Breastfeeding mothers’ experiences with community physicians in Israel: a qualitative study

Fifteen women in total expressed their interest in participating in this study. However, two were excluded following several failed attempts to reach them, so the final sample consisted of 13 women. All the interviews were conducted between December 2020 and May 2021. The interviews ranged from 23 to 61 min in duration, with an average of 41 min. All participants were interviewed in Hebrew.

Participants’ ages ranged from 24 to 37 years. All were married with a child aged two to six months. The children were the first, second, or third in the family. Women were all secular or religious, middle-class in terms of socioeconomic status, living in the southern region of Israel, and registered with MHS.

Main themes

We identified four main themes: physicians’ inconsistent attitudes toward breastfeeding, physicians’ lack of knowledge regarding medical treatment for breastfeeding issues, mothers’ preference for alternative resources over medical treatment for breastfeeding problems, and mothers’ suggestions for PCPs. Each theme contains four to five subthemes (Fig. 1).

Fig. 1figure 1

Themes and subthemes on the experiences of breastfeeding mothers with primary care physicians (PCPs) regarding breastfeeding

Physicians’ inconsistent attitudes toward breastfeeding

For this theme, we identified five subthemes: indifferent attitude, relating to breastfeeding solely in the context of infant development, supporting breastfeeding, opposing breastfeeding, and inappropriate attitude toward breastfeeding.

Indifferent attitude

Women felt their physicians did not care whether they breastfed or not.

‘[The doctor] just asked whether I was breastfeeding or not … She asked what the feeding method was, and as soon as I said exclusive breastfeeding, she never asked again.’ [id #6]

‘I think that they need to record the feeding method in the computer, so they always ask. So, every pediatrician always asks what the baby eats and how he eats… I never felt that it went beyond “what does the baby eat?’ [id #8]

Relating to breastfeeding solely in the context of infant development

This subtheme was touched upon by almost all women. They felt physicians were interested in the way in which the child was fed only in the context of development and normal weight gain.

‘I understood very quickly at the first meeting that he wasn’t necessarily a breastfeeding supporter… I think many doctors are like that. [The doctor] is in favor, very much, of child development, and it doesn’t matter what [the baby] eats, but what interests him is that the boy is developing properly. He said something like “even in pilot training they don’t check whether the child was nursed or not. As far as I’m concerned, baby formula is not a dirty word.”‘ [id #12]

Supporting breastfeeding

Some women felt that some of their physicians, but not all of them, were supportive of breastfeeding.

‘She said it was good and she encouraged it. In other words, she was very supportive. She said, “Great, good for you ... you’re breastfeeding … as long as it goes well, carry on, for sure.”‘ [id #7]

Opposing breastfeeding

A minority of women felt that their physicians were opposed to breastfeeding. They pointed out that they were surprised to find that their physicians had such an attitude.

‘When I got to the second doctor … right away his attitude was totally against breastfeeding … He said to me, “You know, you really don’t have to breastfeed. Even if they say that breastfeeding is better, it’s not necessarily proven.” He had an entire theory … [that] breast[milk] is not necessarily the preferred type of milk.’ [id #5]

Inappropriate attitude toward breastfeeding

Two women revealed troubling stories during the interviews. Both felt that the physician’s behavior had been inappropriate. In the first case, the mother felt uncomfortable about the physician’s comments regarding her breasts.

‘I once went, while nursing, for an annual breast check-up with a surgeon that I always go to. I sat across from him. I didn’t have a shirt on, and I said to him, “Oh, I’m nursing,” and he said, “Yes, I see”…What did he see there? God knows.’ [id #3]

In the second case, the physician showed the woman how to express milk from her breasts. She felt comfortable with it, appreciated the help, and felt it was good advice for her. However, she sensed that this behavior may have been inappropriate for other women and unacceptable to them.

‘He [a gynecologist] told me he had a few things to emphasize and … tell me so that the milk would be from the back and not the front. He … sat me down and showed me exactly what to do … how to massage the breast, really explained it all to me… he asked me if it was OK. Really, suddenly he showed me how the milk was coming out like, like a river...’ [id #11]

Physicians’ lack of knowledge regarding medical treatment for breastfeeding issues

We identified four subthemes of this theme: reluctance of physicians to treat breastfeeding mothers, lack of knowledge regarding medications during breastfeeding, incorrect treatment of breastfeeding problems, and contradictions among HCPs.

Women expressed their feelings that physicians provided insufficient medical treatment for breastfeeding issues. This situation was confusing and frustrating for women who were struggling with these problems and felt they could not receive proper treatment.

Reluctance of physicians to treat breastfeeding mothers

Several women were refused when attempting to make appointments with PCPs regarding their breastfeeding problems.

‘I got blocked up right at the beginning and then it all cleared up and was fine. But after a few days, [my breast] really hurt. I was concerned that it was an infection or some kind of inflammation. My doctor was on maternity leave. I tried to contact another doctor… and [the clinic secretaries] told me that the [family] doctors couldn’t see me … because they didn’t have anything to examine or say.’ [id #10]

Lack of knowledge regarding medications during breastfeeding

Many women felt that when they needed to receive medications while breastfeeding, they were unable to elicit suitable answers from their physicians regarding whether or not certain medications were contraindicated during breastfeeding and whether or not they could be harmful to their babies.

‘I went to the family doctor, who … told me that there was nothing to be done about it, and that even in terms of painkillers there was not much that could be done because I was breastfeeding. Except for [paracetamol]. … [Etoricoxib] and stuff like that wasn’t relevant in my case. I felt like I wasn’t getting any … help.’ [id #4]

Women often felt they had to search this information on their own (through the Teratology Telephone Center at the Ministry of Health).

‘Also, when I checked which drugs could help, he said … maybe yes, maybe no… he said, “Maybe this, but you’re breastfeeding so I’m not sure it’s possible.” That was the dialogue. It’s like there’s some kind of vacuum. If I find myself searching on my own [for information on] whether I can take the drug or not, I think there’s a problem …’ [id #4]

Incorrect treatment for breastfeeding problems

Another source of frustration for women was their sense that physicians were giving them incorrect treatment for their breastfeeding problems. A woman who came to request treatment for her baby’s oral thrush reported the following:

‘I turned to one pediatrician, and he told me that all babies have yeast on their tongues, and it didn’t require treatment. The second one treated it but didn’t relate to me at all … she was very decisive and said, “this is definitely a yeast infection, let’s treat it,” but no one treated me.’ [id #3]

When treating mastitis with antibiotics, physicians advised women to stop breastfeeding, as this excerpt shows:

‘He told me that I had an infection and … needed an antibiotic. He said it automatically, even before he examined me. That I must take an antibiotic. And right away he said, “Because you need an antibiotic you can’t breastfeed him.” So, I asked him why I couldn’t breastfeed, and he said to me “because it can give the baby diarrhea if you have an infection.”‘ [id #10]

In another example, a woman came to her physician and presented her plan to become pregnant while breastfeeding:

‘He started to talk to me about birth control. I said, “No, we don’t need birth control because we want to become pregnant.” And then he said that it wasn’t good when you were breastfeeding. Both because you can’t become pregnant while breastfeeding, and also because it wasn’t healthy or something like that.’ [id #11]

Contradictory information from different professionals

Women felt they had received conflicting information regarding correct breastfeeding behavior from various HCPs, especially physicians and nursing counsellors.

‘I continued to breastfeed. But there were many conflicts. Basic things like nursing counsellors saying I should breastfeed on demand, when the baby wants it, at least … at the beginning. And [the physician] said to me, “That’s completely wrong, the baby needs to eat every three hours. If you feed him more often than every three hours, it causes gas.”‘ [id #12]

Mothers’ preference for alternative resources over medical treatment for breastfeeding problems

For this theme, we identified five subthemes: lack of trust in PCPs regarding breastfeeding issues, mothers’ preference for individualized breastfeeding counselling, mothers’ preference for maternity and childcare nurses, mothers’ preference for mothers’ groups (with virtual access or in-person meetings), and mothers’ preference for family and friends.

Most women reported that they preferred the above-mentioned alternatives to their physicians. It seems that lack of trust has led women to turn to breastfeeding counsellors, nurses, mothers’ groups, or family and friends rather than to their own physicians. Women reported that they trusted these people more than they did their physicians regarding breastfeeding advice and felt more comfortable with them.

Lack of trust in PCPs regarding breastfeeding issues

Most women in this study expressed their lack of trust in their physicians regarding breastfeeding issues. They felt that physicians lacked knowledge and tools with which to address these problems.

‘It’s like grabbing someone in passing on the street, like involving the grocer in breastfeeding problems. It seems disconnected to me.’ (relating to the pediatrician) [id #11]

‘I really like my family doctor. I just didn’t feel that this was something that… I needed her for. I didn’t think it was relevant.’ [id #1]

‘I don’t really see a situation in which someone else can help me … not the family doctor, not the gynecologist.’ [id #4]

Mothers’ preference for individualized breastfeeding counselling

Most women felt confident discussing their breastfeeding issues with individual breastfeeding counsellors. Most mentioned that they had met a counsellor immediately after delivery.

‘If I was seeking advice, I might go to a breastfeeding counsellor, not necessarily to a doctor.’ [id #8]

‘The Maccabi breastfeeding counsellor, I invited her to my house, and she helped me. And in general, you can read a lot in Facebook groups on the internet about whatever is needed.’ [id #7]

‘So, straightaway I spoke to the breastfeeding counselor. That is, I also spoke to all the counsellors at the hospital, but a day later I already had a Maccabi breastfeeding counsellor.’ [id #6]

Mothers’ preference for maternity and childcare nurses

Women in Israel are advised to see childcare nurses seven to ten days after delivery, and then again, every month or two. Most childcare nurses are qualified breastfeeding advisors or counsellors.

‘They say that after three days you have to go to the maternity and childcare center, so I made an appointment. And she calmed me down. She sat me down physically … on the breastfeeding couch and showed me how to breastfeed with the silicon nipple.’ [id #11]

‘The Maccabi maternity and childcare centers are very, very encouraging. I didn’t feel tense at all. They encouraged me, gave me tools . . . more appropriate nursing schedules, and stuff like that.’ [id #1]

Mothers’ preference for frontal or virtual mothers’ groups

Many women told us they attended mothers’ groups, such as La Leche League, to receive support and assistance with breastfeeding issues. There are also virtual groups on social media (especially Facebook) where mothers can share their difficulties and receive help from other mothers.

‘When you give birth, there are all kinds of groups here. You’re already a mother for the third time, and you have friends, there are mothers from the nursery school. There are all kinds of groups whose advice at times helps more than medical opinion.’ [id #6]

Mothers’ preference for family and friends

Other important sources of support and advice were women’s family and friends.

‘I got a lot of support from the family. And … from friends who were also breastfeeding and said to each other “it’s OK, you’ll get through the first three weeks, you get past it. It’s hard at the beginning, it passes.” All kinds of things, you know, things that really helped me carry on … tips that I got from friends, and yes, in general, from other mothers.’ [id #12]

Mothers’ suggestions for primary care physicians

We identified four subthemes of this theme: improving doctor–patient communication, initiating prenatal dialogue on breastfeeding, expanding professional knowledge on breastfeeding, and increasing the availability of treatment for breastfeeding problems.

Improving doctor–patient communication

Women advised physicians to communicate more, be pleasant and polite, and take a genuine interest in breastfeeding issues. Physicians should emphasize the mother’s feelings (her mood). Another suggestion made by several women was not to pressure patients excessively about breastfeeding and to accept and support their decisions regarding whether or not to breastfeed.

‘The doctor should be polite, nice. The communication should really be good; they should really take an interest and ask questions. It is really convenient for me if they are available over the Internet. That’s ideal ...’ [id #10]

‘It’s very important to show the whole picture. Every coin has two sides. [Doctors] do encourage [women] to breastfeed, and that’s good, that’s praiseworthy. But not every woman can breastfeed. And in the end, in my opinion, they do put a lot of emphasis on [breastfeeding], and some women can’t [breastfeed] and then, in the end, they feel bad about themselves that they can’t do it.’ [id #11]

‘A lot of attention [should be given] to how the mother feels, because I think that it has a great effect on breastfeeding. How she feels, how tired she is, what her mood is like, what the source of her support is. I think that these things have a great effect on breastfeeding.’ [id #9]

Initiating prenatal dialogue on breastfeeding

Women suggested that physicians initiate dialogues on breastfeeding during the pregnancy to increase the likelihood of successful breastfeeding.

‘If a woman comes prepared … the path to breastfeeding is much easier for her. If someone who is an authority, like her gynecologist, whom she trusts … throughout the pregnancy … [says something] like, “Sure, nurse the baby. Why not? That’s excellent,” he doesn’t have to say anything else. He doesn’t have to advise her on anything, just to support this thing.’ [id #3]

Expanding professional knowledge on breastfeeding

Most women suggested that physicians expand their knowledge on breastfeeding so that they can provide good therapeutic options for women.

‘Yes, I would be really happy to know whom I could turn to if my breasts were uncomfortable … if I had pain … or something like that. Because nobody actually is responsible for this, like medical breastfeeding. No one actually deals with it. Pediatricians only deal with this within the context of nutrition for babies.’ [id #6]

‘In a utopian world, doctors would be trained … even on the basic things that are common in the community. They don’t have to know the complex clinical things on breastfeeding. But at least the things that are seen in the community. Mastitis, and obstructed ducts, and yeast infections, and all these things … these are the difficulties … most women face.’ [id #3]

‘They should know the basic things, what to [prescribe]. Which antibiotic to give, which ointment … how to advise the woman… and, if necessary, they should refer [her] to a nursing counsellor … from the HMO, or to … professionals who know how to manage the things that they don’t know how to cope with.’ [id #3]

Increasing the availability of treatment for breastfeeding problems

Women suggested that physicians increase their appointment availability for the treatment of breastfeeding problems and lengthen their appointments.

‘Pediatricians are OK, but you feel like they are always in a terrible rush … you feel as soon as you sit down that you have to get up.’ [id #6]

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