Breastfeeding challenges among Thai adolescent mothers: hidden breastfeeding discontinuation experiences

Purpose –The purpose of this studywas to explore the experiences of adolescent mothers whowean their babies from breastfeeding before the first six months from the perspective of a psychosocial aspect in the Thai context. Design/methodology/approach – A descriptive qualitative design was applied to this study to obtain meaningful data. The adolescent mothers for the primary study and nine supplementary participants were recruited from the largest university hospital in Bangkok, Thailand. Semi-structured in-depth interviews were conducted with 20 adolescent mothers. Descriptive statistics and content analysis were used for data analysis. Findings – The average breastfeeding duration was 3.1 months while breastfeeding exclusively lasted 1.3 months. More than half of the adolescent mothers encountered breastfeeding problems at hospitalization including sore/cracked nipples (63.6%), one side breastfeeding (27.3%) and exhaustion (9.1%).According to the content analysis, (1) breastfeeding obstacles concealed by the adolescents’ dependence and (2) repetitive emotional mistakes encountered were the two main themes that emerged. Originality/value – The influence of key family members plays a vital role in breastfeeding and psychological outcomes. Therefore, family-adolescent support programs including support from the adolescents’ mothers and grandmothers may improve breastfeeding outcomes, yield positive emotions and enhance maternal attachment. Moreover, healthcare professions are important mediators to convince adolescent mothers’ key family members to reach an agreement and provide suitable support.


Introduction
Globally, 38% of infants under six months are exclusively breastfed, while the global target is at least 50% [1]. Thailand is the lowest-ranking country in the Asia/Pacific region for Breastfeeding challenges in Thai teen mothers exclusive breastfeeding in the first six months of life, where, in 2016, only 23.1% of Thai infants were exclusively breastfed [2]. Most women who are unable to achieve this endorsement continue to silently promote breastfeeding in society. Maternal age is strongly associated with suboptimal breastfeeding practices [3,4]. Many adolescents complain of difficulties encountered in breastfeeding experiences such as lack of skills, inadequate support, lack of freedom, embarrassment and returning to study/work [5,6]. Adolescent mothers may have difficulties as new parents facing unanticipated stress, especially if the pregnancy was unplanned. Mothers in this group tend to exhibit more emotional distress and stress with lower levels of maternal adjustment, self-esteem and less adequate coping skills [7].
Successful exclusive breastfeeding can provide young mothers with a sense of accomplishment in the maternal role. Biologically, breastfeeding increases the release of several hormones including oxytocin, prolactin and cholecystokinin. These hormones promote maternal behavior and act synergistically to reduce stress by increasing relaxation [8]. On the other hand, the scientific evidence shows that women who do not breastfeed or rapidly stop breastfeeding experience many negative emotions with feelings of anger regarding excessive pressure to breastfeed, a sense of guilt, failure and shame [9,10]. When mothers decide to stop breastfeeding, they may suffer from blame, feelings of failure and a sense of not being good mothers [9]. This group of mothers often wean their infants from breastfeeding early in the face of emotional challenges influencing their maternal identity and role attainment.
Nevertheless, few studies have been conducted to explore the complex experiences of adolescent mothers who breastfeed for less than six months from a psychosocial perspective in the context of promoting breastfeeding through national policy and social media in Thailand. It is important to understand the hidden dilemma among this vulnerable group to prevent and reduce negative breastfeeding experiences. This will be essential for developing a sensitive program to help teenage mothers reconcile their developmental role with motherhood. This study aimed to explore adolescent mothers' experiences when they stopped breastfeeding before the first six months from the perspective of a psychosocial aspect in the Thai context.

Design
In the initial study, a qualitative approach was used. Data was collected and analyzed using a descriptive qualitative design [11]. The initial study allowed the researcher to identify important themes regarding Thai adolescent mothers' viewpoints on their infant feeding and breastfeeding experiences [12]. During data analysis, new insight was gained from the adolescent mothers' words expressing their short-term breastfeeding experiences leading to negative emotional outcomes. The supplementary secondary analysis involved a more indepth focus on emergent issues or unaddressed aspects of the data from the primary research [13]. Eleven adolescent mothers shared their experiences and sub-setting transcriptions were submitted to a second analysis. In addition, a descriptive qualitative design was conducted to saturate qualitative data through in-depth interviews with an additional nine adolescent mothers to collect meaningful data on discontinuing breastfeeding experiences.

Recruitment and participants
The adolescent mothers of the primary study and nine additional participants were recruited from the postpartum units of a university hospital in Bangkok, Thailand, which serves nearly 1,000 adolescent mothers each year. Purposive sampling was used to select the participants without coercion. The sample consisted of adolescent mothers aged 15-19 years who were first-time mothers with full-term infants aged six months, breastfeeding experience and JHR ability to understand and speak the Thai language. Based on the objective, adolescent mothers who were able to breastfeed for six months were excluded from this study. Eleven verbatim transcriptions were analyzed for a second time by using supplementary analysis working together with the new in-depth interviews with the additional nine participants. All participants' demographic data was demonstrated in Table 1 while breastfeeding information was provided in Table 2.

Data collection
Data were collected with face-to-face semi-structured in-depth interviews in two periods including a primary study from April to May 2016 and an additional study from February to March 2018. An interview guide was used to elicit infant-feeding experiences from Thai adolescent mothers at six months postpartum. Each participant was interviewed by appointment and permission to have audio recordings during the interview was sought.
A two-part research instrument developed by the researcher based on the literature reviews was used including 15 close-ended demographic questions and 14 open-ended questions. Fourteen questions consisted of introductory, transition, key and ending questions [14] that focused on the infant feeding experiences in an interview lasting 45-60 minutes. For example, key questions were, "Could you tell me about your breastfeeding experience?" "What difficulties did you experience in breastfeeding?" In addition, probing questions could be asked as open-ended or specific questions within emotional challenges resulting from weaning from breastfeeding. Data collection was continued until data saturation was achieved [11,15].

Breastfeeding challenges in Thai teen mothers
Data analysis Demographic data was demonstrated by using descriptive statistics including frequency, mean, and percentage. The qualitative data obtained from the verbatim transcriptions of eleven adolescent mothers who had breastfed their infants for less than six months in the primary study and saturated data was gained from the new in-depth interviews with the additional nine adolescent mothers. All qualitative data were analyzed with content analysis based on different insight for negative emotions from short-term breastfeeding adolescents. The data analysis process was started with verbatim transcription of the recorded interviews, while field notes were extracted. The data were read line-by-line and coded, highlighting the precise words from the text appearing to identify main concepts. The sorting of various categories into themes was created by a tally sheet [11]. Credibility was ensured by member checking, while dependability was applied by using the thick descriptions of transcriptions and field notes. Confirmability was conducted through audio-recordings, immediately recording in the field notes, rigorous content analysis and peer debriefing. Finally, transferability might have been limited by the ages of first-time mothers. However, the study can be replicated in a similar context or with similar participants.

Results
The following two major themes emerged from the content analysis: (1) breastfeeding obstacles concealed by adolescent dependence and (2) repetitive emotional mistakes encountered. Breastfeeding problems are demonstrated in Table 3.

Theme 1. Breastfeeding Obstacles Concealed by Adolescent Dependence
The breastfeeding obstacles in this study were related to traditional beliefs and interference in the maternal roles of adolescents from family members, particularly the grandmothers and/or mothers. Factors including living with low authority within an extended family setting, cultural norm and lack of financial autonomy. These difficulties affected their decision to stop breastfeeding early. There were two sub-themes including traditional beliefs inherited through the previous generation and taking over the maternal role by the adolescent mothers' family members.

Traditional belief inherited through the previous generation
The traditional beliefs of lactational diets and infant foods were inherited from both mothers and grandmothers based on their own experiences or some inherited beliefs. The beliefs about the lactational diet for increasing breast milk supply led to breastfeeding difficulties, anxiety about harming infant health, and the mothers' aversion to eating preferred foods, avoiding favorite foods and repeating food patterns. Seven adolescent mothers complained about the above uncomfortable feelings.
For example, one mother aged 16 years said that she received a message from her mother about foods for stimulating breast milk supply and safety for her infant. She had to reluctantly follow this advice: I have to eat stir-fried chicken with ginger and dried shredded pork repeatedly every single day. Ugh! I hate it. She [mother] forbids me from eating my favorite foods like cold water, noodles, watermelon, and bean sprouts as this will inhibit my breast milk and make my baby have a stomach ache. (Pt. 6) One mother aged 18 years described her compliance with family suggestions on eating patterns and daily activity. She had to follow her mother's advice, even though she disagreed with the traditional beliefs: I hated a lot of my mom's advice because it made my life so difficult during breastfeeding . . . I did not agree with those age-old wives' tales and illogical ideas, but I did not have any choice but to follow her. (Pt. 10) Most of the adolescent mothers (n 5 15) received traditional information about adding water to prevent infant jaundice. This study shows that 50% of the mothers added water during the first week on the advice of their family members. The adolescent mothers could not refuse them due to their dependent status and cultural norms. For example, one mother said, "Actually, I disagree with it. I know that breast milk is enough to hydrate my baby, but I have to listen to my mom. She helps me take care of my baby and everything." (Pt. 7) However, there were some precautions about older practices that might harm infant health such as adding more water with formula milk to save costs or adding more semi-solid foods to increase the baby's weight during the first six months.

Breastfeeding problems
Breastfeeding challenges in Thai teen mothers milk. However, some of the adolescent mothers perceived pressure and compliance, while others received tangible support. For example, one mother aged 17 years talked about her mother wanting to treat her baby for two months. Her mother preferred to use formula milk instead during separation, as she said: She would bring my baby into her house when she missed him . . ., but she didn't want me there. So, my breasts were going to explode due to breast engorgement at that time. (Pt. 4) However, some mothers perceived that they received support from their families. An adolescent mother aged 17 years commented that her mother-in-law helped her by taking care of her child at night, as she said: My mother-in-law has been willing to take care of my baby all night since the age of two months. Actually, she had planned it this way since I was pregnant. (Pt. 19) One mother aged 15 years explained her feelings about low self-efficacy as a mother, as she said: I understand that I'm still young; I might not be a good mother. (Pt. 5) Also, she described her grandmother-in-law's power affecting infant feeding types and maternal-infant attachment, as she said: Oh! She [grandmother-in-law] loves my baby so much. I can't bring my baby back to my room. She's been adding mashed bananas to his diet since he was a month old. I try to forbid her because my baby gets gas, but she does not believe me. More than that, my baby is not familiar with me. If I could turn back time, I would like to take care of him by myself, but it's too late! (Pt. 5)

Theme 2. Repetitive Emotional Mistakes Encountered
Negative emotions occurring from short-term breastfeeding experiences can seem like a secondary mistake after an unintended pregnancy. More than half of the adolescent mothers experienced these negative emotions after weaning their babies from breastfeeding before six months. In addition, negative emotions were related to experiencing infant sickness and reduced responsiveness to infant and breastfeeding promotions via social media. There were four sub-themes including anxiety about negative forthcoming consequences, shame, regretful memories and feeling guilty.

Anxiety about negative forthcoming consequences
The health messages of breastfeeding benefits were transferred through health professionals and some experiences that could stimulate adolescent mothers' concerns about negative outcomes of infant health in the future. For example, an adolescent mother aged 18 years who had stopped breastfeeding at four months explained about her concern for her child's health when growing up; however, she did not mention breastfeeding exclusively: I am concerned about my baby's health because he didn't receive breast milk for six months. . . I am afraid my baby will get asthma like me and my husband, so this idea keeps running through my head. (Pt. 15) Another mother (aged 15 years) explained the anxiety that her baby had a negative response to her after she stopped breastfeeding and returned to work: I'm afraid my baby is refusing me because he's so familiar with his grandmother-in-law. I'm so worried about that now; he might not want to stay with me anymore. (Pt. 5) Sense of shame Many adolescent mothers had negative experiences after cessation of breastfeeding such as increased frequency of infant sickness and decreased maternal-infant attachment. Some of JHR them explained their emotional perceptions as a shame and wanted to have a new chance to breastfeed again.
For example, a teenage mother aged 19 years breastfed for six weeks and experienced having a sick baby after she stopped breastfeeding. In addition, she had to spend 500-1000 baht per illness. Therefore, she recognized that returning to work early was not worthwhile: I should have been more patient in breastfeeding. . .what a shame! If I could turn back time, I would not return to work early. I would not hesitate and listen to my boss like that. I thought I had no money but being happy is more important and my baby would be healthier. (Pt. 17) In addition, an adolescent mother aged 15 years explained that she had stopped breastfeeding and went to work outside since the first month. She wanted to turn back to breastfeeding again because she hoped to bring herself and her baby closer together: I'm so pathetic. I had breast milk already, but I did not use it the way I should have. . .Now, my baby doesn't want to play with me, because he's not familiar with me. (Pt. 5)

Regret
Five adolescent mothers described their feelings about regretting early weaning from breastfeeding. Their experiences with decreasing maternal-child attachment stimulated their perceived regret.
For instance, an adolescent mother aged 18 years had ceased breastfeeding in the first month stated that she regretted having failed to achieve her breastfeeding goals. Moreover, she felt increasing regret when her baby showed a refusal to respond to her, as she said: I'm so sorry. . .I feel even more regret when I see my baby loving to stay with my mom more than me. My baby refused to sleep and play with me. Now I know exactly how breastfeeding could have linked us together, but it's too late now! (Pt. 20) Moreover, one mother aged 18 years had stopped breastfeeding at four months because she had a urinary tract infection and was taking antibiotics. She perceived different feelings between breastfeeding and formula feeding: I really regret it. I felt so different when I had to start formula feeding for my baby. It is difficult to explain; it's like something is gone, and it's not a joyful feeling to be far apart from my baby. (Pt. 15) An adolescent mother aged 16 years had breastfed for one month, explaining her disappointment and negative feelings after she stopped giving the "best food" to her child. In addition, it affected attachment and the maternal role: I had felt close to my baby since I was pregnant. Moreover, breastfeeding could increase closeness and strengthen the bond between us. . .I feel like a failure, and I'm so sad when I give formula milk to him. Formula feeding is easier, but I feel bad about our relationship and the loss of closeness. (Pt. 6) Feeling guilty Nearly half of the adolescent mothers in this study had feelings of guilt and self-blame when they stopped breastfeeding before achieving their goals. The adolescent mothers were deeply concerned that breastfeeding was their responsibility and the best way to feed their infants. They were fraught with self-blame concerning their lack of patience in coping with breastfeeding difficulties.
For example, an adolescent mother aged 18 years had been able to breastfeed for only three weeks because her baby had pneumonia and had to stay in the hospital for a week. She felt twice as guilty due to the sickness of her baby and weaning from breastfeeding related to faulty maternal responsibility. She also expressed that her positive feelings were disappearing:

Breastfeeding challenges in
Thai teen mothers I could not perform my responsibility fully. It made me greatly disappointed after weaning from breastfeeding. I felt that the initial happiness I had at the beginning was disappearing. (Pt. 16) Similarly, an adolescent mother aged 19 years felt guilty when she breastfed her infant for less than six months, which was associated with maternal responsibility: Breastfeeding is the best, right? I thought it was my responsibility to offer my baby the best. Otherwise, why would women have breasts and breast milk? I feel so guilty that I could not be perfectly responsible in the same way as other mothers. (Pt. 17) Moreover, one adolescent mother aged 19 years described her negative emotions when she was unable to achieve set goals. She blamed herself and received the influence of social norms for promoting breastfeeding continuously; Sometimes, I hated myself because I pitied my baby. Some mothers can achieve the goal, but I could not do it. . .when I read websites promoting breastfeeding, all of the successful mothers share their stories and show breast milk stocks. It makes me feel bad. (Pt. 9) However, some of the adolescent mothers decided on another role in their adolescence as good daughters. They wanted to apologize for their previous mistake with their unintended pregnancy and decided to make amends by accomplishing a lifetime achievement through graduation. Some of them decided to find a job to earn their own income that could result in financial autonomy and responsibility. Some mothers did not experience negative emotions as there had been no concern about their infant's health thus far.

Discussion
Adolescent mothers who were not able to continue long-term breastfeeding disclosed their experiences about difficult barriers and negative emotional outcomes with two emerging themes consisting of breastfeeding obstacles concealed by adolescent dependence and repetitive emotional mistakes as unique problems in this vulnerable group. Adverse emotional outcomes specific to adolescent mothers such as anxiety, shame, regret or guilty feelings about unachieved breastfeeding goals were reported in this study.
Regarding previous studies, adolescent mothers tended to prefer formula feeding as a norm because they were concerned about privacy, sexuality and body image [16]. The literature review described factors associated with early breastfeeding cessation from 19 developing countries, including maternal employment, maternal perceptions of insufficiency, illness of mothers and/or infants, breast problems and beliefs about infant nutrition [17]. However, this study presented a distinctive barrier among adolescent mothers due to the influence of female family members with both traditional beliefs and interference in the maternal role under a dependent situation. The relationships in the adolescent mothers' families were a hidden complexity due to unintended pregnancy. Family characteristics were able to affect breastfeeding outcomes through extended families and dependence because the adolescent mothers lacked financial independence, were unemployed, and had no parenting experience. According to Thai culture, the adolescent state is one that remains under the care of parents where adolescences are too immature to take care of or rely on themselves, while their parents have the power to control and raise children. Some studies have found that family members contribute to encouraging early weaning, especially their mothers, stepmothers or other female relatives [6,18].
Regarding lactational foods, cultural factors show an essential role in the identification of food that is passed down to family members through experience. However, limited existing evidence in adolescent mothers was also discussed. The study by Kaewsarn and colleagues [19] reported similar traditional beliefs such as the idea that postpartum women should drink hot beverages and eat pork broth, Kang Leang (Thai peppery hot, mixed vegetable soup) and black chicken soup to improve breast milk production. In a different context, nuts, oilseeds, millet and leafy green vegetables cooked in butter were identified as rich in minerals and beneficial during lactation in India [20]. However, maternal food safety for maternal breastfeeding should be clarified by scientific evidence to facilitate long-term breastfeeding, enhance comfort, offer more choices and promote satisfaction in adolescent mothers.
Moreover, maternal and significant others' beliefs about infant nutrition often establish solid barriers to exclusive breastfeeding [17]. According to the results of this study, it is indicated that family members lack important knowledge about appropriate infant feeding recommendations, which is reflected by the rates of adding water, formula milk and semisolid foods among Thai adolescent mothers. This represents a troubling situation. Ferreira and colleagues [21] found that 67.3% of grandmothers considered it important to give food to babies before six months of life. The study by Nuampa and colleagues [22] stated that adolescent mothers faced with family conflicts and beliefs about infant foods tended to lean toward early weaning from exclusive breastfeeding. However, grandmothers' correct knowledge could translate into mothers' correct knowledge and achievement of optimal breastfeeding practices. Moreover, suitable support from grandmothers is supposed to be training adolescent mothers to promote parenting efficacy as well as adaptation to the maternal role, which simultaneously affects positive breastfeeding results.
This study found that discontinuation of breastfeeding among adolescent mothers could lead to negative emotions which could result in twofold psychological traps in parenting. The effect of negative sensations depends on how adolescent mothers feel about the maternalinfant relationship depreciating, the negative health of their infants or perceived social pressure. Breast milk is the optimal form of nutrition for newborns and breastfeeding is synonymous with good mothering in many cultures [23]. In previous studies, adult mothers who had had breastfeeding failure disclosed feelings of guilt [9,24] and perceptions of inadequate mothering [10]. However, new insights into adverse emotions concerning adolescent mothers at risk for concerns about psychological problems and maternal adaptation encountered numerous dilemmas due to unintended pregnancy such as sadness, stress, depression and regret as well as less effective parenting adaptation [7,25]. Therefore, healthcare providers should understand the dilemmas among these vulnerable mothers. Furthermore, to protect mothers from negative emotions about breastfeeding failure, promotion of breastfeeding together with well-informed and skillful support is required. In cases of unanticipated weaning from breastfeeding, healthcare providers should provide flexible recommendations and unbiased information on the correct preparation of other infant supplementations. Moreover, adverse emotional outcomes should be concerned in cases involving short-term breastfeeding. However, at-risk cases should be assessed and helped before discharge from the hospital with continued and thorough support.
This result of the study might help to develop more sensitive breastfeeding promotion in this vulnerable group. By working together to create a context of choices related to breastfeeding within the lived reality of a woman's life, specific programs should bring key persons in family participation and agreement with infant-feeding plans to achieve infantfeeding goals and prevent emotional troubles. However, there were some limitations to this study involving secondary data analysis. Even though the primary interview did not mention this objective, the researchers contacted all of the participants to ask for member checks, use of audio-recordings, transcription, field notes and memos to recall rich data in addition to peer debriefing to ensure trustworthiness in this study.

Conclusion
Healthcare professionals should be concerned and offer support to counter adverse emotional outcomes among cases involving short-term breastfeeding among adolescent mothers. The

Breastfeeding challenges in
Thai teen mothers influences of key persons in the family play a vital role in breastfeeding and psychological outcomes. Therefore, family-adolescent programs may improve breastfeeding results, promote positive emotions and strengthen mother-infant attachment. Contributor statement: This paper employed a descriptive qualitative design to explore the experiences of adolescent mothers who wean their babies from breastfeeding before the first six months through the perspective of a psychosocial aspect in the Thai context. The results of this study showed that the influences of key family members play a vital role in breastfeeding and psychological outcomes. I am surely that this paper reflex the main factors and be useful for further sensitive breastfeeding interventions for adolescent mothers. I certify that I have read and approved the final version of the manuscript. I agree to take public responsibility for its contents. All authors have contributed to the design, performance, analysis and interpretation of the research findings. The work reported in the paper has not been and is not intended to be published anywhere, except in the Journal of Health Research.