Introduction

Breastfeeding is one of the public health priorities in the world (1)and is considered as a type of highly effective behavior in promoting health (2). Breastfeeding has been linked with numerous physical, emotional, psychological, and social advantages for both the mother and infant (3, 4). The world health organization (WHO) has endorsed the exclusive breastfeeding for the first 6 months, followed by complementary foods and breastfeeding continuation up to at least 2 years of age (5). WHO has set one of the Healthy People 2020 objectives as increasing the ratio of female parents, who initiate breastfeeding and those who continue it for six months, to 75 and 50 percent, respectively (6). Despite the significance of breastfeeding and the growing emphasis laid on it, the rate of exclusive breastfeeding in the first 6 months is 37% in the world (2014), 36% in the Eastern Mediterranean Region, 10% in Australia, and 42% in Turkey (7). In Iran (2014), this rate decreases to 27.7% in 6-month infants (8). Thus, breastfeeding protection, advancement, and support are considered to be public health priorities (9). According to written reports, various factors affect breastfeeding initiation and sustainability, including demographic, psychological, and social factors related to the mother (1, 2, 10). One of these factors is the social support, i.e. the help people receive from others, which is classified into four types of support (11). House (1981) conceptualized the social support as four behavioral categories: emotional, informational, instrumental, and appraisal (esteem) support. Appraisal (esteem) support involves the communication of information which is relevant to self-evaluation and may result in enhanced self-esteem, which can help an individual be well adapted to stressful events in a number of different ways (12). On the other hand, for some mothers breastfeeding is a harmonious and pleasurable experience and for others, a disruptive, unpleasant, and violent experience (13). As Alianmoghaddam et al. (2018) argue, breastfeeding is a challenging and demanding behavior for breastfeeding mothers for some reasons including a lack of bodily autonomy, wanting their body back, and feeling that their individual circumstances and personal needs are not considered (14). They also highlighted that experiencing difficulties by breastfeeding mothers, including sore nipples, chest pain, inadequate milk production, and ineffective milk transfer led to mothers’ perception of breastfeeding as a stressful process (15) as well as facing a range of psychological stress in the postnatal period (16). In this respect, social support is well recognized as being able to decline mental health issues such as stress, and to boost the individual’s flexibility and self-esteem in coping with such issues (16-18). A review of literature shows that social support for breastfeeding mothers has been widely considered in numerous quantitative and qualitative studies (11, 16, 18-21). To the best of our knowledge, few studies have examined the appraisal support need on the experiences of breastfeeding mothers (20, 22, 23). Considering the studies in Iran, there is no qualitative study conducted with regard to this subject and almost all studies are quantitative (11, 24, 25). Qualitative studies are valuable tools to obtain a deeper understanding of ‘how’ and ‘why’ a phenomenon occurs (26). Thus, adopting a qualitative approach, we designed and conducted this study to explore breastfeeding mother’s perceptions and experiences of appraisal support needs.

Materials and Methods

This study was performed between March 2017 and April 2019 and adopted a qualitative content analysis approach, which is used to acquire deeper knowledge about a phenomenon (27), and therefore allows researchers to better understand breastfeeding mothers’ perceptions and experiences of appraisal support needs. This study was conducted at five health centers, two clinics, and four hospitals affiliated to Mashhad University of Medical Sciences. The participants were 25 breastfeeding mothers, 2 family members, and 9 healthcare providers who were selected using a purposive sampling method. The maximum variation in sampling was considered in terms of social-demographic status. The inclusion criteria applied in this study were: being a volunteer, willingness to take part in the study and be interviewed, speaking Persian language, living in Mashhad, having a term baby, and not suffering from any diseases (both the mother and baby). The exclusion criteria included those breastfeeding mothers who had no inclination to participate in the study. The present study received approval for conducting its research from the Medical Ethics Committee of Mashhad University of Medical Sciences (IR. MUMS. REC.1396.124).

Breastfeeding women were invited to take part in the study. They were informed of the study design and also of the voluntary nature of their participation, their anonymity, and their right to withdraw from the study at any time. Also, their permission to record the interviews was obtained. Semi-structured interviews were conducted by the first author (NMS) at a time and place convenient for the participants. The interviews were provided in hospitals, health centers, and physician offices where they would start with general questions such as “Would you please talk about your experiences of breastfeeding?”, and would then switch to more specific, detailed questions such as “Based on your experience as a breastfeeding mother, what support do you need during this period?”, “Who helped you meet your support needs during the breastfeeding period and how?” and “What actions in this period increased your confidence to continue breastfeeding?”, as the interview proceeded. Probing questions were asked to follow the participants’ perspectives, hence the richness of the interviews and data (28). Data collection continued until data saturation was achieved (29). The mean of interview duration was 40 minutes with a range of 25–140 minutes. Data collection and analysis were performed at the same time. Data were analyzed using directed content analysis based on the approach of Elo and Kyngas with MAXQDA software (version, 2010). Directed content analysis is used when there is a previous knowledge on the phenomenon under study, but it is not complete or needs further description. (30). Deductive analysis approach is represented as three principal phases: preparation, organizing, and reporting. In the preparation phase, the first author listened to the recorded interviews, transcribed them verbatim, and read them several times to achieve a sense of wholeness. Then, meaning units were defined. In organizing phase, using the existing theory, key concepts or variables were identified as initial coding scheme. And so, the researcher then developed an analysis matrix, and coded the data accordingly. Categorization and abstraction were performed in this phase. In reporting phase, researchers reported the analysis process and results (30). Guba and Lincoln’s criteria were applied to assure the trustworthiness and rigor of the data. The researchers had a long and close contact with the participants, hence enough time to gather and analyze the data. Furthermore, the participants were selected from a scope of socio-demographic status to access a diversity of experiences. Likewise, data collection was done until saturation was achieved and no more categories emerged in the analysis. All researchers involved in checking the compatibility between the study objectives, analysis process, and findings. Findings were corroborated using good references to increase credibility. For member checking, mothers were given a report of the findings to confirm if their views and comments had been well reflected. Also, details of the study process along with the participants’ direct quotations were presented to the readers so as to improve the transferability of the results (31).

Results

Socio-demographic characteristics of 36 participants who took part in this study are listed in Table 1.

Four categories, including ‘approval and affirmation from significant others’, ‘the necessity of avoiding social comparisons due to unpleasant corollaries’, ‘offering constructive feedback’, and ‘persuasion’ and 9 subcategories including ‘the need for approval and affirmation from health providers’, ‘the need for approval and affirmation from the husband and family members’, ‘unpleasant feelings caused by being compared to others’ and ‘being blamed when compared with others’, ‘providing breastfeeding mothers with positive feedback’ and ‘not giving breastfeeding mothers negative feedback’, ‘the need to encourage the breastfeeding mother’, ‘the need to be admired the breastfeeding mother’ and ‘the need to be praised the breastfeeding mother’ by significant others, emerged from data analysis of breastfeeding mothers’ appraisal support needs, Table 2.

Approval and affirmation from significant others

For this category, ‘the need for approval and affirmation from health providers’, ‘the need for approval and affirmation from the husband and family members’ were two important subcategories. According to participants in this study, affirmation and approval from others, especially from the husband, couple’s family members, and health personnel, are very important during this period. In this regard, a health provider said: “Confirmation and affirmation from relatives, especially the husband, couple’s family members, and health personnel are very important” (Participant 27, a 45-year-old breastfeeding expert). Approval from relatives about mother’s appropriate breastfeeding practices is important and results in favorable outcomes such as a boost to the mother’s self-esteem and giving her a sense of inner confidence which motivates her to continue breastfeeding. Two participants stated: “Such approval from the health system along with examining the mother’s problems, observing the baby during breastfeeding, and checking her breastfeeding instills inner confidence in mothers…” (Participant 24, a 35-

year-old mother). “When family members or health personnel talk to the mother and approve her breastfeeding practice saying: ‘the baby is now well-nourished…the way you breastfeed the baby is right now….it’s okay, the baby is correctly sucking on the breast...the baby is satiated...’;(others must) see these only and tell her...spend half an hour with the mother and look at what she does...tell her, for example, that she’s been breastfeeding the baby in a correct way up to that moment...especially in the first month...this increases her self-confidence” (Participant 23, a 39-year-old mother). Being approved by others also makes the mother feel highly valuable. One of the participant said: “An important part of the mother’s supportive needs should be met at home, by her husband...i.e. the husband must behave in such a way that the mother realizes the value of her practices, for example, he must approve her actions…” (Participant 18, a 37-year-old mother). Participants’ statements suggest that people need inner confidence and self-esteem if they want to do something and sustain it. In so doing, their performance needs to be approved by others, indicating that their actions are accepted. Likewise, a sense of worthiness of breastfeeding practice is a desirable outcome of such affirmation.

The necessity of avoiding social comparisons due to unpleasant corollaries

This category had two subcategories of ‘unpleasant feelings caused by being compared to others’ and ‘being blamed when compared with others’. Participants believed that during the breastfeeding period, next of kin like the husband, spouses’ mothers, and even relatives, often compare the mother’s breastfeeding performance with others’ and evaluate an optimal breastfeeding practice and nourishing milk in terms of the baby’s weight; comparing babies’ weights with each other. Such comparisons to assess the success and quality of a mother’s breastfeeding practice are absolutely unacceptable. One of the participants stated: “My mother often compared me with other lactating women” (Participant 1, a 32-year-old mother). Another one said: “My relatives compared my baby with their own babies and they asked me, as a doctor, why my baby was thinner? I had heard them saying such words many times. My mother-in-law asked me to feed my baby on formula because the baby was average and not chubby (as they wished), and she blamed me on my breast milk” (Participant 23, a 39-year-old mother). In this regard, a health provider said: “When the baby cries, the husband blames his wife and says: You do not lactate enough breast milk…You do not know how to breastfeed the baby...You cannot even feed a baby…You are good for nothing! ...See how chubby other babies are! They do not know that breastfeeding mothers are different, so are babies...They should never compare mothers with each other” (Participant 27, a 35-year-old breastfeeding expert). Even some mothers compare their babies to others’ and assess their breastfeeding utility in terms of baby’s gain weight. As a corollary of such comparisons, both from the mother’s side and/or from family members’, the mother experiences some positive or negative feelings. Two participants expressed their positive feelings: “My cousins, who were breastfeeding mothers like me, were around me most of the time. I could see them breastfeed their babies whenever they wished to do so and would go to bed to rest and sleep whenever they wanted…But I cared too much for it and breastfed my baby every two hours…. I was extremely keen to breastfeed my baby so that my baby gained weigh very well at six months compared to their babies...When I saw that my baby was gaining weight and growing up well, I was overjoyed” (Participant 20, a 26-year-old mother). Another participant said: “Whenever I saw my baby’s weight gain was better than other babies…and my baby’s nutrition was good, I gained higher self-confidence” (Participant 33, a 40-year-old mother). Some participants, however, talked about their negative feelings in this regard. “As a woman, I felt weak and incapacitated to breastfeed my baby. I compared myself to others and wondered why I could not...?” (Participant 33, a 40-year-old mother). “When my relatives or mother-in-law compared the weight of other babies with mine, I become nervous, I got upset, their words tormented me and drove me up the wall!” (Participant 23, a 39-year-old mother).

Offering constructive feedback

‘Providing breastfeeding mothers with positive feedback’ and ‘not giving breastfeeding mothers negative feedback’ were two subcategories listed in this category. According to participants’ statements, one of the factors which increase breastfeeding mothers’ inner confidence to continue breastfeeding is the positive feedback they receive from significant others, i.e. the husband, the family members, and health personnel. One participant said: “Health providers should give positive feedback to the mother...They should keep motivating the mother.... They should show the mother how valuable the result of her work (breastfeeding) is” (Participant 29, a 45-year-old pediatrician). The participants believed that receiving positive feedback from the environment and others raised mothers’ self-esteem and increased their inner confidence. One of the mothers in this regard said: “If I see a movie in which the mother is breastfeeding her baby well, I may also be encouraged and gain higher confidence...Movies showing successful breastfeeding experiences boost my self-esteem” (Participant 6, a 42-year-old mother). Another mother stated: “Relatives should talk to the mother about the positive outcomes of breastfeeding” (Participant 28, a 34-year-old mother). Participants also stated that the relatives should stop offering negative feedback about breastfeeding because such negative feedback from such close people could result in the mother’s losing self-esteem and a feeling of inability to continue breastfeeding. A health provider said: “A breastfeeding mother comes here (health center) followed by her grandmother or her mother-in-law. They say to her: ‘you do not have enough breast milk...you cannot breastfeed...your milk is not good...the weight of your baby is not good...’ etc. All negative feedback...Such negative feedback badly affects the mother’s ability to breastfeed...and causes her to lose self-esteem” (Participant 27, a 45-year-old breastfeeding expert). Another participant stated: “Sometimes relatives tell me: You cannot…You have inverted nipples. You cannot breastfeed (your baby) …Such negative feedback shatters the mother’s self-confidence” (Participant 28, a 34-year-old mother).

Persuasion

This category had three subcategories of ‘the need to encourage the breastfeeding mother’, ‘the need to admire the breastfeeding mother’ and ‘the need to praise the breastfeeding mother’ by significant others.

The need to encourage the breastfeeding mother

According to the participants, ‘being encouraged’ is one of the breastfeeding mothers’ support needs which is of high importance particularly among the primiparas. Also, from mothers’ points of view, encouragement from family and health providers was more important than from others. One of the participants said: “I needed someone to keep encouraging me! This is more felt among primiparas; they do need someone to encourage them” (Participant 6, a 42-year-old mother). Mothers emphasized that encouragement must be constant and stated that encouraging breastfeeding mothers has positive effects on their morale and increases the mother’s tendency to continue breastfeeding. A participant said: “Well, nobody encouraged me! I, myself, loved to breastfeed my baby, and I had a passion for doing it...particularly when my baby was breastfed well…If I were encouraged, I was definitely much more interested in doing it...” (Participant 20, a 26-year-old mother). As participants believe, relatives can use different ways to encourage the mother, like giving her a gift or a party or in regard to the health centers, displaying promotional posters. A health provider said: “Relatives can give the mother a gift. Pediatricians can hang posters on their office walls, both to encourage the mother to breastfeed her baby and to convey how valuable her role is…” (Participant 26, a 40-year-old pediatrician). Participants believed that mothers who are not encouraged would not have a high level of motivation to breastfeed their babies either, which would eventually lead them to experience a feeling of fatigue to continue breastfeeding. One of the participants said: “As a breastfeeding mother, when no one encourages me…when my husband does not care about my breastfeeding, nor me at all…when it is not important for my relatives either…I cannot continue anymore because I’m left no motivation, no encouragement…” (Participant 28, a 34-year-old mother).

The need to admire the breastfeeding mother

Participants stated that ‘being admired by others’ is among breastfeeding mothers’ support needs, which makes them happy and has a major impact on the continuation of breastfeeding. A health provider explained: “When a breastfeeding mother comes here (health center) and we weigh her baby and see that the baby has gained the right weight...When we admire her, she becomes so happy…When we tell her that her breast milk is good and her baby’s weight gain is ideal, the mother looks utterly thrilled...” (Participant 10, a 45-year-old family health expert). One of the participants said: “Whenever I went to the health center, the health provider told me: ‘well done, the baby’s height and weight are ideal…so are his head circumference and his growth.’ Well, these statements motivated me to nurse my baby” (Participant 22, a 35-year-old mother). Participants also stated that relatives should avoid criticizing the mother’s breastfeeding practice because it would cause the mother to lose confidence, and as a corollary, would reduce her motivation to continue breastfeeding. A participant said: “When relatives try to find fault with you and tell you (sentences like) how thin your baby is...Your breast milk does not suffice…You should give your baby formula...! (etc.), they will sap your (the mother’s) confidence and motivation” (Participant 28, a 34-year-old mother). Also, a health professional said: “If the husband does not care for his wife...or even tells his wife how awful her body shape is or her breasts are sagging, etc., they will definitely reduce the mother’s motivation...The mother might wonder why she should breastfeed the baby when she is not in shape any more, and she can feed the baby with formula” (Participant 26, a 40-year-old pediatrician).

The need to praise the breastfeeding mother

This subcategory encompassed ‘being praised by the relatives and the family members’ and ‘being praised by the health personnel’. Participants stated that when others praised the mother for breastfeeding her baby, she considers it as a kind of support for herself, which is of great importance to her. One of the participants said: “I loved to be appreciated...especially by my husband...I loved my husband to understand me, to understand that I was nursing HIS baby...I loved it when he praised me and my breastfeeding practice. This is really important...That is enough for me” (Participant 34, a 37-year-old mother). Participants recognized others’ appreciation and praise as values for their performance, and stated that husbands must be taught how to appreciate their wives and do not regard nursing as a duty falling to women. Another participant said: “A mother should feel the presence of someone who recognizes the value of her work. She needs to feel that her husband appreciates her...not that he thinks of it as her duty...Men should understand such values…They must be taught to understand that nursing is not a woman’s duty…they should know that mothers are to be respected and appreciated” (Participant 23, a 39-year-old mother). A health provider said: “When a mother comes to this health center to have her baby weighed, it is just enough to tell her that the baby is gaining good weight and thank her for breastfeeding the baby...You cannot believe your ears how much such sentences positively affect her. You can also introduce this mother, as an exemplary successful breastfeeding mother, to other mothers and appreciate her…and give her a gift. These actions are very influential...” (Participant 14, a 37-year-old mother).

Discussion

The present research explored appraisal support needs of breastfeeding mothers and classified them in four categories including, ‘approval and affirmation from significant others’, ‘the necessity of avoiding social comparisons due to unpleasant corollaries’, ‘offering constructive feedback’, and ‘persuasion’. This study revealed that the husband is the most important support provider for many breastfeeding mothers, which were in line with the results of some others studies (20, 32, 33). The majority of participants affirmed the necessity of the provision of these support needs for breastfeeding continuation. They also believed that failure to receive these kinds of social support would reduce their motivation for breastfeeding initiation and continuation. Several previous studies revealed that support had important effects on breastfeeding duration and sustainability (22, 34-36). Several previous studies showed that support had important effects on breastfeeding continuation (22, 34-36), in contrast, the study conducted by Lester et al. (2014) demonstrated some negative forms of support that could suppress breastfeeding continuation (20). In this study, mothers stated that reception of these four types of appraisal support could contribute to positive psychological results such as a boost in self-esteem, self-confidence, self-efficacy, happiness, and a sense of being valuable. In the qualitative study conducted by Rafii et al., (2014), participants described some behavior exhibited by others such as giving feedback, encouragement, and praise (37) as appraisal support, which is in line with the results of the present study. According to the participants, encouragement in its different forms is one of the appraisal support needs which is felt more by the primiparous mothers and must be sustainable for them. Participants emphasized that encouragement had positive effects on breastfeeding and increased the mother’s tendency to continue it. Lester et al. (2014) found similar results and showed that almost all mothers identified receiving encouragement and motivation, especially from their spouse, as a positive support which helped them continue breastfeeding (20). Mukuria et al. (2016) highlighted that provision of encouragement as a kind of social support for breastfeeding mothers could help them improve some breastfeeding practices (21). In this study mothers stated that it was important that the significant others confirm the correctness and accuracy of their breastfeeding performance because it persuaded them to continue their nursing. In accordance with this result, Lester et al. (2014) found that providing affirmation and approval, especially by the husband with statements such as: ‘you are practicing your best’ and ‘you are doing a great job’, was very supportive for breastfeeding mothers (20). Participants recognized other’s appreciation as a valuable aid for sustaining their performance, and explained that husbands were not to see breastfeeding as a duty of their wives. Giugliani et al. (1994) found that the husband’s positive attitude towards nursing and considering it as a valuable practice was the most significant factor associated with breastfeeding (38). This study showed that social comparisons could lead to a series of less positive and more negative impressions. The majority of participants expressed that significant others should keep off making social comparisons because they left mothers with bad feelings such as nervousness, disturbance, torment, distress, and a reduction in self-efficacy. Social support is embedded in ongoing social relationships and interactions (39) and social comparison is one of the central concepts in social relationships (40). Buunk et al. (1990) found similar results and proposed that comparison could produce either positive or negative feelings about oneself, but this would most likely have negative implications (39) such as anxiety, fear, social rejection, and embarrassment (39). In this study, participants stated that one of the factors which contributed to increasing maternal confidence in the continuation of breastfeeding was receiving positive feedback from the significant others. In line with this result, Tardy (1985) highlighted that appraisal support refers to feedback provided by others which allows an individual to assess themselves and their actions (41). Also, Lange et al., (2016) mentioned the role of motivational factors in breastfeeding continuation (42). Findings of this study reinforce the statement by McLorg and Bryant (1989) that “mother’s decision to breastfeed is part of a broader context of social network members’ norms and values” (43). Consistent with this study’s findings, social and behavioral research has recognized that support has a significant impact on the initiation and duration of breastfeeding (20, 44). There is some major strength for this research: it used qualitative methods to collect rich and in-depth data about breastfeeding mothers’ perceptions and experiences of appraisal support needs in the cultural context of Iran for the first time and it is an innovative aspect of the current investigation. One more strength of this study was that data were amassed from the viewpoints of mothers, their family, and health providers to address all perspectives and to gain a deeper insight into all subjects. Another strength was the maximum variation in sampling and data collection. A major limitation of this research, similar to other qualitative studies, is a restriction of generalizability. Apparently, there is a need for further studies in a range of various settings and cultural contexts which focus on the breastfeeding mothers’ experiences and their related appraisal support needs.

Conclusion

According to the findings, breastfeeding mothers identified appraisal support needs which included, ‘approval and affirmation from significant others’, ‘the necessity of avoiding social comparisons due to unpleasant corollaries’, ‘offering constructive feedback’, and ‘persuasion’. Significant others, such as the husband, family members, and health providers have an important role in meeting the appraisal support needs of breastfeeding mothers. Also, health policymakers should pay due attention to these support needs so as to implement effective plans for improving breastfeeding mothers’ social support and reducing the rates of breastfeeding cessation.

Acknowledgements

The authors would like to thank the Deputy Research of Mashhad University of Medical Sciences for their financial support and would also like to appreciate all the participants who contributed to this study and shared their experiences. This study was a part of a PhD thesis in reproductive health with an ethical approval grant no. (IR.MUMS.REC.1396.124) which was financially supported by Mashhad University of Medical Sciences with grant no. 951682.

Conflicts of interest

Authors declared no conflicts of interest.