"It's Like Going Home To Emptiness" Becoming a Mother and Providing Mother's Milk to Premature Infants in the Neonatal Intensive Care Unit

Preterm birth occurs in 12% of US births and Latinas have preterm rates close to national levels. Becoming a mother in the neonatal intensive care unit (NICU) is considered an altered transition experience impacted by psychosocial and cultural factors. Providing mother’s own milk (MoM) to a preterm is challenging due to immaturity and or illness. Despite being the fastest growing, largest minority culture in the US, few studies focus on the experience of Latina mothers in the NICU. The purpose of this mixed methods study was to examine mothers’ experience of becoming a mother in NICU and factors that influence infant feeding decisions in the first month of life and to determine what distinguishes this experience for Latina mothers. Research on breastfeeding in NICU has focused primarily on white, married, middle class women. Despite the benefits of human milk, only one third of all NICUs in the US report routine use of human milk. A convenience sample of 30 mothers with infants ranging from 23 to 35 completed weeks gestational age participated in this study. Data analyses were conducted using NVIVO software for qualitative data and SPSS statistical software version 22 for the quantitative data. There were two primary research questions asked in this study. The first was central to the larger qualitative piece of this work and focused on becoming a mother and providing MoM in the NICU. The second was quantitative in nature and explored the relationship between infant feeding attitudes and key processes with regard to MoM provision outcomes as modified by culture. This mixed methods study is set in a major northeastern perinatal regional center. The dominant qualitative portion used a semi – structured interview guide developed from the main theoretical concepts of becoming a mother (BAM) and the current literature on parenting in the NICU and providing mother’s own milk. The supplementary exploratory descriptive quantitative strand used six standardized measurement tools to explore the relationships between selected psychosocial and cultural factors (maternal moods, decisional conflict, coping strategies, neonatal stressors, infant feeding attitudes and behaviors and psychological acculturation) and continuation of MoM. Data analysis consisted of directed content analysis to describe major themes for the qualitative portion and descriptive statistics and non-parametric tests to identify relationships and group differences. Multivariate analysis using binary logistic regression to describe the strongest relationships was conducted. The data were integrated and discussed for this sample of women. Qualitative results indicated that Latina mothers did fit into the framework described by Hurst and colleagues that proposed that BAM was interrupted with mothers having a paradoxical experience which included negotiations about pumping and the feeling that pumping created a wedge instead of a connection between them and their infants. Cultural themes that emerged included generational differences with Latina mothers less likely to have social support for breastfeeding and to feel uncertain about their decision and transitioning to their maternal role in the NICU. Cultural values, such as familismo, respeto and fatalism, provided a nuanced response to the experience of BAM in the NICU perceived by mothers, leading to an increased sense of uncertainty. Latina mothers described being in a state of parental liminality related to a sense of powerlessness and uncertainty, a theme that was not identified in the original BAM nor previous framework for providing milk in the NICU. Quantitative exploratory analyses revealed that there was a significant difference between Latina and non-Latina groups with Latina mothers demonstrating higher levels of self–efficacy about ability to successfully produce MoM for their infants. For this sample of Latina women, anxiety made a statistically significant contribution indicating that mothers who were anxious were 1.35 times less likely to continue to provide MoM. Decision uncertainty approached significance and mothers who were uncertain about decision to provide breast milk feeds were 1.14 times less likely to continue to provide MoM in the first month of neonatal life in the NICU. It is essential for healthcare providers to be aware that mothers who are anxious, experience decisional uncertainty, perceive alterations in their maternal role, and express a high degree of stress related to the overall NICU environment may be at risk for discontinuing to provide MoM for their premature infants. More research is needed to explore culturally relevant intervention methods aimed at decreasing maternal stress and anxiety and addressing decisional conflict with mothers of premature infants in the NICU.