A Descriptive Qualitative Study of Breastfeeding Challenges,Enablers and Confidence Among Women With Hypertensive Disorders of Pregnancy

Maternal perinatal complications

Several participants described how their hypertensive condition interfered with the initiation of breastfeeding: “Because when you have high blood pressure, you don’t feel good after the birth, so to add on the stress of not being able to feed the baby properly, I think just makes the whole situation harder” (C-13). Pain, weakness and immobility associated with Cesarean birth further challenged early breastfeeding experiences. Some participants described how side effects of medications used to treat their high blood pressure or pre-eclampsia (e.g., dizziness, peripheral neuropathy) made breastfeeding more difficult: “I also had some neurological issues. . . . I had my left hand frozen, so that would be a side effect of labetalol” (C-10). One participant weaned at 7 months following treatment for deep vein thrombosis, a longer-term risk of HDP: “I stopped [breastfeeding] right away when I started taking heparin, but that was a misconception of mine.” (I-03). Five (28%) participants also identified mental health issues including anxiety or postpartum depression as significant challenges to breastfeeding: “I had a depression, so everything connected together, it was like impossible for me” (C-09).

Infant health issues

Infant-related breastfeeding challenges reported by participants included increased risk for hypoglycemia and poor weight gain. For example, as several factors associated with HDP (e.g., prenatal use of beta-blockers, maternal diabetes, preterm birth) enhance the risk for newborn hypoglycemia, many of the participants’ infants were placed on the hospital’s newborn hypoglycemia prevention protocol at birth. This often led to early formula supplementation that undermined breastfeeding plans, as reported by one participant:

For women with high blood pressure who, for example, have received treatment right from the start, the baby remains under surveillance. . . . So, I think that’s the challenge, right at the beginning . . . because she’s going to be forced to give the formula to her baby, even if there’s no drop in glucose. (I-05)

Several participants also described how poor infant weight gain resulted in the need for formula supplementation, contributing to early weaning in some cases: “She basically wasn’t gaining any weight, like I had to give her formula anyways, so I just kept with that one” (C-18). Infant admission to the neonatal Intensive Care Unit (NICU) at birth also disrupted the initiation of breastfeeding, as reported by one participant whose infant required monitoring due to maternal prenatal hypercalcemia (a risk factor for preeclampsia): “My baby was in intensive care for the first 2 days, and within 2 hours of being born, he was fed formula” (C-11).

Breastfeeding difficulties

Only a few participants reported experiencing major problems with common breastfeeding issues, including sore nipples, engorgement, or difficulties with latch-on (related to flat nipples, or tongue-tie). However, more than half the participants (61%) identified insufficient milk supply as an issue, with several describing experiences with low milk production despite concerted attempts to enhance milk production: “So even though I took medication, domperidone, fenugreek and all that, my milk supply was still low” (C-18). Descriptions of poor supply included indicators such as excessive infant crying, low milk volumes when pumping, and infant weight loss: “Our doctor told us also for her 4 months appointment, and she was lighter than I thought. . . . She was in the 40th percentile. . . . I am worried now that I won’t be able to meet her demands” (I-04). Participants further described how worries about milk supply added stress to their postpartum experience: “The C-section [Cesarean section] was difficult for the first few days and then it was good, but this issue [insufficient milk] is like something permanent . . . a challenge that is always with you. This is the most difficult part for me” (C-15).

Insufficient breastfeeding support

Insufficient or contradictory information from healthcare professionals (HCP) about breastfeeding was a commonly reported challenge: “Due to HDP complications] I stayed a little longer in the hospital but the nurses told you different things, the pediatrician, luckily it wasn’t my first [breastfeeding experience] so I knew a little more, and I was more confident” (I-01). Several participants described feeling unprepared for the potential challenges of breastfeeding post-HDP: “I also was hospitalized on and off for a lot of my pregnancy . . . no one had mentioned to me that because I have preeclampsia and because I’m having a C-section that it will be harder to breastfeed” (C-18).

Several participants discussed how breastfeeding support was not readily available during the postpartum hospital stay: “At the hospital, the nurses came to see me for a maximum of 5 minutes and would then leave. . . . I would have liked someone to stay with me just for breastfeeding, until the end to show me the signs” (C-09). One intervention group participant with flat nipples noted a lack of skilled support “until I met [the study’s IBCLC] who came to see me at the hospital, she was the one who encouraged me . . . but the hospital nurse, the delivery room nurse, and the [hospital’s] lactation consultant didn’t help me too much” (I-05). A third of the participants further reported feeling pressured by HCPs to supplement with formula, for example when staff lacked skills to address their feeding issues: “and then every feeding, they were just telling me, ‘well if she’s not latching, just give her the bottle” (C-18). For some, pressures to supplement in the face of feeding struggles continued post-discharge from family members: “My mother-in-law, it’s like ‘You could give her bottles. . . . You look tired, you should stop breastfeeding’” (I-01).

HCP interventions

Almost all the participants described the critical importance of receiving hands-on breastfeeding help and reassurance from HCPs including hospital and/or community nurses, a lactation support specialist, or (in one case) their pediatrician. Technical interventions that were judged to be helpful included physical help with positioning and observational assessment of infant latch and suckling: “She [hospital’s IBCLC] showed us how to check to make sure the baby was swallowing, and different positions to hold the baby that would encourage her to eat more comfortably” (C-13), as well as assisting with milk expression:

[The study IBCLC] was able to show me how to hand express. . . . It was useful to have somebody show me that technique and just give me the reassurance that I did have plenty of colostrum and things at that stage were looking like the way they should. (I-07)

Practical support from HCPs also included procuring and demonstrating breastfeeding aids including nipple creams, breast pumps or supplemental nursing systems; and monitoring the infant’s weight gain: “The [community] nurse gave me the supplemental system, the syringe, and everything” (C-15).

Most participants acknowledged the importance of accessible and pro-active breastfeeding support from HCPs, as noted by an intervention group participant: “She [study IBCLC] called every week to see how it was going, answered any of my questions, just having access to her was reassuring” (I-04). Participants cited multiple ways in which HCPs were (or could be) consistently available, including regular “check-in” rounds by postpartum hospital nurses; follow-up home visits by community nurses; or having email, phone or virtual access to lactation specialists. As one participant who had an emergency c-section for preeclampsia described:

[Hospital support] was crucial, because I was exhausted, I was stressed, and in pain, and so having nurses around us even in the night helping me when the baby was crying to show us, to watch how I was feeding and correct it, was immensely helpful. And when we came back home, we had the [community] nurse coming to see us and my milk had come already and it was very reassuring to hear from her that everything was okay, that the baby is feeding well, that the latch is proper. (C-17)

Several participants described how caring attitudes and emotional support provided by HCPs helped them overcome their breastfeeding struggles: “I kind of flipped out at one point, and then I talked to [a lactation] consultant about it and she had some reassuring words, so that kind of gave me hope again” (C-11).

Breastfeeding information

Many participants discussed the importance of receiving breastfeeding information, especially on how to enhance milk supply. Helpful information included pumping and storage of human milk; expectations for milk volumes; and strategies to increase supply, for example infant re-positioning, food and herbal supplements, feeding frequencies, breast massage and co-sleeping with baby. Other useful information included tips for managing blocked ducts, engorgement, and sore nipples: “The majority of my friends don’t breastfeed, they gave up. They didn’t have the same kind of knowledge that I did, like [the study IBCLC] gave me. So, it really helped encourage me to persevere through it [sore nipples]” (I-02).

Participants reported sourcing breastfeeding information from a wide variety of resources including hospital and community-based HCPs, written materials (e.g., pamphlets, government-issued booklets), videos, and online websites or breastfeeding groups. A few participants also raised the importance of receiving accurate information prenatally to prepare for potential breastfeeding challenges: “Something reliable that has the same basic information to read before they [women with HDP] give birth, because it definitely helped me having read some of the things before” (I-06).

Having personal motivation or determination

Many participants discussed how important it was to remain committed and persistent with breastfeeding to help endure challenges: “I really wanted to breastfeed. I mean like formula was the last resort. To get my milk supply, I pumped, and I pumped. . . . I think that also makes a difference, right?” (I-02). Helpful personal strategies for persisting with breastfeeding included setting longer-term goals, being patient while “getting the hang of it” and keeping volumes of supplemental feeds to a minimum. Several participants discussed how knowing the benefits of breastfeeding helped them maintain their determination to continue, including the maternal cardiovascular benefits: “One thing that I would have never known was the benefit regarding your blood pressure, if it wasn’t for the fact that I was in the study. . . . We always talk about the benefits to the baby” (I-08). Other rewards of breastfeeding reported by participants included enjoying the close contact with their infant, the convenience and being able to use breastfeeding to “take a break.”

Social support

Several participants described how family members or friends provided emotional and/or practical support that enabled them to manage their breastfeeding challenges. Family members were supportive by helping the participants to “calm down,” helping latch the infant, reinforcing teachings given by HCPs, or freeing the participant to breastfeed by doing tasks around the house: “I have my mom here and I think she is my number one support. . . . Having somebody physically here helping me and also getting resources, like reading material, to know how to feed and to increase the milk flow” (C-12). Friends who were also breastfeeding provided advice, resources—including websites for information and support—and helpful products including nipple creams or galactagogue teas. Some participants noted the importance of sharing stories with other new parents in breastfeeding peer support groups, with one suggesting an online group for those with HPD: “A Facebook group or something like that where all of us who have the same condition, the high blood pressure, preeclampsia and breastfeeding could join together” (I-04).

Factors that increased confidence

Participants most commonly identified seeking breastfeeding information from various sources or learning from family or friends (who had positive breastfeeding experiences) as factors that boosted their breastfeeding confidence:

I think friends’ advice who also had babies were helpful and made me feel more confident, like what to ask for. . .just having people share their best tips that worked for them gave me confidence that I could do it. (C-13)

Several participants reported that receiving hands-on breastfeeding support increased their breastfeeding confidence, as described by one participant: “At the hospital, when [the study IBCLC] came, she completely boosted my confidence when she helped me. . . . After that, I was struggling when I got home and the nurse from the CLSC [the community clinic] came and she boosted my confidence again” (I-04). Participants also described how their confidence levels increased when they received positive reinforcement that feedings were going well (e.g., validation that their infant was latched well or was gaining weight) and encouragement for their efforts from HCPs or others: “It was my friend . . . and my husband. They tried to keep my morale up, even when I was tired, and encouraged me not to give up. They would say ‘Oh, you made 60 ml today, bravo!’” (C-14). A few participants also noted personal factors that contributed to their confidence, for example, previous experience with breastfeeding or having strong beliefs in the importance of breastfeeding: “I got this very strong conviction from the nurses that really helps me now to resist this pressure of ‘Oh, you should try giving some formula or just switch to formula all together, it is so much easier.’” (C-17).

Factors that decreased confidence

The most commonly-reported factor undermining breastfeeding confidence was being actively discouraged by others to breastfeed, especially in response to challenges with milk supply: “My partner was too impatient when he heard the baby cry, saying ‘Come on, let’s give him the bottle, it’s not working’ and my mother was the same, ‘Give him the bottle, you don’t have enough milk’” (C-11). Some participants felt indirect discouragement from HCPs who did not actively promote breast- over bottle-feeding: “She (MD) was like telling me ‘You’re doing the best you can, it doesn’t matter if you bottle-feed or not’” (C-18), or from others who were uncomfortable with public breastfeeding: “Having people look at me like, ‘oh, shouldn’t you cover yourself up a bit more?’” (I-08). Finally, a few participants noted that their confidence decreased when they experienced breastfeeding difficulties or knew others who had encountered breastfeeding problems: “I think knowing a handful of people that had trouble breastfeeding made it a bit more stressful” (I-06).