A total of 13 working mothers with different occupations, ages, educational levels, parities, times returning to work, and breastfeeding durations participated in this study. (Table 1 )
The results show that mothers built resilience while continuing to breastfeed after returning to work. The core concept was "dynamic interaction". Other categories were the background and explanation of this phenomenon. For employed mothers who continued to breastfeed, resilience involved "dynamic interaction", which started from "experiencing stressors" and "obtaining support", two factors that interacted with the individual to "stimulate resilience", which led to “behavioral resilience” during the ongoing dynamic interaction between resilience and environmental factors and ultimately led to three different "weaning outcomes". Box 1 summarizes the main categories identified in this study and the elements of each category.
Table 1
Characteristics of mothers in the qualitative study
Mothers
|
Age (years)
|
Education level
|
Number of children in the time of interview
|
Time of returning to work after birth
|
Duration of breastfeeding
|
Occupation
|
1
|
35
|
Bachelor
|
2
|
6m
|
10m
|
Pediatric nurse
|
2
|
29
|
Master
|
1
|
1m
|
10m
|
Nurse intern
|
3
|
38
|
Bachelor
|
2
|
5m
|
13m(1st)
18m(2nd)
|
Policewoman
|
4
|
39
|
Bachelor
|
2
|
6m
|
14m
|
Maternity nurse
|
5
|
34
|
Associate
|
1
|
8m
|
14m
|
Mechanical Designer
|
6
|
31
|
Bachelor
|
1
|
6m
|
18m
|
Financial Accountant
|
7
|
32
|
Bachelor
|
2
|
4m
|
12m(1st)
16m(2nd)
|
Policewoman
|
8
|
42
|
Bachelor
|
2
|
1m
|
9m(1st)
13m(2nd)
|
Policewoman
|
9
|
35
|
Master
|
2
|
4m
|
18m
|
Policewoman
|
10
|
29
|
Master
|
1
|
7m
|
17m
|
University Teacher
|
11
|
38
|
Master
|
2
|
10m
|
11m(1st)
16m(2nd)
|
University Teacher
|
12
|
30
|
Bachelor
|
1
|
6m
|
15m
|
Primary School Teacher
|
13
|
39
|
Bachelor
|
2
|
6m
|
13m(1st)
18m(2nd)
|
Deputy Chief Physician
|
Note: The ‘m’ in the table refers to ‘months’ |
Box 1 Summary of the categories of the study
Dynamic interaction
|
Experiencing stressors
|
Personal pressure: dual role, relapse of old condition and dwindling of milk
External pressure: family and social doubt, lack of spousal support, distance and economic pressure
|
Obtaining support
|
Self-support: began to learn and confidence in milk production
Family support: the importance of maternal grandmothers
Workplace support: peer understanding, a reduced workload, and external support
Role models: family members, colleagues, internet acquaintances
|
Resilience building
|
Traits: tenacity, perseverance, and endurance
Enhanced belief: "give the child the best" and "breastfeeding to ensure a healthy child"
Deepened understanding of their roles: a heightened sense of responsibility and natural instincts and a closer mother–child bond
|
Behavioral resilience
|
Willingness to change: "give up oneself" and began to learn new
Self-adjustment: feeding methods adjustment, milk production adjustment and schedule adjustment
|
Weaning outcomes
|
Natural weaning
Active weaning
Forced weaning
|
Experiencing stressors
For employed mothers, their social roles had changed. Being a working mother involved a myriad of new stressors and challenges, including personal and external stressors.
Personal stressors
Mothers must manage a workload while taking the time to express and store milk. The dual role, relapse of illness and dwindling of milk may lead to physical and mental exhaustion. A mother who was a nurse intern said:
"Work is busy, with many exams, and it takes long time spent to express milk.... I use an electric breast pump to express milk at work, which is time-consuming.... At 1 a.m., in early morning.... Do you know how tiring it is to breastfeed? I am very tired. It takes so much energy and time, which makes it difficult to focus on work." (TYY)
Prolonged physical and mental exhaustion caused some old conditions to relapse in some mothers, which may affect milk production and thus the willingness to continue to breastfeed.
"He is restless when hungry. After spending 2 to 3 months taking care of him around the clock, including several times at night, my cervical condition started to bother me again...." (XHZ)
"I have many stresses at work.... Milk production starts to dwindle over time, which affects my confidence and willingness to continue to breastfeed...." (LJM)
External stressors
For employed mothers, family and social doubt was the first external stressor, which caused mental stress and reflected the current lack of social support for breastfeeding in China.
"My mother-in-law often tells me that I do not produce enough milk and that my milk is water-like with too little nutrition. This causes me to doubt my ability to feed my child." (MRR)
"Sometimes when breastfeeding in public, I hear people talking about why such an ‘old’ child is still breastfeeding and why I am still not weaning my child from breastfeeding? I was very upset at these comments." (GD)
"My colleagues sometimes say, ‘why are you still breastfeeding and not weaning? It affects your work." (LJM)
Lack of spousal support was another stressor. A mother said, "My husband often says that I know more about breastfeeding than he does, as if women should shoulder all the responsibilities in raising a child" (HHT). This attitude made working mothers feel "upset and angry" (HHT). It also reflected the traditional Chinese notion that "women should be responsible for raising children".
The distance between home and work and the economic status also posed challenges to working mothers:
"At the time, my home was far away from my workplace.... I personally breastfed my child. I was busy at work, while thinking about how to rush back home to breastfeed my child. The stress affected milk production, which was the biggest challenge." (MRR)
"Given the economic problems at home, returning to work was my only option." (XHZ)
Obtaining support
Working mothers faced stressors and challenges when continuing to breastfeed, but they were also inspired by personal, family, and workplace support and role models. The level of support varied with the individual conditions.
Self-support
Some mothers began to learn about breastfeeding through maternity check-up bulletin boards, brochures, and baby products starting when they were pregnant, which helped them to “understand more about breastfeeding” (LJM), "strengthen my determination to continue to breastfeed (XHZ)", and "take action to continue to breastfeed despite being tired and even though it was time-consuming because of my desire to keep the child safe and well nourished" (TYY).
Confidence in milk production was the source of confidence and motivation for continuing to breastfeed among working mothers. "The key is having enough milk...” (TYY), and "good milk production gives me the confidence to insist on breastfeeding" (LJM).
Family support
Based on Chinese tradition, most infants are taken care of by elderly family members who live with the parents after the mother returns to work. The active participation, encouragement, and affirmation of family members help working mothers to manage stress and be confident about breastfeeding. In particular, female elders with childbearing experience can pass their breastfeeding experience to working mothers, which strengthens their confidence in continuing to breastfeed. This also reflects the Chinese culture of family and breastfeeding will pass on by generations.
"My mother and mother-in-law put aside their own family and life to support me.... I did not need to do anything except go to work and breastfeed.... They often made soups to help me produce milk." (TYY)
"Whenever I talked to her [my mother] about weaning, she would tell me that it is not good for the development or health of my child.... (LJM)"
"I am confident. She [my mother] believes in me, giving me the confidence to insist on breastfeeding...." (GY)
Workplace support
Workplace support came from peer understanding, a reduced workload, and other external support, which mitigated the negative effect of the conflict between working and breastfeeding.
An employed mother who was a teacher mentioned:
"Whenever I was absent when they did roll-call...they understood, and my boss was fine with it too. My colleagues understood that I was busy, and they were encouraging and appreciating my efforts." (GY)
A working mother who was a mechanical designer recalled:
"Unlike some other jobs that involve urgencies or emergencies, my job environment is stable...we rarely work overtime...with no particular stress."
Two workplaces had refrigerators to store breast milk (XHZ, TYY), one woman got a one-hour breastfeeding break per day (GY), and one woman’s workplace was close to home, all of which made it easier to go home to breastfeed (ZY2), made working mothers feel that their breastfeeding time was "sufficient" (GY), and made breastfeeding "simple" (XHZ).
Role models
Some working mothers looked to role models who continued to breastfeed for how to manage stressors and challenges and to become more confident about breastfeeding. These role models were family members, colleagues, or internet acquaintances.
"My sister-in-law breastfed for two years. I do not want to wean too early. I believe that I can...." (GY)
"A head nurse in our hospital breastfed for 18 months. And her children at the time were generally healthier… I admire her." (HHT)
"I followed the public account of the La Leche League International. Those children were 5 or 6 years old and were still breastfeeding. I admire that.... Whenever I have challenges, I search for what other mothers are doing, which is very helpful." (MRR)
Resilience building
Adversity inspires excellent personal qualities [21]. Employed mothers who insisting on breastfeeding after returning to work by managing stressors and obtaining support demonstrated tenacity, perseverance, and endurance, which strengthened their belief in breastfeeding and deepened their understanding of their roles, thereby building resilience.
Traits
Working mothers who continued to breastfeed demonstrated tenacity, perseverance, and endurance, which were closely related to their personal experience within their family and the personalities of their parents. When facing challenges and hardship, working mothers wanted to "persevere in whatever [they were] doing” (HHT).
"I had some challenges...during breastfeeding, but I was persistent...and resilient.... My mother taught me when I was little that no matter how difficult the situation is, I must persevere in whatever I am doing...." (YXL)
"Negative comments from others only serve to strengthen my belief and actions.... I am as stubborn as my dad, and I will persevere in whatever I want to do, regardless of whether others agree." (GD)
"I continued to breastfeed for the sake of my child.... I was working and needed to take care of sick elderly family members, but I persisted". (TYY)
Enhanced belief
Belief refers to the behavioral tendency of one’s own ideas, thoughts, and awareness, which is demonstrated as strong and unwavering conviction and trust [22]. The instinct to "give the child the best" and the pursuit of "breastfeeding to ensure a healthy child" were strengthened among the working mothers by their breastfeeding knowledge and their mother–child interactions, along with personality traits such as tenacity, perseverance, and endurance.
"I knew before returning to work that breast milk is life-giving and...precious, just like our child...." (XHZ)
"Formula is a substitute, not a necessity. The nutritional value of formula is inferior to that of breast milk.... Breast milk is derived from qi and blood.... It is healthy...." (MRR)
"When I reunite with my child after work, his dependence on me reinforces that I am very important in his life, which strengthens my belief that I must give him the best." (GY)
"I tried to feed other food to my child, but she refused even when she was hungry... She wanted my milk... She looked so helpless, and I was determined...to keep going." (MRR)
Deepened understanding of their roles
The employed mothers faced the dual stresses of work and motherhood, but their children’s dependence on them deepened their understanding of motherhood, which promoted personal growth, leading to a heightened sense of responsibility and natural instincts and a closer mother–child bond.
"After returning to work, my child was still waiting for my milk. Whenever I was back home from work, I felt that I had the obligation to take care of him... Regardless of what happens, I must leave early...and go home to breastfeed...." (MRR)
"Once I was used to work-related stress, breastfeeding became a habit, just like having meals.... It's a natural female instinct." (TYY)
"During breastfeeding, we looked at each other and time just flew. I enjoyed the experience, although it was hard sometimes." (YXL)
"I continued to breastfeed because I wanted to strengthen the mother–child bond.... I think it is difficult to guide and educate her when she gets older, if we do not develop basic intimacy between the two of us...." (LJM)
Behavioral resilience
For working mothers, resilience building was followed by behavior adjustment to manage stress in order to continue to breastfeed. This involved two phases, willingness to change and self-adjustment.
Willingness to change
Some participants who continued to breastfeed were willing to "give up oneself" (GY) to make time for breastfeeding. LJM recalled:
"... I gave up something, such as freedom...to have more time with my child...and for breastfeeding." (LJM)
Some mothers began to learn new things from professionals, such as the causes of reduced milk production and how to improve milk production, so they could plan their breastfeeding times and take actions to improve milk production.
"...I attended an online training course.... It said that breast milk is rich in nutrition and immune factors.... It promotes mother–child bonding and improves the child’s self-confidence and behavior.... I initially planned to breastfeed for 10 to 12 months. After the course, I decided to breastfeed longer...." (LJM) It also means the timely and available professional help may promote the mothers to "change" and then prolong the time of breastfeeding.
Self-adjustment
For some working mothers, self-adjustment is the manifestation of resilience in times of challenges. This includes the adjustment of feeding methods, milk production, and breastfeeding schedule. Some working mothers living far from their workplaces chose to express milk (TYY). Some had their family take their child to their workplace for breastfeeding (XHZ). Some simply adjusted their feeding methods.
"After returning to work, I expressed milk during the day. If I had time, I went back home to breastfeed my child at lunch time.... Once in the evening, once in the morning, that was enough...." (ZQ)
Some working mothers had problems with milk production, and they tried different methods to remedy the issue. XHZ and LJM tried herbs, YXL and HSJ increased their soup intake to improve milk production and confidence, and ZY1 consulted breastfeeding professionals.
In the case of any conflicts between work and breastfeeding, some working mothers talked to their bosses about a flexible work schedule. "I talked to my manager...he agreed that I may come to work at 9:00 a.m. (no later than 9:30 a.m.) ...for field work, I talked to my manager to see if someone else could stand in for me...." (LJM)
Weaning outcomes
As breastfeeding went on, working mothers continued to have new stresses as well as support. Their resilience continued to interact with environmental factors and led to new behavioral resilience to ensure continued breastfeeding. Finally, three weaning outcomes were identified such as natural weaning, active weaning, and forced weaning. The state and emotions of the mother and child varied between scenarios.
Natural weaning
These working mothers enjoyed breastfeeding and were happy about motherhood. They also believed that they met the physical and mental needs of their child after a long time of breastfeeding.
"I enjoyed breastfeeding.... I did it for 16 months before weaning naturally.... At the time of weaning, I believed that my child no longer needed my milk." (YXL)
"Milk preparation was not that hard or tiring. Weaning was natural, and I feel my child was satisfied and happy...." (ZQ)
Active weaning
As breastfeeding went on, some working mothers faced changes in workload. They wanted to resume a normal workload before breastfeeding and adopted active weaning after a time of breastfeeding. The mental needs of their child may or may not have been met.
"Work was getting busier, my child stopped gaining weight.... I had breastfed for 10 months and believed that breast milk was no longer enough to meet his needs. It was time to stop breastfeeding." (TYY)
"I wanted to devote myself to my work as soon as possible." (MRR)
"I planned to breastfeed for 12 months... Once the goal was achieved, it was time to stop breastfeeding, mission accomplished...." (HHT)
Some working mothers were "hesitant" about weaning (HHT), but they felt the stressors outweighed support. "Milk volume started to decline, nighttime was difficult, both my husband and I were tired, I decided it was time to stop breastfeeding.... Then my child was a little sick and caught a cold. I wanted to resume breastfeeding.... But my family disagreed. They said that I had stopped breastfeeding, why restart it?... My child liked to touch my nipples while sleeping. He may have unmet mental needs." (HHT)
Forced weaning
Some employed mothers continued to breastfeed for a long time and faced more stressors than support as well as forced weaning. In this case, both mother and child had unmet mental needs. For XHZ, her cervical condition worsened after returning to work, and her family opposed breastfeeding.
"You don’t have milk for the child, and he is restless... It may be better off to use formula feeding instead of breastfeeding.... I had no choice but to wean him from breastfeeding.... After weaning, whenever he saw me, he just kept crying...and wanted me to hug him." (XHZ)
"Sometimes when we went out to play, we saw other children of a similar age.... I heard others comment about a child of 18 months old who was still breastfeeding.... I felt guilty...." (XHZ)
Dynamic interaction
In this study, the core category was "dynamic interaction", which formed the resilience framework for working mothers who continued to breastfeed based on Kumpfer’s Resilience Framework. Employed mothers faced stressors and support, and their dynamic interaction with these environmental factors stimulated their inherent resilience traits, which continued to dynamically interact with the environmental factors, leading to behavioral resilience as well as three different weaning outcomes. (Figure 1)