Authors: Tippawan Srichalerm, Donruedee Kamkhoad, Ratchanok Phonyiam
Categories: Evidence Syntheses, breastfeeding, experience, preterm infants, qualitative research, systematic review
Source: Jbi Evidence Synthesis
Authors: Tippawan Srichalerm, Donruedee Kamkhoad, Ratchanok Phonyiam
The objective of this review was to explore the breastfeeding experiences and the management of mother’s own milk among mothers of preterm infants during their infant’s hospitalization.
Mothers of preterm infants often face distinct breastfeeding challenges that differ considerably from those experienced by mothers of term infants. The qualitative synthesis of evidence regarding the breastfeeding experiences of mothers with preterm infants in hospital settings is a valuable area of research that remains underexplored.
This systematic review included qualitative studies, as well as the qualitative components of mixed methods studies, that involved mothers of preterm infants, regardless of maternal age or social background. The review specifically focused on studies that explored maternal experiences with breastfeeding and mother’s own milk management during the hospitalization of their preterm infants.
This review was conducted following JBI methodology for qualitative research, with the aim of examining relevant evidence from both published and unpublished studies up to July 2024. The initial search was conducted using PubMed, followed by an extensive search across PubMed, CINAHL (EBSCOhost), Embase (EBSCOhost), and Scopus. Unpublished studies and gray literature were searched through the Mahidol Library Catalogs and the Open Access Theses and Dissertations database. Retrieved records from academic databases, unpublished studies, gray literature, and reference lists of the retrieved records were screened. Studies published in English or Thai were eligible for inclusion. Two reviewers independently screened studies for eligibility and conducted critical appraisals. Data were then extracted and synthesized using meta-aggregation independently by 2 reviewers. All reviewers reached a consensus on the categories and finalized the synthesized findings.
This review included 53 studies conducted across 20 countries spanning 6 continents, involving approximately 1212 mothers. A total of 225 findings were identified and organized into 11 categories based on thematic similarities, resulting in 4 synthesized i) Mothers are central to the breastfeeding process, playing a key role in making decisions regarding the provision of breast milk for their preterm infants; ii) Mothers of preterm infants often encounter unique personal challenges in providing breast milk to their infants; iii) External systems serve as both facilitators and barriers to breastfeeding and mother’s own milk management; and iv) Comprehensive support systems enhance breastfeeding practices and outcomes.
This review provides a systematic synthesis of the experiences of breastfeeding and mother’s own milk management among mothers of preterm infants in hospital settings. It highlights that these mothers face significant breastfeeding difficulties due to their infant’s health-related concerns, emphasizing the need for comprehensive support to overcome these barriers. The limitations of this review include variability in the quality of the included studies and the potential for language bias. Recommendations for future research include further exploration of the breastfeeding experiences of mothers of preterm infants across diverse contexts, including home and community environments. Additionally, comprehensive breastfeeding support strategies, informed by the synthesized findings, should be investigated to enhance breastfeeding practices and outcomes for these mothers.
PROSPERO CRD42024501454
ConQual Summary of FindingsExperiences of breastfeeding among mothers of preterm infants during their infant’s hospital stayBibliography: Srichalerm T, Kamkhoad D, Phonyiam R. Experiences of breastfeeding among mothers of preterm infants during their infant’s hospital a qualitative systematic review. JBI Evid Synth. 2026;24(1):5-76.Synthesized findingType of researchDependabilityCredibilityConQual scoreCommentsMothers are central to the breastfeeding process, playing a key role in making decisions regarding the provision of breast milk for their preterm infants.QualitativeModerate (Downgrade 1 level)Moderate (Downgrade 1 level)LowDependability: Majority of studies (23/42) scored 3/5 for the questions relating to appropriateness of the conduct of the research.Credibility: Downgraded 1 level due to mix of unequivocal (U) and credible (C) findings.U=89, C=1Mothers of preterm infants often encounter unique personal challenges in providing breast milk to their infants.QualitativeModerate (Downgrade 1 level)Moderate (Downgrade 1 level)LowDependability: Majority of studies (22/39) scored 3/5 for the questions relating to appropriateness of the conduct of the research.Credibility: Downgraded 1 level due to mix of unequivocal (U) and credible (C) findings.U=78, C=2External systems serve as both facilitators and barriers to breastfeeding and mother’s own milk management.QualitativeModerate (Downgrade 1 level)HighModerateDependability: Majority of studies (7/13) scored 3/5 for the questions relating to appropriateness of the conduct of the research.Credibility: Remains unchanged due to all findings unequivocal (U).U=16, C=0Comprehensive support systems enhance breastfeeding practices and outcomes.QualitativeHighModerate (Downgrade 1 level)ModerateDependability: Majority of studies (11/20) scored 4/5 or 5/5 for the questions relating to appropriateness of the conduct of the research.Credibility: Downgraded 1 level due to mix of unequivocal (U) and credible (C) findings.U=37, C=2
Breastfeeding and the provision of human breast milk in hospital settings are vital components of neonatal care,1 particularly for preterm infants who face unique challenges due to their underdeveloped physiological and functional systems. Human milk, especially preterm milk, is crucial for these infants, as it provides a rich composition of essential nutrients, antibodies, and growth factors necessary for their growth and neurodevelopment.2,3,4 Furthermore, as preterm infants have immature immune systems that make them more susceptible to infections,5 human milk plays a critical role in offering protection, particularly through antibodies such as immunoglobulin A (IgA).6 Additionally, human milk significantly reduces the risk of necrotizing enterocolitis and supports gastrointestinal health6,7 by promoting the establishment of a healthy gut microbiota, which is essential for immune function and long-term well-being.8 These benefits highlight the importance of promoting and supporting breastfeeding in neonatal care settings to ensure that mothers of preterm infants can provide milk to their vulnerable infants.
Despite these advantages, mothers of preterm infants often face complex breastfeeding challenges, primarily due to the unexpected and unprepared nature of preterm birth, which can significantly impact both breastfeeding and milk production.9 The initiation of lactation is often delayed, as the physical and emotional stress associated with preterm birth can disrupt the hormonal response necessary for milk production.9 Specifically, prolactin and oxytocin—the hormones responsible for milk synthesis and ejection—may be less responsive, particularly when direct breastfeeding is not possible in the early postpartum period.9,10 Research indicates that early skin-to-skin contact and direct breastfeeding stimulate the release of these hormones, facilitating successful lactation.11 However, many preterm infants require extended stays in hospital settings, including the neonatal intensive care unit (NICU) or sick newborn unit, limiting these vital maternal–infant interactions and hindering the initiation and maintenance of breastfeeding. Moreover, the environment of the neonatal unit itself can exacerbate these difficulties, introducing additional stressors, such as maternal anxiety regarding the infant’s survival and long-term health outcomes.12
The emotional and psychological toll of having a preterm infant in a neonatal unit is profound, with studies indicating that stress, anxiety, and depression are common among these mothers.12,13 These psychological factors can disrupt maternal–infant bonding and interfere with the physiological processes necessary for successful breastfeeding.9,14 Postpartum depression, in particular, has been consistently associated with reduced milk supply and increased breastfeeding difficulties.15 The psychological strain of caring for a preterm infant can also diminish maternal confidence and motivation to breastfeed,16 further complicating lactation efforts. Thus, breastfeeding in the context of prematurity is not merely a physical challenge but one deeply intertwined with emotional and psychological factors.
Providing mother’s own milk (MOM),17 whether through direct breastfeeding or expressed milk, is widely regarded as the gold standard for preterm nutrition due to its well-documented immunological and developmental benefits. However, this approach requires mothers to regularly express milk, ensure its safe storage, and coordinate timely delivery to neonatal care units. Unlike mothers of full-term infants, who typically benefit from early skin-to-skin contact and infant-led suckling that stimulate and sustain lactation, mothers of preterm infants often must initiate lactation without these physiological and emotional cues.17,18 Consequently, reliance on mechanical expression may lead to difficulties with milk production, increased emotional stress, and reduced breastfeeding confidence.18
Given these unique demands, the hospital environment and the role of health care staff are pivotal in shaping breastfeeding outcomes for mothers of preterm infants. Inadequate institutional support can create both physical and psychological barriers to successful lactation. Hospital policies, such as restricted visiting hours, limited space, and a lack of private breastfeeding areas, may further discourage maternal involvement. Additional challenges include inconsistent guidance from health care professionals, limited access to hospital-grade breast pumps, inflexible pumping schedules, and insufficient milk storage facilities.19 When neonatal staff do not actively promote breastfeeding or provide consistent support, mothers may feel isolated and discouraged. In contrast, supportive environmental and interpersonal factors, such as family rooms, welcoming signage, knowledgeable staff, and accessible educational materials, have been shown to enhance breastfeeding experiences and outcomes.20
A mother’s attitude toward breastfeeding also plays a pivotal role in the initiation and continuation of breastfeeding practices.21 Preterm birth, often sudden and distressing, can disrupt maternal expectations and introduce a range of breastfeeding difficulties. These may include delayed lactogenesis, poor infant latch due to physiological immaturity, and restricted opportunities for direct breastfeeding during neonatal care. Mothers are often required to manage their milk supply independently, involving frequent expression, safe storage, and transportation of breast milk under stressful and emotionally taxing conditions. Persistent difficulties can lead to increased maternal stress, frustration, and diminished confidence, which may contribute to early cessation of breastfeeding.22 However, successfully navigating these challenges can foster positive emotional outcomes, such as a sense of empowerment, accomplishment, and satisfaction. These positive experiences can enhance maternal self-efficacy, strengthen breastfeeding intentions, and improve the overall duration and quality of breastfeeding.23
The challenges that mothers encounter in initiating and sustaining breastfeeding, particularly during their infant’s hospitalization, can have a substantial impact on breastfeeding outcomes.24 Understanding these mothers’ experiences is essential, not only for addressing the barriers they encounter but also for promoting optimal health outcomes for their infants and fostering strong maternal–infant bonds. Gaining insight into these experiences enables health care professionals to develop targeted interventions and support systems, enhancing the breastfeeding journey for this vulnerable population and increasing the likelihood of successful breastfeeding.
To evaluate the current state of research on this topic, we conducted a thorough preliminary search across databases such as PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis. However, no qualitative systematic reviews on the subject, either published or in progress, were identified. Given the absence of a comprehensive review synthesizing evidence in this area, the objective of this review was to synthesize the experiences of breastfeeding and MOM management among mothers with preterm infants during their infant’s hospital stay.
What are the experiences of mothers of preterm infants regarding breastfeeding and MOM management during their infant’s hospital stay?
This review included studies focusing on mothers or female parents of preterm infants, with no restrictions on maternal age, gravidity, parity, number of pregnancies (eg, singleton, twin, triplet), gender identity, or the gestational age of the preterm infant. The physical and mental health status of the mothers was also considered. Mothers who had previously undergone breast surgeries, whether for aesthetic or medical reasons, were eligible for inclusion, provided they were able to breastfeed or supply their own milk. Additionally, mothers facing mental health challenges, such as those grieving the recent loss of one of their twins, were considered for inclusion as long as no contraindications to breastfeeding were present.
Mothers with a disability, including those with deafness, muteness, blindness, or mobility impairments, were also eligible, provided there were no medical conditions preventing them from breastfeeding or supplying their own milk to their preterm infants. Participants were included irrespective of contextual factors, such as marital or social status, support networks, access to resources, cultural norms, immigration status, and financial circumstances; no exclusions were made on the basis of these factors.
Participants with health conditions requiring medication or with transmissible diseases (eg, hepatitis, HIV, mononucleosis, cytomegalovirus) that posed contraindications to breastfeeding were excluded. Furthermore, mothers with cognitive impairments, such as dementia or Alzheimer disease, were excluded due to the potential challenges in recalling and articulating their breastfeeding experiences. Indirect experiences of breastfeeding, such as those shared by a sister or close friend, were also excluded from this review.
This review considered studies that qualitatively explored 2 key components of i) the experience of breastfeeding—defined as the provision of MOM to an infant, either directly at the breast or through alternative methods such as cup, syringe, or tube feeding; and ii) the experience of MOM management, referring to the coordinated practices involved in establishing and maintaining milk supply, including the expression, collection, storage, and timely administration of MOM to infants in neonatal care settings.17,18 Collectively, these components reflect both the emotional and behavioral dimensions involved in providing MOM in the context of preterm birth.
This review focused on hospital units that provided care for preterm infants, including, NICUs, special care nurseries, sick newborn units, postnatal units, and postpartum units. Other hospital units offering care to preterm infants were also considered.
The review examined various health system and setting factors that impacted mothers of preterm infants. These factors included the characteristics of health care systems, such as whether they were private, public, universally accessible (serving immigrants, refugees, and uninsured individuals), citizen-only, or mixed models (combining both private and public sectors). Additionally, the review considered studies that addressed regulations in maternity units, including policies on parental presence, breastfeeding restrictions, and visiting hours. However, studies focusing on breastfeeding practices for preterm infants after discharge or at home were excluded from the review.
This review included studies that focused on qualitative data, including methodologies such as phenomenology, grounded theory, ethnography, action research, and feminist research. Qualitative data from mixed methods studies were also considered, provided that the qualitative findings could be extracted. Alternative forms of evidence, such as textual analysis or opinion-based research, were excluded from the review.
This systematic review was conducted in accordance with JBI methodology for systematic reviews of qualitative evidence25 and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.26 The review adhered to an a priori protocol27 and was registered with PROSPERO (CRD42024501454).
The authors conducted a comprehensive search using key terms relevant to the focus of this review, with assistance from a health research librarian. The search strategy was designed to identify both published and unpublished studies through a 3-step process. First, an initial limited search was conducted on PubMed, followed by an analysis of the text words in the titles and abstracts, as well as the index terms used to describe the articles. The search strategy was then adapted for each information source, incorporating all identified keywords and index terms. The database search was conducted between July 17 and 31, 2024, across 4 PubMed, CINAHL (EBSCOhost), Embase (EBSCOhost), and Scopus. In addition, unpublished studies and gray literature were accessed through the Mahidol Library Catalogs and the Open Access Theses and Dissertations database. Only studies published in English or Thai, the reviewers’ native languages, retrieved via these sources were included. A health research librarian provided assistance and reviewed the process, following the Peer Review of Electronic Search Strategies (PRESS) guidelines28 to ensure the rigor of the search strategy. Finally, the reference lists of relevant studies were screened to identify additional studies. The detailed search strategies for each information source are provided in Appendix I.
Although language restrictions are ideally avoided in search strategies,29 we limited our systematic review to English and Thai—the reviewers’ native languages. An English-language filter was applied for database searches, whereas other methods, such as hand-searching and reference screening, included studies in both English and Thai. We acknowledge that this approach may introduce language bias and exclude valuable cultural perspectives; however, it was necessary to ensure accurate interpretation and minimize the risk of misinterpretation.
Following the search, all identified citations were collated and uploaded into EndNote v.20 (Clarivate Analytics, PA, USA), and duplicates were removed. A pilot screening of 10 to 20 studies was conducted at both the title/abstract and full-text levels to ensure a shared understanding of the inclusion and exclusion criteria between 2 reviewers (TS, DK). Subsequently, titles and abstracts were independently screened by 2 reviewers (TS, DK) to assess eligibility based on the predefined inclusion criteria. Potentially relevant studies were retrieved in full, and their citation details were subsequently imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).30 Full-text studies that did not meet the inclusion criteria were excluded, with the reasons for exclusion provided in Appendix II. Any disagreements between reviewers were resolved through discussion or with the involvement of a third reviewer (RP). The search results were reported in full and presented in a PRISMA flow diagram.26
Eligible studies were independently appraised for methodological quality by 2 reviewers (TS, DK) using the standard JBI Critical Appraisal Checklist for Qualitative Research.25 Any disagreements between the reviewers were resolved through discussion. For this review, studies were required to meet predetermined quality criteria by receiving a “yes” response on the JBI checklist for key items related to research methodology, data collection methods, data representation and analysis, and the representation of participants’ voices (questions 2-4 and 8). This approach ensured methodological rigor and the inclusion of participants’ perspectives. Studies that did not meet these key items were excluded from the review. Studies were still eligible for inclusion even if they received responses of “unclear” or “no” to questions regarding the philosophical perspective, researcher positioning (cultural or theoretical), researcher influence on the research, ethical approval statements, or conclusions.
Data were extracted from the studies included in the review independently by 2 reviewers (TS and either DK or RP) using the standardized JBI data extraction tool in JBI SUMARI.30 A pilot extraction was conducted using 2 to 3 studies to ensure consistency and clarity in the process. The extracted data encompassed specific details about the participants, context, culture, geographical location, study methods, and the phenomena of interest, all of which were relevant to the review’s objectives of understanding how mothers of preterm infants experience breastfeeding and manage MOM during their infant’s hospital stay. Findings, along with their corresponding illustrations, were extracted, and each finding was assigned a level of unequivocal (evidence beyond reasonable doubt), credible (plausible interpretations inferred from data and theoretical frameworks), or not supported (findings not supported by the data). Any disagreements between the reviewers were resolved through discussion.
Qualitative research findings were pooled using JBI SUMARI with the meta-aggregation approach.31 This process involved aggregating or synthesizing the findings to generate a set of statements that represented the overall aggregation. The findings were first assembled and categorized based on similarities in meaning. These categories were then subjected to further synthesis to produce a comprehensive set of synthesized findings, which could serve as a foundation for evidence-based practice. Only unequivocal and credible findings were included in the synthesis.
The final synthesized findings were graded using the ConQual approach32 to establish confidence in the results of the qualitative research synthesis. These findings were presented in a Summary of Findings (SoF), which outlined the key elements of the review and detailed the development of the ConQual scores. The SoF included the review title, participant characteristics, phenomena of interest, and the specific context. Each synthesized finding was accompanied by the type of research informing it, as well as scores for dependability and credibility, and an overall ConQual rating.
Dependability was first assessed for each individual study included in the synthesis based on 5 criteria from the JBI Critical Appraisal Checklist for Qualitative Research (questions 2-4, 6, and 7). Each study was rated as having high, moderate, or low dependability, and these ratings were applied to the corresponding research findings. The overall dependability score for each synthesized finding was determined by the distribution of dependability levels across the contributing studies. Credibility was assessed based on the proportion of unequivocal and credible findings within each synthesis. Detailed ConQual scores for this review are provided in the SoF.
A comprehensive literature search initially identified 1476 potential articles for inclusion. After removing duplicates (n = 311), 2 reviewers independently assessed the titles and abstracts of the remaining 1165 articles. During this phase, 1039 articles were excluded because they did not meet the inclusion criteria. Subsequently, 126 articles underwent full-text review independently by 2 reviewers to assess eligibility. Studies identified through other methods (gray literature search and citation searching) were subject to the same screening process.
Eight reports were unable to be retrieved. Of the 118 full-text sources, 62 were excluded due to ineligible phenomena of interest, study design, context, or participant characteristics. Following the full-text review, 56 articles were assessed for methodological quality. Five studies were excluded due to concerns about methodological quality, in accordance with the review protocol. Ultimately, 53 studies33-85 were included in the 51 identified from databases and 2 identified through other methods. The study inclusion process is illustrated in the PRISMA flow diagram in Figure 1. Reasons for exclusions at both the full-text screening stage and the methodological quality assessment are detailed in Appendix II and Appendix III, respectively.Figure 1Search results and study selection and inclusion process26
All studies assessed for eligibility at full-text screening underwent critical appraisal (Table 1). The scores for each study ranged from 6 to 10 out of 10. Only 22 studies (42%) had a statement locating the researcher culturally or theoretically, while 17 studies (32%) addressed the influence of the researcher on the research and vice-versa. Almost all studies (94%) except 3 (1 “no”36 and 2 “unclear”51,61) presented evidence of ethical approval by an appropriate body. Most studies (87%) drew conclusions that were clearly supported by the analysis and interpretation of the data, except for 7 studies rated as “unclear.”36,40,50,54,75,79,83 Five studies were excluded due to inadequate methodological quality because they received 1 or more “no” or “unclear” responses on the required criteria (questions 2-4 and 8).Table Critical appraisal of eligible qualitative studiesStudyQ1Q2aQ3aQ4aQ5Q6Q7Q8aQ9Q10Alinejad-Naeini et al.,33 2021YYYYYNNYYYBernaix et al.,44 2006YYYYYNNYYYBjörk et al.,51 2012YYYYYYYYUYBoucher et al.,50 2011YYYYYYYYYUBower et al.,55 2016YYYYYYYYYYBrockway et al.,59 2020YYYYYYYYYYBrødsgaard et al.,60 2022YYYYYYYYYYBrown et al.,67 2013YYYYYNNYYYBujold et al.,68 2018YYYYYNNYYYCescutti-Butler et al.,69 2019YYYYYNNYYYFernández Medina et al.,70 2019YYYYYNNYYYFlacking and Dykes,72 2013YYYYYYYYYYFlacking et al.,73 2006YYYYYNNYYYFroh et al.,42 2017YYYYYNNYYYGondwe et al.,74 2022YYYYYNNYYYGrundvig Nylund et al.,34 2020YYYYYNNYYYHabtu et al.,35 2024YYYYYNNYYYHasselberg et al.,75 2016YYYYYNNYYUHoldren et al.,76 2019YYYYYYYYYYHurst et al.,77 2013YYYYYNNYYYHurst,36 2001YYYYYNNYNUIkonen et al.,61 2016YYYYYNNYUYJonsdottir et al.,62 2022YYYYYNNYYYKair et al.,56 2015YYYYYNNYYYLee et al.,52 2009YYYYYNNYYYLomotey,37 2019YYYYYYNYYYLoVerde et al.,63 2018YYYYYNNYYYMadiba and Sengane,78 2021YYYYYYYYYYMadiba et al.,71 2023YYYYYNNYYYMӧrelius et al.,57 2020YYYYYYNYYYNeu et al.,40 2020YYYYYYNYYUNiela-Vilén et al.,64 2015YYYYYYYYYYPadovani et al.,65 2011YYYYYNNYYYPalmquist et al.,43 2020YYYYYNNYYYParker et al.,80 2020YYYYYNYYYYParker et al.,84 2018YYYYYYYYYYPremji et al.,38 2017YYYYYNNYYYRossman et al.,58 2019YYYYYNNYYYRossman et al.,81 2013YYYYYNNYYYRussell et al.,39 2014YYYYYYYYYYSarapat et al.,85 2017YYYYYNNYYYSchwab et al.,82 2024YYYYYNNYYYSisk et al.,83 2010YYYYYYYYYUSwanson et al.,79 2012YYYYYYYYYUSweet,66 2008YYYYYNYYYYTada et al.,45 2020YYYYYYYYYYTasgit and Dil,46 2022YYYYYYNYYYVan Schalkwyk and Gerber,47 2021YYYYYYNYYYWilson,53 2012YYYYYNNYYYWitt et al.,41 2022YYYYYYYYYYYang et al.,48 2019YYYYYNNYYYYang et al.,54 2022YYYYYYNYYUYu et al.,49 2023YYYYYYNYYYTotal %10010010010010042321009487^a^Required criteria for inclusion in the reviewY, yes; N, no; U, unclearJBI Critical Appraisal Checklist for Qualitative ResearchQ1 = Is there congruity between the stated philosophical perspective and the research methodology?Q2 = Is there congruity between the research methodology and the research question or objectives?Q3 = Is there congruity between the research methodology and the methods used to collect data?Q4 = Is there congruity between the research methodology and the representation and analysis of data?Q5 = Is there congruity between the research methodology and the interpretation of results?Q6 = Is there a statement locating the researcher culturally or theoretically?Q7 = Is the influence of the researcher on the research, and vice-versa, addressed?Q8 = Are participants, and their voices, adequately represented?Q9 = Is the research ethical according to current criteria or, for recent studies, is there evidence of ethical approval by an appropriate body?Q10 = Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?
This qualitative systematic review extracted and synthesized findings from 53 studies exploring the experiences of breastfeeding and MOM management among mothers of preterm infants, capturing a broad spectrum of cultural, socioeconomic, and health care contexts. The included studies, published between 2000 and 2024, were conducted in 20 countries across 6 continents, reflecting the global nature of this topic.
In Asia, studies were conducted in China,48,49,54 Iran,33 Taiwan,52 Thailand,85 and Turkey,46 highlighting diverse perspectives from both Middle Eastern and East/Southeast Asian regions. European research contributions came from Denmark,60 Finland,61,64,76 Germany,82 Iceland,62 Spain,70 Sweden,34,51,57,72,73 and the United Kingdom,39,53,69,72,79 offering insights from countries with well-established neonatal care systems. African countries represented in the review included Ghana,37 Malawi,74 South Africa,47,71,78 and Tanzania,35,45,75 bringing valuable perspectives from low- and middle-income settings where health care infrastructure and cultural norms around breastfeeding may differ significantly from other regions. In North America, Canada38,50,59,68 and the United States36,40-44,55,56,58,63,67,76,77,80,81,83,84 provided extensive data, reflecting a wide range of health care practices and policies in high-income settings. South America was represented by Brazil,65 offering insights into maternal experiences within a Latin American context. Oceania was represented by Australia,66 contributing to the understanding of breastfeeding and MOM practices within a Western but geographically distinct region. The geographical diversity of the included studies underscores the cross-cultural variability in health policies, societal norms, and maternal expectations—factors that significantly shaped mothers’ experiences of breastfeeding and MOM management.
The included studies had sample sizes ranging from 8 to 130 participants, comprising a total of 1212 mothers of preterm infants. Maternal ages ranged from 16 to 50 years, with an average in the early 30s; however, some studies did not report maternal age accurately. The gestational ages of the preterm infants ranged from 22 to 36 weeks. Most studies focused on mothers’ experiences in NICUs, where they encountered challenges related to breastfeeding, milk expression, and emotional bonding with their infants. Other health care settings represented in the studies included the neonatal intermediate care unit, mother and baby units, and neonatal units.
Most of the studies employed qualitative research designs, including grounded theory,33,73 phenomenology,35,37,46,55,66 ethnography,36,72,77 and descriptive qualitative methods.39-45,47-54,56,57,59-61,63,64,67-71,74-76,78-81,83-85 Six studies used mixed methods designs,38,58,62,65,77,82 with qualitative data analyzed separately. The most common method of qualitative data collection was individual interviews, and the data were analyzed descriptively, with results presented as themes, subthemes, or categories, supported by illustrative quotations.
Across the studies, the primary focus was on maternal experiences and perceptions of breastfeeding and infant feeding within hospital settings. A key theme that emerged was the strong association between maternal emotions and infant feeding practices. These experiences were significantly influenced by the level of support provided by health care professionals, as well as by the quality of communication and the extent of maternal involvement in their infants’ care. Further details and characteristics of the included studies are provided in Appendix IV.
The data were synthesized by extracting and qualitatively organizing the 225 findings into 11 categories, which were further grouped into 4 synthesized findings, as illustrated in Figure 2. A comprehensive list of all findings and corresponding illustrations is provided in Appendix V. Of the total findings, the majority (n = 220; 97.8%) were categorized as unequivocal, while a small proportion (n = 5; 2.2%) were classified as credible.Figure 2Meta-aggregation of findings and recommendations for practice from experiences of breastfeeding among mothers of preterm infants during their infant’s hospital stay
Synthesized finding 1 emerged from the analysis of 4 categories, which were derived from a total of 90 findings (89 unequivocal and 1 credible) from 42 studies (Table 2). The central role of mothers in breastfeeding and managing MOM is shaped by their internal mindset and perspectives on breastfeeding. These factors influence maternal decision-making, coping strategies, adaptability, and overall breastfeeding behaviors.Table Synthesis of qualitative synthesized findings, categories, and study findingsSynthesized findingsCategoriesFindings**Synthesized finding ** Mothers are central to the breastfeeding process, playing a key role in making decisions regarding the provision of breast milk for their preterm infants.**Category ** Maternal inner positivityGetting energy from the baby (U)Forming attachments (U)A beautiful bonding experience (U)For the infant’s best (U)Breastfeeding was ‘amazing’ (U)Personal motivation (U)Establishing Getting enough (U)Establishing Latching and direct breastfeeding (U)Successful breastfeeding contributes to the feeling of motherhood (U)Optimistic and confident with success in breastfeeding in the future (U)Being a mother (U)Closeness and positive feelings (U)Breastfeeding as a marker of ‘good’ motherhood (U)‘So much is taken out of your hands’ (U)Experiencing the joy of BF (U)Establishing breastfeeding is a pleasurable experience (U)Bonding with the baby (U)Creating an embodied relationship with the baby - milk expression or breastfeeding reestablished the mother-baby relationship (U)Breastfeeding is comforting and way to bond with a baby (U)Bonding/connecting through the ritual of providing milk (U)Colostrum as the first feeding and no formula feeding (C)Bonding with their babies through breastfeeding (U)Emotional connection (U)**Category ** Maternal perspective on breastfeeding and decision-makingBreastfeeding – wanting to but not always being able to breastfeed (U)Feeding: Mothers’ decision not to provide human milk (U)Altered The NICU setting and the fragile condition of the infant drastically changed their expectations (U)Mother as learner (U)Would do it all again (U)Prioritizing MOM over EHC (U)Perceptions and intentions (U)Providing breast milk is a way to identify as a mother (U)Awareness of human milk management and a willingness to adopt it (U)Milk expression providing a sense of control over the challenges (U)Having sufficient time for expression (U)Having positive perceptions of maternal breast milk and breastfeeding (U)More concerns and doubts in relation to breastfeeding (U)The extremely preterm birth and the decision to provide MOM (U)Positive perceptions of BF (U)Intentions to exclusively breastfeed the infants for six months (U)Intention to continue BF practices (U)Breastfeeding promotes physical growth (U)Breastfeeding promotes cognitive development (U)Breastfeeding offers prevention of illnesses (U)Intentions to avoid formula feeding (U)Negotiating (U)Strength of feeding goals (U)Breast milk is healthy and protective (U)Breast milk is easier to digest and for reflux (U)Directly breastfeeding makes babies ‘‘clingy’’ (U)Fear that the infant is not feeding enough because he/she is small (U)Breast milk is not sufficient (U)Mothers lack control over infants’ preference for formula or bottles (U)Mitigating complications (U)Mothers own milk as the gold standard (U)Attitudes of support and barriers for maintenance of breast milk Positive & negative (U)Believing in the benefits of breast milk (U)Breast milk benefits for premature infants (U)Breastfeeding as a cultural Mothers’ intent to initiate and continue breastfeeding (U)**Category ** Maternal coping mechanisms and adaptability in breastfeedingAdapting to preterm birth and care challenges (U)Rewarding experiences (U)Rewarding: Supporting a sense of mothering (U)Coping mechanisms (U)Understanding infants’ cues and identifying problems (U)Maintaining motivation and connectedness (U)Wanting to compensate (U)Controlling emotions (U)Matching baby’s individual pace (U)The relationship with the Producing milk (U)Increased milk supply motivated a continued expression (U)Familiarity with expression (U)Successful milk extraction reinforced the mothers’ perseverance in the activity (U)Maternal achievement of reading infant’s cues (U)Maternal feeding strategies (U)Finding ways to cope with milk expression helps mothers feel close (U)Overfeeding (U)The ‘hotel room’: The benefit of having a room (U)The ‘loss’ of the infant and the emotional chaos—‘‘putting life on hold’’ (U)The mother has to adapt to the new situation to make breastfeeding natural (U)Controlled or empowering breastfeeding experiences (U)Seeking positive affect and avoiding negative effect (U)Practice, feedback, and success (U)The paradox of providing milk and pumping (U)The maternal healing process (U)Rewards and motivation (U)Sense of purpose and pride in providing milk (U)**Category ** Maternal behaviors supporting breastfeeding and MOM managementDifferentiation of preparations before human milk expression (U)Frequency of milk expression (U)Appropriate feeding behaviors and nutrition as the supporting factors for breastfeeding (U)Enhancing the feeding situation (U)Attempting to produce enough milk supply (U)**Synthesized finding ** Mothers of preterm infants often encounter unique personal challenges in providing breast milk to their infants.**Category ** Infant health conditions influencing breastfeedingBreastfeeding care and education received by mothers from HCWs: Care related to early breastfeeding soon after birth (C)How mothers felt about breastfeeding and the given Difficulty in breastfeeding their baby at discharge (U)Feeding became ‘easier’ as mother and infant ‘got used to it’ (U)Wish to provide own Striving for breastfeeding to function (U)Infant’s labile condition (U)Infant behaviors (U)Breastfeeding is initially not a priority (U)Infant appearance, illness, and Establishment of breastfeeding was slow (U)Inadequate sucking ability (U)Tube feeding is stressful (U)Tube feeding is a necessity (U)Tube feeding delays baby’s suckling reflex (U)Establishing breastfeeding is a daunting experience (U)Latching is difficult (U)Improved suckling reflexes (U)Mothers lack control over the feeding process because of the physical immaturity of infant (U)**Category ** Challenges in breastfeeding and MOM managementChallenging experiences (U)Resolving the failure to recognize an infant’s disorganized behavior during feeding (U)The challenges of expressing breast milk (U)Individual: Describing personal stresses related to providing breast milk for the infants (U)Latching on … to the pump (U)The physical and emotional trauma of giving birth prematurely (U)Separation from their infants intensified mothers’ suffering and disrupted lactation (U)Mothers practiced embodied forms of resistance to cope with both trauma and marginalization (U)Difficult at times to sustain lactation with an ill infant in the NICU setting (U)Long-distance parenting (U)Feeding was a progressive task aimed at ‘going home’ (U)Breastmilk was ‘the biggest thing’ in hospital (U)Milk expression makes mothers exhausted (U)I was heartbroken (U)Medical and physical struggle (U)I failed to meet my expectations (U)Pumping is a full-time thing (U)I literally sacrificed nights (U)Feelings of not being good enough (U)To blame yourself when breastfeeding is not working (U)To start the breastfeeding journey — the first important drops of milk (U)Feeding was a significant contributor to stress ‘in the beginning’ (U)Breastfeeding (U)Unprepared to perform lactation due to preterm birth (U)Unnatural and challenging (U)Milk expression is frightening and frustrating (U)Immature breastfeeding behaviors took considerable time (U)Mothers’ health created the exhaustion and affected the breastfeeding (U)Milk expression was commonly performed using a breast pump (U)Milk supply (U)Reactions to the milk expression experience (U)Guilt (U)Emotional stress as the most common factor that hinders breastfeeding (U)High concerns about quantity of their own milk (U)Being overwhelmed by the challenges and feeling separated (U)Separation from baby (U)The battle to produce milk (U)My job was to make milk (U)The limitations of providing MOM in the NICU (U)The difficulties of having an extremely preterm infant (U)‘You have to do it’ – Expressing is not a choice (U)From the infants’ critical status to survival—alterations in social relations (U)Experiencing difficulties with initiating BF (U)The challenges in breastfeeding premature infants (U)A paradoxical experience (U)Maintaining their milk supply a constant worry (U)Expressing breast milk is difficult (U)The process of expressing milk was stressful and painful (U)Lack of confidence and skill to tube feed (U)Concerns that the baby will lose weight (U)Lack of previous breastfeeding experience by mothers or greater family with a preterm baby (U)Mothers have low milk supply, which is the source of tremendous stress (U)Managing competing priorities and work make it difficult for mothers to breastfeed (U)Multiples add to the complexity of breastfeeding (U)Physical and mental Medication makes it difficult for mothers to comprehend the pumping instructions (C)Distance and separation (U)Time management (U)Mothers struggled with providing sufficient human milk for the infant (U)Confronting problems of breastfeeding (U)Pumping is not the same as breastfeeding (U)Repetition, exhaustion (U)Frustration (U)Sense of loss when unable to provide milk (U)Mother–infant separation during the prolonged hospitalization (U)**Synthesized finding ** External systems serve as both facilitators and barriers to breastfeeding and MOM management.**Category ** Medical expectations and medicalized parentingScheduled parenting (U)To be both stressed by and addicted to the weighing scales (U)Institutional NICU environment (U)Focusing on weight using scheduled feedings, setting amounts of milk, and test weighing (U)Breastfeeding paradox in Risks to the infant’s health (U)Feeding regimes (U)Breastfeeding at ‘‘training-camp’’—care routines and mother–infant interplay (U)Breastfeeding at ‘training-camp’—staff mother–infant interplay (U)**Category ** Physical environmental factorsLoss of Feeling exposed (U)To feel exposed and compared with others (U)Breastfeeding support in hospitals (U)Lack of suitable and comfortable pumping rooms (U)Physical environment (U)Location and environment (U)The ‘womb’: Mother-infant bonding (U)The ‘safe corner’: Not having a private space makes the mother anxious (U)**Synthesized finding ** Comprehensive support systems enhance breastfeeding practices and outcomes.**Category ** The need for physical and emotional supportSecuring meaningful moments (U)Mothers experienced being marginalized in their infant’s NICU care (U)Skilled support was central to mothers’ positive lactation experiences in the NICU (U)Education related to breastfeeding (U)Support the mothers received from HCWs at their first time of breastfeeding (U)Needing ‘extra helping hands’ (U)Lack of support (U)Encouragement (U)To need support from the health professionals (U)Knowledge skills, breastfeeding knowledge accumulation, and skills training (U)Institutional Staff (nurses) (U)Institutional Mother as milk producer (U)Lactation support by consultant (U)Healthcare providers (U)Sharing of knowledge and experience (U)Advice and encouragement (U)Early discharge at the expense of Inadequate mental resources to be interested in breastfeeding in the hospital (U)Breastfeeding paradox in Varying nurse support (U)Breastfeeding paradox in Breast milk before breastfeeding – maintaining milk supply was difficult and burdensome (C)Breastfeeding support was ‘hit and miss’ (U)The need for support (U)The role of culture and space dependent nursing support (U)Seeking role models (U)Seeking relationships with staff (U)Medical providers provide supplies and guidance that mothers need (U)The healing properties of milk related to the infant (U)Continuously checking maternal need for lactation support to enable early recognition of lactation problems and motivate mothers (C)Early breast‑to‑mouth contact and transition to Inadequate support (U)Negative staff support (U)Hospital staff are viewed as more Perceived as racially/ethnically unbiased (U)**Category ** Essential tools and materials for breastfeeding and MOM managementDifferentiation of devices for expressing human milk (U)Insufficient knowledge and understanding (U)The need for more external support (U)Supplies and equipment (U)Maternal access to technology (U)Initiation of Inadequate information (U)Maintaining lactation with a pumping Confusing recommendation (U)**Category ** Kangaroo care for promoting breastfeedingBreastfeeding paradox in Kangaroo care under-utilized for breastfeeding support (U)The initiation of skin-to-skin contact and breastfeeding — a conformational and relational interplay (U)Total synthesized findings = 4Total categories = 11Total findings = 225U, unequivocal; C, credible;BF, breastfeeding; EHC, early hormonal contraception; HCW, health care workers; MOM, mother’s own milk; NICU, neonatal intensive care unit
Mothers of preterm infants often reported a positive mindset and emotional state regarding breastfeeding and milk expression. Many emphasized that breastfeeding, including milk expression, fosters attachment and creates a meaningful bonding experience. One mother [M]y pregnancy was interrupted early. I’m here now at the NICU. There’s not much bonding time, so I think [breastfeeding] is the best way for my daughter and I to bond.50^(p.25)^
Another mother reflected on the unique emotional experience of breastfeeding, despite using a It’s just a wonderful feeling. You pump, but the pump is the pump. But to see your child on your breast. Actually, it’s going straight to him. Actually, it’s a bonding MOMent; it’s a big step. Especially when you’re limited with what you can do with your child. It’s a good feeling.63*^(p.182)^*
Some mothers reported drawing energy from their babies, which served as a personal motivation to produce milk. They explained that this experience reinforced their identity as mothers. One mother shared her emotional shift, describing her feelings as …slowly, he got better … I couldn’t believe that my baby was breastfeeding at all … The doctor said that little by little you should start breastfeeding yourself … I was really happy that day … my mood changed a lot…. honestly, I just admitted that I am becoming a mother.33^(p.4)^
Mothers of preterm infants recognized the benefits of human breast milk. Many reported that their decision to breastfeed was influenced by the understanding that breast milk is uniquely suited to meet the needs of their infants, providing essential immunological support and contributing to improved health outcomes. One mother described her feelings of uncertainty when faced with the prospect of expressing milk. Despite her initial hesitations, the reassurance that breast milk provides optimal nourishment and immune protection motivated her decision to *When the pediatrician came to my room I was bewildered and Do I have to express milk now? I was not strong enough to try it, but when he told me that my milk was the best medicine for my infant, I automatically said yes.*70^(p.356)^
Similarly, another mother expressed her belief in the health benefits of breastfeeding, *I want to breastfeed her only rather than formula feeding her because when I breastfeed her, she can grow and prevent illnesses, she won’t get sick easily.*71^(p.9)^
Some mothers who remained strongly committed to breastfeeding continued to express their milk, even when direct breastfeeding was not feasible. These mothers resorted to alternative feeding methods, such as bottle-feeding, to ensure their infants received their milk. As one mother *Right now I am exclusively pumping, but I hope she will figure out the latch on. But frankly, I don’t care about the method of delivery; if it means I pump exclusively and bottle feed her, as long as my milk supply holds up, so be it.*44^(p.97)^
On the other hand, some mothers expressed concerns about the insufficient nutritional content of breast milk, suggesting that formula milk might offer a more adequate alternative. As one mother *I don’t think breast milk can provide enough nutrition for preterm infants. They need large amounts of nutrients to get the weight gain. But the breast milk looks pretty dilute and the color is clear. It seems that breast milk has fewer nutrients than the formula.*48^(p.3-4)^
Additionally, returning to work significantly influenced mothers’ decisions to discontinue breastfeeding or stop providing MOM to their infants. One mother shared her experience, detailing the challenges she anticipated in maintaining breastfeeding while transitioning back to Well, I was breastfeeding solidly, you know, but I recently stopped. I’m just trying to wean her onto formula because I’m going to start working and it’s going to be hard to work and pump….40^(p.75)^
Mothers of preterm infants reflected on their coping mechanisms and adaptability in breastfeeding. For many, their emotional responses were intertwined with practical strategies for nurturing their infants. One mother conveyed a sense of helplessness yet determination, All I can do for my baby is pray and pump milk.46^(p.297)^
Another mother recounted a more complex emotional journey, expressing a deep sense of responsibility and guilt. Her feelings of fault were evident, and her decision to breastfeed reflected a personal desire to make amends for what she perceived as her role in the premature birth. She Moving was the only reason I could think of. We dug many holes in the wall at that time that might have offended the God of the Foetus seriously. So, he was born early. It was me who let the preterm birth occur, so I have decided to feed him breast milk. It is a sense of compensation for me.52^(p.2525)^
One mother further articulated the connection between her physical actions and emotional healing. Pumping breast milk became both an expression of maternal sacrifice and a way to bridge the emotional gap created by her child’s early birth. As she I’m doing [pumping] for her outside what I couldn’t do for her in my womb.81^(p.363)^
Meanwhile, another mother adopted a more optimistic approach, placing her trust in the medical staff to care for her infant. This reflected an adaptive coping mechanism, where she focused on maintaining positive emotions, believing that her emotional state would benefit her child. As she I knew they [medical staff] would take good care of her so I decided to cheer up and not think about the baby’s problems. I just tried my best to express and send as much as possible. If I relaxed, my baby should feel the joy from my breast milk.52^(p.2527)^
Some mothers described their adaptability in the pumping process, viewing it not solely in terms of quantity but also as a challenge to surpass previous efforts. As one mother It almost becomes a game in your head. How much can I pump this time, how much can I get, can I get more, more, more, more.59^(p.2880)^
Mothers of preterm infants often reported specific breastfeeding behaviors and practices that reflected their personal efforts and challenges in maintaining milk production. One mother shared her experience of initial difficulty in producing milk, suggesting the role of nutrition in stimulating lactation. She When I gave birth I had no milk, but I eat porridge, with piri-piri. When I eat a lot there will be more milk.75^(p.831)^
One mother described a meticulous pumping routine driven by concerns about supply and demand, ensuring that she maintained an adequate milk supply for her infant. She I never stopped pumping my breasts even a single time because I’m worried that if my baby starts getting milk, I would have no breast milk for her… So I try to express milk every 2-3 hours to keep my milk…85^(p.226)^
Another mother further elaborated on the challenges of maintaining a consistent pumping schedule. She highlighted the logistical difficulties she faced while balancing the demands of pumping with the complexities of daily life, If I’m here, I’m constantly pumping every 2-3 hours. But if I’m at home, I tend to stretch it out longer than I’m supposed to. But that’s because I have a lot on my mind. Because I forget to take the hand pump with me places, knowing that I’m not going to be back by a certain time.63^(p.185)^
Synthesized finding 2 was identified from 2 categories that emerged from a total of 80 findings, consisting of 78 unequivocal findings and 2 credible findings, across 39 studies (Table 2). This synthesized finding highlights that mothers of preterm infants often face unique personal challenges in providing breast milk to their infants, particularly in relation to the infants’ health conditions.
Mothers of preterm infants often shared that their infant’s health instability was closely linked to delays in initiating breastfeeding. As one mother After delivery, because my baby didn’t breathe well, he was quickly taken down stairs [another ward] to be given oxygen. I delivered on Monday, so Tuesday, Wednesday, Thursday had passed. I started breastfeeding on Friday, when he was 5 days old.45^(p.4)^
Many mothers described the ongoing difficulties they encountered, particularly the lack of control over the feeding process, which was often attributed to the physical immaturity of their infants. This immaturity hindered their infant’s ability to latch or suck effectively. One mother I have to realize that she was a preemie because she will have days where she’ll forget how to suck a bottle or something that she wouldn’t immediately latch on to her bottle when it came time to feed. It was also an issue with me trying to breastfeed her. She wouldn’t immediately latch on me breastfeeding her which is one of the biggest reasons I just went straight to pumping. She was giving me a hard time with the latching on.80^(p.612)^
Some mothers discussed the necessity of offering multiple feeding methods concerning their infant’s health conditions. One mother described her approach as I give the baby both milk from the breast and milk from the cup. I cannot force her to breastfeed for a long time because she gets tired fast and stops suckling.74^(p.E53)^
However, some mothers noted that feeding was initially challenging, but once both mother and infant adjusted to the process, it became “easier.” As one mother She messed for the first few days – spit it [milk] out, didn’t really know how to swallow it. And then afterwards it got easier for me.47^(p.6)^
Mothers of preterm infants often described the emotional and physical challenges of being separated from their infants after birth. This separation caused considerable stress and made pumping breast milk difficult. Many found pumping, unlike direct breastfeeding, unnatural and challenging. One mother It’s not like waking up to a baby and having the baby there or anything. It’s just going up and hooking yourself on to a machine and not being able to see your babies because they are in the hospital and it’s just stressful.77^(p.368)^
Another mother shared a similar sentiment, emphasizing the emotional toll of pumping instead of The most challenging thing is dealing with it while your child is not here because most people who do breastfeeding have their baby latching on… But you’re latching on a pump as if you’re feeding your baby on a consistent basis, even waking up in the middle of the night acting like you’re feeding this baby.42^(p.528)^
Some mothers described significant physical and emotional challenges related to milk production, including stress over low milk supply, the exhausting process of expression, and frustration with insufficient results. As one mother I felt helpless that I couldn’t feed my daughter as I wanted to… It was frustrating for me to pump out milk because I didn’t see the quantity I wanted, or that they expected me to take to the hospital. So I was sad to get to NICU and take out the containers because it was very little milk…41^(p.197)^
Another mother conveyed the difficult dichotomy between milk expression and direct It’s like in two parts. There’s the expressing part and all that and now there’s this part [at-breastfeeding], which is like the normal part. So it’s got, like, a really nasty bit which is the expressing all the time, … Yeah. It’s horrible. It’s alright, it’s good, but it’s, like, well, you’re going to have to do it, but … but it’s really hard.66^(p.8)^
Moreover, some mothers highlighted the physical demands of pumping, particularly during the nighttime routine. One mother recounted her experience with nighttime pumping, noting the unexpected exhaustion it When I first started again, I was tired but I wasn’t as tired, so I would literally get up, at first, every 3 hours and pump. Which, when you do that, you think, oh well, that’s great, I’ll get 3 hours of sleep and I’ll get up to pump and I’ll get 3 hours of sleep. Well it doesn’t work that way.55^(p.192)^
In addition to the challenges of pumping, some mothers reported difficulties transitioning to direct breastfeeding, particularly due to the pain experienced in the early stages. One mother described the pain as *Breastfeeding is painful, I feel a lot of pain. It is very painful to breastfeed … I was happy to be expressing, but now that she is breastfeeding directly, it is very painful.*71^(p.6)^
Meanwhile, another mother expressed joy in breastfeeding despite the I have joy when breastfeeding although it hurts because my breasts are engorged; I wish he was grown enough to suck better, I would be happier.37^(p.153)^
Synthesized finding 3 was identified through 2 categories, which were analyzed from 16 unequivocal findings from 13 studies (Table 2). External systems, including the expectations of medical professionals and the physical and social environments, influenced mothers’ experiences during the breastfeeding process and their efforts to provide milk for their sick infants. These factors collectively played a significant role in either facilitating or obstructing the breastfeeding process.
Mothers of preterm infants often faced overwhelming expectations that combined medical protocols with their parenting instincts, leading to stress and disempowerment. They navigated both the emotional challenges of having a premature baby and rigid, time-bound breastfeeding practices. One mother’s account starkly contrasted the emotional reality of childbirth with the immediate breastfeeding activities she I hadn’t yet seen my baby when they came to my room with a breast pump… and I didn’t even know if he was alive, but they said it’s good if you get started and pump now.34^(p.978)^
Feeding schedules often disrupt the natural rhythms of mother and child. One mother explained how rigid time constraints hindered her bonding with her infant during It felt like he was allowed to breastfeed but the clock ruled so much. I had to put him to the breast a quarter of an hour before feeding time and then I had a quarter of an hour to hurry him and trying to get him to feed. There wasn’t any tranquility. And then perhaps thought it was odd that he only took 15 (ml). It was hard doing it against time.73^(p.77)^
As medical requirements intensified, mothers were also required to closely monitor and measure their infant’s intake. One mother expressed anxiety about balancing the transition from tube feeding to breastfeeding while ensuring her infant received enough However, it became a bit harder when he started to breastfeed a lot instead of using the tube and I needed to estimate how much he sucked in for himself so that the amount of compensation was right. We weighed him, before and after every meal. This was a bit annoying and stressful, and I became totally absorbed in the scales, and started thinking how we could weigh him at home because you could not borrow one.51^(p.27-8)^
Mothers of preterm infants often faced challenges navigating public spaces, where breastfeeding was often exposed to a constant flow of medical staff and visitors. This lack of privacy created emotional and social barriers. One mother described her Initially, I thought the nursing room might be similar to that in the mall, but later I noticed it was at the end of the aisle with a small table and sofa, even without a door. The hospital was extremely crowded. Despite my embarrassment, I had to breastfeed my hungry baby.49^(p.7)^
Another mother highlighted the lack of designated, private spaces for pumping or breastfeeding, In the NICUs, there was no peaceful location, nowhere that a mom can feel safe and secure. In [university hospital], the pumping machine was in the parents’ recreation room, and if someone was already occupying the room, you had to a) ask that person to move to another area, b) watch the room until it becomes vacant, or c) leave and endure having swollen breasts.61^(p.113)^
However, not all mothers shared negative experiences. Some NICU environments were more supportive of breastfeeding and milk-pumping needs. One mother described a positive …The NICU is wonderful. It’s quiet. They give you your space if you’re pumping…63^(p.183)^
Additionally, some mothers noted the emotional benefits of pumping near their infants. One mother I pump my milk next to my baby’s isolette. I’m able to look at my baby. It’s a nice moment for me, I feel very close to him.68^(p.44)^
Another mother emphasized the importance of physical closeness and bonding during feeding, highlighting the need for optimal environments within neonatal care settings to support continuous interaction between mothers and their infants. She They are lying with me so I know they get what they need. They relax more when they’re on me, in the sack [kangaroo wrapping]. But when they’re like this [in front of her] I can see them. Then it’s easier to see their signs of them being hungry. I try not to breastfeed less than every other hour. Sometimes they want to eat every hour. And sometimes, when I have put them down, they start to squirm and then I breastfeed again. In this room it’s easy to see their signals. I sit and watch them all days. This is how everyone should have it.72^(p.6)^
Synthesized finding 4 was derived from the analysis of 3 categories, based on a total of 39 findings, including 37 unequivocal findings and 2 credible findings, from 20 studies (Table 2). This synthesized finding highlights the essential role of a multifaceted support structure in enhancing breastfeeding practices and outcomes. Such comprehensive supports include maternal physical and emotional support, breastfeeding resources, and interventions designed to promote breastfeeding.
Mothers of preterm infants reported positive breastfeeding support from NICU staff, which helped them connect with their infants, boost their confidence, and overcome breastfeeding challenges. One mother shared how her nurse’s patience was crucial in overcoming *I felt like Karen is the one that needs to learn first, before I try to learn. So then last night, [the primary nurse] really worked with Karen on the nipple feedings and was so patient with her. And the nipple feedings went a lot better. Karen wasn’t stressed out and so I was able to do a lot better, too.*36^(p.73)^
Mothers also emphasized the role of positive reinforcement in maintaining their motivation. One mother recalled how encouragement from the staff, even though small victories, gave her the energy to keep *I was so happy just to get something [expressed breast milk], so they encouraged me and said I was good which was a big thing, which really gave me more energy to continue.*57^(p.2425)^
Another mother described the learning journey she and her husband experienced in understanding the value of her breast milk and the essential support they received. She *I only expressed about 5 cc at first. My husband felt embarrassed when he saw another parent bring a big bottle to the nurse. He wanted to discard my breast milk. Later, we learned how precious it was and were glad he did not waste it.*52^(p.2527)^
However, not all experiences were positive. Some mothers felt unsupported or misunderstood by the staff, which negatively impacted their breastfeeding experiences. One mother expressed her frustration when she was not allowed to breastfeed her infant, despite believing it would be *[…] In the NICU when I asked if I could breastfeed [they told me]: “No, you can’t, yet”, and I still don’t understand why. He didn’t have to drink at all. He could have just sniffed or sucked and I think I just did that at some point under my snuggle blanket. I will never forget my friend saying “Today you go there and you just DO it. It’s YOUR child, you’re allowed to do that”, and that was incredibly good, and through that he felt me somehow. To this day, I don’t understand why they weren’t open to support this concrete closeness more.*82^(p.8)^
Similarly, another mother described her experience with lactation support, which she felt was inadequate and *I didn’t really have anybody to talk to. The lactation teacher came and spoke to me, but it was like, a five second conversation. They didn’t say much to me about what to do.*84^(p.661)^
Moreover, one mother described her experience with varying levels of nurse support in the NICU, highlighting the challenges of breastfeeding *In the NICU some nurses were really sweet and supportive, but some seemed to be a little confused with the whole breastfeeding issue. I think the support is much more than just training the latch or the breastfeeding position, and I was hoping for more information especially about how to manage at home, when the baby is used to the bottle, and what kind of problems may exist and how to manage them. You are not able to ask all relevant questions in hospital when you are worried about the health of your baby and the main issue is that the baby is getting food, one way or another. In hindsight, I would have acted differently when we got home, but then, as a novice, I ruined my opportunity to exclusively breastfeed.*64^(p.717-^8^)^
Mothers of preterm infants highlighted the need for consistent and reliable breastfeeding information to navigate challenges. One mother experienced confusion due to inconsistent instructions from different nurses. She *They made diverging statements. The nurse on the ward who gave me the pump “pump every four hours, that’s enough.” And at the intensive care ward, the nurse “In any case, every two to three and a half [hours] all day”. These were just so very different statements and I was Huh? I don’t know what to do.*82^(p.6)^
Mothers of preterm infants also expressed confusion about the technical aspects of breastfeeding, such as proper milk storage. One mother shared her I don’t know what kind of human milk storage bag is suitable, where to buy it, how long can human milk be stored, and I don’t know if the baby will have other problems with this kind of human milk. I just do it depending on what others do. I would certainly appreciate professional guidance (to allay my concerns).54^(p.6)^
Essential breastfeeding tools, such as breast pumps, should prioritize availability and functionality, particularly for mothers of preterm infants who are unable to breastfeed directly. One mother commented positively on the accessibility and affordability of the pumps available to [The pumps] were all easy to get. The one I rented, the hospital provided the ones here in the NICU, and the one in mother-baby. The one from the gift shop was easy and very reasonable I think.63^(p.184)^
Mothers of preterm infants recognized kangaroo care—holding the infant skin-to-skin on the mother’s chest—as vital for supporting breastfeeding and milk production. One mother emphasized the importance of daily kangaroo care in initiating milk I believe that the daily kangarooing was really important because if the milk secretion didn’t start properly, but during kangarooing it started to flow.64^(p.718)^
Another mother emphasized the importance of skin-to-skin contact and breastfeeding as a relational process. She reflected on how bringing her baby to her breast felt like a natural It (breastfeeding) felt so right. So, both kangaroo holding itself…and…but just to lay her at my breast becomes something that’s approaching the normal.73^(p.74)^
This qualitative systematic review synthesized existing evidence on the challenges faced by mothers of preterm infants with providing breast milk during hospitalization. The findings underscore the central role mothers play in the breastfeeding process, highlighting how their emotional states, perceptions, and attitudes significantly influence breastfeeding-related decisions and behaviors.
One major challenge is the immediate physical separation from the infant following birth, often necessitated by medical interventions. This separation can disrupt the initiation of skin-to-skin contact and direct breastfeeding—both of which are crucial for stimulating lactation and fostering maternal–infant bonding. Research indicates that such disruptions heighten maternal stress and hinder the development of the maternal role, which are associated with delayed onset of lactogenesis and reduced breastfeeding duration.86
In the absence of direct breastfeeding, many mothers rely on breast pumping—a practice often perceived as mechanical and emotionally unfulfilling. When milk expression proves unsuccessful, it can lead to feelings of frustration and isolation, ultimately undermining maternal confidence and motivation. Moreover, pumping is typically associated with lower milk output, particularly when not paired with adequate lactation education and support.87 Another significant barrier involves the management of expressed breast milk, including storage, labeling, and transportation within hospital settings. These logistical challenges can become overwhelming, particularly for mothers recovering from childbirth while managing additional family responsibilities. Inconsistent communication and the lack of standardized hospital procedures further complicate milk handling and may cause anxiety about the adequacy and safety of their infant’s nutrition.88
To address these challenges, targeted interventions are essential. Recommended strategies include the early initiation of kangaroo mother care to enhance maternal–infant bonding, access to hospital-grade breast pumps with hands-on lactation support, and the implementation of structured milk management protocols supported by trained staff. Emotional support interventions, such as peer counseling and parent support programs, have also demonstrated effectiveness in reducing maternal stress and supporting sustained lactation.89,90 Overall, the findings align with previous research suggesting that a strong emotional attachment to the infant and belief in the health benefits of breast milk serve as powerful motivators in overcoming breastfeeding barriers.91,92
Coping strategies such as self-regulation and seeking social support also play a critical role in helping mothers overcome breastfeeding difficulties and maintain consistent milk expression.93 Social support is a modifiable social determinant of health with a significant impact on breastfeeding outcomes.94 Partners and other family members (particularly mothers and mothers-in-law) should be included in breastfeeding education and support programs,95 especially in cases involving preterm birth. Additionally, the number of children in the household has been shown to influence the likelihood of breastfeeding preterm infants during the first 6 months’ postpartum.96 Identifying such social determinants early during hospitalization enables timely screening and the implementation of targeted support measures.
The review also highlights significant personal challenges faced by mothers of preterm infants, including lactation difficulties and psychological distress related to the infant’s medical instability. Common complications such as underdeveloped oral-motor function and low energy levels contribute to difficulties with latching, weak sucking reflexes, and early fatigue during feeding—whether direct or expressed.97 These developmental obstacles can delay the initiation and continuity of breastfeeding, compounding maternal frustration and emotional strain. These findings are consistent with existing literature emphasizing the emotional burden of caring for medically fragile infants and its detrimental effect on breastfeeding.98 Consequently, many mothers experience early cessation of breastfeeding, with evidence indicating that these challenges significantly contribute to premature discontinuation.98,99 Interventions such as occupational therapy and oral stimulation techniques show promise in enhancing oral feeding readiness and skills in preterm infants,100 thereby improving breastfeeding outcomes. Comprehensive psychological and practical support for mothers can help reduce stress and promote continued breastfeeding in this vulnerable population.
External factors, including medical expectations and the physical environment, also shape the breastfeeding experience. Institutional protocols, health care professional attitudes, and the prioritization of medical routines can influence both the initiation and continuation of breastfeeding. In settings where rigid scheduling or early formula supplementation is standard practice, breastfeeding may be inadvertently discouraged.101 In contrast, facilities where staff members are trained in lactation support and institutional policies promote practices such as skin-to-skin contact and rooming-in tend to report significantly higher breastfeeding rates.102 Environmental factors, such as the availability of private, clean, and comfortable spaces for breastfeeding, also play a crucial role. Mothers exposed to overcrowded or unsupportive environments may experience discomfort and stress, which can interfere with milk production and feeding frequency.103 Therefore, supportive institutional policies and conducive physical environments are essential for successful breastfeeding outcomes.
This review contributes to the growing body of literature on the breastfeeding challenges faced by mothers of preterm infants. It emphasizes the need for integrated, multifaceted support systems aligned with current best practices to improve breastfeeding outcomes. Holistic, individualized care—attuned to both physical and emotional needs—is essential, as standardized approaches often fall short in addressing the complexity of these circumstances. Tailored support protocols enable health care professionals to deliver more targeted and effective assistance. The breastfeeding experiences of mothers of preterm infants are shaped by a dynamic interplay of individual, relational, and systemic factors. Comprehensive support—including professional lactation consultation, family engagement, accessible resources, and timely emotional, physical, and informational interventions—can significantly enhance breastfeeding outcomes in clinical settings.
This review demonstrates several notable strengths. First, it is grounded in a large number of eligible studies (n = 53) and encompasses a substantial body of research findings (n = 225), with the majority of findings (97.8%) being unequivocal. Second, the studies included in this review exhibited critical appraisal scores ranging from 60% to 100%. Third, the studies were conducted across various countries and included diverse ethnicities and cultures. Fourth, the review team members possess extensive experience in both practice and research, particularly in qualitative research methodology, literature searching, and conducting JBI qualitative systematic reviews.
This systematic review included studies published in both English and Thai (the reviewers’ native languages) to minimize the risk of errors or misinterpretations that could arise from translating texts in languages other than those spoken by the reviewers. While translation tools can be employed, they often fail to fully capture the cultural and contextual nuances embedded in the original texts, which may influence the interpretation of key concepts. Although studies published in either language were eligible for inclusion, no studies published in Thai were included. As a result, this review includes only studies published in English, which may introduce language bias by excluding relevant studies published in other languages.
Another notable limitation of this review is that the majority of the included studies did not provide explicit statements regarding the cultural or theoretical positioning of the researchers. This absence of self-location may influence the interpretation of the research and the way researchers’ biases and perspectives shape the study’s findings. Failing to acknowledge the potential impact of researchers’ positioning could undermine the dependability of the studies, ultimately affecting the ConQual scores.
A further challenge related to the context of the included studies. Some explored mothers’ breastfeeding experiences with preterm infants across various settings, including post-discharge care and breastfeeding at home. This presented a limitation for our analysis, which focused specifically on maternal breastfeeding and the provision of MOM during the infant’s hospital stay. To address this, we carefully reviewed each data extract to ensure that only quotations and findings directly relevant to the hospital context were included. This selective approach was essential to maintain contextual consistency and uphold the integrity of the thematic analysis.
This review examines the challenges faced by mothers of preterm infants in relation to breastfeeding and the management of MOM during their infants’ hospitalization. The findings are consistent with existing literature, which demonstrates that mothers of preterm infants often encounter significant breastfeeding difficulties due to the premature birth of their infants, leading to various health-related concerns. These challenges underscore the need for comprehensive support to assist mothers in overcoming such barriers. Furthermore, the review highlights the importance of an individualized approach to care in promoting successful breastfeeding practices among these mothers. While the review provides a thorough evaluation of the methodological quality of the included studies, there is considerable variation in study quality. It is also crucial to acknowledge the potential for language bias, arising from the limitations in the eligibility of languages other than English and Thai.
The following recommendations for practice have been developed based on the review findings and graded either A (strong) or B (weak) based on JBI’s grades of recommendation104: Health care professionals across various maternal and child health settings should assess mothers’ perspectives on breastfeeding, especially among mothers with an increased risk of preterm birth (Grade B).Health care professionals should emphasize the significant benefits of providing MOM to vulnerable infants, foster positive breastfeeding experiences, and encourage mothers to develop a strong intention to supply their own milk for as long as possible (Grade B).Health care professionals should assess the specific challenges faced by mothers of preterm infants, recognize their unique needs, and provide tailored support in promoting breastfeeding or managing MOM for hospitalized infants (Grade B).Health care professionals should adopt a flexible and individualized approach to breastfeeding practices and ensure the availability of appropriate spaces and resources for breastfeeding in health care settings (Grade A).Health care professionals should develop specific breastfeeding support guidelines to ensure that all individuals adhere to establish standards for promoting breastfeeding within clinical care settings (Grade A).Health care professionals should prioritize the integration of kangaroo care within clinical care settings, ensuring their contextual appropriateness to support breastfeeding (Grade A).
Future research should explore the breastfeeding experiences of mothers of preterm infants across diverse contexts, including home and community settings. It is important to examine how family dynamics, cultural influences, and community support systems influence breastfeeding challenges and outcomes. Identifying context-specific barriers and facilitators can inform the development of targeted, evidence-based interventions. Mixed methods studies are recommended to capture the depth of maternal experiences while also quantifying the impact of specific approaches. Research should also focus on strategies that enhance both immediate and long-term breastfeeding outcomes. These may include technical guidance on milk expression and storage, emotional and psychological support, infant care education, and sustained access to skilled lactation resources.
Kanokon Chaiyarat, health research librarian at the Faculty of Medicine Ramathibodi Hospital, Mahidol University, for her valuable assistance and insightful feedback on the development of the search strategy.
TS made significant contributions to the conception of the qualitative systematic review. TS and DK contributed to the screening and critical appraisal processes. All authors were involved in the extraction of qualitative data, development of thematic categories, and synthesis of findings. TS drafted the initial manuscript and organized the results tables. All authors reviewed and revised the manuscript, and approved the final version prior to submission.