Empowerment in breastfeeding as viewed by women: A qualitative study.

BACKGROUND: The positive effect of breastfeeding on health is globally accepted. However, breastfeeding has not yet practiced at a favorite level. Empowerment of mothers is an important factor for continuing breastfeeding. This study was conducted to explore women's perception of empowerment in breastfeeding.
METHODS: The present qualitative study was conducted in conventional content analysis method. Thirty-four semi-structured deep interviews were conducted with 18 mothers, four key family members, and 12 other personnel involved in breastfeeding counseling services.
RESULTS: Analysis of participants' descriptions led to the emergence of five main categories: Enough knowledge and skill for breastfeeding, feeling adequacy in breastfeeding, overcoming breastfeeding problems, informed belief in the value of breastfeeding, and perceiving comprehensive support for breastfeeding.
CONCLUSION: In participants' point of view, empowerment in breastfeeding can be formed through an acquisition of "Enough knowledge and skill for breastfeeding" as well as assurance about the proper quality and quantity of mother's milk. As well as overcoming breastfeeding problems will lead to stabilization empowerment in breastfeeding. In addition, data analysis showed that informed belief in the value of breastfeeding strengthens the empowerment in breastfeeding and presence of perceived comprehensive support for breastfeeding facilitates empowerment in breastfeeding continuance. Thus, comprehensive plans should be designing for promoting breastfeeding.

Introduction

The significance and effect of breastfeeding on mother's and infant's short-term and long-term health, infant's optimal physical and cognitive growth, infant's intelligence, satisfaction of mother's and infant's emotional needs, decreased risk of respiratory and gastrointestinal infections, sudden infant death syndrome, conditions such as asthma, obesity, and diabetes, and economic savings of family and society are globally accepted.[1] The statement of the American Academy of Pediatrics recognizes mother's milk as the golden standard for healthy neonates and infants’ nutrition. The World Health Organization has also puts an emphasis on exclusive breastfeeding in the first 6 months and continued breastfeeding with complementary foods up to 2 years of age.[2]

Despite the significance and emphasis on exclusive breastfeeding in the first 6 months of infant's life, the rate of exclusive breastfeeding in the first 6 months is 37% in the world, 36% in the Eastern Mediterranean Region, 10% in Australia, and 42% in Turkey.[3] Breastfeeding rate decreases over time, such that breastfeeding in American women is 79% in early postpartum period and reaches 18.8% in the first 6 months.[4] In Iran, despite the most mother begin breastfeeding in early postpartum,[5] the rate of exclusive breastfeeding decreases to 27.7% in 6–-month-old infants.[67]

Various factors such as mothers’ knowledge about the advantages of breastfeeding, supportive systems, mothers’ socioeconomic and cultural condition, and professionals health-care skill can affect mothers’ decision on breastfeeding and its continuity.[89] In addition, studies show that mother's idea of the insufficiency of their milk is one of the reasons for why exclusive breastfeeding fails, that is an internal weakness and doubt about their ability in breastfeeding causes their failure in continued breastfeeding.[1011] Empowering women results in the improved quality of their maternal role and decreases the psychological distress of the families.[12] In addition, empowerment of women for controlling their own health, especially their reproductive health aspects, was emphasized in the Conference on Population and Development held in Cairo.[13]

Demographic, social, and psychological factors complicate breastfeeding and its continuity. One element that is missing from the studies is how women perceive breastfeeding empowerment when making decisions to breastfeed her infant. Thus, for promoting breastfeeding, effective factors beyond health system which are present in sociocultural environments should be taken into consideration, especially from women's point of view so that proportionate interventions to those properties can be planned.

Qualitative studies are a valuable tool for gaining a deep understanding of how and why phenomena.[14] Thus, this study with a qualitative approach was designed and conducted to explore Iranian women's understanding of empowerment in breastfeeding.

Methods

Data collection

To explore women's perception of empowerment in breastfeeding, this qualitative study was conducted with naturalism paradigm and through conventional content analysis method. Participants included all women with breastfeeding experience and personnel providing breastfeeding counseling services in Isfahan which selected through purposive sampling. Inclusion criteria for mothers were having breastfeeding experience, being Iranian and being able to speak Persian, being willing to participate in the study, and talking about experiences. Inclusion criteria for personnel were having at least 1 year of experience in providing breastfeeding consultation to mothers. Sampling continued with maximum variation (regarding age, education, occupation, the number of children, and failure or success in breastfeeding).

Deep semi-structured interviews were carried out for data gathering. Interview sessions were held according to participants’ preference, either in health-care centers or any other places of their choice. Study objectives, confidentiality of their information, and recording of interviews were explained and assured them before the beginning of interviews. The interviews started with an open-ended and general questions such as “Tell me about the few first days of your breastfeeding” or “describe about your breastfeeding experience.” Then, further questions, such as “please describe more about this,” were followed to clarifying the subject of the study. Interviews took around 20–90 min and were recorded. Notes were taken from discussions and participants’ reactions. Data collection and sampling continued until data saturation.

Data analysis

Alongside data collection, the interviews were analyzed through conventional content analysis method. In this approach, codes and categories are derived from the raw data directly, without being imposed to preconceived categories or previous theoretical perspectives.[15] Researcher listened to the recorded interviews after the interview sessions. After gaining an overall view regarding to the interviews, the whole interviews were transcribed verbatim and then the analysis unit was formed. The transcriptions were then read line by line, and important sentences and expressions were determined and labeled as codes. Similar codes were assimilated, and primary categories were formed. Data reduction continued in all analysis units up to the emergence of main categories.

For example, conceptual code “breastfeeding value in improving attachment and bonding” has been emerged from this expression of a 23-year-old mother “I got more resolute to breastfeed my infant when I saw the breastfed kids were healthier and had better emotional relationships with parents,” and then the subcategory “attempt to gain knowledge about the value of breastfeeding on health” formed.

In the next step, the main category “informed belief in the value of breastfeeding” was formed from two subcategories “religious belief in breastfeeding” and “attempt to gain knowledge about the value of breastfeeding on health.”

To ascertain the credibility of the data, the transcriptions were reviewed by participants and the supervisor professor, advisor, and colleague; maximum variation was also taken into consideration in the sampling. To improve the confirmability of data, transcriptions, codes, and extracted categories were reviewed by qualitative researchers, and a proper agreement was reached in this regard.

Ethical considerations

The study was also approved in the Isfahan University of Medical Sciences Ethical Committee. Participants’ written consent was also obtained, and they were informed that they could withdraw from the study whenever they desired.

Results

The main participants of the study were breastfeeding mothers, but data analysis showed that we should interview with other people. Thirty-four interviews with 18 mothers with breastfeeding experience, four key family members (two grandmothers and two fathers), and 12 personnel in breastfeeding health services system (including pediatricians, midwives, pediatric nurses, breastfeeding counselors in hospital and health centers, and policy makers) were carried out.

Mothers were between 22 and 37 years old and had from 1 to 47 months experience in breastfeeding to 1–3 term and preterm infants. The majority of the mothers had diploma degree and were housewife. Occupational experience of the breastfeeding services personnel also ranged between 2.4 and 34 years.

Eight hundred and twenty primary codes were extracted from rich and deep descriptions provided by participants. After several iterations of review, the codes were summarized and then categorized in terms of proportion and similarity. Through comparison and analysis, five main categories: “Enough knowledge and skill for breastfeeding,” “feeling adequacy in breastfeeding,” “overcoming breastfeeding problems,” “informed belief in the value of breastfeeding,” and “perceiving comprehensive support for breastfeeding” were emerged. These main categories reflect the empowerment aspects from their view [Table 1].

Table 1

Empowerment in breastfeeding from the Iranian women's perception

Enough knowledge and skill for breastfeeding

An analysis of participants’ descriptions showed that empowerment in breastfeeding is formed through an acquisition of “Enough knowledge and skill for breastfeeding.” In their view, “acquisition knowledge and skill for breastfeeding” and “the ability to assess breastfeeding status” were the main factors for empowerment in breastfeeding.

Acquisition knowledge and skill for breastfeeding

Participants mentioned that their empowerment in breastfeeding was dependent on acquiring adequate information and practical skills for breastfeeding. Most of the participants also mentioned that mothers’ familiarity with correct techniques of breastfeeding such as correct way of holding infant and placing the nipples in infant's mouth and are among the key aspects of empowerment in breastfeeding. These techniques should be taught to mothers before starting breastfeeding and during their pregnancy. Furthermore, the way mothers breastfeed should be observed by the health-care professionals during the first days of breastfeeding, and their mistakes should be corrected.

A 28-year-old housekeeper mother said, “It is very important to know the correct way of breastfeeding. In breastfeeding classes that I attended, they taught us how to hold the baby and touch the corner of infant's lip with the nipple so that the infant opens his/her mouth so that the mother can put the whole Areola in his/her mouth. This helped me with breastfeeding a lot.”

The ability to assess breastfeeding status

Participant's description showed that if mothers were able to assess their breastfeeding status correctly, they could look for solutions to increasing their milk or ask for help in cases they felt any insufficiency of their milk. In their view, mother's familiarity with foods that increase milk, as well as complementary and alternative medical methods such as acupressure are significant factors contributing to women's empowerment in continued breastfeeding.

A 23-year-old mother said, “during the first days after delivery, I felt like my milk was little. My mom practiced the massage they had taught; then I felt like my milk increased.”

Feeling adequacy in breastfeeding

Data analysis shows that concern over the quantitative and qualitative adequacy of milk for supplying infant's needs can be observed in most of the mothers. In their view, empowerment in breastfeeding depends on “assurance about infant's proper growth and health” and “receiving positive feedback” from health-care professionals and family.

Assurance about infant's proper growth and health

In participants’ opinion, mothers’ assurance about their infants’ growth and health played a significant role in their empowerment in breastfeeding such that one of the factors undermining mothers’ empowerment, and ultimately making them not follow the exclusive breastfeeding, is their nonassurance about infants’ proper nutrition and adequacy of mothers’ milk in supplying infants’ needs. Thus, when a mother knows how to get assured about the adequacy of her milk and observes the signs in her infant, then becomes confident that her infant has proper growth and her milk is adequate for supplying her infant's needs. Such confidence leads to mother's empowerment in breastfeeding. They emphasized that the signs of the adequacy of mother's milk should be taught to mothers and the properties, such as infant's growth chart, should be checked and explained to mothers in each visit so that mothers could get assured about the adequacy of their milk for infant's proper growth and health.

A 23-year-old employed mother said, “Each time I took my infant for checking his/her weight and height, they drew its growth chart. They said the chart looked good. It made me feel my infant's growth was good and my milk sufficed for its growth.”

Receiving positive feedback

Most of the participants stated that one of the breastfeeding adequacy factors is receiving positive feedback on breastfeeding from health-care professionals and family. Most of the positive feedback received from health-care professionals leads to empowerment in breastfeeding and ultimately continued breastfeeding.

A 36-year-old employed mother said, “I think my infant's growth is good, the doctor also says the growth is good. This makes me more confident and more empowered.”

Furthermore, in participants’ view, families’ reaction is also one of the factors affecting empowerment in breastfeeding. Thus, be advised that effective people, such as husband, should be present ever care is delivered to infant. They should also receive necessary training so that they can encourage mothers properly through their positive feedback.

Overcoming breastfeeding problems

Participants’ description showed that breastfeeding problems, especially during the 1st week of infant's birth, is a great challenge that threatens continuity of breastfeeding. Participants think of overcoming breastfeeding problems as a factor empower mothers in breastfeeding. Thus, they stated that mothers should be taught about “knowledge and skills to prevent and solve breastfeeding problems” that will lead to their “self-efficacy in solving breastfeeding problems.”

Knowledge and skills to prevent and solve breastfeeding problems

Most of the participants believed that mothers with the knowledge and skills to prevent and solve breastfeeding problems are more prepared to confront and solve the problems upon occurrence. This factor enables them to overcome breastfeeding problems and also consolidate and continue their breastfeeding. They recommended that these knowledge and skills should be taught to mothers.

A breastfeeding counselor said, “We should train mothers how to prevent and solve breastfeeding problems; for instance, nipple fissure is caused by wrong way of breastfeeding. So, before breastfeeding starts and during pregnancy, the correct method of breastfeeding should be taught to avoid nipple fissure.”

Self-efficacy in solving breastfeeding problems

Participants mentioned that mothers should develop their own self-efficacy in solving breastfeeding problems so as to get empowered in breastfeeding. They emphasized that mothers should be calm and patient at the face of problems. They should also trust themselves when encountering problems and ought to look for a way to solve them. They suggested that there must be centers for mothers to refer when facing breastfeeding problems and proper information should be offered to them regarding their problems.

A 28-year-old housekeeper mother said, “When I got a nipple fissure, I referred to a breastfeeding counselor. She advised me to leave one drop of milk on the nipple and let it dry there when I finished the breastfeeding. This method healed the fissure a lot.”

Participants’ experience indicates that empowered mothers have certain self-confidence and show greater resistance when faced with breastfeeding problems and ultimately find a way for encountering hardships.

Informed belief in the value of breastfeeding

An analysis of participants’ statements showed that “informed belief in the value of breastfeeding” can result in greater empowerment in breastfeeding. In the understudy population, “religious belief in breastfeeding” and an “attempt to gain knowledge about the value of breastfeeding on health” were the most important aspects of this category.

Religious belief in breastfeeding

In participants’ opinion, the emphasis which placed by religious instructions on breastfeeding is an effective factor in empowerment in breastfeeding. Breastfeeding has been pointed out directly in some verses in Quran. For instance, verse number 233 of “Baqarah Sura” states that mothers who want to fulfill their breastfeeding duty should breastfeed their kids for 2 full years.

A 23-year-old housekeeper mother said, “One of the important factors that made me decide to breastfeed and bear its hardships and problems was the encouragement and emphasis placed by Islam on breastfeeding.”

Participants also mentioned that family belief in breastfeeding is an encouraging factor in empowerment in breastfeeding. When one's spouse and family members believe in breastfeeding and emphasize it, then mother is encouraged and feels empowered.

A 23-year-old mother said, “My spouse firmly believes in the idea that mother's milk is infant's right. This made me stronger in breastfeeding.”

Attempt to gain knowledge about the value of breastfeeding on health

Most of the participants’ statements showed that mothers’ knowledge about the positive effect of breastfeeding on infant's health and her own health facilitates continued breastfeeding and has a significant role in empowerment for breastfeeding. Thus, they recommended that new findings about the positive effect of breastfeeding on mother's and infant's health, the relationship between parents and infant, and bonding and attachment be taught to mothers in breastfeeding classes.

A 23-year-old mother said, “I got more resolute to breastfeed my infant when I saw the breastfed kids were healthier and had better emotional relationships with parents.”

Perceiving comprehensive support for breastfeeding

In participants’ view, “perceiving comprehensive support for breastfeeding” is one of the facilitating factors of empowerment in breastfeeding. This category is comprised three subcategories of “perceiving health professional support for breastfeeding,” “perceiving family support for breastfeeding,” and “perceiving social support for breastfeeding.”

Perceiving health professional support for breastfeeding

Participants’ descriptions showed that hospital personnel's positive attitude toward, and practical assistance in, early beginning of breastfeeding plays a great role in initiation of breastfeeding, and hospital personnel should assist mothers who breastfeed and teach them the practical skills just after delivery.

A 33-year-old employed mother said, “The first time I breastfed my infant was after delivery. A midwife brought the infant to me, put it under my breast and practically helped me do it.”

Participants specifically placed emphasis on supporting mothers through hard breastfeeding conditions such as mothers experiencing their first delivery or those who had a Cesarean delivery.

A 33-year-old mother said, “Practical trainings provided after my first childbirth on how I should hold my infant and how long the nipple should remain in infant's mouth were really helpful. These made me feel empowered in breastfeeding.”

In addition, participants mentioned that training by health-care professionals for mothers and families on breastfeeding is another effective factor in women's empowerment in breastfeeding.

Perceiving family support for breastfeeding

In participants’ view, receiving assistance from husband and family facilitates the breastfeeding process. They stated that when family, especially husband, is involved in breastfeeding process, mothers are more successful in it.

A 33-year-old mother said, “during the 1st months of my infant's birth, when the kid needed a lot of care, it was very nice if husband and family could help the mother with taking care of the infant, especially for the first baby, as mother has no experience.”

Participants also mentioned that when families maintain a positive attitude and help to mother regarding solving her problems when she faces breastfeeding problems, the mother then feels more empowered in her breastfeeding experience.

Perceiving social support for breastfeeding

Participants’ description showed that presence of social facilities dedicated to breastfeeding mothers, such as kindergarten, paid maternity leave, and short-term leave for employed mothers can help mothers adapt themselves better with the breastfeeding process.

A 37-year-old employed mother said, “Maternity leave is very good for employed mothers. It would be really helpful if the mother can have maternity leave to dedicate it to a 6-month exclusive breastfeeding period.”

According to the majority of the participants, information dissemination in media, on the web and in society can encourage mothers, promote breastfeeding, and also improve public opinion regarding breastfeeding and their empowerment in breastfeeding. It is thus advised that books and programs be prepared and published on the positive effects of mother's milk and encouraging breastfeeding.

Discussion

This study was conducted, for the first time, aiming to assess Iranian women's perception of empowerment in breastfeeding by qualitative approach. Participants mentioned empowerment in breastfeeding in five aspects: enough knowledge and skill for breastfeeding, feeling adequacy in breastfeeding, overcoming breastfeeding problems, informed belief in the value of breastfeeding, and perceiving comprehensive support for breastfeeding.

Kang et al. study indicated that the breastfeeding empowerment was effective in increasing the breastfeeding rate and helped mothers to actively solve problems that they encountered.[16]

The findings of the present study indicate that adequate knowledge and skill for breastfeeding has a decisive effect on the formation of empowerment in breastfeeding. Mother's mastery over correct breastfeeding techniques and her ability to assess their own breastfeeding status and using appropriate solutions for increasing her milk when needed lead to continued breastfeeding. The results obtained by Ong et al. also showed that mothers have inadequate knowledge in different aspects of infant care such as breastfeeding. Participants of this study emphasized on acquiring more information and learning practical skill before discharge from hospital.[17]

Participants of some other studies also mentioned that precise information and practical guidance for breastfeeding would be beneficial and helpful.[1819]

The results of the present study showed that feeling of adequacy in breastfeeding is a key aspect in empowerment in breastfeeding. This adequacy depends largely on assurance about Infant's proper growth and health and receiving positive feedback from family. Participants of Scott et al.'s study also described inadequacy of milk as a major concern for mothers. This was identified according to infant's incessant crying, not sleeping, and also mother's changed nutrition pattern, and some mothers had actually stopped breastfeeding because of inadequacy.[20] In addition, Nelson meta-analysis study showed that mothers’ concern over their ability for producing adequate and good quality milk for fulfilling their infant's needs can be observed in all studies.[21] The results of the present study also recommend that mothers’ knowledge of the signs of breastfeeding adequacy and interpretation of these signs by health-care professionals for mothers leads to empowerment in breastfeeding.

According to the participants of this study, overcoming breastfeeding problems consolidates empowerment in breastfeeding. Furthermore, their knowledge and skills to prevent and solve breastfeeding problems, and self-efficacy in solving breastfeeding problems is one of the significant factors of empowerment in breastfeeding. These findings conform to those obtained by previous studies on the idea that overcoming breastfeeding problems play a great role in empowerment in breastfeeding.[1719]

Powell et al. mentioned in their study that providing information on breastfeeding problems in training classes along clinical visits leads to greater preparation and empowerment in mothers. However, health-care professionals do not train mothers how to resolve breastfeeding problems.[22]

The study findings showed that participants placed special emphasis on mothers’ and family members’ informed belief in the value of breastfeeding leads to acquisition of knowledge and skills for breastfeeding and greater preparation for coping with breastfeeding hardships and issues. In Abolghasemi and Merghati Khoie's qualitative study also, a belief held by mothers, family members, and society in breastfeeding is counted as one of the effective factors in breastfeeding.[23]

In the current study, participants maintained that knowing about the benefits of breastfeeding as well as bonding and attachment are important factors for empowerment in breastfeeding. Hannon et al. also showed that mothers’ knowledge of breastfeeding advantages had a positive effect on their decision for breastfeeding and its continuity.[24] Findings of other studies also showed that in mothers’ view, breastfeeding is an important factor in mother and infant's bonding and attachment and it leads to a better and faster understanding of infant's needs.[2125]

The present study showed that the other aspect of empowerment in breastfeeding is perceiving comprehensive support for breastfeeding such as receiving breastfeeding support from health-care professionals, family, and society. Participants in McLelland et al.'s study emphasized the positive effect of health-care professionals’ support, especially during breastfeeding sensitive periods.[26] In others studies, grandmother and husband's support was mentioned as an important source of emotional and instrumental support in the postpartum period.[2127]

In participants’ view, organizational support for breastfeeding (such as paid maternity leave, short leave for breastfeeding, and kindergarten) is a key factor in women's empowerment in breastfeeding. In Iran, the length of paid maternity leave is 6 months and the support law for breastfeeding mothers allows 1 h leave per day for mothers having infants of under 2-year-old. Findings of other studies also emphasized that social supports regarding working conditions (such as delivery leave for parents and flexible working hours) increasing the breastfeeding rate.[2829]

Conclusion

Analysis of participants’ descriptions showed that empowerment in breastfeeding is formed through the acquisition of enough knowledge and skill for breastfeeding and feeling adequacy in breastfeeding. They also believed that due to the prevalence of breastfeeding problems, especially in the first days after delivery, overcoming breastfeeding problems will lead to stabilization empowerment in breastfeeding. They also maintained that informed belief in the value of breastfeeding also strengthens women's empowerment in breastfeeding and presence of comprehensive support for breastfeeding facilitates the empowerment. Thus, to promote breastfeeding, comprehensive programs with a focus on empowering women in breastfeeding should be devised and developed.

Financial support and sponsorship

This study was financially supported by Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.