Can Preterm Baby Be Brust Feed After Dismis From Hospital

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Open Admission

Peer-reviewed

Research Article

Cessation of breastfeeding in mothers of preterm infants—A mixed method report

• Lina Palmér

Abeyance of breastfeeding in mothers of preterm infants—A mixed method study

• Jenny Ericson,
• Lina Palmér

x

• Published: May xv, 2020
• https://doi.org/x.1371/journal.pone.0233181

Figures

Abstract

Introduction

Many women terminate breastfeeding earlier than desired. This study examined the cessation of breastfeeding among mothers of preterm infants. Thus, the aim was to describe the cessation of breastfeeding in mothers of preterm infants up to 12 months after birth.

Method

This mixed methods study used a convergent design with both qualitative data, consisting of written comments, and quantitative data, on breastfeeding status and breastfeeding satisfaction. The data were nerveless from questionnaires sent to the mothers at three points during the outset year afterwards nativity. In total, 270 mothers of preterm infants who breastfed at the time of discharge from the neonatal unit provided information for the written report. The quantitative and qualitative information were analysed separately with statistical tests and hermeneutical analysis, respectively and and so together according to the convergent mixed methods blueprint.

Results

Four themes of the meanings of the cessation of breastfeeding were identified in the qualitative analysis: "Desire to regain the mother'due south and the infant's well-being", "The mothers interpretation that the infants actively ceased breastfeeding", "The mother'due south torso and/or the infants' signals showing the fashion" and "The mother'south ain will and perceived external obstacles". Mothers who did not breastfeed equally long every bit they wanted were more probable to report less satisfaction with breastfeeding, a shorter breastfeeding catamenia, and less action when ceasing breastfeeding. In comparing, mothers who breastfed as long as they wanted were more satisfied with breastfeeding, breastfed for a longer menses of time and were more active in decision making in breastfeeding cessation.

Conclusion

Maternal passivity or activity influenced the cessation of breastfeeding in mothers of preterm infants who breastfed at the time of discharge from the neonatal unit. Passive behaviour related to breastfeeding may result in early cessation of breastfeeding, and depression breastfeeding satisfaction while active behaviour may increment breastfeeding length and satisfaction.

Commendation: Ericson J, Palmér L (2020) Abeyance of breastfeeding in mothers of preterm infants—A mixed method study. PLoS ONE 15(5): e0233181. https://doi.org/10.1371/journal.pone.0233181

Editor: Joann Chiliad. McDermid, Academy of Virginia, UNITED STATES

Received: January 11, 2020; Accustomed: Apr 29, 2020; Published: May 15, 2020

Copyright: © 2020 Ericson, Palmér. This is an open admission article distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because of upstanding and legal regulations. According to the ethical approval, answers from participants should be candy so that unauthorized persons cannot access them. Data are available from the corresponding writer for researchers who encounter the criteria for access to confidential data. For that, an ethical approval from the Swedish ethical review authorization (www.etikprovningsmyndigheten.se) is needed. An alternative non author point of contact for access to the data underlying the results presented in the study are Dalarna Academy (www.du.se).

Funding: This study was supported by the Middle for Clinical Research Dalarna, Dalarna canton, Dalarna University and Academy of Borås. The funders had no role in study pattern, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors take declared that no competing interests exist.

Introduction

In Sweden, almost all mothers initiate breastfeeding at birth, but during the first week, xx% cease breastfeeding, and by two months, most 35% have ceased [1]. In Sweden, there was a decline in exclusive breastfeeding of preterm infants from 2004–2013 [2], and the decline continued from 2013–1017 [3]. Approximately 60% of mothers ceased breastfeeding earlier than they desired. Difficulties with lactation, infant diet and weight gain, affliction, medication and difficulties with expressing breast milk have been reported to be associated with the earlier cessation of breastfeeding [iv].

Mothers of preterm infants are in a vulnerable and frail situation in which breastfeeding may be considered a key aspect of becoming a mother; in addition, motherhood and breastfeeding often begin in a medical and unfamiliar setting [v]. The initial period of breastfeeding is important since early on breastfeeding experiences cause mothers to question their suitability for motherhood [vi].Mothers of preterm infants experience breastfeeding in the first 12 months subsequently birth as a journey to finding their own way in breastfeeding, which means that every female parent has her own experiences of being in this situation and copes with these experiences according to her ain unique situation [7].Withal, mothers of preterm infants may struggle with breastfeeding for example, with breastfeeding sleepy or immature infants, infant latching, disorganized feeding behaviour or bereft milk supply, which may go on over a long time [8, 9]. If breastfeeding difficulties occur, a female parent may experience threatened and exist consumed by concerns about her ain body and/or her baby due to hurting, discomfort or questions most the amount of milk she is or should be producing. In addition, women's own expectations and/or experiences of objectifying intendance within the health care organisation tin lead to feelings of loneliness and anxiety [10]. For a mother to have the possibility of breastfeeding as long as she wants, breastfeeding support is crucial [xi]. However, mothers of preterm infants take lilliputian control over breastfeeding support they receive and inadequate support diminishes breastfeeding [12]. Previous inquiry has found that lower breastfeeding satisfaction, lower self-efficacy, fractional breastfeeding at discharge, a low maternal educational level, the use of soothing methods, negative maternal experiences and longer stays in the neonatal unit increased the risk of breastfeeding cessation in mothers of preterm infants [13–xv]. In summary, our literature review shows that few studies take examined the cessation of breastfeeding during the first year after birth in mothers of preterm infants; to exist able to support breastfeeding, farther research in this expanse is important. The aim of the study is to depict the cessation of breastfeeding in mothers of preterm infants up to 12 months afterward birth.

Materials and methods

Blueprint

The nowadays written report adopted a mixed method design with a convergent approach [xvi]. This design was used to ascertain the relationships between breastfeeding cessation, maternal explanations for breastfeeding cessation, breastfeeding satisfaction and breastfeeding status throughout the first year of life.

Inclusion and exclusion criteria and setting

During a randomized controlled trial (RCT) conducted afterwards belch from 6 neonatal units in Sweden, breastfeeding mothers of preterm infants (gestational age <37 weeks) provided information about breastfeeding cessation during the outset 12 months after nascency. The results from the RCT are presented elsewhere [17, eighteen]. The inclusion criteria in the RCT were mothers of preterm infants who breastfed (whatsoever breastfeeding) at discharge and had been hospitalized for at to the lowest degree 48 hours in the neonatal unit of measurement. Exclusion criteria were mothers who had severe physical or mental illness, language difficulties that could not be resolved, or who had an infant who was transferred to another ward or hospital or where the babe was terminally ill. Eligible mothers were invited to participate in the report approximately ane week before discharge. Additional inclusion criteria were providing left written comments on the questionnaire, answering the questions on breastfeeding satisfaction and/or whether the mother breastfeed every bit long as she wanted. A flowchart over the enrolment is presented in Fig ane. The half-dozen neonatal units were level IIIa or IIIb units according to American University of Pediatrics Commission on Fetus and Newborn [19]. None of the units were certified equally baby friendly. The study received ethical approval from the regional ethical review lath in Uppsala, No. 2012/292 and 2012/292/2. After receiving oral and written information well-nigh the written report, all participating mothers signed a written consent class.

Author JE is a paediatric nurse, and author LP is a midwife by profession with long-term experiences in neonatal and midwifery care. Our preunderstanding and experiences from our professions requite us openness to new experiences and insights inside the cessation of breastfeeding in mothers of preterm infants. We questioning and continuously reverberate over our preunderstanding in relation to analyzing and interpret the data.

Information collection

Quantitative and qualitative information were collected simultaneously via questionnaires sent to the mothers 8 weeks later discharge from the neonatal unit of measurement and 6 and 12 months after the birth of their infants as office of the RCT. The data were collected between March 2013 and December 2015.

Wellness care professionals collected quantitative demographic data and breastfeeding (sectional or partial) data at the fourth dimension of the infant's discharge from the neonatal unit. Breastfeeding (exclusive, partial or no) and breastfeeding satisfaction were measured with self-report questions in the questionnaires at all follow-ups. The World Wellness Organization's definition of breastfeeding and a 24 hours recall menstruum were used. Exclusive breastfeeding was divers as follows: feeding with breast milk only, regardless of the feeding method, as well as whatsoever medications, fortification and vitamins. Fractional breastfeeding was divers every bit follows: feeding with breast milk in combination with formula and/or solid food. No breastfeeding was divers as follows: fully feeding with formula and/or solid food [xx]. The questions to both health care professionals and mothers about breastfeeding included the definitions of exclusive, partial and no breastfeeding.

Measures

Breastfeeding satisfaction was measured with the following question at all follow-ups: "Are yous satisfied with your breastfeeding experience?" A 10-centimetre visual analogue scale ranging from very dissatisfied to very satisfied was used for responses. Data regarding whether the female parent breastfed equally long every bit she wanted were collected in the 12-calendar month questionnaire with the following question: "If you take ceased breastfeeding, did y'all breastfeed as long every bit you lot wanted?" The response options were yes or no.

The qualitative information consisted of written comments from the mothers. The comments were collected with i open-ended question (asked at the follow-ups) and one question with a gratis text option (asked in the 12 month questionnaire). Only the data describing the cessation of breastfeeding were used. In the questionnaires, the following open-ended question was asked at all follow-ups: "If you lot want, feel gratuitous to write about what you have experienced while breastfeeding/canteen-feeding your baby". Furthermore, in the 12-month questionnaire, the mothers had the option to provide a gratis-text response to the post-obit question: "If yous have ceased breastfeeding, did yous breastfeed as long as y'all wanted?"

Assay

The quantitative and qualitative data were analysed separately with statistical tests and hermeneutical analysis, respectively, and and so together according to a convergent design, equally described past Creswell (2017). In some analyses, the information were divided based on whether the female parent breastfed as long as she wanted.

The quantitative data were analysed using IBM SPSS Statistics for Windows, version 25.0 (Armonk, NY: IBM Corp.). The statistical significance level was set up to p <0.05. Descriptive statistics were presented every bit the numbers, percentages, and means and standard deviations (SDs) for normally distributed variables and as the medians and interquartile ranges (IQRs) for non-commonly distributed variables. The Mann-Whitney U-test was used to analyse the potential differences between breastfeeding satisfaction and whether the mothers breastfed equally long equally they wanted. Breastfeeding satisfaction was unevenly distributed. A chi² test was used to analyse the potential associations betwixt the dichotomous variables i.e., demographic data and whether the mothers breastfed as long every bit they wanted.

The qualitative data were analysed through hermeneutic analysis based on a cogitating lifeworld approach inspired by hermeneutical and phenomenological philosophy [21, 22]; this analysis aimed to explore the mothers' experiences of breastfeeding cessation. Nosotros chose the approach and method in order to provide rigorous scientific foundation for the analysis. The intention of the hermeneutical part of the assay was to gain agreement of the meanings in the data. The lowest level of the hermeneutical spiral includes the identification of themes related to the meanings in the data, and the most abstract form of explanation is the overall theme. A hermeneutical explanation is not a cause-result explanation but rather an intentional explanation of the variation in the meanings in the information and why this variation occurs [22].

The mother's written comments were transcribed from the questionnaires to a Microsoft Word certificate by JE. Start, the written comments from the two open-ended questions were read as a whole. And then, the Word document was printed on paper, and all comments regarding the cessation of breastfeeding were cut into separate pieces of paper. These comments were sorted into groups with similar meanings, which ultimately resulted in the identification of four themes of the meaning of breastfeeding cessation. Second, all comments corresponding to each of the four themes were then sorted by whether the mother breastfed as long every bit she wanted and were marked with each female parent's breastfeeding condition at each follow-upward, resulting in the emergence of a pattern of meaning of breastfeeding cessation. Each comment was marked with the mothers' code, and the same code was used in the quantitative data set. Hence, we were able to connect the written comments with answers to the question about whether the mother breastfed as long as she wanted and breastfeeding result. Quotes from the mothers are presented in the results with each female parent'south randomized code, for example, SU10. Each mother's breastfeeding status at each follow-up, for case, sectional (east), partial (p) or no (north), is too presented in chronological gild as follows: (discharge), (8 w subsequently discharge), (6 months later nativity), (12 months later nativity). Finally, the total number of months spent breastfeeding is presented, for example, ceased breastfeeding at 8 months (m). Some mothers (northward = 16) left written comments in 1 or more than of the follow-up questionnaires but did non answer the question about whether they breastfed as long as they wanted. Their comments did not differ from the other comments; hence, all comments were analysed together.

Finally, an overall theme was interpreted through the linking of the themes of the meaning of the cessation of breastfeeding from the qualitative data and the quantitative information to grade an overall theme, i.e., a new whole. To determine the overall theme, an analysis of the mothers' approaches, concepts, words or ways of reasoning, breastfeeding data and breastfeeding satisfaction besides as mothers' descriptions of breastfeeding cessation and its meanings was conducted. We jointly carried out the analysis betwixt the two authors past grouping and discussing the data, individual themes of the meaning of breastfeeding cessation and overall theme until we reached consensus. An illustration of the analysis and the coding procedure is presented in Tabular array ane.

Results

The characteristics of the participating mothers are presented in Table 2. In total, 270 mothers contributed data to the study. The open-ended question and the optional free-text response yielded 165 written comments about breastfeeding cessation from 149 mothers. The mothers who breastfed as long every bit they wanted left 55 comments, and the mothers who did not breastfeed equally long every bit they wanted left 94 comments. Sixteen mothers left written comments simply did not answer the question about whether they breastfed as long equally they wanted.

Significantly more mothers breastfed as long as they wanted than did not breastfeed as long as they wanted. Mothers who breastfed as long as they wanted reported significantly higher breastfeeding satisfaction at 8 weeks after discharge and 6 and 12 months after birth than mothers who did non breastfeed as long as they wanted (Tabular array 3).

Tabular array 3. Breastfeeding satisfaction, exclusive breastfeeding and demographic factors for mothers who breastfed equally long every bit they wanted and mothers who did non breastfeed equally long as they wanted (n = 185).

Presented equally the percent (%) or median [interquartile range, IQR] and p-value.

https://doi.org/10.1371/journal.pone.0233181.t003

There was a statistically significant difference in exclusive breastfeeding betwixt mothers who breastfed as long every bit they wanted and mothers who did non breastfeed as long equally they wanted at belch and 8 weeks after discharge, merely there was not a pregnant divergence in exclusive breastfeeding half-dozen months after birth or in partial breastfeeding 12 months subsequently birth (Table three). Mothers who breastfed as long as they wanted breastfed (any breastfeeding) an average of ten weeks longer than mothers who did non breastfeed as long as they wanted (p<0.001) (Table 3).

There were no statistically meaning differences between mothers who breastfed as long as they wanted and mothers who did not breastfeed every bit long as they wanted in maternal educational level, parity, gestational week (<32 or >32) or maternal nascence country. However, significantly more mothers with twins than mothers with singleton infants did not breastfeed as long as they wanted (Tabular array 3).

The comments from the two open-ended questions resulted in the identification of four themes of the significant of the cessation of breastfeeding, which are described below.

The female parent's torso and/or the baby'south signals showing the fashion was one of the themes that emerged in mothers' descriptions of the cessation of breastfeeding. The mothers described their perceptions that they had a depression milk supply, that the breast milk vanished or that there was not enough breast milk for the infant to be satisfied when breastfeeding and/or to gain weight. Some mothers too explained that when they started to requite the infant formula or solid food, the breast milk dried up, and it was difficult to go on breastfeeding.

Based on the mothers' descriptions almost bereft milk supply, the drying up of chest milk appeared to happen suddenly, quickly and/or without warning. Negative feedback from the body e.grand., insufficient milk supply seemed to reduce the mothers' belief in their ability to breastfeed. The body "lived" its own life and the body thus became an object that the mother adapted to. The mothers became passive and seemed awestruck.

The milk started to dry up. Did not take enough milk. SU21, p, p, n, north (ceased breastfeeding at 3 m)

he breastmilk vanished. K89, p, p, n, due north (ceased breastfeeding at iii yard)Did not have plenty breast milk; in the terminate, my daughter would rather accept the canteen. F107, p, p, n, n (ceased breastfeeding at four 1000)

Regarding this theme, there was a divergence between mothers who did and did not breastfeed equally long as they wanted; mothers who did not breastfeed as long equally they wanted wrote more descriptions (n = 33) and seemed to finish breastfeeding earlier than the mothers who breastfed equally long every bit they wanted (n = 16). More than mothers who did not breastfeed as long every bit they wanted were partially breastfeeding at discharge than mothers who breastfed as long as they wanted. Some of the mothers who did not breastfeed as long equally they wanted as well described their infants equally not having the free energy/ability to breastfeed. Amidst the mothers who breastfed as long as they wanted, the most prominent change in breastfeeding was between nine and 12 months after nascence, compared to ane to six months subsequently nascency for the mothers who did not breastfeed as long as they wanted.

The milk [breast milk] was not plenty for the infant to be satisfied, and when the bottle came into the flick, the infant did non suck also on the breast. T1, east, due east, n, due north (ceased breastfeeding at half dozen 1000)

Another theme that emerged was the mother's interpretation that the infants actively ceased breastfeeding. The mothers explained that their infants were no longer interested in breastfeeding or that the infant did not want to breastfeed. Other descriptions noted that the infant chose to cease or was prepare to cease breastfeeding. The mother'south interpretation that the infant rejected breastfeeding was a more active activity than the mother's interpretation that her body or her infant was showing the mode. Perceived negative feedback from the child further reduced the desire to breastfeed among mothers who breastfed as long equally they wanted.

The child did not want to breastfeed; he simply became uninterested, which made me lose my interest. T12, e, p, p, n (ceased breastfeeding at nine m)

Yet, mothers who did not breastfeed equally long equally they wanted expressed a desire to continue breastfeeding.

My son suddenly chose to stop breastfeeding. I had wanted to continue for a few more months. T5, p, p, p, n (ceased breastfeeding at 10 m)

Mothers whose data supported this theme breastfed their infants half-dozen to xiii months, with most of them breastfeeding approximately ix–12 months; yet, more mothers who did not breastfeed as long as they wanted breastfed for a shorter period.

Regarding the theme of the desire to regain the female parent's and infant's well-being, the mothers stated that they ceased breastfeeding considering of pain; for most of them, this pain was a result of the infant' biting on the breast. Several mothers described their ain mental health and medication as reasons for ceasing breastfeeding. In addition, in some cases, the mothers reported that their infants health, such as fussiness and screaming that was associated with an allergy to the protein in cow'south milk or other sicknesses. Therefore, ceasing breastfeeding was something the female parent did to improve her own or her babe'due south well-being.

I wanted to breastfeed for longer, but decreased mental wellness made the decision to stop breastfeeding the best for everyone. SK50, east, e, p, northward (ceased breastfeeding at 8 k)

A few mothers described that a new pregnancy hindered the continuation of breastfeeding; all of these mothers breastfed as long as they wanted. The mothers described that their breasts were sore, they felt unwell, their milk supply decreased or the infant did not breastfeed considering of a new pregnancy. One female parent wanted to cease breastfeeding to regain menstruation to become pregnant once again.

Near mothers in this theme, including both mothers who breastfed as long as they wanted and mothers who did non breastfeed as long equally they wanted, breastfed for 9–12 months. The exceptions were mothers who indicated their own mental health as the reason for breastfeeding cessation; these mothers ceased early (one–iii months).

The mother'south own will and perceived external obstacles were additional reasons to cease breastfeeding. An external obstruction was returning to work. Mothers described returning to work either as obstacle or equally a choice; work was described equally an obstacle just past mothers who did not breastfeed as long as they wanted. One mother wrote that breastfeeding did not piece of work at all, while others wrote that they wanted to breastfeed for longer.

I chose to start working afterwards seven months. I was forced to terminate breastfeeding when [babe's] the father would be habitation. T20, e, e, eastward, n (ceased breastfeeding at 7 k)

Several mothers wrote that they wanted to cease breastfeeding or that they felt that they had breastfed enough; notwithstanding, these feelings were described just past mothers who breastfed for every bit long equally they wanted. Some mothers described that they ceased breastfeeding to get more sleep at night, while other mothers ceased breastfeeding so that they could share the feeding with the father.

I felt that I wanted to stop and information technology went great. SU 53, due east, east, p, northward (ceased breastfeeding at 8 chiliad)

The mothers who breastfed as long every bit they wanted breastfed for 8 to >12 months or more, while the mothers who did not breastfeed as long as they wanted breastfed for 2–12 months.

Overall theme: Breastfeeding cessation–an human action based on passivity or activity

The triangulation and interpretation of the qualitative and quantitative data revealed that the mothers who breastfed every bit long every bit they wanted and the mothers who did not breastfeed as long as they wanted showed some similarities. However, they also differed in terms of the meaning of breastfeeding cessation and how many mothers described the reasons for cessation.

In the analysis, it was observed that the mothers who did non breastfeed as long as they wanted were less agile in promoting their chest milk supply and were less agile when breastfeeding ceased. These mothers likewise described less harmonious breastfeeding and used powerless language when discussing the abeyance of breastfeeding. They described their experiences of cessation with phrases such as "stale upward", "not enough", "ran out", "was not enough", "unfortunately, [the milk] left", "never got [the milk]", "in that location is nil" or "nothing comes". Such expressions were interpreted equally indication their passivity and their not taking command over their bodies and milk production, which were related to thoughts of having a biologically predetermined amount of breast milk that could not be influenced by the female parent herself, fifty-fifty if the babe was breastfeeding. In other words, these mothers saw their lack of breast milk as something they could not do anything and therefore passively accepted it. They were also generally more dissatisfied with breastfeeding and breastfed for a significantly shorter time than mothers who breastfed as long as they wanted. If the female parent took a passive approach to her trunk'due south ability for milk production, in that location was a risk of her beingness more passive in breastfeeding and a gamble of breastfeeding cessation earlier she wanted.

On the other mitt, mothers who breastfed as long equally they wanted seemed to exist more agile in making decisions and to take power over breastfeeding cessation. These mothers also described responses from their infant that they interpreted to betoken that the babe did not want what was offered. However, these mothers described more harmonious breastfeeding (i.e., breastfeeding went smoothly with no major bug or difficulties) and used more empowered language when discussing the cessation of breastfeeding. For instance, when they described their experiences, they used phrases such every bit "decided", "chose", "lost interest", "feel set up", "does non want" or "satisfied". The meanings of such language suggest that the mothers perceived their own trunk's ability to exist more powerful and influential than did mothers who did non breastfeed every bit long as they wanted; in add-on, they perceived the amount of chest milk to be something that they themselves could command. Therefore, mothers who breastfed as long equally they wanted were interpreted every bit taking an active approach to allow them to take control over the breastfeeding situation and abeyance. The mothers who breastfed as long as they wanted were more often than not more than satisfied with their breastfeeding and breastfed significantly longer than the mothers who did not breastfeed every bit long every bit they wanted. Existence more active in decision making and taking ability seemed to facilitate breastfeeding. A schematic effigy of the results is shown in Fig 2.

Fig 2. Schematic effigy.

A schematic figure of the overall estimation and the themes of the meaning of breastfeeding abeyance in relation to breastfeeding length, breastfeeding satisfaction and breastfeeding cessation.

https://doi.org/ten.1371/journal.pone.0233181.g002

Discussion

The results of this study showed that for mothers of preterm infants who breastfed at the fourth dimension of belch from the neonatal unit, the decision to cease breastfeeding seemed to depend on the mother's passivity or activity in relation to her body'due south ability, her breast milk production, and her own volition besides as the infant's behaviour and signals. Mothers who did not breastfeed as long as they wanted were less satisfied with breastfeeding, breastfed for a shorter period and were less active; they did not accept command over breastfeeding and were not reflective when ceasing breastfeeding. In contrast, mothers who breastfed equally long as they wanted were more satisfied with breastfeeding, breastfed for a longer period of time and were more active in decision making and in taking command in breastfeeding.

The mothers who did not breastfeed as long as they wanted breastfed an average of 10 weeks less than did the mothers who breastfed as long equally they wanted. This shorter breastfeeding duration may reflect that the mothers had breastfeeding problems. In our study, a few mothers described breastfeeding problems such equally mastitis, wounds and/or cracked nipples equally reasons for breastfeeding cessation, which has been a mutual finding in other studies [23, 24]. However, in our study, many mothers described issues with their milk supply. This has as well been described in other studies, for example, that of Gianni et al. (2018), who found that mothers who were admitted to a neonatal unit and had issues expressing breast milk or provided an inadequate amount of breast milk had a college run a risk of breastfeeding cessation prior to discharge [25, 26]. Even in studies with mothers of full-term infants, concern about milk supply was a cause of breastfeeding abeyance [27, 28]. Additionally, Collin et al. (2002) showed that the baby'south behaviour and signs of being unsatisfied were interpreted as an indicator of an insufficient milk supply [28]. In our study, the mothers did not seem to take activity to address milk supply issues, such as trying to increase milk production or seeking help. This inaction may have been due to a lack of knowledge or trust in their own ability to breastfeed. Avery et al. (2009) suggested that mothers who are confident about breastfeeding and chest milk production during pregnancy develop a "confident commitment", in which the decision to continue breastfeeding is made [29]. Without such commitment, the cessation of breastfeeding may follow challenges with breastfeeding, which indicates that breastfeeding is a learned skill and not a predetermined skill. This proffer is interesting in relation to the results of the present report, which indicated that mothers who did not breastfeed as long as they wanted were passive and had a predetermined negative view of their trunk'southward power to breastfeed and to produce chest milk. Both Dykes (2006) and Martin (2001) highlighted that the Western view and industrialized dualistic manner of thinking virtually women'southward bodies as producers and as objects may have consequences for individual women, who imagines themselves as being alienated from their own bodies [30, 31]. Dykes (2006) suggested that doubt and mistrust towards the body and breast milk product, presented in the present study every bit passivity and not taking control, can be a effect of a Western view of women's bodies, which become dominated into beingness passive objects. Instead, the breastfeeding trunk must exist considered from a non-dualistic way of thinking, and the breastfeeding experience must exist seen equally an embodied feel [30]. Information technology seems to be of import for health care professionals who support mothers of preterm infants in breastfeeding to be aware that mothers seem to take different views on the ability of their bodies to produce breast milk. Mothers who tend to run into their bodies as passive objects and who practise not accept control in an active fashion must exist strengthened to believe in their bodies ability to breastfeed every bit long as they desire. Genuine support strengthens mothers, as shown by Ericson and Palmer (2018). Genuine support is individually adjusted and includes both practical and emotional support. Furthermore, genuine back up also includes being listened to and beingness met with respect, understanding and cognition [12]. In a caring situation in which back up is provided, there must be an openness towards each mother's unique breastfeeding state of affairs. Such openness was described by Galvin and Todres (2009) as openheartedness [32]. Existence openhearted involves presence for the other person, embodiment and practical responsiveness.

Some other interesting event was that many mothers, particularly those who breastfed as long every bit they wanted, stated that their infants wanted to cease breastfeeding and/or lost involvement in breastfeeding. About mothers who breastfed as long as they wanted ceased breastfeeding approximately 8–12 months later nascence, which is the time when solid foods are introduced according to national recommendations. In Sweden, few mothers breastfeed their infants after one year of age [1]. This tin can exist compared to a study examining breastfeeding length in non-industrial populations, which showed that breastfeeding until two to four years of age was common [33]. A book on cultural perspectives on breastfeeding claimed that both culture and the medicalisation of breastfeeding are responsible for the shortened periods of breastfeeding in the Western world. Observations of the mother-baby relationship in traditional societies has shown that all mothers breastfed their children, often until iii to 4 years of age, which is also supported past palaeontological evidence [34].

Limitations

The trustworthiness of the report is strengthened by the mixed method pattern, which strengthens the understanding of breastfeeding cessation through the apply of both qualitative and quantitative data [16]. Many mothers provided similar comments on the cessation of breastfeeding; hence, the estimation of the themes of the meaning of breastfeeding cessation is likely trustworthy. Additionally, the results can probably as well be transferred to like contexts because of the relatively large number of comments and the similarities in the comments on abeyance of breastfeeding despite the participants being spread over a large role of Sweden. Although the comments provided past the mothers were relatively short, there were many comments, leading to the identification of a wide variety of meanings in the information instead of an in-depth description of meanings. This broad variety of meanings may be of involvement to investigate in more depth in future research [35]. Withal, to deepen the understanding of breastfeeding cessation, it may be beneficial to perform in-depth interviews with mothers. The authors remained open up to the data but too questioned and continuously reflected on the assay and results, which strengthened the credibility and confirmability of the findings. A farther strength of the study was the long follow-up, during which we measured breastfeeding satisfaction repeatedly and assessed the cessation of breastfeeding close to the time of effect/experience. Information technology does non appear that the intervention in the RCT report afflicted the results of this study. The intervention lasted until 14 days after belch and did not affect breastfeeding [eighteen]. Information technology seems unlikely that the intervention would have affected the cessation of breastfeeding, which usually happened much later, every bit supported by the analysis.

A limitation is that the questions measuring breastfeeding satisfaction and whether the female parent breastfeed every bit long equally she wanted were not validated. Yet, the breastfeeding satisfaction question had a strong correlation (r = 0.70–0.74) with the validated Maternal Breastfeeding Evaluation Calibration [36], which also measures breastfeeding satisfaction. That the mothers answered at all follow-ups.

Conclusion

Passive and active behaviour influence the cessation of breastfeeding in mothers of preterm infants who breastfed at the fourth dimension of discharge from the neonatal unit. Passive behaviour increases the gamble of early on breastfeeding cessation and lower breastfeeding satisfaction, while agile behaviour increases breastfeeding length and satisfaction. This is of import knowledge when supporting breastfeeding and designing interventions to support breastfeeding.

Acknowledgments

The authors would like to thank all mothers who participated in the study.

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