Background
Methods
Research site and sampling
Recruitment and interviews
Process of interpretative phenomenological analysis
Results
Socio-demographic characteristics
Numbers | |
---|---|
Age (years) | |
20–24 | 2 |
25–29 | 6 |
30–34 | 5 |
35–39 | 2 |
40–44 | 1 |
Educational level | |
Secondary school | 6 |
Degree | 7 |
Postgraduate | 3 |
Employment status | |
Housewife | 7 |
Student | 3 |
Employed | 6 |
Age of last child (months) | |
Under 6 | 4 |
6–12 | 5 |
Over 12 | 7 |
Main Themes | Sub-themes | |
---|---|---|
Facilitators | Barriers | |
Up against the system | Breastfeeding information and advice | Do it yourself Breastfeeding discouragement Unhelpful advice Unfriendly environment |
Social support and negativity | Breastfeeding encouragement and support | Negative comments Conflicting advice Poor understanding of breastfeeding needs |
Managing tension | Belief | Multiple roles Concerns and worries |
Up against the system
Participants reported being advised directly by staff to breastfeed during pregnancy, and/or once they gave birth, and/or before leaving hospital. This also gave them encouragement to breastfeed when the staff put the babies on their mothers’ chests or handed them to the mothers:Dalia: I had breastfeeding leaflets from the hospital for my first baby till the last one from the clinics and wards. I read . . . read all breastfeeding papers . . . handouts . . . mm . . . they gave me [information] each time I give birth, that’s why I know it’s [breastfeeding] important.
However, the majority reported that policy, staff and systems were crucial barriers to continuing to breastfeed. Participants felt they were left to ‘do it yourself’ once they had started. Most mothers reported that they had been left unaided when breastfeeding, without any effective support:Besma: She [a nurse] talked to me after delivery. She advised me to let my baby suck my breast very well to get used to sucking my breast from early days.
“Natural feeding” is an Arabic phrase that was reported by mothers and it means breastfeeding in English. Mothers also commonly reported being discouraged from breastfeeding, for example because of their health status – such as having had a caesarean section (CS):Ola: the first time for breastfeeding was on the second day after birth [because the staff kept her baby in the nursery due to the hospital policy]. I went there again [nursery] and held my baby and put her on my breast, but I had no previous experience with natural feeding . . . I was left alone with my baby in a corner . . .
Unhelpful advice was reported by the majority of mothers if, after a few weeks or months, they sought guidance from paediatricians or pharmacists. These professionals encouraged and/or instructed the mothers to combine breastfeeding with infant formula.Gala: I requested my baby but they refused and told me “you are tired and exhausted, it’s contraindicated”. I also asked them to bring my baby to be with me in the same room because I wanted to look at him to stimulate my breast for milk production, they also refused that. I also asked them to bring my baby when he wanted a feed because I wanted to feed him from my breast, but they said “you cannot breastfeed him because you are under analgesia and anaesthesia drugs”.
Most of the mothers who were studying or who had returned to work reported an unfriendly environment. They reported the inconvenience of trying to combine breastfeeding with full-time working or studying and that there were no breastfeeding facilities. For example, when Isra explained that she needed to leave work early to continue breastfeeding, staff refused her request.Fulla: I told the paediatrician that “my baby is not sucking my breast very well . . . he told me “your baby is very hungry he’s crying because he’s hungry”. He told me to feed him artificial food if he didn’t take or refused my breasts.
Kady: He was three months old when I returned to college . . . at the beginning I faced issues because my breast was engorged and became like a rock because I’m not feeding my baby for hours and I didn’t know where to breast pump at the university . . . and as I told you, I was patient until I finished my lectures, then I went back home.
Social support and negativity
Husbands were also reported as having a crucial role to play:Ola: At mum’s house, my sisters were there and taught me the steps of breastfeeding . . . the holding, cuddling and positioning . . .
Nonetheless, negativity was a critical barrier to breastfeeding; negative comments and criticism of both mothers and babies were reported. The most common unsolicited Arabic word from other women was “Ya-haram”. There is no direct English equivalent but, essentially, it means “oh, poor baby” or “oh, how sad” or “oh, insufficient milk”. Mothers declared this the most disliked word:Nuha: My husband encouraged me to breastfeed my baby everywhere —at land, air and sea. He told me not to be embarrassed in public places and if I felt embarrassed, he would stand in front of me if I wanted. He asked me to continue breastfeeding [not in a hurry] several times.
Kady: “Oh, Ya-haram, you have insufficient milk, or your baby needs more milk and you don’t have enough. Oh, your baby is still hungry.”
Other distressing comments referred to mothers’ breast becoming saggy, or their body size and shape being imperfect. These comments influenced the mothers’ feelings since they reported that they were being scrutinised both visually and verbally when nurturing their babies in front of relatives and friends.Meha: my grandmothers and his grandmothers kept repeating this phrase: “You have no milk, your breast has no milk, give him a bottle.” All people around me were repeating this expression: “Ya-haram you have no breast milk.”
Poor understanding by others of breastfeeding needs arose, particularly when these changed. This often occurred after mothers returned to university or work, because they were working or studying full-time.Fulla: Mum told me: "Why are you doing that? [following the steps of breast attachment as she learned from educators at hospital] Just pick up your baby and put him on your breast . . . you don't know how to breastfeed your baby!"
Fulla: “If it’s as bad as what you are saying, they wouldn’t sell it in pharmacies, they wouldn’t use it in hospitals, they wouldn’t sell it with medications that treat people and kids.” So, after this argument I just give him [baby] a bottle of artificial milk.
Managing tension
Besma: I decided to breastfeed … (and) to continue breastfeeding because I want to feed my baby naturally. I feel and believe that natural feeding . . . causes less suffering with the newborn baby.
Emotional communication between mothers and babies during breastfeeding was the main reported self-belief that encouraged mothers to continue breastfeeding. Several added that they felt more kindness and tenderness when nursing their babies.Esmat: only the natural milk [breastfeeding] has full benefits for babies.
Overwhelmingly, they believed in breastfeeding because it was recommended by Allah; this was the foremost reported reason for insisting on or persisting with breastfeeding. Several mothers cited the Quran in support of this.Lena: I love feeding him naturally and I’m feeding him my love
The following mother clarified her belief in the Quranic instructions that extended to the responsibilities of the father to his wife during breastfeeding:Asma: Two years definitely, I’ll breastfeed him for two years as Allah says in the Quran: “mothers, who gave birth, shall breastfeed their babies two complete years” . . . there is wholesomeness from this verse; it’s the Quranic foresight.
However, most mothers faced challenges after a few months of juggling multiple roles, leading some to stop breastfeeding earlier than they had wished. This was particularly so for mothers who were working or studying, or who had health issues.Nuha: There are other things (verses) and I was stressing the idea of nursing expenditure (laughter). For me as a nursing mother, I need to feel well, so presents and such stuff make me feel good and I took advantage of these religious recommendations (laughter).
Concerns were commonly reported when mothers worried about their babies’ crying, sleeping and preferring formula:Ola: I gave her natural milk and artificial milk, both. I only used the artificial when I was busy. For example, when I had to go for follow-up appointments or when I was in a lecture and she was in nursery . . . and it’s out of my hands [forced factors].
Some mothers limited breastfeeding in public and sometimes covered their breast because they either believed or had been advised not to practise frequent and long breastfeeding in front of other women in order to avoid “the eye” or “evil eye”. “The eye” and “evil eye” were concepts believed by several mothers in this study; it affected their breastfeeding practises in front of other women.Nuha: So she [infant] started to love artificial milk before I returned to work and I felt that she accepted artificial milk more than my breast milk, so I knew that she liked to take milk from the bottle, not from my breasts.
Most mothers said that they breastfed in front of children and other women but only in front of close male relatives. However, they made specific arrangements for their personal beliefs when they breastfed in the presence of male non-relatives in public places by covering their breast with a light scarf or fabric, adjusting their seating, or trying to find a private women’s section.Fulla: a bad thing would happen to you as result of evil eyes . . . for example, I wanted to breastfeed my baby in front of other women but sometimes my relatives prevented me because they said “be careful of evil eyes!!”
Esmat: I breastfeed everywhere and every time and just cover the upper side [pointed on her shoulder] in front of non-relative men