During the study, 7 mothers withdrew or were lost to follow up, 3 stopped breastfeeding soon after hospital discharge, 8 prior to six months, and only 11 (35%) continued breastfeeding for one year. Breastfeeding continuation rates were highest among mothers recruited from AUBMC (61.5% at 6 months; 54% at 1 year) followed by SGH (33% at 6 months; 27% at 1 year). Interestingly, mothers recruited from HDF had the lowest continuation rates (20% at 6 months; 0% at 1 year) despite being the only Baby Friendly hospital. Similarly, six-month breastfeeding exclusivity was highest among AUBMC mothers (61.5%), followed by SGH (20%) and lowest by HDF mothers (0%).
The major themes generated from focus group discussions and in-depth interviews are described below:
Breastfeeding is a joyful and connected experience
Mothers (34/46) described breastfeeding as a joyful, entertaining, relaxing experience that strengthens mother-baby emotional bonding and attachment:
..a beautiful feeling!...relaxing...your private time with baby away from the world.. as if you're walking in nature...your relation with him becomes stronger... he is happier, comfortable and secure. I loved it so much and would wait for the time to breastfeed! (Mother of two)
Breastfeeding provided great tenderness enabling mothers to tolerate any associated discomfort:
Initially, it is painful...after a difficult pregnancy I thought I will not care much for this baby. Yet, when I put her on my breast, I felt the tenderness. Breastfeeding brings baby and mother closer, especially when she latches on the breast...despite your pain, you tolerate it for the sake of your baby..(Mother of two)
... a mother not breastfeeding cannot be a mother because she cannot feel her baby and her baby cannot feel her..they will be strangers..when he's on your breast, he feels your tenderness and love, will know that you're his mother.. Any woman can bottle-feed but only with breastfeeding he will feel the affection! (First-time mother)
Naturalness and benefit
Mothers acknowledged that breastfeeding is the best nutrition for babies because of its naturalness:
Breast milk is natural whereas formula is artificial..as if you're cheating on yourself! You don't know how is artificial milk made and of what chemicals! (First-time mother)
Most participants were aware of breastfeeding benefits to mother and child:
Breastfeeding is beneficial for a mother's health..her uterus returns to normal size quickly..she also loses weight...
It decreases the risks of breast, uterine and ovarian cancers..how can I not breastfeed?
.. my son who breastfed longer is stronger and more intelligent than his brother who breastfed for 3 months..also my daughter, breastfed for 2 years is stronger and more intelligent..I don't know if it's breast milk!.
Breastfeeding changes figure and breast shape
Despite their knowledge of its advantages, some mothers expressed fears pertaining to the negative effects of breastfeeding on their breasts and figure: (14 mothers):
..breastfeeding may change the breasts' shape and result in sagging....(Mother stopping at 1 month)
..about ¾ of women who don't breastfeed are scared for their figure and beauty, although it's not true! (Mother of three; breastfed all children)
I breastfed my baby exclusively..but became fatter..gained so much weight and became depressed.. You are instructed to eat well when breastfeeding.. I ate and became much fatter..then decided to stop breastfeeding and go on diet..The husband may not care about your weight problem but may start looking at other women..(Mother of two)
Having bad or harmful milk
There were beliefs that maternal illness, stress, drug intake, or even pregnancy would cause bad or harmful milk:
I had a cold... the doctor prescribed cold medicine and I was scared it might harm the baby... (Mother of two)
..a frightened or stressed mother's milk is bad.. I stopped breastfeeding at 4 months..I was very frightened then [war] and they told me I should not breastfeed..bad luck.. (Mother of two who breastfed her first baby for 2 years)
Breastfeeding is painful and tiring
Negative breastfeeding experiences seemed to have a significant impact on a mother's decision not to continue breastfeeding. Ten participants described their experience as painful, tiring and difficult; requiring frequent, day and night, time-consuming feeds, and resulting in maternal sleep deprivation:
You are told about all the positives of breastfeeding! No one tells you about the severe pain, or the struggle to make her latch on your breast...as you are unable to breastfeed, the baby cries more and more, and you become frustrated!.. it is very distressing! (First-time mother)
It is difficult and tiring..feeding every 2 hours... you're worried and lost..don't know if he is satiated, or if positioning is correct...(Mother of two)
Breastfeeding is tiring, waking up at night! I don't know how mothers do it but it is really very exhausting.. from 10:30 pm till 12:30 am and she barely took a little!...it takes a lot from the mother...all the time it has to be me, no one can replace me except when she's asleep... Yes, sleep deprivation is a barrier! (First-time mother)
I'm tired, not eating well, and don't have time .. my milk decreased..I have to work at home but prefer to take care of her..it is unreasonable to leave her and go eat..My mother in law helps with house work but no one helps with the baby! (First-time mother)
Mastitis, or sore nipples, resulting in painful breastfeeding may force a mother to stop breastfeeding:
I had sore nipples and my breast bled with pieces of nipple coming off. It started soon after breastfeeding initiation and continued thereafter.. I insisted on breastfeeding so that my baby will have good immunity..pain was so severe I cried loudly! My doctor prescribed different creams...finally I became very sad, depressed..it was God's will.. I had twins previously who breastfed for 1 year..this baby!.I am very sad to stop despite my will..(Mother of three; stopped at one month due to lack of appropriate professional advice)
Mother's milk is insufficient
Insufficient milk was reported by 15 mothers who had to supplement their babies with artificial milk:
I am breastfeeding and supplementing with formula because I feel he is still hungry..he continues to cry so I give the bottle to make him sleep.. bottle is easier...a mother's milk may be insufficient or non-nutritious..(Mother of three)
One mother described how routine hospital practices interfered with breastfeeding her hospitalized baby:
They put him in intensive care for 12 days and was bottle-fed...then they allowed me to breastfeed but my milk decreased and he refused my breast...he got used to the bottle!
Stopping breastfeeding because of work
Maternal employment constituted an important barrier for many mothers; especially because maternity leave in Lebanon is only 40 days. The job barrier is best described by this second-time mother and teacher who stopped breastfeeding her first child at two months to return to work. This time, determined to breastfeed for a longer time, she took an additional two-month leave to pump and store breast milk for later. Despite having a supportive husband and family, she became very tired, could not cope and finally stopped at three months:
It is very difficult..I'm like a robot! I have a 4-year old who goes to school, plus my work at home, and my job... I stopped breastfeeding because of work...
Maternal will and unselfishness
Despite the negative experiences, some women continued breastfeeding for one year. The theme recurring most in interviews with those participants was their preparedness for breastfeeding, and determination to face any difficulty. They showed deep conviction of the importance of breastfeeding and its benefits to mother and baby. Whether they faced pain, sleep deprivation, tiredness, house work or job, they overcame obstacles through proper time management, family support and determination. They often identified maternal will and unselfishness as being key factors for successful breastfeeding:
A mother should not think of herself, her comfort or sleep. She needs to think of the baby before herself. I moved my job to a location next to where my baby is so that I can teach for 2 hours and then breastfeed. He never took the bottle. I also minimized my working schedule..(A working mother of 3 children)
Initially, she didn't know how to take the breast. For 1 month, I kept trying without sleeping... I pumped even if I had to throw milk away, so that my breasts continue giving milk. After a month, her mouth grew bigger and she could breastfeed directly..at the end, there has to be a way! (A mother of two children; left her job to be with her children)
A mother needs to be aware that she has a new life now, that the baby will need time and will change her daily routine.. she should be ready to make that sacrifice.. some don't accept the change and feel that breastfeeding is restrictive, so they don't breastfeed. (A mother who breastfed all four children, pumped breast milk for her hospitalized newborn)
Being a working mother should not be a barrier..one can store breast milk or support with additional formula, but not stop breastfeeding completely....
Perceptions of family and society
Half of the participants were concerned that breastfeeding may cause excessive weight gain or breast sagging. Whereas some were explicit about this personal concern, others stated that it was the perception of society, friends or family:
Many of my friends do not breastfeed.. they're concerned it makes their breasts bigger or causes weight gain..my sister, like my friends, believes it too...they believe there is no difference between breast milk and artificial milk (First-time mother)
The belief that breast milk was insufficient to achieve satiety in the baby, and that a bottle is necessary to ensure satiety and a good night sleep seemed to be transmitted from one generation to another:
My mother did not have milk and none of my siblings were breastfed. My mother-in-law too, none of her four children were breastfed..and my sister also did not have milk to breastfeed her 2 boys.. it is familial.. some families are like that... (Mother of two)
Family perceptions of breastfeeding can influence a mother's decision to breastfeed:
..my husband liked the idea of breastfeeding, but grandparents prefer the bottle because baby remains hungry with breast milk..they think I don't have enough milk because my breasts are small..that my milk is dilute and not nutritious..(Mother of two)
On the other hand, family support of a breastfeeding mother is expected in our culture and acts as an important promoter:
Our eastern society encourages breastfeeding because it is nutritious and results in bonding with baby..when family members see you breastfeeding they become happy, and you will be happy too: your mother, sister, husband ..they're all happy because you're breastfeeding (Mother of four)
When I go back to work, I will not be able to breastfeed..you cannot concentrate on the baby 100%..you need to take care of your work, your home or find someone you can leave the baby with. Thanks God I have my mother! (A recently divorced mother of three)