Abstract
Breastfeeding is seen as a natural and physiological mothering behaviour. Yet breastfeeding is also a health related behaviour, subject to social and cultural influences. Additionally, breastfeeding is an infant care response practised and experienced differently by mothers. Thus mothers feed their infants differently for different contextual reasons. Given the role that perceived insufficient milk appears to have in shortening breastfeeding duration, a better understanding of the experience of perceived insufficient milk and its relationship with breastfeeding duration may identify interventions that could help more mothers exclusively breastfeed to six months.
A study using a convergent mixed methods design was conducted. Qualitative and quantitative data were collected in parallel, analysed separately and findings were merged in an integrative phase.
In phase I, qualitative data were collected through in-depth, semi-structured interviews with twelve Dunedin mothers who had reported experiencing perceived insufficient milk during their participation in a randomised controlled trial (POI.nz). Phase I investigated the symptoms of (objective 1), responses to (objective 2), and lived experience of (objective 3) perceived insufficient milk. Interviews were transcribed and analysed using a grounded theory approach and the constant comparative method of analysis.
In phase II, quantitative data were collected from 114 Dunedin mothers in the control group of POI.nz during pregnancy, and at three, seven, eleven, fifteen and nineteen weeks postpartum to determine: the prevalence of different infant feeding methods iii (objective 4); predictors of exclusive breastfeeding duration and any breastfeeding duration (objectives 5 and 6); the prevalence of perceived insufficient milk (objective 7); and predictors of perceived insufficient milk (objective 8). Predictors of exclusive and any breastfeeding duration were determined using survival analyses and predictors of perceived insufficient milk were analysed using logistic regression.
In phase III, quantitative (QUAN) data that complemented the qualitative (QUAL) themes were described, and quantitative results and qualitative results were integrated.
Three themes were developed in the qualitative analysis: urgency of the perceived insufficient milk situation, persistence with breastfeeding in spite of perceived insufficient milk, and pressure to breastfeed.
Between two and nineteen weeks postpartum the prevalence of exclusive breastfeeding from birth markedly decreased from 73% to 32% and the prevalence of any breastfeeding from birth decreased from 92% to 78%. Perceived insufficient milk was the most frequently provided reason (58%) for introducing non-breastmilk liquids or solids and one of the strongest predictors of a shorter duration of exclusive breastfeeding. More than half of the participants (61%) perceived they had insufficient milk at some time before nineteen weeks.
The following factors were predictors of perceived insufficient milk: worry about infant weight gain in the first three weeks, average breastfeed duration at three weeks, the introduction of non-breastmilk liquids or solids before seven weeks, breastfeeding frequency at seven weeks, and rating of infant sleep as a problem at seven weeks.
Phase III integrated the qualitative and quantitative results. A mother.s worry about her infant.s inadequate weight gain was important, as it was a symptom of perceived insufficient milk (QUAL and QUAN), a predictor of perceived insufficient milk (QUAN), a predictor of a shorter duration of exclusive breastfeeding (QUAN) and a reason for the introduction of infant formula (QUAL and QUAN). Baby behaviours such as crying were the most common symptoms of perceived insufficient milk (QUAN).
Persistence with exclusive or full breastfeeding after perceived insufficient milk was evident in both phases, with 50% (19/38) of mothers exclusively breastfeeding at nineteen weeks having reported perceived insufficient milk at some time (QUAN). This iv sometimes involved mothers changing their breastfeeding practices by breastfeeding more often or expressing breastmilk to increase their milk supply (QUAL and QUAN).
Pressure to breastfeed exclusively was evident in both phases and mothers said this resulted in a lack of options, making some mothers angry (QUAL). This pressure was mainly described as coming from health professionals (QUAL). Not all mothers felt angry about the advice they received to keep breastfeeding, as some considered being pushed to continue to breastfeed was the most helpful breastfeeding advice they received (QUAL and QUAN).
Perceptions of insufficient milk are very common among breastfeeding mothers and differ from mother to mother. The baby.s behaviour, sleeping patterns or weight gain may cause mothers to question their milk supply with varying degrees of urgency. Not all mothers stop exclusively breastfeeding when they perceive they have insufficient milk suggesting that some mothers are able to manage or overcome their milk supply concerns enough to continue breastfeeding. This finding provided insight into the diversity of mothering practices, a diversity that was further illustrated by mothers. different opinions of breastfeeding advice. Health professionals working with breastfeeding mothers need to know that mothers who are concerned about their baby.s weight before three weeks of age, or their baby.s sleep pattern between three and seven weeks of age are at risk of questioning their milk supply, as are mothers who may be having other problems with their breastfeeding; shown by a longer duration of breastfeeding at three weeks or less frequent breastfeeding at seven weeks. These mothers may need further investigation to determine whether their milk supply is inadequate, and support targeting those issues. However, this study also shows the need to avoid rigid pressure when a mother encounters breastfeeding problems, while also encouraging continuation of exclusively breastfeeding to six months.