615992

research-article2015
PSH0010.1177/2010105815615992Proceedings of Singapore HealthcareChoo and Ryan

PROCEEDINGS
Original Article OF SINGAPORE HEALTHCARE

Proceedings of Singapore Healthcare

A qualitative study exploring first time 2016, Vol. 25(1) 5­–12

© The Author(s) 2015
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DOI: 10.1177/2010105815615992

in Singapore psh.sagepub.com

Pey Jia Choo1 and Kath Ryan2

Abstract
Background: The exclusive breastfeeding rate (for the first 6 months of a baby’s life) remained low in Singapore despite
active promotion of breastfeeding by government bodies and hospitals. The aim of this study was to explore the breastfeeding
experiences of first time mothers and the difficulties they faced during their breastfeeding period.
Methods: A qualitative descriptive study design was adopted. Participants were chosen from a purposive sampling technique
and data were collected from 10 semi-structured in-depth interviews. All interviews conducted were audio-taped and
transcribed verbatim. Interview transcriptions were analysed using the qualitative content analysis approach.
Results: The breastfeeding period of the 10 first time mothers in this study ranged from 3 days to 10 months, and four
participants were still breastfeeding at the time of interview (4–12 months after delivery). The interview transcriptions
generated 54 nodes, 12 sub-themes and four key themes. The four key themes identified were: (a) challenges and support
for breastfeeding in the initial period after birth; (b) low degree of support for breastfeeding in the workplace; (c) unease at
breastfeeding in front of others; and (d) emotional and psychological aspects of breastfeeding.
Conclusion: This study provided a better understanding of the breastfeeding experiences of first time mothers in
Singapore. Initiating and sustaining breastfeeding is still challenging for first time mothers. Greater public awareness, laws that
support breastfeeding in public and the workplace, as well as support of family members could be fundamental to successful
breastfeeding.

Keywords
Breastfeeding experiences, first time mothers, qualitative

Background
Breastfeeding is the most effective way to provide essential breastfeeding. In addition, the Health Promotion Board of
nutrients for infants to ensure healthy growth and develop- Singapore actively works with the hospitals to implement
ment.1 Breastfeeding prevents diseases in infants, reduces WHO guidelines that form the baby friendly hospital initia-
risks of breast and ovarian cancer in women and helps with tive.6 Despite the efforts of the government and hospitals,
early return to pre-pregnancy weight.2 The World Health the latest statistic in 2013 showed that the exclusive breast-
Organization (WHO) has recommended exclusive breast- feeding rate remained relatively low in Singapore.7 The
feeding for the first 6 months of an infants’ life since 1992.1 National Breastfeeding Survey in 2013 reported 99% of new
In Singapore, various initiatives to promote breastfeeding mothers attempted to breastfeed their babies. However, only
have taken place over the last 10 years. The Association for 50% continued exclusive breastfeeding after discharge from
Breastfeeding Advocacy Singapore was founded in 2001 to hospital and the number dropped to 28% after 2 months.7
provide support for breastfeeding mothers.3 Singapore’s
Ministry of Health also promoted exclusive breastfeeding by
establishing the Sale of Infant Foods Ethics Committee to 1Division of Nursing, Singapore General Hospital, Singapore
guide the marketing practices of infant formula milk.4 All 2School of Nursing and Midwifery, La Trobe University, Australia
Singapore hospitals have stopped providing free formula milk
Corresponding author:
since January 2012 to encourage breastfeeding.5 Most of the Choo Pey Jia, Division of Nursing, Singapore General Hospital, 31 Third
hospitals in Singapore also conduct antenatal counselling and Hospital Avenue, Bowyer Block B, Level 2, 168753, Singapore.
postnatal support to promote the practice of exclusive Email: choo.pey.jia@sgh.com.sg

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6 Proceedings of Singapore Healthcare 25(1)

Literature review Perceived inadequate milk supply was a major stressor, and
advice from health professionals over help lines was not deemed
Most previous studies on breastfeeding practices focused on to be practical or useful. Some thought of supplementing with
evaluating interventions8 to promote or sustain breastfeed- formula feed but felt pressurised to continue exclusive breast-
ing, with a small number describing the actual experiences of feeding. Participants also thought that it would be impossible to
mothers who breastfed. maintain exclusive breastfeeding once they resumed work.
Previous studies conducted in western countries tend to However, given that the interviews were carried out within
focus on vulnerable groups such as adolescent mothers or 7–11 days after discharge from hospital, the study did not
ethnic minorities. For example, qualitative studies by Dykes explore mothers’ experience of continuing to breastfeed while
et al.,9 Bailey et al.,10 Dodgson et al.11 and Scott and Mostyn.12 resuming work (4 months) or of breastfeeding for the recom-
concluded that inconsistent messages about breastfeeding, mended length of time (6 months) and beyond.
lack of time and access to quality resources, lack of family sup- It is well recognised that numerous social and cultural factors
port and discomfort with feeding in public negatively impacted influences a woman’s decision and efforts to initiate and con-
on the initiation and duration of breastfeeding. In another tinue breastfeeding.18 Given the lack of in-depth studies on first
qualitative study on middle-eastern mothers residing in time mothers’ experiences of breastfeeding in the Singapore
Canada,13 it was found that religious belief was the strongest context, this study aimed to explore the breastfeeding experi-
influencing factor for deciding to breastfeed. Mothers in the ences of these mothers, in order to gain a better understanding
study also commented about lack of support in the work of their breastfeeding experiences and related challenges, with
environment, and breastfeeding in public places being a prob- special focus on the continuation of breastfeeding.
lem due to environmental barriers such as lack of nursing
rooms. On the other hand, in an analysis of middle class, well-
educated women’s perceptions about breastfeeding, Hall and Methods
Hauck14 concluded that they had similar experiences with
women from vulnerable groups. Respondents in their study
Design
reported inadequate and inconsistent support from care pro- A qualitative descriptive study design was adopted.
viders during the early postpartum period, which had detri- Breastfeeding stories were collected from participants’ lived
mental effects on the initiation of breastfeeding. They also experiences, perceptions were comprehensively summarised
reported that their expectation of breastfeeding being ‘natu- and reported narratively.19
ral’ and ‘problem-free’ did not fit with their actual experi-
ences. These women also commented about the lack of
family support and discomfort with breastfeeding in public.
Setting and sample
However, the study’s findings were based on brief written Participants were recruited using a purposive sampling tech-
replies to an open-ended question about breastfeeding expe- nique from Singapore General Hospital Neonatal Department
riences as part of a randomised controlled trial on the effec- between January and March 2012.
tiveness of a breastfeeding journal. The inclusion criteria were first time mothers who had
Some studies focused on the experiences of first time non-complicated normal vaginal delivery (spontaneous deliv-
mothers. Williamson et al.15 studied eight British first time ery of full-term babies, requiring little medical intervention),
mothers who struggled with breastfeeding in the early post- delivered a healthy baby without any medical conditions, and
delivery period. Results highlighted the discrepancy between initiated breastfeeding while in the hospital. Exclusion criteria
the new mothers’ experiences of struggling to breastfeed and were first time mothers who underwent caesarean section,
social portrayal of breastfeeding as natural and synonymous and/or could not breastfeed for medical reasons.
with ‘good mothering’. New mothers tend to self-blame for In accordance with the qualitative descriptive approach,
being unable to breastfeed successfully. All eight mothers also the criterion of saturation (whereby no new information
experienced severe breastfeeding-related pain, and were emerges with the addition of new cases)20 was used to deter-
confused about whether the amount of pain was to be mine the sample size. Data saturation was achieved by the
expected or signalled something wrong. However, that study tenth interview.
was conducted 10–11 days post-delivery, and hence results
could not inform the experiences of mothers who continue
to breastfeed despite the initial struggles. Few studies were
Data collection
carried out in Asian countries. In a qualitative study on breast- Data were collected using moderately structured open-
feeding experiences of first time mothers in Lao People’s ended individual interviews. An interview guide (Table 1) was
Democratic Republic, Lee et al.16 reported that first time used and questions were derived from literature review and
mothers generally had a positive perception of breastfeeding researchers’ insight on breastfeeding experiences. The first
and followed WHO guidelines on initiation of breastfeeding. author is a nurse clinician with 5 years of working experience
Nonetheless, less than half of the mothers in that study in maternity and postnatal units, while the second author is an
breastfed for 6 months; the main reasons being maternal associate professor and research director in the School of
employment and perceived inadequacy of milk supply. Nursing and Midwifery at La Trobe University.
In the local context, Ong et al.17 explored 13 first time moth- All interviews started with the question ‘Can you please
ers’ postnatal experiences and support needs. These mothers tell me about your breastfeeding experiences?’, and par-
in Singapore also found breastfeeding to be challenging. ticipants were also asked prompting question such as ‘Any
Choo and Ryan 7

Table 1. Interview guide.

Hi, XXX, Thank you for your time for this interview.
In this interview, I would like to know more about your breastfeeding experiences after you have gave birth to your child, is that okay?
Could you please tell me how long have you breastfed your baby?
Could you please tell me about your breastfeeding experiences for the past XX months?
How do you feel?
Do you breastfeed exclusively? Which means you are giving purely breast milk without supplement?
How do you feel about it?
Do you receive any advice or education on breastfeeding from hospital or friends?
Are you receiving any support from your family or friends?
How do you feel about it?
Do you face any difficulty in breastfeeding?
(Social, emotional, cultural, religion, psychological, environmental, work, family, friends)
How do you feel about it?
Is there any forbidding factor that stops you from breastfeeding?
Is there anything that you think you have given up because of breastfeeding?
How do you feel about it?
To clarify point: Could you explain that in more detail, please?
To reflect more: What did that mean to you?
To reflect more: How did it make you feel?
Are there any more things that you wanted to share with me?
It is very nice to hear from your experiences.
Thank you once again for giving me time for this interview.

problem with breastfeeding?’ Other issues raised by partici- NVIVO 10 (QSR International Pte Ltd, Doncaster, Victoria,
pants during the interviews were used as cues for additional Australia) software was also used to aid in the analysis.
prompting questions.
Interviews were conducted in the participants’ preferred
venue (six at homes and four at offices) at least 4 months after Results
their delivery. In Singapore, working mothers are entitled to 16 Ten participants were interviewed and their ages ranged
weeks of government-paid maternity leave at the birth of their from 20 to 40 years at the time of delivery (all participants
Singapore citizen child. Hence, interviews were conducted at had reached the age of 21 years at the time of signing of
or after 4 months post-delivery, so as to allow ample time for informed consent).
the participants to adjust to motherhood, be prepared to talk Seven participants were Chinese, two were Indian and
about their experiences and also to discuss their experiences one was Malay. A summary of the participants’ demographics
of breastfeeding upon returning to the workforce. (age, ethnicity), employment status and breastfeeding period
is presented in Table 2.
Ethical considerations A total of 54 nodes was generated with 277 references.
Nodes were organised into 12 sub-themes, and four key
Ethical approval was obtained from La Trobe University
themes were finally generated. The four key themes were:
human research ethics committees and the hospital’s institu-
(a) challenges and support for breastfeeding in the initial
tional review board in Singapore (SingHealth Centralised
period after birth; (b) low degree of support for breastfeed-
Institutional Review Board). Informed consent was obtained
ing in the workplace; (c) unease at breastfeeding in front of
from participants prior to commencement of interviews.
others; and (d) emotional and psychological aspects of
breastfeeding.
Data analysis A summary of the themes and sub-themes is presented
All recorded data from the interviews were fully transcribed in Table 3.
verbatim; the qualitative content analysis method was used to
summarise the informational contents of the data. Data anal- Challenges and support for breastfeeding in
ysis was conducted by both authors and performed simulta- the initial period after birth
neously with data collection. Themes and categories were
formed after the first two interviews. Subsequent informa- Latching on technique. All participants had their babies latched
tion gathered was fitted into the categories and some new on during hospital stays, but some (n=4) experienced help-
categories were formed.21 This was to inform each following lessness with inadequate support and felt frustrated when
interview and to detect that there were no new themes baby could not latched on at home. Participant 7 stated: ‘She
emerging. To ensure the trustworthiness of the analysis, both (baby) cries a lot because she couldn’t latch properly. When
authors independently read all the transcripts multiple times she cries, everybody is panicked. Then I feel frustrated. She
to analyse the text. When there were disagreements on can’t latch on. Other mum can but she just can’t….’
interpretations, both authors returned to the transcript to Inability to latched on and baby crying made the first time
remain close to the participants’ expressed meanings. mothers (n=3) panicked and worried about not providing
8 Proceedings of Singapore Healthcare 25(1)

Table 2. Demographic Data of the Participants.

Age ( at Race Interviewed Employment status at Breastfed for Still breastfeeding

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

Table 3. Summary of the Themes and Sub-Themes.

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

enough breast milk. Participants ended up giving up breast- caregivers repeatedly offered to feed formula milk to their
feeding and fed their babies formula milk. Participant 3 men- baby. Participant 3 stated: ‘Since she (baby) came back from
tioned: ‘First three day is purely breast milk, after that I think hospital, the confinement lady also came, my mother-in-law
she didn’t want to latch on, so I give up and give formula milk.’ also comes, they encouraged half-half that means formula milk
Participant 8 commented: ‘I didn’t know how to do it; she and breast milk. I feel quite stressed and disappointed….’
got frustrated when she couldn’t suck. The milk doesn’t flow Participant 2 commented: ‘Even my mum, I thought all
through. I just worried that the baby not having enough so I along they breastfeed during the olden days, but my mum
just give formula milk. And then from there I stop breastfeed- keep encouraged me to go for formula…. And because I real-
ing already….’ ize my baby keep crying every 2 hours, then my mum will say
why don’t you try formula? Formula will be more filling to the
View of important others to provide formula milk. Confinement is a baby and he won’t cry so much. So you know, I struggled
traditional practice among Asian women for the body to recu- between formula and breast milk….’
perate and regain energy from childbirth. It lasts a month and
mothers are required to follow traditional practice advice such Importance of support from own mother and spouse. Some moth-
as ‘no bathing’, ‘no washing hair’, ‘no drinking of plain water’, ers (n=6) felt appreciated when they were supported by fam-
‘eat food that is cooked with Chinese herbs’ and so forth.22 ily members. They mentioned that family support was
Most mothers experienced ‘confinement’ during their first essential during the initial period.
month after delivery regardless of ethnicity.23 They were usu- Participant 10 claimed: ‘I think the first 3 months (my
ally taken care of by their own mother, mother-in-law or con- emotion) more labile, then I try to blasted on my husband.
finement nanny. A confinement nanny is typically someone His tolerance quite high. Hahaha….’
who provides infant and maternal care at the woman’s home, Participant 4 verbalised: ‘My mum is always there to guide
according to traditional methods during the first month post- me. My husband was always there, they always reassure me I
delivery. First time mothers (n=3) were stressed when their wasn’t alone…. They wake me up, making hot drinks for me,
Choo and Ryan 9

and moral support, carrying the baby from the cot and pass Participant 5 reported: ‘my work environment is very
to me….’ rushing…. Although they understand. But half an hour you
Participant 7 mentioned: ‘No doubt (breastfeeding) is very are gone for that (express milk), I would see that my col-
tiring. Even my mum assist me, ask me to wake up in the middle leagues might think “why you have this priority?”…. Like half
of the night just for breastfeeding, it is very tiring. But I don’t an hour you are disappear, almost an hour throughout the
know why some people may just give up, maybe they didn’t have day apart from lunch time, that is not your benefit…. It might
enough support. But to me, in a way my husband is very sup- affect my job….’
portive. It is just give me the feeling I am being appreciated….’
Discrepancy between period of paid maternity leave and recom-
Coping – seeking help and support from the wider commu- mended period of time for exclusive breastfeeding. Another
nity. While some participants experienced insufficient sup- participant mentioned the lack of support from the gov-
port during this crucial period, others (n=2) sought help from ernment for working mothers who were still breastfeeding:
breastfeeding consultants when they experienced difficulties ‘Considering we have 4 months maternity, under the gov-
with latching on. Participant 1 reported: ‘After 2 to 3 days, I ernment advice that we should breastfeed at least 6
couldn’t take it, I go the prenatal class, the parent link, so what months, then what happen to that last 2 months? Must I
I did was, I actually called her up, her name is XX, she actually take no-pay leave? Or what shall I do? The government sup-
send this breastfeeding consultant over here, so she actually port is still quite not…. They haven reach the certain level
told me that there was nothing wrong, I am feeding her the yet….’ (Participant 2)
right feed, it is just the nipples are sore….’
Two participants sought support from internet forums, Sense of guilt. Guilt was described by participants (n=3) when
one of whom expressed a lack of support from the family. they had to feed formula milk to their babies due to work
Participant 6 did not receive support from family and friends, commitments.
and she claimed that: ‘I got other mothers’ experiences like Participant 5 reported: ‘During that time I will feel that
forum. Not join but just read what other people say….’ very stressful and disappointed, and think that should I be a
The other mentioned it was more trustworthy to get full time mummy? Is a decision, is very stressful, but you need
advice and support from those who were in the same situa- to work…. You cannot quit the job also…. I feel very guilty at
tion. Participant 7 illustrated: ‘I actually join a forum, for the the beginning. Even I start formula milk I also feel guilty. But I
baby who born in January, we actually form a group, on and off think is no choice….’
we actually meet up and go for gathering and bring the baby
along, go for swimming or even Halloween party, we actually
have a Facebook page, so if we have question we will post on
Unease at breastfeeding in front of others
that, so to get other mums who have same block of months, Public’s reaction. Participants felt uncomfortable in breast-
because our baby going to the same stage, so any problem or feeding their baby in public, as people tend to stare at
issue we will actually ask each other. Even like breastfeeding them when they nursed the baby. All participants expressed
topic. One of us feels like stop breastfeeding, and you will then that they will either go to a nursing room or nursed the
get encourage (to carry on). So sort of support from there….’ baby with adequate cover when no nursing room was
available.
Participant 6 reported: ‘When you breastfeed in public
Low degree of support for breastfeeding in
there will be a lot of people stare at you. I tried once breast-
the workplace
feed in public, some people like just stand there and stare….
Attitudes of superiors and colleagues. The level of breastfeeding I feel like… its quite rude. Because I am feeding baby and they
support varied with companies. While some workplaces did keep staring….’
have breastfeeding facilities for working mothers, the accep- Participant 1 commented: ‘it is quite inconvenient, I need
tance of breastfeeding practices in the workplace, however, extra towels, it is a bit messy when I am outside…. Actually I
was still dependent on the superior’s and colleagues’ attitudes have the nursing shawl but I am not comfortable in using it in
towards it. Participants (n=3) were sensitive and mindful the public…. There were times where a friend who came
about their absences from work especially in front of their over, she was sitting outside, but I keep running into the room
supervisors. Taking time away from work to express milk was to feed her (baby), I am not comfortable. In fact not even in
associated with inefficiency. front of my mum….’
Participant 7 stated: ‘In Singapore, everything is fast fast
fast, and breastfeeding actually take up time. And people will Embarrassment when baby grows bigger. A participant did
think you are not productive enough…. I think I better do it not mind nursing her baby in public, using a shawl when
(express milk) in office, faster and easier, and within sight, the baby is only a few months old, but she felt embarrassed
they don’t feel that I am going somewhere else…. Because to latch on a baby bigger than a year old. She expressed
some people will think that why you go away for so long…. awkward feelings when a big baby is sucking on the breast
But if I am inside 20 minutes, and my office has pantry, so I am in the public.
still within sight. Visually I am only away for 20 minutes. But if Participant 5 reported: ‘I think about this age (10 months),
I go another building (nursing room), visually I am away for 40 if I still have breast milk, might be hesitate. Because when I see
minutes, to them I am eating up the working hours….’ big baby still latch on, it looks like a bit funny….’
10 Proceedings of Singapore Healthcare 25(1)

Emotional and psychological aspects of Participant 10 commented: ‘Initially was very tiring. The
breastfeeding first 2 months very tired. But you keep feeding the child. No
one else can help you. And nobody told you it is so tired…. I
Bonding and sense of achievement. All participants associated think there are a lot of mothers are quite pro-breastfeeding.
breastfeeding with positive feelings, especially with the bond It just for the first time mothers, no matter how much ante-
that they had with their child despite some negative natal class you attend, you wouldn’t expect it is so tired….’
experiences. Other participants (n=4) claimed that what they learnt
Participant 2 stated: ‘The experiences is can’t really about breastfeeding was totally different from their actual
describe, basically the feel was good…. It is very personal, experiences.
when baby feeling hungry, he know where to get milk, he Participant 3 mentioned: ‘The real experiences I can’t read
know how to latch on immediately…. When he latches on, from book….’
his hand will move around, and then he will touch you, he will
feel you, then that kind of warmth, that kind of interaction,
you will feel very good…. Physically you feel very tired, but Discussion
overall experiences were very good….’ The analysis presented in this paper is based on the accounts of
Some participants (n=5) felt proud and gain a sense of a group of first time mothers who delivered healthy full-term
achievement in breastfeeding. babies and had initiated breastfeeding while in the hospital.
Participant 5 stated: ‘After 3 months he grew very fast, I Similar to the results of previous studies,15,17,24,25 mothers
would see that he only take my breast milk, and I feel quite in this study reported struggling with breastfeeding after they
successful. I very happy about it. When he just born he was were discharged from hospital. Some had trouble trying to
only 2.6 kg, and then just breastfeeding he grow until now. I get their babies to latch on, and experienced conflicting
am very happy.’ advice from their own mothers or confinement nannies. As
narrated by the participants in this study, the need for breast-
Feelings of uncertainty, emotional insecurity and self-sacri- feeding support when they returned home was crucial to
fice. Feelings of uncertainty were mentioned by two partici- ensure the continuity of breastfeeding after discharge. Similar
pants as no one could advise them on their breastfeeding to previous study findings,26 first time mothers might not
queries. For first time mothers with a poor support net- know what questions to ask prior to their discharge from
work, feelings of uncertainty continued to appear through- hospital. Even though discharge advice was provided, many
out the breastfeeding journey and they learnt from their mothers are still unsure of who and where to seek help in
own experiences. Fear of making the wrong decision to times of need. For first time mothers, interventions by trained
choose breastfeeding instead of giving formula milk in the nurses in the home setting could help to guarantee successful
initial period was cited by participants (n=3). With little or breastfeeding at home.27 In another study,28 home visits by
poor support, they felt stressed and helpless about breast- midwives or maternity care assistants were described as
feeding. Some participants (n=2) reported that they felt overwhelmingly positive experiences by the young mothers
emotionally unstable and confused when people gave differ- who received the care. Having home visits by midwives or
ent advice. Most participants panicked when the baby cried maternity healthcare professionals might be beneficial for
and worried about their milk supply. mothers in Singapore because most practised ‘confinement’
Participant 3 mentioned: ‘My supply cannot meet my baby at home.29 A local study conducted by Shorey et al.25 found
demand. If she drinks 7 times, I can only supply for 3 times. I that home visits by midwives helped first time mothers to
did ask my friend, they ask me to drink more water, eat more cope better physically and emotionally in the initial postnatal
fish, and have more rest. But when you start to feel stress, period. Proper education and social support can be given
your milk flow will drop.’ during home visits to increase maternal self-efficacy and pre-
Some participants (n=4) felt ‘sacrificed’ when they were vent postnatal depression.25
told they couldn’t take their favourite food such as spicy food Support from the first time mothers’ own mothers and
and seafood, and had lesser time to go out with friends due spouses, as well as the wider community, was helpful in ena-
to the need to breastfeed. Lack of personal time due to bling the first time mothers in this study to continue to
breastfeeding commitments and the adaptation period to breastfeed. Similar findings were reported in previous studies
their new role were also discussed. Participant 1 stated: ‘After by Jessri et al.13 and Hjalmhult and Lomborg,30 whereby social
delivery you so tired, and then it is like I get up, I feed her, she support enabled the mothers to continue to breastfeed
sleep, I need to shower, I shower come back, she gets up, and despite initial challenges. In a qualitative synthesis paper by
I feed her, I need to go and eat, then she sleep, she gets up McInnes and Chambers,31 it was concluded that mothers may
again, I didn’t have time for myself, for the initial 1 to 2 months consider social support (from a mother, friend or partner) to
was a bit crazy, it was the baby me, the baby me, the baby me. be more important than health professional support.
It is a bit stressing….’ However, social support may exert a negative influence if
there is a lack of breastfeeding knowledge or experience
Tough and challenging at first. The first 2 weeks after the baby within the social group.
was born was described as ‘tough’ and ‘stressful’, and was As discussed in many previous studies,26,32–35 perceived
often associated with physical tiredness. Some participants inadequate milk supply issues could be due to lack of knowl-
(n=5) claimed that ‘no one has warn you it’s that tiring’ for edge on the physiological process of lactation. First time
breastfeeding, and ‘no one can help you with it’ too. mothers in our study narrated similar perceptions of
Choo and Ryan 11

inadequate milk supply, especially when the baby cries. Limitations and implications for practice and
Education of first time mothers during the antenatal period research
could help to address this concern. Education could place
The findings cannot be generalised to other settings as the
emphasis on recognising infant hunger cues, the physiology of
sample size was small and the study focussed on first time
breast milk production, ways to monitor if the baby is getting
mothers. Although efforts were made to ensure the main
enough nourishment and ways to boost breast milk
races in Singapore, that is, Chinese, Malay and Indians, were
production.8
represented in the study, the predominant ethnicity was
Workplace support is crucial for working mothers who
Chinese. Given ethnic differences in postnatal practices and
are still breastfeeding. Although amenities to express breast
beliefs, the results might not be representative of all ethnic
milk were provided, participants in this study expressed
groups in Singapore.
concerns about being seen as ‘unproductive’ if they take
As the first time mothers in this study reflected, more
time to express milk while at work. Breastfeeding had the
resources are needed to support and promote breastfeeding in
potential to put women in the spotlight and to make them the community. During the first few weeks after birth, continual
highly visible, thus affecting their breastfeeding decision.36 support from health professionals such as midwives and signifi-
Strategies promoting breastfeeding in the workplace need cant others are important in order to establish breastfeeding. In
to be implemented. For example, in the USA, the US the long haul, changes in workplace practices and understanding
Federal Patient Protection and Affordable Care Act (2010) from co-workers and the general public would then help to
ensures that companies give breastfeeding mothers of chil- enable mothers to breastfeed for a longer period of time.
dren under the age of 1 year reasonable time to express Future studies should look into the needs of mothers who
milk in a clean and private lactation room.37 Companies did not breastfeed their first born but who wanted to do so
should practise flexibility such as providing working moth- for their subsequent children. It is also important to look into
ers with lactation breaks and the physical space to express the experiences and needs of mothers who work shift duties
milk or breastfeed.38 and/or irregular hours, and how workplace practices can pro-
Contrary to previous study findings,16,39 five out of nine mote breastfeeding.
first time mothers in our study who resumed full-time work
managed to breastfeed for the recommended period of 6
months or longer, despite narrated challenges of expressing Conclusion
breast milk while at work. This could be due to the availability This study provided a better understanding of the breast-
of facilities to express breast milk and support from spouses feeding experiences and challenges of first time mothers in
to continue breastfeeding. Singapore. Initiating and sustaining breastfeeding is still chal-
Similar to previous study findings,13 participants in this lenging for first time mothers. Greater public awareness and
study regarded breastfeeding and expressing of breast milk as laws that support breastfeeding in public and the workplace,
intimate activities. Although more lactation rooms are found as well as the support of family members, could be helpful in
in public areas of Singapore, the most important issue still promoting successful breastfeeding.
relies on society’s attitudes and cultural norms.
First time mothers in this study experienced different Declaration of Conflicting Interests
emotions and states of mind. Being able to breastfeed was The author(s) declared no potential conflicts of interest with respect
associated with positive loving feelings of bonding with the to the research, authorship, and/or publication of this article.
baby, and mothers experienced a sense of achievement for
successful breastfeeding. On the other hand, they also felt Funding
uncertain about their abilities to breastfeed and resented The author(s) received no financial support for the research,
changes to their lifestyle because of the commitment to authorship, and/or publication of this article.
breastfeed. This finding was similar to that in previous
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