The struggles of breastfeeding mothers of preterm infants: a qualitative study

Abstract

Background

Breast milk, with its rich bioactive components and numerous maternal and infant health benefits, is globally recommended as the ideal food for babies, especially premature infants. With the elevated incidence of premature births, suboptimal breastfeeding rates are detrimental, especially considering numerous efforts to promote breastfeeding. The reasons for breastfeeding cessation remain unclear. This study utilizes the social-ecological system theory to explore reasons for the cessation of breastfeeding among mothers of premature infants in China.

Methods

An interpretive phenomenological research design was implemented in Wuhan. Through purposive sampling, 14 mothers of premature infants who had discontinued breastfeeding were recruited in Wuhan, China. Semi-structured interviews were conducted to collect data guided by an interview outline developed by the theoretical framework. Content analysis was applied to analyze the interview data.

Results

The overarching theme of this study was: “On the journey of breastfeeding, who will hold up the sky for me?” This theme encapsulated the multifaceted challenges faced by mothers before discontinuing breastfeeding and their urgent need for comprehensive support. For these mothers, breastfeeding represented not only a physiological challenge but also a significant psychological and emotional burden. The analysis identified three primary categories: Microsystems—the challenges of breastfeeding and adaptation barriers; Mesosystems—dysfunctional support systems within families and hospitals; and Macrosystems—insufficient social support systems.

Conclusions

Mothers of premature infants experienced weakened breastfeeding support systems, highlighting the need for (1) Enhancing psychological support and targeted breastfeeding guidance for mothers of preterm infants; (2) Establishing an evidence-based, coordinated support system that integrates hospital and family networks; (3) Strengthening monitoring and enforcement mechanisms for birth policies, enhancing breastfeeding facilities in public spaces, and improving the capacity for breastfeeding education and promotion within communities.

Background

Globally, around 13.4 million preterm births occur each year, with approximately 750,000 (6.1%) of these in China [1]. Premature infants are prone to experience impaired organ development leading to complications like neonatal sepsis [2]. Though breastfeeding is widely considered as the optimal food for infants based on numerous positive effects for both premature infants and their mothers [3,4,5,6], the current status of low breastfeeding rates among premature infants worldwide is concerning, (e.g., Vietnam,24.3% [7], in 2014; England,34% [8], in 2017), specifically exclusive breastfeeding rates [9].

In China, the exclusive breastfeeding rate at six months stands at only 29.5% [10], which indicates that less than one-third of infants receive only breast milk without the introduction of complementary foods or liquids. This prevalence remains significantly below the World Health Organization’s target of achieving a 50% exclusive breastfeeding rate by 2025 [11]. Moreover, breastfeeding rates for premature infants in China at various milestones (1, 3, 6, 12, and 24 months) fall significantly below this target [10, 12]. This low rate of breastfeeding is closely related to the management practices of neonatal intensive care units (NICUs). In China, 75.5% NICUs are not yet fully open to the families of infants, and 60.4% of NICUs have not yet implemented family participatory nursing, resulting in maternal-infant separation [13]. Additionally, breastfeeding poses risks as most women’s milk contains cytomegalovirus(CMV), which can harm newborns [14]. Statistics indicate that CMV seroprevalence is highest in South America, Africa, and Asia, reaching up to 90%, and lowest in Western Europe and the United States, at approximately 40–60% [15, 16]. Globally, in women of childbearing age, CMV seroprevalence is 86% (95% UI: 83–89) [17]. In China, however, the CMV seroprevalence was up to 98.11% [18]. While pasteurization can mitigate this risk, its implementation in some Chinese hospitals remains limited, complicating breastfeeding promotion [13, 14].

Breastfeeding preterm infants have significant clinical benefits. However, many mothers discontinue breastfeeding prematurely, limiting the health advantages for their infants. Research indicates that although most mothers of preterm infants can start breastfeeding during the hospitalization of their babies, the rate of exclusive breastfeeding drops sharply within 4 to 8 weeks postpartum, and the proportion of mothers who completely cease breastfeeding can reach 50% or more within 3 to 6 months after discharge [19]. The factors contributing to breastfeeding cessation among mothers of preterm infants are multifaceted, primarily involving challenges related to lactogenesis, neonatal conditions, maternal health, psychosocial experiences, and lifestyle, with lactation difficulties being the most commonly reported reason [20]. Dependence on expressed breast milk and supplementation with formula during NICU hospitalization may undermine maternal belief in breastfeeding [21, 22], and inadequate professional lactation support may prevent some mothers from mastering the techniques required to sustain milk production and transition to direct breastfeeding. This further increases the risk of breastfeeding discontinuation.

Various measures have been implemented worldwide to improve breastfeeding rates, such as providing proactive telephone-based support from peer volunteers and offering antenatal breastfeeding education [23, 24]. However, most interventions focus on enhancing the mothers’ breastfeeding self-efficacy to improve both the exclusivity and duration of breastfeeding [25]. Yet, sustained breastfeeding is influenced not only by maternal behaviors but also by various societal and environmental factors. Focusing solely on modifying individual behavior cannot fully integrate the latest research into breastfeeding interventions, which thus neglects crucial predictive factors. Utilizing a sound theoretical framework aids in implementing interventions comprehensively and multilaterally, thus promoting breastfeeding [25].

The Social-Ecological Systems Theory is a theoretical framework that examines the dynamic interactions between human behavior and the social environment. This theory underscores the bidirectional influence between individuals and their social contexts, conceptualizing the social environment as a complex, multi-layered ecosystem. The system can be categorized into three levels: Microsystem, Mesosystem, and Macrosystem. The Microsystem encompasses immediate environments that directly affect individuals, such as nutritional knowledge, demographic characteristics, and physiological factors. The Mesosystem involves the interconnections between Microsystems, including family dynamics, peer relationships, educational settings, and workplace environments. The Macrosystem comprises broader societal structures and influences, such as policies, media, cultural norms, and community contexts [26]. The decision of mothers of preterm infants to discontinue breastfeeding is shaped by multifaceted factors. The Social-Ecological Systems Theory situates this behavior within its relevant social contexts, enabling multilevel analysis to systematically and comprehensively elucidate contributing factors. In contrast, other theories like the Theory of Planned Behavior or the Health Belief Model predominantly focus on individual cognitive perceptions and behavioral intentions, often overlooking the interplay of environmental and societal factors [27]. Consequently, this study adopts the Social-Ecological Systems Theory to uncover the complex determinants underlying breastfeeding cessation among mothers of preterm infants. Through this approach, we aim to propose holistic and effective strategies to improve their breastfeeding experiences.

Thus, based on the social-ecological system theory, this study adopted a qualitative design. We specifically explored the reasons for breastfeeding cessation among mothers of preterm infants discharged from the NICU hierarchically. This design aids in providing more targeted solutions to improve breastfeeding rates among premature infants.

Methods

Study design

The study employed an interpretive phenomenological research framework to examine the phenomenon of breastfeeding cessation among mothers of premature infants. Qualitative data was obtained through semi-structured interviews and subjected to content analysis [28, 29].

Study setting

The study was conducted in a comprehensive tertiary care hospital, which is also a certified Baby-Friendly Hospital. Its NICU admits approximately 1,000 patients annually and serves as Wuhan’s neonatal emergency transport center, covering Hubei Province and nearby regions. Despite its Baby-Friendly designation, many preterm infants in the NICU cannot be breastfed due to several factors. To support breastfeeding, the NICU implements practical measures, such as kangaroo care when feasible and regular maternal education on breastfeeding. However, challenges remain, including: (a) The closed monitoring system that limits mother-infant contact; (b) Medical conditions, such as maternal infections or chronic illnesses, that may contraindicate breastfeeding; (c) Logistical difficulties in delivering breast milk for mothers living far from the hospital; and (d) The absence of a breast milk bank, leaving infants without access to donor milk.

Participants

Purposive sampling was used in this study. Recruitment for this study commenced 3 to 12 months post-discharge of preterm infants. All of the participants in the interviews were mothers of preterm infants discharged from the NICU. Collectively, they had stopped breastfeeding their infants within the first 12 months at the corrected age. Potential participants were identified through the NICU follow-up WeChat group and contacted via WeChat, a widely used social media and messaging application in China, which supports voice and video calls, enabling convenient and real-time communication. This facilitated introducing the purpose and main content of the study while informing them that participation was voluntary. Inclusion criteria were as follows: (1) Mothers of singleton preterm infants with a gestational age between 29 and 37 weeks. (2) No contraindications to breastfeeding, such as active tuberculosis infection, receiving radioisotope diagnosis or treatment. (3) No apparent language communication barriers. Exclusion criteria included a history of severe mental illness. The sample size was determined by achieving information saturation, ensuring no new themes emerged. A total of 14 mothers of preterm babies who had stopped breastfeeding were recruited to participate in this study. The study was approved by the hospital ethics committee (WDRY2023-K041). Informed consent was obtained from all the respondents in this study.

Data collection

Semi-structured in-depth interviews were conducted to collect data. Interviews were conducted via WeChat voice call. Data was collected from June 2023 to December 2023. Prior to the interviews, the study purpose, significance, methodology, and duration of the interview were explained to the respondents, ensuring confidentiality and anonymity. Consent for recording and other matters was obtained from the mothers of preterm babies. Participants were reassured that their access to healthcare guidance services would not be affected, regardless of their participation in the study. To prevent potential problems with network connectivity, it was decided that participants should conduct a pretest of their internet connection. Additionally, interviewers were required to transcribe the data into written format within 24 h of completing each interview. The duration of interviews ranged from 25 to 60 min and were scheduled at a mutually agreed time according to the mothers. To keep identities anonymous, every participant was assigned a code (N1-N14). The interview environment was quiet and free from disruptions. Throughout the interview, the researcher listened attentively, encouraged open expression of feelings and experiences, and adjusted questioning methods as needed. Non-verbal behaviors, such as tone of voice and emotions, were also noted. Probing questions were used, such as “Can you provide more detail?” and “How do you feel about that?” After the fourteenth interview, data saturation was achieved since no new data emerged, leading to the conclusion of data collection.

The interview guide for this study was developed using the socio-ecological system theory as a conceptual framework. This theory guided the design of questions to explore the multi-level factors influencing the breastfeeding experiences of mothers of preterm infants. Micro-level questions focused on mothers’ personal experiences, emotional responses, and challenges. Meso-level questions examined the role of family support, healthcare providers, and social networks. Macro-level questions addressed societal and policy-level factors, such as workplace policies and public support systems. A comprehensive literature review informed the initial design, and feedback from qualitative research experts refined the questions. To further ensure clarity and relevance, two mothers of preterm infants participated in pre-interviews, providing insights that refined the interview guide. While the pre-test data was not included in the final analysis, their feedback helped to adjust question phrasing and improve the flow of the interviews. Additionally, the interview guide was continuously optimized throughout the data collection process, based on emerging content and alignment with the study objectives. The interview guideline is provided as an attachment in Additional file 1.

Data analysis

The audio recordings of interviews were transcribed verbatim. A primarily deductive qualitative content analysis was applied [28, 29]. The Socio-Ecological System Theory served as the primary guiding framework, offering a systematic structure to categorize and interpret the multi-level influences on breastfeeding experiences. While the deductive approach remained the dominant method, in cases where text segments did not align with the categorization matrix, an inductive approach was selectively applied to capture emerging themes that were not anticipated by the initial theoretical framework. For example, the theme “Infant Health Conditions and Maternal Emotional Conflict” reflected mothers’ intense emotional responses to their infants’ health challenges. One mother expressed deep regret upon realizing that formula feeding might have contributed to better weight gain for her baby, highlighting her persistent internal conflict and self-blame. These nuanced emotional experiences extended beyond the explanatory scope of SET, which primarily addresses external environmental influences. This dual approach enabled a more comprehensive understanding of mothers’ experiences. NVivo 12 (QSR International) was used for data management, coding, and categorization. The different domains of the Socio-Ecological System Theory (microsystems, mesosystems, and macrosystems) provided an a priori framework of categories for data analysis. The analysis process followed these key stages: (1) Familiarization: the researcher carefully read through the interview material, immersing themself in the content until fully familiar with the overall information. (2) Initial Coding: the data were analyzed line by line, with significant statements identified and subjected to open coding. For example, a statement like “I am too tired to continue breastfeeding” was coded as “maternal fatigue”. This stage was iterative to ensure all relevant information was captured. Throughout the process, the researcher maintained memos to document thoughts and reflections, which enhanced objectivity and minimized bias. (3) Application of Framework: following the initial coding, the Socio-Ecological Systems Theory framework was applied as the primary structure for categorizing the data. For instance, “lack of professional support” was categorized under mesosystems, reflecting the influence of healthcare providers, while “national healthcare policies affecting breastfeeding promotion” was categorized under macrosystems. (4) Category Development: after the initial coding, similar codes were grouped into categories and subcategories. The constant comparative method was used to refine categories by comparing new and existing codes. For example, the microsystem category titled “Challenges of Breastfeeding and Adaptation Barriers” included subcategories such as “Breastfeeding Decision Dilemmas” and " Infant Health Conditions and Maternal Emotional Conflict.“(5) Refinement and Validation: once categories and subcategories were defined, the researcher revisited the data for further refinement, ensuring that the categories were comprehensive and well-supported. Representative quotes were selected to illustrate each category.

To ensure reliability and enhance the validity of the analysis, each transcript was independently coded by two researchers. Discrepancies were discussed in regular research team meetings to reach a consensus, minimizing bias and strengthening the consistency of the findings. Additionally, debriefing sessions were conducted to ensure alignment with the coding scheme, and the codebook was refined iteratively. The research team, comprising members with diverse professional and personal backgrounds, contributed valuable perspectives that enriched the analysis. Reflective memos were maintained to document decision-making, ensuring transparency and providing an auditable trail that upheld the rigor and trustworthiness of the study. An example of the category extraction procedure is shown in Fig. 1.

Fig. 1

The category extraction process example

Results

Among the 14 mothers of preterm infants, 13 were primiparous and delivered by cesarean section, with only one having prior breastfeeding experience; nevertheless, all 14 mothers recognized the benefits of breastfeeding and expressed a desire to breastfeed. The average age of the 14 mothers of premature infants was 30.43 ± 4.89 (range 21–40 years). Among 14 preterm infants, there is an equal distribution of males and females. Of these infants, 12 ceased breastfeeding by 6 months of age, with 3 premature infants transitioning to exclusive formula feeding upon discharge from the NICU. The characteristics of the participants are shown in Table 1.

Table 1 Demographic characteristic of research participants

The final theme was “On the journey of breastfeeding, who will hold up the sky for me?” This theme was developed through three categories and eight subcategories. All categories reflect the challenges mothers encounter prior to weaning and their profound need for comprehensive support. Table 2 provides a visual representation of the theme, categories, and subcategories. The frequencies of categories are described in Fig. 2.

Table 2 Overarching categories, sub-categories and theme

Fig. 2

Frequencies of categories that describes the results of interviews

Categories

Category 1: microsystems: the challenges of breastfeeding and adaptation barriers

This category encompassed the multifaceted difficulties mothers of preterm infants encounter while attempting to establish and sustain breastfeeding. It highlighted both the physical and emotional challenges associated with breastfeeding, as well as the external factors that hindered successful adaptation. These barriers often led to heightened maternal distress, characterized by feelings of anxiety, frustration, guilt, and self-doubt. The psychological toll of navigating these challenges, combined with concerns for their infant’s well-being, further exacerbated emotional turmoil. Ultimately, this category reflected the complex interplay between maternal determination, infant health, and the surrounding support environment, which profoundly shaped mothers’ emotional experiences and breastfeeding decisions.

Breastfeeding decision dilemmas

The reasons for discontinuing breastfeeding among mothers of preterm infants were shaped by factors such as mother’s knowledge, personality traits, and the experiences of those in their immediate social network. As a result, the decision to continue breastfeeding was complex and multifaceted.

In the interviews, many mothers of preterm infants reported lacking essential lactation knowledge and childcare skills, such as proper breast pumping, milk storage, and lactation massage. Their understanding of breastfeeding benefits remained incomplete. When faced with breastfeeding challenges, they often struggled to make informed decisions, frequently focusing only on immediate or surface-level issues. Some mothers assumed their breast milk lacked nutrition when their babies’ weight gain was slow, leading them to introduce formula. When their infants showed better growth with formula, it further reinforced the perception that formula feeding was a more effective or reliable choice, reflecting a common misconception rooted in limited breastfeeding knowledge.

The feeding practices of friends, family members, or their siblings also influenced the mothers’ decisions. Positive breastfeeding experiences could encourage continued breastfeeding, while negative experiences might increase concerns or contribute to early discontinuation. Several mothers mentioned that their husbands, siblings, or even they themselves were raised on formula, making them more inclined to believe formula feeding to be an acceptable option, especially if breast-milk supply seemed insufficient. A few mothers also noted a belief that lactation ability might be hereditary. When their sisters struggled to breastfeed, they became concerned about their own capacity to breastfeed successfully.

“My mother, brother-in-law, and grandmother-in-law held her down while a lactation specialist helped with milk expression. This event left me with a terrifying impression, giving me a fear of breastfeeding.” (N8,362/7 weeks, Breastfeeding for 7 months).

Additionally, personality traits played a significant role in feeding decisions. Many mothers of preterm infants demonstrated strong autonomy in decision-making, with several stating, “I have my own opinions, and I make my own decisions.” Consequently, the decision to breastfeed often depended on the mothers’ individual beliefs and attitudes toward breastfeeding. If these beliefs were undermined, the likelihood of early breastfeeding cessation increased.

“For me now, I think it’s definitely more about what the mom wants. If you want to breastfeed, go ahead, if not, don’t.” (N11, 31^0/7weeks, Breastfeeding for 1 month).

Infant health conditions and maternal emotional conflict

The health status of preterm infants during breastfeeding was a pivotal factor influencing maternal decisions regarding breastfeeding continuation. Health complications such as choking during feeding, anemia, vomiting, pneumonia, cow’s milk protein allergy, cytomegalovirus infection, or suboptimal growth and developmental outcomes often evoked intense emotional responses in mothers, characterized by heightened tension, anxiety, worry, and uncertainty about the safety and adequacy of breastfeeding. While mothers generally acknowledged the nutritional superiority of breast milk, perceived inadequacy or potential harm may lead them to make the difficult choice to cease breastfeeding. Feelings of guilt, frustration, and self-blame were frequently reported, contributing to a significant emotional burden. This burden was further intensified by societal expectations and external judgment, fostering internal conflict as mothers questioned whether breastfeeding remains in their child’s best interest. For instance, one mother described a progression of emotions — from confusion and anxiety to profound internal struggle — when her preterm infant experienced inadequate weight gain and allergic reactions. Despite her initial determination to continue breastfeeding, unsuccessful attempts with various formulas and medical recommendations ultimately led her to transition to an amino acid-based formula. Even after making this decision, she remained deeply conflicted, as her infant showed a stronger preference for breast milk. Her experience vividly illustrated the persistent emotional turmoil and the profound sense of loss mothers may endure when the desire to breastfeed is at odds with their infant’s health needs.

“During the early period after the baby’s birth, he had difficulty gaining weight and frequently spit up milk. I felt guilty and anxious for most of the first 100 days.” (N9, 34^2/7weeks, Breastfeeding for 3 months).

Maternal struggle through relentless neonatal challenges

The closed management of neonatal intensive care units and limited support for parents in providing breast milk often led to increased formula feeding and inadequate milk supply. With limited opportunities for parental involvement, parents relied solely on phone updates from doctors to learn about their infants’ condition, which heightened maternal anxiety, further inhibiting lactation and diminishing confidence in breastfeeding. After discharge, mothers of preterm infants faced numerous challenges, including frequent nighttime feedings, diaper changes, and breast-pumping, which severely disrupted their daily routines. These difficulties led to physical exhaustion, sleep deprivation, and a sense of losing control over personal tasks, causing mothers to feel overwhelmed, emotionally low, or irritable, further weakening their motivation to continue breastfeeding. In addition, infant challenges such as refusal to latch, irregular feeding patterns, nipple pain, and blocked milk ducts intensified mothers’ distress. For many mothers of preterm infants, the complexities of breastfeeding posed significant physical and emotional strain. Conversely, a minority of mothers found breastfeeding deeply fulfilling but were unable to continue, resulting in complex emotions, including regret, sympathy for their infants, and remorse.

“I barely drift into sleep before having to commence breast pumping, which proves vexing. Furthermore, the interruption of sleep following pumping exacerbates the challenge, as just as drowsiness sets in, the cycle repeats.” (N11, 31^0/7weeks, Breastfeeding for 1 month).

Category 2: mesosystems: dysfunctional support systems within families and hospitals

This category refered to the lack of coordination in the support received by mothers of preterm infants from both their families and hospitals during the breastfeeding process. Families often provided adequate emotional and practical support, frequently indulging the mother’s thoughts and behaviors, and lacking scientific guidance and objective advice. Such unprincipled support could reinforce the mother’s tendency to abandon breastfeeding when faced with difficulties, ultimately leading to early cessation of breastfeeding. In contrast, hospital support was markedly insufficient, including shortages of equipment, limited knowledge dissemination, and the absence of relevant policies. This lack of support prevented mothers from receiving the necessary guidance and assistance, leading to feelings of isolation, frustration, and self-doubt, significantly hindering the successful initiation and continuation of breastfeeding. This category underscored the critical role of systematic and coordinated support in promoting positive breastfeeding experiences and safeguarding maternal mental health.

Inadequate hospital management and support

Inadequate hospital management, including insufficient breast milk storage facilities, poor coordination of maternity and infant care, and lack of postpartum support, directly impacted the breastfeeding journey of mothers with preterm infants. Such issues could delay milk storage, disrupt early bonding, and lead to mother-infant separation, all of which hindered successful breastfeeding initiation. Furthermore, dissatisfaction with paediatric consultations often left mothers feeling unsupported and uncertain about their ability to continue breastfeeding. For instance, one mother reported receiving no substantial guidance despite expressing concerns during consultations. Collectively, these factors increased the likelihood of breastfeeding discontinuation.

“I lacked the means to store breast milk initially, as the hospital lacked suitable conditions, resulting in my husband consuming it.” (N1, 30^6/7weeks, Breastfeeding for 1 week).

Medical professionals played a pivotal role in the breastfeeding practices of mothers with preterm infants. Although all preterm mothers wished to breastfeed, healthcare providers often recommended postponing breastfeeding to safeguard the health of both mother and infant. Consequently, some preterm infants were fed formula during hospitalization. Many mothers expressed a need for greater support from healthcare professionals to facilitate their adjustment and success with breastfeeding. However, when breastfeeding issues arose, immediate access to expert guidance was often unavailable, as consultations were typically scheduled in advance. Consequently, mothers frequently turned to online resources or sought assistance from peers and “cuirushi” (non-professional lactation consultants). Yet, the abundance of online information complicated the identification of appropriate solutions, and the scientific reliability of these resources was often uncertain. These challenges further exacerbated the breastfeeding journey for mothers of preterm infants.

“During my hospitalization in the gastroenterology department, where I underwent fasting and received intravenous antibiotics, all the expressed breast milk was discarded under the explicit instruction of the doctor.” (N4, 30^6/7weeks, exclusive formula feeding).

Family support and attitudes

The families of preterm infants provided significant psychological and physical support, aiding mothers in postpartum recovery and enhancing their confidence in making breastfeeding decisions. This support exerted a dual influence on breastfeeding outcomes.

Husbands, in-laws, and parents shared childcare and household responsibilities, making infant care a collective family effort. While mothers primarily focused on the baby’s care and their own well-being, family members handled tasks such as cleaning, cooking, and laundry. Some husbands also assisted with nighttime duties, including diaper changes and soothing the infant. Families with sufficient resources may hire postpartum doulas and breastfeeding consultants to support both the mother and infant. Such assistance helped mothers maintain a positive emotional state, equipping them with the energy necessary to successfully practice breastfeeding.

“Following nighttime breastfeeding, her husband assumes responsibility for cleaning and sterilizing the breast pump, in addition to assisting with household tasks, with further support from in-laws.” (N8,36^2/7weeks, Breastfeeding for 7 months).

However, family attitudes toward breastfeeding were generally neutral. Families neither strongly advocated for breastfeeding nor opposed it. If the mother had sufficient milk, they supported breastfeeding; otherwise, they did not exert pressure. Their primary concern was the health of both the mother and infant. When the mother’s health was compromised or the infant experienced feeding difficulties, family members—particularly older caregivers—perceived these as risks and recommended discontinuing breastfeeding. Some mothers reported that their husbands would support the decision to stop breastfeeding, prioritizing the mother’s well-being.

I weaned upon my mother’s recommendation, as she observed diminishing milk supply resulting in inadequate infant nutrition and choking incidents during feeding.” (N6, 35^3/7weeks, Breastfeeding for 1 month).

This ample support empowers mothers of preterm infants who are committed to breastfeeding to continue with greater confidence and perseverance, whereas for those with uncertain beliefs in breastfeeding, it may hasten the cessation of breastfeeding.

Category 3: macrosystems: insufficient social support systems

This category addressed the lack of a robust external social support network for mothers of preterm infants, which significantly impaired their ability to successfully cope with the challenges of breastfeeding and infant care. Insufficient social support included inadequate implementation of maternity policies by workplaces, limited community involvement, and the lack of support from social service agencies and relevant government policies. This deficiency in support often led to a decrease in mothers’ confidence in their parenting abilities. The absence of a strong support system exacerbated feelings of inadequacy and stress, thereby hindering mothers’ capacity to sustain breastfeeding and manage other caregiving responsibilities. This category highlighted the critical importance of comprehensive social networks in promoting maternal well-being and ensuring the successful continuation of breastfeeding.

The inadequacy of public facilities

Public transportation systems, including buses, subways, and trains, often lacked designated spaces for breastfeeding or diaper changing, posing significant challenges for mothers, particularly those with preterm infants. The absence of essential amenities, such as private nursing areas or breast milk storage options, could result in considerable stress and discomfort during commutes. Participant N8 expressed concerns about the risk of breast milk spoilage or loss of freshness when traveling without proper storage facilities. Similarly, Participant N11 highlighted the pressing need for mother and baby rooms on trains to accommodate breastfeeding and diaper changes. Although commercial complexes may offer mother and baby rooms, these facilities are frequently inadequate, typically providing only basic diaper-changing stations without essential amenities like hot water or private nursing areas. This further exacerbated the difficulties breastfeeding mothers face. The widespread lack of supportive infrastructure in both public transportation and commercial spaces not only increased maternal stress but may also contribute to the premature cessation of breastfeeding.

The implementation and improvement of maternity policies are needed

Support for breastfeeding policies in workplaces and schools remained insufficient. In the workplace, there are deficiencies in the implementation of maternity policies, with some employers failing to enforce the daily one-hour breastfeeding break, leading to the premature introduction of formula feeding or cessation of breastfeeding before returning to work. Furthermore, male leaders often overlooked the needs of breastfeeding women during this period. Despite entitlement to maternity leave, factors such as high work pressure and short break times continued to impede the promotion of breastfeeding. Several mothers highlighted the need for extended parental leave for both mothers and fathers to ensure equitable participation in childcare responsibilities. They emphasized that the societal burden of childbirth and childcare should not fall solely on families, advocating for government and corporate support in sharing these responsibilities. Additionally, participants believed that encouraging fathers to take on caregiving roles through equal parental leave could foster stronger paternal bonds and reduce workplace discrimination against women. In addition, although college students had reached the legal age for marriage, in educational institutions there was a lack of corresponding support in terms of maternity policies, including maternity leave and accommodation arrangements for students.

“It’s actually a very inhumane thing, that’s how I truly feel. My baby is now 7 months old, and this is when she needs her mom the most, but I have no choice but to return to work.” (N8,36^2/7weeks, Breastfeeding for 7 months).

Insufficient community-based breastfeeding promotion

Community healthcare workers rarely engaged in the proactive promotion of breastfeeding. Many community workers provided only basic breastfeeding guidance during home visits, such as distributing informational brochures, without offering more detailed practical guidance. This lack of thorough assistance left mothers feeling unsupported, increasing the likelihood that they would struggle with breastfeeding and, eventually, stop.

Mothers were seldom involved in community activities. They perceived community healthcare workers as lacking expertise in breastfeeding knowledge, being less prompt in addressing any related issues, and lacking contact information for the relevant personnel. Consequently, mothers were more inclined to seek advice from healthcare professionals rather than community workers when facing breastfeeding challenges. Some individual mothers of preterm infants believed that community doctors prioritized marketing postpartum care services rather than genuinely focusing on breastfeeding support. This negative perception led mothers to lose confidence in the support offered by community workers and, as a result, caused them to seek help elsewhere, including considering the possibility of formula feeding when they did not receive adequate breastfeeding assistance.

“They lack professional knowledge, and they may not even have a good understanding of pregnancy-related matters themselves.” (N4, 30^6/7weeks, exclusive formula feeding).

The theme: on the journey of breastfeeding, who will hold up the Sky for me?

The theme “On the journey of breastfeeding, who will hold up the sky for me?” highlighted the challenges faced by mothers of preterm infants when discontinuing breastfeeding and their strong desire for support from healthcare providers and society. For these mothers, breastfeeding represented not only a physical challenge but also a significant psychological and emotional burden. After enduring prolonged periods of nighttime feedings, pumping, the emotional and physical tolls of breastfeeding and concerns over their infant’s health risks, many mothers opted to switch to formula feeding due to exhaustion. This decision, often not their initial choice, stemmed from insufficient support. Throughout this process, mothers needed not only emotional support from family members and partners but also broader support from healthcare systems and society, including professional medical guidance, workplace accommodations, and assistance through social policies and resources. Such support could alleviate physical and emotional burdens, empower mothers, and help them navigate the emotional struggles associated with considering whether to discontinue breastfeeding.

Discussion

Through the narratives of mothers of premature infants, we heard their poignant plea, “On the journey of breastfeeding, who will hold up the sky for me?” This underscored the challenges they encountered in sustaining breastfeeding while caring for their preterm infants. Although prepared to bring their infants home, they did not anticipate the complexities of caregiving, particularly during breastfeeding. These mothers faced numerous hardships, including frequent nighttime care, pumping, insufficient milk supply, health issues affecting both mother and baby, and inadequate hospital and social support. Despite their persistent efforts to overcome these challenges, limited resources ultimately led them to discontinue breastfeeding. This finding aligns with the study by Brown et al. [30], which identified maternal fatigue and insufficient milk supply as primary reasons for breastfeeding cessation. Similar findings were also documented in a study of working mothers in Malaysia [31].

Our study highlighted the significant challenges faced by mothers of preterm infants during breastfeeding, which were deeply rooted in the microsystem. Mothers often experienced emotional distress and physical exhaustion, leading to dissatisfaction and early cessation, consistent with Mӧrelius et al.‘s findings [32]. Limited lactation knowledge and childcare skills further contributed to inappropriate coping strategies and misconceptions about milk supply adequacy [33,34,35]. The lack of education about breastfeeding and childcare also contributed to a sense of isolation, with mothers feeling unprepared to manage both their infant’s needs and their own emotional responses. Family influence also played a critical role, as negative breastfeeding experiences among relatives and beliefs about hereditary lactation difficulties undermined maternal confidence. Mothers who lacked confidence in their breastfeeding ability were more susceptible to external pressures and doubts, making them more likely to cease breastfeeding prematurely [36, 37]. Targeted breastfeeding education programs that involve both mothers and family members are essential to address these gaps and foster a supportive environment.

Infant health conditions were another decisive factor in maternal breastfeeding decisions. Health complications, including feeding difficulties, anemia, and poor weight gain, intensified maternal anxiety and emotional conflict. Previous research had linked maternal stress to early breastfeeding discontinuation [36, 37]. Some mothers experienced heightened distress when their infants required medical interventions or showed signs of inadequate growth. This emotional strain was further exacerbated by the absence of a consistent professional guide to help them navigate these challenges. Providing multidisciplinary support from lactation consultants, neonatologists, and mental health professionals is crucial. Counseling and peer support programs could reduce maternal distress, supporting breastfeeding continuation and enhancing maternal-infant well-being [23, 24]. Implementing family-centered care models in neonatal intensive care units may further alleviate parental anxiety and promote breastfeeding success [38, 39].

In terms of microsystems, our study found that support from both hospitals and families was a key factor influencing the cessation of breastfeeding among mothers of preterm infants. Poor hospital management—manifested in inadequate breast milk storage facilities and a lack of systematic postpartum follow-up—directly affected breastfeeding continuity. Our data indicated that these shortcomings delayed proper milk storage, disrupted early mother–infant bonding, and hindered timely access to medical guidance. For example, one participant mentioned that after her baby was transferred to the NICU due to prematurity, she missed the opportunity for early skin-to-skin contact, and because of insufficient storage conditions, her expressed milk was given to her husband. This finding aligns with Hege Grundt et al.’s report on limited skin-to-skin contact and inadequate breastfeeding support in neonatal intensive care units [40]. Furthermore, our evidence showed that clinical practices and guidance from healthcare providers were key determinants in the progression of breastfeeding for preterm infants [41]. Therefore, improving hospital resources by establishing adequate storage facilities and implementing robust postpartum follow-up mechanisms may significantly enhance breastfeeding success.

Regarding family support, our findings revealed its dual impact—both beneficial and risky—which is consistent with existing research [42]. Families often support mothers by providing emotional encouragement and sharing household responsibilities, contributing to the continuation of breastfeeding. However, they can also negatively influence breastfeeding behavior through excessive interference and family conflicts. Our study further expanded on this understanding by highlighting that unprincipled support—such as unconditionally endorsing a mother’s decision regardless of whether she chooses to continue or cease breastfeeding—without a scientifically guided framework, could negatively affect breastfeeding outcomes. Our data indicated that when family members offered excessive or unbalanced support, mothers were more likely to discontinue breastfeeding. In contrast, systematic and coordinated support between hospitals and families, based on sound scientific guidance, could bolster maternal confidence and help sustain breastfeeding. This duality was evident in the varied experiences reported by participants: some mothers received beneficial support, while others prematurely ceased breastfeeding due to excessive support. By integrating these findings with existing literature, we emphasize the critical need for a coordinated mesosystem support framework to improve breastfeeding outcomes and safeguard maternal mental health.

In regards to macrosystems, our research found that the supportive conditions in public places, workplaces, or schools were inadequate. The findings are in line with a previous study in the Philippines, which found that even though the Philippines implemented a 105-day Expanded maternity leave law included in the Expanded Breastfeeding Promotion Act of 2009, its impact on changing breastfeeding practices remains limited [43]. Mothers of premature infants long for better support as university students reaching the marriage age, insisting that longer maternity leave for themselves and their partners is needed [44, 45]. As for employed mothers, they required more rest time, a supportive work culture, and lactation facilities [44, 46, 47]. Hence, it is imperative to employ a range of strategies to bridge the chasm between breastfeeding policy formulation and the actual execution. This is crucial for the effective implementation of reproductive policies, standardizing managerial practices, and bolstering maternal confidence in breastfeeding. Subsequent research endeavors could delve deeper into gauging the degree of reproductive policy enactment. Additionally, they could assess how improving lactation facilities or breast milk storage options in public transportation affects breastfeeding decisions and practices among mothers of preterm infants.

Furthermore, our study identified shortcomings in community breastfeeding support, including insufficient promotion, limited knowledge among community workers, and poor communication with breastfeeding mothers. These findings align with previous research highlighting persistent issues in breastfeeding promotion at the community level in China, such as inadequate infrastructure, lack of professional and technical support, and insufficient publicity [48]. Research indicated that community-based, one-to-one, or group peer support can extend breastfeeding duration, facilitate earlier initiation of breastfeeding, and alleviate adverse mood [49, 50]. Future research could further explore the role of communities in promoting breastfeeding, with a focus on the following aspects: (1) Providing specialized training on breastfeeding knowledge and skills for community workers to build trust with mothers of infants. (2) Establishing effective communication channels between communities and residents to ensure timely access to relevant professionals for preterm infant mothers seeking guidance. (3) Developing comprehensive regulatory frameworks to oversee breastfeeding counseling provided by community healthcare providers, ensuring that practices are evidence-based and rigorously supervised.

Limitations

We acknowledge the limitations of this study. First, in our study, the respondents were all mothers of discharged premature babies from a tertiary hospital in Wuhan, which may not fully represent the experiences of premature mothers across China. Second, the study primarily included mothers of single or first-born premature infants, limiting generalization to mothers of multiple or second-born children. Third, this study conducted interviews after mothers of preterm infants had ceased breastfeeding, rather than during the breastfeeding period. This timing may increase the risk of recall bias, as mothers might struggle to accurately recall their experiences and the specific factors influencing their breastfeeding decisions. Finally, this study excluded mothers of extremely preterm infants from the interviews, thereby overlooking critical insights into the unique breastfeeding challenges and support needs of this vulnerable population. This exclusion also limits the generalizability of the findings to the context of extreme prematurity. Future research could encompass a broader participant pool to deepen our understanding of breastfeeding cessation among premature mothers.

Conclusion

These mothers articulated the challenges and struggles they faced in breastfeeding, as well as their expectations for broader societal support. Drawing from social ecological theory, it identifies key reasons for premature infants’ mothers discontinuing breastfeeding: (1) At the microsystem level, mothers’ breastfeeding decisions were influenced by their own perceptions and the intimate social networks around them. They faced ongoing challenges and emotional distress throughout the breastfeeding process, highlighting the critical need for enhanced psychological support and targeted breastfeeding guidance; (2) At the mesosystem level, inadequate hospital support and a lack of coordinated family assistance limited mothers’ ability to successfully breastfeed. Establishing an evidence-based, coordinated support system that integrates hospital and family networks is essential for sustaining breastfeeding; (3) At the macrosystem level, it is essential to strengthen monitoring and enforcement mechanisms for birth policies, improve breastfeeding facilities in public spaces, and enhance community capacity for breastfeeding education and promotion. Advocacy and guidance for breastfeeding should be integrated into hospital routine care and community work. Future research could focus on exploring measures to encourage hospital professionals and community workers to support breastfeeding among mothers of premature infants.