Original Article

Mothers’ Breastfeeding Experiences of Emotional Support Needs: A Qualitative Study in Iran

Introduction

Breastfeeding is an important strategy to ensure health promotion and wellbeing. ¹ Breastfeeding provides a number of short- and long-term health benefits for both the mother and infant. ^2,3 The WHO recommend the exclusive breastfeeding for the first 6 months and its continuation up to at least 2 years of age. ⁴ Scientific evidence from several studies has also highlighted the importance of breastfeeding. ^2,3,5-8 However, the methods of nutrition for infants are not favorable and breastfeeding rates have consistently decreased around the world. ⁶ The level of exclusive breastfeeding in the six-month period in America, Australia, Eastern Mediterranean region, Iran, and other parts of the world has been reported to be 16%, 36%, 10%, 28%, and 37% respectively. ⁹ Breastfeeding initiation and its sustainability are affected by various issues like the mother’s demographic and psychological factors as well as cultural and social factors like breastfeeding social support, etc. ^7,10-14 House categorized the concept of social support into four types of behavior including emotional, informational, instrumental, and appraisal support. Emotional support allows people to express their feelings; thereby reducing their tension and improving the person’s relationships. ¹⁵ these feelings involve expression of empathy, caring, understanding, love, and concern toward a person. ¹⁶

If mothers can recognize, understand, and communicate their needs to other people of social network, they will probably achieve successful breastfeeding, but then again mothers experience breastfeeding as a challenging and demanding behavior; they face a range of difficulties and stressors in this period. ^5,6,17

Social support has a buffering and health-benefit effect during the stressful events such as breastfeeding and helps a person adjust to a new situation. ¹²

The majority of breastfeeding studies focused on quantitative methods and those adopting a qualitative approach on social support needs and experiences of breastfeeding mothers are few. ^{2,3,7,8,10,11,18-20} Similiarly, almost all studies conducted in Iran on this subject have employed quantitative methods, hence a dearth of qualitative research. Since, there has been a paucity of information on breastfeeding mothers regarding social support needs especially emotional support needs in Iran, it is crucial to address such needs so that appropriate support programs can be designed during this period. This qualitative study was conducted to explore emotional support needs of breastfeeding mothers who were living in Mashhad, Iran. It help to deeply understanding of their emotional support needs so that providing proper support can apply for increasing the level of exclusive breastfeeding.

Materials and Methods

This study used a qualitative method and a directed content analysis approach at five health centers and four hospitals affiliated to Mashhad University of Medical Sciences and medical clinics in Mashhad, Iran, between March 2017 and April 2019. Participants in this study were 25 breastfeeding mothers, two family members, and 9 healthcare providers (2 pediatrician, 2 experts in promoting breastfeeding, 2 midwives, 3 family health experts) who were selected using a purposive maximum variation sampling method. The maximum variation in sampling was reflected in terms of socio-demographic level (Table 1).

Being a volunteer, readiness to take part in the study and be interviewed, speaking Persian language, living in Mashhad, having a term baby, and not suffering from any diseases (both the mother and baby) were the inclusion criteria in this study. Breastfeeding mothers who showed no willingness to go on participation in the study were excluded.

Breastfeeding mothers were invited to participate in this study and were informed of voluntary nature of participation, their right to withdraw from the study at any time, anonymity and the confidentiality of all their information. No participants asked to withdraw from this study.

Data were collected using semi-structured interviews at a time and place appropriate for the participants to gain an insight into breastfeeding mother’s perceptions and experiences. During the interview, the researcher introduced herself and explained the objectives of the study and obtained an informed consent to record interviews with a recorder. The interview began with general questions and proceeded to ask the participants to explain their experiences of breastfeeding. Subsequent questions were based on the participants’ responses and the social support conceptualization by House. ¹⁵

The main questions were:

Based on your experiences as a breastfeeding mother;

simple

• - Would you talk about your breastfeeding experiences?

• - What support do you need during this period? Who helped you to meet your support needs during the breastfeeding period and how?

• - What types of behavior in this period decreased your stress and made you feel more relaxed?

• - With whom did you share your emotions during this period and how did they support you?

• - Based on your experiences as an expert;

• - How are mothers supported during breastfeeding? And what are their support needs?

• - Who is involved in meeting the support needs of breastfeeding mothers and how?

• - What types of behavior in this period decreased mothers stress and made them feel more relaxed?

Probing questions such as “Could you tell me more about that, please?” were asked to find additional data. The mean duration of each interview was 40 minutes (range: 25-140). Data collection continued until data saturation was achieved.

The interviews were performed, recorded, and transcribed verbatim by the first author (NMS) but all authors analyzed the data. Researchers had already experienced conducting qualitative research, guiding qualitative interviews, making advancement and analysis of qualitative data, and also had professional experiences of and activities in the field of midwifery, reproductive health, and social sciences.

Data were analyzed using directed content analysis based on the Elo and Kyngas ²¹ method with MAXQDA software (version, 2010). This approach has three main stages including preparation, organization, and reporting. In preparation stage, the first author (NMS) listened to the recorded interviews and transcribed them. In the second stage, the transcriptions were read line by line, and important words, sentences or paragraphs were underlined and labeled as codes according to categorization matrix (or framework) that formed based on House’s conceptualization of social support ¹⁵ (Table 2) and then data grouping, categorization, and abstraction were performed. In the final stage, researchers reported the analysis process and the discoveries. ²¹

Guba and Lincoln’s criteria were utilized to assure the trustworthiness and rigor of the data. ²² To establish credibility, long-term involvement and continuous observation by the researcher, review of transcriptions by participants, and triangulation and maximum variation in the sampling were put into operation. Some external supervisors were requested to ensure the dependability of the study. Transcriptions, codes, and extracted categories were reviewed by qualitative researchers in order to improve the confirmability of data; hence an appropriate agreement was attained in this regard. Also, details of the study process and the participants’ direct quotations were provided to enhance the transferability of the results. ^23,24 Data saturation was reached by the 36 interviews, and thus recruitment ended at that point, because of further coding is no longer feasible and the researcher was convinced that additional new information has not been attained and there is enough information to replicate the study.

Results

Table 1 shows the socio-demographic data of 36 participants who took part in this study.

Four categories emerged during the content analysis process identifying 4 types of emotional support needs which were ‘need to tranquility and solace’, ‘sense of being loved and belongingness’, ‘creating hope, motivation, and confidence’, and ‘empathy and companionship’, and 12 subcategories including ‘not inducing stress’, ‘relieving the mother’s stress and worries’, ‘creating and maintaining tranquility’, ‘understanding and attention’, ‘receiving affection from significant others’, ‘being respected by others’, ‘ being inspired by significant others’, ‘being assured by family members’, ‘being motivated by significant others’, ‘interacting with others’, ‘having the companionship and presence of others’, and ‘receiving empathy from others’.

Need to Tranquility and Solace

Three subcategories of ‘not inducing stress, ‘relieving the mother’s stress and worries’, and ‘creating and maintaining tranquility’ were included in this category. According to participants’ statements, the need for a sense of tranquility and solaceduring breastfeeding is of high importance. A health professional stated: “pacifying the mother during this period is very important.... Sometimes the tranquility that a physician gives to her patient can be very effective, perhaps more effective than medicine” (Participant 26, pediatrician, 40 years old). As participants stated, family members should not induce stress to the breastfeeding mother. Also, various settings such as work place, educational environment, etc. must be stress-free; a health provider said: “I think it will be fine [enough] if the work place, itself, does not create stress for the mother” (Participant 4, a 47-year-old midwife).

The participants acknowledged that stress and worry for breastfeeding mothers should be resolved quickly, because they can lead to adverse outcomes such as reducing breast milk production. The husband plays an important role in assuaging the mother’s worries. One of the participants said: “when I had stress and discomfort, I realized that I could not produce breast milk! My breast milk was so little! And this expression people say ‘the breast milk begins to dry up’ was about to happen” (Participant 6, a 42-year-old mother). According to participants’ points of view, other people such as family members, health personnel, and colleagues should bring calmness for breastfeeding mothers. A health provider emphasized that “colleagues should take care of the breastfeeding mother and collaborate with her...if she comes late to the work place...or does the tasks ahead or behind time...they should understand her condition so that the mother becomes calm and relaxed” (Participant 4, a 47-year-old midwifery expert). In this regard, one of the mothers said: “once I burst into tears because my baby was crying and I could not pacify him by breastfeeding, I cried...I was crying... my downstairs neighbor showed up and asked why I was crying? And she calmed me down” (Participant 6, a 42-year-old mother). Avoiding disputes and arguments in the presence of the breastfeeding mother is a strategy suggested by a health professional to achieve a sense of tranquility. She said: “there should not be any arguments in the presence of the mother...either verbally or physically...and disputes must be avoided in the presence of the mother” (Participant 4, a 47-year-old midwife).

Sense of Being Loved and Belongingness

For this category, there are three subcategories including ‘understanding and attention’, ‘receiving affection from significant others’, and ‘being respected by others’. Participants stated that during the breastfeeding period, other people like their spouse, family members, friends, relatives, and health personnel should understand the mother’s condition, and in this regard, the role of the spouse is more important than others so that spouse’s lack of understanding of the mother’s condition will cause her discomfort.

One of the mothers said: “my husband expects too much of me in doing household chores... for example, he never says he didn’t mind if I could not cook...[on the contrary], he keeps asking why I didn’t cook anything...he does not understand me at all....well, these [things] affect me...they let me down...” (Participant 5, a 35-year-old mother). Participants believe that attention from the spouse in this period is very important. Mothers said that during this period, they needed a great deal of attention from the spouse. One of the mothers in this regard said: “I love my husband to be more attentive to me...I love he pays as much attention to me as he pays to [our] children and cares for me as much...my husband is too busy...he is preoccupied with his job” (Participant 3, a 34-year-old mother).

A health professional stated: “the spouse should pay special attention to the woman in this period...I mean a special conjugal attention between the spouses...” (Participant 26, a 40-year-old pediatrician). Affection from significant others, such as the husband, family members, and health personnel, was identified to be one of the emotional support needs during breastfeeding period. Most mothers need to be loved by their spouse both verbally and physically. Participants in this regard stated: “in this period, you need a lot of emotional support, especially affection and love from your spouse” (Participant 12, a 28-year-old mother). “Husband’s affection is very important...the husband should kiss and hug his wife... when the mother is breastfeeding her baby, he should come and caress his wife and his baby. When your husband supports you, hugs you and uses words of love talking to you and assures you that he is with you... it persuades me as a mother to breastfeed my baby much more and in a better way” (Participant 28, a 34-year-old mother).

Some mothers referred to the unkind and aggressive behavior and bad temper of their spouse, his family members, and health personnel, and talked about their experience about unkind behavior and lack of understanding from others during breastfeeding period, and emphasized that such behavior caused depression. One of the participants said: “whenever I went to a health center to check my baby’s weight, if my baby had lost some weight, they’d [the personnel] have reprimanded me!!! They would angrily asked why my baby had lost weight; they became aggressive and I became depressed instead of being energetic...” (Participant 7, a 35-year-old mother). Another participant stated: “my husband has some annoying habits, for example he treats me as if I’m a servant...he argues all the time...he gets up on the wrong side of the bed!” (Participant 11, a 35-year-old mother). Participants considered the respect from others, including their spouse, family members, and health personnel, as one of the emotional supportive needs for mothers. Some mothers pointed out that the disrespectful and abusive behavior of healthcare personnel would cause depression. In this regard, one of the participants expressed: “I am glad that my daughter-in-law breastfeeds my grandson, and I respect her decision and I’ve asked my son to thank her when he is home [from work] and respect her” (Participant 32, a 66-year-old grandmother). Another participant said: “after delivery in the maternity ward of the hospital, I heard one of the personnel humiliating a mother in an offensive way because she was fat with inverted nipples, had given a Cesarean birth to her baby, could not move appropriately, and could not breastfeed her baby well. The mother was terribly depressed because of this behavior...” (Participant 28, a 34-year-old mother).

Creating Hope, Motivation, and Confidence

Three subcategories of ‘being inspired by significant others’, ‘being assured of support by family members’, and ‘being motivated by significant others’ are included in this category. According to participants’ experiences, encouraging the mother, giving her assurance of support, inspiring her and trying not to discourage her by significant others such as the husband, family members, and health personnel are among the breastfeeding mothers’ emotional support needs.

In this regard, one of the participants stated: “in this period, it is necessary that the health care personnel motivate mothers” (Participant 7, a 35-year-old mother). Another participant emphasized on the role of the significant others, such as the husband, family members, and health personnel in motivating the mother during breastfeeding period. One of the participants said: “my wife had a problem breastfeeding the baby on the first days, and we were very worried about this issue at that time. I tried not to show my concerns but to understand her condition... to motivate her not to be frantic with worries. I told her that it was not a big deal and the problem was to be figured out... I gave her the spirit this way so that she’d never get discouraged” (Participant 36, a 37-year-old husband). Another participant said: “health personnel should motivate the mother to continue breastfeeding her infant and not to stop breastfeeding” (Participant 28, a 34-year-old mother). Also, based on participants’ experiences, it is important that husband and family members give the mother assurance of support during the breastfeeding period in order to sustain breastfeeding. A health professional said: “mother’s relatives, including the spouse and family members must give her the assurance that this is a temporary period and then she will return to the same condition as before- either physically or in terms of problems she has now- only this very first 3-6 month period is difficult” (Participant 26, a 40-year-old pediatrician).

Empathy and Companionship

This category includes three subcategories of ‘interacting with others’, ‘having the companionship and presence of others’, and ‘receiving empathy from others’. Participants acknowledged that mothers need a companion to talk to during breastfeeding period, and such companionship would have good results for them, including keeping spirits up, inspiring feelings, and reducing stress and depression. A health provider said: “when we talk to mothers, it reduces their stress dramatically. Many mothers who come to this center have psychological problems...they have family problems...especially those who live in the suburb...when a mother comes here and has a chat for ten or fifteen minutes, and makes small talk with us, it is a very effective way to raise her spirits” (Participant 14, a 37-year-old family health expert).

According to the experiences participants shared, the mother feels a great need for the presence and companionship of others during the breastfeeding period, especially her husband; this sense of being together has good fruits for her, including feeling capable and not feeble, feeling no sore points or weaknesses but confidence, enjoying good sleep, enjoying comfort both for the mother and baby, and having a sense of pleasure and satisfaction. One of the participants stated: “I kept asking my husband to be near me all the time...I do not know why? But perhaps when you think he is in the room with you and is present there, it brings you a sense of pleasure and satisfaction” (Participant 21, a 40-year-old mother). A health professional said: “in this period, the breastfeeding mother needs to be near the family members specially her mom at least for one month...but when after ten days she is left alone with a baby…it becomes so hard” (Participant 33, a 40-year-old member of the university’s breastfeeding committee). According to participants’ experiences, another emotional need for mothers is the others’ empathy which brings the mother calmness and tranquility. In some breastfeeding stages, such as weaning, mothers emphasized that they needed others’ empathy more. They also stated that when group classes were held, their need for empathy was met more because of the presence of their peers. One health professional said: “you must empathize with the mother” (Participant 33, a 40-year-old member of the university’s breastfeeding committee). Another participant stated: “when I wanted to wean my baby, my mother told me about her experiences and empathized with me, because it’s really difficult to wean a baby. You feel that your relationship with your baby is being cut off, and on the other hand, you see that the baby suffers and turns sulky and you understand it. This is not an easy situation” (Participant 23, a 39-year-old mother).

Discussion

This study explored the experiences and emotional support needs of breastfeeding mothers in Mashhad, Iran. Qualitative methods empowered a deep and rich exploration of the matters from the perspective of breastfeeding mothers.

This research identified 4 types of emotional support needs, namely ‘need to tranquility and solace’, ‘sense of being loved and belongingness’, ‘creating hope, motivation, and confidence’, and ‘empathy and companionship’. Our research results, in regard to emotional support as a kind of social support needs for mothers, are in accordance with the results of previous studies which have shown that emotional support is a frequently-mentioned form of social support needs identified by breastfeeding mothers. ^17-19,25,26

Similar to the present study, the results of a qualitative study conducted by Lester revealed that breastfeeding mothers recognized emotional support as the most valuable form of social support they received from their partner during breastfeeding period. ¹⁹ Findings of this study about partner’s important role in bolstering emotional support is consistent with the findings of qualitative studies conducted by other researchers. ^18,19,27

The present research indicated that the motivation generated by significant others, such as the husband, family members, and health personnel, in mothers during breastfeeding period is a kind of emotional support need which is important for sustaining breastfeeding; previous studies found similar results and showed that motivation from family members affected mothers’ infant feeding practices. ^17-19 According to the results of this study, raising confidence and holding the mother in respect are some components of the mother’s emotional needs. In line with the results of this study, findings of other research corroborated such participants’ needs for assurance and respect. ^26,28

Based on the participants’ experiences, mothers feel a great need for the empathy and companionship of others, particularly their husband, during the breastfeeding period; other studies also found similar findings. ^17,19,29-31

Participants emphasized that during the breastfeeding period, other people should understand the mother’s condition, and in this regard, the role of the husband is more critical where lack of understanding would cause the mother’s discomfort. This finding is consistent with the results of research carried out by Lester who found that understanding all breastfeeding issues, such as hormonal changes, stress, fatigue, etc. was a matter of great importance for the mother. ¹⁹

According to participants’ statements, the need for tranquility and solaceduring the breastfeeding period is absolutely necessary and others should not be a source of stress to the mother in various settings. Other studies have also highlighted the importance of the mother’s psychological comfort in breastfeeding success. Husbands should be trained to maintain the tranquility and reduce the mother’s anxiety. ^30,32

Making the presence of others, especially the husband, felt by the breastfeeding mother is another emotional support need producing good results for her; this is consistent with the findings of other studies which reported the importance of such presence of others during breastfeeding period and their involvement in the breastfeeding process. ^19,30,32 The majority of breastfeeding mothers who participated in this study emphasized that, as an important emotional support, they needed to receive care from others, especially their husband; the findings of other studies revealed similar results. ^17,19,33

Similar to this study, other research studies also showed that emotional support was a crucial factor in facilitating mothers’ breastfeeding experiences and played a pivotal role in breastfeeding promotion and initiation. ³⁴ There are several major strengths of this research study. First and foremost, this qualitative research contributes to new knowledge about emotional support needs of breastfeeding mothers through the sociocultural context of Iran. Also, this study used qualitative methods to gather rich, in-depth personal experiences of breastfeeding mothers. An additional strength of this study is the participation of health care providers and 2 family members in the development of the research.

As with most qualitative studies, a limitation of this study is its generalizability. Due to the nature of this study, a high degree of subjectivity of research methods during both data collection and analysis influenced the results through the researcher’s personal biases. So there is a need for further research in other areas and cultural contexts to gain a deeper insight into the subject under study.

Conclusion

This study contributes to an understanding of emotional support needs of breastfeeding mothers within four categories of ‘need to tranquility and solace’, ‘sense of being loved and belongingness’, ‘creating hope, motivation, and confidence’, and ‘empathy and companionship’. Significant others, i.e. the husband, family members, and health providers, have an important role in meeting such needs. Also, health policymakers should pay attention to these emotional support needs to implement effective programs to improve breastfeeding mothers’ social support and reduce the rates ofbreastfeeding cessation.

Acknowledgements

This study was a part of a PhD thesis in reproductive health with an ethical approval grant no. (IR.MUMS.REC.1396.124) which was financially supported by Mashhad University of Medical Sciences with grant no. 951682. The authors would like to thank the Deputy of Research for their financial support and would also like to appreciate all the participants who contributed to this study and shared their experiences.

Ethical Issues

Breastfeeding mothers were informed of the study’s purpose, voluntary nature of participation, their right to withdraw from the study at any time, anonymity and the confidentiality of all their information. Also written consent was obtained from each participant prior to the interview. This study obtained approval for the research plan from the Medical Ethics Committee of Mashhad University of Medical Sciences (IR. MUMS. REC.1396.124).

Conflict of Interest

There is no conflict of interest to be declared.

Authors’ Contributions

NMS, KHMN: Involved in the conception, designing the study, preliminary data analysis and data gathering; NMS: Performed the data analysis and interpretation, wrote the manuscript; KHMN, HE, HK: Supervised the development of work, helped in data analysis and interpretation and manuscript evaluation; KHMN, FZF: Helped to evaluate and edit the manuscript.

Research Highlights

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