A qualitative study exploring first time mothers’ experiences of breastfeeding in Singapore

Abstract

Background:

The exclusive breastfeeding rate (for the first 6 months of a baby’s life) remained low in Singapore despite active promotion of breastfeeding by government bodies and hospitals. The aim of this study was to explore the breastfeeding experiences of first time mothers and the difficulties they faced during their breastfeeding period.

Methods:

A qualitative descriptive study design was adopted. Participants were chosen from a purposive sampling technique and data were collected from 10 semi-structured in-depth interviews. All interviews conducted were audio-taped and transcribed verbatim. Interview transcriptions were analysed using the qualitative content analysis approach.

Results:

The breastfeeding period of the 10 first time mothers in this study ranged from 3 days to 10 months, and four participants were still breastfeeding at the time of interview (4–12 months after delivery). The interview transcriptions generated 54 nodes, 12 sub-themes and four key themes. The four key themes identified were: (a) challenges and support for breastfeeding in the initial period after birth; (b) low degree of support for breastfeeding in the workplace; (c) unease at breastfeeding in front of others; and (d) emotional and psychological aspects of breastfeeding.

Conclusion:

This study provided a better understanding of the breastfeeding experiences of first time mothers in Singapore. Initiating and sustaining breastfeeding is still challenging for first time mothers. Greater public awareness, laws that support breastfeeding in public and the workplace, as well as support of family members could be fundamental to successful breastfeeding.

Keywords

Breastfeeding experiences first time mothers qualitative

Background

Breastfeeding is the most effective way to provide essential nutrients for infants to ensure healthy growth and development.¹ Breastfeeding prevents diseases in infants, reduces risks of breast and ovarian cancer in women and helps with early return to pre-pregnancy weight.² The World Health Organization (WHO) has recommended exclusive breastfeeding for the first 6 months of an infants’ life since 1992.¹

In Singapore, various initiatives to promote breastfeeding have taken place over the last 10 years. The Association for Breastfeeding Advocacy Singapore was founded in 2001 to provide support for breastfeeding mothers.³ Singapore’s Ministry of Health also promoted exclusive breastfeeding by establishing the Sale of Infant Foods Ethics Committee to guide the marketing practices of infant formula milk.⁴ All Singapore hospitals have stopped providing free formula milk since January 2012 to encourage breastfeeding.⁵ Most of the hospitals in Singapore also conduct antenatal counselling and postnatal support to promote the practice of exclusive breastfeeding. In addition, the Health Promotion Board of Singapore actively works with the hospitals to implement WHO guidelines that form the baby friendly hospital initiative.⁶ Despite the efforts of the government and hospitals, the latest statistic in 2013 showed that the exclusive breastfeeding rate remained relatively low in Singapore.⁷ The National Breastfeeding Survey in 2013 reported 99% of new mothers attempted to breastfeed their babies. However, only 50% continued exclusive breastfeeding after discharge from hospital and the number dropped to 28% after 2 months.⁷

Literature review

Most previous studies on breastfeeding practices focused on evaluating interventions⁸ to promote or sustain breastfeeding, with a small number describing the actual experiences of mothers who breastfed.

Previous studies conducted in western countries tend to focus on vulnerable groups such as adolescent mothers or ethnic minorities. For example, qualitative studies by Dykes et al.,⁹ Bailey et al.,¹⁰ Dodgson et al.¹¹ and Scott and Mostyn.¹² concluded that inconsistent messages about breastfeeding, lack of time and access to quality resources, lack of family support and discomfort with feeding in public negatively impacted on the initiation and duration of breastfeeding. In another qualitative study on middle-eastern mothers residing in Canada,¹³ it was found that religious belief was the strongest influencing factor for deciding to breastfeed. Mothers in the study also commented about lack of support in the work environment, and breastfeeding in public places being a problem due to environmental barriers such as lack of nursing rooms. On the other hand, in an analysis of middle class, well-educated women’s perceptions about breastfeeding, Hall and Hauck¹⁴ concluded that they had similar experiences with women from vulnerable groups. Respondents in their study reported inadequate and inconsistent support from care providers during the early postpartum period, which had detrimental effects on the initiation of breastfeeding. They also reported that their expectation of breastfeeding being ‘natural’ and ‘problem-free’ did not fit with their actual experiences. These women also commented about the lack of family support and discomfort with breastfeeding in public. However, the study’s findings were based on brief written replies to an open-ended question about breastfeeding experiences as part of a randomised controlled trial on the effectiveness of a breastfeeding journal.

Some studies focused on the experiences of first time mothers. Williamson et al.¹⁵ studied eight British first time mothers who struggled with breastfeeding in the early post-delivery period. Results highlighted the discrepancy between the new mothers’ experiences of struggling to breastfeed and social portrayal of breastfeeding as natural and synonymous with ‘good mothering’. New mothers tend to self-blame for being unable to breastfeed successfully. All eight mothers also experienced severe breastfeeding-related pain, and were confused about whether the amount of pain was to be expected or signalled something wrong. However, that study was conducted 10–11 days post-delivery, and hence results could not inform the experiences of mothers who continue to breastfeed despite the initial struggles. Few studies were carried out in Asian countries. In a qualitative study on breastfeeding experiences of first time mothers in Lao People’s Democratic Republic, Lee et al.¹⁶ reported that first time mothers generally had a positive perception of breastfeeding and followed WHO guidelines on initiation of breastfeeding. Nonetheless, less than half of the mothers in that study breastfed for 6 months; the main reasons being maternal employment and perceived inadequacy of milk supply.

In the local context, Ong et al.¹⁷ explored 13 first time mothers’ postnatal experiences and support needs. These mothers in Singapore also found breastfeeding to be challenging. Perceived inadequate milk supply was a major stressor, and advice from health professionals over help lines was not deemed to be practical or useful. Some thought of supplementing with formula feed but felt pressurised to continue exclusive breastfeeding. Participants also thought that it would be impossible to maintain exclusive breastfeeding once they resumed work. However, given that the interviews were carried out within 7–11 days after discharge from hospital, the study did not explore mothers’ experience of continuing to breastfeed while resuming work (4 months) or of breastfeeding for the recommended length of time (6 months) and beyond.

It is well recognised that numerous social and cultural factors influences a woman’s decision and efforts to initiate and continue breastfeeding.¹⁸ Given the lack of in-depth studies on first time mothers’ experiences of breastfeeding in the Singapore context, this study aimed to explore the breastfeeding experiences of these mothers, in order to gain a better understanding of their breastfeeding experiences and related challenges, with special focus on the continuation of breastfeeding.

Methods

Design

A qualitative descriptive study design was adopted. Breastfeeding stories were collected from participants’ lived experiences, perceptions were comprehensively summarised and reported narratively.¹⁹

Setting and sample

Participants were recruited using a purposive sampling technique from Singapore General Hospital Neonatal Department between January and March 2012.

The inclusion criteria were first time mothers who had non-complicated normal vaginal delivery (spontaneous delivery of full-term babies, requiring little medical intervention), delivered a healthy baby without any medical conditions, and initiated breastfeeding while in the hospital. Exclusion criteria were first time mothers who underwent caesarean section, and/or could not breastfeed for medical reasons.

In accordance with the qualitative descriptive approach, the criterion of saturation (whereby no new information emerges with the addition of new cases)²⁰ was used to determine the sample size. Data saturation was achieved by the tenth interview.

Data collection

Data were collected using moderately structured open-ended individual interviews. An interview guide (Table 1) was used and questions were derived from literature review and researchers’ insight on breastfeeding experiences. The first author is a nurse clinician with 5 years of working experience in maternity and postnatal units, while the second author is an associate professor and research director in the School of Nursing and Midwifery at La Trobe University.

Table 1.

Interview guide.

Hi, XXX, Thank you for your time for this interview.
In this interview, I would like to know more about your breastfeeding experiences after you have gave birth to your child, is that okay?
Could you please tell me how long have you breastfed your baby?
Could you please tell me about your breastfeeding experiences for the past XX months?
How do you feel?

Do you breastfeed exclusively? Which means you are giving purely breast milk without supplement?
How do you feel about it?

Do you receive any advice or education on breastfeeding from hospital or friends?
Are you receiving any support from your family or friends?
How do you feel about it?

Do you face any difficulty in breastfeeding?
(Social, emotional, cultural, religion, psychological, environmental, work, family, friends)
How do you feel about it?

Is there any forbidding factor that stops you from breastfeeding?
Is there anything that you think you have given up because of breastfeeding?
How do you feel about it?

To clarify point: Could you explain that in more detail, please?
To reflect more: What did that mean to you?
To reflect more: How did it make you feel?
Are there any more things that you wanted to share with me?

It is very nice to hear from your experiences.
Thank you once again for giving me time for this interview.

All interviews started with the question ‘Can you please tell me about your breastfeeding experiences?’, and participants were also asked prompting question such as ‘Any problem with breastfeeding?’ Other issues raised by participants during the interviews were used as cues for additional prompting questions.

Interviews were conducted in the participants’ preferred venue (six at homes and four at offices) at least 4 months after their delivery. In Singapore, working mothers are entitled to 16 weeks of government-paid maternity leave at the birth of their Singapore citizen child. Hence, interviews were conducted at or after 4 months post-delivery, so as to allow ample time for the participants to adjust to motherhood, be prepared to talk about their experiences and also to discuss their experiences of breastfeeding upon returning to the workforce.

Ethical considerations

Ethical approval was obtained from La Trobe University human research ethics committees and the hospital’s institutional review board in Singapore (SingHealth Centralised Institutional Review Board). Informed consent was obtained from participants prior to commencement of interviews.

Data analysis

All recorded data from the interviews were fully transcribed verbatim; the qualitative content analysis method was used to summarise the informational contents of the data. Data analysis was conducted by both authors and performed simultaneously with data collection. Themes and categories were formed after the first two interviews. Subsequent information gathered was fitted into the categories and some new categories were formed.²¹ This was to inform each following interview and to detect that there were no new themes emerging. To ensure the trustworthiness of the analysis, both authors independently read all the transcripts multiple times to analyse the text. When there were disagreements on interpretations, both authors returned to the transcript to remain close to the participants’ expressed meanings.

NVIVO 10 (QSR International Pte Ltd, Doncaster, Victoria, Australia) software was also used to aid in the analysis.

Results

Ten participants were interviewed and their ages ranged from 20 to 40 years at the time of delivery (all participants had reached the age of 21 years at the time of signing of informed consent).

Seven participants were Chinese, two were Indian and one was Malay. A summary of the participants’ demographics (age, ethnicity), employment status and breastfeeding period is presented in Table 2.

Table 2.

Demographic Data of the Participants.

	Age ( at time of delivery)	Race	Interviewed at xx months after delivery	Employment status at time of interview	Breastfed for (at time of interview)	Still breastfeeding at time of interview
Participant 1	28	Indian	6 months	Full time working	6 months	Yes
Participant 2	40	Chinese	7 months	Full time working	7 months	Yes
Participant 3	30	Chinese	10 months	Full time working	7 months	No
Participant 4	27	Indian	4 months	Full time working, quit after 2nd pregnancy during maternity leave	2 months	No
Participant 5	26	Chinese	6 months	Full time working	4 months	No
Participant 6	20	Chinese	8 months	Not working	8 months	Yes
Participant 7	27	Chinese	10 months	Full time working	10 months	Yes
Participant 8	35	Chinese	6 months	Full time working	1 week	No
Participant 9	29	Malay	4 months	Full time working	3 days	No
Participant 10	32	Chinese	12 months	Full time working	8 months	No

A total of 54 nodes was generated with 277 references. Nodes were organised into 12 sub-themes, and four key themes were finally generated. The four key themes were: (a) challenges and support for breastfeeding in the initial period after birth; (b) low degree of support for breastfeeding in the workplace; (c) unease at breastfeeding in front of others; and (d) emotional and psychological aspects of breastfeeding.

A summary of the themes and sub-themes is presented in Table 3.

Table 3.

Summary of the Themes and Sub-Themes.

Themes	Sub-themes
Challenges and support for breastfeeding in the initial period after birth	• Latching on technique
	• View of important others to provide formula milk
	• Importance of support from own mother and spouse
	• Coping – seeking help and support from the wider community
Low degree of support for breastfeeding in the workplace	• Attitudes of superiors and colleagues
	• Discrepancy between period of paid maternity leave and recommended period of time for exclusive breastfeeding
	• Sense of guilt
Unease at breastfeeding in front of others	• Public’s reaction
	• Embarrassment when baby grow bigger
Emotional and psychological aspects of breastfeeding	• Bonding and sense of achievement
	• Feelings of uncertainty, emotional insecurity and self-sacrificial
	• Tough and challenging at first

Challenges and support for breastfeeding in the initial period after birth

Latching on technique

All participants had their babies latched on during hospital stays, but some (n=4) experienced helplessness with inadequate support and felt frustrated when baby could not latched on at home. Participant 7 stated: ‘She (baby) cries a lot because she couldn’t latch properly. When she cries, everybody is panicked. Then I feel frustrated. She can’t latch on. Other mum can but she just can’t….’

Inability to latched on and baby crying made the first time mothers (n=3) panicked and worried about not providing enough breast milk. Participants ended up giving up breastfeeding and fed their babies formula milk. Participant 3 mentioned: ‘First three day is purely breast milk, after that I think she didn’t want to latch on, so I give up and give formula milk.’

Participant 8 commented: ‘I didn’t know how to do it; she got frustrated when she couldn’t suck. The milk doesn’t flow through. I just worried that the baby not having enough so I just give formula milk. And then from there I stop breastfeeding already….’

View of important others to provide formula milk

Confinement is a traditional practice among Asian women for the body to recuperate and regain energy from childbirth. It lasts a month and mothers are required to follow traditional practice advice such as ‘no bathing’, ‘no washing hair’, ‘no drinking of plain water’, ‘eat food that is cooked with Chinese herbs’ and so forth.²² Most mothers experienced ‘confinement’ during their first month after delivery regardless of ethnicity.²³ They were usually taken care of by their own mother, mother-in-law or confinement nanny. A confinement nanny is typically someone who provides infant and maternal care at the woman’s home, according to traditional methods during the first month post-delivery. First time mothers (n=3) were stressed when their caregivers repeatedly offered to feed formula milk to their baby. Participant 3 stated: ‘Since she (baby) came back from hospital, the confinement lady also came, my mother-in-law also comes, they encouraged half-half that means formula milk and breast milk. I feel quite stressed and disappointed….’

Participant 2 commented: ‘Even my mum, I thought all along they breastfeed during the olden days, but my mum keep encouraged me to go for formula…. And because I realize my baby keep crying every 2 hours, then my mum will say why don’t you try formula? Formula will be more filling to the baby and he won’t cry so much. So you know, I struggled between formula and breast milk….’

Importance of support from own mother and spouse

Some mothers (n=6) felt appreciated when they were supported by family members. They mentioned that family support was essential during the initial period.

Participant 10 claimed: ‘I think the first 3 months (my emotion) more labile, then I try to blasted on my husband. His tolerance quite high. Hahaha….’

Participant 4 verbalised: ‘My mum is always there to guide me. My husband was always there, they always reassure me I wasn’t alone…. They wake me up, making hot drinks for me, and moral support, carrying the baby from the cot and pass to me….’

Participant 7 mentioned: ‘No doubt (breastfeeding) is very tiring. Even my mum assist me, ask me to wake up in the middle of the night just for breastfeeding, it is very tiring. But I don’t know why some people may just give up, maybe they didn’t have enough support. But to me, in a way my husband is very supportive. It is just give me the feeling I am being appreciated….’

Coping – seeking help and support from the wider community

While some participants experienced insufficient support during this crucial period, others (n=2) sought help from breastfeeding consultants when they experienced difficulties with latching on. Participant 1 reported: ‘After 2 to 3 days, I couldn’t take it, I go the prenatal class, the parent link, so what I did was, I actually called her up, her name is XX, she actually send this breastfeeding consultant over here, so she actually told me that there was nothing wrong, I am feeding her the right feed, it is just the nipples are sore….’

Two participants sought support from internet forums, one of whom expressed a lack of support from the family. Participant 6 did not receive support from family and friends, and she claimed that: ‘I got other mothers’ experiences like forum. Not join but just read what other people say….’

The other mentioned it was more trustworthy to get advice and support from those who were in the same situation. Participant 7 illustrated: ‘I actually join a forum, for the baby who born in January, we actually form a group, on and off we actually meet up and go for gathering and bring the baby along, go for swimming or even Halloween party, we actually have a Facebook page, so if we have question we will post on that, so to get other mums who have same block of months, because our baby going to the same stage, so any problem or issue we will actually ask each other. Even like breastfeeding topic. One of us feels like stop breastfeeding, and you will then get encourage (to carry on). So sort of support from there….’

Low degree of support for breastfeeding in the workplace

Attitudes of superiors and colleagues

The level of breastfeeding support varied with companies. While some workplaces did have breastfeeding facilities for working mothers, the acceptance of breastfeeding practices in the workplace, however, was still dependent on the superior’s and colleagues’ attitudes towards it. Participants (n=3) were sensitive and mindful about their absences from work especially in front of their supervisors. Taking time away from work to express milk was associated with inefficiency.

Participant 7 stated: ‘In Singapore, everything is fast fast fast, and breastfeeding actually take up time. And people will think you are not productive enough…. I think I better do it (express milk) in office, faster and easier, and within sight, they don’t feel that I am going somewhere else…. Because some people will think that why you go away for so long…. But if I am inside 20 minutes, and my office has pantry, so I am still within sight. Visually I am only away for 20 minutes. But if I go another building (nursing room), visually I am away for 40 minutes, to them I am eating up the working hours….’

Participant 5 reported: ‘my work environment is very rushing…. Although they understand. But half an hour you are gone for that (express milk), I would see that my colleagues might think “why you have this priority?”…. Like half an hour you are disappear, almost an hour throughout the day apart from lunch time, that is not your benefit…. It might affect my job….’

Discrepancy between period of paid maternity leave and recommended period of time for exclusive breastfeeding

Another participant mentioned the lack of support from the government for working mothers who were still breastfeeding: ‘Considering we have 4 months maternity, under the government advice that we should breastfeed at least 6 months, then what happen to that last 2 months? Must I take no-pay leave? Or what shall I do? The government support is still quite not…. They haven reach the certain level yet….’ (Participant 2)

Sense of guilt

Guilt was described by participants (n=3) when they had to feed formula milk to their babies due to work commitments.

Participant 5 reported: ‘During that time I will feel that very stressful and disappointed, and think that should I be a full time mummy? Is a decision, is very stressful, but you need to work…. You cannot quit the job also…. I feel very guilty at the beginning. Even I start formula milk I also feel guilty. But I think is no choice….’

Unease at breastfeeding in front of others

Public’s reaction

Participants felt uncomfortable in breastfeeding their baby in public, as people tend to stare at them when they nursed the baby. All participants expressed that they will either go to a nursing room or nursed the baby with adequate cover when no nursing room was available.

Participant 6 reported: ‘When you breastfeed in public there will be a lot of people stare at you. I tried once breastfeed in public, some people like just stand there and stare…. I feel like… its quite rude. Because I am feeding baby and they keep staring….’

Participant 1 commented: ‘it is quite inconvenient, I need extra towels, it is a bit messy when I am outside…. Actually I have the nursing shawl but I am not comfortable in using it in the public…. There were times where a friend who came over, she was sitting outside, but I keep running into the room to feed her (baby), I am not comfortable. In fact not even in front of my mum….’

Embarrassment when baby grows bigger

A participant did not mind nursing her baby in public, using a shawl when the baby is only a few months old, but she felt embarrassed to latch on a baby bigger than a year old. She expressed awkward feelings when a big baby is sucking on the breast in the public.

Participant 5 reported: ‘I think about this age (10 months), if I still have breast milk, might be hesitate. Because when I see big baby still latch on, it looks like a bit funny….’

Emotional and psychological aspects of breastfeeding

Bonding and sense of achievement

All participants associated breastfeeding with positive feelings, especially with the bond that they had with their child despite some negative experiences.

Participant 2 stated: ‘The experiences is can’t really describe, basically the feel was good…. It is very personal, when baby feeling hungry, he know where to get milk, he know how to latch on immediately…. When he latches on, his hand will move around, and then he will touch you, he will feel you, then that kind of warmth, that kind of interaction, you will feel very good…. Physically you feel very tired, but overall experiences were very good….’

Some participants (n=5) felt proud and gain a sense of achievement in breastfeeding.

Participant 5 stated: ‘After 3 months he grew very fast, I would see that he only take my breast milk, and I feel quite successful. I very happy about it. When he just born he was only 2.6 kg, and then just breastfeeding he grow until now. I am very happy.’

Feelings of uncertainty, emotional insecurity and self-sacrifice

Feelings of uncertainty were mentioned by two participants as no one could advise them on their breastfeeding queries. For first time mothers with a poor support network, feelings of uncertainty continued to appear throughout the breastfeeding journey and they learnt from their own experiences. Fear of making the wrong decision to choose breastfeeding instead of giving formula milk in the initial period was cited by participants (n=3). With little or poor support, they felt stressed and helpless about breastfeeding. Some participants (n=2) reported that they felt emotionally unstable and confused when people gave different advice. Most participants panicked when the baby cried and worried about their milk supply.

Participant 3 mentioned: ‘My supply cannot meet my baby demand. If she drinks 7 times, I can only supply for 3 times. I did ask my friend, they ask me to drink more water, eat more fish, and have more rest. But when you start to feel stress, your milk flow will drop.’

Some participants (n=4) felt ‘sacrificed’ when they were told they couldn’t take their favourite food such as spicy food and seafood, and had lesser time to go out with friends due to the need to breastfeed. Lack of personal time due to breastfeeding commitments and the adaptation period to their new role were also discussed. Participant 1 stated: ‘After delivery you so tired, and then it is like I get up, I feed her, she sleep, I need to shower, I shower come back, she gets up, and I feed her, I need to go and eat, then she sleep, she gets up again, I didn’t have time for myself, for the initial 1 to 2 months was a bit crazy, it was the baby me, the baby me, the baby me. It is a bit stressing….’

Tough and challenging at first

The first 2 weeks after the baby was born was described as ‘tough’ and ‘stressful’, and was often associated with physical tiredness. Some participants (n=5) claimed that ‘no one has warn you it’s that tiring’ for breastfeeding, and ‘no one can help you with it’ too.

Participant 10 commented: ‘Initially was very tiring. The first 2 months very tired. But you keep feeding the child. No one else can help you. And nobody told you it is so tired…. I think there are a lot of mothers are quite pro-breastfeeding. It just for the first time mothers, no matter how much antenatal class you attend, you wouldn’t expect it is so tired….’

Other participants (n=4) claimed that what they learnt about breastfeeding was totally different from their actual experiences.

Participant 3 mentioned: ‘The real experiences I can’t read from book….’

Discussion

The analysis presented in this paper is based on the accounts of a group of first time mothers who delivered healthy full-term babies and had initiated breastfeeding while in the hospital.

Similar to the results of previous studies,^15,17,24,25 mothers in this study reported struggling with breastfeeding after they were discharged from hospital. Some had trouble trying to get their babies to latch on, and experienced conflicting advice from their own mothers or confinement nannies. As narrated by the participants in this study, the need for breastfeeding support when they returned home was crucial to ensure the continuity of breastfeeding after discharge. Similar to previous study findings,²⁶ first time mothers might not know what questions to ask prior to their discharge from hospital. Even though discharge advice was provided, many mothers are still unsure of who and where to seek help in times of need. For first time mothers, interventions by trained nurses in the home setting could help to guarantee successful breastfeeding at home.²⁷ In another study,²⁸ home visits by midwives or maternity care assistants were described as overwhelmingly positive experiences by the young mothers who received the care. Having home visits by midwives or maternity healthcare professionals might be beneficial for mothers in Singapore because most practised ‘confinement’ at home.²⁹ A local study conducted by Shorey et al.²⁵ found that home visits by midwives helped first time mothers to cope better physically and emotionally in the initial postnatal period. Proper education and social support can be given during home visits to increase maternal self-efficacy and prevent postnatal depression.²⁵

Support from the first time mothers’ own mothers and spouses, as well as the wider community, was helpful in enabling the first time mothers in this study to continue to breastfeed. Similar findings were reported in previous studies by Jessri et al.¹³ and Hjalmhult and Lomborg,³⁰ whereby social support enabled the mothers to continue to breastfeed despite initial challenges. In a qualitative synthesis paper by McInnes and Chambers,³¹ it was concluded that mothers may consider social support (from a mother, friend or partner) to be more important than health professional support. However, social support may exert a negative influence if there is a lack of breastfeeding knowledge or experience within the social group.

As discussed in many previous studies,^26,32–35 perceived inadequate milk supply issues could be due to lack of knowledge on the physiological process of lactation. First time mothers in our study narrated similar perceptions of inadequate milk supply, especially when the baby cries. Education of first time mothers during the antenatal period could help to address this concern. Education could place emphasis on recognising infant hunger cues, the physiology of breast milk production, ways to monitor if the baby is getting enough nourishment and ways to boost breast milk production.⁸

Workplace support is crucial for working mothers who are still breastfeeding. Although amenities to express breast milk were provided, participants in this study expressed concerns about being seen as ‘unproductive’ if they take time to express milk while at work. Breastfeeding had the potential to put women in the spotlight and to make them highly visible, thus affecting their breastfeeding decision.³⁶ Strategies promoting breastfeeding in the workplace need to be implemented. For example, in the USA, the US Federal Patient Protection and Affordable Care Act (2010) ensures that companies give breastfeeding mothers of children under the age of 1 year reasonable time to express milk in a clean and private lactation room.³⁷ Companies should practise flexibility such as providing working mothers with lactation breaks and the physical space to express milk or breastfeed.³⁸

Contrary to previous study findings,^16,39 five out of nine first time mothers in our study who resumed full-time work managed to breastfeed for the recommended period of 6 months or longer, despite narrated challenges of expressing breast milk while at work. This could be due to the availability of facilities to express breast milk and support from spouses to continue breastfeeding.

Similar to previous study findings,¹³ participants in this study regarded breastfeeding and expressing of breast milk as intimate activities. Although more lactation rooms are found in public areas of Singapore, the most important issue still relies on society’s attitudes and cultural norms.

First time mothers in this study experienced different emotions and states of mind. Being able to breastfeed was associated with positive loving feelings of bonding with the baby, and mothers experienced a sense of achievement for successful breastfeeding. On the other hand, they also felt uncertain about their abilities to breastfeed and resented changes to their lifestyle because of the commitment to breastfeed. This finding was similar to that in previous studies, in which a combination of positive and negative feelings was reported. In an analysis of responses to telephone interviews, Forster and McLachlan.⁴⁰ reported that women found breastfeeding to be difficult, especially at the beginning. They recognised that breast milk is good for the baby and benefited the baby’s immunity; and reported feelings of closeness between mother and baby. Kronborg et al.²⁴ described first time mothers’ experiences as being on a breastfeeding–bonding trajectory. Mothers started off on ‘shaky ground’, characterised by painful breastfeeding and conflicting advice. They then proceeded to ‘searching for a foothold’, being able to recognise baby’s cues, concerned about the amount of milk produced and searching for support. Finally, mothers became ‘at ease with choice of feeding’, characterised by a thriving baby and gaining confidence.

Limitations and implications for practice and research

The findings cannot be generalised to other settings as the sample size was small and the study focussed on first time mothers. Although efforts were made to ensure the main races in Singapore, that is, Chinese, Malay and Indians, were represented in the study, the predominant ethnicity was Chinese. Given ethnic differences in postnatal practices and beliefs, the results might not be representative of all ethnic groups in Singapore.

As the first time mothers in this study reflected, more resources are needed to support and promote breastfeeding in the community. During the first few weeks after birth, continual support from health professionals such as midwives and significant others are important in order to establish breastfeeding. In the long haul, changes in workplace practices and understanding from co-workers and the general public would then help to enable mothers to breastfeed for a longer period of time.

Future studies should look into the needs of mothers who did not breastfeed their first born but who wanted to do so for their subsequent children. It is also important to look into the experiences and needs of mothers who work shift duties and/or irregular hours, and how workplace practices can promote breastfeeding.

Conclusion

This study provided a better understanding of the breastfeeding experiences and challenges of first time mothers in Singapore. Initiating and sustaining breastfeeding is still challenging for first time mothers. Greater public awareness and laws that support breastfeeding in public and the workplace, as well as the support of family members, could be helpful in promoting successful breastfeeding.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

World Health Organization. Breastfeeding, http://www.who.int/topics/breastfeeding/en/ (2014, accessed 5 November 2015).

American Academic of Pediatrics. AAP policy on breastfeeding and use of human milk, http://www2.aap.org/breastfeeding/policyOnBreastfeedingAndUseOfHumanMilk.html (2013, accessed 20 February 2013).

Association for Breastfeeding Advocacy (Singapore). Mission, http://www.abas.org.sg/aboutus.htm (2001, accessed 25 February 2013).

Health Promotion Board. Sale of infant foods ethics committee Singapore, http://www.hpb.gov.sg/foodforhealth/article.aspx?id=7112 (2013, accessed 25 February 2013).

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