RESEARCH ARTICLE
The Joys and Frustrations of Breastfeeding and
Rooming-In Among Mothers With Opioid Use
Disorder: A Qualitative Study
Mary Beth Howard, MD, MSc,
a,b
Elisha Wachman, MD,
b
Emily M. Levesque, BA,
b
Davida M. Schiff, MD, MSc,
c
Caroline J. Kistin, MD, MSc,
a
Margaret G. Parker, MD, MPH
b
ABSTRACT
OBJECTIVES: To investigate perspectives of mothers with opioid use disorder regarding breastfeeding
and rooming-in during the birth hospitalization and identify facilitators and barriers.
METHODS: We conducted in-depth qualitative interviews with 25 mothers with opioid use disorder
1–12 weeks after delivery. Grounded theory analysis was used until thematic saturation was reached.
Findings were triangulated, with experts in the field and a subset of informants themselves, to ensure
data reliability.
RESULTS: Among 25 infant-mother dyads, 36% of infants required pharmacologic treatment, 72% of
mothers initiated breastfeeding, and 40% continued until discharge. We identified the following themes:
(1) information drives maternal feeding choice; (2) the hospital environment is both a source of
support and tension for mothers exerting autonomy in the care of their infants; (3) opioid withdrawal
symptoms negatively impact breastfeeding; (4) internal and external stigma negatively impact mothers’
self-efficacy; (5) mothers’ histories of abuse and trauma affect their feeding choice and bonding;
(6) mothers’ recovery makes caring for their infants emotionally and logistically challenging; and (7)
having an infant is a source of resilience and provides a sense of purpose for mothers on their path
of recovery.
CONCLUSIONS: Future interventions aimed at increasing breastfeeding and rooming-in during the
birth hospitalization should focus on education regarding the benefits of breastfeeding and
rooming-in, supporting mothers’ autonomy in caring for their infants, minimizing stigma, and
maximizing resilience.
a
Boston Combined
Residency Program in
Pediatrics, Boston
Children’s Hospital,
Boston, Massachusetts;
b
Department of
Pediatrics, Boston
Medical Center, Boston,
Massachusetts; and
c
Division of General
Academic Pediatrics,
Massachusetts General
Hospital for Children and
Harvard Medical School,
Boston, Massachusetts
www.hospitalpediatrics.org
DOI:https://doi.org/10.1542/hpeds.2018-0116
Copyright © 2018 by the American Academy of Pediatrics
Address correspondence to Mary Beth Howard, MD, MSc, Department of Pediatrics, Boston Medical Center, Dowling Building 4013,
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by the Boston Combined Residency Program, the Boston Medical Center Committee of Interns and Residents Quality
Improvement Grant, the Boston Children’s Hospital Fred Lovejoy Resident Research and Education Fund, and the Massachusetts Health
Policy Commission.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Dr Howard conceptualized and designed the study, coordinated the data collection and analysis, and drafted the initial manuscript; Drs
Schiff and Kistin contributed to the study design and reviewed and revised the manuscript; Dr Wachman supervised the study design,
data collection, and data analysis and reviewed and revised the manuscript; Ms Levesque coordinated the data collection, performed
most of the qualitative interviews, and reviewed and revised the manuscript; Dr Parker supervised the study design, data collection, and
data analysis, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.
HOSPITAL PEDIATRICS Volume 8, Issue 12, December 2018 761
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
In the past decade, there has been a
significant increase in the prevalence of
pregnant women with opioid use disorder
(OUD) in the United States and an
associated rise in the incidence of neonatal
abstinence syndrome (NAS).
1,2
NAS is defined
as signs and symptoms of withdrawal that
infants develop after in utero exposure to
opioids.
3
Nonpharmacologic care, including
breastfeeding and rooming-in, are
recommended as first-line treatments for
NAS during the birth hospitalization
4
and
are associated with a reduction in
pharmacologic treatment and shorter
hospitalizations.
5
Breastfeeding optimizes opportunities for
bonding and has been shown to decrease
rates of pharmacologic treatment and
length of hospitalization in infants with
opioid exposure.
5
Despite this, breastfeeding
initiation and continuation among mothers
with OUD is markedly lower than that in
mothers without OUD.
6
There is limited
research on the reasons for this disparity.
In a recent qualitative study of 8 mothers
with OUD that was focused on infant feeding
decisions, the authors found that what
mothers had heard about breastfeeding and
their beliefs on how their breast milk
impacted their infant’s health influenced
their decision to breastfeed.
7
The barriers
and facilitators mothers faced while
breastfeeding during the hospitalization
was not addressed in this study.
Additionally, a descriptive survey study of
30 mothers with OUD revealed that barriers
to breastfeeding included lack of education
by health providers and mother-infant
separation that occurred when infants were
cared for in the NICU.
8
A facilitator was
intent to breastfeed before or during
pregnancy.
8
Because this survey study had
only 3 open-ended questions, the depth of
the perspectives of mothers with OUD was
difficult to assess. Infants with NAS may also
have difficulty latching on to the breast,
9,10
and women with OUD experience stigma by
health care providers
11,12
; however, the
extent to which these issues may impact
breastfeeding success among mothers with
OUD is poorly understood.
Rooming-in is defined as parent
cohabitation with a hospitalized infant, and
has been associated with higher rates of
breastfeeding, maternal involvement in
care, maternal satisfaction, decreased rates
of pharmacologic treatment, and shortened
hosptializations.
13
In settings where
rooming-in is available, the barriers and
facilitators to being at the bedside have not
been well explored. In a single qualitative
study of families of infants with NAS, the
authors reported that the physical
environment, transportation issues, and
mothers’ medical needs impacted rooming-
in.
14
This study was performed at a large
academic center in a rural area at a time
when infants with NAS who received
pharmacologic treatment were removed
from their mothers’ rooms and cared for in
an open-layout NICU.
14
Mothers’ experiences
with rooming-in within different models of
NAS care (in which infants do not routinely
receive treatment in the NICU) or mothers
living in urban settings have not been
explored.
Promotion of nonpharmacologic treatment,
including breastfeeding and rooming-in for
infants with opioid exposure is a public
health priority.
15
To develop effective
interventions, a better understanding of the
barriers and facilitators to breastfeeding
and rooming-in is critical. The purpose of
this study was to explore the perspectives
of mothers with OUD regarding
breastfeeding and rooming-in during the
bir th hospitalization and identify
perceptions of facilitators and barriers to
these practices.
METHODS
Setting and Participants
We interviewed mothers who were cared for
at a large urban safety-net hospital. More
than 95% of mothers with OUD who were
cared for in this institution received
prenatal care at a multidisciplinary prenatal
program with obstetrical care, addiction
treatment, and mental health services, and
90% were of non-Hispanic white race and
ethnicity. Mother-infant dyads with opioid
exposure were initially cared for in single-
family rooms in the mother-infant unit. If
infants required pharmacologic treatment,
they were cared for in a central nursery
space to allow for cardiac monitoring. When
mothers were discharged, infants were
transferred to the general pediatrics unit
for on-going care, which required 2 patients
per room (regardless of need for
pharmacologic treatment) and included a
bed available for 1 parent to room in. Our
institution initiated the eat, sleep, console
model of care for infants with NAS in 2016.
Since that time, the rate of pharmacologic
treatment has been 40%.
16
Our institution
has maintained Baby-Friendly designation,
as defined by the World Health Organization,
since 1999.
17
In-depth interviews occurred from June
2017 to June 2018. Mothers were
approached for participation during the
postpartum hospitalization if they met the
following study eligibility criteria: (1)
English speaking, (2) receipt of medication
treatment of OUD with methadone or
buprenorphine during pregnancy, (3)
eligibility to breastfeed per hospital criteria
(negative urine toxicology screen on
admission to labor and delivery and,
enrollment in a treatment program with
adequate prenatal care at least 4 weeks
before birth, and absence of extreme social
circumstances in which social services
maintained custody of the infant at the time
of discharge), and (4) infants $36 weeks’
gestation and medically stable (no
hemodynamic instability or need for
respiratory support). Interviews occurred
1 to 12 weeks after delivery either during
the birth hospitalization, at pediatric clinic
visits, or by phone. Mothers received a
$30 gift card as an incentive for
participation. Enrollment continued until
thematic saturation was reached. The
institutional review board deemed this
study exempt.
Data Collection
In-depth, semistructured interviews were
conducted by 2 study team members (M.B.H.
and E.M.L.). Interviews lasted 30 to 45
minutes; they were audiotaped and
transcribed verbatim. An interview guide
consisted of questions and topics based
on existing literature (Table 1). Questions
were asked in an open-ended format,
and the question guide was revised
throughout the interview process. Questions
regarding mothers’ stressors, previous life
experiences, symptoms of withdrawal, and
762 HOWARD et al
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
interactions with the health care team were
added over the course of the study to
better elaborate on emerging themes.
Descriptive demographic and health
data were abstracted from the medical
record.
Data Analysis
A grounded theory analysis was used to
build on theories from the data through an
iterative process of systematic data
collection and analysis.
18,19
Each transcript
was reviewed by investigators (M.B.H., M.G.
P., and E.W.) with expertise in breastfeeding
and the care of infants born to mothers with
OUD. During the review of the initial
transcripts, each reviewer developed a list
of codes. The coding structure was
discussed and revised as a group before the
independent coding of future transcripts.
The team met at regular intervals to discuss
findings, refine interview questions, and
monitor for thematic saturation. To
maximize the reliability of the analysis,
2 members of the group reviewed each
transcript independently. Disagreements
were resolved through discussion. Data
collection ended when the group
established a set of themes and no new
themes were identified. Transcripts were
sorted into coded passages by using NVivo
software.
20
In addition to investigator triangulation, as
described above, the team ensured data
reliability by expert triangulation,
21
whereby
exper ts reviewed the study methodology,
coding, and results. Experts were convened
on 2 separate occasions and included
general pediatricians, neonatologists, an
obstetrician, lactation consultants, nurses,
and social workers who interact frequently
with mothers with OUD during pregnancy
and the birth hospitalization as well as
pediatric health services researchers with
exper tise in qualitative analysis. Member
checking
21
was also performed, whereby
findings were communicated to a subset of
mothers to ensure their accuracy and
intended meaning.
RESULTS
Participant characteristics are summarized
in Table 2. Thirty-six percent of infants
received phar macolo gic the rapy and the
median length of hospitalization was
8 day s (interquartile range [IQR]:
7– 22 days). Among mothers, 100% were
of non-Hispanic white race and ethnicity,
and the median age was 29 years (IQR:
24–34 years); 60% received methadone
and 40% recei ved buprenorph ine as an
opioid agonist therapy during pregnancy.
Seventy-two percent of mothers initiated
breastfeeding and 40% continued until
discharge. Main t hem es and subthemes
are d isplayed in Table 3.
Theme 1: Information Drives
Maternal Feeding Choice
Mothers reported that information they
received about the benefits and risks of
breastfeeding for mother-infant dyads
exposed to opioids during pregnancy
influenced their feeding choice. Information
about breastfeeding reported by mothers
was both medically accurate and
inaccurate. Some mothers reported that
they chose to breastfeed because they
heard that breastfeeding reduces the
severity of the infant’s withdrawal and may
prevent the need for pharmacologic
treatment (representing medically accurate
information). Other mothers reported a
decision to formula feed because they heard
that transmission of methadone or
buprenorphine through breastfeeding may
increase the severity of infant withdrawal,
or mothers reported the inability to
breastfeed with hepatitis C (representing
medically inaccurate information). Mothers
received information from a variety of
sources, including pre- and postnatal health
care providers; employees of the
Supplemental Nutrition Program for Women,
Infants, and Children; family; and the media.
Both medically accurate and inaccurate
information were reported from all sources.
Additionally, some mothers commented that
they received information about the benefits
and role of breastfeeding from health care
providers but not the technical aspects of
pumping, engorgement, and latching before
delivery, which would have been helpful.
Theme 2: The Hospital Environment
Is Both a Source of Support and
Tension for Mothers Exerting
Autonomy in the Care of Their Infants
Many mothers with OUD described the
hospital environment as highly supportive
and enabling of their ability to feed and care
for their infants. Mothers reported that
doctors, nurses, and lactation consultants
were helpful with technical aspects of
feeding care (ie, using a pump and infant
latching on to the breast), explaining the
medical needs of infants with symptoms of
NAS, and providing emotional support.
TABLE 1 Probe Questions
Question
General parenting Tell me what parenting has been like since your infant was born; what are
your fears about parenting?
a
How are you taking care of yourself and the
infant? How does taking care of your infant make you feel as a mother in
recovery?
a
How has the experience of having an infant compares with other
stressful life experiences for you?
a
Feeding Feeding infants is a really important part of taking care of them. How has
feeding your infant been? Are you breastfeeding or giving formula to your
infant? Can you tell me how you came to that decision? We are interested in
knowing how mothers learned about breastfeeding. Can you tell me where
you learned about breastfeeding? Do you feel that your infant’s withdrawal
affected his or her ability to be breastfed or formula fed?
a
What has helped
you with breastfeeding or formula feeding your infant? What has made it
hard to breastfeed or formula feed your infant? (For mothers who are
breastfeeding): Our team is doing these interviews so that we can learn
new ways to help mothers with their breastfeeding in the future. Are there
things that you think would have helped you with your breastfeeding?
Maternal involvement in
care and rooming-in
What is (or was) it like when your infant was staying in the same room as you
in the hospital? What made it hard or easy? If you were to imagine an ideal
environment for caring for your infant in the hospital, what would it look
like to you? What have your interactions with the health care team been
like while in the hospital?
a
a
Added during iterative data analysis.
HOSPITAL PEDIATRICS Volume 8, Issue 12, December 2018 763
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
Mothers described the physical
environment of the hospital, when single
rooms were available for the infant to be
in the same room as the mother, as ideal.
Other mothers reported that the hospital
environment was a source of tension that
undermined autonomy. Mothers felt that
their perspectives were not always
acknowledged by health providers. They
reported frustrations due to disagreements
with providers’ view of the subjective signs
of infant withdrawal or with decisions made
about their infants’ care. In situations in
which the infants had to be separated
temporarily from their mothers for
cardiac monitoring while receiving opioid
medication, mothers had significant
concerns that their infants were not being
cared for as they would have wanted.
Mothers reported a lack of privacy when
they had to share rooms with another
family, which negatively impacted mothers’
perceived comfort. Finally, mothers
commented that the shared rooms made
it noisier, which worsened their infants’
withdrawal. They noted a lack of
comfortable furniture for breastfeeding
and doing skin-to-skin care, particularly
when recovering from a cesarean delivery.
Theme 3: Opioid Withdrawal
Symptoms Negatively Impact
Breastfeeding
Mothers reported that difficulty in infant
latching, resulting from oral-motor
dysregulation (a common symptom of infant
opioid withdrawal), negatively impacted
breastfeeding success. This made mothers
feel stressed, frustrated, and defeated. The
majority of infants in the study received
formula supplementation because of
concerns for weight loss, which, for some
mothers, diminished the perceived benefits
of exclusive breastfeeding. Mothers felt
uninformed and surprised that infant
formula supplementation would be needed,
and overall, formula supplementation made
breastfeeding mothers feel defeated and
discouraged.
Theme 4: Feelings of Internal and
External Stigma Negatively Impact
Mothers’ Self-Efficacy
Some mothers expressed internal guilt and
shame that their infants’ withdrawal and
need for prolonged hospitalization occurred
because of their history of opioid use. This
impacted mothers’ ability to exhibit self-
efficacy and confidence in caring for their
infants.
Mothers had a heightened awareness that
external stigmatization among hospital staff
may occur. In several instances, it did occur,
and mothers said that staff members
attended to their infants less often,
communicated less, and were more
stringent in enforcing hospital rules
because of their addiction histories.
Perception of unequal treatment made
mothers feel frustrated, anxious, and
stressed. Conversely, when staff members
were not judgmental and treated the
mothers as equals, mothers felt respected
and empowered, and this greatly enhanced
their confidence in caring for their infants.
Mothers felt fortunate and grateful toward
staff members in these situations.
Theme 5: Mothers’ Histories of Abuse
and Trauma Affect Their Feeding
Choice and Bonding
Mothers with OUD described past traumatic
experiences that impacted their ability to
care for their infants. Mothers described
histories of sexual abuse and trauma that
guided decisions not to breastfeed. One
mother said that the physical act of
breastfeeding incited past emotions related
to sexual trauma. Histories of trauma also
affected how mothers bonded with their
newborns. Mothers described previous
stressful experiences that were relived with
having a newborn. One mother described
great fear and anxiety in caring for her
infant because of a worry that the infant
would be removed from her custody, as
experienced with her previous children.
Theme 6: Mothers’ Own Recovery
Makes Infant Care Emotionally and
Logistically Challenging
Mothers also talked about specific aspects
of their own recovery that made it more
difficult for them to care for their infants.
Mothers had to leave the hospital to travel
to methadone clinics for hours a day and
visit their own health care providers. These
competing demands significantly impacted
mothers’ ability to be present at the bedside
during the hospitalization. Mothers were
stressed and anxious about this. Some
mothers expressed worry that they may
develop postpartum depression and that
this would impact caring for their infants.
Theme 7: Having an Infant Is a
Source of Resilience and Provides a
Sense of Purpose for Mothers on
Their Path to Recovery
Mothers noted the positive impact that
having an infant had on their self-esteem
and motivation to continue on their
recovery. Caring for their infant gave
mothers a sense of purpose. Related
emotions of comfort, bonding, and joy also
served as a source of motivation for these
mothers to breastfeed and room in.
DISCUSSION
In this qualitative study, we provide insights
into the perspectives of mothers with OUD
during the birth hospitalization and identify
TABLE 2 Characteristics of 25 Mother-
Infant Pairs
Characteristics Results
Infant
Gestational age at birth, wk (%) 39 (5)
Length of hospitalization, d (%) 8 (19)
Received pharmacologic
treatment, n (%)
9 (36)
Age at time of interview, wk (%) 7 (8)
Mother
Maternal age, y, median (IQR) 29 (24–34)
Non-Hispanic white race and
ethnicity, n (%)
25 (100)
Delivery mode, n (%)
Vaginal 16 (64)
Cesarean 9 (36)
Opioid agonist treatment during
pregnancy, n (%)
Methadone 16 (64)
Buprenorphine 10 (40)
Psychiatric medications during
pregnancy, n (%)
10 (40)
Hepatitis C–positive, n (%) 13 (52)
Nicotine smoking in third
trimester, n (%)
14 (56)
Initiated breastfeeding, n (%) 18 (72)
Continued breastfeeding until 24 h
before discharge, n (%)
10 (40)
764 HOWARD et al
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
TABLE 3 Themes and Subthemes
Themes and Subthemes Interview Quotes
Information drives maternal feeding choice
Medically accurate information “The OBGYN doctor said it would help the withdrawal…. I wanted to do anything
extra that I could do to help her…so I breastfed her.”
Medically inaccurate information “I do not breastfeed because of babies being on methadone, or Subutex. It gets
inside of the breast.… If he’s already detoxed, and you get it done and over
with, why would I give him breastmilk that has methadone or whatever left
inside of it, so he has to detox later on?”
The hospital environment is both a source of support and tension for mothers
exerting autonomy in the care of their infants
Supportive staff “It really makes me feel good, too, that, like, the doctors and the nurses have told
me I’ve been doing, like, their words were, ‘A phenomenal job.’ And then, the
doctor said that, you know, he does perfect when he’s with me, and then, he’s
like, she’s the one that said it, she was like, ‘He’s perfect when he’s with you,
which means you’re doing a phenomenal job.’”
Supportive physical environment “The dim lighting, the skin to skin, me getting to hold him a lot, being in the room
with him, I get to sing to him, he gets that bond with me early on, and I’m able
to comfort him a lot better than I would be if he was just in the NICU.”
Unsupportive staff “I want the best for my baby, so when they’re not taking my wishes into
consideration, it’s just kind of, like, disheartening”; “I did feel judged, and I did
feel like they implemented the rules strictly with me, but with that other family,
it was a little more flexible. Why? It shouldn’t be like that. It was really hurtful.”
Unsupportive physical environment “He’s not being, like, held enough in the nursery”; “Comfortability was a little off
because we shared the room, and I get along with most people, but the person
that we had around was not very pleasant.”
Opioid withdrawal symptoms negatively impact breastfeeding
Difficulty latching “He would latch, and he would suck, but it would be intermittent; it wasn’t regular.
And then, it started slowly deteriorating after that. … He was on the bottle; he
didn’t even want my breast anymore. So, that was, like, really upsetting, and I
cried”; “I wish I could have done breastfeeding. When I was in the hospital, it
took 1 time of using the bottle, and after that 1 time, it seemed like it was a lot
harder for her to latch on.”
Formula supplementation for weight loss “Even if I did a perfect job breastfeeding…he would need supplementation”;
“What’s the point if they are going to add formula to my breastmilk?”
Feelings of failure “You feel defeated”; “I tried my best and couldn’t do it. I bawled my eyes out. I felt
like a failure”; “He just didn’t want my breast anymore; I felt awful. It was really
upsetting, and I cried.”
Feelings of internal and external stigma negatively impact mothers’ self-
efficacy
Internal “It’s my fault she’s like this”; “I was crying my eyes out…. I felt so guilty that my
daughter had to go over there in the first place.”
External “It’s not a good feeling when you know you’re being judged by the people who are
supposed to help you”; “The mother being treated with respect is very
important because she needs to believe in herself so she can take care of the
baby.”
Mothers’ histories of abuse and trauma affect their feeding choice and
bonding
Sexual abuse “It [deciding not to breastfeed] has to do with me being molested as a kid. I just
don’t like being touched up there”; “Of course being abused affects how willing
you are to breastfeed.”
History of trauma “You’re traumatized, and there’s just no way you’
re going to be able to
breastfeed”; “I’ve been through hell, and there’s no way that doesn’t affect how I
deal with the stress of having a baby”; “I know what it is like to be cold and
alone, and I never want him to feel that way”; “I couldn’t spend time with my
older son when he was a baby.… He was taken away. I worry about the same
thing happening again”; “The stress of it impacts our parenting, and it is a
snowball effect.”
HOSPITAL PEDIATRICS Volume 8, Issue 12, December 2018 765
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
the perception of barriers and facilitators of
breastfeeding and rooming-in that may
serve as future intervention targets. Overall,
mothers experienced internal and external
stigma yet simultaneously felt joy and a
sense of purpose and responsibility in
caring for their infants. Breastfeeding
initiation was influenced by information
received about the specific benefits and
risks of breastfeeding in the setting of
opioid use, and many women reported
incorrect information, which dictated their
feeding choice. Breastfeeding success was
influenced by hospital provider support,
infant withdrawal symptoms, and past
traumatic experiences. Rooming-in was
facilitated by hospital policies allowing for
infants to be at the bedside and was
hindered by competing demands related
to mothers’ addiction treatment.
In this study, we explored the perspectives
of mothers with OUD during the birth
hospitalization. Similar to McGlothen et al,
7
we also found that the information mothers
heard about breastfeeding informed their
feeding choice; with this finding, the
importance of accurate maternal education
on the role of breastfeeding is reiterated.
Mothers in our study also expressed
frustration and surprise with the need for
formula supplementation and difficulty with
infant latching, as a consequence of NAS.
This reveals the importance of education for
mothers that includes preparation for the
need for formula supplementation and
difficulty with infant latching. Future
investigation regarding the short- and
long-term risks and benefits of formula
supplementation as it relates to infant
weight trajectories and breastfeeding will
also guide future education interventions.
Oral-motor dysfunction observed in NAS has
not been well characterized nor have
approaches to support mothers who are
breastfeeding infants with NAS exhibiting
oral-motor dysfunction. Like Jansson et al,
22
we also found that past sexual abuse
negatively impacted mothers’ decision to
breastfeed. Previous research has revealed
a strong link between history of sexual
trauma and substance use
23,24
with ∼45% of
pregnant women reporting a history of
sexual abuse.
25
In our experience,
discussions about past sexual trauma are
neglected when counseling mothers with
OUD about breastfeeding. In this study, we
highlight the importance of consideration of
this issue when developing breastfeeding
promotion interventions in this vulnerable
population.
Similar to Atwood et al,
14
we found that any
separation of the infant from the mother at
any stage of the bir th hospitalization,
competing medical demands by the mother,
and logistical transportation issues
impacted mothers’ ability to remain at the
bedside. These data can be used to
emphasize the importance of hospital
policies to minimize mother-infant
separation during the birth hospitalization
and of assistance with transportation as key
aspects of future interventions to maximize
rooming-in.
We found that internal and external stigma
played a large role in mothers’ self-efficacy
to care for their infants. Self-efficacy, or
confidence in one’s ability to perform, is a
critical factor in infant care practices, such
as breastfeeding continuation,
26
and
promotion of self-efficacy is a key
mechanism used to enhance mothers’ role
in infant care.
27,28
Internal and external
stigmatization have been previously
described among mothers of OUD.
11,28
Our
finding that mothers had a heightened
awareness to stigmatization and felt
empowered when they felt that they
were not being judged by hospital staff
reveals the impor tance of interventions in
which stigmatization is addressed directly
in staff training and counseling of
mothers.
12
Strengths of this qualitative study include
the recruitment of mothers who did and did
not attempt breastfeeding, which allowed
for the examination of a breadth of feeding
perspectives. However, we restricted our
sample to mothers who were eligible to
breastfeed at our institution, which meant
that participants received opioid agonist
treatment in prenatal care. Mothers not
eligible to breastfeed (who used illicit drugs
at the time of delivery or who did not
receive opioid agonist treatment during
prenatal care) may have had different
perspectives that we did not capture. This
may have limited perspectives of the
range of mothers with OUD. Our sample
also came from a single, urban, Baby-
Friendly–designated hospital that
specializes in multidisciplinary care for
mother-infant dyads with opioid exposure
and endorses many breastfeeding support
practices, which also might have limited the
TABLE 3 Continued
Themes and Subthemes Interview Quotes
Mothers’ recovery makes caring for their infants emotionally and logistically
challenging
“Because you’re dealing with your own addiction, and you’re dealing with your
own problems…but then again, I am a mother, and I chose to have him, so
you’re going to deal with both sides at the same time”; “It makes it harder
because I have to go to the clinic every single morning. Babies aren’t always
predictable; I have to get him and make sure he’s fed and clean and stuff
before I leave and hopefully put him back to sleep before I go”; “I’m going to
have to bring him to the clinic with me and expose him to a lot of germs and
the cold”; “The postpartum is scary because you just don’t want to be around
your child.”
Having an infant is a source of resilience and provides a sense of purpose for
mothers on their path to recovery
“I never thought I would get the chance because of my addiction and the road I
was going down, and it still feels like a dream”; “It’s [having a baby] more
motivating to continue, and it’s a reminder of why I’m still here.”
OBGYN, obstetrics-gynecology.
766 HOWARD et al
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
perspectives that we captured. All
participants were of non-Hispanic white
race and ethnicity, and breastfeeding rates
vary across races and ethnicities,
independent of OUD.
29
Variability in the
timing and setting of interviews might have
led to recall bias in which mothers further
removed from hospitalization might have
forgotten details of their hospitalization. It is
also possible that mothers who were
interviewed while their infant was still
hospitalized might have been reluctant to
criticize care while still in contact with
health providers. The possibility of socially
desirable responses, therefore, cannot be
discounted.
CONCLUSIO NS
Targeted interventions that support the
needs of mothers with OUD during the infant
hospitalization with breastfeeding and
rooming-in are urgently needed. With the
findings of this qualitative study, we suggest
that future intervention targets include the
promotion of maternal education in the
benefits and technical challenges of
breastfeeding an infant with opioid
withdrawal symptoms, of hospital policies
and environments that minimize mother-
infant separation and allow for privacy, and
of maternal self-efficacy by the provision of
nonjudgmental care that supports mothers’
autonomy.
Acknowledgments
We thank the patients and families who
made this research possible, the Boston
Medical Center Department of Pediatrics,
Inpatient Pediatric Unit, Supporting Our
Families Through Addiction and Recovery
clinic, and NAS Quality Improvement and
Research groups for their support, and Hira
Shrestha and Rose Allocco, who assisted
with recruitment.
REFERENCES
1. Patrick SW, Davis MM, Lehmann CU,
Cooper WO. Increasing incidence and
geographic distribution of neonatal
abstinence syndrome: United States
2009 to 2012 [published correction
appears in J Perinatol. 2015;35(8):667].
J Perinatol. 2015;35(8):650–655
2. Jansson LM, Velez M, Harrow C. The
opioid-exposed newborn: assessment
and pharmacologic management.
J Opioid Manag. 2009;5(1):47–55
3. Ko JY, Patrick SW, Tong VT, Patel R, Lind
JN, Barfield WD. Incidence of neonatal
abstinence syndrome - 28 states, 1999-
2013. MMWR Morb Mortal Wkly Rep.
2016;65(31):799–802
4. Hudak ML, Tan RC; Committee on Drugs;
Committee on Fetus and Newborn;
American Academy of Pediatrics.
Neonatal drug withdrawal [published
correction appears in Pediatrics. 2014;
133(5):937]. Pediatrics. 2012;129(2).
Available at: www.pediatrics.org/cgi/
content/full/129/2/e540
5. Wachman EM, Schiff DM, Silverstein M.
Neonatal abstinence syndrome:
advances in diagnosis and treatment.
JAMA. 2018;319(13):1362–1374
6. Jansson LM, Velez M. Lactation and the
substance-exposed mother-infant dyad.
J Perinat Neonatal Nurs. 2015;29(4):
277–286; quiz E1
7. McGlothen KS, Cleveland LM, Gill SL. “I’m
doing the best that I can for her”: infant-
feeding decisions of mothers receiving
medication-assisted treatment for an
opioid use disorder. J Hum Lact. 2018;
34(3):535–542
8. Hicks J, Morse E, Wyant DK. Barriers and
facilitators of breastfeeding reported by
postpar tum women in methadone
maintenance therapy. Breastfeed Med.
2018;13(4):259–265
9. Maguire DJ, Shaffer-Hudkins E,
Armstrong K, Clark L. Feeding infants
with neonatal abstinence syndrome:
finding the sweet spot. Neonatal Netw.
2018;37(1):11–18
10. Maguire DJ, Rowe MA, Spring H, Elliott
AF. Patterns of disruptive feeding
behaviors in infants with neonatal
abstinence syndrome. Adv Neonatal
Care. 2015;15(6):429–439; quiz E1–E2
11. Cleveland LM, Bonugli R. Experiences of
mothers of infants with neonatal
abstinence syndrome in the neonatal
intensive care unit. J Obstet Gynecol
Neonatal Nurs. 2014;43(3):318–329
12. Schiff DM, Zuckerman B, Wachman EM,
Bair-Merritt M. Trainees’ knowledge,
attitudes, and practices towards caring
for the substance-exposed mother-
infant dyad. Subst Abus.2017;38(4):
414
–421
13. MacMillan KDL, Rendon CP, Verma K,
Riblet N, Washer DB, Volpe Holmes A.
Association of rooming-in with
outcomes for neonatal abstinence
syndrome: a syst ematic review and
meta-analysis. JAMA Pediatr.2018;
172(4):345–351
14. Atwood EC, Sollender G, Hsu E, et al.
A qualitative study of family experience
with hospitalization for neonatal
abstinence syndrome. Hosp Pediatr.
2016;6(10):626–632
15. Kocherlakota P. Neonatal abstinence
syndrome. Pediatrics. 2014;134(2).
Available at: www.pediatrics.org/cgi/
content/full/134/2/e547
16. Wachman EM, Grossman M, Schiff DM,
et al. Quality improvement initiative to
improve inpatient outcomes for neonatal
abstinence syndrome. J Perinatol. 2018;
38(8):1114–1122
17. World Health Organization. Baby-Friendly
Hospital Initiative: Revised, Updated and
Expanded for Integrated Care. Geneva,
Switzerland: World Health Organization;
2009
18. Corbin JM, Strauss A. Grounded theory
research: procedures, canons, and
evaluative criteria. Qual Sociol. 1990;
13(1):3–21
19. Glaser BG, Strauss AL. The Discovery of
Grounded Theory: Strategies for
Qualitative Research. Chicago, IL: Aldine;
1967
20. QSR International Pty Ltd. NVivo
[computer program]. Version 10.
Doncaster, Australia: QSR International
Pty Ltd; 2012
21. Bernard HR. Research Methods in
Anthropology: Qualitative and
Quantitative Approaches. 3rd ed. Walnut
Creek, CA: AltaMira Press; 2002
22. Jansson LM, Velez ML, Butz AM. The
effect of sexual abuse and prenatal
substance use on successful
breastfeeding. J Obstet Gynecol Neonatal
Nurs. 2017;46(3):480–484
HOSPITAL PEDIATRICS Volume 8, Issue 12, December 2018 767
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
23. Najavits LM, Weiss RD, Shaw SR. The link
between substance abuse and
posttraumatic stress disorder in
women. A research review. Am J Addict.
1997;6(4):273–283
24. McHugo GJ, Caspi Y, Kammerer N, et al.
The assessment of trauma history in
women with co-occurring substance
abuse and mental disorders and a
history of interpersonal violence. JBehav
Health Serv Res. 2005;32(2):113–127
25. Velez ML, Montoya ID, Jansson LM,
et al. Exposure t o violence among
substance-dependent pregnant
women and their children.
J Subst Abuse Treat. 2006;30(1):
31– 38
26. Ingram J, Johnson D, Copeland M,
Churchill C, Taylor H. The development of
a new breast feeding assessment tool
and the relationship with breast feeding
self-efficacy. Midwifery. 2015;31(1):
132–137
27. Ent wistle F, Kendall S, Mead M.
Breastfeeding suppor t - the
impor tance of self-efficacy for low-
income women. Matern Child Nutr.
2010;6(3):228–24 2
28. Chan MY, Ip WY, Choi KC. The effect of a
self-efficacy-based educational
programme on maternal breast feeding
self-efficacy, breast feeding duration and
exclusive breast feeding rates: a
longitudinal study. Midwifery. 2016;36:
92–98
29. Cleveland LM, Gill SL. “ Try not to judge”:
mothers of substance exposed infants.
MCN Am J Matern Child Nurs. 2013;38(4):
200–205
768 HOWARD et al
Downloaded from http://publications.aap.org/hospitalpediatrics/article-pdf/8/12/761/814705/hpeds_2018-0116.pdf by Univ of North Carolina at Chapel Hill user on 05 February 2022
