Introduction

Breastfeeding is the optimum feeding method for infants until two years, and this practice has been recommended until the sixth month for all newborns and supported for over two decades by the World Health Organization (HWO) and healthcare professionals in premature newborns (PN)(^{Lee & Huang, 2022}; ^{World Health Organization, 2018}). Nevertheless, mothers' breastfeeding decisions are a complex and multifactorial process, thus many stop earlier than they intended before giving birth. WHO estimates that 15 million babies are born preterm (under 37 completed gestation weeks) every year across 184 countries, ranging from 5% to 18% (1 in 10). The evidence strongly supports that breastfeeding newborns receive the best nutrition and optimal nurturance due to close physical contact with their mothers. Breast milk is a complete, natural, alive and suitable food (with rare exceptions) for almost all newborns (Lee & Huang, 2022; ^{Sánchez et al., 2021}) with extensive benefits, especially in PN. Breast milk protects against infections and allergies in the first months of life (Sánchez et al., 2021), is crucial for a child´s neuro and psychomotor development and healthy growth, promotes the baby´s better adaptation to food (^{Han et al., 2019}; ^{Monteiro et al., 2020}), and reduces neonatal morbidity and mortality (^{World Health Organization, 2018}).

Breastfeeding advantages are multiple and well-known for mother and child, both in the short and the long term, and worldwide is consensual that the best way to feed a child until six months is exclusive breastfeeding (^{Sánchez et al., 2021}). Nevertheless, almost half of mothers who initiate breastfeeding give up during the first month, earlier than they intended (^{Lima et al., 2019}). Previous positive experiences positively influence the mother's decision to breastfeed (^{Giannì et al., 2016}, 2018) as well as having a partner (Lima et al., 2019).

Prematurity is the most frequent cause of bringing to an end breastfeeding, and the barriers that inhibit breastfeeding are mostly linked to PN (low birth weight, comorbidity, ICU environment) and the mother´s conditions (stress and anxiety about PN clinical situation, pain and difficulty during milk extraction, lack of support from health professionals) (^{Matriano et al., 2022}). Overall, prematurity disturbs the maternity project since introduces a gap between the imaginary baby(expected) and the real baby (^{Lee & Huang, 2022}). Breastfeeding a PN in the ICU stressful and hostile environment is a significant challenge for mothers, mainly due to emotional stress and insecurity (Matriano et al., 2022). In ICU mothers face difficulties that can affect their breastfeeding process and decision, such as concerns about PN's clinical condition, early milk extraction, PN's difficulty in suction-swallow-breath coordination (physiological and neurological immaturity), lack of privacy for lactation, and distance from home (^{Bezerra et al., 2017}).

However, literature is scarce focusing on women's feelings about their breastfeeding decisions. Studies focus mostly on the factors that influence women’s pre-birth decisions but fail to point out the reasons that influence mothers’ decisions to stop breastfeeding during the postnatal period, and about personal and contextual features from the mother-centred perspective (breastfeeding giving up too early) (^{Abugov et al., 2021}). From a maternal perspective, knowing the factors that influence the breastfeeding of PN and outlining woman-centred recommendations is relevant to practice. Thus, mapping the needs and challenges experienced by mothers with their PN is the starting point for optimised breastfeeding. In this sense, this scoping review aims to map factors that influence the breastfeeding of PN from the maternal perspective.

1. Methods

The scoping review (SR) methodology follows the Joanna Briggs Institute (JBI) recommendations and adheres to the Preferred Reporting Items for Systematic Reviews (PRISMA-ScR)(The Joanna Briggs Institute, 2017). The SR protocol follows six consecutive stages: (1) formulation and identification of the research question and objective; (2) identification of potentially relevant studies, which will enable the extent and scope of the review's purposes; (3) selection of eligible studies, according to the criteria predefined (4) data extraction and coding, mapping; (5) compiling, summarizing and interpreting the results using a qualitative thematic analysis with the objective and question; (6) reporting the results, identifying the implications for practice or research (^{Arksey & O’Malley, 2005}).

The research question is defined using the acronym PCC (Population-Concept-Context), and the respective results of interest. The SR started with the research question: What factors influence the breastfeeding of PN, according to the mother's perspective? followed by the search strategy protocol using the Boolean operator (AND) or (OR) in English. The database search strategy protocol combined central concepts using PCC acromion (P=Population: Mothers of Premature Newborns, C=Concept: Maternal breastfeeding, and C=Context: Influencing Factors). The search script terms match the Health Science Descriptors with the exact terms Breast Feeding (Mesh ID: D001942), Health Promotion (Mesh ID: D006293), Mothers (Mesh ID: D009035), Nursing (Mesh ID: D009729), Infant, Extremely Premature (Mesh ID: D0062071). Database search was conducted on the Web of Science, Core Collection via Web of Science, B-On with full-text, and PubMed, carried out between December 2019 and January 2021, available in full text in Spanish, Portuguese, and English. The final search protocol included #1: (“mothers*”)AND (“breast feeding*”) AND (“Nursing*”) (“Infant, Extremely Premature*); #2: (“mothers*”)AND (“breast feeding*”) AND (“Nursing*”) (“Infant, Extremely Premature*)AND (“Health Promotion”*); #3: (“mothers*”) AND (“breast feeding*”) AND (“Nursing*”) (“Infant, Extremely Premature*) OR (“Health Promotion”*); #4: (“mothers*”)AND (“breast feeding*”) AND (“Nursing*”) (“Infant Premature*) AND (“Health Promotion”*). The search was also carried out on grey literature using Google Scholar with the following terms: "mothers/mothers AND breastfeeding/breastfeeding AND premature newborn/premature infant". These sources were included to capture all existing research about mothers of PN with no time limit; studies that explore breastfeeding in PN and factors that influence breastfeeding. Figure 1 presents the PRISMA-ScR flowchart diagram to systematise the research process for data extraction.

Figure 1 PRISMA-ScR flowchart diagram (^{The Joanna Briggs Institute, 2017}) 

To assess the relevance and trustworthiness, two authors independently appraised all included articles using the JBI. Studies were excluded if including nurses, health professionals or informal family caregivers as participants; case studies and theoretical reviews; and studies not in Spanish, Portuguese and English. The inspection process reached a consensus and generated fifteen records published, but only ten studies met the inclusion criteria for further analysis. Three researchers (SCMR, CAVS, and PMAP) screened the titles, abstracts, and then full texts of the remaining fifteen articles according to inclusion and exclusion criteria. The full-text papers were read thoroughly, several times to capture all relevant information and to ensure that nothing important was missed. Disagreements were resolved by consensualizing with the researchers (MJN and DT) when required, and finally, results were summarized and reported.

2. Results

3. Discussion

The current findings reflect that breastfeeding mothers' main difficulties are the anguish of PN´s clinical instability, PN´s separation, and the stress involved in maintaining breastfeeding (^{Amando et al., 2016}; ^{LoVerde et al., 2018}; ^{Méio et al., 2018}). Parents of PN experience guilt, anxiety, impotence, uncertainty, fear for the baby's future, and suffering associated with routine changes and personal and professional life (^{Almeida et al., 2020}). PN requires specialized ICU for a long time, undermining mothers' expectations and ideals about motherhood during pregnancy meddling in the breastfeeding process (^{Matriano et al., 2022}). Among the difficulties, mothers indicate the NICU environment, surrounded by technologies, as a barrier to natural contact between mother and children and breastfeeding (Amando et al., 2016; ^{Giannì et al., 2016}, 2018). Overall, mothers recognize that breastfeeding is essential for the PN hospital recovery, growth and healthy development (^{Bezerra et al., 2017}). Nevertheless, maintaining lactation this a complex process that faces several obstacles that mothers must learn to go through (Méio et al., 2018), like the torment of PN hospitalisation caused by the PN´s clinical instability, low birth weight, comorbidities, and immaturity (ineffective holding and sucking) (^{Lee & Huang, 2022}). But also, due to the mother's insufficient milk and/or delayed lactation, breast pain, discomfort, difficulty in extracting milk, and lack of support from health professionals (^{Yang et al., 2019}), worry, and a sense of abandonment (^{López-Maestro et al., 2017}). The adjusting process to the new reality of motherhood, taken by surprise after childbirth, mothers of PN demonstrate greater ambivalence about their feelings, and several emotions arise, like alienation, despair, and grief, often due to the expectations created during pregnancy (Lee & Huang, 2022). Mothers described themselves as ambivalent, like swaying between hope and hopelessness and fear of the affective bond with the baby in the first weeks (López-Maestro et al., 2017). The combination of adverse factors such as the risk of morbidity and mortality of the child; the crisis atmosphere associated with the NICU; the inevitable separation from the RN; time and cost of hospitalization, produce severe impacts on parents (Matriano et al., 2022). In these circumstances, mothers are more likely to develop blues and/or postnatal depression (Lee & Huang, 2022), and authors argue that a woman’s decision to breastfeed results from the balance between her intrinsic and extrinsic factors, where she tries to find a balance (Matriano et al., 2022). Despite multiple barriers, mothers of hospitalised PN perceived breastfeeding as an accomplishment achieved largely through the joint efforts of the mother-child binomial (Bezerra et al., 2017). However, after the shock and surprise phase, the parents start the second stage - the bonding process, starting to build a relationship with the new and real baby, not the idealised one (López-Maestro et al., 2017). This process between the mother and the PN must begin as early as possible, for instance, through the kangaroo technique with skin-to-skin contact and frequent breastfeeding (^{Bruce et al., 2022}; ^{Pereira et al., 2015}). The Kangaroo technique increases the mother's self-esteem, sense of competence and confidence in caring for the baby, and promotes bonding and trust ensuring a greater success rate in breastfeeding (Bruce et al., 2022; ^{Sweeney et al., 2017}). Also, reduces mothers' anxiety and stress, eases breastfeeding (Bezerra et al., 2017; Méio et al., 2018a) is associated with a decrease in the NICU length stay, the risk of post-traumatic stress and post-partum depression (^{Abugov et al., 2021}).

Parenthood adjusting to PN is an urgent issue, thus NUIC professionals must find supportive environmental mechanisms to help families overcome this complex transitional crisis, especially mothers (^{Abugov et al., 2021}). The opportunity to stay with the PN during hospitalisation promotes the mother-infant bond and strengthens, mothers´ calmness and happiness, which in turn, increases milk production (^{Lee & Huang, 2022}). Mothers must be empowered by healthcare staff to increase self-efficacy and reduce negative feelings and emotions. The NICU´s multidisciplinary team is crucial in this adaptation process and must adopt the family-centred care model, which focuses on strengthening affective bonds in the family by providing continuum support from the PN's admission to the home, after discharge (Lee & Huang, 2022) since mothers of PN need to be supported by partners, family, and friends (^{LoVerde et al., 2018}). Particularly, NICU nurses are key elements in building flexible care plans to prepare parents for autonomous parenting based on their needs, and respect for their culture and beliefs (Abugov et al., 2021; ^{Bruce et al., 2022}). The nursing strategies to provide parents with emotional and practical support include educational and nutritional programs, developing coping skills, support groups, NP-adapted developmental care, telenursing, and spiritual care (Lee & Huang, 2022). Furthermore, nurses are actively facilitating agents helping mothers gain confidence and security, defeat fears, clarify doubts and help support the difficulties that arise in the breastfeeding process of PN (LoVerde et al., 2018). Supporting mothers towards breastfeeding practices must begin by focusing on the features tailored for a woman's comfort so she can feel safe about breastfeeding decisions.

The study has some limitations. Several papers were excluded due to the Chinese language, and the time interval of the article´s search protocol may have excluded relevant articles. These results encourage an active change in healthcare practices like woman-centred care, family education about breastfeeding and mother-child bonding. Further research must be conducted to provide evidence for mother-child bonding practices and a supportive breastfeeding environment. Also, future investigations must study the weight of the difficulties most reported by mothers in dropout breastfeeding PN. Finally, a systematic review will assess the effectiveness of nurse strategies and interventions to assist and support optimal breastfeeding practices.

Conclusion

From the mothers' perspective, the factors that positively and negatively influence the breastfeeding process of PN are complex and multifactorial. The inhibitors most reported were fear, anxiety, insecurity, stress, prematurity, pain and discomfort, the NICU environment, mother and child separation, and difficulty in breastfeeding and extracting milk. As positive factors, mothers mention active support and guidance from health professionals to establish and sustain good breastfeeding practices, and to feel safe and comfortable. The review reinforces the nurses' role as active players in promoting, protecting, and educating families about women's breastfeeding needs and mother-child bonding. Approaches to promote and support breastfeeding must be mother-centred and consider the mother's social network, where she can feel safe and comfortable about breastfeeding.

Author contributions

Conceptualization, M.J.N., S.R., C.S., P.P. and D.T.; data curation, M.J.N., S.R., C.S. and P.P.; formal analysis, M.J.N., S.R., C.S., P.P. and D.T.; investigation, M.J.N., S.R., C.S., P.P. and D.T.; methodology, M.J.N., S.R., C.S., P.P. and D.T.; project administration, M.J.N.; resources, M.J.N., S.R., C.S., P.P. and D.T.; supervision, M.J.N. and D.T.; visualization, M.J.N., S.R., C.S., P.P. and D.T.; writing-original draft, M.J.N., S.R., C.S., P.P. and D.T.; writing-review and editing, M.J.N. and D.T.

Conflicts of interest

The authors declare no conflict of interest.