Trustful bonds: A key to “becoming a mother” and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit

Abstract

A preterm birth and subsequent hospitalization of an infant at a neonatal unit (NU) implies an extraordinary life situation for mothers, in which the maternal role and breastfeeding begin and evolve in a medical and unfamiliar setting. Descriptions of how women experience “becoming a mother” and breastfeeding in such a situation are sparse and this question was addressed in the present study. In this qualitative study, inspired by the grounded theory approach, in-depth interviews were conducted with 25 mothers whose very preterm infants had been cared for in seven NUs in Sweden. Findings indicated the importance of quality in social bonds with the infant, father, staff and other mothers at the NU, for “becoming mothers” and experiencing mutually satisfying breastfeeding. Three themes comprised a structure for descriptions of experiences, social bonds and mediated emotions: (1) ‘loss’ of the infant and the emotional chaos—“putting life on hold”; (2) separation—a sign of being unimportant as a person and mother; and (3) critical aspects of becoming more than a physical mother. The qualities were described as trustful or distrustful, characterized by accompanying feelings of pride/trust or shame/distrust. Social bonds were affected not only by the interpersonal interplay but also by the public environment and care routines. In conclusion, the contextual setting and distrustful social bonds impaired the ability to “become mothers” and the sensation of reciprocity i.e. breastfeeding becoming dutiful and not mutually satisfying. As breastfeeding is an intimate interplay and a personal choice it was considered that the best breastfeeding support would seem to be provision of a favorable environment that enhances the mother's confidence in herself. The contextual setting should be modeled such as to create conditions for a trustful and reciprocal mother–infant bond.

Introduction

Becoming a mother is a process that begins when a woman becomes pregnant, or even before. During pregnancy, the cognitive activities alter. The last 2 months are a period of preparation for the birth and the infant and for nesting, and fantasies about the infant that have developed earlier in pregnancy are diminished (Mercer, 1995). But when the infant is born very preterm, women give birth to infants for whom they are not mentally prepared (Bruschweiler Stern, 1998). In addition, preterm birth and subsequent hospitalization of infants at a neonatal unit (NU) imply an extraordinary life situation for women in which the maternal role begins and evolves in a public and medically focused context (Zabielski, 1994).

Rubin (1984) suggests that maternal role attainment is a dynamic process derived from interactions with the infant in a social environment. Emotions are vital in these interactions and in the evolving relationship, as emotions constitute the principle means of communication and enable reciprocity. Reciprocity has been described as a mutually satisfying relationship, in which affects and experiences are shared (Osofsky & Thompson, 2000). Achievement of this requires an environmentally facilitative culture that supports the mother's belief in herself as a mother and enables her to feel free to act in a way that she wants to (Winnicott, 1990). In the NU, where there is a power difference between mothers and the institutional authority and staff (Hurst, 2001), the maternal attainment process becomes more vulnerable than in the case of mothers of term, healthy infants, and need for a supportive staff is increased (Bruns & McCollum, 2002; McGrath & Meyer, 1992). A positive mother–staff relationship tends to enable mothers to connect with their infants and facilitates the establishment of maternal competence, whereas a negative relationship may lead to a disconnection between mother and infant (Lupton & Fenwick, 2001).

Mothers of preterm or ill infants are most often separated from their infants immediately after birth and during the hospital stay, and the clinical practice can be perceived as task-oriented and focused only on the physical needs of the infant (Fenwick, Barclay, & Schmied, 1999). Infant illness, concern about the outcome, lack of information, poor family functioning and lack of social support also add negatively to the maternal attainment process, causing mothers to experience more stress, depressive symptoms, decreased self-esteem and impaired later attachment (Coyne, 1995; Doering, Moser, & Dracup, 2000; Holditch-Davis & Miles, 2000; McGrath, Boukydis, & Lester, 1993; Redshaw & Harris, 1995; Shields-Poe & Pinelli, 1997; Singer et al., 1999).

Breastfeeding is an essential component in the confirmation of motherhood (Bottorff, 1990), although this is culturally and contextually dependent (Scott & Mostyn, 2003; Small, 1998; Tarkka, Paunonen, & Laippala, 1999). But as Winnicott (1990) states, “The mother's pleasure has to be there or else the whole procedure is dead, useless, and mechanical” (p. 27). Proposed factors associated with successful breastfeeding in term infants are infant health, infant satisfaction, maternal enjoyment, attainment of the desired maternal role and life-style compatibility (Leff, Gagne, & Jefferis, 1994). Concerning very preterm infants, previous studies on breastfeeding have mainly focused on the nutritional, immunological and cognitive benefits of breast milk (Lucas, Morley, & Cole, 1998; Schanler, Shulman, & Lau, 1999), or on the incidence and duration of breastfeeding, which are reported to be lower than in term infants (Flacking, Nyqvist, Ewald, & Wallin, 2003; Killersreiter, Grimmer, Buhrer, Dudenhausen, & Obladen, 2001). Other studies have described common breastfeeding concerns, for example whether the infant consumes enough milk during breastfeeding, whether the milk supply is sufficient, conflicting advice from health professionals, and lack of privacy or inadequate support and encouragement (Jaeger, Lawson, & Filteau, 1997; Kavanaugh, Mead, Meier, & Mangurten, 1995). More infant medical complications, lower social class and lower educational level are demographic factors important for not initiating or shortening breastfeeding (Espy & Senn, 2003; Furman, Minich, & Hack, 1998; Killersreiter et al., 2001). Thus, there is a sparsity of research concerning the way in which mothers of very preterm infants emotionally experience breastfeeding and how these emotions relate to the maternal attainment process.

The aim of this study was to explore how mothers of very preterm infants experienced the breastfeeding process emotionally and how this related to the process of becoming a mother, from the time before the infants’ birth until discharge from the NU.