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Extended Breastfeeding Was the Right Choice for My Family

Medical review policy, latest update:, why we chose extended breastfeeding, read this next, what it's like breastfeeding a toddler, how others reacted to my decision to keep breastfeeding, how i knew our extended breastfeeding journey was over.

Extended breastfeeding was a beautiful experience for our family. And while in my community it may not be the norm, I hope that more beautiful Black women will embrace their ability to give and sustain life with their bodies. We were made for this. 

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My Breastfeeding Journey: Overcoming Challenges and Embracing Lessons

The other day, while I was breastfeeding my six-month-old baby boy until he drifted off to sleep, I casually scrolled through my social media feeds. Among the content, I stumbled upon a viral video featuring a young mother driving an e-rickshaw. In the video, her toddler was latched onto her breasts, all while waiting for a passenger to get on board. Shielding her eyes from the blazing sun in the scorching afternoon, she wiped her face with her scarf and drove off, merging with the heavy traffic on the road. Before becoming a mother, I might have viewed it as just another video of a woman working hard to provide for her family. However, now that I am a mother myself, it resonates with me on a deeper level, evoking a more profound emotional response. The inspiring image of a helpless but determined and confident young mother is forever etched in my memory. 

As a first-time mom, I embarked on my breastfeeding journey with excitement and anticipation. While I was fortunate to experience a relatively smooth breastfeeding journey, there was still a learning curve for me. By sharing my personal experience, I wish to highlight some of the challenges in the breastfeeding journey with the hope of creating a nurturing and supportive environment that empowers and encourages breastfeeding mothers.

Learning about Proper Latch: Learning about how to encourage proper latch was crucial for successful breastfeeding. Initially, I struggled with understanding the correct positioning, which led to soreness and discomfort for both my baby and me. I didn’t feel comfortable asking anyone about it because socially conditioned to feel embarrassed discussing it. Thankfully, I could access high-quality content and infographics online on breastfeeding online by the World Health Organization , which proved invaluable in understanding the right techniques to encourage a correct latch. 

As I educated myself on early infant care and breastfeeding, I also learned about tongue tie, a condition that can hinder proper latching. While its occurrence ranges from 3% to 16% worldwide, the condition is an overlooked complication in an Indian scenario . Tongue tie refers to a restricted range of motion of the tongue, where an unusually short, thick, or tight band of tissue tethers the bottom of the tongue's tip to the floor of the mouth, potentially interfering with breastfeeding. Although my baby didn't have this issue, it is essential to be aware of it in case your baby faces difficulties in feeding.

If faced with such challenges, expressing breast milk and feeding through a bottle is often recommended. While some mothers may find the idea of using an expensive breast pump intimidating, I found that hand-expressing milk is a straightforward and effective alternative.

Proper Nutrition for Breastfeeding Mothers:   In the first month after my delivery, I was in a challenging situation when all my family members had to go away due to unavoidable reasons.  My baby and I were home alone for three days. During this time, I struggled to cook and eat properly, resulting in a decision to order food from an online app. Unfortunately, this choice led to food poisoning, causing extreme discomfort with severe diarrhea, dehydration, and exhaustion that ultimately required me to rush to the emergency room. Feeding a baby when unwell can be doubly challenging. 

Consequently, my baby also experienced stress and diarrhea, leading us to visit the emergency room again. Eventually, we both recovered but suffered significant weight loss within a week. It was a trying experience highlighting the importance of having a support system and proper self-care during the initial postpartum weeks.

India has a rich tradition of caring for new mothers by providing foods known for their health and healing properties. Many families offer foods that are believed to enhance milk production, such as fenugreek and fennel seeds. However, it is disheartening to acknowledge that not all mothers have access to family support or the resources to afford nutritious food.

Thankfully, I could hire a helper to prepare clean and homemade meals such as khichdi, oatmeal porridge, soups, and ajwain (carom seeds) water. The combination of homemade food and maintaining regular meal times played a crucial role in supporting and enhancing my breastfeeding journey. I genuinely empathize with working mothers and those who take care of themselves and their babies single-handedly. 

Supporting Breastfeeding through Nights: Going into child delivery, I knew I would have to breastfeed frequently and that a good night's sleep might elude me. However, no amount of literature or information had prepared me for the reality of actually breastfeeding throughout the night. Complicating matters, my baby had a significant reflux problem, necessitating that he be fed in an upright position, which meant I had to sit up to feed him each time. After each feeding session, I had to spend at least twenty more minutes ensuring he had a proper burp before laying him in bed. 

During the first month, my baby’s sleep patterns seemed to be reversed, as he slept more during the day and fed more frequently at night, adding to the challenges of nighttime feedings. As a new mother, my body was still recovering from c-section. The improper attempt to use an epidural (an injection in your back to stop you from feeling pain) during delivery also left me with severe back aches, I couldn’t bend or sit for extended periods of time which added to the challenges of feeding at night. To say it was exhausting is an understatement. There were nights when tears would stream down my face, but the thought of mothers who are less privileged than me (I am privileged to be on paid maternity leave) motivated me to rise up and stop feeling sorry for myself.

Speaking to other moms, I realized that babies have different feeding and sleeping patterns. We can gently encourage the change in their patterns. I began to feed frequently during the day to reduce night-time waking for my baby, and gradually it became better. While pumping breastmilk is not a common practice in India, promoting its use could help mothers maintain breastfeeding while taking some time off to rest, either at night or during the daytime. 

I cannot fathom the challenges faced by new mothers who juggle responsibilities such as cooking, cleaning, or working in farms and factories. By shedding light on these difficulties, I hope that families and employers will recognize the need to create a more supportive environment for mothers, not only in corporate settings but also in informal sectors.

The Role of a Supportive Husband or Partner: When babies cry out of hunger, everything else takes a backseat as we promptly sit down to breastfeed. I usually keep my mobile phone nearby to call on my husband for assistance, but sometimes it isn’t feasible. I am immensely grateful for my husband, who makes sure to check on me in the room regularly. Though it may seem like a small gesture, it is an enormous help. With my baby on my lap, breastfeeding or sleeping, it is impossible for me to move or make any sound.  In that moment, I need someone to adjust the fan, bring me water, fetch a swaddle, provide support with a pillow, or turn the light on or off. When my husband was not around, I would sit helplessly, unable even to reach the water placed on the table beyond my easy grasp. The thirst would be unbearable, but I had to wait until someone checked on me. These seemingly small acts of support from a partner or family members are of immense significance for a breastfeeding mom, making the challenging journey of motherhood a bit more manageable and comforting.

Breastfeeding in Public Places and Overcoming Social Pressure: Breastfeeding in public places is unavoidable. I encountered various situations where I had to nurse my baby, be it in public transport, public park, or market areas. Unfortunately, not all public spaces provide breastfeeding facilities, which can be challenging for mothers. I experienced judgment from others while nursing in public, highlighting the need to destigmatize breastfeeding and create a more accepting environment for breastfeeding mothers.

I will never forget my train journey, which turned into a challenging and emotional experience due to an encounter with a woman who had reservations about breastfeeding in public. As I sat down to feed my three-month-old baby, the woman approached me and asked me to fully cover myself and my baby's face because of her twenty-year-old son present nearby. However, I had already noticed that my baby was uncomfortable with his face covered during feedings, so I politely declined her request, prioritizing my baby's comfort. 

In response, the woman seemed upset and decided to play loud music on her phone when my baby needed to sleep. It was a distressing moment for me, as I felt caught between wanting to nourish and soothe my baby and not wanting to create discomfort for others. Eventually, I realized that it was unfair to let my baby suffer because of someone else's discomfort.

As the situation escalated, I made the difficult decision to leave my seat and exchange it with another passenger in the same coach. It was heart-wrenching to think that a simple act of breastfeeding had caused such tension and discomfort for all involved.

Reflecting on that moment, I couldn't help but wish that people could set aside their personal differences or embarrassment and instead support the needs of an innocent infant. Breastfeeding is a natural and essential process for a baby's well-being, and it is crucial for society to embrace, support, and normalize it without judgment or discomfort.

Emotional Bonding through Breastfeeding: The emotional bond I formed with my baby during breastfeeding was priceless. Moments like my baby looking at me with contentment or seeking comfort during a painful experience showed the deep connection between us.The very first time my baby looked at me and made a cooing sound was during one of our breastfeeding sessions. Breastfeeding should never be rushed or treated as mere survival feeding. Instead, it should be acknowledged as a crucial opportunity for both mother and baby to bond deeply. Loving family members should avoid rushing the process or unnecessarily interrupting these moments, allowing the mother and baby to experience the full benefits of breastfeeding and emotional connection.

The Significance of Breastfeeding: Breastfeeding holds immense importance for both infants and mothers. Not only does breast milk provide optimal nutrition tailored to the baby's needs, but it also offers vital antibodies and immune factors, protecting against various infections and promoting cognitive development. Breastfeeding has numerous health benefits for mothers, aiding in postpartum recovery and reducing the risk of various diseases. Additionally, the emotional bond formed during breastfeeding is invaluable, promoting the well-being of both mother and baby.

Conclusion: My breastfeeding journey has been a transformative experience, and I feel privileged to have nourished and nurtured my baby through this process. I have become an advocate for breastfeeding and believe that creating a supportive environment is essential for mothers to overcome challenges and provide the best nourishment for their babies. I do want to insert a note that my intention here is not to disregard or criticize mothers who, due to specific medical or valid reasons, cannot breastfeed. I fully acknowledge the challenges they face, and it is essential to understand that some situations are beyond our control. Each mother's journey is unique, and we must support and respect their individual choices and circumstances.  

This year's Breastfeeding Week campaign by WHO and UNICEF, focuses on the integration of breastfeeding and work to ensure a harmonious balance. I am fortunate to work with an organization and colleagues that fully support my breastfeeding journey. By promoting breastfeeding education, lactation support services, workplace accommodations, and public awareness, we can empower mothers to make informed decisions and embrace the beauty of breastfeeding. 

Regardless of the circumstances, mothers consistently go above and beyond to nurture their children. Just like the inspiring mother I saw in the video, who was driving an e-rickshaw while breastfeeding. Witnessing such dedication should evoke feelings of compassion and a desire to offer support. Rather than idolizing mothers for their capabilities, what they truly need is better support. Every mother deserves the chance to rest, receive adequate nutrition, and have basic comforts to feed and nurture her baby. If each of us rallies behind these resilient and strong mothers, we can create an environment where motherhood is cherished and supported, leading to a more nurturing society for all.

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How to Balance Hormones While Breastfeeding

Dr. Jolene Brighten Published: June 30, 2023 Last Reviewed: June 29, 2023 Balancing Your Hormones , Breastfeeding , Postpartum Leave a Comment

The postpartum time is a tumultuous period for women’s hormones, to say the least. You just grew a tiny human, which consumed a lot of your body’s resources. As you heal from delivery and begin nursing, the demands are even higher. Mix in the stress of adjusting to a new routine, having little time for yourself, and sleep deprivation, and you have a recipe for a postpartum hormone roller coaster. 

This article will dive into all the details you need to know to support hormonal health during this exciting yet challenging time. 

I will cover these most-asked questions:

• Does breastfeeding cause hormonal imbalance?
• How do hormones change postpartum?
• When do hormones return to normal?
• When do periods return postpartum?
• What are postpartum hormone imbalance symptoms?
• What nutrients do breastfeeding mothers need?
• How to balance hormones while breastfeeding

Does Breastfeeding Cause Hormonal Imbalance? 

While your hormone profile during postpartum and while breastfeeding may be different from the rest of your childbearing years, the shift is normal. Breastfeeding is a natural state and requires certain hormones to adjust so that you can produce milk for your baby. 

It’s not a defect that you need to correct — nutritional support is a good move, but most of the time breastfeeding hormones do not require medical intervention. Still, you may feel the effects. Symptoms like mood changes, night sweats, and breast tenderness may arise after you give birth until your body settles in. ,

Breast milk production is nutrient and energy intense. It requires a lot from your body, impacting the nutrients available for other things, like hormones. In addition, postpartum hormone changes are dramatic, impacting how you feel. Supporting your body with a high-quality prenatal vitamin can help.

How Hormones Change Postpartum

During pregnancy, many hormones are elevated to support the pregnancy but rapidly fall after the baby is born. Other hormones rise after birth to promote bonding and breastfeeding. These quick changes may lead to the baby blues, characterized by a low mood or mood swings in the weeks following delivery. 

The baby blues, also called maternity blues or postnatal blues, affects between 13 and 76% of new moms , depending on culture, geography, and other factors. These emotional changes are typically transient and resolve quickly. 

If you find that these emotional changes are too much to handle or if you are thinking of harming yourself or your baby, call your doctor immediately.

During postpartum time and breastfeeding, women are also vulnerable to perinatal mood disorders, including perinatal depression (aka postpartum depression). Perinatal mood disorders affect about 10-20% of postpartum women and have many root causes, including lack of sleep , hormone changes , and more.  

Let’s take a look at specific hormones while breastfeeding and how they contribute to symptoms or possible imbalances. 

Sex Hormones

Sex hormones, especially estrogen and progesterone, play a critical role during pregnancy, supporting physical changes, growth and development, placental health, and more. These hormones are essential for healthy menstrual cycles and pregnancy but tend to stay low during breastfeeding. 

During early breastfeeding and for some amount of time, you won’t be menstruating and ovulating, which means much less progesterone production. Ovulation is required prior to progesterone production at pre-pregnancy levels. 

Estrogen and Progesterone

During pregnancy, estrogen and progesterone are at an all-time high, but immediately after the baby and placenta are delivered, levels rapidly drop to low levels like those in menopause . 

Symptoms of low estrogen include: 

• Vaginal dryness
• Hot flashes 
• P ostpartum hair loss

Symptoms of low or no progesterone include: 

• Sleep disruption 
• Estrogen dominance  

It’s natural and necessary to have low estrogen and progesterone while nursing. Some women may experience more symptomatic effects than others and benefit from supporting these hormones. 

Oxytocin and Prolactin

While estrogen and progesterone plummet, the breastfeeding hormones (oxytocin and prolactin) rise. 

During labor, oxytocin promotes uterine contractions, and contractions cause more release of oxytocin. After delivery, oxytocin levels remain high to promote bonding and caretaking. 

Breastfeeding induces oxytocin release from the brain, which signals the breasts to release milk. Oxytocin levels remain high with baby suckling and then fall when not nursing. Higher oxytocin means higher prolactin and lower cortisol . 

Prolactin is the other essential hormone released during breastfeeding. It’s produced by the placenta and brain, remaining elevated after delivery. High prolactin suppresses the menstrual cycle by keeping estrogen and progesterone low and stimulates breast milk production. 

Thyroid Hormones

Because of changes in the immune system that occur with pregnancy, along with the influence of estrogen and other hormones on thyroid health, women are more vulnerable to thyroid imbalances during postpartum and breastfeeding. 

T3, T4, and TSH

Thyroid health tests (T3, T4, TSH, thyroid antibodies) are recommended around 6 to 12 weeks postpartum for those with Hashimoto’s thyroiditis, Graves’ disease, or another autoimmune disease, along with women using thyroid hormone replacement. Women with symptoms of thyroid imbalances should also be tested, even if outside of this early postpartum window. 

Postpartum Thyroiditis

Postpartum thyroiditis is a specific thyroid disorder occurring in the postpartum period. It primarily resembles hyperthyroidism, or overactive thyroid, followed by symptoms of hypothyroidism or under-active thyroid. Some women will only experience hypothyroid symptoms. 

Postpartum thyroiditis is challenging to distinguish from other thyroid conditions, hormone imbalances, and symptoms new mothers experience, like sleep deprivation and stress. It can occur up to one year after delivery , which is a time when many women aren’t regularly seeing their healthcare provider like they were during pregnancy. 

To learn more about postpartum thyroiditis and what to look for, read this article . 

Adrenal Hormones

Adrenal health is another area greatly affected by the postpartum period. Low sleep, new routines, the nutrition demands of breastfeeding, going back to work, lack of a community to help with the baby, and other life factors increase stress for new moms. More stress means more cortisol. 

Cortisol is one of the main adrenal hormones. It has a natural rhythm where it’s high in the morning and drops at night to promote sleep. Cortisol also spikes in response to acute stress, and chronic stress can lead to HPA-axis dysfunction . Clinically, I’ve seen this a lot in postpartum women. 

A literature review looked at cortisol levels in postpartum women, finding that high cortisol is associated with transient depression, while low cortisol levels correlate with chronic postpartum depression. If you’re experiencing sadness or mood changes, let your doctor know so that depression, existing or emerging, can be addressed.

Insulin and Blood Sugar Balance

Insulin is another postpartum hormone to watch. Insulin plays a primary role in blood sugar regulation by helping move glucose from the blood into the cells for energy.  

During breastfeeding, women become temporarily insulin resistant , which supports producing high-calorie breastmilk. Low estrogen contributes to insulin resistance.

Insulin resistance may be an issue for some women during breastfeeding in terms of weight and metabolic health, especially in the context of a standard American processed food diet and those with diabetes or who had gestational diabetes. 

When Do Hormones Return to Normal?

When is it normal for your period to return? Some women will get their period back in the first few months, and others won’t have a period for as long as they are breastfeeding. Most women will fall somewhere in between, which is completely normal. 

Often the menstrual cycle returns when there is a reduction in nursing. Less suckling means prolactin reduces, which allows estrogen levels to rise and kickstart ovulation. Examples include night weaning or adjusting feedings to return to work. 

What happens to your hormones when you stop breastfeeding? If your cycle doesn’t return while nursing, when you stop breastfeeding, you can expect sex hormones to rise and your period may return soon. It often takes a few cycles for hormones to regulate to pre-pregnancy levels. 

Postpartum Hormone Imbalance Symptoms 

Some symptoms like the baby blues are a normal response to the rapid and profound hormone changes you experience after having a baby. If symptoms are severe, persistent, and impact your daily life, please speak with your doctor. Even mild symptoms that are concerning are worth a conversation with your doctor. 

Hormone imbalance symptoms to watch for postpartum include: 

• Anxiety and depression 
• Anger or irritability
• Insomnia 
• Loss of interest in favorite things 
• Decreased ability to take care of your baby
• Rapid weight loss
• Weight gain
• PMS-type symptoms

Some doctors will recommend the birth control pill to manage postpartum symptoms, but there are also other options. Check out my article on Birth Control While Breastfeeding and my first book, Healing Your Body Naturally After Childbirth .. 

What Nutrients Do Breastfeeding Mothers Need?

A foundation for hormone balance while breastfeeding is solid nutrition. Eating a nutrient-dense diet and appropriate supplementation helps ensure you have the nutrition you need for balanced hormones and breast milk production.

Check out my free nutrition guide , with 7 days of hormone-balancing recipes, for added nutritional support on your breastfeeding journey!

Getting omega-3 fats in the diet is essential for pregnancy and lactation. They promote neurodevelopment in the baby and help prevent postpartum depression for the mother. 

Try getting three servings of low-mercury fish such as wild salmon, mackerel, and sardines each week. In addition, continue taking your omega-3 supplement while breastfeeding. 

Iron is a critical nutrient during pregnancy to support blood volume expansion and fetal growth and development. Many women don’t get enough iron during pregnancy. Then, because of blood loss during delivery, breastfeeding mothers are at risk of iron-deficiency anemia too. 

Continue to eat iron-rich foods, including grass-fed beef, shellfish, legumes, and leafy greens. Continue taking your prenatal vitamin to replenish iron levels during the postpartum period. Note that not much iron passes through breast milk, so this nutrient is all for you!

Vitamin D is another nutrient to have your eye on while breastfeeding. You need to be getting enough for your own needs and to pass through the breastmilk to your baby while exclusively breastfeeding, although you can supplement your infant directly as well. You’ll likely need 6000IU per day or more from a combination of your prenatal vitamin and additional vitamin D3 supplementation , depending on blood test results.

Let’s consider additional ways to promote postpartum hormone balance, including exercise, blood sugar balance, and supplements. 

Exercise 

Once you are cleared for exercise at your 6- or 8-week postnatal checkup, begin moderate exercise for its positive effects on your mood, hormones, metabolism, and more. Be careful not to push exercise too much, especially if sleep is poor, because it may add more stress, increase cortisol, and contribute to hormone imbalances instead of helping balance them. 

Nutrient-Dense Diet

I’ve talked about the importance of a nutrient-dense diet to meet the high demands of breastfeeding. In addition, be sure to eat enough overall food in a way that balances blood sugar. Balancing blood sugar will help to support healthy hormone levels. 

Balance hormones by including protein, healthy fats, and fiber-rich carbs at each meal. Snack as needed (and you’ll need to!) with nutrient-dense options. Grab my free hormone-balancing meal plan for added support 

Prenatal and Postnatal Supplements 

Just because pregnancy is over doesn’t mean it’s time to stop your prenatal supplements. In fact, your prenatal vitamin and other supplements are just as crucial after pregnancy as they were before. 

My Pregnancy Support Kit is designed to carry you from pregnancy and through your postpartum and breastfeeding journey. It includes Prenatal Plus, Omega Plus, and Women’s Probiotic to fill in dietary gaps and support healing from labor and breast milk production. 

If you are looking for how to balance your hormones while breastfeeding, get back to the basics. Prioritize nourishing food , gentle movement, sleep (as you are able), and foundational supplements to support your own health and the health of your newborn. And most of all, be gentle with yourself while you enjoy the journey of motherhood.

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• Van Niel MS, Payne JL. Perinatal depression: A review. Cleve Clin J Med. . 2020. 87. 273-277.
• Ross LE, Murray BJ, Steiner M.. Sleep and perinatal mood disorders: a critical review.. J Psychiatry Neurosci . 2005. 30. 247-256..
• Hwang WJ, Lee TY, Kim NS, Kwon JS.. The Role of Estrogen Receptors and Their Signaling across Psychiatric Disorders. Int J Mol Sci. . 2020. 22. 373.
• Uvnäs­Moberg K, Ekström-Bergström A, Buckley S, Massarotti C, Pajalic Z, et al.. (2020) Maternal plasma levels of oxytocin during breastfeeding—A systematic review.. PLOS ONE . 2020. 15. e0235806.
• Rana M, Jain S, Choubey P.. Prolactin and its significance in the placenta.. Hormones (Athens) . 2022. 21. 209-219..
• Peng CC, Pearce EN.. An update on thyroid disorders in the postpartum period.. J Endocrinol Invest. . 2022. 45. 1497-1506.
• Lee SY, Pearce EN.. Assessment and treatment of thyroid disorders in pregnancy and the postpartum period. Nat Rev Endocrinol. . 2022. 18. 158-171..
• Seth S, Lewis AJ, Galbally M.. Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review.. BMC Pregnancy Childbirth. . 2016. 16. 124.
• Ramos-Roman MA, Syed-Abdul MM, Adams-Huet B, Casey BM, Parks EJ. Lactation Versus Formula Feeding: Insulin, Glucose, and Fatty Acid Metabolism During the Postpartum Period.. Diabetes. . 2020. 69. 1624-1635..
• Nevins JEH, Donovan SM, Snetselaar L, et al. Omega-3 Fatty Acid Dietary Supplements Consumed During Pregnancy and Lactation and Child Neurodevelopment: A Systematic Review. J Nutr. . 2021. 151. 3483-3494.
• Mocking RJT, Steijn K, Roos C, et al.. Omega-3 Fatty Acid Supplementation for Perinatal Depression: A Meta-Analysis. J Clin Psychiatry . 2020. 81. 19r13106.
• Georgieff MK.. Iron deficiency in pregnancy.. Am J Obstet Gynecol. . 2020. 223. 516-524.
• Domenici R, Vierucci F.. Exclusive Breastfeeding and Vitamin D Supplementation: A Positive Synergistic Effect on Prevention of Childhood Infections?. Int J Environ Res Public Health. . 2022. 19. 2973.

About The Author

Dr. Jolene Brighten

Dr. Jolene Brighten, NMD, is a women’s hormone expert and prominent leader in women’s medicine. As a licensed naturopathic physician who is board certified in naturopathic endocrinology, she takes an integrative approach in her clinical practice. A fierce patient advocate and completely dedicated to uncovering the root cause of hormonal imbalances, Dr. Brighten empowers women worldwide to take control of their health and their hormones. She is the best selling author of Beyond the Pill and Healing Your Body Naturally After Childbirth. Dr. Brighten is an international speaker, clinical educator, medical advisor within the tech community, and considered a leading authority on women’s health. She is a member of the MindBodyGreen Collective and a faculty member for the American Academy of Anti Aging Medicine. Her work has been featured in the New York Post, Forbes, Cosmopolitan, Huffington Post, Bustle, The Guardian, Sports Illustrated, Elle, and ABC News. Read more about me here.

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These raw and real photos tell the truth about breastfeeding

Breastfeeding is many things, but it's seldom effortless or free of emotion.

While chic breastfeeding photo shoots on social media may make it look so easy, we're here for the 81% of mothers who say that breastfeeding and the postpartum experience is not “realistically portrayed” in the media, according to a 2021 survey by baby supply company Lansinoh.

Not everyone will breastfeed, and that's OK: Fed is best, whether that's formula, breastfeeding, pumping or some combination of all three.

We're observing World Breastfeeding Week (Aug. 1 to Aug. 7), by asking moms to share the real side of breastfeeding — the joyful, frustrating and unconventional — as captured in photos.

'I felt badass'

Two months ago, Oregon mom Ali gave birth to her second child, sparking an endorphin-packed "moment of empowerment."

Portland birth photographer Natalie Broders was there to capture Ali's joy — after a successful VBAC (vaginal birth after a previous cesarean), her daughter Freyja took to breastfeeding right away.

"I felt badass," Ali (who requested that TODAY Parents omit her last name for privacy) told TODAY Parents . "I shot my fist in the air, like ‘Go me!’”

Four years ago, nursing her daughter Kaiya was "tumultuous," explained Ali. "I stopped after five months because she had tongue and lip ties."

When Freyja immediately latched, Ali cried. "I realized, that's how it's supposed to feel like instead of guilt," she said. "Nursing hasn't been a breeze, but we're powering through it."

'I had so much mom guilt'

Four days after Tanefer Camara delivered her fourth child, Esangu, at home in 2020, he was lethargic, floppy and his eyes had a yellow tinge.

Camara, a doula and lactation consultant, knew Esangu had jaundice , just like her three other children, who had mild cases that didn't need treatment.

The condition, confirmed by doctors at the hospital, means an infant's blood contains too much bilirubin (a yellow substance found in digestive fluid) that cannot be passed through urine or stool. The typical treatment for jaundice is phototherapy . In Camara's case, she had a blood incompatibility with Esangu that caused his jaundice.

"I thought, 'Did I do something to cause this?' I had so much mom guilt," Camara, 40, of Oakland, California, told TODAY Parents.

Camara worried about being able to breastfeed in the hospital. While many NICU babies nurse , formula is sometimes supplemented to avoid disturbing phototherapy. As a lactation consultant, Camara knows of mothers who were outright discouraged from breastfeeding in the NICU.

To nurse Esangu, Camara kept him wrapped in his portable phototherapy device and swiveled the overhead light in her direction, placing him on her breast.

One night, she snapped a photo of her son bathed in the blue light of the equipment while he nursed.

“Breastfeeding does not have to be interrupted because of jaundice,” said Camara. "The experience helped me provide a whole new level of advocacy for parents going through this."

Related: Breastfeeding diet: What to eat and drink while breastfeeding

'Mission accomplished'

Maryah Laine's childbirth experience was "the best and the saddest" moment of her life, she said.

When the 24-year-old nurse went into labor with daughter Kataleya two years ago, she was living in New York, with her husband stuck in the Dominican Republic, due to COVID travel restrictions. They spoke via FaceTime during the 36-hour labor and delivery.

Laine was supported by her doula, a midwife, her family and birth photographer Colby Tulachanh of The House of Wild, who shot Laine breastfeeding her daughter for the first time.

"They put her on my chest and I just collapsed," Laine told TODAY Parents. "Everything felt really blurry around me but I felt like, mission accomplished. I have my daughter now."

Although her daughter latched on immediately, Laine's milk ducts later clogged ( which can happen , for example, with changes in feeding schedules or if the breast doesn't completely drain milk).

"It was the most miraculous breastfeeding journey and I was ready for it," said Laine. "There's a lot of relief in that photo."

Related: 5 breastfeeding positions for moms to try

'Not one of my favorite photos'

Ana Martinez, a certified lactation counselor and registered nurse in Las Vegas, Nevada, is uncertain how she feels about this photo, snapped in July 2020.

Although it shows her daughter Aesir latching, "It's not one of my favorite photos. I don't look pretty — it's too raw," Martinez, a mother of three, told TODAY Parents.

The 31-year-old gave birth at home and was in the third stage of labor (delivering the placenta) when she began breastfeeding, surrounded by three midwives, a doula, a friend, her mother-in-law, her husband and their daughter Amelia, now 6. She didn't notice her birth photographer Lisa Weingardt of Little Loo Photography snapping photos.

Martinez didn't know what to expect on her second breastfeeding journey, having "zero" support in that area with her first child.

"Aesir was a problematic breastfeeder because she had tongue and lip ties ," said Martinez, an oral restriction that makes nursing difficult.

After a frenectomy  (an oral procedure) and feeding therapy to strengthen Aesir's tongue muscles, she was able to nurse and has been going strong for two years.

Martinez also has an 11-week-old daughter, Adelyn, who she said nurses “like a champ.” Because she has an oversupply of breast milk, Martinez has donated it to a mom whose baby has feeding challenges.

'I am blessed'

For Cyarra Miller of Lexington, Kentucky, breastfeeding bonded her family.

When her 16-month-old son Cyrus was born, Miller's daughter Charlotte, now 3, joined the feedings with her baby doll.

"She would say, 'The baby wants milk,'" Miller told TODAY Parents. "The first time she did it, I laughed. It was so cute. So I encouraged her by saying, 'You're feeding your baby. Good job!'"

During a family shoot with photographer T.A. Yero of Two Hearts Media, Charlotte mimicked her mom breastfeeding Cyrus.

The tradition is informative for Charlotte, who is learning about how bodies work. "She knows where milk comes from," said Miller.

Miller didn't have problems breastfeeding either of her children, thanks to her web of social support, which studies found encourages longer breastfeeding outcomes .

"I had people around me who were passionate about it so she educated me on how to be successful," explained Miller.

"Breastfeeding both my kids has been incredible," she said. "I am blessed."

'Breast on fire'

New York City doula Lindsey Bliss took a selfie in her most vulnerable moment, only to see it shared everywhere on social media.

During a 2017 ride home from a baby shower, the mother of seven felt heat and tightness in her left breast. She recognized it as mastitis , an agonizing breast infection that develops from clogged milk ducts or a bacterial infection.

Bliss had forgotten to pump milk for her one-year-old daughter Olympia before leaving the house and her breasts were engorged. Months ago, she had mastitis, but Bliss assumed it wouldn't happen again as it mostly surfaces during the newborn period.

"I was shocked by how sick I was," Bliss, 43, told TODAY Parents. "My breast was on fire."

Antibiotics brought down her fever and inflammation. However Bliss was advised by a lactation consultant to continue nursing her baby, a conventional treatment .

Bliss took a breastfeeding selfie for Instagram — “I hadn’t even washed off my makeup” — where it boomed.

“I don’t want the photo to deter anyone from breastfeeding but we see many unrealistic images,” said Bliss. “Some moments were pure magic and others were hell. For me, it was worth it. But we don’t talk enough about the realities of this journey.”

'Crazy and wild'

"If you had asked me ten years ago I'd be breastfeeding my 3-year-old minutes before pushing out another baby, I wouldn't have believed you," Kate Lyons, of Pittsburgh Born Photography, told TODAY Parents.

In 2017, while Kate Lyons was laboring to birth her second child Maci, her first daughter Ella experienced "big feelings."

"We had prepared her for the birth by watching videos and explaining that mommy might make funny noises," recalled Lyons. "At the 11th hour, she got super tired and upset."

Lyons had nursed Ella during labor but when it came time to push, she got on all fours. "I yelled, 'That's it, the baby is coming!' and kept nursing," she said. "Then my mother-in-law carried Ella out and I pushed out the baby."

Jessica Thomas, a photographer, took the image, which unbeknownst to the women, sparked a new life chapter.

"Photography was always a hobby and a dream job but this (photo) motivated me to do it (professionally)," said Lyons.

The women stayed in touch and in 2018, they launched their photography business, Pittsburgh Born Photography, to preserve birth memories for other families.

As Lyons explained, "I want other birthing people to see themselves in that same empowerment."

Related video:

Elise Solé is a writer and editor who lives in Los Angeles and covers parenting for TODAY Parents. She was previously a news editor at Yahoo and has also worked at Marie Claire and Women's Health. Her bylines have appeared in Shondaland, SheKnows, Happify and more.

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The best breastfeeding photography that shows every nursing journey is different.

by Sabrina Rojas Weiss

Sabrina Rojas Weiss

Parenting Editor

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The social norms around breastfeeding have been changing rapidly in recent years. More and more nursing parents have become comfortable with feeding their children out in the open, celebrating this very beautiful, natural act. They’ve also found another way to celebrate this physical bond with their babies and toddlers, through professional breastfeeding portraits.

SheKnows embarked on a search for the best breastfeeding photography, and the results did not disappoint. Some of the photographers we encountered specialize in newborn portraits, and breastfeeding just comes with the territory. Others are wedding photographers who occasionally branch out. Still others go much deeper with their relationships to parents, combining doula services, lactation consulting, and birth photography, often culminating with breastfeeding portraits as an end result of all their other work.

“Most of what we do in the days and weeks after birth are checking in on families and seeing how breastfeeding is going,” Jess Thomas of Pittsburgh Born Photography tells SheKnows. “Being a birth photographer and doula is an all-encompassing service.”

It’s not always easy or comfortable for the parent of a newborn or a toddler to sit for a photo shoot, so there’s more than one skill involved in taking these pics.

“For moms who have not utilized my support services [as a doula and lactation consultant], we typically spend the beginning of the session getting to know each other and chatting about their motherhood journey so far, their experiences, their challenges, and their dreams and goals,” Jaimie Laki of Little Bear Photography in New Jersey tells us. “By the time their baby is feeling fussy, they’re usually happy for me to document them doing what they do best: soothing their baby. I am a strong advocate for responsive and instinctive parenting, which is another reason documentary photography is so special — we’re rarely aiming for the ‘picture perfect’ moments. Instead, we’re embracing the real. In doing that, I’m able to capture genuine emotions, connections, and relationships.”

As with any other form of photography, there’s a variety of styles of breastfeeding photography. They might be posed against a beautiful backdrop, looking like the angelic subjects of a 19th century painting. Or they could go for a more documentary style.

“I like to think my images are powerful works of art, and when the mothers look back at their shoot, they can FEEL the moment,” Trina Cary , a photographer based in British Columbia, says. “I don’t focus on perfection or ask moms to wear outfits to hide their postpartum body . I encourage moms to get photos done right away before their bump goes away, before they are fit and ‘photo ready,’ because I think it is important to remember all the stages of your pregnancy and love and give gratitude to your body and the beauty that it is. For me rawness and vulnerability are what makes art.”

While the parents in these photos are eager to capture this too-fleeting moment in time with their children, there are still those in the world who object to breastfeeding photography.

“I do think the more popular these kind of images have become to share, the more I see people learning how to be supportive or keep their opinions to themselves,” Zaki says. “Of course, there is still much work to do in making these images normalized, and there is always someone who is still offended. But they are becoming the minority.”

Mother and Child

With this beautiful image, Austrian photographer Verena Panzitt hopes to help normalize extended breastfeeding. “Breastfeeding is not only food for the body, it also feeds soul,” she says. “Society makes breastfeeding in public difficult, especially a toddler. This picture should help to show how great, normal, and beautiful this special connection between a mother and the kid can look like, to make it normal again.”

Nobody Said It Would Be Easy

Photographer Annemarie of Annmarie Lea Geburtsfotografie highlighted this mom’s tandem nursing journey — and the fact that it isn’t always an easy or even pleasant experience, and that’s OK.

Figuring Things Out

This image of the first few precious moments of breastfeeding is from a “beautiful family-centered home birth,” photographer Charlotte Highfield of Little Rose Photography tells  SheKnows.

Beautiful Chaos

An entry from the 2022 image competition of the International Association of Professional Birth Photographers (IAPBP), this shot by Carmen Bridgewater of Carmen Bridgewater Photography shows that breastfeeding can be a family affair.

Exhausted But Happy

Birth photographer Charlotte Highfield ( Little Rose Photography ) captured this blissful moment of post-birth nursing after a home water birth. The relief on this new mama’s face is palpable!

Learning to Latch

German birth photographer Meike Nagorny ( Meike Nagorny m.o.m.e.n.t.s. ) beautifully captured the valiant attempt to make that important first latch.

Fed is Best

“This woman is amazing,” says photographer Trina Cary. “She is always the first person to jump at an opportunity to empower herself and others. She wanted to do this shoot to show a different angle of feeding your baby, as she used all three methods with hers: breastfeeding, pumping, and formula. We wanted to show the world that you are not ‘lesser’ for having to use alternatives. You are a mother, and you are doing your best.”

Moms are Superheroes

This powerful image by Lyubov Chaykovskaya of Birth Moments is a perfect illustration of a mom doing superhero things. This mother is exhausted from labor and birth, but still managing to offer comfort to her older child. There’s always enough love to go around!

Under the Full Moon in Australia

“I dreamt up this session,” Trina Cary tells us. “It was when I was living in Australia, and I had no idea breastfeeding in public was still such a taboo thing there still. I dreamed of photographing a group of women feeding their babies at full moon with the waves rolling in. It went viral. Local news came and interviewed me, and this image broke down barriers for many mothers to come. It told the world you CAN feed your baby WHEREVER you please and kicked off a global trend for photographers to showcase groups of women feeding their babies. Such a beautiful and powerful movement.”

From a Tent City in India

“I went to India with a friend to shoot for her clothing company,” Trina Cary says. “As we were traveling around Pushkar, women approached us to buy them milk powder for their babies. One woman who seemed to be the leader and spoke decent English grabbed us and motioned the others away. She told us they lived on the outskirts of town in a tent city. I had seen these as we were driving, so I asked if we could come visit. Their shelters were made of discarded sari fabric, most with no tarps during their flood season. This image was of a 15-year-old girl breastfeeding her baby while she made us chai. I remember looking at how beautiful and young she was, recently married, with her first baby … thinking of how different her life was to mine.”

The Baby Who Feeds Anywhere

“I met this woman at a pottery class in Australia when I lived there,” Trina Cary says. “She was at another table, and I knew the second I met her we would create art together one day. Shortly after the class had come to an end, we set a date to shoot at her house. There are ENDLESS photos from this session. This bub could breastfeed anywhere in any position.”

Pure and Real

“I took this image when I was living in Switzerland,” Trina Cary says. “The most genuine woman messaged me wanting me to capture motherhood my way. I was shocked because I did not get a lot of Swiss mothers wanting me to photograph them raw like this. Later I found out it was because she was Greek! She paid for me to take a train to the French part of Switzerland, where I spent the day and night with her and her family documenting their love. It was beautiful and pure and real.”

Fleeting Moments

On Trina Cary’s blog , this mother named Azaria wrote about trying to relish the early days of her second child’s life: “In the in betweens of the early mornings filled with tired eyes, feeling already what seems to be fleeting moments of those tender sweet hours of snuggling my newborn and feeling every wave of emotion at the same time. My body still raw, still tired and that strange feeling of realizing my baby is no longer making its home in me and all that is left is this soft, warm, hormonally discoloured skin, where I can find traces from what was a wild ride the last 9 months.”

“This shoot was all about how fascinating the woman’s body is, and how incredibly beautiful Azaria’s skin was, after going ombre from her pregnancy,” Trina Cary says. 

A Special Family Meal

This married couple share breastfeeding of their baby and 3-year-old, but they knew they wouldn’t be able to for much longer and wanted to capture this moment in time, Trina Cary explains. The resulting session actually got her permanently banned from Facebook.

“If I could go back and do this shoot again and again and again, these women, this family,” Cary says. “I am so incredibly honoured to have gotten to photograph them in New York. Their love was so gentle, so kind, so raw, and their story was just beautiful to see. It took guts for them to let me share their session, but their breastfeeding journey was coming to an end and they wanted to document it.”

Sunset Feeding

“We had gone out to do a promotion for our annual breastfeeding event and were about to go home when the sun started to go down and everything turned beautiful,” Jess Thomas told us of this photo of her partner at Pittsburgh Born Photography , Kate Lyons. “Kate has always had no fears breastfeeding in public and has never been uncomfortable taking all the photos I have of her breastfeeding.”

Baby Takes the Lead

“We always let our families know that it’s important to have the baby take the lead in any session,” Jess Thomas says. “We try our best to keep moments candid and genuine. Sometimes we get babies that are not interested at all in feeding, and that’s OK. We have to be patient and take our time. If parent is relaxed, baby will often follow and eventually latch, even if it is for a short time.”

Giving Birth & Giving Comfort at Once

“This laboring mother was so close to having her baby,” Jess Thomas recalls. “She was probably 7-9 cm dilated at this point. As she became more vocal and needed to focus on herself, her little one asked for her comfort. Instead of pushing her away and telling someone to take her away, she let her first-born climb up to the bed and nurse for a bit. She had the baby less than an hour after this moment. This is one of my favorite moments in birth ever.”

Moms of Pittsburgh

“This was our annual breastfeeding group photo in downtown Pittsburgh,” Jess Thomas explains. “We had such an amazing response from the previous year that we had to do it again. All the families who participated had different stories. In our intake forms to register, we always ask for families to tell us their breastfeeding journey stories. They are often so inspiring and we love reading them. It makes the photo we do every year even more special to us and that what we are doing matters. We couldn’t do a photo for 2020, and it broke our hearts.”

Aerial Shot

“This was a former birth client of ours who had been disappointed she could never make it out to our big breastfeeding events any year,” Jess Thomas recalls. “I asked her if she wanted to do a private session and she said yes. She had a wonderful breastfeeding experience with her first and is currently on the second go around with her newest addition.”

A Bridge to Everywhere

“My partner and I had big dreams doing this photo and it lived up to what we hoped it would be,” Jess Thomas says. “The day of the session there was a big downpour, Pittsburgh style. I was literally walking to the spot in heavy rain and my umbrella trying to fly away from me. Then the clouds parted, and the beautiful blue sky peaked through. It got a lot of response in our community, and we loved doing this photo shoot. It is one of my favorite days as a photographer.”

Giving Tandem a Try

“This mother had barely given birth and was newly figuring out tandem breastfeeding. It’s always so fun to capture tiny babies and their older siblings feeding together.” — Jess Thomas

A Tandem Pro

“This parent was super confident and experienced in her tandem feeding,” Jess Thomas says. “We knew her from our birth community as a doula. We are always so happy when our fellow colleagues want to participate or hire us for any of our photography. I don’t think we would often see tandem nursing years ago when I had my firstborn nine years ago. I think with the internet and groups, a lot of families can connect with one another now.”

The First Latch

“Most of what my partner and I do is birth. We are always there assisting with that first latch. Sometimes parents and babies need a lot of help and assisting. Sometimes babies latch on right away with very little maneuvering.” — Jess Thomas

A Latch of Joy

“I love capturing a good latch, and especially a latch the parent is also thrilled about!” Jess Thomas says. “These two moms were so happy their new baby latched with ease and that our bodies can do the most incredible things. There is so much joy in these kinds of moments.”

The Public Breastfeeding Warrior

“In 2019, Olivia was publicly shamed for nursing her baby in a pizza restaurant in Gettysburg, PA,” Jaimie Zaki of Little Bear Photography tells us. “When she went public with her story, she became the target of many people who do not believe mothers should always nurse out of sight and therefore decided to organize a public nurse-in. Unfortunately the restaurant was closed, so instead, a group of mothers gathered to protest on the street. I went to high school with Olivia, so as a friend and fellow mother, I chose to gift her a breastfeeding photo shoot to celebrate her bravery and strong stance to speak up, so other mothers can feel empowered to just nurse their babies anywhere they have the legal right without being attacked.”

When Your Photographer Is a Lactation Consultant

“Shelby hired me to document a ‘Fresh 48’ session the day after her baby was born,” Jaimie Zaki says. “Many mothers love these sessions because you get to capture the cute little whisps of newborn hair and that squished up face. During the session, Shelby was having a hard time getting the hang of nursing (like most new mothers), and I asked if I could offer a few tips. I donned my lactation consultant hat in the middle of our session and guided her through latching in the football hold. This photo was shortly after getting her first easy, comfortable latch, and she was so excited!” 

The Gift of Easy Labor

“I was Deevy’s doula and birth photographer, but I missed her birth by about 15 minutes,” Jaimie Zaki says. “Deevy had what we call ‘precipitous labor.’ She was experiencing signs of early labor when she called me to start heading in her direction, shortly after the call, her water broke. Her husband got her to the car and she began pushing on the short drive to the hospital. When she arrived to her room, her baby was already crowning before she got into the bed. The most amazing part? She was SO thrilled with that birth experience because she got everything she wanted: support from her family, low/no intervention, and a short labor. Her attitude leading up to birth was one of pure confidence, and witnessing her joy immediately afterward as she bonded with her baby was an honor like no other.”

Baby Brother’s Homecoming

“This image was from the first mother I worked with after the outbreak of the COVID-19 pandemic,” Jaimie Zaki says. “She planned an out-of-hospital birth … [but] as COVID restrictions began occurring in hospitals, she found out she would have to transfer care to the hospital for health concerns, and I would not be allowed in to support her as her doula or photographer. Worse? It would be days before she’d be able to introduce her new baby (surprise gender) to these three big sisters. She kept the secret for the few days at the hospital, and then I documented her ‘coming home’ story, where she introduced a baby BROTHER to his sisters. I love this image because as newborns do, he quickly wanted to nurse and there was no hesitation from the sisters to continue admiring him, asking questions about nursing, and loving on their brother. This image is not just powerful because of the story behind it, but because of what it is for the future: This is normalizing breastfeeding for future generations.”

Marking a Milestone of Breastfeeding

“Typically the breastfeeding photos just happen as part of a birth or newborn lifestyle session,” Jaimie Zaki says. “But this Mama Bear reached out to me to document her achieving her goal of one year of breastfeeding — something that, a year prior when I met her, felt so unreachable to her. Being able to work with a mom and see the transformation from uncertain new mother to confident fierce Mama Bear is one of the most special parts of the work I do. This image to me speaks of the peace, comfort, and love experienced during these moments with her baby, where there used to be feelings stress and worry.”

Empowered Mama, Empowered Child

Photographer Molly Grunewald took this photo as part of her Women’s Empowerment Boudoir shoot in Detroit in 2020. In the accompanying blog post, subject Marisa doesn’t mention breastfeeding but instead of how she came to embrace her alopecia after a life of fighting it: “I needed to figure out how to love myself regardless of how much hair I had. So here I am at 27 years old, working every single day on not only my own self-love, but whoever else needs just a little bit more too. I want my son to see his mama live her most authentic life and feel safe to live his also, whatever that may look like.”

Mama’s Perspective

Anna Ginda of Ginda Photography in Chicago is typically a wedding photographer, but she branched out into breastfeeding portraits to celebrate World Breastfeeding Week in 2016.

The Golden Hour

German photographer Miriam Allermann of Kids in Frames captured this heartwarming after-birth shot of Baby’s furry “sibling” sweetly supervising the first breastfeeding moments. 

A Crowning Moment

“I just love documenting breastfeeding journeys. They are very special to me and I also think that it deserves to be shown more in our society.” — Anna Ginda

Making Tandem Look Easy

Not only can she feed two babies at once, but this mom also braves doing so without diaper protection!

Dressing Up for Dinner

“Breastfeeding has a face. It’s personal. And these women are proud to show it.” — Anna Ginda

A Pastoral Scene

Anna Ginda wanted to take these photos “to support breastfeeding which improves the health, wellbeing and survival of women and children around the world.”

All Gowns Should Have Breastfeeding Access

Who says nursing parents can’t do it in style?

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Former teacher shares journey in supporting lactating mothers

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Currently viewed by: Marcus Rosit

• by Jamie Joie Malingan
• Apr. 12, 2024 5:17 pm in Features

BAGUIO CITY (PIA) -- A former teacher from Baguio City took a leap of faith, transforming her career path from teaching to a successful social entrepreneur fostering maternal well-being and child development.

While her initial passion is education, Di Anne Mendoza, drawn by her strong desire to support lactating mothers to breastfeed their babies to build a strong bond, established the Breastfeeding Care Center of the North in 2018.

To ensure that the center offers the best support, Mendoza and her team went through training and certifications to become lactation management specialists, breastfeeding peer counselors, and licensed therapists.

“Since ang background ko is teaching, kailangan kong magkaroon ng certification on how to be a lactation management specialist, and a breastfeeding peer counselor. So, we got the first certification from the Arugaan, a non-profit organization wherein they train breastfeeding peer counselors.  Then after that, we had our certifications from DOH in which we’re able to undergo lactation management training. As to our therapists, they are licensed therapists, lahat sila na nagwo-work sa’min,” she stated. 

This pioneer lactation support center in the Cordilleras offers a blend of therapeutic and lactation massage services tailored for the whole family. It offers lactation massage, prenatal massage, infant child massage, and breastfeeding counseling. It has expanded its services to include dad-and-baby massage and therapeutic massage. 

Located at the Ecco Building, Assumption Road, corner Gen. Luna Road, Baguio City, the center also provides services in  homes, and hospitals.

Mendoza said that the center is also part of the International Baby Foods Action Network, an international organization that protects breastfeeding workers all over the world.

Mendoza shared that the Breastfeeding Care Center of the North has thrived through determination and participation in various competitions. 

 “We join competitions since wala po kaming funding. Maliit lang po talaga 'yung capital namin nung umpisa kaya we look for several institutions and foundations that could help social enterprises like us," she said. 

In 2022, the organization was the top awardee of the BPI Sinag Evolution Social Entrepreneurship Business Challenge, winning cash incentives, and a six-month mentorship program.

Last year, Mendoza was chosen as the Luzon Area winner and the grand winner of the NxtGen in Franchising Philippines 2023, organized by the Philippine Franchise Association to help entrepreneurs grow their businesses.

The P1.5 million-worth of prizes include the Franchise Development Program from Francorp, the world's largest franchise consultant with over 3,000 clients.

Mendoza happily announced that with this development, the Breastfeeding Care Center of the North is rebranding, and expanding. It is now called “My Breastfriends Massage and Breastfeeding Care Center,” and is set to open its first franchise at SM North Edsa. 

She assured that the same quality and family-oriented services being offered in Baguio City will be provided in their franchise. 

For all the great things happening to the My Breastfriends Massage and Breastfeeding Care Center, Mendoza is grateful for the support from government agencies such as the DOH, the Baguio General Hospital and Medical Center, and the Department of Trade and Industry.

She is a mentee of the DTI’s Kapatid Mentor Me Program (KMME-MME), which empowers micro, small and medium enterprises through mentorship, financial resources, and market insights.

“We’re so humbled that we were given an opportunity to join this program since we don’t have any business background. Kaya sobrang laking bagay po talaga na may inio-offer ang DTI na coaching and training program through this KMME,” she said. 

Mendoza is one of the 20 awardees of the 2023 Search for the Most Inspiring Micro, Small, and Medium Enterprises in the country.

The My Breastfriends Massage and Breastfeeding Care Center stands as a testament to the positive impact social enterprises can have on communities, empowering mothers, and fostering a healthier future for children. (JDP/DEG-PIA CAR with Venus Mei Caguio- BSU intern)

About the Author

Jamie Joie Malingan

Regional Editor

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Be honest, I can’t be the only one. Breastfeeding Husband?

My breasts always produced a lot of milk from the get go. It has even gotten to the point where I was sick with a fever, body aches, chills etc because of how engorged and blocked my milk ducts became. I went to the hospital too.

TMI: So funny enough while in bed he was sucking on my nipples (he did this a lot before I was pregnant), and sure enough I felt my let down and milk went into his mouth. He pulled away but he said he didn’t mind. So he continued and even said he loves my breast milk.

I also feel it brings us closer on another level.

Be honest �� Does anyone else do this with their significant other??

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Experiences that influence how trained providers support women with breastfeeding: A systematic review of qualitative evidence

Mary jo chesnel.

School of Nursing and Midwifery, Medical Biology Centre, Queen’s University Belfast, Belfast, Northern Ireland

Maria Healy

Jenny mcneill, associated data.

All relevant data are within the manuscript and its Supporting Information files.

Introduction

There is a need to improve breastfeeding support interventions as although many are evidence-based, a sequential increase in breastfeeding rates is not evident. It is crucial to understand why the implementation of evidence-based guidelines in practice does not always translate to positive experiences for women and improve breastfeeding rates. This systematic review aims to synthesise breastfeeding support experiences of trained support providers and their impact on breastfeeding support practices.

A strategy was developed to search seven databases including Medline and CINAHL and grey literature for qualitative studies. Studies eligible for inclusion reported professional and trained peer experiences of supporting women to breastfeed. PRISMA guidelines were followed and included studies were quality appraised using the CASP Qualitative Checklist. A thematic synthesis of included studies was undertaken and confidence in the review findings was assessed using the CERQual tool. The study protocol, registered in the International Prospective Register of Systematic Reviews PROSPERO registration number: CRD42020207380, has been peer reviewed and published.

A total of 977 records were screened, which identified 18 studies (21 papers) eligible for inclusion comprising 368 participants. Following quality appraisal, all studies were deemed suitable for inclusion. The thematic synthesis resulted in four analytical themes: 1) A personal philosophy of breastfeeding support 2) Teamwork and tensions in practice 3) Negotiating organisational constraints and 4) Encounters with breastfeeding women. Findings demonstrated that a range of experiences influence practice, and practice evolves on continued exposure to such experiences. The potential of each experience to facilitate or inhibit breastfeeding support provision is fluid and context specific.

Conclusions

Experiences, as named above, are modifiable factors contributing to the development of a philosophy of breastfeeding support based on what the provider believes works and is valuable in practice. Further research is required into the range of factors which underpin context-specific breastfeeding support practice, to improve both women’s experiences and intervention effectiveness.

Global breastfeeding rates fail to reach the World Health Organization (WHO) target of 50% exclusive breastfeeding until 6 months of age by 2025 [ 1 ]. This occurs despite a wealth of evidence of the health risks to mother-infant dyads of not breastfeeding [ 2 – 4 ], and recognition that breastfeeding is key to meeting the United Nations Sustainable Development Goals 2 and 3 for 2030 aiming to end hunger, improve nutrition and promote health [ 5 ]. Low rates of duration and exclusivity of breastfeeding are more prevalent in high-income countries (as classified by World Bank ratings) despite a range of public health interventions focusing on promoting and protecting breastfeeding [ 3 , 6 – 8 ]. Further research into breastfeeding support interventions is required in order that the intended outcomes of increasing breastfeeding rates and positive experiences for women are more easily achieved [ 1 , 9 ].

Evidence from existing reviews demonstrate that organised support from trained breastfeeding supporters, whether lay or professional, can prevent early unintended breastfeeding cessation [ 3 , 10 , 11 ]. Breastfeeding support is regarded as a complex intervention which involves sharing of advice and information, provision of skilled help, reassurance and increasing the mother’s confidence [ 12 ] within interpersonal interactions. Healthcare staff involved in maternal and child health services, lactation consultants and trained volunteers who have received training on how to support women to breastfeed are key to implementing effective breastfeeding support services.

Supporting the women who want to breastfeed to meet their breastfeeding goals as part of an evidence-based intervention appears to be a simple task. However, many women cease breastfeeding before they intended to do so [ 13 – 15 ] and some women are disappointed with the support they receive from trained providers [ 16 – 18 ]. Little attention is paid to the influence of factors other than evidence-based research on healthcare professional practice in relation to breastfeeding [ 19 ]. It is important to explore this knowledge gap in the context of all trained breastfeeding support providers, whether lay or professional. Indeed, the Medical Research Complex interventions framework [ 20 ] highlights the importance of the context of intervention implementation, as much as the intervention itself for successful outcomes.

Several systematic reviews have examined breastfeeding support interventions, but these studies prioritised effectiveness outcomes in terms of breastfeeding rates [ 3 , 6 , 21 – 23 ]. Such evidence is valuable but does not closely examine the underlying context of supporter behaviour. To improve provision of breastfeeding support, questions now need to be asked about contextual factors that may influence the practices of the support providers.

Relevant qualitative reviews in this area have found that, although breastfeeding support is viewed as important by both women and midwives, it can be difficult to implement the intervention effectively and compassionately. Schmied et al . [2011] demonstrated that women experience breastfeeding support along a continuum from a woman-centred ‘authentic presence’ to ‘disconnected encounters’ which reflect a lack of relational-based support from providers [ 16 ]. Swerts et al . [ 24 ] explored midwives’ perceptions of their role in support provision, reporting variance in how midwives support women with their breastfeeding [ 24 ]. These authors propose that while midwives mostly practice as a ‘technical expert’ they would prefer to practice as a ‘skilled companion’, however this requires an appropriately supportive working environment. Gaps in current knowledge persist as little is known about the factors that influence practice of the range of both healthcare professionals and trained lay breastfeeding supporters who provide routine, everyday breastfeeding support. Exploring experiences which may influence routine practice across a range of breastfeeding support provider roles is novel in relation to population and outcome, while building upon previous studies to advance the work of improving breastfeeding support provision for women. This systematic review sought to answer three research questions:

• What is known about experiences that influence provision of breastfeeding support?
• How do the experiences of trained breastfeeding support providers influence their breastfeeding support practices?
• Which experiences facilitate or impede provision of breastfeeding support to women?

PRISMA guidelines were followed in conducting this review [ 25 ]. The review protocol is registered in the International Prospective Register of Systematic Reviews PROSPERO registration number CRD42020207380 and has been published [ 26 ].

Definitions

Trained breastfeeding supporters.

Trained breastfeeding support providers refers to trained healthcare staff working with breastfeeding women and healthy infants/children as part of their role, and non-healthcare breastfeeding support providers such as peer breastfeeding supporters and lactation consultants who have undertaken formal accredited training. Students, untrained volunteers, healthcare staff working with sick infants/children were not included in the review as the focus was on routine breastfeeding support for mothers with healthy babies.

Breastfeeding support

The term “breastfeeding support” in this review refers to proactive or reactive interactions between women, infants and trained breastfeeding support providers offering reassurance, praise, skilled help, problem solving, information and social support in face-to-face, group or digital settings such as social media groups, telephone calls or text messages. Support may be provided in acute hospital, maternity units, primary care, voluntary and community settings and women’s own homes. This definition is adapted from McFadden et al . (2017). This systematic review focuses on routine breastfeeding support in the absence of complication.

Search strategy

A systematic search strategy was developed in collaboration with an expert subject librarian guided by a PEOT [ 27 ] question format. For the purposes of this review, Context replaces Outcome in the mnemonic as outcomes are not directly measurable in qualitative studies: Population (trained breastfeeding support providers as per study definition above), Exposure (breastfeeding and breastfeeding support provision), Context (experiences that influence breastfeeding support practices), Type of study (studies that have qualitative methods or findings).

Study selection

Inclusion criteria.

Qualitative studies and mixed methods studies with qualitative methods and findings were included. Study findings were required to focus on trained breastfeeding support providers’ personal and professional experiences (emotions, past encounters, training, practice) in relation to breastfeeding and supporting women to breastfeed, and the influence of those experiences in providing breastfeeding support.

Reporting of ethical committee approval and evidence of data to support findings was required. The population comprised of trained breastfeeding support providers who provide routine breastfeeding support to healthy women with healthy infants in high income countries as defined by the World Bank [ 28 ]. Studies of the experiences of supporting women with breastfeeding in acute hospital, maternity units, primary care, voluntary and community settings and women’s own homes were included.

Exclusion criteria

Mixed-methods studies that did not report qualitative findings were excluded. Studies of students, untrained volunteers and healthcare staff working with sick infants/children were not included as the focus of this review is on routine breastfeeding support for healthy mothers with healthy infants. Breastfeeding support was not considered routine when delivered to women with additional care needs [ 29 ] or delivered in a neonatal or paediatric setting. Studies with heterogeneous samples including, for example, school nurses or paediatricians were excluded if data pertaining to the experiences of trained breastfeeding support providers routinely working with women and healthy infants/children could not be isolated from dataset. Studies from low-income countries were excluded.

The search was undertaken using CINAHL +, MEDLINE ALL, Maternity and Infant Care, EMBASE, APA PsycINFO, Web of Science and Scopus databases. Reference lists of retrieved eligible studies were hand-searched for further eligible studies. An English language restriction and a methodological filter for qualitative studies was included. The reference lists of unpublished literature sourced via Open Grey and British Library Ethos were searched for relevant published studies. The search period included year 2003 –current, with the latest search completed on 16 th June 2021. The start year of 2003 was chosen in order to identify research undertaken following publication of the World Health Organization’s Global Strategy for Infant and Young Child Feeding (2003) [ 30 ] which advised that women exclusively breastfeed for 6 months and continue breastfeeding for two years and beyond for optimal health benefits to mother and infant. A search strategy based upon MeSH headings, related keywords and truncations was developed for each database. Boolean Operators OR and AND were used with the search terms. The search strategy is given in S1 Table of Search histories.

Study selection procedure

Studies were selected for inclusion following a two-stage process using Covidence software. Findings from the searches were exported to Covidence via EndNote X9 reference management system enabling de-duplication of records and teamwork amongst the three reviewers. Firstly, title and abstracts were screened by the first author MJC with verification by another independent reviewer (JM or MH). Secondly, all three reviewers screened full texts independently (MJC, JM, MH).

Data extraction

A data extraction form adapted from Healy et al . [ 31 ] was developed to capture information on each study’s key characteristics including study location, aim, participant demographics, methodology and method, and main findings. All text in the Findings sections of the papers, alongside verbatim quotes elsewhere in the papers, were extracted if relevant to the three research questions of the review. Meaningful sections of text were extracted that identified experiences (emotions, past encounters, training, practice) that influenced how breastfeeding support was practiced by the provider, from their personal perspective, or as observed by researchers in the included study using a discourse analysis method [ 40 ]. Data extraction was carried out by MJC and reviewed by JM & MH.

Reflexive note

The review team are all midwives and mothers who have supported women to breastfeed as part of their career. All believe that effective breastfeeding support can enable breastfeeding which is important for the physical and psychological well-being of the mother-baby dyad. Discussion within the team was used to minimise any bias due to undue focus on study findings that aligned with personal views.

Quality assessment

All studies were critically appraised by MJC with discussion amongst the review team. The Critical Appraisal Skills Programme (CASP) Qualitative checklist tool [ 32 ] was used to assess the quality of the studies. The COREQ tool [ 33 ] was used to assess the comprehensiveness of the reporting of study design, analysis and findings. The CERQual tool [ 34 ] was used to assess confidence in the review findings as an overall body of knowledge.

A systematic three-step approach to analysis was used to develop themes relevant to understanding which experiences of breastfeeding and breastfeeding support influence practice. A thematic synthesis as described by Thomas and Harden [ 35 ] was conducted. An inductive approach was chosen as the authors had no assumptions about what the dataset would reveal. Thematic synthesis facilitates an interpretation of concepts across different types of intervention, which is appropriate for breastfeeding support research because the intervention is carried out in multiple formats and settings. Thomas and Harden propose that thematic synthesis is the process of recognising cross-cutting concepts across studies, even though they may not be expressed using identical words, in order to provide new insights into policy, practice and further research [ 35 ]. Principles of thematic analysis [ 36 – 38 ] were used throughout coding and theme development.

Coding was conducted primarily by MJC and reviewed by the co-authors. Firstly, line-by-line coding of all relevant text extracted from the Findings sections of the papers was undertaken. Excel software was used to manage data. Resultant free codes were transcribed together with supportive verbatim text to enable ease of searching and linking to data in the studies. Descriptive themes were developed in an iterative process, moving forwards and back between suggested commonalities and disparities in the meanings of the free codes. Potential descriptive themes were discussed amongst the review team and compared across studies. Analysis of the descriptive themes led to development of four core analytical themes which reflected the synthesis of all papers in the review, agreed by all members of the review team.

Included studies

The database search resulted in 1811 records, of which 834 duplicates were removed leaving 977 records for screening by title and abstract. Exclusion of 933 records following screening left 46 records for assessment, including two additional records retrieved from reference list sources. From these 46 records, 25 were excluded for reasons of wrong population (e.g. not providing routine breastfeeding support), wrong exposure (no data on breastfeeding or breastfeeding support), wrong context (no data on experiences that influence breastfeeding support practices) or wrong type of study (pilot evaluations) and 21 records were included in the review. A flow diagram adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidance [ 25 ] was used to report the study selection process. Fig 1 shows the study selection process.

Study characteristics

The dataset included 300 trained healthcare staff with identified roles: 210 midwives, 16 Health Visitors, 14 Public Health Nurses, 12 Maternal Newborn Nurses and 9 Post-partum nurses. Three studies did not specify individual role prevalence in sample groups, with one describing the sample as 20 primary healthcare professional participants comprising nurses, midwives and family physicians [ 39 ], another sample was described as 10 ward staff who were trained to support women to breastfeed including midwives, maternity care assistants and nursery nurses working on maternity ward [ 40 ] and sample group of 9 doctors and nurses was reported in a third study [ 41 ]. The trained breastfeeding support providers in non-healthcare roles in the data set comprised 56 lactation consultants and 12 peer supporters.

Eligible studies were published between 2005 and 2020 and conducted in 8 high income countries. Included papers reported qualitative designs with either interviews or focus groups apart from one Australian solely observational study [ 42 ]. Several studies used participant observation alongside interview and focus group methods. Research took place within hospitals, community primary care, community and voluntary settings and private practice. Two studies reported UNICEF Baby Friendly accreditation [ 43 ] of their setting [ 44 , 45 ]. Furber’s UK based studies [ 46 – 48 ] reported that their setting was not Baby Friendly accredited, and all other included studies did not report Baby Friendly Accreditation status.

Data was extracted from each study comprising Title, Author, Year, Country, Study aim or research question, Practice setting, Methodology and method, Population and sample size, COREQ score and Findings (Themes/subthemes). Study characteristics and quality appraisal scores are summarized in Table 1 .

Critical appraisal

The Critical Appraisal Skills Programme (CASP) Qualitative checklist [ 32 ] was used to initially assess the quality of each study. A numerical score for quality was not assigned, rather, the tool prompted focused reading of papers regarding potential methodological limitations. The quality of reporting in the studies ranged from a score of 16 to 27 out of a possible 32 items in the COREQ checklist. Most studies did not report on researcher reflexivity. Description of analytical methods was limited in five of the studies. Information from the COREQ and CASP assessments enabled trustworthiness in the findings of each study to be gauged, and informed subsequent assessment of confidence in the findings using the Confidence in the Evidence from Reviews of Qualitative Research tool (CERQual) [ 49 – 53 ]. Overall, the strengths of the studies lay in the congruence of research aims and objectives with the study design.

This review aimed to answer three research questions, asking what is known about experiences that influence provision of breastfeeding support, how such experiences influence breastfeeding support practices, and which experiences facilitate or impede provision of breastfeeding support to women. The findings of this review suggest that a range of prior and current experiences relating to breastfeeding and breastfeeding support provision, reported here as analytical themes, are very likely to contribute to breastfeeding support practices, either facilitating evidence-based compassionate care or hindering such provision. Synthesis of the data resulted in the generation of 85 free codes, eleven descriptive themes and four analytical themes supported by summary statements ( Table 2 ). The prevalence of the descriptive themes and analytical themes in the papers is reported in S2 Table . Confidence in the review findings was assessed using the CERQual tool [ 34 ]. There was high confidence in three of the descriptive themes. Confidence was downgraded to moderate (five descriptive themes) or low (three descriptive themes) when there was concern about any of the four components of the CERQual assessment [ 34 ] methodological limitations, coherence, adequacy of data and relevance as reported in S3 Table . The analytical themes are titled 1) A personal philosophy of breastfeeding support 2) Teamwork and tensions in practice 3) Negotiating organisational constraints and 4) Encounters with breastfeeding women .

For brevity, exemplar quotes of data are presented below and further supporting quotes for each descriptive theme are found in the CERQual Evidence table ( S3 Table ).

A personal philosophy of breastfeeding support

A personal philosophy of breastfeeding support was the most dominant analytical theme of the review. It is comprised of three descriptive themes, further detailed in subsequent sections, which show that breastfeeding support is delivered according to the providers prior experiences, established beliefs and preferences in applying knowledge for practice from various sources. Participants in all studies spoke of experiences which were developed into 3 interlinked descriptive themes to form a personal philosophy of breastfeeding support: Personal breastfeeding experience [ 39 , 40 , 42 , 44 , 45 , 54 – 60 ] rated by CERQual assessment as having a high level of confidence in the finding, Belief in the value and process of breastfeeding [ 39 – 42 , 45 , 58 , 60 – 63 ] which also had high confidence as a finding, and Knowledge for practice [ 39 , 40 , 42 , 44 , 45 , 47 , 48 , 56 , 57 , 59 – 64 ] in which there was moderate confidence in the finding.

Personal breastfeeding experience

Participants frequently described having a personal understanding of ‘what matters’ and ‘how-to’ in breastfeeding support, borne of prior experience. Both positive and negative personal breastfeeding experiences increased empathy for breastfeeding women. Participants tried to help women avoid the physical discomfort or psychological distress that they had encountered personally, either encouraging women that breastfeeding difficulties were surmountable, or not. Participants spoke of giving women permission to stop breastfeeding or supplement with formula, or spending time and offering breastfeeding tips and tricks learned from personal experience: “Before I had [my baby] it was like, “Oh, you want formula? Okay, I’ll go get it.” It was more patient satisfaction versus “what was your intention when you came in? You wanted to breastfeed. I will help you become successful in breastfeeding” [ 60 ] (Post-partum nurse in a hospital setting). The above quote illustrates how personal experiences of breastfeeding could both inform and transform practice.

Belief in the value and process of breastfeeding

There was little diversity across the studies in terms of belief in the value and process of breastfeeding. Most participants spoke of the importance and value of breastmilk and/or breastfeeding to a mother/baby dyad: “…midwives focused on ensuring that the infant had sufficient access to ‘liquid gold’ . Midwives drew on their ‘expert’ knowledge to introduce a range of techniques and technology to ensure that the infant received breastmilk” [ 61 ]. Although belief in the value of breastfeeding was widely represented in the data, beliefs about the skills involved in breastfeeding varied. Some participants believed that breastfeeding was a natural skill that anyone could do if they were prepared to work at it, whereas others saw breastfeeding as a technical skill that women had to be taught.

Knowledge for practice

Participants spoke of the personal and vicarious learning experiences that informed their practice. Experiential knowledge, attending training courses, following guidelines and policies, engagement with research and learning from colleagues were all identified as influential. Participants selected what information, gained from experience, they felt may be useful in different situations. This was then tested against knowledge from prior breastfeeding support episodes and input from colleagues. However, working in accordance with guidelines resulted in some participants expecting to physically intervene in breastfeeding support: ‘…midwives described an expectation of giving “hands on” help with attachment in the labour ward… This may arise in part from BFI guidelines [which recommend skin-to-skin and breastfeeding within the first hour of birth]’ [ 45 ]. The experience of working to guidelines influenced the physical approach to support.

Teamwork and tensions in practice

Data from 14 papers contributed to this analytical theme, comprised of 3 descriptive themes: Collaboration [ 48 , 54 , 55 , 64 ] in which there was moderate confidence in the finding, Inconsistency in support and advice [ 45 , 48 , 54 , 55 , 58 , 64 ] in which there was also moderate confidence and Opinions of others [ 44 , 45 , 47 , 55 , 56 , 61 ] in which the authors had low confidence.

Collaboration

Positive collaborative experiences included effective communication with others involved in breastfeeding support, a visible and effective referral system in place and respectful relationships between providers. Good teamwork with sharing of knowledge facilitated breastfeeding support provision. Nevertheless, participants often reported problems with collaboration and referral, either with the availability of staff such as lactation consultants only working certain shifts, or with other support providers waiting too long before referring a mother to expert help. The following quote highlights the frustration felt by a lactation consultant when late referrals impeded the ability to provide effective support to women experiencing breastfeeding difficulties: “they’re usually train wrecks” [ 54 ]. This reveals a sense of despair that other breastfeeding providers do not refer women in a timely manner so that early problems may be resolved more easily.

Inconsistency in support and advice

Inconsistency in support and advice was a common theme. Participants undertake damage limitation techniques to reassure the woman that what they perceive as inconsistent advice is a normal aspect of the breastfeeding learning journey. Managing conflicting and potentially damaging input from others resulted in trying to achieve a balance between offering effective support and not wishing to undermine a mother’s belief in other breastfeeding supporters and healthcare providers. This was an uncomfortable experience for some participants.

Opinions of others

Differing philosophies of breastfeeding support between providers impeded effective provision. Participants experienced intimidation and disapproval from some colleagues if they devoted time to breastfeeding support. Peer opinion also facilitated a more physical direct approach: ‘ …being able to competently attach an infant , often referred to as ‘having the knack’ , was a highly prized and sought-after skill that afforded some midwives a sense of status within their professional peer group’ [ 61 ]. Experiences of perceived credibility with colleagues therefore influenced how breastfeeding support was provided.

Negotiating organisational constraints

Participants in 11 papers contributed to the 3 descriptive themes informing this overall analytical theme: Time and resources [ 40 , 42 , 44 , 45 , 47 , 48 , 54 – 56 , 58 , 61 , 62 ] which had high confidence in the findings, Organisational values [ 45 , 47 , 54 , 55 ] in which there was moderate confidence in the findings and Expectation of role [ 41 , 45 , 47 , 56 , 58 ] in which the authors had low confidence as a finding when assessed using CERQual.

Time and resources

The impact of being under-resourced in terms of time pressures and staff shortages prevented participants from providing optimal breastfeeding support. Participants spoke about stepping in to physically attach babies to the breast in the hope that it would save time and free them to attend to other clinical duties. In acute settings it was common for staff to default to such time-saving approaches to breastfeeding support even when there was no pressure on resources. Conversely, some participants who independently organise and control their workload, for example privately practising midwives, were able to spend time to optimise the support given to breastfeeding women.

Organisational values

The low priority given to breastfeeding as a maternity care issue was identified as something which hinders good breastfeeding support practices. One midwife in a hospital setting spoke of decision-making in terms of breastfeeding support and available resources: “Sometimes you have to say I’ll send a midwife out , but you know that’s a resource that is precious . All you can do is make sure they’ve got a visit the next day if it’s the middle of the night . [Pause] But that’s a long gap and that’s not her answer at that time” [ 47 ] (midwife providing telephone support on night shift). When the organisation is under-resourced breastfeeding support is not always viewed as a worthy recipient of an organisation’s resources.

Expectation of role

This descriptive theme relates to the complex issue of being a breastfeeding supporter who is on one hand tasked with promoting and protecting breastfeeding, and on the other, being respectful of women’s choices. One maternal newborn nurse in a postpartum unit reported “ Breastfeeding shouldn’t be a hard sell … I mean my job is not to push somebody” [ 58 ] demonstrating that self-perception of role led to decisions about how much encouragement to give to women.

Encounters with breastfeeding women

Participants in all but one of the papers contributed to this analytical theme relating to interactions with breastfeeding women, comprised of 2 descriptive themes: Perceptions of women’s breastfeeding reality [ 42 , 44 , 45 , 47 , 48 , 54 – 56 , 58 , 61 – 64 ] in which there was low confidence in the finding, and Relationship and communication [ 39 , 41 , 42 , 44 , 47 , 48 , 54 , 56 – 58 , 60 – 65 ] in which there was moderate confidence in the finding. Encounters with women were opportunities to assess the woman’s individual needs and also her commitment to breastfed. This information then influenced how support was provided in terms of motivation to provide support and time spent with women. However, capturing the woman’s wishes required open communication and some connection or relationship to be established.

Perceptions of mothers breastfeeding reality

Perceptions of the mother’s motivation and capability in relation to achieving breastfeeding goals were early signs used by the provider to gauge how to provide support. Some participants spoke of the impact of a mother’s commitment on their own motivation in practice, for example midwives in a hospital setting: “the women have to have some sort of commitment as well . If they don’t have that commitment , then there’s no point in us busting our gut to do it , either ” [ 61 ]. Thus some participants made value judgements on breastfeeding women to assess whether it was a worthwhile priority for care. This was not reported in settings were women actively sought support, for example in drop-in clinics or during consultation with a lactation consultant.

Relationships and communication

Some participants spoke about their sensitivity to women’s views on their practice which influenced how information was conveyed: ‘Sometimes you know you’ve to be careful that it doesn’t come across very dictatorship’ [ 55 ]. They were aware of the potential vulnerability of women and the need to communicate sensitively. Relaxed and companionable relationships were used to dismantle a novice/expert dynamic in breastfeeding support in some community settings and private practice. Encounters that respected breastfeeding women’s autonomy facilitated breastfeeding support that did not involve touching the woman or “doing for” her.

Thematic synthesis

The thematic synthesis resulting from the interpretation of the four analytical themes demonstrates that trained breastfeeding support providers carry a philosophy of breastfeeding support with them as they start out on a journey to provide support. Findings indicate that providers have an established philosophy of support informed by personal and vicarious breastfeeding experiences, a belief (or not) in the value of breastfeeding, and preferences for “what works” in breastfeeding support practice. The philosophy of breastfeeding support develops over time with accumulation of experience. Training may shape an initial philosophy derived from participants’ personal and socio-cultural reference points, but it is further developed by the experiential knowledge from practice and any new personal and vicarious breastfeeding support experiences. Reflection on and feedback from experience therefore inform the philosophy of support in a feedback system, either re-enforcing existing beliefs or introducing new information for future practice. The philosophy of support can be suppressed or enabled depending on the immediate context in which the support is being provided. There is fluidity in how the experiences affect eventual support provision, as supporting individual women in specific settings is dynamic and responsive to the overall context within which care is given. The Thematic Synthesis is represented in Fig 2 .

Three research questions were posed in this review; what is known about experiences that influence breastfeeding support practices, how those experiences are influential and how experiences impede or facilitate support provision. This section of the paper will initially explore how the research questions have been addressed and continue with a discussion of results in the context of the wider evidence base. In our view this is the first qualitative evidence synthesis of research reporting on breastfeeding and breastfeeding support related experiences that influence the practice of a range of trained breastfeeding support providers. From the inclusion of 21 papers in the systematic review four analytical themes were generated which illustrate experiences that influence how breastfeeding support is valued, prioritised, and delivered in practice: A personal philosophy of breastfeeding support , Teamwork and tensions in practice , Negotiating organisational constraints , and Encounters with breastfeeding women . Findings reveal that exposure to and engagement with these diverse experiences cut across both professional and peer role-types, and apply across maternity and family care settings. Regardless of training undertaken, the life history of the provider and the context bound nature of breastfeeding support practice influence how providers enact their role. A philosophy of breastfeeding support develops over time. Positive and resilient philosophies of breastfeeding support are informed by positive personal experiences, belief in the value and process of breastfeeding, service models that enable open communication with women, adequate resourcing in terms of workforce and time to spend with women, and appropriate information sources to inform practice.

The second research question focused on how experiences influence practice. Findings indicate that a range of experiences influence provider motivation and the approach to support. Decisions about whether to step away to leave a woman to learn about breastfeeding herself, whether to stay with a woman and spend time discussing her breastfeeding, or whether to take over and intervene are underpinned by the provider’s own philosophy of support, their experience of colleagues breastfeeding knowledge, skills and attitudes, the resourcing of services and experiences of prior interactions with breastfeeding women. These experiences ebb and flow in their contribution to practice which can both hinder and facilitate breastfeeding support provision. Supporting a particular mother, with particular colleagues, in a particular organisation influences behavioural aspects of how support is provided.

Finally, the review sought to explore which experiences facilitate or impede support provision. Having a belief in the value of both breastmilk and the breastfeeding relationship, having positive personal experiences including having overcome difficulties, and use of a wide range of knowledge sources (including women’s feedback about support received) appear to facilitate breastfeeding support provision. Honest, trusting relationships with women, respectful collegiate relations, peer learning and providing support in well-resourced organisations which visibly value breastfeeding also facilitate compassionate evidence-based breastfeeding support. Negative breastfeeding experiences or no breastfeeding experience can result in doubt about the value of breastmilk and the breastfeeding relationship, particularly when mothers are struggling with feeding challenges. Vicarious experiences of colleagues’ behaviours may re-enforce outdated or insensitive practices. Funding cuts to breastfeeding support services and a lack of training opportunities beyond a basic level, send a signal that breastfeeding support is not valued by an organisation. Lack of personal and professional reference points about successful breastfeeding (including no feedback from women) can result from fragmented care. An implication of such lack of feedback is that there is an absence of recognition of “what works” in practice, limiting growth and progression in the philosophy of breastfeeding support.

This review extends our understanding of why breastfeeding support provision can tend toward non-standardised, inequitable delivery and why women are reporting some dissatisfaction with their breastfeeding support despite providers being trained for the role. New insights into the importance of personal and vicarious experiences of breastfeeding and breastfeeding support have emerged that require us to think differently about the influence of provider’s ongoing experiences of breastfeeding and breastfeeding support, and the communities of practice in which women are supported. Findings complement prior studies reporting low confidence and learning deficits in breastfeeding support providers [ 66 , 67 ]. Furthermore, findings suggest that attention be given to personal and organisational factors in addition to education when considering how best to support women to breastfeed. Prior research has reported that effective support intervention implementation is complex and culturally specific [ 68 , 69 ]. This systematic review enhances our understanding of the complexity in implementing breastfeeding support interventions. The principal implication is that an individual’s approach to breastfeeding support is shaped by personal preferences, which are influenced by organisational culture, wider society and the breastfeeding support education that they receive.

The key message from the first theme A personal philosophy of breastfeeding support is that provider approach and behaviour during breastfeeding support encounters is grounded in how they personally make sense of breastfeeding. Exposure to skilled sensitive breastfeeding support in practice, evidence-based education, and opportunities to reframe negative experiences through reflection are required to develop a positive philosophy of breastfeeding support. Prior and current experiences of breastfeeding and breastfeeding support underpin what is valued in sharing information and teaching practical techniques. Various practice styles have been identified in earlier research into the woman’s perspective of breastfeeding support, for example perception of the encounter by women as authentic or disconnected [ 16 ] or the provider acting as a skilled companion or a technical expert [ 24 ]. The findings of this systematic review give insight into such variations. Providers tended to either step in and intervene, distance themselves so that the woman learns about her own breastfeeding by herself, or be present with a woman to discuss her breastfeeding and provide support in a partnership approach. Time spent with women, the type of information and encouragement given, and behaviour during skilled help depend on both the provider’s philosophy of support, and the ability of the provider to practice according to their philosophy within their particular workplace or volunteer setting.

The Teamwork and tensions in practice theme highlighted the importance of collegiate relations in practice. Development of communities of breastfeeding practice with skilled and motivated colleagues enhances teamwork and minimises tensions. Positive collaboration, efficient referral systems amongst support providers and the experience of being part of a knowledgeable team that values breastfeeding facilitates the creation of ad-hoc learning opportunities, easy access to breastfeeding expertise, and freedom to dedicate time to breastfeeding support without disapproval from colleagues. Lactation consultants were identified as a good resource for clinical staff when they were integrated into healthcare structures. These findings support the idea that informal learning and role modelling from experts in practice across multisector breastfeeding support settings are useful experiences that develop confidence in breastfeeding support skills [ 70 ]. Such opportunities should be recognised for their value in order to support the sustainability of this model [ 71 ]. The challenge now is to deliver effective breastfeeding services which foster peer learning in practice from valued experts, ease of referral to specialist breastfeeding support and everyday exposure to positive breastfeeding support provision from colleagues.

Attention must also focus on the influence of environments with tensions in practice due to differences in individual philosophies of breastfeeding support. The findings demonstrate that support providers can feel pressure from colleagues to underplay their breastfeeding support role or deviate from the evidence-base to free up time for other duties. This adds to existing evidence that experiencing colleagues outdated practice [ 72 ] and disjointed services [ 73 ] impede effective breastfeeding support provision. There is a need for ongoing breastfeeding education in practice with opportunity for providers to reflect on and in practice together. Pragmatically, multi-sector case study presentations could be scheduled as part of continuing breastfeeding education, with collaborative learning and exposure to positive examples of how skilled professional and peer support can enable women to overcome breastfeeding challenges. The importance of multisector collaborative working supports a recent qualitative evidence review into experiences of breastfeeding peer support [ 74 ] which proposed that tension between peer supporters and health professionals can be overcome through building trusted relationships in integrated services. This systematic review extends knowledge about the benefits of multisector working as experiencing the enthusiasm and skill of a variety of motivated providers allows others to develop their own confidence and skill in practice, benefitting women and ensuring that integrity in breastfeeding support services is upheld.

The third theme Negotiating organisational constraints illustrates how underfunding and the low prioritisation of breastfeeding support services limits role-enactment. Full implementation and funding of evidence-based breastfeeding support interventions is imperative for providers to experience services that value breastfeeding. Consistent with the literature, participants from studies included in this review reported that working under organisational constraints, especially time pressures, impedes practice [ 75 – 77 ]. The experience of providing support in well-funded services with adequate providers available enables provision of meaningful breastfeeding support because time, training and informal learning opportunities are available. Findings are consistent with components of the Breastfeeding Gear Model [ 78 ]. This tool is a multi-level and multi-sector approach to scaling up intervention implementation and identifies resourcing and political will as indispensable factors that enable sustainable and effective evidence based breastfeeding support intervention implementation [ 69 ]. If providers experience under-resourcing they make decisions about care priorities and breastfeeding support is not prioritised. These findings support the work of other studies linking understaffing and lack of time with lack of breastfeeding support provision [ 75 , 79 , 80 ] and women’s perceptions that providers are unable to provide breastfeeding support due to a lack of time and resources within healthcare organisations [ 75 , 77 ]. Funding cuts to breastfeeding support services are therefore not only detrimental to women’s breastfeeding experiences [ 81 ] but also detrimental to provider development. Such cuts to services impede exposure to breastfeeding that could influence a provider’s philosophy of support. In addition, when organisations do not prioritise breastfeeding, the lack of breastfeeding education beyond a basic level limits new knowledge development, sending a signal that breastfeeding support is not a priority and providers lose motivation to enact their role.

The final theme Encounters with breastfeeding women describes how the experience of interacting with breastfeeding women enables support to be tailored to women’s perceived needs. Models of relational continuity in breastfeeding support should be promoted as these foster individualised breastfeeding support provision. It is known that making a connection with women, and communicating openly about breastfeeding goals, enables effective breastfeeding support provision [ 82 , 83 ]. Overall this systematic review strengthens the idea that support which involves insight into the woman’s needs and preferences about breastfeeding can be facilitated by relational continuity of carer [ 83 , 84 ]. Relationship has previously been highlighted in the literature as an important component of breastfeeding support [ 76 , 85 ]. These findings also concur with research demonstrating the complexities in providing individualised breastfeeding support [ 86 ] because providers want to support breastfeeding yet avoid being viewed as ‘bullies’ by women [ 87 ]. A review of models of care provision could inform which models prioritise open communication of women’s goals, and informed and sensitive assessment of the need for individualised care during each woman’s breastfeeding experience. These findings support the evidence that women display greater autonomy about breastfeeding issues when the relationship with the provider enables exploration of options together [ 88 ].

This thematic synthesis of published qualitative research has highlighted that experiences in practice and in personal lives can both facilitate and impede breastfeeding support provision. Providers need adequate support to enact their role, and to understand how their positioning shapes their values and contributes to their individual philosophy of breastfeeding support. Context specific experiences may be modifiable through improved prioritisation and resourcing of breastfeeding support services, development of breastfeeding communities of practice within organisations enabling multidisciplinary and multisector learning opportunities, and appropriately implemented and funded relational models of care. Prior personal experiences and challenges in practice that negatively influence support may be reframed through sensitive reflection during formal breastfeeding education and informal debriefing with other support providers in a well-resourced and educated team. Breastfeeding support interventions should be based on evidence of outcome effectiveness [ 3 ] women’s perspectives [ 89 , 90 ] and as this review demonstrates, the context within which the trained provider experiences breastfeeding and breastfeeding support. Continued efforts are needed to enhance experiences which enable effective support, such as learning from experts in practice, being part of an organisation that values breastfeeding, and time to spend with women.

Implications for practice

The overall contribution of this systematic review of qualitative evidence is a deeper understanding of experiences which influence how breastfeeding support is provided, and the significance of such experiences on the approach taken within support encounters. There are three specific implications for practice. Firstly, development of a multisector breastfeeding team in maternity and family services can harness the enthusiasm and expertise of self-selected healthcare professionals, trained peer supporters and lactation consultants. Shared learning through the integration of regular presentations of case histories to the wider multidisciplinary team will enhance potential for continued development and professional support networks. These teams, working alongside other healthcare professionals should ensure ready access to expertise and referral, and enable other providers to witness confident timely breastfeeding support provision. Secondly, developing and appropriately implementing models of service provision that prioritise relational continuity can enable exposure to longer term routine breastfeeding journeys. Experiencing knowledge of the outcomes of one’s support can build confidence in practice, influencing belief in the value and process of breastfeeding. This will provide the opportunity to build wisdom in the approach to take with certain women, for example when to step in and intervene and when to encourage women to manage their breastfeeding independently underpinned with provider support. Thirdly, consistent full implementation and resourcing of evidence-based breastfeeding support services specifically, and maternity and family services in general, can help organisations ensure that providers are able to enact their role.

Future research

This systematic review of qualitative evidence provides evidence that the context in which women are supported with breastfeeding in terms of working with colleagues, resourcing and valuing of breastfeeding services, and time in partnership with women has an important and ongoing influence on the development of breastfeeding support knowledge and practice. Due to heterogeneity amongst the included papers, further research with more focus on practice context and the factors which influence practice from the perspective of a range of providers in accredited settings is warranted, for example UNICEF Baby Friendly accreditation which is an international standard of best practice in multi-level breastfeeding support [ 43 ]. The potential to optimise the positive factors and minimise the negative factors influencing practice in specific settings may be addressed through evidence-based provider education and service design.

Strengths & limitations

This review has demonstrated consistency across included papers of common experiences that influence the practice of breastfeeding support providers. Quality appraisal of the studies, data analysis, theme development and application of the CERQual tool have been described in detail in the text and supplementary material, increasing transparency for the reader and trustworthiness of the review. There was high confidence in the descriptive themes Personal breastfeeding experience , Belief in the value and process of breastfeeding and Time and resources due to the adequacy of relevant coherent data and only minor concerns about possible methodological bias.

Methodological limitations within studies include lack of transparency in reporting. No study fulfilled all of the COREQ reporting criteria, with researcher reflexivity under-reported in most studies. Limitations of the review findings in their entirety were assessed using the CERQual tool. Concern about inadequate, irrelevant or incoherent data resulted in the downgrading of some of this review’s descriptive themes from high confidence to moderate or low confidence in findings. There is a paucity of general practitioner, health visitor and trained peer supporter representation in the studies, midwives and lactation consultants predominate in the sample. Some participants identifying as lactation consultants held dual roles, for example as midwife or paediatrician. For the purpose of this study participants were identified as the role-type of the study inclusion criteria in which they participated. Sub-group analysis by role-type was not possible due to heterogeneity of the population. Heterogeneity of methodologies, population demographics and the settings of breastfeeding support provision represented in this review has limited the synthesis and as such the wider transferability of findings. Despite conducting an extensive database search it is possible that not all relevant records were retrieved due to the use of search limiters such as English language and publication date.

This systematic review has identified personal, professional and workplace experiences which inform the development of a philosophy of breastfeeding support, and experiences which facilitate or hinder expression of that philosophy. This evidence contributes to our understanding of why breastfeeding support interventions can be experienced in a variety of ways by women. The findings suggest the more exposure to effective breastfeeding support that a provider experiences, the richer their philosophy of support becomes. This qualitative evidence synthesis adds to the growing body of literature indicating that successful implementation of complex breastfeeding support interventions requires a deeper understanding of the relational aspects of support between the provider and the woman, and the context within which support is provided.

Supporting information

S1 checklist, funding statement.

The authors received no specific funding for this work.

Data Availability

• PLoS One. 2022; 17(10): e0275608.

Decision Letter 0

15 Mar 2022

PONE-D-21-32296Supporting breastfeeding women: a thematic synthesis of experiences which influence trained providers' practice.PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Yes

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Reviewer #1: This work is novel and raises relevant public health issue. Structure of the paper is well established. There is a clear aim of the study. I found that you missed PRISMA flow chart with systematic search criteria, inclusion and exclusion criteria in the figure. Please do not start sentence with number (eg line 37).

Reviewer #2: The methodology of this systematic review is well conducted and reported. It also covers an important area of breast feeding which demands in-depth understanding through qualitative research. The necessary supporting information for different steps of systematic review is provided in the supplemental file. However, discussion section could have been richer.

Following comments could help improve the quality of this manuscript.

1. Title: It is better to clearly specify that it is a systematic review of qualitative research or evidence in the title. The current title doesn’t clearly give that message to the readers

2. Abstract:

Findings- Please don’t start the sentence with number. Please also specify the total search results out of which the 21 papers were included.

-Please begin this section by specifying that you have followed PRISMA guidelines, and also provide details of protocol registration as mentioned in the abstract.

-Search strategy – line 123 – Please clearly specify what your PEOT is by elaborating criteria for each category.

-Though the authors have mentioned the inclusion and exclusion criteria, it is better to present it in a more structured way sooner so that the readers don’t have to search through the text to figure it out.

4. Findings- please cite the flow diagram of the findings described in the main text.

-Study characteristics- please break the paragraph.

-Pls, dedicate a paragraph to describe PRISMA flow chart and another paragraph describing the study characteristics and describe the table on characteristic of studies.

-Pls also cite the table that is included in the supplemental file.

-Technically, that table should be part of main text rather than a table in supplemental file.

-The PRISMA flow chart should also be part of the main text.

-Line 241- Subheading “Findings” here makes no sense. Please rename with what this subsection represents. Probably the themes?

5. Discussion

Discussion section needs a bit of restructuring. This is just a suggestion; the flow seems a bit interrupted which could be improved. For example, it could make sense to discuss the research questions before going to each theme. Also the paragraphs elaborating on themes seems simplistic. It doesn’t provide as much depth as it demands. While the authors have compared and contrasted the findings of each theme with other studies, it would be better if the authors could also provide deeper insights into the “why” and “how” for each theme and what the authors think can be done to improve things under each theme.

There are typing errors at some places. Please thoroughly proofread the manuscript before submitting the revised version.

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Reviewer #1:  Yes:  Dr Shalik Ram Dhital, MScPH, PhD

Reviewer #2: No

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Author response to Decision Letter 0

28 Apr 2022

Reviewer Comment 1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

Author response: The manuscript has been edited accordingly and figures have been uploaded to PACE tool. Unfortunately we were unable to achieve permissions for the illustrations in the original graphic Figure 2 Thematic synthesis and these have been removed from the Figure.

Reviewer comment 2: We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. Please clarify whether this publication was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

Author Response: This manuscript does not represent dual publication. Only the protocol (the planned approach that would be undertaken) for this systematic review has been published [1]

Reviewer comment 3: Please note that in order to use the direct billing option the corresponding author must be affiliated with the chosen institute. Please either amend your manuscript to change the affiliation or corresponding author, or email us at gro.solp@enosolp with a request to remove this option.

Author response: Direct billing is not required as Queen’s University Belfast has an institutional agreement with PLOS One for publication. The corresponding author is a PhD candidate at Queen’s University and has previously published in PLOS One [1]

Reviewer comment 4: Please include a caption for figure 1.

Author response: Edited, Line 221: Caption included

1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Author comment: Data does support the conclusions as highlighted by reviewer #2

Reviewer #1: No

Reviewer #2: N/A

Author comment: N/A as per Reviewer 2

3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Author comment: Yes, data underlying the findings is fully available as highlighted by Reviewer #2. This manuscript is a systematic review of qualitative evidence and the published papers from which the data have been extracted are referenced.

4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Author comment: Edited. Proof reading carefully undertaken and edits of typographical and grammatical errors amended

Reviewer #1: This work is novel and raises relevant public health issue. Structure of the paper is well established. There is a clear aim of the study. I found that you missed PRISMA flow chart with systematic search criteria, inclusion and exclusion criteria in the figure. Please do not start sentence with number (eg line 37).

Author comment: Thank you for your comments, I have addressed the issues as follows:

Line 219: PRISMA reference included

Line 221: Figure of PRISMA flow chart included in text (Figure 1). Inclusion and exclusion criteria now included in the PRISMA flow chart figure.

Line 163-164: The reader is directed to the supplementary file S1 Table of Search histories.

Lines 131-151: Now includes Inclusion & Exclusion Criteria

Line 41: Edited to read ‘This systematic review includes 21 papers…’

Reviewer #2: The methodology of this systematic review is well conducted and reported. It also covers an important area of breast feeding which demands in-depth understanding through qualitative research. The necessary supporting information for different steps of systematic review is provided in the supplemental file. However, discussion section could have been richer. Following comments could help improve the quality of this manuscript.

Author comment: Thank you for your comments. I have changed the title in response and Line 1 now reads ‘Experiences that influence how trained providers support women with breastfeeding: a systematic review of qualitative evidence’

Reviewer comment 2. Abstract: Findings- Please don’t start the sentence with number. Please also specify the total search results out of which the 21 papers were included.

Author comment: Edited as requested. Line 41: The sentence no longer starts with a number, it now reads: This systematic review includes 21 papers comprising 368 participants from the 1811 records retrieved.

Reviewer comment 3. Methods. Please begin this section by specifying that you have followed PRISMA guidelines, and also provide details of protocol registration as mentioned in the abstract.

Author response: Edited as requested Line 106-108: This sentence now reads: PRISMA guidelines were followed in conducting this review [2]. The review protocol is registered in the International Prospective Register of Systematic Reviews: PROSPERO registration number CRD42020207380 and has been published.

Reviewer comment: Search strategy – line 123 – Please clearly specify what your PEOT is by elaborating criteria for each category.

Author response: Edited and now included. In addition this information is included in the Supplementary Information file S1 Table of Search histories.

Line 124-128: This section specifies the PEOT and now reads: A systematic search strategy was developed in collaboration with an expert subject librarian using a PEOT [27] question format: Population (trained breastfeeding support providers as per study definition above), Exposure (breastfeeding and breastfeeding support provision), Outcome (experiences that influence breastfeeding support practices), Type of study (studies that have qualitative methods or findings).

Line 163-164 now reads: The search strategy is given in the supplementary file S1 Table of search histories.

Reviewer comment: Though the authors have mentioned the inclusion and exclusion criteria, it is better to present it in a more structured way sooner so that the readers don’t have to search through the text to figure it out.

Author response: Edited so that inclusion and exclusion criteria are presented sooner, following PEOT information. A brief summary of the inclusion and exclusion criteria has also been included in the PRISMA flow chart. Lines 131- 164: Inclusion and Exclusion criteria presented to reader sooner in the manuscript. Line 221: Figure 1 PRISMA flow chart contains a brief summary of the inclusion and exclusion criteria

Reviewer comment 4. Findings- please cite the flow diagram of the findings described in the main text.

Author response: Edited as follows: Line 219: PRISMA referenced. Line 221: PRISMA figure cited

Reviewer comment: -Study characteristics- please break the paragraph.

Author response: Edited. The paragraph has been split into two smaller paragraphs with the first focusing on study characteristics and the second focusing on the study quality

Line 236-255: Study characteristics section

Line 256-263: Critical appraisal section

Reviewer comment: Pls, dedicate a paragraph to describe PRISMA flow chart and another paragraph describing the study characteristics and describe the table on characteristic of studies.

Author response: Edited. Lines 214- 220: Paragraph describes the PRISMA flow chart

Lines 236-255: Paragraph describes the study characteristics.

Lines 228-239 describe the table of study characteristics and the first sentence now reads: Table 1 describes data extracted from each study and the study quality under the headings Title, Author, Year, Country, Study aim or research question, Practice setting, Methodology and method, Population and sample size, COREQ score and Findings (Themes/subthemes).

Lines172-179 also describe the data extraction form and study characteristics of interest.

Reviewer comment: Pls also cite the table that is included in the supplemental file.Technically, that table should be part of main text rather than a table in supplemental file.

Reviewer response: Edited and the Study characteristics table has been moved into main text as requested rather than being a supplemental file and cited. Line 228-230: Now cites Table 1 Study characteristics in text

Line 225: Now contains Table 1 Study characteristics.

Reviewer comment: The PRISMA flow chart should also be part of the main text.

Author comment: Edited as requested. PRISMA flow chart moved into main text as figure 1.Line 221 will now contain PRISMA flow chart in text as Figure 1

Reviewer comment: Line 241- Subheading “Findings” here makes no sense. Please rename with what this subsection represents. Probably the themes?

Author comment: Renamed as requested, Line 256 edited to read ‘Themes’

Reviewer comment: Discussion section needs a bit of restructuring. This is just a suggestion; the flow seems a bit interrupted which could be improved. For example, it could make sense to discuss the research questions before going to each theme.

Author response: Thank you for your comment, The discussion has been edited, restructured and additional content included as follows:Lines 422-582: The discussion has been restructured and now begins with a discussion of the research questions as requested.

Reviewer comment: Also the paragraphs elaborating on themes seems simplistic. It doesn’t provide as much depth as it demands. While the authors have compared and contrasted the findings of each theme with other studies, it would be better if the authors could also provide deeper insights into the “why” and “how” for each theme and what the authors think can be done to improve things under each theme.

Author response: Thank you for these suggestions. The discussion has been revised as follows:

The discussion has been enhanced with revisions to the theme sections in lines 483-567 and inclusion of additional references [3-6] (See Response to reviewer letter for references) .

In each paragraph discussing a theme (within this discussion section) the second sentence summarizes improvements to be made in practice in relation to each theme, and then further insights are developed for the remainder of each paragraph, for example lines 530-533.

In addition, lines 586-602 now include three examples for practice improvement.

Reviewer comment. There are typing errors at some places. Please thoroughly proofread the manuscript before submitting the revised version.

Author response: Edited. Supplementary information files have been re-numbered due to some information now being presented as Figures/ Tables instead of supplementary information. The PRISMA 2020 checklist was edited to reflect the page numbers in the revised manuscript. Supplementary Information now ordered as follows:

S1 Table of Search histories

S2 Prevalence of themes

S3 CERQual Evidence table

S4 COREQ Appraisal of Reporting

S5 PRISMA 2020 Checklist

Submitted filename: Response to Reviewers .docx

Decision Letter 1

26 Jul 2022

PONE-D-21-32296R1Experiences that influence how trained providers support women with breastfeeding: a systematic review of qualitative evidencePLOS ONE

Please submit your revised manuscript by 25 August 2022 11:59pm. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at  gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Guest Editor

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

3. Has the statistical analysis been performed appropriately and rigorously?

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: Dear Author

This is a novel work that you have addressed reviewers' comments nicely. However, Please final check the language before the publication of this manuscript.

Reviewer #2: Overall, the authors have addressed the comments and the manuscript looks better. However, there are still a few points that could help further in improving the quality. Some comments are as follows. The line numbers mentioned below refers to numbers in the file with track changes.

Line 45-46 findings –is it 1811 record screened or retrieved? Perhaps screened would be the more appropriate term.

It is also better to report the impression of quality assessment/ risk of bias assessment of the included studies.

Pls refer to PRISMA 2020 checklists for abstract

https://prisma-statement.org//documents/PRISMA_2020_abstract_checklist.pdf

to ensure all the information needed to be reported for the abstract are included

For systematic review of qualitative studies, we focus on PICo which stands for population, interest, and context as the outcomes are not directly measurable in qualitative studies unlike for quantitative studies. The term “Outcome” could be replaced with Context instead. E.g search strategy Lines 136-138 and Data Extraction Line 215 of the tack changes file.

Included studies – as per the PRISMA checklist, it is also important to mention the reasons for exclusion for the studies excluded after full-text screening.

The tables should follow the description (text) and not precede it. Pls re-order the description of Table 1 followed by the Table placed below it.

Line 292- Please provide the full name of the tool. CASP has different tools for different study designs. So please specify it as the CASP Qualitative Studies Checklist if that was the tool used.

The critical appraisal in the results section should elaborate on the overall impression based on CERQual Evidence Profile and COREQ. What were the areas that were not reported by most studies? How many studies showed low and moderate confidence and what they lacked in their methods which lead the studies to be rated as moderate or low? Also what were the strengths of most studies in terms of critical appraisal?

Limitations

Limitations need to be elaborated. As per the PRISMA the limitations can be divided into two parts. The first part should focus on the limitations within the included studies such as their methodological biases, overall impression from critical appraisal. What the studies lacked which may have affected the interpretation in this systematic review? There seemed to be a few studies that showed low to moderate confidence in CERQual Evidence Profile, which need to be addressed as limitation of the included studies. Also not all studies fulfilled all the reported criteria as per COREQ.

The second part should focus on the limitations that may have arisen during the review method such as limitations in search, inclusion, language bias (as you’ve only included English studies), etc.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #1:  Yes:  Dr Shalik Ram Dhital

Author response to Decision Letter 1

17 Sep 2022

Thank you for reviewing our submission titled “Experiences that influence how trained providers support women with breastfeeding: A systematic review of qualitative evidence.” I am attaching a revised manuscript updated with the minor revisions advised and would like to thank the reviewers for their helpful suggestions which we believe has strengthened the paper.

The request for re-submission included suggested improvements in the formatting of the document and specific comments. Detail in relation to these requirements from the reviewers is provided below.

We hope this has answered all of the comments received and appreciate the review of our paper. If further clarity is required on any aspect we are happy to address and look forward to your response on our revised version.

This Response to Reviewers has also been uploaded in this submission in tabular format for ease of reading. Line numbers in the text below refer to the Revised track changes document.

Reviewer comment: Line 45-46 findings –is it 1811 record screened or retrieved? Perhaps screened would be the more appropriate term

Author response: Edited to reflect the number of records screened by title and abstract. Of note, 1811 records were identified and duplicates were removed by Covidence software leaving 977 for screening.

Line 44-45 now reads “977 records were screened”

Reviewer comment: It is also better to report the impression of quality assessment/ risk of bias assessment of the included studies. Pls refer to PRISMA 2020 checklists for abstract https://prisma-statement.org//documents/PRISMA_2020_abstract_checklist.pdf to ensure all the information needed to be reported for the abstract are included

Author response: The PRISMA abstract has been reviewed and the abstract complies with all elements with the exception of the requirement for funding information which is provided in the financial disclosure statement of the PLOS submission. The abstract has been reworded slightly to ensure the PRISMA abstract checklist elements are included within the limits of the PLOS abstract word limit.

Line 35 now reads: “including Medline and CINAHL”

Line 36-39 now read: “Studies eligible for inclusion reported professional and trained peer experiences of supporting women to breastfeed. PRISMA guidelines were followed and included studies were quality appraised using the CASP Qualitative Checklist.”

Line 46 now reads: “Following quality appraisal, all studies were deemed suitable for inclusion”.

Reviewer comment: For systematic review of qualitative studies, we focus on PICo which stands for population, interest, and context as the outcomes are not directly measurable in qualitative studies unlike for quantitative studies. The term “Outcome” could be replaced with Context instead. E.g search strategy Lines 136-138 and Data Extraction Line 215 of the tack changes file.

Author response: Edited with suggestion to replace outcome with context – thank you for this suggestion. This necessitated a slight restructuring of the sentence, and replacement of the word “Outcome” with “Context” in Supplementary material S1 (Table of search histories) and Figure 1 (PRISMA flow diagram), and removal of the word “outcomes” from line 181 to ensure consistency throughout the manuscript.

Lines 128-130 now read: “A systematic search strategy was developed in collaboration with an expert subject librarian guided by a PEOT [27] format. For the purposes of this review “context” replaces “Outcome” in the mnemonic as outcomes are not directly measurable in qualitative studies.”

Line 181 now reads: “Meaningful sections of text were extracted that identified experiences...”

Reviewer comment: Included studies – as per the PRISMA checklist, it is also important to mention the reasons for exclusion for the studies excluded after full-text screening.

Author response: Edited to include a sentence stating reasons for exclusion as illustrated in Figure 1 PRISMA flow chart.

Line 223-226 now read: “25 were excluded for reasons of wrong population (e.g. not providing routine breastfeeding support), wrong exposure (no data on breastfeeding or breastfeeding support), wrong context (no data on breastfeeding support practices) or wrong type of study (e.g. pilot evaluations).”

Reviewer comment: The tables should follow the description (text) and not precede it. Pls re-order the description of Table 1 followed by the Table placed below it.

Author response: Edited so that the description precedes the table. Also text omitted in error (theme names in table) has now been included.

Line 248-251 now read: “Data was extracted from each study comprising Title, Author, Year, Country, Study aim or research question, Practice setting, Methodology and method, Population and sample size, COREQ score and Findings (Themes/subthemes). Study characteristics and quality appraisal scores are summarized in Table 1.”

Reviewer comment: Line 292- Please provide the full name of the tool. CASP has different tools for different study designs. So please specify it as the CASP Qualitative Studies Checklist if that was the tool used.

Author response: Edited as advised.

Line 277 now reads: “The Critical Appraisal Skills Programme (CASP) Qualitative Checklist [32] was used…”

Reviewer comment: The critical appraisal in the results section should elaborate on the overall impression based on CERQual Evidence Profile and COREQ. What were the areas that were not reported by most studies? How many studies showed low and moderate confidence and what they lacked in their methods which lead the studies to be rated as moderate or low? Also what were the strengths of most studies in terms of critical appraisal?

Author response: Edited to explain the overall impression of study quality. Further information has been included to demonstrate how the quality appraisal based on CASP and COREQ informed the CERQual Evidence Profile of confidence in this reviews’ findings. This explanation of confidence in our findings, informed by prior quality appraisal of the contributing studies, has been added further into the findings section as it relates to the overall research output of this review.

Lines 281-282 now reads: “Most studies did not report on researcher reflexivity. Description of analytical methods was limited in five of the studies.”

Lines 285-286: “Overall, strengths of the studies lay in the congruence of the research aims and objectives with the study design.”

Lines 297-303: “Confidence in the review findings was assessed using the CERQual tool [34]. There was high confidence in three of the descriptive themes. Confidence was downgraded to moderate (five descriptive themes) or low (three descriptive themes) when there was concern about any of the four components of the CERQual assessment [34]: methodological limitations, coherence, adequacy of data, and relevance as reported in supplementary information S3.”

Reviewer comment: Limitations need to be elaborated. As per the PRISMA the limitations can be divided into two parts. The first part should focus on the limitations within the included studies such as their methodological biases, overall impression from critical appraisal. What the studies lacked which may have affected the interpretation in this systematic review? There seemed to be a few studies that showed low to moderate confidence in CERQual Evidence Profile, which need to be addressed as limitation of the included studies. Also not all studies fulfilled all the reported criteria as per COREQ. The second part should focus on the limitations that may have arisen during the review method such as limitations in search, inclusion, language bias (as you’ve only included English studies), etc.

Author comment: The strengths and limitations section has been edited, firstly, to highlight methodological limitations within the included studies. Secondly, the CERQual evidence profile provides a measure of confidence in the findings of the review itself once the thematic synthesis is complete, to enable transparency of the review findings for the reader. Limitations in the review are now stated in terms of confidence in findings as per CERQual assessment, the limited representations of certain roles, and limits in search including language and publication date limiters.

Lines 653-666 now read: “Quality appraisal of the studies, data analysis, theme development and application of the CERQual tool have been described in detail in the text and supplementary material, increasing transparency for the reader and trustworthiness of the review. There was high confidence in the descriptive themes Personal breastfeeding experience, Belief in the value and process of breastfeeding and Time and resources due to the adequacy of relevant coherent data and only minor concerns about possible methodological bias. Methodological limitations within the studies include lack of transparency in reporting, as no study fulfilled all of the COREQ reporting criteria, with researcher reflexivity under-reported in most studies. Limitations of the review findings in their entirety were assessed using the CERQual tool. Concern about inadequate, irrelevant or incoherent data resulted in the downgrading of some of this review’s descriptive themes from high confidence to moderate or low confidence in findings. There is a paucity of general practitioner, health visitor and trained peer supporter representation in the studies…”

Line 671-675 now read: “Heterogeneity of methodologies, population demographics and the settings of breastfeeding support provision represented in this review has limited synthesis and as such the wider transferability of findings. Despite conducting an extensive database search it is possible that not all relevant records were retrieved due to the use of search limiters such as English language and publication date.”

Submitted filename: Response to reviewers.docx

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20 Sep 2022

Experiences that influence how trained providers support women with breastfeeding: a systematic review of qualitative evidence

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23 Sep 2022

Experiences that influence how trained providers support women with breastfeeding: a systematic review of qualitative evidence.

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