“I Pumped That Milk Off My Breast and Dumped It in Trash”: Breastfeeding Experiences of Mothers Working in Hospital Radiation Settings

Abstract

Purpose:

The qualitative study was conducted to determine the breastfeeding experiences of mothers working in radiation areas in hospitals.

Materials and Methods:

The study was conducted in Turkey between December 2022 and February 2023 through in-depth interviews held with 13 mothers who met the inclusion criteria. The content analysis method was used in the analysis of the data.

Results:

As a result of the analyses of the data obtained in the interviews, four themes regarding the breastfeeding experiences of health professionals working in radiation environments in hospitals were identified. These themes were institutional/administrative obstacles, support systems, unhealthy childcare, and feeling of incompetence as a mother. The main theme of unhealthy childcare consisted of four categories, which were low-quality breast milk, toxic breast milk, frequent diseases, and future risk of cancer. The main theme of feeling of incompetence as a mother was composed of three categories, which were fear, feeling of guilt, and “Am I a mother?” The theme of institutional/administrative obstacles consisted of three categories, namely working environment, working duration, and awareness of managers. Finally, the theme of support systems included two categories, positive perceptions and negative perceptions.

Conclusion:

In this study, it was determined that the mothers who worked in radiation areas in hospitals experienced problems due to individual, social, and institutional factors. The main concern of the mothers was found to be hurting their infants with their breast milk. Suitable working environments and the adequacy of practices related to daycare centers, social support, and motherhood rights are the main needs of working mothers aiming to keep breastfeeding their infants.

Introduction

Many devices are used in diagnosis and treatment in the field of health care by benefiting from ionizing radiation. Along with these developments, the effects of the dose of radiation that individuals are exposed to have come to the fore. While radiation leads to various negative biological impacts on living things depending on its dosage and exposure time, it has an inevitably important place in diagnosis and treatment. In radiology, in line with the principle of “as low as reasonably achievable” (ALARA), the aim is to expose the patient and the radiology employee to the lowest possible dosage of radiation.^1,2

Health care professionals who work in radiation environments must work in accordance with the rules in a more protected and careful manner. Devices that emit radiation and the dosage of radiation that employees are exposed to are particularly important for female health professionals working in their breastfeeding period. Although we have enough evidence regarding the benefits of breastfeeding, after working mothers return to their jobs, they either cannot continue breastfeeding their infants due to various reasons or are affected by worrying about the effects of their work environments on their childcare processes. Working mothers experience issues regarding breastfeeding due to both lack of knowledge and working conditions, and they may stop breastfeeding their infants in the early period. Problems stemming from the mothers returning to work, physiological problems about the breasts, and problems related to the infant are effective in the increase in the rates of cessation of breastfeeding in early periods.^3–5 It was also determined that in addition to these factors, women stop breastfeeding their infants due to difficulties they perceive.⁶

There are legal regulations for women working in radiation environments in Turkey. These regulations restrict the inclusion of women who are in their pregnancy and breastfeeding periods in environments in which they would be exposed to ionizing radiation.⁷ In addition, as per the provision of the directive stating that “pregnant or breastfeeding employees cannot be required to work for more than 7.5 hours a day,” it is prohibited to require pregnant women to work for more than 7.5 hours a day under any circumstances.⁸ Besides, it is prohibited to have pregnant, puerperal, and breastfeeding women employees to work overtime.¹² According to Article 8/4 of the Regulation on Radiation Dosage Limits and Working Principles for Staff Working with Ionizing Radiation Sources in Healthcare Services, women employees in their breastfeeding period cannot be employed in jobs such as nuclear medicine in which exposure to ionizing radiation is possible through the skin, by inhalation, or by digestion.⁹

Another important regulation about women employees is about breastfeeding leave that is issued for new mothers to breastfeed their infants. According to Article 104/D of the Civil Servants Law, “starting from the end of maternity leave, female civil servants are entitled to three hours a day in the first 6 months and one and a half hours a day in the second 6 months to breastfeed their infants.”^10,11

Mothers working in radiation areas in hospitals continue to work in these environments following childbirth. While these mothers continue to breastfeed their infants, they need a functional protective intervention so that they receive the lowest dosage of radiation possible.¹² The review of the relevant literature that was carried out for this study revealed no previous study in which the experiences of mothers working in radiation areas in hospitals in their breastfeeding period were examined. Hence, the aim of the study was to determine the breastfeeding experiences of mothers working in radiation areas in hospitals.

Materials and Methods

Study design and participants

To obtain in-depth insights into the breastfeeding experiences of mothers, a descriptive qualitative study design was used.¹³ This qualitative study was conducted using the interpretative phenomenological analysis approach. In this approach, the experiences, understandings, perceptions, and opinions of the participants are the basic areas of interest.¹⁴

The study was conducted with the participation of female health care professionals with breastfeeding experience working in X-ray, Computed Tomography, Radiation Oncology, Radioscopy, Mammography, and PET/CT units of a university hospital between December 1, 2022 and February 1, 2023. The purposive sampling method was used in selecting the participants to be included in the sample.^15,16 When data saturation was reached, participant enrolment was terminated. Interviews were held with 13 mothers (Table 1).¹⁷ The inclusion criteria were determined as (1) working in X-ray, Computed Tomography, Radiation Oncology, Radioscopy, Mammography, or PET/CT units, (2) having breastfeeding experience, (3) being able to read, speak, and understand Turkish, and (4) agreeing to participate in the study.

Table 1.

Sociodemographic Information About the Participants (n = 13)

Participants	Age	Educational status	Occupation	Family type	Number of children	Average breastfeeding period		Working period in radiation areas	Time of returning to work after birth		Economic status
P1	41	Undergraduate	Nurse	Nuclear family	2	24 Months	18 Months	4 Years	12 Months	12 Months	Income equal to expenses
P2	41	Undergraduate	Radiology Technician	Nuclear family	2	5 Months	18 Months	22 Years	4 Months	15 Months	Income equal to expenses
P3	38	Undergraduate	Nurse	Nuclear family	2	12 Months	6 Months	6 Years	6 Months	5 Months	Income more than expenses
P4	40	Undergraduate	Radiology Technician	Nuclear family	2	12 Months	12 Months	15 Years	4 Months	9 Months	Income equal to expenses
P5	42	Undergraduate	Radiology Technician	Nuclear family	2	3 Months	0 Month	22 Years	10 Months	6 Months	Income equal to expenses
P6	38	High school	Radiology Technician	Nuclear family	2	6 Months	8 Months	20 Years	3 Months	6 Months	Income equal to expenses
P7	33	Undergraduate	Radiology Technician	Nuclear family	2	24 Months	22 Months	13 Years	2 Months	6 Months	Income equal to expenses
P8	40	High school	Radiology Technician	Nuclear family	1	13 Months		21 Years	3 Months		Income equal to expenses
P9	41	Associate degree	Radiology Technician	Fragmented family	1	8 Months		20 Years	6 Months		Income less than expenses
P10	38	Associate degree	Radiology Technician	Nuclear family	2	3 Months	5 Months	15 Years	2 Months	5 Months	Income less than expenses
P11	44	Associate Degree	Radiology Technician	Fragmented family	1	26 Months		22 Years	5 Months		Income less than expenses
P12	38	Undergraduate	Radiology Technician	Nuclear family	1	30 Months		17 Years	12 Months		Income equal to expenses
P13	40	Undergraduate	Radiology Technician	Nuclear family	1	24 Months		18 Years	6 Months		Income equal to expenses

Data collection

Information about the purpose, method, and confidentiality of the study was provided to the potential participants who met the inclusion criteria. Participation in the study was on a voluntary basis. Interview dates and hours were arranged based on the availability of the participants. The authors of the study are specialized in pediatric nursing and have experience in qualitative research and in-depth interview techniques.¹⁸ The participants had no relationships to the researchers, including friendship or previous contact. All interviews were held face-to-face. The interviews were held in an isolated interview room to ensure privacy, comfort, and relaxation. Each interview lasted ∼40–60 minutes. An audio recording device was used in the interviews based on the approval of the participants.

In line with the purpose of the study and in light of the relevant literature,^12,19 a semistructured interview form was developed by the researchers. The semistructured interview form included questions on the demographic characteristics of the participants, as well as their perceptions regarding breastfeeding, the problems they experienced, risks related to working in radiation environments, infant-mother interactions, and difficulties they experienced. The questions in the form were determined as (1) How did working in a radiation environment affect your breastfeeding process? (2) What problems did you experience in the breastfeeding period due to working in a radiology unit? (3) How do you think a radiation environment affects breast milk? (4) How did working in a radiation environment affect you in the breastfeeding period? (5) How did working in a radiation environment in the breastfeeding process affect your infant? (6) What were your individual and institutional support expectations regarding your employment in a radiation environment in the breastfeeding process? The questions were tested through a pilot study for comprehensibility and responsiveness.

Data analysis

In the analyses of the data that were collected in the study, the content analysis method was used. All recordings were listened to and transcribed by the researchers in the computer environment, and based on the interview data, first themes and, then, categories were determined. The stages of analysis in the study were as follows: (1) transcribing the data, (2) coding the data, (3) creating categories and themes, (4) arranging the categories and themes, and (5) noting down the findings and interpreting them. After the categories and themes were read, and an agreement was reached on these categories and themes by the researchers, they were presented to the opinions of three experts in the fields of pediatric nursing and qualitative analysis methods. In the next step, after obtaining the opinions of the experts, the final versions of the categories and themes were formed.^17,20

The researchers listened to the audio recordings several times to have mastery over the dataset.²¹ The transcribed data were carefully examined to identify applicable codes. Repetitive codes in the dataset were brought together and separated into different categories. As a result, themes and categories were created. Thus, a complete overview of the findings was ensured.²² The researchers analyzed the transcribed recordings and compared their analyses. Differences in opinions were resolved by reaching a consensus. Themes with similar content were renamed and reshaped. Thus, the final versions of the themes and categories were formed. The Consolidated Criteria for Reporting Qualitative Research (COREQ)²³ checklist was used to report the findings of the study.

Ethical considerations

Before starting the study, ethical approval was obtained from Zonguldak Bulent Ecevit University Clinical Studies Ethics Committee (Decision Date: November 30, 2022, Decision No.: 448). The study protocol was carried out in accordance with the principles of the Declaration of Helsinki. Participation in the study was completely voluntary. The participants were informed that they could leave the study at any stage. The confidentiality of the participants was protected, and they were informed that the data obtained in the study would only be used for the purposes of the study.

Reliability

To ensure the reliability of the study, necessary precautions were taken to verify credibility, reliability, transferability, and confirmability. For reliability purposes, the researchers received training on holding qualitative interviews. A pilot study was conducted to ensure the applicability of the semistructured interview form. Moreover, to ensure the reliability of the study, all documents used in data collection and analysis were made accessible when needed.²⁴ After each interview, a journal was kept by the researcher to keep their individual opinions under control.²⁵ To ensure confirmability (to avoid the influence of the opinions or bias of the researcher), repetitive analyses were performed among other researchers.²⁶ When differences in opinions occurred, these conflicts were discussed, and an agreement was reached. Data saturation was the basis of data collection to ensure transferability. Two researchers independently performed coding to ensure consistency in the data coding process. In case of any discrepancies, a third researcher decided on the codes in question. It was ensured that all methods were used in line with the relevant regulations and arrangements.

Findings

As a result of the analyses of the data obtained from the interviews, four themes emerged from the experiences of the participants. These themes were institutional/administrative obstacles, support systems, unhealthy childcare, and feeling of incompetence as a mother (Table 2). The issue that the participants were concerned about the most was whether their breast milk was contaminated with radiation. The participants thought that they gave toxic food with poor content and contamination with radiation to their infants through their breast milk. In their opinion, their infants were therefore frequently sick, and diseases such as cancer could develop in their infants in the future. Moreover, some participants had to work in units where the dose of radiation was high such as radioscopy and computed tomography units in their breastfeeding periods, and they had not received any support in this regard from the managers of the institutions in terms of their working environments and working hours. The participants suggested working for shorter periods in environments where there is the possibility of exposure to ionizing radiation in the breastfeeding period as a solution recommendation.

Table 2.

Themes and Categories Identified in the Study

Main themes	Unhealthy childcare	Feeling of incompetence as a mother	Institutional/administrative obstacles	Support systems
Categories	Low-quality breast milk	Fear	Working environment	Positive perception
	Toxic breast milk	Feeling of guilt	Working hours	Negative perceptions
	Frequent diseases	Am I a mother?	Awareness of managers
	Future risk of cancer

Theme 1: Unhealthy childcare

All participants thought that their breast milk was affected by radiation. They expressed their concerns that the content of the breast milk and its protein, vitamin, and mineral structures deteriorated. They emphasized that they considered their infant's benefit by giving them breast milk instead of baby formula, but the nutritional value of their breast milk decreased due to radiation exposure. The mothers saw breast milk as a processed product.

Everyone was making fun of me, but I believe that the color of my breastmilk changed in that period. I was at home in the first six months. Then, I returned to work. In one and a half months after I started work, the color of my breastmilk was different. It appeared as if it was whiter than it used to be. P9

Breastmilk can be affected in terms of its content. Its amount depends on the mother's breastfeeding [behaviors] and her nutrition. Nevertheless, I believe that radiation diminishes vitamins. P11

I think my milk is not organic. I feel like it has been processed. P7

Some of the participants considered breast milk as a product that would directly harm their infants and lead them to have cancer. They described their breast milk using terms such as poison and radiological drug.

I do not even pass the bag including my baby's food through X-ray devices (gates). …but I feed him/her with my breastmilk. P3

I did not directly feed my baby with this milk. I dumped the milk that I pumped in my working hours into trash. I expressed breastmilk when I returned home from work, and I waited for new milk production. Then, I breastfed my baby. P11

My baby drinks radiated milk. It is something like the radiological drugs we administer in radiology imaging. That milk is like that radioactive matter. I feel like I am feeding my baby with poisonous milk. Is my milk a radioactive substance? P12

The participants reported that their children had very frequent infections as the content and nutritional value of their breast milk were negatively affected, and their growth and development were also negatively affected. In addition, the participants believed that due to exposure to radiation in their breastfeeding process, their children would develop metabolic diseases in later stages of their lives.

The teeth of my children decay very early. One of them has overgrowth in the kidneys, and the other has that problem in the spleen. Other nurses working in other units do not have these problems in their children. I agree, some things are God's will, but I cannot help thinking when I encounter consecutive diseases. P8

I think my child is also affected by this milk, because although my baby sucks milk from my breast regularly, s/he frequently gets sick. We used too many antibiotics. P11

The participants thought that due to the exposure of their breast milk to radiation, the risk for their children having cancer in the future was quite high. The participants therefore tried to get information from radiology experts or pediatricians with whom they worked.

Although we are not directly exposed to radiation, we are still affected. What if health problems such as irreversible cancer emerge in my child in the future? P4

I felt doubt. I talked to doctors. They told me that we could not prove anything at the moment even if we give a blood sample, and consequences would be seen in the future. I continuously check my child's body for bruises. P7

Theme 2: Feeling of incompetence as a mother

The emotion that was felt the most by the participants in the breastfeeding process was fear. Causing unintentional harm to their children with the breast milk they gave them was a considerable source of fear for them.

I was at home and comfortable when I breastfed my first baby. …but I was working when I breastfed my second child. I could not help thinking whether my milk was contaminated with radiation. What if I was hurting my child? P1

In fact, I worked in that area. I also continued to breastfeed my baby. Therefore, I was nervous and afraid. P3

According to the participants, any health problem or change that developed in their children was related to their breast milk. Especially the participants who had children with health problems were skeptical about everything and blamed themselves as they worked in a radiation environment in their breastfeeding periods.

I become suspicious when my child had the flu or a tiny change occurred on his/her body. I start to feel guilty asking myself whether these things were happening because I work here. P2

I was working in a radiation area in the breastfeeding period. Both my children are being treated for cancer. I always blame myself for this. P3

The participants considered breastfeeding to be their essential responsibility in the postpartum period. However, they could not experience an efficient breastfeeding process as they did not feel safe in the environment they worked, and their breast milk and their children's health were negatively affected by this situation. They emphasized that they could not fulfill their motherhood responsibilities because of this condition.

My lactation period lasted shorter than normal due to the stress I experienced. [To me,] motherhood meant breastfeeding my baby in that period. I questioned my motherhood a lot. P2

What kind of a mother am I? My sole responsibility is to breastfeed my baby, and I cannot even perform it properly. I breastfeed my baby as it [breastmilk] is healthier than baby formula, but it is contaminated with radiation. P5

Theme 3: Institutional/administrative obstacles

The majority of the participants emphasized the importance of working in units where the degree of their exposure to ionizing radiation was lower in their breastfeeding process. They wanted to be assigned to duties such as meeting the patients and collecting blood samples instead of drug administration and imaging when they worked in these units. They also wanted to have a room in their working environment for breastfeeding their children and pumping milk off their breast as they could not be at home during breastfeeding hours.

I think we should stay away from radiation until the end of the breastfeeding period. …or we should do other jobs which do not require exposure to radiation. P6

Patient load is high, and working hours are long; so, we cannot leave the unit we are working at. I wanted my baby to be brought, but our clothes are dirty, and we do not have a room for breastfeeding. P11

I would like to be working in an environment where [the dose of] radiation was the lowest. Not a radioscopy environment. The MRI unit would be appropriate. We are exposed to ionizing radiation. We are not even sure about the safety in protected areas. P13

Another issue that the participants emphasized was their working durations. Being in a radiation area for a long time increased their exposure to radiation. They thought this meant a higher dose of radiation passing into their breast milk.

Our working durations can be reduced. Thus, we could be exposed to less radiation. If we are working in the outpatient clinic, and we are working for 7 hours, we can split our working hours among three colleagues. P4

The vast majority of the participants had to work in a radiation environment as their managers required them to do so, or their managers did not understand the sensitivity of the breastfeeding process. They had to work with stricter rules than others who worked in radiation-free areas. Some of the participants preferred to get a sick report to avoid going to work as a solution.

They gave me a hard time. I was told to work in the mammography unit. So, I got a sick report and did not go to work. P5

I could not use any of my legal rights. They lost my documents. I could not claim anything as I was working in the private sector. P9

Managers are more tolerant towards those working in units other than radiology. When a mother returns from maternity leave, she is told that she has been away for a long time and is pushed to work more. This means more exposure to radiation. P11

Theme 4: Support systems

Some of the participants stated that they received negative reactions from their environments regarding their children's health problems that were considered to develop due to their employment in radiation areas. Even though these health problems were not related to breast milk and other foods, people in their social circles perceived them as a consequence of exposure to radiation.

I keep wondering if any radiation-related health problems will occur in the future. Even if I do not worry… My son is dyslexic. My husband once asked me if it could be related to my work in a radiation area. Actually, it was genetic. When my child gets sick, it is associated [people associate it] with my workplace. This is how they always perceive me. P5

From the statements of the participants, the codes of positive social support systems and coping with problems stemming from exposure to radiation in the breastfeeding process emerged. The participants reported that in addition to negative perceptions, they were able to cope with fear and feelings of guilt and working conditions in the breastfeeding process through spouse, family, and friend support. Especially the thoughtful approaches of their colleagues facilitated this process.

My closest friends in my working environment supported me. They took over my shifts. Our manager also allowed this situation saying that they could take over my shifts until my son started to walk. Other colleagues did not agree to take over my shifts. P11

My greatest source of support was my mother. She both took care of my child and supported me financially. She was always understanding towards me in this process. P9

Discussion

Radiation exposure among pregnant or breastfeeding health care professionals due to their employment in radiation areas in hospitals is still a current issue, and it needs to be investigated in depth.^12,27 In the literature review, no study in which the experiences of mothers working in radiation areas in hospitals in the breastfeeding process were examined could be found. Hence, it was aimed in this study to examine the breastfeeding experiences of mothers working in radiation environments in hospitals through in-depth interviews. As a result of the analysis of the data obtained from the interviews, the experiences of the participants regarding breastfeeding were gathered under four themes, namely institutional/administrative obstacles, support systems, unhealthy childcare, and feeling of incompetence as a mother.

The participants believed that the content of their breast milk was changed due to their working in radiation environments and that it even poisoned their children. Therefore, they were pumping the milk produced in their breast during working hours and dumping it in the trash. Exposure to radiation can occur at any time when a radioactive material is being produced or used, and the risk continues to exist even after these procedures have been completed.²⁸ Thus, the personnel who are performing the procedure, as well as the patient, can potentially be exposed to radiation.²⁹

Due to the potential release of radioactivity through breast milk, breastfeeding after the therapeutic application of radiopharmaceuticals is generally a contraindicative situation.^30,31 In relation to radiopharmaceutical practices in radiological diagnosis procedures, it may be necessary to stop breastfeeding for a while and even stop it completely after these procedures.³² In most cases, it may be a sufficient measure to store the breast milk pumped before examinations and stop breastfeeding temporarily until the breast milk produced after the procedure is discharged in a few hours or days. The same situation is valid for mothers working in such environments.³³

The participants described motherhood as breastfeeding. Pumping and dumping the milk, not being able to feed the infant with adequate amounts of breast milk, and having doubts about the milk they gave to their infants were situations that the participants had difficulty in coping with. Breastfeeding is also important for the infant, and this process should not be interrupted.³⁴ However, mothers who are exposed to radiopharmaceuticals should avoid breastfeeding or take a break for some time. Explaining this process to mothers through guides and evidence-based research can prevent their motherhood perceptions from being negatively affected.¹²

The participants were experiencing great concern due to health problems that they thought could develop in their children as a result of breastfeeding them. They even blamed themselves for the frequent illnesses and chronic diseases their children had. The potential of cancer was the issue that the participants feared the most in their children. Exposure to radiation in childhood or adulthood should be evaluated in terms of cancer risk. Although exposure in the pregnancy period is emphasized more, the breastfeeding period is equally important. This represents the stochastic risks of radiation along with its long-term genetic effects.^12,35

The participants were required to work in radiation areas as the managers of their institutions pushed them to do so and as they were not aware of the sensitivity of the situation. Heavy workload, patient circulation, poorly planned working schedules, and insufficient protection methods cause health care professional to be exposed to radiation and increase related risks.³⁶ The level of exposure to radiation varies greatly depending on job responsibilities and units. Almén and Mattsson¹⁹ stated that women working in radiation areas are not informed by institution managers about standards and regulations in this regard. It is important that institutions plan measures for protection from radiation exposure, and they should publish their own regulations.

It is also recommended that jobs that do not require any restrictions for pregnant and breastfeeding employees be defined and working lists be prepared. It was emphasized that such responsibilities assigned by coercion in the pregnancy and breastfeeding periods increase the potential levels of exposure to radiation.¹⁹ At this point, those who manage such areas have a great responsibility. When planning is made considering working hours and the number of employees, workload and circulation could progress in a more organized manner.

Another issue that the participants had problems with was the duration of their work. Longer working shifts and intense patient circulation meant more exposure to patients receiving radiopharmaceutical treatment and more exposure to radiation. Health care professionals should be at a safe distance from these patients. Training in this regard should be provided to all health care professionals. Particularly health care professionals who are in their pregnancy and breastfeeding periods should stay as far as possible from patients receiving radiopharmaceutical treatment, and they should not even be in the same area.^19,29 In addition, protective measures should be taken in procedures in which ionizing radiation is used (e.g., computed tomography imaging procedures), and exposure to radiation should be minimized.

Conclusion

In conclusion, it was determined that the mothers working in radiation areas in hospitals experienced problems in terms of individual, social, and institutional factors. The greatest concern of the mothers was causing harm to their children with their breast milk. It was also determined that the mothers had to work in radiation areas due to strict rules in their workplaces. Basic needs for mothers to continue to feed their infants with their own breast milk include suitable workplace conditions and adequate measures and practices related to daycare centers, social support, and motherhood rights. When such conditions are provided, when it is ensured that mothers working in radiation environments work with adequate protective equipment, and when the breastfeeding processes of working mothers are supported, awareness of the positive effects of breastfeeding will be raised in society more easily.

Footnotes

Authors' Contributions

All authors listed met authorship criteria. Authorship credits should be based on substantial contributions to: (1) conception and design, or analysis and interpretation of data: M.Ö., A.K., and T.K.A.; (2) drafting the article or revising it critically for important intellectual content: M.Ö., A.K., and T.K.A.; (3) final approval of the version to be published: M.Ö., A.K., and T.K.A.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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“I Pumped That Milk Off My Breast and Dumped It in Trash”: Breastfeeding Experiences of Mothers Working in Hospital Radiation Settings—A Qualitative Study