Abstract
Maternal wellness and breastfeeding is an emerging area of practice in which occupational therapy practitioners can provide new mothers with supports that help them maintain self-efficacy related to breastfeeding and other meaningful occupations.
Breastfeeding is an occupation in which roughly 81% of mothers initially engage after their baby’s birth (Centers for Disease Control and Prevention, 2016). Although breast milk is considered the best form of nutrition for newborns, many mothers discontinue breastfeeding before originally planned (Pitonyak, 2014). Clinicians who work in emerging health and wellness practice settings, such as breastfeeding centers, may play a key role in helping clients successfully sustain breastfeeding. However, gaps in knowledge exist as to how much and what type of support mothers require to continue breastfeeding for the optimal amount of time (Perez-Blasco et al., 2013).
Breastfeeding Benefits for Mother and Child
The value and practice of breastfeeding have implications for both the mother and child. For the mother, the act of breastfeeding causes positive physiological changes that aid with recovery after birth (Allen & Hector, 2005) and diminish the mother’s risk of certain diseases (Godfrey & Lawrence, 2010). Breastfeeding can also facilitate mother–child bonding and reduce postpartum depression (Bigelow et al., 2014). Breastfed babies may have fewer developmental delays in language, motor, and intellect (Dee et al., 2007) as well as protection against infectious diseases (Allen & Hector, 2005).
Supports for Mothers Who Breastfeed
Although the World Health Organization (WHO; n.d.) recommends breastfeeding for a child’s first 6 mo, a mother’s achievement of this objective can be influenced by her degree of support (Burns & Schmied, 2017). Mothers who participate in group breastfeeding support sessions with lactation consultants (Silbert-Flagg et al., 2016) or other professionals (Vari et al., 2000) tend to breastfeed for a longer time. An online component of support has also been shown to be beneficial in terms of sustaining breastfeeding (Wagg et al., 2019). The mother’s opportunities for personal self-determination and her ability to maintain a positive attitude about breastfeeding (Hauck et al., 2016) have been connected to breastfeeding initiation and continuance.
Research has more recently begun to propose wellness models for mother-centered postpartum care to support breastfeeding mothers and infants (Cornell et al., 2016). For example, Fahey and Shenassa (2013) articulated a maternal health promotion model that identifies three key tasks for a healthy postpartum period: (1) care of self, infant, and family; (2) maternal role attachment; and (3) physical recovery. Four critical skills are described: (1) social support mobilization, (2) positive coping, (3) self-efficacy, and (4) realistic expectations (Fahey & Shenassa, 2013). Another evidence-based model that draws on cognitive–behavioral therapy (CBT) and interpersonal therapy (IPT) is Reach Out, Stand Strong: Essentials for New Mothers (Zlotnick et al., 2016). Group sessions help mothers create a healthy physical, social, and psychological environment for themselves and their infants. Topics covered include stress management, social support systems development, role transitions, and handling interpersonal conflicts that frequently surround childbirth.
Occupational therapists can help mothers form new routines and habits that promote a smooth transition to breastfeeding and complement lactation consultant input. Occupational therapy support can also help infants with feeding difficulties, including breastfeeding (Pitonyak, 2014). The literature, however, lacks examples of program evaluation data from occupational therapy interventions with this population. In the current study, we developed occupation-based programming implemented by occupational therapists for postpartum breastfeeding mothers at outpatient lactation centers to support both maternal health and wellness and mother and child breastfeeding success, and then examined its impact. We hypothesized that such programming would increase the ability of postpartum mothers to meet personal wellness goals and adjust to their role as new mothers.
Method
Research Design and Participant Sampling
This pilot study had a concurrent triangulation mixed-methods design, which allowed us to combine the strengths of both qualitative and quantitative methods and form a composite model to interpret the impact of the intervention (Creswell, 2014). After receiving institutional review board approval, convenience sampling was used to obtain participants, who were recruited from a nonprofit center that provides lactation consulting services in the suburbs of a large east coast U.S. city. Recruitment methods included flyers posted at the center, verbal descriptions of the study to clients by lactation consultants, and a written description on the center’s social media web page. Women who had been breastfeeding an infant for less than 6 mo, who were not currently weaning, and who had met with a lactation consultant at least once since giving birth were recruited.
Procedure
After providing informed consent, each woman independently spent approximately 25 min completing an occupational profile created specifically to reflect the multilayered occupation-based needs of mothers who breastfeed. The occupational profile form, which was reviewed by occupational therapy researchers and content experts, included basic demographic questions and inquiries about any occupation-based performance challenges that connected to personal priorities; social networks; hobbies; patterns of behavior, habits, and values; body function changes related to childbirth; and individual contextual and environmental factors.
The occupational profile was then used to develop an initial goal attainment scale (GAS; Turner-Stokes, 2009) in a 45-min individualized occupational therapy treatment session. For the GAS, clients created, with support from occupational therapists, three personal wellness goals that were person centered, measurable, achievable, and functional. Each goal was assigned a quantitative value (from –2 to +2) representing how the mothers perceived their current ability to meet each goal within a 10-wk timeframe. The GAS process allows each respondent to create their own outcome measures but is scored in a standardized way that allows for statistical analysis (Turner-Stokes, 2009). As a data collection tool in this study, the GAS was used to individually measure the efficacy of occupational therapy programming as perceived by each mother; as an intervention, the GAS helped mothers feel more empowered and self-efficacious by setting and meeting their personal wellness goals.
Next, mothers participated in occupational therapy programming that offered 10 weekly 1-hr occupational therapy group sessions in the center’s community room led by trained occupational therapists and occupational therapy graduate research assistants. Occupational therapists determined session content by integrating data from occupational profiles and GAS goals and partnering with the lactation consultants to identify topics that complemented and augmented the support they provide. Group content included subjects related to mothering within occupational therapy’s scope of practice; the 10 group topics were body mechanics, babywearing, infant development (2 sessions), stress management, work–life balance, tummy time, bedtime routine and infant massage, community integration, and role transitions. Using a topical group format, sessions comprised an instructional, educational component, drawing on evidence-based CBT and IPT therapy pedagogies aimed at assisting mothers with problem solving, coping, and interpersonal skills. Follow-up weekly emails included personalized check-ins on individualized GAS goals and additional resources.
After 10 wk of occupational therapy programming, all of the women rescored their GAS goals to determine whether progress had been made. They also completed a 45-min semistructured exit interview to share their perspective regarding the occupational therapy intervention process. Interview responses were recorded manually by a second researcher acting as a scribe, with frequent member checks to maximize accuracy. The entire study took place across 15 wk, including initial occupational profile and GAS scoring, 10 wk of programming, and the data collection phase. Data from participants attending at least 5 of the 10 weekly group sessions were included in the results.
Analysis
First, responses from individual occupational profiles were tabulated and then summarized using descriptive statistics presented as ratios. Next, participant-assigned numeric values from the first and second ratings of the GAS scale were compared by researchers and then reviewed by a biostatistician. These data were analyzed using a statistical formula (Turner-Stokes, 2009) that transforms the composite GAS scored into a standardized T score (M = 50, SD = 10). Higher composite GAS scores indicate that a better outcome has been achieved (Turner-Stokes, 2009). Qualitative data from semistructured exit interviews were then analyzed, using open, axial, and selective coding, creating an auditable trail of thematic development (Creswell, 2014). Two researchers who had not conducted the interviews coded the interview data independently and compared themes, enhancing trustworthiness by expanding the iterative process of coding analysis and enabling researchers to refine the codes identified. Finally, researchers reviewed results from all three data sources (occupational profiles, GAS scores, and thematic codes) holistically to triangulate findings to derive meaningful interpretations of their interrelationships and significance.
Results
Of the 17 mothers who returned consent forms and completed the study intake phases, 3 were disqualified: 2 because of insufficient group attendance and 1 because she stopped breastfeeding for health reasons. Therefore, 14 mothers ultimately participated in this pilot research.
From Occupational Profiles
Data from occupational profiles revealed that all 14 participants identified as female and were married, with ages ranging from 25 to 39 (5 did not report their age; Table 1). Nine participants were not employed; all described their roles as mother and wife as the roles that they valued most. Regarding body functions, all participants reported breastfeeding as their main focus; however, 6 participants reported having pain from breastfeeding or postpartum injuries. Three-quarters (10 of 14) of the mothers stated that they had difficulty with current social interactions, saying that they had support systems as new mothers but struggled to ask for help and guidance. All participants agreed that their physical and social environments created barriers that impeded their ability to breastfeed and perform other valued occupations. In particular, issues of family or community pressure related to culture were cited (4 of 14) as a negative factor. In sum, shortages of time, lack of knowledge and support, and excess stress were cited as reasons why mothers struggled to simultaneously meet their mothering and personal goals.
Occupational Profile and Sociodemographic Results (N = 14)
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Results From Goal Attainment Scale Scoring
An examination of the data revealed that mothers chose goals that reflected typical occupations for women of childbearing age who had recently given birth (Table 2). Goals included getting adequate sleep, going out on regular date nights with their husbands, following through with an exercise or weight loss program, and returning to a work setting. Results of an analysis of GAS values from the beginning to end of the occupational therapy programming yielded a mean preintervention score of 50.00 and a mean postintervention score of 56.50, indicating that most goals were reached by the mothers. The range of composite final GAS scores varied from 45.44 to 63.69, and the mode was 63.69. The one mother with a GAS pre–post intervention composite value of 45.44 had particular struggles with a baby who had severe colic, which researchers attributed to her difficulty in meeting her personal goals. There was no significance noted in the scores between the mothers who were or were not working outside of the home.
GAS Levels and Corresponding Examples
Note. GAS = goal attainment scale.
Results From Exit Interviews
Coding analysis of the interview data revealed three themes regarding occupational therapy’s impact: the mother’s ability to persevere with breastfeeding (Theme 1, persevering), her feelings of competence about the tasks of motherhood (Theme 2, self-confidence), and the degree to which she valued herself in addition to her baby (Theme 3, valuing oneself). Mothers reported, for example, that the occupational therapists provided ergonomic techniques for breastfeeding (Theme 1). “Some of the techniques taught made feeding her easier and less painful,” said one new mother. Another mentioned a change in routine that occupational therapists suggested, saying “I never thought time management was something to worry about as a new mother, but the suggestions provided were life-changing in my day-to-day routine.” Several participants shared that they felt reassured by a comprehensive review by occupational therapists of typical infant development (Theme 2). Another participant stated, “My baby wants to be held all the time; [occupational therapists] taught me how to ‘wear’ her safely.” Mothers also appreciated explicit education about valuing themselves in addition to their infant (Theme 3). A working mother said, “It was nice to feel reassured that it’s ok that I am happy about going to work and that I shouldn’t feel ashamed.” One mother who did not meet her GAS goals described how the occupational therapy sessions helped her cope with her son’s severe colic: “The OTs gave me reassurance and tools that helped me feel adequate as a mother.” Another mother stated, “I appreciated that they talked to me about thinking about myself more and reminded me not to be a martyr.”
Concurrent triangulation was used to synthesize the occupational profiles, GAS outcomes, and interview themes. The overarching concern of the mothers, on the basis of all of the data, was their ability to meet their own needs while meeting the needs of their infant and family. Occupational therapy group support was valued for providing interpersonal opportunities to process these concerns, paired with problem-solving strategies for addressing them, using an occupation-based framework.
Discussion
Both the quantitative and qualitative pilot data gathered in this study suggest that occupational therapy can help support the occupation-based wellness goals of breastfeeding mothers at lactation centers and influence their perseverance at the occupation of breastfeeding. Although lactation consultants have a narrow scope of practice (International Board of Lactation Consultant Examiners, 2018), occupational therapists bring to this setting a broader, holistic background; a more extensive academic and clinical training period; consistent board certification; and a unique, occupation-based perspective. The occupational nature of valued personal activities was reflected in the goals mothers set for themselves in the GAS process, guided by their occupational profile responses. On conclusion of the occupational therapy programming, the increase in participants’ median GAS score indicated that most reported progress toward meeting their three individual goals. Qualitative data revealed that mothers experienced a greater sense of competence and self-worth after the occupational therapy intervention, enhancing their psychological well-being and confidence in being able to address their own needs along with the needs of their infant and family. Combined, these results point to the potential for a unique role for occupational therapists in helping new mothers achieve greater personal health and well-being while breastfeeding.
Limitations and Future Research Directions
Limitations of this pilot study include its small sample size and the absence of a control group that received another type of intervention instead of occupational therapy. In addition, future studies could track breastfeeding mothers receiving occupational therapy for a longer time period to strengthen the research and align with the WHO’s (n.d.) goal of mothers exclusively breastfeeding for at least 6 mo.
Implications for Occupational Therapy Practice
On the basis of the data gathered, this exploratory study suggests that occupational therapists can offer a unique contribution to breastfeeding mothers, who may benefit from occupational therapy support and services delivered in the postpartum period. The health and wellness of a mother, reflected in her ability to maintain meaningful personal daily occupations, affect her ability to sustain breastfeeding as well as successfully follow through with other parenting responsibilities and cherished activities. Receiving skills through occupational therapy input that encompass physical, social, and psychological domains for both mother and baby is often the additional piece that is missing for the mother to feel confident in her role while maintaining her sense of individual self-efficacy. Maternal wellness and breastfeeding represent an emerging area of practice that holds potential for an expanded role for occupational therapy in collaboration with lactation consultants. As occupational therapists define their niche with breastfeeding mothers, further studies need to be completed to determine best practice and treatment effectiveness.
Conclusion
Despite numerous benefits to both mother and infant (Godfrey & Lawrence, 2010), there are gaps in the literature about what support mothers need to continue breastfeeding for the recommended first 6 mo of life. Research suggests that new mothers who breastfeed face challenges in maintaining a sense of self-efficacy, health, and wellness (Hauck et al., 2016). This study’s purpose was to explore whether occupational therapy programming that provides group and individualized support could effectively assist breastfeeding mothers at lactation centers to set and reach personal wellness goals while continuing to breastfeed. The results indicate that occupational therapists helped most mothers meet their occupation-based goals successfully while sustaining breastfeeding. These findings align with conclusions from previous studies showing that educating mothers about breastfeeding’s physical and psychological benefits for both them and their babies may help them continue (Hauck et al., 2016).