"I Had One Job and That Was To Make Milk"

Achieving sufficient milk supply supports mothers to cope with premature birth

AIM

To explore whether and how expressing breast milk is perceived as helpful in coping with negative emotions due to premature birth by mothers of very low birth weight (VLBW) infants.

METHODS

Qualitative interviews and a retrospective cross-sectional questionnaire with mothers of VLBW infants were conducted and analysed using an exploratory sequential mixed-method design. Hypotheses were built using qualitative content analysis and quantitatively tested using multivariate regression analysis.

RESULTS

Interviews with 12 mothers and questionnaires of 518 mothers were analysed. Coping with prematurity by expressing milk was seen as a way to maintain the caregiving role for the mothers, where three relevant factors arouse: making up for what happened, providing the best for their infant and fear of low milk supply. Quantitative analysis showed that mothers with a high milk supply (Coef. = 1.1, p < 0.000) and more feelings of guilt due to premature birth (Coef. = -0.1; p = 0.015) perceived expressing breast milk significantly more as a resource for coping.

CONCLUSION

This study adds knowledge on how expressing breast milk for their VLBW infant may support mothers in coping with premature birth, by revealing the association with milk supply and feelings of guilt due to premature birth.

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].

Breastfeeding sick children in hospital: Exploring the experiences of mothers in UK paediatric wards

There is a paucity of literature exploring the challenges of breastfeeding sick children in hospital. Previous research has focused on single conditions and hospitals which limits understanding of the challenges in this population. Although evidence suggests that current lactation training in paediatrics is often inadequate, it is unclear where the specific training gaps are. This qualitative interview study of UK mothers aimed to explore the challenges of breastfeeding sick infants and children on a paediatric ward or paediatric intensive care unit. From 504 eligible respondents, a sample of 30 mothers of children aged 2-36 months with various conditions and demographic backgrounds was purposively chosen, and a reflexive thematic analysis undertaken. The study identified previously unreported impacts such as complex fluid needs, iatrogenic withdrawal, neurological irritability and changes to breastfeeding behaviour. Mothers described breastfeeding as emotionally and immunologically meaningful. There were many complex psychological challenges such as guilt, disempowerment, and trauma. Wider struggles such as staff resistance to bedsharing, inaccurate breastfeeding information, lack of food and inadequate breast pump provision made breastfeeding more challenging. There are numerous challenges related to breastfeeding and responsively parenting sick children in paediatrics, and these also impacted maternal mental health. Staff skill and knowledge gaps were widespread, and the clinical environment was not always conducive to supporting breastfeeding. This study highlights strengths in clinical care and provides insight into what measures are perceived as supportive by mothers. It also highlights areas for improvement, which may inform more nuanced paediatric breastfeeding standards and training.

Breastfeeding a Premature Baby During the Covid-19 Pandemic in Perinatology: An Exploration of Mothers' Experiences

This study was conducted to explore the meaning of mothers' experiences of breastfeeding premature babies while being treated in the perinatology room during the COVID-19 pandemic. A descriptive phenomenological design was used in this study to describe the meaning of mothers' experiences. In-depth interviews were conducted with 11 mothers. The analysis of transcribed data resulted in three themes: (1) The pandemic has made it difficult for me to meet my baby, (2) Breastfeeding is not easy, and (3) I am a breast milk pumper. The breastfeeding experience of having a premature baby and being cared for by perinatology during a pandemic is full of challenges and limited support. The results of this study suggest that a review of the current regulations be carried out, and the staff be given continuing lactation education to strengthen breastfeeding support to mothers with premature babies.

Emotional journey of Asian mothers of premature infants who received pasteurised donor human milk: a qualitative study

OBJECTIVE

To explore the effect of donor human milk usage on the emotional experience of mothers with premature infants in a multiracial Asian population.

DESIGN

A qualitative descriptive study. Semistructured individual interviews were audio-recorded, transcribed and analysed using Braun and Clarke's process of thematic analysis.

SETTING AND PATIENTS

Seventeen mothers whose premature infants received donor human milk in a level III neonatal intensive care unit.

MAIN OUTCOME MEASURES

Perceptions of mothers whose premature infants received donor human milk.

RESULTS

Mothers described their experience as a journey of acceptance with three sequential themes. 'Resistance to receiving somebody else's milk' was a process of overcoming initial hesitation and concerns. 'Recognising maternal limitations and baby's needs' depicted the mothers' struggles in reconciling their infant's milk demand and their low milk supply. 'Embracing benefits of donor human milk and acceptance with gratitude' illustrated the mothers' joy and gratitude to milk donors as they embraced benefits of donor human milk usage. Although participants had agreed to use of donor human milk after counselling, many still struggled with negative emotions of anxiety and guilt. Mothers of Muslim faith had additional concerns about milk kinship and religious permissibility of donor human milk.

CONCLUSION

Mothers undergo a spectrum of complex emotions from initial hesitation to acceptance with gratitude, when their premature infants receive donor human milk. Some continue to struggle with negative emotions and require more support. By recognising their emotional responses, healthcare providers can support mothers in their breastfeeding journey with targeted counselling.

A report on parent involvement in planning a randomised controlled trial in neonatology and lactation – insights for current and future research

Background

Patient and Public Involvement (PPI) is a rich and valuable part of the process of planning, designing, carrying out and disseminating research. It is important to communicate PPI findings in detail so that the contributions of those involved are fully utilised and disseminated. The extended and iterative PPI process used within a neonatal randomised controlled trial related to the expression of breastmilk after very preterm birth is reported here.

Methods

Seven iterative stages of PPI were used. Stage 1 was informal PPI using historical interaction with parents and publicly available resources. Stage 2 was an online questionnaire open to parents of premature babies and advertised via a charity collaborator. Stage 3 was partnership with a charity collaborator. Stage 4 was a set of online panels focusing on study design and documents. Stage 5 was an interactive exercise to modify the trial intervention. Stage 6 is the presence of PPI contributors on the trial steering committee. Stage 7 is a dissemination panel. At each stage attention was paid to the diversity of participants involved, with strategies to increase the involvement of parents from under-reached groups.

Results

Six hundred and seventy-five participants responded at Stage 2, six parents were involved at Stage 4 and 12 parents at Stage 5. PPI contributed to the choice of study question, outcomes and produced a set of questions for future research. PPI impacted on the study design, with specific emphasis on reducing participant distress related to lactation, and reducing the burden of being involved in research at a time of significant stress.

Conclusions

PPI had a far-reaching influence on this neonatal randomised controlled trial during the planning and design phase, which reinforces the importance of PPI at the earliest stages of the research cycle. The online questionnaire format elicited an unexpectedly deep and broad pool of transferable insights, which will have an impact on future research focus and design in the area of lactation and prematurity. Approaches to increasing PPI involvement from under-reached populations are important and can be successful despite resource constraints.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00509-1.

Exclusive breastmilk pumping: A concept analysis

AIM

To analyze and examine the concept of exclusive breast pumping (EP).

BACKGROUND

Breastmilk is the ideal nutrition for infants, yet when breastfeeding is unsuccessful, parents resort to informal breastmilk sharing, artificial formula feeding, or EP. A growing proportion of families exclusively pump yet they often receive guidance from social media rather than healthcare providers because healthcare providers are uninformed about this feeding method.

DATA SOURCE

Cumulative Index of Nursing and Allied Health Literature, PubMed, and Google Scholar databases were searched using the following keywords: human milk express*, breast express*, breast milk express, breastmilk express*, exclusive pump, exclusive breast pumping, and exclusive expression.

REVIEW METHODS

Concept analysis design using Walker and Avant's method.

RESULTS

Three defining attributes of (1) absence of direct breastfeeding, (2) breastmilk expression, (3) and an enduring infant feeding pattern of feeding expressed breastmilk only via a bottle were identified. All three attributes are required to confirm the presence of the concept of exclusive pumping. Definitions, antecedents, consequences, and empirical referents are described. Model and contrary cases are discussed.

CONCLUSION

This exclusive pumping concept analysis allows for consistency in terminology in practice and research. EP is a feeding method which can increase the proportion of infants who are fed breastmilk and may reduce the risks that arise from artificial formula feeding.

Comparing the effect of a lactation-specific relaxation and visualisation intervention versus standard care on lactation and mental health outcomes in mothers of very premature infants (the EXPRESS trial): study protocol for a multi-centre, unmasked, randomised, parallel-group trial

Background

Premature birth is the leading cause of neonatal death and can cause major morbidity. Maximising the amount of maternal breastmilk given to very premature infants is important to improve outcomes, but this can be challenging for parents. Parents of infants receiving neonatal care also have high rates of anxiety and distress. There is growing evidence for the impact of maternal relaxation interventions on lactation, as well as mental health. The trial will assess whether a brief self-directed relaxation and visualisation intervention, recommended for use several times a day during expression of milk, improves lactation and mental health outcomes for mothers of very premature infants.

Methods

Multi-centre, randomised, controlled, unmasked, parallel-group trial with planned 132 participants who have experienced premature birth between 23 weeks and 31 weeks and 6 days of gestation and plan to express milk for at least 14 days. The primary outcome is the highest 24-h expressed milk yield recorded on any of day 4, day 14 or day 21 after birth. Secondary outcomes include exclusive breastmilk feeding at 36 weeks post-menstrual age and at 4 months after the estimated date of delivery, Spielberger State Trait Anxiety Index at day 21 and Post-traumatic stress Check List (for DSM 5) at day 21.

Discussion

Breastmilk feeding for premature infants is an important research priority, but there are few randomised controlled trials assessing interventions to help parents reach lactation goals in this challenging context. This trial will assess whether a no cost, easily scalable relaxation tool has a role in this setting. Given the lack of harm and potential for immediate dissemination, even a small benefit could have an important global impact.

Trial registration

ISRCTN16356650. Date assigned: 19/04/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06570-9.

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.

Expectations and Experiences of Spanish Primiparous Women Who Decide to Breastfeed Their Infants and Strategies for Change in 2020—A Qualitative Study

To describe the experiences and expectations of Spanish women regarding breastfeeding and the support they receive from healthcare professionals, family, and friends during the breastfeeding journey, A qualitative study using an empirical-phenomenological approach was conducted. Primiparous women that had already given birth were interviewed using a purposive and snowball sampling. In-depth interviews were conducted between 1 January and 30 April 2020. The interviews were transcribed verbatim and analysed using Haase’s adaptation of Colaizzi’s phenomenological method. We recruited 14 women who had recently become mothers. Three major themes describing experiences of infant feeding by maternal lactation were identified—institutional influences, establishing breastfeeding, and cessation of breastfeeding—as well as the following 10 categories: hospital routines, lactation concerns (amount and infant nutrition), antenatal breastfeeding decision, embarrassment to breastfeed, and normalisation of breastfeeding. Prior education and support were identified as key elements in possible breastfeeding support strategies.

Advice from Canadian Mothers Who Express Human Milk: An Interpretive Description Qualitative Study

OBJECTIVES

Human milk expression has become an increasingly common means for providing milk to an infant, with women expressing to address breastfeeding problems or to allow for flexible feeding options. This study explored the experiences and recommendations of mothers who expressed human milk, with this paper reporting on the advice mothers would offer to other mothers to address common challenges.

METHODS

Interpretive description was used in this qualitative project. Using purposive sampling, mothers of infants aged 0-24 months who expressed human milk were recruited to participate from two health regions in western Canada. Individual, audio-taped interviews were completed with 35 women. NVIVO™ software was used for data analysis.

RESULTS

Mothers reported the desire to offer experiential advice to other mothers navigating milk expression and encouraged other mothers to seek guidance from health care professionals such as lactation consultants, peer support online, and from family and friends. Experiential knowledge shared included: (a) product recommendations, (b) expression tips, (c) support for workplace expression, (d) encouragement to seek help, and (e) moral support.

CONCLUSIONS

Healthcare professionals should include evidence-based expression information as part of routine lactation support, while recognizing the importance of mother-to-mother knowledge transfer and emotional support. Services that assist mothers to determine and access pumps appropriate to their unique breastfeeding needs and goals should be offered, and the opportunity for peer support through creation of, or referral to, appropriate in-person or online support groups should be made available.

Tube Feeding Practices and Transition to Breastfeeding Experiences of Mothers of Preterm Infants at a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa

To receive human milk, most preterm infants initially receive the mothers’ expressed milk through a nasogastric tube. However, breast milk feeding the preterm infant and making the transition to direct breast-feeding come with significant challenges. The study explored and described the experiences of mothers of preterm infants regarding initiation and expressing breast milk, tube feeding practices, and transition to breastfeeding during the infants’ stay in a kangaroo care unit (KMC) of an academic hospital in South Africa. Using a qualitative design, focus group interviews were conducted with 38 mothers of preterm infants after discharge from the neonatal intensive care unit (NICU). We analyzed transcripts following the 5 steps for qualitative thematic data analysis. Tube feeding and breastfeeding preterm infants was challenging and exhausting for the mothers. Many described their experiences of initiating expression and sustaining milk supply as negative. They had constant concerns about their ability to produce adequate milk volumes to feed their infants. They had immense dislike of expressing, which they described as physically exhausting, stressful, and painful. Those who had initiated breastfeeding were highly motivated to breastfeed their preterm infants. They described breastfeeding as a positive bonding experience that they derived pleasure from. The mothers’ dislike of expressing was overshadowed by their emotional obligation toward their preterm infants. Although the KMC unit promotes breastfeeding, mothers encountered problems and struggled to initiate expression and sustain milk production. Mothers of extreme and very preterm infants need support to continue with milk expression during the long NICU and KMC stay.

The Critical Window of Opportunity: Lactation Initiation Following Cesarean Birth

Introduction: Cesarean birth is reported to be risk factor for the delayed onset of maternal lactation. The purpose of this study was to describe the timing of lactation initiation, subsequent feeding/milk expression patterns, and daily milk volumes among women who had a cesarean birth of an infant with a known congenital anomaly during the 3-day postpartum hospital stay. Materials and Methods: Retrospective descriptive cohort study. The electronic medical records of dyads, between 2014 and 2017 at the study setting, were abstracted for demographic and clinical data. Milk expression and milk volume data were abstracted from maternal lactation logs. Data were analyzed using descriptive statistics. Results: Among the cohort (n = 468 dyads), the mean time from infant delivery by cesarean to lactation initiation was 257.5 minutes. The cohort was divided into three groups by the timing of lactation initiation: EARLY (≤60 minutes; n = 112), MID (>60 minutes to ≤360 minutes; n = 309), and LATE (>360 minutes; n = 47). Statistically significant differences are seen between groups for the daily means: number of feeds/pumps and maternal milk volumes (irrespective of the presence of lactation risk factors). Discussion: This is the first study to explore the relationship of lactation initiation among women postcesarean birth whose infants have a known congenital anomaly. The time between the infant's birth and the first feed/milk expression, and the patterns of feeding/milk expression during the postpartum hospital stay, are key drivers for maternal milk supply.

Use of the Theory of Planned Behavior Framework to Understand Breastfeeding Decision-Making Among Mothers of Preterm Infants

Background: Mothers of preterm infants face significant challenges to breastfeeding. The theory of planned behavior (TPB) is a well-known framework comprising three domains (attitudes, perceived control, and social norms), which has been used to conceptualize the array of factors that influence health-related behaviors and develop interventions to promote behaviors. Aim: We used the TPB framework to determine the array of factors that contribute to breastfeeding among mothers of preterm infants. Materials and Methods: Using qualitative research methods, we conducted in-depth, semistructured interviews with mothers regarding their experiences feeding their preterm infants according to TPB domains. We developed themes based on an iterative process of review of transcripts and conducted interviews until thematic saturation was reached. Results: We interviewed 23 mothers in 3 states 2 to 6 months after hospital discharge; 22 mothers initiated milk production and 6 were breastfeeding at the time of the interview. Factors that were positive and negative toward breastfeeding were present for all three TPB domains. Regarding attitudes, mothers felt that breastfeeding was a way to bond, that breast milk was healthy and protective, and that breast milk alone was insufficient for a growing preterm infant. Regarding perceived control, mothers felt empowered to breastfeed due to encouragement from hospital staff, friends, and family, and had difficulty overcoming their infant's immature oral feeding skills, competing responsibilities, and perceived infant preference for bottle feeding. Regarding social norms, mothers reported support for and against breastfeeding among hospital and Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) providers, family, friends, and the media. Conclusion: Interventional studies geared toward breastfeeding promotion among mothers of preterm infants may focus on addressing barriers to direct breastfeeding during the neonatal intensive care unit and early post-discharge time periods.

Psychometric properties of the modified breastfeeding self-efficacy scale-short form (BSES-SF) among Chinese mothers of preterm infants

OBJECTIVE

Preterm mother-infant dyads face more challenges than healthy term infants in breastfeeding initiation and continuation due to maternal health status, preterm infant's immaturity or comorbidities, and breastfeeding policy of the neonatal units. Breastfeeding self-efficacy affects breastfeeding outcomes in preterm infants. No specific instrument in Chinese is available to assess maternal breastfeeding self-efficacy of preterm infants. This study aims to assess the psychometric characteristics of the modified Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) among Chinese mothers of preterm infants.

DESIGN

A cross-sectional study was conducted.

SETTING

Two tertiary hospitals in China.

PARTICIPANTS

A total of 153 women who gave birth before 37 weeks of gestation.

MEASUREMENTS

The instrument was translated and back translated. The internal consistency reliability was investigated using Cronbach's alpha coefficient. The content validity, construct validity, and criterion validity were conducted to evaluate the validity of the scale. Exploratory factor analysis was used to investigate the factor structure.

FINDINGS

The scale had good reliability with Cronbach´s alpha above the acceptable level of 0.7. The Item-Content Validity Index (I-CVI) ranged from 0.800 to 1.000, and the Scale-Content Validity Index (S-CVI) is 0.950. The principal component analysis revealed the presence of two factors with eigenvalues greater than 1, explaining a total variance of 74.665%. The modified BSES-SF scores were correlated with women's parity, breastfeeding knowledge, previous breastfeeding experience, perceived support from the spouse and health professionals, and amounts of expressed milk.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The Chinese version of modified BSES-SF is a reliable, valid screening instrument to evaluate the maternal breastfeeding self-efficacy of preterm infants. It is recommended to provide interactive, face-to-face breasting education and support to help mothers of preterm infants maintain high level of breastfeeding self-efficacy and further to achieve satisfactory breastfeeding outcomes.

Troubling care in the neonatal intensive care unit

The neonatal intensive care unit (NICU) is a site of medical treatment for premature and critically ill infants. It is a space populated by medical teams and their patients, as well as parents and family. Each actor in this space negotiates providing and practicing care. In this paper, we step away from thinking about the NICU as only a space of medical care, instead, taking an anti-essentialist view, re-read care as multiple, while also troubling the community of care that undergirds it. Through an examination of the practice of kangaroo care (skin-to-skin holding), human milk production and feeding, as well as, practices related to contact/touch, we offer a portrait of the performance of the community of care in the space of the NICU. We argue that caring practices taking place in the NICU are multiple and co-produced, while simultaneously being subject to power and knowledge differentials between actors. Here we analyze the negotiations over the knowledge and practice of care(s) to open up the NICU as a particular community of care, and consider care as a both a joint accomplishment and a gatekeeping practice.

Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration

BACKGROUND

Breastmilk feeding reduces morbidities and improves outcomes related to prematurity. However, breastmilk feeding rates in preterm infants are substantially lower than those in term infants. Breastfeeding self-efficacy theory is a social change theory, which is predictive of exclusive breastmilk feeding at 2 months postpartum in mothers of full-term infants. However, this theory has not been well explored in mothers of moderate and late preterm infants.

AIMS AND OBJECTIVES

To explore maternal experiences with feeding moderate (32^0/7 - 33^6/7  weeks' gestational age) and late preterm infants (34^0/7 - 36^6/7  weeks' GA) in neonatal intensive care units and assess applicability of breastfeeding self-efficacy theory.

METHODS

We conducted a qualitative descriptive exploration of maternal experiences with infant feeding in neonatal intensive care units. Using purposive, maximum variation sampling, we selected mothers of preterm infants born at 32^0/7 - 34^6/7  weeks, who experienced high mean differences in their BSE scores between admission and discharge. Fourteen mothers participated in semi-structured telephone interviews. Data were examined using thematic analysis. To explore and describe breastfeeding self-efficacy within the context of neonatal intensive care units, we super-imposed the four sources of information from breastfeeding self-efficacy theory onto the defined themes.

RESULTS

Three main themes emerged: (a) institutional influences, (b) relationship with the pump and (c) establishing breastfeeding, with an emphasis on the importance of direct breastfeeding at discharge. Overlaying the four sources of information from breastfeeding self-efficacy highlighted the presence of three sources of information: verbal persuasion, performance accomplishment and physiologic/affective responses. Vicarious experience was not identified in maternal experiences with infant feeding.

CONCLUSION

Our findings indicate that breastfeeding self-efficacy is an applicable theory for mothers of preterm infants.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to be aware of the influence that institutional culture and policies may have on maternal breastfeeding self-efficacy and breastfeeding outcomes.

"We Just Kind of Had to Figure It Out": A Qualitative Exploration of the Information Needs of Mothers Who Express Human Milk

BACKGROUND

Human milk expression, primarily by pump, is practiced by the majority of breastfeeding mothers in affluent countries. Existing literature is focused on determining prevalence and duration rates and the factors behind this trend. There is less research exploring mothers' perspectives and experiences related to expression.

RESEARCH AIM

To gather the experiential wisdom of mothers with a focus on their information needs and sources related to human milk expression.

METHODS

Audiotaped interviews were conducted with 35 mothers of infants, aged birth to 24 months, who had expressed milk at least once in western Canada. This study was guided by interpretive description, an applied qualitative research approach.

RESULTS

Registered nurses and international board-certified lactation consultants were the most common sources of information, with Internet, friends/family, and other mothers also important. Inconsistent expression advice was confusing for participants, and many reported health care providers did not address all their expression learning needs. Desired topic areas included practical advice on how to express, determining expression frequency/timing/duration, milk storage guidelines, the influence of expression on milk supply, product information, and general support/encouragement.

CONCLUSIONS

Assessment of expression learning needs should be part of routine lactation support at each encounter. Nonjudgmental, factual guidance will assist mothers in making evidence-informed decisions related to expression practices that are consistent with their unique breastfeeding goals. This should be supplemented by reputable online resources that provide timely and accurate information as well as efforts to connect mothers with peer support groups.

Breastfeeding experiences and perspectives on support among Chinese mothers separated from their hospitalized preterm infants: a qualitative study

Background

Chinese mothers of preterm infants often face obstacles to breastfeeding and commonly experience prolonged maternal-infant separation when their high-risk infants are hospitalized in a Neonatal Intensive Care Unit (NICU). This separation hinders mother-infant attachment and the establishment of breastfeeding. Currently, little is known about Chinese mothers’ experiences breastfeeding their preterm infants, or their support needs. The aim of this study was to develop an understanding of mothers’ experiences breastfeeding a hospitalized preterm infant and the support needed to establish a milk supply during the period separation from their infants.

Methods

A qualitative descriptive study was conducted in Beijing in 2017. A total of 11 Chinese mothers were individually interviewed while separated from their infants. The interviews were audio-recorded and transcribed verbatim. A thematic analysis involving a seven-step protocol identified key themes.

Results

Mothers of preterm infants reported physically and mentally challenging breastfeeding experiences during the period they were separated from their babies. They viewed expressing breast milk as integral to their maternal role, even though some found expressing breastmilk exhausting. With little professional support available, the mothers depended upon nonprofessionals to establish breastfeeding.

Conclusions

The study identified the difficulties mothers experienced establishing a milk supply while separated from their preterm infants, and the importance of access to health professional support.

"It was all taken away": Lactation, embodiment, and resistance among mothers caring for their very-low-birth-weight infants in the neonatal intensive care unit

The prevalence of infants born before 37 weeks of gestation continues to rise in the United States. Advances in neonatology have led to improved survival rates among preterm infants, including those born at a very-low-birth-weight (VLBW). Exclusive human milk feeding is a therapeutic intervention for VLBW preterm infants, and mothers are encouraged to provide their own milk. Yet, it is well-established that mothers and infants may face extraordinarily complicated lactation and infant feeding challenges in NICU settings, many of which emanate from birth trauma. The purpose of this study is to gain a deeper understanding of the ways in which the hyper-medicalized management of preterm birth and infant feeding in NICU environments affect mothers' postpartum health and well-being. Seventeen mothers of VLBW preterm infants were interviewed August 2016-June 2017 within three years of their infant's NICU discharge about their feeding decisions and experiences. Narrative analysis yielded five themes: (1) the physical and emotional trauma of giving birth prematurely impacted mothers' lactation experiences; (2) separation from their infants intensified mothers' suffering and disrupted lactation; (3) mothers experienced being marginalized in their infant's NICU care; (4) mothers practiced embodied forms of resistance to cope with both trauma and marginalization; and (5) skilled support was central to mothers' positive lactation experiences in the NICU. We draw upon feminist theory in the anthropology of reproduction to examine the fundamental hierarchies of power in U.S. neonatal critical care systems that fracture mothers' interembodied relationships to their newborns, exacerbate lactation failure, and engender traumatic postpartum neglect. Moreover, we theorize mothers' expressions of suffering in the context of preterm birth and lactation insufficiency as idioms of distress engendered by the violence of neglectful care. Narrative inquiry is instrumental to designing structural transformations in the systems of care available to mothers of preterm infants who are admitted to a NICU.

A qualitative cross-cultural analysis of NICU care culture and infant feeding in Finland and the U.S

BACKGROUND

The benefits of family-centered care for the health and well-being of preterm infants and their families include increased parent-infant closeness, improved lactation, and positive mental health outcomes; however, it is known that the extent to which family-centered care is adopted varies by unit. This study aimed to understand how differences in neonatal care culture in two units in Finland and the U.S. were translated to parents' infant feeding experiences in the hope of improving relationally focused feeding practices in both locations.

METHODS

This qualitative, cross-sectional study utilized narrative methodologies to understand the lived experiences of 15 families hospitalized in a tertiary neonatal intensive care unit in Finland (n = 8) and the U. S (n = 7).

RESULTS

A global theme of lactation as a means or an end showed that lactation and infant feeding were framed differently in each location. The three supporting themes that explain families' perceptions of their transition to parenthood, support as a family unit, and experience with lactation include: universal early postnatal challenges; culture and space-dependent nursing support; and controlled or empowering breastfeeding experiences.

CONCLUSIONS

Care culture plays a large role in framing all infant caring activities, including lactation and infant feeding. This study found that in the unit in Finland, breastfeeding was one method to achieve closeness with an infant, while in the unit in the U.S., pumping was only an end to promote infant nutritional health. Therefore, breastfeeding coupled with closeness was found to be supportive of a salutogenic, or health-promoting, care approach for the whole family.

Barriers to Providing Mother's Own Milk to Extremely Preterm Infants in the NICU

BACKGROUND

Mothers' own milk (MOM) has more than nutritional benefits for extremely preterm infants (<28 weeks). However, mothers encounter barriers that make it difficult to provide their own milk to their extremely preterm infants.

PURPOSE

The aim of this study was to describe and understand the experiences of mothers of extremely preterm infants regarding barriers to providing their own milk during infant hospital stay in the neonatal intensive care unit (NICU).

METHODS

This study followed a qualitative, interpretative design using Gadamer's hermeneutic approach and included 15 in-depth semistructured interviews. The data were analyzed using a modified form of the steps described by Fleming.

RESULTS

Fifteen mothers of extremely preterm infants participated in the study. The following themes were extracted from the data analysis: (1) "unexpected and unusual lactation," including the subthemes "the extremely preterm birth and the decision to provide MOM," "the battle to produce milk," and "my job was to make milk"; and (2) "providing MOM to a tiny infant in an unknown technological environment," with the subthemes "the limitations of providing MOM in the NICU" and "the difficulties of having an extremely preterm infant."

IMPLICATIONS FOR PRACTICE

To provide MOM to an extremely preterm infant, there is a need for informational and practical counseling by neonatal nurses educated in breastfeeding according to mothers' requirements and emotional needs.

IMPLICATIONS FOR RESEARCH

Future research may analyze the parents' and neonatal nurses' experience about facilitators to improve MOM provision and the influence of women's sociodemographic characteristics in providing MOM to the extremely preterm infants.

Breast milk expression for premature infant in the neonatal intensive care unit: A review of mothers' perceptions

OBJECTIVE

To identify the existing literature on mothers' perception towards the impact of expressing breast milk for their premature infant in the neonatal intensive care unit.

METHOD

Guided by the PRISMA Statement review checklist, a systematic review of the Scopus and Web of Science database has identified 10 related studies. The articles were assessed and analyzed after evaluated using The Joanna Briggs Institute Critical Appraisal tools (JBI). Thematic analysis was obtained after using Nvivo software as a tool for data analysis by author.

RESULT

Further review of these articles resulted in three main themes-maternal changes during expressing breast milk, pumping challenges and impact of motivation factors to initiating lactation.

CONCLUSION

Expressing breast milk should be recognized as an important way to restructure motherhood with a preterm infant in NICU. However, maintaining expressed breast milk during preterm infants' treatment period in NICU may increase stress and difficulties for some mothers. Some recommendations are emphasized in relation to the need for more qualitative studies in this issue, which is to have a specific and standard systematic review method for guide research synthesis in context of climate change adaptation.

IBCLC Role Differences

Lactation consultants working with mothers and babies in different settings — whether hospital, clinic, home or support group — may find themselves not understanding the challenges and dissimilarities that are part of a distinctive lactation setting. In an effort to even the playing field, allowing for a bird's-eye view of inpatient and outpatient work life issues, this is an article designed to hone in on the variances that confront LC's depending upon where they interface with the breastfeeding dyad.

A Typology of Breastfeeding Mothers of Preterm Infants: A Qualitative Analysis

BACKGROUND

Breastfeeding is an important element of motherhood with a preterm infant, but the role of maternal emotions in relation to breastfeeding is vague.

PURPOSE

To describe maternal emotions regarding and insights into breastfeeding during the first year after a preterm birth.

METHODS

In total, 80 mothers of preterm infants (<35 gestational weeks) participated in this secondary analysis of a larger study. The data were collected with an open question at discharge and 3, 6, and 12 months after the expected birth date and analyzed using thematic analysis.

FINDINGS

A typology of breastfeeding mothers of preterm infants was created. The group of survivors wished to be breastfeeding mothers, but after some unexpected difficulties, they had to give up their dream. The disappointment alleviated with time, but some of the mothers still harbored self-accusations after a year. The highfliers were mothers who succeeded in breastfeeding because of their own persistence. They described breastfeeding as enjoyable for both the mother and the infant. The pragmatist mothers breastfed because it was the general norm and a practical way to feed the infant; breastfeeding caused neither passion nor discomfort. The group of bottle-feeding-oriented mothers expressed that breastfeeding did not interest them at any point.

IMPLICATIONS FOR PRACTICE

Being aware of the typology could help nurses and midwives carefully observe mothers' individual counselling needs. Mothers' wishes and decisions regarding breastfeeding need to be respected and supported without any judgment.

IMPLICATIONS FOR RESEARCH

The possibilities to tailor breastfeeding interventions based on the typology should be investigated.

"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.