Sexual & Reproductive Healthcare 6 (2015) 82–87

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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g

First time mothers’ experiences of breastfeeding their newborn Hanne Kronborg *, Ingegerd Harder, Elisabeth O.C. Hall Section for Nursing, Department of Public Health, Aarhus University, Aarhus, Denmark

A R T I C L E

I N F O

Article history: Received 10 February 2014 Revised 4 August 2014 Accepted 20 August 2014 Keywords: Breastfeeding Postpartum period Mother–child relationship Postnatal care Professional–patient relations Communication

A B S T R A C T

Objective: Despite efforts to improve continued breastfeeding, the percentages of exclusively breastfeeding remain low. To help the breastfeeding mother and reshape professional practice, we need more knowledge of maternal experiences of breastfeeding in the first months. The objective was to explore mothers’ early breastfeeding experiences. Method: Qualitative content analysis was used to analyse data from 108 Danish first time mothers who had answered an open-ended question 6 months after birth. Results: All the mothers started breastfeeding. We identified three overlapping phases presented as dominant themes: (1) on shaky ground, characterised by breastfeeding interwoven with mothering, painful breastfeeding, and conflicting advice, (2) searching for a foothold, characterised by reading the baby’s cues, concerns about milk production, for or against breastfeeding, and looking for professional support, and (3) at ease with choice of feeding, characterised by a thriving baby, trust in breastfeeding capability, and approval of feeding preference. Together these themes and subthemes constituted the overall theme: being on a breastfeeding–bonding trajectory. Conclusion: Supporting the new breastfeeding mother should include facilitation of the transition to motherhood, learning to read the baby’s cues, developing a sense of the right attachment at the breast, and building up the mother’s confidence in her capability to care for the baby and produce a sufficient milk supply. © 2014 Elsevier B.V. All rights reserved.

Introduction The benefits of breastfeeding are well-documented. The World Health Organization therefore recommends every woman who is giving birth to breastfeed for 6 months [1]. In Scandinavia, nearly all mothers start breastfeeding. However, despite efforts to improve continued breastfeeding the percentages of women who engage in exclusive breastfeeding until 4–6 months after birth remain low [2–4]. The aetiology of breastfeeding cessation is multi-factorial. Sociodemographic factors (such as age, parity, education, racial/ethnic group and income) and psychosocial factors (such as intention, confidence and knowledge) are well-known determinants of both the choice to breastfeed and the duration of breastfeeding [5]. Further, behavioural factors, such as unrestricted mother–infant contact [6], frequent feeding, and having mastered breastfeeding techniques [7] have been shown to play a role in successful breastfeeding.

This study was approved by the Science Ethics Committee for the Counties of Ringkjoebing, Ribe and Soenderjylland, Denmark and the Danish Data Protection Agency. * Corresponding author. Tel.: +45 87167891. E-mail address: [email protected] (H. Kronborg). http://dx.doi.org/10.1016/j.srhc.2014.08.004 1877-5756/© 2014 Elsevier B.V. All rights reserved.

Breastfeeding is often described as the most difficult thing in the learning process of becoming a parent [8]. One in every two new mothers reports having experienced early breastfeeding problems [7,9]. Mothers may experience sore nipples and concerns about having enough milk and at the same time experience anxiety about becoming a parent with concerns about the safety of the new baby [10]. The expectations towards breastfeeding being a natural process are replaced by experiences of breastfeeding being difficult and requiring perseverance to succeed [11]. Giving up breastfeeding is often described by mothers as experiencing mixed feelings of guilt and failure [12]. The decision made by some mothers to cease breastfeeding may be based on family needs and individual attitudes towards breastfeeding [13] or necessary for the well-being of their child [11]. To help the breastfeeding mother, health care providers need extensive knowledge of the maternal situation in the first months to provide individualised guidance and ensure that early breastfeeding problems are resolved [14]. The main barrier related to breastfeeding counselling may be deficits in knowledge among health professionals [15]. A number of studies concerning the mothers’ needs for support call for reviewing practices that provide an individualised approach to meet the needs of the breastfeeding mother and guide her to feel secure in caring for her baby [10,13,16,17]. Individually adapted types of support seem to have a more positive outcome

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than support focusing on generalised instructions [18], and longterm interventions using various methods have been shown to be more effective than interventions that focus only on the technical aspect of breastfeeding [19]. Despite the continued search for a more complete understanding of first time mothers’ breastfeeding experiences and why mothers decide to stop or continue in spite of initial problems, there is a need to disseminate additional personal stories to inform practice and improve knowledge [20]. To help understand the mothers’ reflections and choices about breastfeeding their newborns, this study employs a secondary analysis of qualitative data previously collected in a randomised trial [21]. This paper reports findings from first time mothers’ answers to an open-ended question about their breastfeeding experiences. The aim of the study was to explore Danish mothers’ breastfeeding experiences when they were given the opportunity to describe them in writing. Material and methods Design and Setting We used qualitative data from a cluster randomised communitybased trial, aimed at prolonging the breastfeeding period by focusing on improving maternal confidence [21]. The trial took place in 22 municipalities in Western Denmark including both rural and urban areas in 2004. Nearly 98% of all births took place in five hospitals that had adopted the standards of The Baby-Friendly Hospital initiative. Primiparae mothers and those who had a caesarean section usually stayed in the hospital for 4 days, whereas multiparae without complications returned home within 24 hours of giving birth. Following hospital discharge, the new family received home visits by a health visitor for approximately 1–2 weeks post-partum. Denmark is known for its high social support for breastfeeding and new parenthood, including a 14-week paid maternity leave followed by a 32-week paid parental leave, which is often utilised by the mother. The proportion of Danish mothers who breastfeed is high compared with other western countries. In Denmark nearly every new mother (96–98%) starts breastfeeding after having given birth and about 60% of the mothers continue full breastfeeding until the infant is 4 months old [4]. Participants and data collection The mothers in this study were enrolled by the health visitor at the first visit 1–2 weeks after their births and followed for a 6 month period (26 weeks) from February 2004. All Danish speaking mothers who lived in the study region and gave birth to a single child with a gestational age of not less than 37 full weeks and who started breastfeeding were invited to participate. Mothers of non-Danish ethnicity were excluded because of cultural and language differences, mothers with premature deliveries or twin births were excluded because of difference in breastfeeding practice. Data were collected from mothers by two self-administrated questionnaires together with stamped addressed envelopes for reply. Questionnaire I was delivered by the health visitor at the first visit and questionnaire II was delivered or mailed to the mothers approximately 5 months after birth. Both questionnaires contained structured questions that related to the breastfeeding period. In questionnaire II, we included an open-ended question inviting the mothers to describe their breastfeeding experiences. This question had the following wording: “Here at the end of the questionnaire, you have the opportunity to describe in your own words your breastfeeding experience. Please give examples”. The open question was phrased so that the mothers could decide which experiences they found essential to share. Our request for examples aimed to ensure detailed descriptions for analysis.

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Of the 1760 mothers who fulfilled the inclusion criteria, 1597 agreed to participate. Questionnaire II was returned by 1336 (84%). Of these, 280 mothers answered the open question, 108 primiparae and 171 multiparae. All of these mothers had started breastfeeding after having given birth. Their child was approximately 5–6 months old when they answered the question. A supplemental quantitative analysis revealed that the responding 108 primiparae did not differ from the 474 primiparae who had not responded with respect to age, educational level, smoking habits, social group family or BMI. In comparison with the non-responding mothers, the responding mothers had a significantly higher frequency of reporting breastfeeding being more difficult than expected. This was interrelated with having early breastfeeding problems and a delayed onset of milk. Analysis For the purpose of this study, the mothers’ written answers to the open-ended question were transcribed verbatim including details such as capital letters, dashes, and underlines and after that compiled into one document comprising 82 pages. Data were analysed for both manifest and latent content by using a qualitative content analysis, a method that is suitable when analysing texts, distilling by analysing words into a few contentrelated categories, ensuring that words when clustered and categorised share the same meaning [22]. We considered the mothers’ writings to convey what was really going on related to their breastfeeding experiences. The study epistemology was based on the assumption that data are truthful expressions of an experienced reality [23]. The inductive analysis process ran in three phases. In the first phase, we read all the transcribed text to get a big picture of the entire content. In the second phase, and in order to group the data and increase the trustworthiness and dependability of the analysis [22,24], we reread the text independently word by word while going back to the aim of the study and going forward looking for sentences that connected to meaning units, asking the text for mothers’ expressed experiences and use of special words and metaphors in their descriptions. In this second phase, we realised when discussing the meaning units that the narratives from multiparous mothers often referred to their previous breastfeeding experiences. Taking into account that these mothers’ earlier experiences were unknown to us and that primiparous and multiparous mothers’ experiences may differ [6], we decided to continue the analysis focusing only on narratives from the 108 primiparous mothers. In the third phase, the text was clustered and the meaning units were organised into themes with particular attention to the patterns and time frame in the data material. Subsequently, we discussed the themes until we reached consensus on an overall theme, 3 dominant themes and 10 subthemes. There was good interrater reliability, and all three authors found the presented themes. Finally, a description of the substance of each theme was put into writing, citations from the original text were selected to illustrate themes and subthemes, and a figure was elaborated, all issues to help the readers judge the credibility of the analysis process. Results The mothers’ breastfeeding experiences in the first 6 months were characterised by a range of emotions from deep frustration to confidence and a sense of capability of doing anything that was necessary for their baby. The mothers’ descriptions of their breastfeeding experiences had focus on the expectations they had, why they started, why they continued or stopped, and how they regarded the professional help that they did or did not receive. Regardless of whether the stories were brief or detailed, their

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Being on a breastfeeding-bonding trajectory On shaky ground

Searching for a foothold

• breastfeeding interwoven with mothering • painful breastfeeding • conflicting advice

• reading the baby’s cues • concerns about milk production • for or against breastfeeding • professional support

At ease with choice of feeding • a thriving baby • trust in breastfeeding capability • approval of feeding preference

Fig. 1. Identified themes in first time mothers’ breastfeeding experiences.

descriptions of breastfeeding, becoming a mother, and feelings of pleasure and insecurity were interwoven. There were as many breastfeeding and bottle-feeding experiences as there were mothers. Each mother had her own unique story and had solved the problems that arose in her own specific way with or without help. Yet, through the mothers’ description of their experiences, we identified three overlapping phases presented as themes: (1) on shaky ground, (2) searching for a foothold, and (3) at ease with choice of feeding. Together these themes constituted the overall theme: being on a breastfeeding–bonding trajectory (Fig. 1). All mothers started to breastfeed after having given birth and the goal for them was that the baby should be thriving. Finding their way to this goal differed across the phases. All the mothers though were preoccupied with establishing a relationship with the child, with their supporting network and with developing a trust in their breastfeeding capability. First phase: on shaky ground Many of the mothers felt they were on shaky ground while in hospital and during the first days or weeks at home; they felt insecure and were taken by surprise by the new and unexpected things that happened, a baby depending on them and breasts producing milk. “It looked so easy,” one mother said addressing the opposite. Mothers found themselves trapped between a feeling of happiness in becoming a mother and a feeling of hardship finding out how to adopt mothering and meet the baby’s needs. They were preoccupied with breastfeeding techniques and doing things right, and described how they had to get used to being a mother and learn mothering and breastfeeding at the same time. Even though the babies were 5–6 months old, the mothers recollected initiating breastfeeding, their efforts to find out about mothering and breastfeeding and their efforts to overcome breast pain. Breastfeeding interwoven with mothering The early mother–baby relationship was marked by the success of the baby latching on and sucking. Learning to breastfeed thus became crucial in developing mothering. For some mothers it just happened; the baby latched on without problems and started to suck, “what a great feeling the first time I breastfed my baby.” Others found themselves in “deep trouble” getting the baby to suck, “I was fighting with my baby to get him to suck.” Mothers spoke about the first couple of weeks after having given birth, about the difficulties and the fatigue, and how they “struggled and suffered” to make breastfeeding work. Some mothers talked about “a vicious circle” when the baby did not suck and did not sleep, and the mother felt

extremely tired. One mother recalled “21 days and nights without sleep.” Painful breastfeeding Although the mothers started breastfeeding months before answering the open-ended question, the memory of difficulties involving pain remained. They had experienced extremely painful breastfeeding onsets that had called for all the mental strength they could mobilise to keep putting the baby to the breast. They had been breastfeeding with cracked nipples while crying or stamping their feet in pain, which resulted in sores, missing parts of skin or nipples that were close to falling off. “Breastfeeding was very painful because the baby was hungry after 14 days past due date and sucked my nipples to sores already on the second day. The milk came on the fifth day. She could suck for 1½ hours while I was crying in pain.” Words like “indescribable”, “dreadful”, “being in hell”, and “how to survive” were clear indications that the mothers had suffered both physically and mentally. For some mothers, the painful start had spread through the first months. One mother stated that for those who absolutely wanted to breastfeed, “you just had to swallow the pain.” Conflicting advice Many mothers complained that they had received conflicting advice, especially during hospitalisation. This made insecure mothers feel even more at a loss because they were not in a condition to choose between different kinds of advice. One mother claimed, “there were just as many ideas about how to breastfeed as there were nurses.” Other mothers felt they were not listened to. The health professionals’ availability, empathy, and acceptance were crucial to the mothers. According to the mothers’ descriptions, the decisive support when they felt most insecure was that the health professionals adapted breastfeeding advice to their individual situation and everyday world. The worst-case scenario was lack of support. This was remembered 6 months later, “I tried everything to make it work. . .I would have liked some more support while I was still in the hospital.” Second phase: searching for a foothold In the second phase, mothers were trying to gain a foothold from where to establish an everyday life with the baby. The phase differed in duration for the mothers and was characterised by both doubt and determination. Some stopped breastfeeding and started bottle-feeding, others continued breastfeeding, and others again did

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both. The mothers who managed to address the difficulties and sustained breastfeeding reasoned that their baby had gained weight; they had decided to breastfeed and believed in it; they were persistent, giving it a second chance when doubt and insecurity appeared. One mother stated, “I think that the will to succeed and faith in it keep you going.” Some explained how they kept on breastfeeding simply because it was healthy for the baby and cheap and easy for the mother. The mothers who stopped breastfeeding in this phase did so because of concerns for their baby’s wellbeing. Pain, fatigue, and lack of milk contributed to ending breastfeeding. Some mothers ceased because they felt that the baby disliked being breastfed. Reading the baby’s cues The relationship with the baby was marked by the mother’s capability to interpret the baby’s different cues. Some babies were easy to interpret. They gave their mother faith in breastfeeding by clearly showing when they were hungry and satisfied, “my son is happy when he is at the breast and very comfortable afterwards.” Other babies were less easy to read, “I had to interpret whether she was tired or hungry,” “it triggered a doubt whether I had enough milk, in particular when my baby refused to take the breast every time it was offered.” Concerns about milk production A great concern for the mothers was whether their babies got enough to eat. Some mothers felt secure about the milk production, “luckily, I never experienced not having enough milk.” The babies’ crying left other mothers at a loss and weakened their confidence in breastfeeding, “I was often unsure about him thriving because he screamed so much,” “there were difficult episodes in the evening where she began to cry and went off the breast all the time. We never found out why, we doubted that she got enough.” Insecurity and feelings of empty breasts left the mothers with little confidence that they were sufficient sources of nutrition for their babies. “Was at the doctor when he was 5 weeks old – he thought he looked underfed and I should supply with a bottle. I reluctantly did this for 1½ weeks after breastfeeding and thereafter I breastfed exclusively. But the fear of not having enough milk still haunts me.” For some mothers who had experienced that their babies were not thriving, “it felt like a disaster.” Even a subtle suggestion by a health professional could overwhelm the mothers with a feeling of insecurity that subsequently kept them in a state of constant alertness; it planted a seed of doubt that kept on chasing them, and they never fully regained faith in their breasts. For or against breastfeeding In this phase breastfeeding became a talking point, not only among the health professionals but also among family and friends. This created feelings of frustration among the mothers. Everybody seemed to have a point of view either for or against breastfeeding, “is he getting enough; don’t you think he would be happier with a bottle?” Even among mothers who regarded themselves as having plenty of surplus energy, comments like that disturbed them causing doubt. One mother stated, “the outside world expects me to breastfeed but also insinuates that I might not be able to do it.” Such insinuations or direct comments may have contributed to feelings of failure, which mothers experienced in connection with stopping breastfeeding, “it cannot be true that you should feel having failed as a mother just because you do not breastfeed your child,” “I was an insufficient source of nutrition.” These feelings were not just explained by their personal disappointment of not being able to breastfeed but also by the lack of acceptance from their surroundings; they had to defend themselves and be apologetic,

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“I am sorry that I am not as good a mother in your and other people’s eyes.” Professional support Mothers reported being helped through this phase by health professionals who supported them with practical and informative assistance that took into account the actual context in the embedded problem, “it can be a great help boosting one’s confidence in breastfeeding.” The decisive kind of help in this period of transition was that health professionals remained in contact and provided continued support that signalled faith in the mother and her capability to breastfeed. Some mothers were also helped by being informed of their baby’s weight. Third phase: at ease with choice of feeding The mothers’ stories about this final phase revolved around gaining maternal confidence. The mothers described how their baby was content and thriving and how they felt at ease with their choice of feeding, breast or bottle, or both. Regardless of their choice, the mothers described the joy, confidence and the loving smile from their baby when feeding. A thriving baby Bottle-feeding mothers expressed a “good mother” feeling about their choice. They particularly emphasised their relationship with the baby, which had developed positively; they could see that their baby was thriving. Breastfeeding mothers described how they had defeated the difficulties at the beginning, had got back on track and now felt committed to breastfeeding. Similar to the bottle-feeding mothers, they emphasised their special relationship with the baby that had developed through the breastfeeding process. Trust in breastfeeding capability Breastfeeding mothers were more committed to continue once they began to feel confident that they could produce enough milk and it was clear to them that their baby was thriving. Some mothers felt tied down by breastfeeding, whereas others felt good about it, “breastfeeding has tied me down, but not more than I have found it okay,” “It cost blood, sweat and tears but it was worth it.” The breastfeeding mothers were still in a process and had thoughts about how long they were going to breastfeed. Among bottle-feeding mothers, some enjoyed being free of breastfeeding and expressed the freedom it gave them to bottle-feed. Others were still speculating about their capability to breastfeed, wondering what went wrong and what to do next time. Approval of feeding preference Some mothers experienced the health professionals’ disapproval of their decision to bottle-feed, “I felt that our health visitor looked down on me when we gave him a bottle after 14 days of evening screaming.” The focus on breastfeeding, particularly among health professionals, was a stressor. Mothers could feel that formula was taboo and that the health professionals disapproved their decision to stop breastfeeding, “when I decided to bottle-feed they dissociated themselves from me and I was left to my own devices.” Other mothers expressed gratitude when meeting acceptance of their choice to bottle-feed. The decisive support during this phase was acceptance by the health care professionals of mothers’ feeding preference; a decision taken after thorough consideration. Discussion The experiences that 108 Danish first time mothers described in the open-ended question of a randomised trial indicated that the first 6 months was like a breastfeeding–bonding trajectory.

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Starting to breastfeed was closely connected to becoming a mother. Feelings of pleasure and insecurity were interwoven, and pain related to the early breastfeeding act could be overwhelming. The mothers described how insecurity grew out of difficulty reading the babies’ cues and not knowing how much breast milk the baby had consumed. These experiences made the mothers dependent on professional support. According to the mothers, the health professionals should take great care to understand the mother’s perspective on the whole breastfeeding situation. Furthermore, the mothers described the pressure they felt from their surroundings having an opinion about breastfeeding. We found first time mothers to be on a breastfeeding–bonding trajectory searching for a foothold. Breastfeeding has previously been described as a challenging and engrossing personal journey [25–27]. In our study, the mothers overcame pain, insecurity and pressure before they felt happy with their choice of feeding and could enjoy a thriving baby. We asked the first time mothers about their breastfeeding experience and they chose to describe becoming mothers, learning mothering and breastfeeding simultaneously. Being able to breastfeed the child seemed important to most of these mothers; their perception of themselves as new mothers hinged on how the breastfeeding progressed. The findings support that becoming a mother occurs through stages of establishing maternal identity and that a mother’s evaluation of her competence plays a significant role in this process [26]. We found that each mother was doing her best to make the child thrive regardless of choice of feeding. The relationship with the breastfed child was often described through a focus on the difficulties in understanding the baby’s cues. Many described this directly, others in more indirect ways. Supporting the first time breastfeeding mother and preventing complications with initial breastfeeding problems should not only focus on learning the breastfeeding process, but also facilitate the individual process of transition to motherhood and learning to read the baby’s cues. The goal for the mothers was to develop a close relationship with a thriving baby, but the road to this goal was painful for some. It has been shown that pain is the most important negative feature on the way to successful breastfeeding among first time mothers [27] and our findings highlight how intense the pain and despair can be. Repeated reports emphasise that a large percentage of first time mothers experience early breastfeeding problems [7,9,10] and that all types of problems cause pain for the mother, from sore nipples to engorgement and mastitis. Initial breastfeeding experiences, such as sore and cracked nipples, are risk factors for early discontinuation or cessation, and pain related to the baby sucking may be exhausting and delay establishing the relationship with the child [28]. No single agent has been shown to be effective in helping the breastfeeding mother with this early nipple pain except education in breastfeeding technique and latching on. However, the effect of this kind of support on nipple trauma and breastfeeding duration lacks documentation from studies with a randomised design [29]. Recent studies have pointed to the influence of vacuum in the baby’s mouth in attachment of the baby at the breast and how the baby itself is capable of positioning the nipple appropriately in the mouth [30]. Early in the breastfeeding process more focus is needed on maternal comfort and discomfort and on mothers’ feeling the right attachment of the baby at the breast. When the health professionals first raised questions about the baby’s thriving or the mother’s milk production, they left some mothers with perceptions of themselves as insufficient milk suppliers. This doubt tended to stay with the mothers making them constantly alert throughout the breastfeeding course. The basis for building up motherhood is to succeed in making the baby grow and thrive, keeping in mind that new mothers, especially primiparae often experience anxiety and uncertainty [31]. Psychosocial factors, such as mother confidence to overcome difficulties and succeed with

breastfeeding (self-efficacy) have a positive influence on the breastfeeding duration [21]. In contrast, experiences of poor breastfeeding might influence the mothers’ confidence negatively. McCarter-Spaulding and Kearney [32] found a correlation between low self-efficacy and perception of insufficient milk production. Recently Brown and Lee [33] found that confidence and determination were significant for successful breastfeeding among first time mothers. Continuing this line of reasoning, health professionals should be concerned with building confidence in breastfeeding by facilitating in a sensitive way rather than discouraging [17]. The unsettled baby calls for a more complex and holistic understanding than just blaming the breastfeeding act [34]. In the mothers’ descriptions, a fragility appeared that made them vulnerable to their surroundings and dependent on the health professionals who had helped them or let them down. Especially in the beginning, these first time mothers experienced conflicting advice. They wanted to be heard and searched for understanding of their personal breastfeeding situation and for individual guidance. Recent research has found similar results and calls for an awareness of mixed messages to mothers [13,17]. Taking into consideration that individualised support seems to influence maternal behaviour more than persisting with generalised standardised support, we need to pave the way for a more personal, family-focused approach to breastfeeding support. This does not mean moving away from evidence-based practice. We need to implement evidence-based care in ways that prevent conflicting advice and set the standard for good clinical practice. Health professionals must at all times be responsive to the needs of the family and individualise breastfeeding support, based on both research and the mother’s perspective of the breastfeeding situation and recognizing the mother as a source of knowledge in her own right. When searching for a foothold, mothers in this study felt conflicted by their surroundings. Everybody seemed to have an opinion on breastfeeding. Our findings support those of Burns and colleagues [8] who described breastfeeding as embedded in a social and cultural context. The findings in our study of breastfeeding pressure and the sense of failing as mothers if mothers gave up breastfeeding were also found in an Australian study [35]. The discourse that a good mother is associated with breastfeeding seems to be grounded in the Scandinavian and the Australian cultures. This discourse is the opposite of what Scott and Mostyn found in Scotland in areas where bottle-feeding remains the cultural norm [36]. In Scotland low income breastfeeding mothers were met with little understanding and encouraged by their surroundings to bottlefeed [36]. Thus, cultural norms and pressure must be taken into consideration when health professionals offer advice to mothers to establish the best possible way to feed their newborn. In our study the mothers who chose to answer the openended question were more likely than the non-responding mothers to have experienced breastfeeding being more difficult than they had expected. Our sample might be skewed in the sense that more mothers with breastfeeding problems answered the open-ended question. However, we consider the experiences from these more than 100 first time mothers to provide valuable knowledge. The mothers gave highly personal accounts of their experiences. Whether their stories were brief or detailed, the descriptions of their individual breastfeeding experience and of becoming a mother revealed strong feelings of both joy and hardships. The mothers’ use of dramatic metaphors and emotive words in their descriptions confirm how their experiences with breastfeeding remained with them and that more action needs to be taken by researchers and clinicians. It was striking how the fathers were absent in the mothers’ descriptions. The few times the fathers were mentioned were mostly in a helping and supporting role. We have no explanation for this, other than it was the mothers’ choice at the time of answering our question. The mothers’ descriptions did not provide enough data

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to give valid information about fathers and the role fathers played in the breastfeeding course. This is a limitation in the data as breastfeeding the baby may be a family concern. We acknowledge that the data were collected in 2004 but find that these mothers’ stories provide valuable knowledge about the seemingly persistent challenges connected to breastfeeding. A number of more recent studies show similar findings [9,27,35] thus revealing the timelessness of breastfeeding issues and a need for professional and political initiatives. A limitation of this study is that only one-fifth of the total sample of mothers answered the open question and the respondents were mothers who to a greater extent than non-responders had experienced breastfeeding as more difficult than expected. Other mothers who did not respond might have had quite different experiences of the breastfeeding course, or their choices concerning feeding might have been straightforward whether they continued breastfeeding or turned to bottle-feeding. These aspects might mean that our findings are especially transferable to mothers who experience breastfeeding as more difficult than expected. Conclusion This study underlines how breastfeeding is closely connected to mothering and getting to know the baby, and how painful experiences in the initial phase can be overwhelming. Supporting the breastfeeding first time mother should imply facilitation of the act of breastfeeding as well as consideration of the individual transition to motherhood and her learning to read the baby’s cues. Mothers’ insecurity about milk production and conflicting advice from their surroundings should be addressed proactively by health professionals. The study points to the necessity of early on, and all through the breastfeeding–bonding trajectory to build up the mothers’ confidence in breastfeeding and be sensitive and responsive to the needs of the new family. Conflict of interest statement Authors declare no conflicts of interest. References [1] World Health Organization. Infant and young child nutrition, global strategy on infant and young child feeding. Geneva: WHO; 2002. 55th World Health Assembly (A55/15). [2] Häggkvist AP, Brantsæter AL, Grjibovski AM, et al. Prevalence of breast-feeding in the Norwegian Mother and Child Cohort Study and health service-related correlates of cessation of full breast-feeding. Public Health Nutr 2010;13(12):2076–86. [3] Brekke HK, Ludvigsson JF, van Odijk J, Ludvigsson J. Breastfeeding and introduction of solid foods in Swedish infants: the All Babies in Southeast Sweden study. Br J Nutr 2005;94(3):377–82. [4] Christensen AM, Brixval CS, Svendsen M, Laursen B, Holstein BE. Report for children born in 2008 and 2009. Breastfeeding in 14 municipalities [Danish: Amning i 14 kommuner. Årsrapport for børn født I 2008 og 2009]. Copenhagen: National Institute of Public Health; 2011. [5] Kronborg H, Vaeth M. The influence of psychosocial factors on the duration of breastfeeding. Scand J Public Health 2004;32(3):210–16. [6] Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012;(5):CD003519.

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