceived with the help of ART tend to breastfeed for less time and are more likely to provide formula.^12,13,24 According to other studies, the difficulties in establishing an adequate milk supply are one of the main causes of the abandonment of breastfeeding in women who have conceived through ART, independent of preterm birth.^12,23 Milk supply difficulties are more prevalent among women who conceive via ART,¹⁰ so that the relationship between fertility drugs and milk supply should be explored. Women who give birth after experiencing infertility doubt their maternal abilities,²⁵ which is a stressor that could influence the production of human milk, and also, the anxiety in late pregnancy is a predictor for shorter duration of breastfeeding.²⁶

As a result of difficulties women experience in becoming mothers, it has been speculated that these women might be more anxious about the health of the newborn and they need more time to establish a secure bond with their infant,²⁷ and as a result some women might attempt to breastfeed their infant for as long as possible. Similar to our results, the intense desire to breastfeed and the cessation of breastfeeding causes a permanent feeling of failure in women.²¹ In addition, previous infertility and ART have been associated with a decrease in self-esteem, maternal self-efficacy, and self-confidence in the postnatal period²⁸ and therefore need to be emotionally supported to strengthen their identity and skills as a mother, especially from family and partner.^25,29

Our results showed that women whose own mothers had breastfed them would usually favor breastfeeding.²⁹ In addition, family support with upbringing and housework has been connected to a longer duration for breastfeeding.²⁵ This study shows the importance and influence of hospital factors such as lack of intimacy and inadequate professional support for breastfeeding. Women who do not have professional support feel more insecure and tend to breastfeed for shorter periods.²⁶ Therefore, it is necessary to develop interventions and assistance programs adapted to the needs of women who have conceived using ART. Health care professionals should pay special attention to the emotional well-being of the women during the postnatal period and provide guidance and support about breastfeeding difficulties such as low milk supply.

Limitations

The qualitative approach offered the opportunity to explore the experience of women in depth, but the results may not be generalizable due to convenience sample method. Participants' demographic characteristics are similar, a large proportion of the women were married, older, and highly educated, which could have contributed to increase the desire to breastfeed.

Conclusions

Women who conceive by using the ART experience a strong desire to breastfeed. The cessation of breastfeeding is especially associated with low milk supply, and mothers experience feelings of guilt, shame, and failure as mothers. It is important that mothers have the necessary information and positive social networks, especially family and partner support, to help their breastfeeding experience during early postpartum and after discharge. Future interventions should include professional support and counseling to reduce the emotional impact from infertility and the pressure to breastfeed in the prenatal and postnatal period.

Footnotes

Acknowledgments

We are grateful to all participants for their contribution to the study and sharing their experiences with us.

Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Research Group Health Sciences CTS-451, and the Centro de Investigación en Salud (CEINSA), University of Almería.

References

Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss: A Committee Opinion. Fertil Steril, 2020; 113:533–535.

Massarotti

, Gentile

, Ferreccio

, et al. Impact of infertility and infertility treatments on quality of life and levels of anxiety and depression in women undergoing in vitro fertilization. Gynecol Endocrinol, 2019; 35:485–489.

European IVF-Monitoring Consortium (EIM); European Society of Human Reproduction and Embryology (ESHRE), Kupka

, et al. Assisted reproductive technology in Europe, 2011: Results Generated from European Registers by ESHRE. Hum Reprod, 2016; 31:233–248.

Vander Borght

, Wyns

. Fertility and infertility: Definition and Epidemiology. Clin Biochem, 2018; 62:2–10.

Farquhar

, Marjoribanks

. Assisted reproductive technology: An Overview of Cochrane Reviews. Cochrane Database Syst Rev, 2018; 8:CD010537.

Zhu

, Zhang

, Liu

, et al. Maternal and live-birth outcomes of pregnancies following assisted reproductive technology: A Retrospective Cohort Study. Sci Rep, 2016; 6:35141.

Davies

, Rumbold

, Moore

. Assisted reproductive technologies: A hierarchy of risks for conception, pregnancy outcomes and treatment decisions [published correction appears in J Dev Orig Health Dis 2018;9:241–246]. J Dev Orig Health Dis, 2017; 8:443–447.

Liberman

, Getz

, Heinke

, et al. Assisted reproductive technology and birth defects: Effects of subfertility and multiple births. Birth Defects Res, 2017; 109:1144–1153.

Wennberg

, Opdahl

, Bergh

, et al. Effect of maternal age on maternal and neonatal outcomes after assisted reproductive technology. Fertil Steril, 2016; 106:1142–1149.

10.

Michels

, Mumford

, Sundaram

, et al. Differences in infant feeding practices by mode of conception in a United States Cohort. Fertil Steril, 2016; 105:1014–1022.e1.

11.

Ghaffari

, Rakhshanderou

, Harooni

, et al. Prenatal interventional program about mothers' behavior related to exclusive breastfeeding: Findings of planned behavior theory-based research. J Lifestyle Med, 2019; 9:143–149.

12.

Barrera

, Kawwass

, Boulet

, et al. Fertility treatment use and breastfeeding outcomes. Am J Obstet Gynecol, 2019; 220:e1–e7.

13.

Cromi

, Serati

, Canderolo

, et al. Assisted reproductive technology and breastfeeding outcomes: A case-control study. Fertil Steril, 2015; 103:89–94.

14.

Azjen

The theory of planned behaviour: Reactions and reflections. Psychol Health, 2011; 26:1113–1127.

15.

Montaño

, Kasprzyk

Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In: Health Behavior: Theory, Research and Practice, 5th ed. Glanz K, Rimer BK, Viswanath K, eds. San Francisco, CA: Jossey Bass, 2015, pp. 95–124.

16.

Zhang

, Zhu

, Zhang

, et al. What factors influence exclusive breastfeeding based on Theory of Planned Behaviour. Midwifery, 2018; 62:177–182.

17.

Lau

CYK

, Lok

KYW

, Tarrant

. Breastfeeding duration and the theory of planned behavior and breastfeeding self-efficacy framework: A systematic review of observational studies. Matern Child Health J, 2018; 22:327–342.

18.

Gadamer

HG.

Verdad y método [True and Method]. Salamanca: Sígueme, 2005, 23 p.

19.

Fleming

, Gaidys

, Robb

. Hermeneutics research in nursing: Developing a Gadamerian-based research method. Nurs Inq, 2003; 10:113–120.

20.

Tong

, Sainsbury

, Craig

. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care, 2007; 19:349–357.

21.

Ladores

, Aroian

. First-time mothers with a history of infertility: Their internalized pressure to breastfeed. J Human Lact, 2015; 31:504–510.

22.

Mohammadi

, Shamshiri

, Mohammadpour

, et al. ‘Super-mothers’: The meaning of mothering after assisted reproductive technology. J Reprod Infant Psychol, 2015; 33:42–53.

23.

Wiffen

, Fetherston

. Relationships between assited reproductive technologies and initiation of lactation: Preliminary observations. Breastfeed Rev, 2016; 24:21–27.

24.

Sha

, Yan

, Gao

, et al. Association of assisted reproductive techniques with infant feeding practices: A community-based study in China. Breastfeed Med, 2019; 14:654–661.

25.

Hammarberg

, Fisher

, Wynter

, et al. Breastfeeding after assisted conception: A prospective cohort study. Acta Paediatr, 2011; 100:529–533.

26.

Barnes

, Roiko

, Reed

, et al. Experiences of birth and breastfeeding following assisted conception. Breastfeed Rev, 2013; 21:9–15.

27.

Maehara

, Iwata

, Kosaka

, et al. Experiences of transition to motherhood among pregnant women following assisted reproductive technology: A systematic review protocol of qualitative evidence. JBI Evid Synthesis, 2020; 18:74–80.

28.

Saleh

, Zadeh Modarres

, Esmaeili

, et al. Effects of assisted reproduction techniques on breastfeeding outcomes. J Matern Fetal Neonatal Med, 2020; 1–5. [Epub ahead of print]; DOI: 10.1080/14767058.2020.1786518.

29.

Castelli

, Perrin

, Thirion

, et al. Maternal factors influencing the decision to breastfeed newborns conceived with IVF. Breastfeed Med, 2015; 10:26–30.