Although the focus of this research question was on addressing postpartum breastfeeding chal- lenges, many research articles included in this review also included an element of antepartum breastfeeding education and support. Overall, the studies support the profound effect that antepar- tum interventions can have on preventing postpartum breastfeeding challenges in the first place.
174 Chapter 15 Overcoming Breastfeeding Challenges: A Case Study
For instance, Metallinos-Katsaras, Brown, and Colchamiro (2015) found in their longitudinal retrospective study of mothers in the Massachusetts WIC program that mothers who entered WIC prenatally were more likely to initiate breastfeeding and were more likely to have longer per- iods of breastfeeding duration than those women who entered WIC after delivery of their baby.
The authors suggested that this longer exposure helped give breastfeeding mothers education and support needed to successfully initiate and prolong breastfeeding.
Areas of Agreement and Disagreement
One area of agreement in the literature was in the common barriers that mothers encountered during their breastfeeding experience. Studies, as a whole, reported that common challenges that led to breastfeeding cessation were lack of social support from family or partners, perceived or actual poor milk supply, perceived infant preference for formula, sore breasts or nipples, increased stress, diffi- culty returning to work or school, a lack of knowledge related to breastfeeding, and a lack of health- care support (Brand et al., 2011; Chen et al., 2012; Cross-Barnet et al., 2012; Dunn, Kalich, Henning,
& Fedrizzi, 2015; Kadakia, Joyer, Tender, Oden, & Moon, 2015; Martino, Wagner, Froh, Hanlon, &
Spatz, 2015; Smith et al., 2012; Wambach, Domlan, Page-Goertz, Wurtz, & Hoffman, 2016).
While factors that contributed to improved breastfeeding rates and duration were not as com- monly studied as factors that contributed to breastfeeding cessation, authors agreed that factors that aided in breastfeeding were improved familial or social support and maternal self- efficacy (Chen et al., 2012; Dunn et al., 2015; Negin, Coffman, Vizintin, & Raynes-Greenow, 2016; Wambach et al., 2016.)
Areas of disagreement mainly involved the use of interventions to improve breastfeeding.
Various suggestions were found throughout the literature, including interventions by lactation consultants (Bonuck et al., 2014), enhancement to the education healthcare providers themselves receive in regard to breastfeeding (Chen et al., 2012), use of breastfeeding logs (Pollard, 2011), increased use of social media forms of support (Asiodu et al., 2014; West et al., 2011), and delay- ing the return to work until a normalized mother-baby routine had been established (Froehlich et al., 2015). None of these interventions were, on their own, considered to be completely unhelp- ful, but there was disagreement as to which would provide the most benefit and which should be the area of most focus.
State of the Art in the Literature
One strength of the literature was that research has produced a thorough appraisal of the common difficulties faced by breastfeeding mothers. The literature also provided a good focus on the point of view of the breastfeeding mothers themselves, as opposed to medical professionals in the field.
Eleven of the sixteen studies included in the review included some qualitative aspect (whether they were strictly qualitative or included some sort of mixed methodology), allowing researchers to gain insight into the experience and perspective of the group under study and to provide base- line data for future study.
Gaps in the literature, however, include a lack of focus on specific interventions to overcome barriers. While barriers were identified readily enough, the research did not address what interven- tions breastfeeding mothers could then take to overcome specific problems. As evidence of this sit- uation, the literature also has a lack of quantitative data to support specific measures—only two of the studies were randomized, controlled trials that showed the direct effects of specific interventions.
The Literature 175
While the study under proposal is also qualitative in design, it would help address gaps in the research with its focus on resources and interventions used to overcome specific breastfeed- ing concerns of a particular mother. Ideally, this data will help target future research on successful community breastfeeding interventions.
▸ Methods
Design
This research was a qualitative study, comprising a case study conducted via semistructured interview.
Sample
The desired sample for the study was one woman in the northern Atlanta/Alpharetta area who had breastfed or was currently breastfeeding her infant(s). Specifically, the desired participant would have faced significant challenges during her breastfeeding experience, but she would have con- tinued to breastfeed her infant in the face of these challenges.
The researcher posted to a Facebook page for a group called “Alpha Mamas,” an online group created to provide online parenting support for mothers in the Alpharetta/Northern Roswell area of Georgia. Within 24 hours, 4 of the group’s 119 members had responded to express interest in participating in the study. Further selection of a study participant was based on potential participants’
availability, proximity, length of total time spent breastfeeding, and how recently the participants’
breastfeeding experience had occurred. Also, since the aim of the research was to assess barriers to breastfeeding and how those barriers can be overcome, preference was given to those interested individuals who underwent an unusual number of challenges or problems during breastfeeding.
From these four interested respondents, one participant was chosen for the sample— Elizabeth (a pseudonym used to maintain privacy), a woman who had breastfed both of her children (and was, in fact, still nursing her youngest son), lived locally, had flexible availability, and had journeyed through a markedly turbulent breastfeeding experience.
Procedures were put in place to protect the rights and privacy of the participant and IRB approval was obtained.
Setting
The interview occurred at the home of one of the participant’s close friends. The friend watched the participant’s two children downstairs while the interview was recorded in a quiet, comfortable, private study upstairs.
Instrument and Data
The study was completed using a semistructured interview, composed of the following questions:
1. Tell me a little about yourself and your child(ren).
2. When and how did you make the decision to breastfeed?
3. What were your goals for breastfeeding?
4. What were the biggest barriers or challenges that you faced during breastfeeding?
5. What did you do to overcome those barriers?
176 Chapter 15 Overcoming Breastfeeding Challenges: A Case Study
6. What did you see as your greatest sources of support for breastfeeding?
7. What could have made your breastfeeding experience better for you and your child(ren)?
Additional follow-up questions were added, as needed, based on the participant’s responses.
The digital recording of the interview was transcribed by the study’s author to create a verba- tim written record of the interview. Afterward, the responses to the interview questions were ana- lyzed via content analysis. Sections of the transcript that correspond to the aim of the study were underlined and coded. These final coded sections of the transcript were then reviewed and ana- lyzed for emerging themes and subthemes.
Rigor
Houghton, Casey, Shaw, and Murphy (2013) suggest several methods to increase reliability and valid- ity in case study research. One such method is to ensure a sufficiently prolonged interview time, to allow a thorough and complete enough discussion that no new themes or emerging data would be forthcoming, even given more time. To achieve this goal, the author asked broad initial questions, asked appropriate follow-up questions, and allowed the participant adequate time to fully answer all inquiries to allow for data saturation.
Another way to increase the reliability and validity of the study involves member checking. In this case, Elizabeth was emailed a copy of the full transcript of the interview, which she agreed had been transcribed accurately and appropriately.
Procedure
The interview took place and was recorded in a study upstairs, while the friend watched Elizabeth’s two children for the duration of the interview. This setting allowed for privacy, convenience, and com- fort. Having a trusted babysitter allowed for the interview to be conducted without childcare-related interruptions.
Following the recording session, the author created a complete written transcript of the inter- view. A copy of the transcript was sent to Elizabeth for review, and she attested that, from her per- spective, the interview had been accurately transcribed. A thorough review and content analysis then followed, with one follow-up email sent to the participant for clarification on some small points. Prominent sections of the interview were underlined and analyzed until dominant themes emerged from the interview data.
▸ Results
Participant
The participant in this case study was Elizabeth, a 34-year-old Caucasian woman from Georgia.
She graduated with a bachelor’s degree, as well as a child development associate (CDA) degree. She was married, and she had two sons, a 3-year-old and an 11-month-old. She breastfed her first son until he was 26 months old, and she was still currently breastfeeding her youngest son. After hav- ing her children, she stayed at home to care for her children, but prior to that, she worked as the head of warranty and an assistant to the CFO for a manufacturing company, and following that, she worked as a preschool teacher.
Results 177
The concepts that emerged from the interview fell into two broad categories: barriers to breast- feeding and factors that helped to overcome these barriers.
Barriers to Breastfeeding
Physical Barriers
One major obstacle that Elizabeth had to contend with was the issue of physical barriers to breast- feeding. In Elizabeth’s case, these broke down further into maternal factors and infant-related factors.
Maternal Factors. Elizabeth endured several physical conditions related to breastfeeding, the most prominent of which was breast and nipple pain. She described the first 4 months of breastfeeding her eldest son as “constant, excruciating pain.”
One major factor contributing to this pain was vasospasm in her breasts. Elizabeth described that, after breastfeeding her eldest son, her “whole nipple would be white . . . and then, like, a min- ute later, the blood would come back, so it would get red again, but it would hurt so bad when the blood went back. Like someone had just slammed the door on [my] nipple, every time after he’d feed.” In addition, Elizabeth experienced repeated cases of thrush, a Candida albicans infection of the breast that characteristically causes stabbing, severe pain (Pessel & Tsai, 2013). The thrush infections were exacerbated by Elizabeth’s tendency toward engorgement of the breasts, caused by an overabundant supply of breast milk. The oversupply of milk was in and of itself painful, due to increased breast swelling; but the increased levels of breastmilk provided an optimal environment for growth of the Candida organism, which in turn contributed to Elizabeth having yet more cases of thrush. Finally, Elizabeth experienced nipple tenderness simply related to poor latching of the infant to the breast. Nipple pain is a common and undertreated problem in breastfeeding women, in general; it is a frequently cited reason for early breastfeeding cessation (McClellan et al., 2012), although Elizabeth was later able to overcome the pain in this case.
Another physical barrier that affected Elizabeth was exhaustion. Her first son, in particular, nursed every 2ẵ hours “night and day” until he was 2 years old. The same child would frequently be awake from midnight to 3 a.m., “no matter what,” in the first year of his childhood. The effect of constantly feeling tired decreased her sense of physical well-being and made her feel unable to function as well during the day.
Infant-Related Factors. Elizabeth’s children also had factors that made breastfeeding difficult.
Her second child was born 4 weeks before his due date. Preterm infants are more likely to have difficulties with breastfeeding, such as increased lethargy and inefficient sucking (Mulready-Ward &
Sackoff, 2013). As may then be expected, Elizabeth’s youngest was not vigorously active at the breast, which impacted her milk supply. Elizabeth stated that her milk “wouldn’t come in, since he was so early, so we had to . . . feed him, then pump, then supplement after every feeding for 2 weeks. So that was really hard.”
The same infant also had a labial frenulum, or lip tie. Research has demonstrated that infants with a superior labial frenulum have difficulty flanging the upper lip properly while nursing, lead- ing to poor latch and nipple pain (Kotlow, 2013)—precisely what came to pass with Elizabeth.
Lack of Breastfeeding Knowledge
The second main barrier from Elizabeth’s narrative was a lack of breastfeeding knowledge, encom- passing both Elizabeth’s and her medical providers’ lack of information.
178 Chapter 15 Overcoming Breastfeeding Challenges: A Case Study
Elizabeth’s Lack of Knowledge. Elizabeth had taken a lactation class prior to delivering her first son, which made her feel empowered and prepared to breastfeed. But she reported, “Then the baby came out, and I was like, I have no idea what [the instructor] told me!” Taking the information she had learned and putting it into practice at the actual time of delivery was a problematic transition.
Also, the class did not cover all the difficulties she eventually ran into—for example, Elizabeth
“thought it was supposed to hurt that bad every time you fed.” She had no way to tell a normal breastfeeding experience from an abnormal one. Smith et al. (2012) mention this problem in their study, as well—that frequently, prenatal breastfeeding education does not teach adequately about the challenges of breastfeeding and the skills to use in the face of these challenges.
Healthcare Providers’ Lack of Knowledge. Elizabeth’s healthcare providers were also not fully prepared to respond to her physical breastfeeding challenges. When Elizabeth approached her pro- viders with problems, they often did not react aggressively or seriously to her concerns. She said,
“When I called the OB . . . they were very relaxed about it. But, like, it’s a big deal when it’s three in the morning and your baby wants to eat and you’re in pain. You kind of need a little bit more addressed.” Regarding her vasospasm, Elizabeth’s providers did not know at all what her condition was and were unable to properly diagnose her. Only after Elizabeth did extensive research on her own and brought the research (including recommended treatment) to her provider did she receive the care needed to overcome the problem. Inconsistency of medical advice was also a problem.
Elizabeth reported that, when she and some other mothers were discussing a breastfeeding issue, each woman reported what their pediatrician had recommended, and each woman had received completely different advice. Cross-Barnett et al. (2012) discuss that inconsistent information from medical providers, such as the example here, is an issue that frustrates many women and motivates them to discontinue breastfeeding.
Social Stigma
A final concept that emerged as a breastfeeding challenge was encountering the social stigma associated with breastfeeding, particularly out in public. While Elizabeth was eventually able to transition into breastfeeding comfortably in public spaces, at first, she felt “super shy,” because “you don’t see so many women breastfeeding.” She would arrange her day so that she could be home in time for feedings, to avoid this discomfort. At first, too, she had to navigate friends and family mem- bers who were uncomfortable with breastfeeding. Elizabeth explained how her father had an issue with it, “Even if I have a cover and you can’t see anything, he’s still like, I’ll wait in the other room!”
She reported that, while some bystanders were very kind and supportive of breastfeeding in public, she did experience “dirty looks” and “stares” that she had to get accustomed to. She also shared one story of a mall employee who approached her and told her to cover up when she was breastfeeding her son in public. This attitude is not unusual, and a community perception of distaste for public breastfeeding has been documented in the research literature (Mulready-Ward & Hackett, 2014).
Methods of Overcoming Barriers
There were four main concepts that emerged as a means of overcoming the hardships of breastfeeding.
Education and Expert Advice
While she acknowledged the limitations in some of her providers’ breastfeeding knowledge, Elizabeth still found the advice and education she received from medical providers very useful overall. She Results 179
particularly praised the nurse practitioner at her OB/GYN office, who was very well versed in breast- feeding support. She also enjoyed the antepartum and postpartum support given by lactation consul- tants associated with her local hospital. Finally, she also relied on Internet resources, particularly the website of Dr. Jack Newman, a Canadian physician and breastfeeding authority, which allowed her to find the resources she needed to identify and treat her vasospasm (Newman & Kernerman, 2009).
Medical Interventions
Several medical interventions allowed Elizabeth some relief from breastfeeding challenges.
A chief intervention included medications of various sorts—diflucan and other antifungals for the treatment of thrush; nifedipine, a calcium channel blocker, for successful treatment of vasospasm (she took the medication for 2 months, then weaned off it with no resurgence in symptoms), and a medication called “triple nipple cream,” a compounded mix of a topical antibiotic, antifungal, and corticosteroid, for nipple pain. Elizabeth described this last medication, in particular, as being “from heaven,” and found it very effective at treating nipple pain (although Elizabeth described some dif- ficulty in getting the medication, both due to trouble finding a compounding pharmacy and due to her provider’s reluctance to give a prescription). Though evidence suggests that providers should use caution and thorough examination to ensure an accurate diagnosis prior to writing prescrip- tions, these treatments are supported by research as helpful in treating nipple pain and infection and, thus, in promoting prolonged breastfeeding (Kent et al., 2015).
Other interventions initiated by medical providers included the frenulotomy done by Eliza- beth’s pediatrician to clip her youngest son’s lip tie to improve his latch, and the initiation of pump- ing to help establish milk supply and to help in the treatment of engorgement.
Community Support
Another theme in overcoming breastfeeding challenges was the support Elizabeth received from various places in her community. Without these examples of support, Elizabeth stated that “I don’t think I would have made it those first few months.” She went into detail about the support she received from the individuals in her life, from her husband helping her hold her breast to latch the baby after her C-section and getting up to wash pump parts at night, to family members helping to plan activities around the times her children had to nurse, to friends who encouraged her and made her feel more comfortable about breastfeeding in public.
In addition to friends and family, Elizabeth attended a free-of-charge weekly breastfeeding sup- port group run by the local hospital. A lactation consultant attended every meeting and helped lead discussions about breastfeeding among the women in attendance. Elizabeth found this experience invaluable, since “you’re like, I must be doing something wrong, everybody else makes it look so easy,” but hearing other mothers recount their stories helped normalize her experience and gave her new ideas and solutions to problems she was having. These examples of support, from family and friends and peers, are in keeping with the research, which shows that a positive support sys- tem contributes to longer breastfeeding times (Chen et al., 2012; Reeder, Joyce, Sibley, Arnold, &
Attindag, 2014; Wambach et al., 2016).
This group also created a Facebook page to provide additional support for its members. Mem- bers could post questions, or articles regarding breastfeeding or parenting, or helpful tips for other mothers to review. This forum was particularly helpful to Elizabeth as a new mother, since “if at 3 am you’re having problems, usually there’s someone else who’s awake, so . . . it’s like a target audi- ence that’s with you.” Emerging research into breastfeeding support has begun investigating methods 180 Chapter 15 Overcoming Breastfeeding Challenges: A Case Study