Barriers to breastfeeding

Why is breastfeeding so hard?

There are many possible barriers to breastfeeding. As a result, many mothers do not meet their breastfeeding goals. There can be physical barriers such as pain or having a sick baby or emotional ones such as sadness, depression, or anxiety. Mothers may lack confidence or worry about the amount of milk their babies are taking in. They may be frustrated by conflicting advice. Mothers should consider obtaining support from family and friends as well as their health-care providers. 

A) Barriers to breastfeeding

Most organizations recommend breastfeeding for at least two years because of the extensive health benefits for babies, their mothers, and their families. Only rarely is it not advised

The choice and the decision to breastfeed is influenced by many factors (ACOG 2021). 

While some mothers choose to partially breastfeed or not to breastfeed at all, most mothers around the world choose to breastfeed. Unfortunately, many encounter barriers. One study (Giannì 2020) reported that 80% of the mothers studied had breastfeeding difficulties, and another (Nelson 2017) showed that one-third of the mothers surveyed did not meet their breastfeeding goals. As a result, mothers may experience negative emotions such as guilt.

Barriers can be obvious, such as a medical reason for not breastfeeding or less so, as with no formal education (Neves 2021). In our clinic, most mothers have said the biggest barrier to breastfeeding is that everyone, including family, friends, health-care providers, offer different advice. The internet can be particularly confusing.

Documented barriers to breastfeeding include (Patil 2020): 

1) Medical systems

Medical systems can create barriers to breastfeeding:

2) Breastfeeding or medical problems

Breastfeeding or medical problems can prevent effective breastfeeding and may include (Morrison 2019):

3) Lack of support

Mothers need support in order to achieve their breastfeeding goals and it may be lacking in the following situations:

4) Lack of confidence and emotional struggles

We have found a lack of confidence is an extremely common barrier to breastfeeding and often leads to the following (Brockway 2017; Gerhardsson 2018; Lau 2018; O'Brien 2020; Sandhi 2020; Wu 2018): 

Mothers may have other emotional barriers such as:

  • Not being comfortable breastfeeding in public
  • Feeling sad or tired
  • Depression
  • Sadness or other negative emotions with the let-down
  • Stress including (Buck 2018; Dugat 2019; Johnson 2021; Shiraishi 2020)
    • Racism
    • Poverty
    • Difficult life events 
  • An unplanned pregnancy

5) Infant formula promotion

Infant formula manufacturers have been shown to undermine mother’s confidence using a range of marketing strategies including unjustified claims for quick solutions and equating breast milk and formula (Parry 2013; WHO 2017).

B) Getting help

Barriers to breastfeeding may be overcome with proper tools and support. For example, delivering in a baby-friendly hospital, which have policies that support breastfeeding, increases the rate of exclusive breastfeeding. 

In addition to asking for help, mothers can consider decreasing stress and looking after themselves. First-time mothers and those who have had previous breastfeeding difficulties are less likely to breastfeed and may benefit from extra qualified, appropriate support from breastfeeding specialists (Huang 2018).

Support for mothers, which can reduce negative maternal feelings, can also help babies. Stress and fear can be communicated to the baby in how they are parented and through hormones in breast milk. This may result in irritability in the baby and even in long-term emotional priming (Nolvi 2018). Stress may slightly decrease the amount of antibodies in breast milk (Moirasgenti 2019).  

References

Barriers to Breastfeeding: Supporting Initiation and Continuation of Breastfeeding: ACOG Committee Opinion, Number 821 (ACOG). Obstet Gynecol. 2021 Feb 1;137(2):e54-e62

Buck CO, Gjelsvik A, Vivier PM, et al. Prenatal Exposure to Stressful Life Events and Infant Breastfeeding. Breastfeed Med. 2018 Jul/Aug;13(6):426-432
 
Brockway M, Benzies K, Hayden KA. Interventions to Improve Breastfeeding Self- Efficacy and Resultant Breastfeeding Rates: A Systematic Review and Meta-Analysis. J Hum Lact. 2017 Aug;33(3):486-499
 
Dugat VM, Chertok IRA, Haile ZT. Association Between Stressful Life Events and Exclusive Breastfeeding Among Mothers in the United States. Breastfeed Med. 2019 Sep;14(7):475-481
 
Gerhardsson E, Hildingsson I, Mattsson E, et al. Prospective questionnaire study showed that higher self-efficacy predicted longer exclusive breastfeeding by the mothers of late preterm infant. Acta Paediatr. 2018 May;107(5):799-805

Giannì ML, Lanzani M, Consales A, et al. Exploring the Emotional Breastfeeding Experience of First-Time Mothers: Implications for Healthcare Support. Front Pediatr. 2020 May 7;8:199 

Huang Y, Ouyang Y, Redding SR. Previous breastfeeding experience and its influence on breastfeeding outcomes in subsequent births: A systematic review. Women and Birth. 2018 Sept 28

Johnson AM, Menke R, Handelzalts JE, et al. Reimagining Racial Trauma as a Barrier to Breastfeeding Versus Childhood Trauma and Depression Among African American Mothers. Breastfeed Med. 2021 Mar 10
 
Kim SK, Park S, Oh J, et al. Interventions promoting exclusive breastfeeding up to six months after birth: A systematic review and meta-analysis of randomized controlled trials. Int J Nurs Stud. 2018 Jan 12;80:94-105
 
Lau CYK, Lok KYW, Tarrant M. Breastfeeding Duration and the Theory of Planned Behavior and Breastfeeding Self-Efficacy Framework: A Systematic Review of Observational Studies. Matern Child Health J. 2018 Mar;22(3):327-342
 
Nelson JM, Li R, Perrine CG, et al. Changes in mothers' intended duration of breastfeeding from the prenatal to neonatal periods. Birth. 2017 Nov 17

Moirasgenti M, Doulougeri K, Panagopoulou E, et al. Psychological stress reduces the immunological benefits of breast milk. Stress Health. 2019;10.1002/smi.2903

Morrison AH, Gentry R, Anderson J. Mothers' Reasons for Early Breastfeeding Cessation. MCN Am J Matern Child Nurs. 2019;44(6):325‐330

Neves PAR, Barros AJD, Gatica-Domínguez G, et al. Maternal education and equity in breastfeeding: trends and patterns in 81 low- and middle-income countries between 2000 and 2019. Int J Equity Health. 2021 Jan 7;20(1):20

Nolvi S, Uusitupa HM, Bridgett DJ, et al. Human milk cortisol concentration predicts experimentally induced infant fear reactivity: moderation by infant sex. Dev Sci. 2018 Jul;21(4):e12625

O'Brien M, Buikstra E, Hegney D. The influence of psychological factors on breastfeeding duration. J Adv Nurs. 2008;63(4):397‐408

Odar Stough C, Khalsa AS, Nabors LA, et al. Predictors of Exclusive Breastfeeding for 6 Months in a National Sample of US Children. Am J Health Promot. 2019 Jan;33(1):48-56 

Parry K, Taylor E, Hall-Dardess P, et al. Understanding women's interpretations of infant formula advertising. Birth. 2013 Jun;40(2):115-24

Shiraishi M, Matsuzaki M, Kurihara S, et al. Post-breastfeeding stress response and breastfeeding self-efficacy as modifiable predictors of exclusive breastfeeding at 3 months postpartum: a prospective cohort study. BMC Pregnancy Childbirth. 2020 Nov 25;20(1):730

World Health Organization (WHO). Guidance on ending the inappropriate promotion of foods for infants and young children: implementation manual. Geneva: World Health Organization; 2017
 
Wu YH, Ho YJ, Han JP, et al. [The Influence of Breastfeeding Self-Efficacy and Breastfeeding Intention on Breastfeeding Behavior in Postpartum Women] [Article in Chinese; Abstract available in Chinese from the publisher] Hu Li Za Zhi. 2018 Feb;65(1):42-50