Mother's Emotional Experiences of Breastfeeding with Primary Low Milk Supply in the First Four Months Postpartum: An Interpretative Phenomenological Analysis

Abstract

Background:

Primary low milk supply (PLMS) prevents mothers from producing sufficient milk to breastfeed exclusively. However, limited evidence exists regarding women's experiences of breastfeeding with PLMS.

Objective:

This article aims to investigate the emotional experiences of mothers breastfeeding with PLMS in the first 3 months postpartum.

Materials and Methods:

The study was conducted in Ireland and used a phenomenological methodology to investigate the lived experiences of breastfeeding mothers with PLMS. Nine first-time breastfeeding mothers with PLMS participated, and data collection took the form of unstructured interviews. Data analysis was completed using Interpretative Phenomenological Analysis.

Results:

Being in the Whirlwind is one of four superordinate themes identified in this study. This theme relates to participants' internalized experiences of breastfeeding with PLMS in the first 3 months postpartum. During this time, participants struggled to come to terms with having PLMS and became caught up in all-consuming efforts to increase their milk supply. They experienced guilt, sadness, confusion, anger, and anxiety, with many describing the early months postpartum as traumatic. Participants revealed how triple-feeding (a regime of breastfeeding, pumping, and supplementing) negatively affected their mental health and reported that supplementing with infant formula was emotionally upsetting.

Conclusions:

Our findings reveal that the combination of PLMS and triple feeding can negatively impact a mothers' mental health. A greater understanding among health care professionals of the emotional impact of having PLMS and triple-feeding could enhance the provision of sensitive and person-centered support for those with PLMS. Antenatal breastfeeding education should acknowledge that PLMS is a challenge for a small cohort of women and place greater emphasis on the emotional aspects of breastfeeding challenges.

Introduction

One of the most common reasons cited by mothers for stopping breastfeeding is low milk supply.¹ Low or insufficient milk supply is a blanket term which covers any real or perceived maternal difficulty producing enough milk to exclusively breastfeed. It can be classified as perceived, secondary, or primary. While many women report perceived low milk supply^2,3 (an unfounded belief that they are not producing sufficient milk for their babies) and some experience secondary low milk supply⁴ (a drop in milk supply caused by extrinsic factors or poor breastfeeding management), a small proportion of women experience primary low milk supply (PLMS). PLMS is an intrinsic condition that prevents the synthesis of adequate breast milk to meet infant growth and development needs.⁵

Insufficient glandular tissue (IGT) has been identified as a risk factor for PLMS.^6,7 While there is a dearth of research on causes of IGT and other conditions associated with PLMS, there is growing evidence to suggest that maternal genetics, diet, endocrine disrupting chemicals, and mammary gland physiology can play a role.^6,8 A 2020 study found that a common genetic variant of the zinc transporter ZnT2 was present in 20% of women with low milk volume, resulting in altered lysosome function and cell energetics.⁹

There is limited research on the prevalence of PLMS.^8–10 A large 1958 study reported that 4% of participants experienced “primary failure of lactation”¹¹ while a 1990 study concluded that 15% of participants had “persistent milk insufficiency.”¹² PLMS is not currently listed among conditions deemed by the WHO and UNICEF as acceptable medical reasons for the use of breast milk substitutes.¹³

There has been a growing awareness in the last decade of the importance of understanding the emotional impact on mothers of difficult breastfeeding experiences.^14–17 Breastfeeding difficulties can result in a sense of loss¹⁴ and a feeling of being lost,¹⁷ feelings such as grief, guilt, and shame can result from earlier than intended cessation of exclusive breastfeeding,^13,15,18 and breastfeeding problems may be related to psychological distress, mental health problems, and perceived negative consequences for mother-infant bonding.^3,16 It has been argued that specific supports should be directed to women experiencing breastfeeding difficulties, not just from the perspective of prolonging breastfeeding but also in regard to supporting maternal well-being.¹⁹ Regarding research that focuses specifically on the lived experiences of women breastfeeding with PLMS, there is a significant gap in the literature. We located only one study that investigated how women experience breastfeeding with PLMS.²⁰

Our study aims to address this knowledge gap by exploring what it means from an ontological perspective to be a mother who is unable to exclusively breastfeed because of PLMS. Specific aspects that we aimed to explore were participants' emotional experiences of breastfeeding with PLMS, participants' experiences of interacting with health care professionals (HCPs) and breastfeeding supporters, participants' lived experiences of transitioning to motherhood, and the embodied experience of having PLMS. This article addresses the first of these aims—participants' emotional experiences of breastfeeding with PLMS. Some new insights are provided which will help guide lactation professionals in providing sensitive and empathetic support to women breastfeeding with PLMS.

Methodology and Methods

Design

Interpretative Phenomenological Analysis (IPA) was used in this study (Fig. 1 ). IPA is a qualitative seven-step, structured research methodology that is based on three main areas of philosophy: phenomenology, hermeneutics, and idiography.²¹ Phenomenology is concerned with the study of lived experience and uncovering new insights into how people experience phenomena.²¹ Hermeneutics is the theory of interpretation and allows for a deeper understanding of the meaning of phenomena, and idiography is concerned with detail and the uniqueness of each individual case being studied.²¹ IPA is suitable for exploring topics with an emotional dimension²² and has two broad aims: a detailed exploration of how individuals make sense of a particular life experience in a particular context, and interpretation of these accounts to reveal new insights about their experience.²³

FIG. 1.

A flowchart of the study design representing each stage of the process, including recruitment, data gathering, the seven-stages of IPA, and reflexive practices undertaken by the researcher (CW). IPA, Interpretative Phenomenological Analysis.

Recruitment and selection

The inclusion criteria for the study were mothers who had partially breastfed an infant for at least 4 months, were identified as having PLMS by an International Board-Certified Lactation Consultant (IBCLC) or a HCP, were less than 2 years postpartum, and were older than 18 years of age. The rationale for having breastfed for at least 4 months was based on the probable timeframe required to establish breastfeeding and identify PLMS. IPA researchers usually aim for a small and relatively homogenous sample of participants to allow for a detailed and in-depth exploration of the phenomenon being studied.^21,24 With this in mind, the sample for this study was purposely limited to the first nine women who responded to the call for participants and met all the inclusion criteria. Flyers seeking participants were posted on Instagram, Twitter, and Facebook. Thirty women responded to the call within 2 weeks.

The participants were all white, married, heterosexual, cis-gender, middle-class, third-level educated, and first-time mothers living in Ireland. All participants had partially breastfed, supplemented their babies with infant formula (Table 1). All participants reported having made a conscious decision before giving birth to exclusively breastfeed and discovered that they had PLMS by working one-to-one with an IBCLC.

Table 1.

Participant Profile

	Pseudonym	Age	Age of baby at time of interview	Breastfeeding duration	Reported cause of PLMS
1	Caroline	33	11 months	5 months	PPH, PCOS
2	Fiona	37	11 months	9 months	IGT
3	Megan	40	16 months	11 months	IGT and PCOS
4	Amy	31	13 months	5 months	IGT, Familial Alactogenesis
5	Sinead	32	11 months	10 months	IGT
6	Kate	34	14 months	14 months +	IGT
7	Orla	32	10 months	10 months +	Hypothyroidism, possible IGT, Familial Alactogenesis
8	Ruth	36	9 months	9 months +	ICT, Familial Alactogenesis
9	Donna	38	24 moths	18 months	IGT

IGT, insufficient glandular tissue; PCOS, polycystic ovarian syndrome; PLMS, primary low milk supply; PPH, postpartum hemorrhage.

Data collection

Interviews were conducted online on Zoom between April 2021 and November 2021 by a lead researcher (C.W.). They ranged from 55 to 75 minutes. The interview guide included questions about participants' motivation to breastfeed, experience breastfeeding and supplementing, and encounters with HCPs, IBCLCs, and others. Both structured and unstructured interviews are appropriate for IPA research.²¹ The initial plan was to conduct semistructured interviews, but it was found that unstructured interviews yielded richer data. In general, the participants needed very little prompting to talk about their experiences. For some, it was the first time they had spoken in-depth about having PLMS. Zoom interviews were audio recorded.

In keeping with the ethical principle of beneficence, the researcher was cognizant that talking about difficult breastfeeding experiences had the potential to trigger difficult emotions. This was discussed with participants, and they were informed that if they felt emotionally overwhelmed during their interview, they could take a break or terminate it. While many participants were upset during the interviews, they were happy to complete them. Participants were emailed the following day to thank them for their participation.

Data analysis

Interview recordings were transcribed by the main researcher (C.W.). Smith et al.'s seven-step approach to data analysis was systematically followed.²¹ In accordance with this method, each transcript was read several times, paying careful attention to language used, tone of voice, embodied expressions of emotions, metaphors used by participants, and facial expressions. Initial notes and exploratory comments were made and then used as the basis for the development of subthemes. Once all transcripts had been individually analyzed, patterns across cases were identified, deeper levels of interpretation were explored, and superordinate themes were identified (Fig.1).

Reflexivity

Reflexivity is central to this study. This technique enables researchers to acknowledge their position in relationship to their participants and is used to increase the credibility of qualitative findings.²⁵ The researcher invites the data into their lifeworld and allows it to inhabit their thinking, while also maintaining awareness of their potential to influence the research.²⁶ The main researcher (C.W.) started the reflexive process with a statement of positionality. This allowed her to unpack her own stance on the research as a mother of three breastfed infants, as a breastfeeding advocate, and as an IBCLC.

Other reflexive techniques used by C.W. during the study included keeping a reflective journal to reflect on personal interpretations and understandings; seeing a psychotherapist every 6 weeks during the data gathering phase to debrief from emotionally grueling interviews; engaging regularly with supervisors to limit the subjectivity of interpretations; and writing interpretative summaries of ∼3,000 words after each participant interview. Writing interpretative summaries provides the researcher with an opportunity to consider early patterns and themes and engage in a hermeneutic manner with the data.²⁷ It was found that writing interpretative summaries enabled C.W. to maintain a more objective view of the data collected and reflect on her own potential to influence the interview process.

Ethical approval

Ethical approval for the study was granted by the Human Research and Ethics Committee of University College Dublin. The research process adhered to strict ethical guidelines upon which ethical approval was granted. This included the requirement for informed consent and the management of data to compliance with the General Data Protection Regulation (GDPR).

Results

Four superordinate themes were identified during the data analysis process: Being in the Whirlwind, Being with Others, Reimagining Motherhood, and Embodiment. Herein, this article focuses on Being in the Whirlwind. This superordinate theme describes the participants' emotional experiences in the first 3 to 4 months postpartum. During this timeframe, participants were confronted by the reality that they were unable to exclusively breastfeed, and overwhelmingly described how they became caught up in all-consuming efforts to increase their milk supply. All participants experienced difficult emotions such as guilt, sadness, confusion, anger, and anxiety. They also struggled to find information about PLMS and expressed anger about the lack of knowledge about the phenomenon among HCPs. Five subthemes were developed for Being in the Whirlwind: “Heart-set and Hellbent on Breastfeeding,” “Obsessed: Every Drop Counts,” Formula: Giving my Baby Second Best,’ “Dark Days and Dark Emotions,” and “The Frustrating Search for Information.”

While not all participants used the word traumatic to describe their early months postpartum, they all described a combination of emotions and experiences that collectively could be defined as traumatic and overwhelming. The most salient features of participants' experiences of the “Being in the Whirlwind” subthemes are as follows.

Heart-set and hellbent on breastfeeding

All participants spoke about how much they had wanted to exclusively breastfeed and how determined they were to make it work. They gave the overwhelming impression that it was not simply a case of choosing one mode of feeding over another, but rather an embodied decision about the kind of mother they believed they would be. Participants talked about knowing that they would breastfeed and used words like “hellbent” and “heart-set” to convey how they felt about it. Before the birth of her baby, Amy reveals how vested she was in breastfeeding:

I was so excited to breastfeed. I had equipped myself with a lot of information. I knew it wasn't going to be a walk in the park… I was just so determined… I had read about all the benefits…, I was so passionate about doing it, I felt like if I couldn't give him all that I could that I would be failing him. [Amy, L118–174]

Amy perceived being unable to breastfeed in the way she had wanted to as “failing” her baby, and this belief was echoed by many of the other participants. Participants struggled to make sense of the strong feelings they had about breastfeeding:

I thought, why did I want to breastfeed so much?…it's like this really inherent, natural, like, hormonal thing…It wasn't just about the baby being fed. I wanted the whole breastfeeding relationship; I wanted the whole piece [tone of incredulity]. [Sinead]

Through the process of articulating her struggle to understand herself, Sinead eventually comes to the insightful conclusion that breastfeeding was about “the whole piece.” The use of the word “whole” is suggestive of breastfeeding being everything to Sinead in a way she cannot fully make sense of; something that is longed for by the whole of her being.

Most participants expected that breastfeeding would be challenging, but appeared to have had a strong conviction that they would be able to make it work by virtue of their own research, education, and determination:

I knew I was going to breastfeed. I had done my preparation for breastfeeding course, I had joined the La Leche League….I knew breastfeeding was going to be really hard. So, I was prepared. [Caroline]

I just thought my body would work the way it's supposed to. [Kate]

Gaining these insights into the participants' strong desire to breastfeed and their certainty that they could make breastfeeding work by doing adequate preparation, helps in understanding the subsequent shock and devastation they go on to experience when they discover they have PLMS.

Obsessed: every drop counts

One of the defining features of breastfeeding with PLMS for all participants was that it completely dominated their lives in the first few months postpartum. Their response to the realization that they were unable to exclusively breastfeed was to try to exert control over their situation by harnessing all their time and energy into breastfeeding and increasing their milk supply. Participants overwhelmingly gave the impression of being trapped in a continuous cycle of triple feeding, whereby they were breastfeeding, pumping after most breastfeeds and supplementing with expressed breast milk and/or infant formula. Orla's account of triple feeding is typical:

It is all-consuming…Everything becomes about the breastfeeding…I was constantly thinking about it, constantly doing something about it or thinking that I should be doing something about it. [Orla]

Similarly, Caroline describes what her life was like when she was triple feeding. Her description reveals a constant tension, whereby she was trying to limit the amount of formula and ensure adequate weight gain, while also constantly thinking about milk supply:

“I spent a lot of time trying to drop the top ups, only wanting to give a certain amount…but that's what your life becomes when you are triple feeding…a balancing act of the most minute amount of formula to get the weight on but you're always thinking about your supply…” [Caroline]

Many participants became distressed when they reflected on their experience of triple feeding, variously describing it as “soul-destroying,” “exhausting,” “anxiety-inducing,” and “relentless.” Donna sobbed when she reflected on her 4 months of triple feeding, giving the impression that it overshadowed her experience of new motherhood:

It was so hard, and I was always thinking about it, and there are other things to think about (crying, voice cracking), happier things… [Donna]

Donna also put herself under a great deal of pressure in the first few months postpartum:

I'd say I was on the border of PND, probably more likely postnatal OCD, with all the pumping and tracking and all of that. I think all of those were perfect storm territory for how much pressure I put myself under. [Donna]

Donna would have described herself as a perfectionist who believed strongly that breastfeeding was about doing the right thing and being seen to be doing the right thing. While she was not diagnosed with either postnatal depression or obsessive-compulsive disorder, the above quote gives the clear impression that she perceived that the demands of triple feeding had a detrimental effect on her mental health.

Participants also described how triple feeding caused them to feel a constant fear that they would lose their milk supply or that their baby might end up refusing to breastfeed:

I had it constantly in my head “oh your supply will drop if you don't keep getting all the milk out.” I was just so obsessive. [Amy]

I had this fear of breast aversion…at every feed…It is like a constant, a very insecure, shaky relationship with breastfeeding. [Sinead]

Some participants even suggested that triple feeding acted as a barrier to being able to enjoy and get to know their baby. Several times during her interview, Fiona referred to not being able to see her baby and not being able to able to get to know her:

I would get up in the morning and think “how many times will I have time to pump today?,”…I don't think I could ‘see’ her for a long time… [Fiona]

Most participants seemed to emerge from the all-consuming and obsessive whirl of “doing everything” at around 3 months postpartum. But they all appeared to still feel a lingering sense of sadness and loss when they spoke about triple feeding, framing it as something which had robbed them of what should have been a happier time.

Formula: giving my baby second best

None of the participants had planned to or had wanted to use infant formula, and they found having to give it to their babies upsetting. The participants' accounts revealed that infant formula evoked very negative connotations and a sense emerged that its' use was tantamount to breastfeeding failure and something to be ashamed of:

I hated the idea of supplementing, I almost feel like I was brainwashed….I got the message that formula is poison…and I was really upset about having to give it to her. [Kate]

I had taken in a lot of the messaging around formula being really bad, and felt it would be a bad thing to give my baby. I felt really guilty about that. [Megan]

Donna, like the other participants, regarded formula as “second best.” She was upset about using it and framed having to give it to her baby as being unable to give him what he needed:

…that I couldn't give him what he needed at the time, that I had to give him formula. I mean you look at him now and there are no ill effects, maybe, probably, right? But you know it's not the best, it's second best. [Donna]

Donna asserts that there have been no ill effects for her baby due to having had infant formula, but then seems unsure about this, giving the impression that there is still lingering doubt in her mind about how it might have affected her baby's health.

Caroline and Amy also provided insights into the negative emotional impact that using infant formula had on them:

Once I started the formula…I was gutted, I was really upset,… [Caroline]

…if I had to give him more formula than I had planned to, I would get really upset over it, like cry over it.… [Amy]

Fiona experienced anxiety every time she gave her baby formula, fearing that if she gave her too much, it could “ruin” their breastfeeding journey. Supplementing with formula seemed to represent an ever-present threat that had the potential to sabotage Fiona's breastfeeding relationship, and she encapsulated this tense relationship when she said

…if I decided to give her less formula or decided to give her more formula at one feed, I felt like every decision was like the decision. This was the decision that was going to ruin our whole breastfeeding journey. [Fiona]

Comments from the participants indicated that they were very attuned to the negative attitudes and remarks from other people about infant formula, particularly other breastfeeding mothers and HCPs. Sinead became deeply upset as she recalled how she perceived negative attitudes among mothers in a Facebook breastfeeding support group:

I understand the disdain for formula, I have the same…and the way that they treat formula, like it's a dirty word. It was really upsetting in my situation, I mean, I already think that, I don't need someone else to tell me [very upset, voice shakes]….. [Sinead]

Sinead's sensitivity to comments about formula by group members seems to amplify her feeling of shame about using formula and makes her feel stigmatized. Sinead was also unhappy about how formula use was addressed by the two IBCLCs she saw. Neither of them suggested that she used formula, advising her instead to give her baby expressed breast milk:

….they didn't ever say you can give formula…It was like, you can try to supplement with pumped breast milk, but I'm like “do you know how hard it is for me to pump breast milk?,” there's not going to be enough. [Sinead]

By not mentioning formula, the IBCLCs (knowingly or not) gave Sinead the message that they did not approve of it. Sinead was at this point highly sensitized to others' comments about formula, and she internalizes this message to feel shame and anger.

Several participants eventually managed to make peace with using infant formula. Kate described how joining a low milk supply support group on Facebook helped her to reframe her attitude to formula:

…and they gave like, fact-based information on formula. They were like “it's a medicine for babies whose mums can't provide all the breast milk that they need. It's not bad.” [Kate]

This supportive and accepting attitude to formula contrasts sharply with the views on formula that Sinead perceived in the Facebook group she joined. Kate went full circle in how she regarded formula, from viewing it as poison, to believing it to be a medicine that could support her breastfeeding relationship.

While some participants expressed stronger feelings about formula than others, all of them found having to give it to their babies emotionally upsetting and hard to accept and were highly sensitized to comments from others about formula. They gave the impression that negative comments about formula amplified their own self-conscious emotions about having to use it.

Dark days and dark emotions

It was a very grim period, almost kind of nightmarish…. [Orla, L246]

When talking about their experiences of breastfeeding with PLMS, a common theme among participants was the emotional turbulence of the early postpartum period. They referred to this time variously as “an emotional whirlwind,” “a grim period,” “a dark pit,” “horrendously stressful,” “traumatic,” and “an awful time.” The dominant emotions that participants described were guilt, anxiety, sadness, grief, anger, shame, fear, and vulnerability. They also talked about how exhausted they were by triple feeding, and some expressed feelings of failure.

Most participants experienced guilt in relationship to having PLMS; guilt that they could not exclusively breastfeed, that they had to use infant formula, that they were not pumping often enough, and a retrospective guilt that there may have been times when their babies were hungry or not gaining weight appropriately. Amy gives the impression of feeling that whatever she did in terms of trying to optimize breastfeeding and milk supply, it was never enough. This account is typical of the other participants:

Some days I would feel fine about it and other days I would feel this guilt that I hadn't pumped more or that I had had a nap and hadn't pumped. [Amy]

Caroline described guilt as being one of the hardest parts of the journey:

I was upset that it was harder, more exhausting than I thought it was going to be, it was draining you know, you're always pressuring yourself, lots of guilt, and that was one of the hardest parts of the journey, the guilt. [Caroline]

The guilt and the pressure were unrelenting, such that there appeared to be little room for much else in her life at that time. Caroline cried as she went on to describe ongoing retrospective guilt:

I have guilt about how hungry she was [upset, starts to cry] and I feel bad that I was pushing it, she wanted to be fed…I pushed it…[voice is breaking, crying, clearly very upset]. She must have been so hungry, how can I not feel guilty about that?…she didn't sleep for months…maybe if she had been satisfied she might have been able to sleep, I still feel guilty [crying]. [Caroline]

Even at the time of the interview when she was 11 months postpartum, Caroline's feelings were very raw, and it was clear that the guilt she was feeling was continuing to cause her emotional pain. Orla said she always felt guilty, but in contrast to Caroline, she seems to have been able to process this guilt and acknowledge that having PLMS was not her fault:

I was really, really sad….it was a feeling of inadequacy, like it is my fault. I always felt guilty, although I realize now looking back I shouldn't have felt guilty, but I did feel guilty, and it was really heart-breaking. [Orla]

Another emotion that loomed large when participants spoke about the early months postpartum was anxiety. It stemmed from triple feeding, concerns about their baby's weight gain, fear of losing their milk supply and of their baby developing an aversion to breastfeeding, and concerns about the baby's health and development. Kate spoke of a deep anxiety around whether her baby's slow weight gain would affect her development. She purchased a baby weigh scale and continued to weigh her regularly, even after she had regained her birth weight and appeared to be growing optimally:

I was so obsessed with her weight, I used to…weigh her on the kitchen scales…and I still put her on the scales at least twice a week… to make sure she is in the right percentile. [Kate]

This anxiety about her baby's weight gain seemed to cast a shadow over Kate's experience of motherhood and had an ongoing impact on her sense of confidence as a mother. Kate went on to talk about a time during the early days postpartum when she felt fearful that she would lose custody of her baby:

In the haze of postpartum emotions and hormones and everything, I was sitting on the end of the bed holding her and I was like, crying, and like…“…if I can't take care of her, they are going to take her away from me” [Kate]

This revelation captures Kate's state of mind at this time; anxious, vulnerable and fearful that her baby could be taken from her. Similarly, Megan talked about bringing her baby back into the hospital to be weighed when she was just a few days old:

It's just [crying, pauses to catch her breath], I don't know, I just found there was a lack of compassion and any kind of sensitivity to me in that situation, and the implication I got was that they were suggesting that I was neglecting my child…I felt like they were going to get social services on to me. [Megan].

This quote implies a perception that she was being blamed for her baby's poor weight gain, that she perceived a lack of support and understanding, and a genuine fear that her baby could be taken from her by social services.

In addition to feeling guilt, anxiety and fear, most of the participants described themselves as sad and vulnerable when they reflected on the early postpartum period. Ruth reflected on her early months breastfeeding with great sadness:

“I failed her, that kind of way, that she deserved the best, to get fed naturally and I suppose they are the kinds of thoughts that come into your head. Also…years ago, when there was no formula, my baby would have died. That's what I was kind of freaked out by.” [Ruth]

Ruth seems to be still grieving for what should (in her mind) have been, and saying that years ago her baby would have died suggests that she is still processing some deep lingering trauma from the early months postpartum. Caroline also seemed very sad when she spoke about breastfeeding in the first few months postpartum:

I was very sad, you know, it was more than that…I'm trying to think, you know like….I don't know how to explain it. [Caroline]

She cannot quite find the words to express what it was she experienced; she was “sad” but it was “more than that.” It is almost as if she is struggling to comprehend the enormity of what she went through and how it impacted on her.

Other emotions that participants variously talked about were grief that they were not able to breastfeed in the way that they had hoped, anger about lack of information and poor support from HCPs, and feelings of failure and shame at not being able to exclusively breastfeed. But the common denominator for all of them was the real sense of having been sucked into a whirlwind of dark and difficult emotions over which they had little control. The participants would emerge from this whirlwind, but often with lingering feelings of sadness, guilt, and loss:

I suppose I do have happy memories, but they are kind of tarnished…it's so fresh. They are tarnished with this thing, that it's gone, I didn't get to do it as much or in the way that I wanted to. [Caroline]

The frustrating search for information

All participants talked about the difficulty they had finding information about PLMS, and how frustrating it was that no one seemed to be able to tell them why they had PLMS. They reported a lack of information antenatally and postnatally, lack of knowledge and conflicting advice among HCPs, and a lack of referral pathways to skilled breastfeeding support. Apart from Caroline, none of the participants was referred to an IBCLC.

In general, participants were angry and frustrated at the lack of information and support available to them postpartum. Sinead's anger was palpable as she reflected on her search for information about PLMS:

I would always seek out loads of information and try to understand things, and the thing that got me most upset was that there was no information anywhere… [Sinead]

Participants found it hard to understand why HCPs appeared to know so little about PLMS IGT. Caroline's concerns about her milk supply the day after her baby was born were dismissed:

….they were like “it's nothing to do with the size of your breasts” and they ruled it [IGT] out straight away…if this is a real thing and I haven't got enough breast tissue I shouldn't be told “it's fine, everything is fine”… [Caroline]

The tone of this quote conveys how angry Caroline still feels that she was not listened to and there was no one who was able to provide her with information about IGT.

Amy saw an IBCLC antenatally and so knew in advance that she might have challenges with milk supply, but she still found the lack of knowledge about IGT among hospital staff frustrating:

…the midwife didn't know anything about it so I was just kind of, not alone but, I was trying to explain to her that I was going to have issues and she was “oh no you'll be fine.” [Amy]

Amy's use of the word “alone” suggests that she found the lack of knowledge and having her concerns dismissed isolating. Neither Amy's PHN nor her GP knew anything about IGT either. Instead, Amy relied on her private IBCLC for information and support.

Of all the participants, Sinead seemed to struggle most with lack of information. She saw two IBCLCs, both of whom mentioned IGT, but Sinead was unhappy with how they communicated this information:

…..she was like “I think it looks like you have IGT” and kinda just like left it at that, she said “you might be able to breastfeed, you can try to pump,” all this kind of stuff…. [Sinead's voice breaks and she starts to cry]. [Sinead]

Sinead became very upset at this recollection. It seemed to bring up a lot of emotional pain for her and provided some insight into how vulnerable Sinead was at the time. After the consultation, Sinead went online in search of further information and the upshot of this was more confusion:

I had never heard of it in my life…obviously googled ridiculously and didn't find very much…it was all very confusing. [Sinead]

Many other participants described efforts to find information about PLMS and IGT. Ruth also turned to Google after an IBCLC made a passing reference to the spacing between her breasts. She described a conversation with her PHN a few days later:

I was tearful and I said to her, “I think I might have something called breast hypoplasia, ….” She…didn't respond at all. She didn't say “I know about this” or “I haven't heard about it.” [Ruth]

Another aspect of accessing information that came up in interviews was that of receiving conflicting advice from HCPs:

… the midwives, the PHN and the doctor…they all gave me different advice, like completely different advice. Like I'd say “this person gave me that advice and you're giving me this advice, which advice should I take?” and they'd be like “oh don't listen to them, follow my advice!” [laughter]. [Orla]

Orla's laughter was tinged with anger at the absurdity of getting not just slightly different advice from HCPs, but completely different advice, and how utterly confusing this was for her. Orla also sought out support from La Leche League:

I was talking to La Leche League and the ladies were just telling me “…put him on the boob, don't worry, the milk will come in, don't give him formula” and then you have someone else telling you to give him formula, and you think “I have no idea what I am doing!” [laughter]. [Orla]

Orla's belies an anger at the ridiculous situation she found herself in whereby she was being given such contradictory advice.

Several of the participants spoke angrily about how suggestions that low milk supply is very rare or not a real phenomenon affected them:

The thing that made me feel the worst was when they would say ‘oh low supply is so rare, you definitely don't have low supply because it like only happens to one percent of women’ and I'm like grr…[angry sound]. [Kate]

I kept thinking when I was cluster feeding “everyone has enough milk so you just have to get through it” because that's what you're told, “less than five percent of people have low supply so you don't have low supply” but I actually do. And that was really harmful for me…and they keep telling you no one has it [sounds exasperated, angry]. [Sinead]

Sinead's use the word “harmful” underscores how this experience impacted her. Being told that PLMS is very rare could be interpreted as being akin gaslighting, a form of emotional abuse whereby individuals are made to question their own perception of reality. This is not to suggest that Sinead was emotionally abused, but this is how she appears to have internalized the experience.

The over-overarching impact on participants of lack of information about PLMS and conflicting information was anger, frustration, confusion, and a feeling of isolation.

Discussion

Most participants in this study articulated idealized visions of being a breastfeeding mother, while also acknowledging that they anticipated it could be challenging. This finding contrasts with findings reported previously that women expected breastfeeding to be easy.^13,28,29 The participants in the current study expressed the belief that they would have the breastfeeding journey they desired by virtue of their determination and access to appropriate supports. This unshakable belief among participants that they could breastfeed as they wanted may have been influenced by the phrase “there is almost always a breastfeeding solution to a breastfeeding problem.”³⁰ Participants often seemed to be at a loss to make sense of their longing to breastfeed, using words like “primal” and “animalistic” to describe it.

This finding builds upon what is known and adds to previous research that found breastfeeding to be a trigger of embodied emotional sensations.³¹ Infant feeding tends to be presented antenatally in binary terms and little consideration is given to the complex reasons why women might want to breastfeed.³² The finding that participants longed for an idealized vision of breastfeeding concurs with earlier evidence revealing a gap between women's expectations of breastfeeding and the reality of the challenges it can present.^28,33

Challenging emotions, such as guilt, grief, failure, and sadness, have been explored in the literature as a consequence of unmet breastfeeding expectations or breastfeeding difficulties.^{13,17,31,34–36}). These studies reveal that this is a global issue and that unmet expectations coupled with anxiety, depression, and/or negative emotional states lead to shorter breastfeeding duration and decreased exclusive breastfeeding.³⁵

The current study echoes research that finds that unmet breastfeeding expectations lead to negative and self-conscious emotions. Participants experienced the first 3 to 4 months postpartum as an emotionally turbulent whirlwind, variously describing it as “nightmarish,” “grim,” and “traumatic.” Most participants described how their obsession with triple feeding and efforts to increase their milk supply acted as a barrier to being able to enjoy their baby.

Our study also offers new insights into the emotional experiences of women with PLMS. One of these new insights, which has not been discussed in previous research, is that of retrospective guilt, a feeling of guilt that participants experienced beyond the postpartum period. Participants not only felt guilty that they gave their babies infant formula, but also felt guilty when reflecting on how their babies might have been hungry, how much they had cried, and their slow weight gain. This finding provides more insight into the long-term psychological impact on mothers of having PLMS.

Another new insight revealed was how participants experienced triple feeding. Many participants described becoming obsessed with breastfeeding and trying to increase milk supply. This specific aspect of the phenomenon of breastfeeding with PLMS strengthens the findings reported by Farah of being on a “hamster wheel,”¹³ the only previous study to have considered this phenomenon. However, our study goes further by defining the existential nature of being caught up in a regime of triple feeding. The desire to maximize milk supply and protect breastfeeding became all-consuming for participants. Triple feeding took over the participants' lives and overshadowed their first few months of motherhood.

Furthermore, some participants described how triple feeding acted as a barrier to their ability to enjoy their babies. Triple feeding is widely accepted as a standard practice in Western countries for women who have PLMS. However, guidelines on the practice rarely address appropriate timeframes for it or its' emotional impact.

New insights were shed into the nature of the anxiety experienced by women with PLMS in the early months postpartum. While previous studies have identified an association between anxiety and lactation performance,³⁷ very little has been written about how anxiety manifests in women with PLMS. Our findings revealed that participants experienced anxiety about the volume of milk they were producing, losing their milk supply, and their babies' weight gain and development. The study also indicated that participants felt anxious that they were not doing enough to increase their milk supply and how they were perceived by others. Furthermore, two participants expressed a fear that they would lose custody of their babies because of slow weight gain. This unexpected finding suggests that the degree of anxiety experienced by some mothers with PLMS may be more significant than previously thought.

Many participants conveyed that they felt very vulnerable as they tried to come to terms with having PLMS. This description is consistent with the existential lostness experienced by mothers facing breastfeeding difficulties and struggling to find their way into motherhood.¹⁷

The feelings that participants in the study expressed about infant formula echo the findings of previous research.^18,34 A further insight our study revealed was participants' perceptions of HCP communication around the use of formula. Many participants relayed instances where they felt that HCPs failed to give them sufficient information on where to buy formula, how to prepare it, and which type to use. This speaks to a need among women with PLMS for clear, nonjudgmental, evidence-based information, and support around supplementing with infant formula, as highlighted by previous research that examined parents' views and experiences of early life interventions to promote healthy growth and associated behaviors.³⁸ Understanding this need may help guide communication skills training for HCPs involved in delivering breastfeeding education and support, particularly in relationship to providing information about infant formula to mothers with PLMS.

Furthermore, it supports previous research that found that there is a need to explore the relationship between formula use during breastfeeding and maternal emotional health more closely.³⁴

The frustrating search for information about PLMS emerged as a theme for all participants. This finding is consistent with those of other studies on breastfeeding difficulties,²⁸ but goes further in its description of how participants experienced this lack of information. Participants expressed anger at the apparent lack of information about PLMS that was available to them. Some even seemed to regard it as absurd that no one could tell them why they were unable to produce enough milk. This highlights the gap in knowledge about PLMS among HCPs and volunteer supporters. Participants also expressed frustration when receiving conflicting advice from HCPs. This accords with previous studies that have explored women's experiences of postnatal breastfeeding support.^39,40

Furthermore, the participants' experiences of trying to find information about PLMS revealed a heightened sensitivity to how information about PLMS was conveyed to them. One participant even suggested that being told PLMS is “rare” was harmful to her, as it made her feel like an anomaly. This contrasts with research that normalizing breastfeeding challenges and enhances women's belief that these challenges can be overcome.⁴¹

These findings have implications for antenatal breastfeeding education, postnatal support for mothers with PLMS, and the training of HCPs on PLMS and communication skills.

Conclusion

The findings of this study confirm what previous research has revealed about women's experiences of breastfeeding difficulties and of having PLMS, that they may experience a range of emotions, such as anger, guilt, anxiety, disappointment, and sadness. However, the study adds new insights into the phenomenon of breastfeeding with PLMS: women with PLMS experience acute anxiety and the practice of triple feeding has the potential to completely dominate a mother's life in the postpartum period. Most participants described how they became “obsessed” with triple feeding. The study concluded that women with PLMS experience the first 3 to 4 months as an emotionally traumatic whirlwind and struggle to accept that they are unable to exclusively breastfeed in the way they had hoped to.

We recommend that antenatal breastfeeding classes address how PLMS may be a challenge for a small cohort of mothers and acknowledge the strong embodied desire to exclusively breastfeed that some mothers may experience. Regarding postpartum breastfeeding support, we recommend that more training for HCPs and IBCLCs around PLMS would enhance the provision of sensitive and individualized support for mothers who experience the phenomenon. Specifically, HCPs and IBCLCs should receive training on the causes and prevalence of PLMS; counseling skills to support mothers who are breastfeeding with PLMS or experiencing significant breastfeeding difficulties; and on devising care plans for mothers with PLMS that balance maximizing milk supply with the mother's emotional well-being.

Limitations

Participants were privileged in terms of ethnicity, class, and education. It is reasonable to surmise that these factors contributed to their determination to breastfeed and to having the financial means to pay privately for IBCLCs. The study does not tell us what the experiences of less-privileged women with PLMS might have been like. In future studies, women in marginalized groups and those with lower socioeconomic backgrounds could be reached through targeted recruitment by HCPs working among these groups. However, for this study, ethical approval was granted on the basis that the researcher did not directly contact potential participants.

Footnotes

Acknowledgments

The authors wish to thank the women who participated in this study.

Authors' Contributions

C.W.: conceptualization (lead); writing—original draft (lead); formal analysis (lead); methodology (lead); and investigation (lead); D.O’.B.: writing (review and editing) and supervision; A.H.: writing (review and editing) and supervision.

Further Research

The authors recommend further research to explore optimal timeframes for triple feeding.

Disclosure Statement

No competing financial interests exists.

Funding Information

No funding was received for this article.

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