Why do some mothers stop breastfeeding early even when they understand its benefits?
Picture a new mother on the postnatal ward. Her baby cries after a feed. A relative suggests that her milk may not be enough; another recommends formula; a nurse gives hurried advice before moving on. By the end of the exchange, the problem is no longer only technique. The mother has begun to doubt whether she can breastfeed at all. (This scenario is a composite of experiences mothers described to us, not a single case.)
That is why knowledge alone does not guarantee continuation. Mothers may understand the benefits of breastfeeding and still face pain, latch difficulties, exhaustion, uncertainty about milk supply, pressure to supplement, or contradictory advice. These experiences accumulate. Once every feed starts to feel like a test, correct information may not be enough to sustain confidence. Our work at Dr. S.S. Tantia Medical College, Hospital and Research Centre in Sriganganagar focused on those moments where confidence begins to unravel.
What made you look beyond breastfeeding knowledge and focus specifically on a mother’s confidence in her ability to breastfeed?
The shift came from a mismatch we repeatedly saw in clinical practice: mothers often knew what they were supposed to do, yet still felt they were failing. That led us to breastfeeding self-efficacy – a mother’s belief that she can breastfeed successfully – rather than knowledge alone.
We measured confidence using the 14-item Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) . In our survey of 232 women, the mean score was 46.2, and 32% scored below 47, which we classified as low confidence. Earlier breastfeeding difficulties, lower social support, depressive symptoms and first-time motherhood were independently associated with lower scores. The important point was that confidence was not simply an individual personality trait. It was being shaped, positively or negatively, by experiences, relationships and healthcare interactions around the mother.
What were the most common difficulties and concerns shared by mothers in your study, and which had the greatest impact on their confidence?
The most common concern was perceived inadequate milk supply, reported by 63% of women. Pain or discomfort was reported by 58%, conflicting family advice by 49%, latch difficulties by 41%, and feeling overwhelmed by 38%. One-third had experienced pressure to use formula, and 28% felt provider support was inadequate.
Milk-supply concerns had one of the strongest independent associations with lower confidence, while pain and latch difficulty also mattered. Psychosocial factors were important too: low social support and depressive symptoms were independently associated with lower BSES-SF scores. These findings reminded us that breastfeeding difficulties rarely arrive one at a time. A physical problem can quickly become an emotional one when it is reinforced by uncertainty, fatigue, family pressure or inconsistent professional advice.
How do family members, particularly partners and mothers-in-law, influence a mother’s breastfeeding experience in the Indian context?
Family members can be either a major source of resilience or a source of doubt. In many Indian households, partners, mothers, mothers-in-law and other elders are closely involved in the first weeks after birth. Their advice carries weight, particularly when a new mother is tired, in pain or unsure whether feeding is going well.
Supportive relatives can protect rest, encourage persistence and reinforce professional guidance. But the same influence can undermine confidence when normal newborn crying is interpreted as hunger, milk supply is repeatedly questioned, or prelacteal feeds and formula are recommended because they are familiar practices. Multi-level family influence on infant feeding is well recognised in Indian settings. In our study, conflicting family advice was common enough that counselling only the mother clearly seemed incomplete. The goal is not to cast relatives as barriers; it is to recruit them as allies.
What role can doctors, nurses, and other healthcare professionals play in building confidence rather than simply providing breastfeeding instructions?
Healthcare professionals can build confidence by changing the quality of the interaction, not simply by adding more information. A directive such as “feed more frequently” may be technically correct, but it does little for a mother who is worried that her baby is still hungry. She needs consistent troubleshooting, clear explanations of what is normal, and reassurance that an early difficulty can be worked through.
This sits comfortably within the Baby-friendly Hospital Initiative. The revised WHO/UNICEF Ten Steps already call for competent staff, discussion of breastfeeding with women and families, practical support with common difficulties and continuity after discharge . Our confidence-focused approach is not an alternative to BFHI. It is a way of operationalising those standards around locally identified barriers. In our co-design work, providers favoured short communication prompts and confidence-building language that could be used during ordinary ward rounds and discharge counselling rather than creating a separate service.
Your team developed a model combining peer support, improved provider communication, and family counseling. How would this work practically during routine hospital care?
Forty-one stakeholders – hospital staff, mothers and family members – took part in the co-design workshops. They prioritised three components. The first was peer support, with experienced breastfeeding mothers offering one-to-one encouragement to new mothers during postnatal rounds. The second was a provider communication toolkit for physicians, nurses and counsellors, using brief prompts for common problems, emotional validation and consistent troubleshooting during rounds and discharge. The third was structured family counselling, bringing in a partner, mother-in-law or other key relative to address common misconceptions such as prelacteal feeding and feeding frequency.
The family session was designed as a 15-minute format; in the micro-pilot, the median recorded time across delivered components was seven minutes per patient, with no additional staff required. Among 26 postpartum women, 88% rated the intervention acceptable or very acceptable. Mean BSES-SF scores increased from 43.8 before the intervention to 52.1 afterwards, but with a small uncontrolled pilot that change is descriptive, not proof of effectiveness.
Could this low-cost approach eventually be expanded to other hospitals and communities across India, and what further research is needed before that can happen?
Potentially, yes – but the part worth scaling is the process, not necessarily an identical package. The barriers in Sriganganagar will not be the same as those in a metropolitan private hospital, a rural district facility or a community programme. Staffing, family structures, local beliefs and access to post-discharge support all differ.
A more useful model is to identify where mothers are losing confidence, measure which barriers matter locally, bring mothers, families and healthcare workers together, and design support around clinical touchpoints that already exist. One setting may need peer support; another may need more consistent bedside counselling, stronger antenatal family engagement or better follow-up after discharge.
The next step is larger, controlled and preferably multi-centre research. We need to know whether these approaches produce sustained improvements in confidence, exclusive breastfeeding and breastfeeding duration, whether benefits persist after discharge, and what adaptation and resources are required in different settings. If those questions are answered, a low-cost, locally co-designed model could have relevance well beyond a single hospital.
