Human Milk Provision Experiences, Goals, and Outcomes for Teen Mothers with Low-Birth-Weight Infants in the Neonatal Intensive Care Unit

What supports mothers of very preterm babies to start and continue breast milk feeding neonatal units? A qualitative COM-B analysis of mothers' experiences

BACKGROUND

It is challenging for mothers who give birth very preterm to produce sufficient breast milk by expressing for weeks before their baby is able to feed from the breast, and then to transition from tube feeding to breastfeeding. Lactation is most successful when stimulated shortly after birth, established within 72 h, and maintained by expressing 6-8 times a day. This study explored mothers' experiences of how breast milk feeding and breastfeeding for very preterm babies can be supported by staff and the facilities of a neonatal unit.

METHODS

Twenty-three mothers of very preterm babies were interviewed, from four neonatal units in England with high or low rates of breast milk feeding at discharge. Interviews were analysed using the COM-B framework to consider how mothers' behaviour (breast milk feeding and breastfeeding) is affected by capability, opportunity and motivation.

RESULTS

Mothers' motivation in the traumatic situation of very preterm birth was strongly affected by information from staff about the benefits of breast milk for their baby, the importance of early and frequent expressing, and how to assess the effectiveness of direct breastfeeding. It was maintained through positive feedback about their efforts which built their confidence, and reassurance about what is 'normal' growth when a baby begins direct breastfeeding. Motivation needed to be supported by opportunity, including access to equipment for expressing and facilities to stay near the neonatal unit, and also by capability, which required proactive and skilled information and support from staff. Specialist support and facilities varied between units, and some mothers were not given necessary information or had their motivation undermined by staff comments.

CONCLUSIONS

Interventions to increase breast milk feeding and breastfeeding for very preterm babies should address mothers' motivation, capability and opportunity, aiming for systematic elimination of obstacles. Mothers value personalised and skilled specialist support, but also need other staff to be able to give consistent information and affirmation focused on their efforts rather than their success, with a trauma-informed approach. Investing in rooming-in facilities that minimise the separation of mothers and babies is likely to overcome a key obstacle.

Barriers and Facilitators in Lactation Support for the Preterm Mother-Infant Dyad: An Integrated Approach

Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

Breastfeeding Needs in Adolescent Mothers: A systematic review

Adolescent mothers face numerous challenges while breastfeeding. This study aimed to assess the breastfeeding needs of adolescent mothers. For this systematic review, Web of Science, PubMed, Scopus, Cochrane Library, SID and Magiran databases were searched. The initial search yielded 2,290 studies, of which 41 were included in this review. Adolescent mothers' breastfeeding requirements were grouped into 8 categories: (1) social support from healthcare providers, partners and families; (2) school support for breastfeeding mothers; (3) breastfeeding counselling based on cultural sensitivities; (4) educational assistance from health providers for adolescent mothers' families; (5) changing harmful cultural values and judgments about adolescent mothers' breastfeeding; (6) additional home or outpatient visits in the days following hospital discharge; (7) peer support and counselling; and (8) economic needs. To promote breastfeeding, policymakers and healthcare providers should devise specifically tailored programmes and interventions to cater to the specific requirements of adolescent mothers.

Mothers' experiences of breast milk expression during separation from their hospitalized infants: a systematic review of qualitative evidence

BACKGROUND

Mother-infant separation, which is occurring with an increasing incidence, is a barrier to direct breastfeeding. Owing to the importance of breast milk to hospitalized infants, mothers are actively encouraged to express milk during their infants' neonatal intensive care unit (NICU) stay. However, mothers are often faced with a number of challenges in this process. There is a need to understand such mothers' real-life experiences of breast milk expression to develop supportive strategies to reduce the burden on mothers and increase breastfeeding rates.

METHODS

A comprehensive search of 12 databases was conducted for relevant studies published from database construction to December 2022. All qualitative and mixed-method studies published in English and Chinese that reported on mothers' experiences of human milk expression during separation from their hospitalized infants were included. Two reviewers independently conducted screening, data extraction, and quality appraisal, with disagreements resolved by a third reviewer. The process of searching followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The JBI Qualitative Assessment and Review Instrument was used to assess study quality and the credibility of study findings. Meta-aggregation was performed to integrate the results.

RESULTS

This systematic review aggregated mothers' experiences of milk expression during separation from their hospitalized infants. Database search yielded 600 records, of which 19 full-text documents were screened. Finally, 13 studies of good quality were included with data from 332 mothers across seven countries. A total of 61 primary findings with illustrations were extracted from the 13 eligible studies, the findings were generalized into 16 categories, and further were concluded as four synthesized findings: purpose and motivation, physical and emotional experiences, barrier factors, and coping styles.

CONCLUSION

Mothers were driven by extrinsic motivation in their decision to express breast milk. They experienced physical exhaustion and many negative emotional feelings while expressing. This process was affected by numerous barriers. Social support was essential to the initiation and maintenance of milk expression. Medical staff and families should pay more attention to the mental health of mothers with infants in the NICU. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing milk expression.

SYSTEMATIC REVIEW REGISTRATION

[ www.crd.york.ac.uk ], identifier [PROSPERO 2022 CRD42022383080].

Breast milk expression as a challenge for mothers of premature infants

The aim of this study was to examine the psychometric properties of the 11-item Breast Milk Expression Experience Scale and determine the level of breast milk expression experience of mothers after preterm delivery in Turkey. 165 mothers who agreed to participate between February 2019 and March 2020 used the Breast Milk Expression Experience Scale (BMEE-S). The general Cronbach alpha coefficient was 0.82 for the BMEE-S. The fit indices calculated by confirmatory factor analysis were χ² (41) = 87.95, p = .00003, χ^2/sd = 2.15, GFI = 0.91, NNFI = 0.93, CFI = 0.95, RMSEA = 0.08 and SRMR = 0.078. The BMEE-S three-factor structure was verified by the confirmatory factor analysis. The BMEE-S was a valid and reliable instrument for mothers of preterm infants. Multiparity and high-risk pregnancy history negatively affected the milk expression experience, whereas spousal support positively affected it.Impact statementWhat is already known on this subject? The risk of infectious diseases, obesity, diabetes, and impaired intellectual development increases in children who do not breast milk (Verduci et al. 2014). International breastfeeding guidelines recommend supporting all mothers to start breastfeeding within one hour of birth, and counselling mothers who are separated from their babies about expressing milk.What the results of this study add? The breast milk expression experience scale is a valid and reliable tool for women who give preterm birth and express milk. The experience of expressing breast milk can affect the amount of milk that passes from mother to baby. Multiparity and high risk pregnancy history of mothers negatively affects the milk expression experience while husband support positively affects the milk expression experience.What the implications are of these findings for clinical practice and/or further research? Our study provides a quantitative examination of the experiences of mothers who are separated from their babies. The BMEE-S should be adapted to different cultures and the experiences of mothers in this process should be determined.

Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

Navigating a Minefield: Meta-Synthesis of Teen Mothers' Breastfeeding Experience

Teen mothers have lower rates of breastfeeding duration and exclusivity than older mothers. A growing body of qualitative research on teen mothers' experience helps to explain these disparities. Following a systematic search to identify relevant research, we synthesized the findings from 22 primary studies to conclude that teen mothers navigate a minefield that undermines their intention to breastfeed and their breastfeeding confidence and skill. This metaphorical minefield reflects competing norms for infant feeding and good mothering, as evident in mixed support from teens' social networks; fragmented and stigmatizing healthcare; and spaces that are inhospitable to teen mothers and breastfeeding mothers in general.In recognition of this minefield, we urge clinicians to: respect teen mothers' infant feeding decisions; develop collaborative relationships based on the principles of patient-centered and strength-based care; challenge stigmatizing healthcare practices; welcome teen mothers and their significant others to clinical settings; and press health systems to fully implement probreastfeeding policies. We also recommend further study to extend our knowledge about teen mothers' breastfeeding experiences.

Mediators of racial and ethnic disparity in mother's own milk feeding in very low birth weight infants

BACKGROUND

Despite high initiation rates for mother's own milk (MOM) provision, MOM feeding at discharge from the neonatal intensive care unit (NICU) drops precipitously and reveals a racial/ethnic disparity. This study sought to identify factors that (1) predict MOM feeding at NICU discharge, and (2) mediate racial/ethnic disparity in MOM feeding at discharge.

METHODS

Secondary analysis of prospective cohort study of 415 mothers and their very low birth weight infants. Variables were grouped into five categories (demographics, neighborhood structural, social, maternal health, and MOM pumping). Significant predictors from each category were entered into a multivariable logistic regression model.

RESULTS

Although 97.6% of infants received MOM feedings, black infants were significantly less likely to receive MOM feeding at discharge. Positive predictors were daily pumping frequency, reaching pumped MOM volume ≥500 mL/day by 14 days, and maternal age. Negative predictors were low socioeconomic status (SES) and perceived breastfeeding support from the infant's maternal grandmother. Low SES, maternal age, and daily pumping frequency mediated the racial/ethnic differences.

CONCLUSIONS

Multiple potentially modifiable factors predict MOM feeding at NICU discharge. Importantly, low SES, pumping frequency, and maternal age were identified as the mediators of racial and ethnic disparity. Strategies to mitigate the effects of modifiable factors should be developed and evaluated in future research.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Expressing Human Milk in the NICU: Coping Mechanisms and Challenges Shape the Complex Experience of Closeness and Separation

BACKGROUND

Human milk has multiple benefits for human health; however, rates of infants receiving human milk at discharge in Canadian neonatal intensive care units (NICUs) are far below recommendations of the Baby Friendly Hospital Initiative supported by the Canadian Pediatric Association. Mothers of infants requiring NICU care usually need to express their milk, especially mothers of premature infants, since for some time their infant is unable to feed directly at the breast. Expressing human milk for an extended period can be challenging for mothers.

PURPOSE

To document maternal experiences expressing human milk for their infant in the NICU as a closeness or separation experience, and to discover what factors gave rise to these perceptions.

METHODS

In this descriptive qualitative cross-sectional study, 15 mothers whose infants were hospitalized in a level III NICU and who were expressing human milk audio recorded their thoughts and feelings with a smartphone application for 48 hours while they were expressing milk. A thematic content analysis was used to analyze data.

FINDINGS

Expressing human milk for their hospitalized infant was a difficult experience for all mothers, and most described both closeness and separation feelings while expressing milk. Their feelings fluctuated depending on their coping mechanisms, perceived challenges, as well as their location and environment. Mothers were all pursuing their goal of continued milk expression with various levels of motivation.

IMPLICATIONS FOR PRACTICE

NICUs should adopt a family-centered approach to care whereby mothers' care needs related to milk expression are addressed. Nurses can ask open-ended questions to explore how mothers are coping, and they can assist mothers to find effective coping strategies to minimize the challenges related to milk expression to promote mother-infant closeness.

IMPLICATIONS FOR RESEARCH

The impact of environment and location on mothers with hospitalized infants should be explored, as unit designs could be altered to foster closeness.