“Navigating Emotional Turbulence of Exclusive Breastfeeding”: A qualitative study

“Navigating Emotional Turbulence of Exclusive Breastfeeding”: A qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “Navigating Emotional Turbulence of Exclusive Breastfeeding”: A qualitative study Zukiswa T Dasheka, Ntombana M Rala This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7233573/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Exclusive breastfeeding (EBF) during the first six months of life is vital to infant health, yet remains as low as 34% in South Africa. While clinical and systemic challenges to EBF are well documented, emotional experiences particularly among first-time mothers are underexplored. Guided by Mercer’s Maternal Role Attainment theory, this study aimed to explore the emotional journey of first-time mothers as they initiate and maintain EBF in Buffalo City Municipality, Eastern Cape. Methods A qualitative, exploratory, descriptive, and contextual design study was conducted with ten purposively selected first-time mothers who had chosen to breastfeed exclusively. In-depth semi-structured interviews were conducted in isiXhosa or English. Transcripts were thematically analysed using Tesch’s approach. Trustworthiness was enhanced through corroboration with the participants and by engaging with colleagues or experts to review interpretations and findings, minimising researcher’s bias. Results Two key themes emerged: ( 1 ) the emotional journey during the initiation of EBF and ( 2 ) emotional dynamics in the maintenance of EBF. Mothers reported both positive emotions (pride, fulfilment, joy) and negative emotions (frustration, guilt, shame, confusion). Perceived milk insufficiency, infant distress, and conflicting advice from healthcare workers and family were major emotional triggers. Emotional resilience was reinforced by peer and professional support. These stages of emotional development reflected Mercer’s theory of maternal role attainment. Conclusions The emotional fluctuations first-time mothers experience during EBF are real and justified. Mercer’s theory confirms that maternal role development is an evolving psychosocial process. EBF support must therefore address not only technical knowledge but also emotional adaptation. Policies should integrate emotional and psychosocial support into breastfeeding promotion frameworks. Exclusive breastfeeding first-time mothers maternal role attainment emotional experience qualitative study Background Exclusive breastfeeding (EBF) is widely recognised for its role in reducing infant morbidity and mortality ( 1 ). The World Health Organisation (WHO) recommends EBF for the first six months of life ( 2 ). However, South Africa continues to report alarmingly low rates of EBF, with only 34% of infants meeting the six-month recommendation ( 3 ). Most interventions to increase EBF have focused on physical or informational barriers ( 4 , 5 ). Yet a growing body of research suggests that emotional experiences, such as feelings of failure, guilt, or isolation, play an important role in EBF discontinuation, particularly among first-time mothers, which needs exploring ( 6 ).These emotional experiences may highlight the vulnerability of first-time mothers during exclusive breastfeeding (EBF), a vulnerability further compounded by challenges such as adult-infant relationships shaped by existential and social conflicts in child-rearing ( 7 ). Moreover, breastfeeding is a physiological process influenced by the mother’s body’s responses to stress or excitement ( 8 ). Breastfeeding, therefore, affects mothers’ moods and stress levels due to increased oxytocin and prolactin levels coupled with lowered levels of adrenocorticotropic hormone (ACTH) and cortisol (stress hormones) ( 8 , 9 ). Finally, there is also a psycho-social aspect that influences first-time mothers in the form of social expectations versus their norms and values ( 7 ). These norms include the fact that mothers who successfully breastfeed are labelled as good mothers, while those who struggle with or stop the practice are ostracised and labelled as bad and unnatural. Consequently, this leads to first-time mothers experiencing both positive and negative feelings within the continuum of EBF. It was thus critical to explore the emotions experienced by first-time mothers during EBF to improve maintenance and support. This study was framed within Mercer’s Maternal Role Attainment (MRA) Theory, which conceptualises the transition to motherhood as a psychosocial developmental process and emotional journey through four phases: anticipatory, formal, informal, and personal ( 10 ). Each stage involved changes in identity, behaviour, and emotional perception, all of which were impacted by emotional experiences and external support. This framework was particularly relevant to understanding first-time mothers who experienced a range of emotions from joy and pride to guilt, shame, and confusion and who struggled with identity shifts, unrealistic expectations, and inconsistent support. Understanding these emotions was critical in developing support systems that acknowledge breastfeeding as both a physiological and psychosocial endeavour. Methods Study Design The aim was to explore the emotions experienced by first-time mothers during EBF to improve maintenance and support. This study adopted a qualitative approach following an exploratory-descriptive-contextual design grounded in a constructivist paradigm, allowing for a deep understanding of mothers’ lived emotional experiences ( 11 ). Ten first-time mothers who had given birth to live, full-term, healthy infants in one of the community health centres (CHCs) or hospitals, from Buffalo City Municipality (BCM), Eastern Cape (EC), South Africa, chose EBF were purposively selected. All participants who planned and had initiated EBF, regardless of whether they maintained EBF for six months or not participated in the study. The Eastern Cape has the highest unemployment rate in South Africa, at 41.4%. BCM is made up of both urban and rural areas with low socio-economic households, with the highest informal settlement in EC at 3.1%. The Rural Development Plan (RDP) housing and an average household size of 3.9 for EC, the highest in South Africa. The setting influenced first-time mothers 'choice of EBF ( 12 ). The University Research Ethics Committee granted ethical approval for this study, while the Eastern Cape Provincial Department of Health and the BCM sub-district health permitted the researcher’s access to the relevant health facilities ( 13 ). Informed consent was sought from participants. Data collection involved semi-structured, face-to-face interviews, conducted in isiXhosa or English ( 13 ). Interviews lasted 45–60 minutes and were audio-recorded with consent at their homes or the local clinic. Field notes were also taken. Pseudo-names (#1, #2, #3, etc.) were given to the first-mothers to ensure confidentiality. The principle of data saturation was adhered to ( 14 ). Audio recordings were transcribed verbatim, and IsiXhosa versions were translated into English by the first author and back translated by a colleague not involved in data collection. Thematic analysis was performed using Tesch’s eight-step approach. Coding was supported by manual categorisation and reviewed by a co-coder to ensure consistency and triangulation ( 13 ). Trustworthiness was observed by following the principles of transferability, confirmability, dependability, and credibility ( 14 ). The researchers allowed anyone to decide on the extent to which the findings could be transferred to other settings or groups based on the degree of similarity to the BCM, through the full presentation of the context, and characteristics of first-time mothers. Since the study further utilised an independent translator to back-translate the translated transcripts to the original language of the interview, confirmability was ensured through the checking of accuracy. Furthermore, the researcher confirmed the study’s dependability through the analysis and coding of data recorded in the transcript, waiting at least a day or two to re-code it and compare the results before combining two or more transcripts. To ensure the credibility of the data, two researchers independently coded and interpreted the data, providing a basis for reflective discussions and analysis. For data analysis, Creswell's steps of thematic analysis were used ( 13 ). Codes, categories, sub-categories, and themes were then formulated ( 14 ). Findings Two themes emerged from the data, namely, Emotional Journey During Initiation of EBF and Emotional Dynamics in Maintenance of EBF. Theme 1: Emotional Journey During Initiation of EBF These findings resonate with the formal stage of Mercer’s theory, where mothers begin to adopt the maternal role and heavily rely on external guidance. The emotional upheaval noted during this stage often stems from uncertainties and performance anxieties inherent in early mothering. First-time mothers experienced both positive and negative emotions. These emotions were associated with either the perceived successful initiation of EBF or challenges experienced by first-time mothers. Positive Emotions Successful breastfeeding for the first time made them feel happy. These mothers felt good when their babies enjoyed the breast and fell in love with their babies. Many participants described feelings of joy, pride, and achievement upon successfully awakening their motherly instinct, initiating breastfeeding. One mother reflected: “ I was happy, it feels good because he can breastfeed.” (P4) “I was happy because they are my first babies, I breastfed them with enthusiasm because I am their mother.” (P8) “ I became happy seeing him suckling because my wish is to breastfeed. I am happy because ultimately that was my main aim …” (P7) “ It feels good, alright, he enjoys the breast. It is nice, he will smile, stop sucking, smile, laugh and enjoy, it is nice. I enjoy breastfeeding” (P3) "I am full of love towards my baby, and I am going to breastfeed for six months.” (P9) Negative Emotions Conversely, early breastfeeding was often associated with pain, fear, and helplessness. Challenges with latching and a lack of immediate success created self-doubt: “ I was shaking. How am I going to hold him?” (P5) “ I was afraid to put the nipple in. I was afraid to breastfeed, I was afraid now because breastfeeding was painful” (P9) “ I was stressed because they were small, and I was really stressed, such small children I have never seen.” (P8) “… from that day I delivered, how small my baby was. I was scared of him, I did not even have hope that he would survive .” (P2) “I used to have stress, … so maybe that is what affected me with my breastmilk. I was not feeling well.” (P8) First-time mothers were worried about several issues, not knowing why the baby cries, the possibility of HIV infections and relationships with other family members. Key triggers included perceived milk insufficiency, baby distress, and mixed messages from healthcare workers and families. Peer and nurse support were reported as helpful in mitigating emotional distress. “There are so many things that I was afraid of, such as when the baby is crying, you do not know why he is crying, you also just break down and see yourself crying too.” (P1) “ I was scared …afraid, I had not tested for HIV at that time.” (P5) “ Bad things ‘said by my mother do not sit well with me, and they make me feel sad, furious. I become stressed. I go now and express the breast outside and come now and breastfeed.” (P5) One mother reported being annoyed because of a lack of practical support during the initiation of breastfeeding. “The nurses just told me verbally to breastfeed. She is telling you that no put the breast in … while passing by.”(P1) These experiences correspond with the formal stage of Mercer’s theory, where new mothers rely on external validation and instructions while struggling to internalise the maternal role. Theme 2: Emotional Dynamics in Maintenance of EBF As first-time mothers gained experience, many entered Mercer’s formal, informal and personal stages, developing their style of mothering and deriving confidence from mastery and emotional connection. Emotional resilience, as seen in mothers who overcame frustration or confusion, aligns with Mercer’s assertion that personal validation and social reinforcement are key to successful role attainment. Satisfaction and Confidence As breastfeeding progressed, many mothers reported emotional satisfaction and stronger bonds with their infants. Support from peers, nurses, family and community members bolstered their confidence. “I became happy seeing him suckling because my wish is to breastfeed. I am happy because ultimately that was my main aim…” (P7) “It feels good, alright, also he enjoys this breast. It is nice, he will smile, stop sucking, smile, laugh, and enjoy, it is nice. I enjoy breastfeeding.” (P3) "I am full of love towards my baby when I am going to breastfeed for six months.” (P9) “In maternity, we are given information whether you are going to breastfeed your baby or bottle feed only.” (P7) “ At the clinic, they say if you are schooling or there is a place you are in a hurry to go to pour your milk into something." (P3) “ At the clinic, we are taught to exclusively breastfeed the baby and then give food and other things after six months." (P1) "The nurses really supported us, shame, when you explain that you are struggling, the breasts are dry, they inject you or give you an injection. We were taught not to stress." (P8) “ His weight was already increased; the nurses said, 'Well done. I love what you have done.'" (P5) “ My mother motivated me to drink tea continuously, to keep full and often drink water so that the baby will be able to breastfeed and get milk.” (P4) "I was not even able to hold him, how am I going to hold him? The Nurse showed me how to do it. Even when breastfeeding, what to do?" (P3) “They said I need to hold him at the back as if holding the back of the head. I did not know” (P10) , These supportive acts increased the first-time mother’s confidence and lessened stress levels. Frustration and Guilt Mothers experienced frustration due to inconsistent advice from healthcare providers and family members. Cultural expectations and pressure to supplement caused emotional turmoil. One mother experienced maltreatment from the family, leading to feelings of despair, but she continued to maintain exclusive breastfeeding as she enjoyed breastfeeding her baby. “At night I am just crying, late and in the morning, I am still crying. All the time I am cursed at home.” (P5) "My mother said, 'We did not grow up like this, we fed children roasted this and that." (P3) “I used to have stress, … so maybe that is what affected me with my breastmilk. I was not feeling well.” (P8) “…In our homes, you are shown the thing this way but when you arrive at the clinic, all of that is criticised…” “…At home you are told to use the second finger next to the “He was crying… my cousins, my friends came to see the baby and they already have children, said ‘I did not breastfeed … I bought formula… buy him formula milk.” (P3) "I did not want anyone who is going to say, 'No feed, steal a spoon for him or two spoons of porridge. Yes, there are such ones, who say, 'No, this child is not getting enough from the breast.” (P7) “I do not feel well because my friends want me to be able to leave the baby behind to go out with them. So I do not feel well.” (P9) "…In our homes, you are shown the thing this way, but when you arrive at the clinic, all of that is criticised … the thumb and the one next to it, you put the breast in and support with your thumb.” (P1) While the cultural and family expectations brought about stress, these afforded the first-time mothers growth in the motherhood role, thus resilience grew. Support and Resilience Mothers who maintained EBF credited peer counselling, internal motivation, and emotional resilience. These coping mechanisms indicate progression toward Mercer's informal and personal stages, where mothers become confident and self-directed. Most mothers enjoyed the support from the family members, friends and other mothers in the delivery unit, whom they deemed more experienced in breastfeeding than they were. “ I do not have a mother anymore, it is just me and the man of the house, … he supports me to breastfeed” (P2) “ My mother … assists me, she shows me how I must breastfeed" (P4) “ It is my grandmother and my older sister, my family and my cousins. When I have a problem, I tell them." (P6) "My Aunt taught me, showing me how the breast is held. My cousin sister had two children already, so she supported me. At home, they said I must breastfeed until six months …" (P9) “ My sister said … my mother-in-law said …. It is just general people from the locality” (P7) “ There is one of my friends from King William’s Town that is also a mother” (P1) “Another lady I was with there said it is not the first time she is having a baby, I must request tablets to produce milk. She said ‘I have seven children but my children, I do not have a child that I say he is not breastfeeding.” (P7) With time, first-time mothers develop a sense of motherhood that allows them to distinguish between good and bad advice. These mothers explained the need to reject unhelpful advice while accepting good advice. “… your child will never gain weight. Your child will never grow well because you are exclusively breastfeeding. Give him porridge. Do not listen to a friend because a friend sometimes misleads” (P5) “ People from the streets will advise them wrong things. Their motive … is that as she is getting the grant on the date for grant pay-outs, they want to go with her to the shebeen." (P6) Emotional support on socio-cultural values for first-time mothers allowed the mothers to enjoy motherhood, be resilient and overcome challenges faced and thus maintain EBF. Discussion Mercer’s Maternal Role Attainment (MRA) theory provides a comprehensive framework for understanding the emotional and psychosocial transitions of first-time mothers during exclusive breastfeeding ( 15 ). The process of becoming a mother as a psychosocial journey through four stages: anticipatory, formal, informal, and personal. These stages aligned closely with the findings of this study, revealed that emotional experiences and support systems significantly impacted the initiation and maintenance of EBF ( 10 ). The anticipatory stage, occurred during pregnancy, characterised by preparation and expectation regarding motherhood and breastfeeding ( 15 ). However, this study highlighted a gap between the preparation received during antenatal care and the reality of initiating EBF. Despite receiving information on the benefits of EBF, first-time mothers reported emotional distress when faced with challenges such as latching difficulties, infant distress, and perceived milk insufficiency ( 16 ). The mismatch between expectations and reality often led to negative emotions such as fear, stress, and self-doubt, as mothers struggled to adapt to their new roles ( 7 ). For instance, participants expressed concerns about their ability to hold the baby properly or manage breastfeeding pain. These challenges underscore the need for emotional readiness and tailored antenatal preparation that goes beyond technical knowledge to address the psychological aspects of breastfeeding. The formal stage began during postpartum when mothers started adopting the maternal role, relying heavily on external guidance and support. This resilience was evident in the findings, where mothers reported both positive and negative emotional experiences during the initiation of EBF ( 17 , 4 ). Positive emotional experiences were related to successful breastfeeding initiation and elicited feelings of joy, pride, and fulfilment. Mothers described emotional satisfaction when their babies latched successfully or showed enjoyment during breastfeeding. These positive emotions acted as intrinsic motivators, reinforcing their commitment to EBF ( 17 ). Conversely, negative emotional experiences were associated with challenges such as inconsistent advice from healthcare workers, cultural pressures to supplement breastfeeding, and lack of practical support, which triggered frustration, guilt, and confusion. For example, some mothers felt let down by healthcare providers who gave verbal instructions without hands-on guidance. Others struggled with conflicting advice from family members, which created additional stress. This stage highlights the critical role of external support constructs, including healthcare providers, family, and peers, in shaping mothers’ emotional experiences ( 4 , 10 , 18 ). Positive reinforcement and consistent, practical guidance can enhance maternal confidence, while inconsistent or unsupportive interactions can exacerbate emotional distress. In the informal stage, mothers begin to develop their style of mothering, relying less on external validation and more on their instincts and experiences. The findings show that as mothers gained experience, many transitioned into this stage, becoming more confident and resilient, thus achieving emotional stability and resilience ( 19 ). Mothers who overcame initial challenges reported emotional satisfaction and stronger bonds with their infants ( 20 ). Support from peers, nurses, and family members played a crucial role in building their confidence. For instance, participants expressed gratitude for practical advice from experienced mothers and healthcare workers, which helped them navigate breastfeeding challenges. The informal stage also highlighted cultural and social dynamics as it involved navigating cultural expectations and social pressures. Mothers who received conflicting advice from family members or faced criticism for exclusive breastfeeding demonstrated emotional resilience by rejecting unhelpful advice and focusing on their goals. This ability to filter external influences reflects a growing sense of autonomy and mastery in their maternal roles ( 21 ). The personal stage represents the culmination of the maternal role attainment process, where mothers internalise their maternal identity and derive emotional satisfaction from their achievements. The study findings suggest that mothers who maintained EBF for extended periods experienced a sense of fulfilment and pride, reflecting their progression into this stage. Support constructs, such as emotional and social support, were critical in helping mothers reach this stage ( 4 , 10 ). Peer counselling, family encouragement, and professional guidance provided the emotional reinforcement needed to sustain EBF ( 20 , 22 ). For example, mothers credited nurses and family members for teaching them breastfeeding techniques and motivating them to continue despite challenges. By the personal stage, mothers demonstrated a strong sense of autonomy, confidently rejecting societal pressures to supplement breastfeeding and relying on their instincts to make decisions. This aligns with Mercer’s assertion that personal validation and emotional stability are key outcomes of maternal role attainment. Recommendations These results highlight the importance of training for healthcare providers in emotional counselling and the delivery of consistent breastfeeding messages. Also, the establishment of peer support groups to foster emotional solidarity and reduce isolation becomes critical. Individualised postnatal education that integrates emotional preparation with breastfeeding skills and routine screening for emotional distress during postnatal care would assist. Finally, the use of Mercer’s theory to guide supportive interventions across different stages of maternal role development is suggested. Conclusion The transition to motherhood, as conceptualised by Mercer’s MRA theory, is a dynamic process influenced by emotional and psychosocial factors. The study findings reinforce the need for stage-specific support that addresses both the technical and emotional aspects of EBF. Healthcare systems must integrate emotional readiness into antenatal and postnatal care, providing first-time mothers with consistent, empathetic support throughout their motherhood journey. By addressing the unique emotional experiences of first-time mothers, interventions can enhance maternal confidence, promote EBF continuity, and improve both maternal and infant health outcomes. Abbreviations ACTH: Adrenocorticotropic hormone BCM: Buffalo City Municipality CHC: Community Health Centre EBF: Exclusive Breastfeeding EC: Eastern Cape MRA: Maternal Role Attainment RDP: Rural Development Plan WHO: World Health Organisation Declarations Ethics Approval and Consent to Participate This research was conducted following the Declaration of Helsinki. Ethical approval was obtained from the University of Fort Hare Research Ethics Committee (UREC) RAL011SDAS01, and the Eastern Cape Department of Health issued permission to access participants. Informed consent was secured from all participants before their involvement in the study. The researchers ensured the confidentiality and anonymity of participants throughout the research process and adhered to ethical guidelines to protect their rights and welfare. Consent for Publication Not applicable. Availability of Data and Materials Transcripts and anonymised data are available upon reasonable request via the corresponding author. Competing Interests The authors declare no competing interests. Funding Part of this study and the writing workshop were supported by the Govan Mbeki Research and Development Centre; however, the researchers are independent of the funder. Authors’ Contributions (1) ZTD initiated conception and design, acquisition of data, analysis and interpretation of data, while NMR reviewed, corrected and approved the final product. (2) ZTD drafted the manuscript under the supervision of NMR. Both ZTD and NMR read and approved the final manuscript. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7233573","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509243372,"identity":"80655e4a-80ff-408e-bfbf-7bbd4c07f4b1","order_by":0,"name":"Zukiswa T Dasheka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYFCCBAZmEMHPwPiMRC2SDcxmJGoxOECsFvn25MefCyrS5I1vJLM9YKixA4ocwK+FseeZmfSMMzmG224ksxswHEsGiiTg18IskWDGzNtWwbjtRv4xCQa2A0BnEtDCJpH++TPvvwr7zTOS2SQY/h1gYON/gF8Lj0SOgTRvQ07iBgmgFsa2A0ARArZI8Lwpk+Y5lpY848xjNonEvmQeCQkCtsi3p2/+zFOTbNvfDrTlwzc7Ofl+AragAqBiHlLUj4JRMApGwSjAAQBsUDr0OOjfFAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Fort Hare","correspondingAuthor":true,"prefix":"","firstName":"Zukiswa","middleName":"T","lastName":"Dasheka","suffix":""},{"id":509243373,"identity":"cb6e04bc-e3b4-4aad-a81a-06858cbbb585","order_by":1,"name":"Ntombana M Rala","email":"","orcid":"","institution":"University of Fort Hare","correspondingAuthor":false,"prefix":"","firstName":"Ntombana","middleName":"M","lastName":"Rala","suffix":""}],"badges":[],"createdAt":"2025-07-28 11:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7233573/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7233573/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92266593,"identity":"f54b4645-b392-4160-b181-09e73ae2ddd2","added_by":"auto","created_at":"2025-09-26 13:39:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":485712,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7233573/v1/9a3ba361-25ec-4a5c-8d0b-a7629a8141d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Navigating Emotional Turbulence of Exclusive Breastfeeding”: A qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eExclusive breastfeeding (EBF) is widely recognised for its role in reducing infant morbidity and mortality (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The World Health Organisation (WHO) recommends EBF for the first six months of life (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, South Africa continues to report alarmingly low rates of EBF, with only 34% of infants meeting the six-month recommendation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Most interventions to increase EBF have focused on physical or informational barriers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Yet a growing body of research suggests that emotional experiences, such as feelings of failure, guilt, or isolation, play an important role in EBF discontinuation, particularly among first-time mothers, which needs exploring (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).These emotional experiences may highlight the vulnerability of first-time mothers during exclusive breastfeeding (EBF), a vulnerability further compounded by challenges such as adult-infant relationships shaped by existential and social conflicts in child-rearing (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMoreover, breastfeeding is a physiological process influenced by the mother’s body’s responses to stress or excitement (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Breastfeeding, therefore, affects mothers’ moods and stress levels due to increased oxytocin and prolactin levels coupled with lowered levels of adrenocorticotropic hormone (ACTH) and cortisol (stress hormones) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Finally, there is also a psycho-social aspect that influences first-time mothers in the form of social expectations versus their norms and values (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These norms include the fact that mothers who successfully breastfeed are labelled as good mothers, while those who struggle with or stop the practice are ostracised and labelled as bad and unnatural. Consequently, this leads to first-time mothers experiencing both positive and negative feelings within the continuum of EBF. It was thus critical to explore the emotions experienced by first-time mothers during EBF to improve maintenance and support.\u003c/p\u003e\u003cp\u003eThis study was framed within Mercer’s Maternal Role Attainment (MRA) Theory, which conceptualises the transition to motherhood as a psychosocial developmental process and emotional journey through four phases: anticipatory, formal, informal, and personal (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Each stage involved changes in identity, behaviour, and emotional perception, all of which were impacted by emotional experiences and external support. This framework was particularly relevant to understanding first-time mothers who experienced a range of emotions from joy and pride to guilt, shame, and confusion and who struggled with identity shifts, unrealistic expectations, and inconsistent support. Understanding these emotions was critical in developing support systems that acknowledge breastfeeding as both a physiological and psychosocial endeavour.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe aim was to explore the emotions experienced by first-time mothers during EBF to improve maintenance and support. This study adopted a qualitative approach following an exploratory-descriptive-contextual design grounded in a constructivist paradigm, allowing for a deep understanding of mothers’ lived emotional experiences (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Ten first-time mothers who had given birth to live, full-term, healthy infants in one of the community health centres (CHCs) or hospitals, from Buffalo City Municipality (BCM), Eastern Cape (EC), South Africa, chose EBF were purposively selected. All participants who planned and had initiated EBF, regardless of whether they maintained EBF for six months or not participated in the study. The Eastern Cape has the highest unemployment rate in South Africa, at 41.4%. BCM is made up of both urban and rural areas with low socio-economic households, with the highest informal settlement in EC at 3.1%. The Rural Development Plan (RDP) housing and an average household size of 3.9 for EC, the highest in South Africa. The setting influenced first-time mothers 'choice of EBF (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe University Research Ethics Committee granted ethical approval for this study, while the Eastern Cape Provincial Department of Health and the BCM sub-district health permitted the researcher’s access to the relevant health facilities (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Informed consent was sought from participants. Data collection involved semi-structured, face-to-face interviews, conducted in isiXhosa or English (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Interviews lasted 45–60 minutes and were audio-recorded with consent at their homes or the local clinic. Field notes were also taken. Pseudo-names (#1, #2, #3, etc.) were given to the first-mothers to ensure confidentiality. The principle of data saturation was adhered to (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Audio recordings were transcribed verbatim, and IsiXhosa versions were translated into English by the first author and back translated by a colleague not involved in data collection. Thematic analysis was performed using Tesch’s eight-step approach. Coding was supported by manual categorisation and reviewed by a co-coder to ensure consistency and triangulation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTrustworthiness was observed by following the principles of transferability, confirmability, dependability, and credibility (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The researchers allowed anyone to decide on the extent to which the findings could be transferred to other settings or groups based on the degree of similarity to the BCM, through the full presentation of the context, and characteristics of first-time mothers. Since the study further utilised an independent translator to back-translate the translated transcripts to the original language of the interview, confirmability was ensured through the checking of accuracy. Furthermore, the researcher confirmed the study’s dependability through the analysis and coding of data recorded in the transcript, waiting at least a day or two to re-code it and compare the results before combining two or more transcripts. To ensure the credibility of the data, two researchers independently coded and interpreted the data, providing a basis for reflective discussions and analysis. For data analysis, Creswell's steps of thematic analysis were used (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Codes, categories, sub-categories, and themes were then formulated (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eTwo themes emerged from the data, namely, Emotional Journey During Initiation of EBF and Emotional Dynamics in Maintenance of EBF.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: Emotional Journey During Initiation of EBF\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings resonate with the \u003cem\u003eformal\u003c/em\u003e stage of Mercer’s theory, where mothers begin to adopt the maternal role and heavily rely on external guidance. The emotional upheaval noted during this stage often stems from uncertainties and performance anxieties inherent in early mothering. First-time mothers experienced both positive and negative emotions. These emotions were associated with either the perceived successful initiation of EBF or challenges experienced by first-time mothers.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePositive Emotions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSuccessful breastfeeding for the first time made them feel happy. These mothers felt good when their babies enjoyed the breast and fell in love with their babies. Many participants described feelings of joy, pride, and achievement upon successfully awakening their motherly instinct, initiating breastfeeding. One mother reflected:\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI was happy, it feels good because he can breastfeed.” (P4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I was happy because they are my first babies, I breastfed them with enthusiasm because I am their mother.” (P8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI became happy seeing him suckling because my wish is to breastfeed. I am happy because ultimately that was my main aim …” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eIt feels good, alright, he enjoys the breast. It is nice, he will smile, stop sucking, smile, laugh and enjoy, it is nice. I enjoy breastfeeding” (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I am full of love towards my baby, and I am going to breastfeed for six months.” (P9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eNegative Emotions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eConversely, early breastfeeding was often associated with pain, fear, and helplessness. Challenges with latching and a lack of immediate success created self-doubt:\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI was shaking. How am I going to hold him?” (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI was afraid to put the nipple in. I was afraid to breastfeed, I was afraid now because breastfeeding was painful” (P9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI was stressed because they were small, and I was really stressed, such small children I have never seen.” (P8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“… \u003cem\u003efrom that day I delivered, how small my baby was. I was scared of him, I did not even have hope that he would survive\u003c/em\u003e.” (P2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I used to have stress, … so maybe that is what affected me with my breastmilk. I was not feeling well.” (P8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFirst-time mothers were worried about several issues, not knowing why the baby cries, the possibility of HIV infections and relationships with other family members. Key triggers included perceived milk insufficiency, baby distress, and mixed messages from healthcare workers and families. Peer and nurse support were reported as helpful in mitigating emotional distress.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“There are so many things that I was afraid of, such as when the baby is crying, you do not know why he is crying, you also just break down and see yourself crying too.” (P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI was scared …afraid, I had not tested for HIV at that time.” (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eBad things ‘said by my mother do not sit well with me, and they make me feel sad, furious. I become stressed. I go now and express the breast outside and come now and breastfeed.” (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eOne mother reported being annoyed because of a lack of practical support during the initiation of breastfeeding.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“The nurses just told me verbally to breastfeed. She is telling you that no put the breast in … while passing by.”(P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThese experiences correspond with the \u003cem\u003eformal\u003c/em\u003e stage of Mercer’s theory, where new mothers rely on external validation and instructions while struggling to internalise the maternal role.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Emotional Dynamics in Maintenance of EBF\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs first-time mothers gained experience, many entered Mercer’s formal, informal and personal stages, developing their style of mothering and deriving confidence from mastery and emotional connection. Emotional resilience, as seen in mothers who overcame frustration or confusion, aligns with Mercer’s assertion that personal validation and social reinforcement are key to successful role attainment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSatisfaction and Confidence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs breastfeeding progressed, many mothers reported emotional satisfaction and stronger bonds with their infants. Support from peers, nurses, family and community members bolstered their confidence.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I became happy seeing him suckling because my wish is to breastfeed. I am happy because ultimately that was my main aim…” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“It feels good, alright, also he enjoys this breast. It is nice, he will smile, stop sucking, smile, laugh, and enjoy, it is nice. I enjoy breastfeeding.” (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I am full of love towards my baby when I am going to breastfeed for six months.” (P9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“In maternity, we are given information whether you are going to breastfeed your baby or bottle feed only.” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eAt the clinic, they say if you are schooling or there is a place you are in a hurry to go to pour your milk into something.\" (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eAt the clinic, we are taught to exclusively breastfeed the baby and then give food and other things after six months.\" (P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"The nurses really supported us, shame, when you explain that you are struggling, the breasts are dry, they inject you or give you an injection. We were taught not to stress.\" (P8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eHis weight was already increased; the nurses said, 'Well done. I love what you have done.'\" (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eMy mother motivated me to drink tea continuously, to keep full and often drink water so that the baby will be able to breastfeed and get milk.” (P4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I was not even able to hold him, how am I going to hold him? The Nurse showed me how to do it. Even when breastfeeding, what to do?\" (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“They said I need to hold him at the back as if holding the back of the head. I did not know” (P10)\u003c/em\u003e,\u003c/p\u003e\u003cp\u003eThese supportive acts increased the first-time mother’s confidence and lessened stress levels.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFrustration and Guilt\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMothers experienced frustration due to inconsistent advice from healthcare providers and family members. Cultural expectations and pressure to supplement caused emotional turmoil. One mother experienced maltreatment from the family, leading to feelings of despair, but she continued to maintain exclusive breastfeeding as she enjoyed breastfeeding her baby.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“At night I am just crying, late and in the morning, I am still crying. All the time I am cursed at home.” (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"My mother said, 'We did not grow up like this, we fed children roasted this and that.\" (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I used to have stress, … so maybe that is what affected me with my breastmilk. I was not feeling well.” (P8)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“…In our homes, you are shown the thing this way but when you arrive at the clinic, all of that is criticised…” “…At home you are told to use the second finger next to the “He was crying… my cousins, my friends came to see the baby and they already have children, said ‘I did not breastfeed … I bought formula… buy him formula milk.” (P3)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I did not want anyone who is going to say, 'No feed, steal a spoon for him or two spoons of porridge. Yes, there are such ones, who say, 'No, this child is not getting enough from the breast.” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“I do not feel well because my friends want me to be able to leave the baby behind to go out with them. So I do not feel well.” (P9)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"…In our homes, you are shown the thing this way, but when you arrive at the clinic, all of that is criticised … the thumb and the one next to it, you put the breast in and support with your thumb.” (P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the cultural and family expectations brought about stress, these afforded the first-time mothers growth in the motherhood role, thus resilience grew.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSupport and Resilience\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMothers who maintained EBF credited peer counselling, internal motivation, and emotional resilience. These coping mechanisms indicate progression toward Mercer's \u003cem\u003einformal\u003c/em\u003e and \u003cem\u003epersonal\u003c/em\u003e stages, where mothers become confident and self-directed. Most mothers enjoyed the support from the family members, friends and other mothers in the delivery unit, whom they deemed more experienced in breastfeeding than they were.\u003c/p\u003e\u003cp\u003e“\u003cem\u003eI do not have a mother anymore, it is just me and the man of the house, … he supports me to breastfeed” (P2)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eMy mother … assists me, she shows me how I must breastfeed\" (P4)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eIt is my grandmother and my older sister, my family and my cousins. When I have a problem, I tell them.\" (P6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"My Aunt taught me, showing me how the breast is held. My cousin sister had two children already, so she supported me. At home, they said I must breastfeed until six months …\"\u003c/em\u003e (P9)\u003c/p\u003e\u003cp\u003e“\u003cem\u003eMy sister said … my mother-in-law said …. It is just general people from the locality” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003eThere is one of my friends from King William’s Town that is also a mother” (P1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e“Another lady I was with there said it is not the first time she is having a baby, I must request tablets to produce milk. She said ‘I have seven children but my children, I do not have a child that I say he is not breastfeeding.” (P7)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWith time, first-time mothers develop a sense of motherhood that allows them to distinguish between good and bad advice. These mothers explained the need to reject unhelpful advice while accepting good advice.\u003c/p\u003e\u003cp\u003e\u003cem\u003e“… your child will never gain weight. Your child will never grow well because you are exclusively breastfeeding. Give him porridge. Do not listen to a friend because a friend sometimes misleads” (P5)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e“\u003cem\u003ePeople from the streets will advise them wrong things. Their motive … is that as she is getting the grant on the date for grant pay-outs, they want to go with her to the shebeen.\" (P6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEmotional support on socio-cultural values for first-time mothers allowed the mothers to enjoy motherhood, be resilient and overcome challenges faced and thus maintain EBF.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMercer\u0026rsquo;s Maternal Role Attainment (MRA) theory provides a comprehensive framework for understanding the emotional and psychosocial transitions of first-time mothers during exclusive breastfeeding (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The process of becoming a mother as a psychosocial journey through four stages: anticipatory, formal, informal, and personal. These stages aligned closely with the findings of this study, revealed that emotional experiences and support systems significantly impacted the initiation and maintenance of EBF (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The anticipatory stage, occurred during pregnancy, characterised by preparation and expectation regarding motherhood and breastfeeding (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, this study highlighted a gap between the preparation received during antenatal care and the reality of initiating EBF. Despite receiving information on the benefits of EBF, first-time mothers reported emotional distress when faced with challenges such as latching difficulties, infant distress, and perceived milk insufficiency (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The mismatch between expectations and reality often led to negative emotions such as fear, stress, and self-doubt, as mothers struggled to adapt to their new roles (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For instance, participants expressed concerns about their ability to hold the baby properly or manage breastfeeding pain. These challenges underscore the need for emotional readiness and tailored antenatal preparation that goes beyond technical knowledge to address the psychological aspects of breastfeeding.\u003c/p\u003e\u003cp\u003eThe formal stage began during postpartum when mothers started adopting the maternal role, relying heavily on external guidance and support. This resilience was evident in the findings, where mothers reported both positive and negative emotional experiences during the initiation of EBF (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Positive emotional experiences were related to successful breastfeeding initiation and elicited feelings of joy, pride, and fulfilment. Mothers described emotional satisfaction when their babies latched successfully or showed enjoyment during breastfeeding. These positive emotions acted as intrinsic motivators, reinforcing their commitment to EBF (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Conversely, negative emotional experiences were associated with challenges such as inconsistent advice from healthcare workers, cultural pressures to supplement breastfeeding, and lack of practical support, which triggered frustration, guilt, and confusion. For example, some mothers felt let down by healthcare providers who gave verbal instructions without hands-on guidance. Others struggled with conflicting advice from family members, which created additional stress. This stage highlights the critical role of external support constructs, including healthcare providers, family, and peers, in shaping mothers\u0026rsquo; emotional experiences (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Positive reinforcement and consistent, practical guidance can enhance maternal confidence, while inconsistent or unsupportive interactions can exacerbate emotional distress.\u003c/p\u003e\u003cp\u003eIn the informal stage, mothers begin to develop their style of mothering, relying less on external validation and more on their instincts and experiences. The findings show that as mothers gained experience, many transitioned into this stage, becoming more confident and resilient, thus achieving emotional stability and resilience (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Mothers who overcame initial challenges reported emotional satisfaction and stronger bonds with their infants (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Support from peers, nurses, and family members played a crucial role in building their confidence. For instance, participants expressed gratitude for practical advice from experienced mothers and healthcare workers, which helped them navigate breastfeeding challenges. The informal stage also highlighted cultural and social dynamics as it involved navigating cultural expectations and social pressures. Mothers who received conflicting advice from family members or faced criticism for exclusive breastfeeding demonstrated emotional resilience by rejecting unhelpful advice and focusing on their goals. This ability to filter external influences reflects a growing sense of autonomy and mastery in their maternal roles (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe personal stage represents the culmination of the maternal role attainment process, where mothers internalise their maternal identity and derive emotional satisfaction from their achievements. The study findings suggest that mothers who maintained EBF for extended periods experienced a sense of fulfilment and pride, reflecting their progression into this stage. Support constructs, such as emotional and social support, were critical in helping mothers reach this stage (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Peer counselling, family encouragement, and professional guidance provided the emotional reinforcement needed to sustain EBF (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). For example, mothers credited nurses and family members for teaching them breastfeeding techniques and motivating them to continue despite challenges. By the personal stage, mothers demonstrated a strong sense of autonomy, confidently rejecting societal pressures to supplement breastfeeding and relying on their instincts to make decisions. This aligns with Mercer\u0026rsquo;s assertion that personal validation and emotional stability are key outcomes of maternal role attainment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese results highlight the importance of training for healthcare providers in emotional counselling and the delivery of consistent breastfeeding messages. Also, the establishment of peer support groups to foster emotional solidarity and reduce isolation becomes critical. Individualised postnatal education that integrates emotional preparation with breastfeeding skills and routine screening for emotional distress during postnatal care would assist. Finally, the use of Mercer\u0026rsquo;s theory to guide supportive interventions across different stages of maternal role development is suggested.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe transition to motherhood, as conceptualised by Mercer\u0026rsquo;s MRA theory, is a dynamic process influenced by emotional and psychosocial factors. The study findings reinforce the need for stage-specific support that addresses both the technical and emotional aspects of EBF. Healthcare systems must integrate emotional readiness into antenatal and postnatal care, providing first-time mothers with consistent, empathetic support throughout their motherhood journey. By addressing the unique emotional experiences of first-time mothers, interventions can enhance maternal confidence, promote EBF continuity, and improve both maternal and infant health outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACTH: Adrenocorticotropic hormone\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBCM: \u0026nbsp; \u0026nbsp;Buffalo City Municipality\u003c/p\u003e\n\u003cp\u003eCHC:\u0026nbsp; \u0026nbsp;\u0026nbsp;Community Health Centre\u003c/p\u003e\n\u003cp\u003eEBF:\u0026nbsp; \u0026nbsp; \u0026nbsp;Exclusive Breastfeeding\u003c/p\u003e\n\u003cp\u003eEC: \u0026nbsp; \u0026nbsp; Eastern Cape\u003c/p\u003e\n\u003cp\u003eMRA: \u0026nbsp;Maternal Role Attainment\u003c/p\u003e\n\u003cp\u003eRDP: \u0026nbsp;Rural Development Plan\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organisation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted following the Declaration of Helsinki. Ethical approval was obtained from the University of Fort Hare Research Ethics Committee (UREC) RAL011SDAS01, and the Eastern Cape Department of Health issued permission to access participants. Informed consent was secured from all participants before their involvement in the study. The researchers ensured the confidentiality and anonymity of participants throughout the research process and adhered to ethical guidelines to protect their rights and welfare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTranscripts and anonymised data are available upon reasonable request via the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePart of this study and the writing workshop were supported by the Govan Mbeki Research and Development Centre; however, the researchers are independent of the funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(1) ZTD initiated conception and design, acquisition of data, analysis and interpretation of data, while NMR reviewed, corrected and approved the final product. (2) ZTD drafted the manuscript under the supervision of NMR. Both ZTD and NMR read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the participants and the supporting healthcare facilities in Buffalo City Municipality.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNdlovu S, David-Govender C, Tinarwo P, Naidoo K. Changing mortality amongst hospitalised children with Severe Acute Malnutrition in KwaZulu-Natal, South Africa, 2009\u0026ndash;2018. BMC Nutr [Internet]. 2022;8(1):1\u0026ndash;10. 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J Nurs Heal Care. 2019;4(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEastern Cape Socio-Economic Consultative Council. The 2024 Annual Socio-Economic State of the Eastern Cape Report (SERO). 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW, Creswell JD. Research design: qualitative, quantitative and mixed methods approaches. London: SAGE; 2017. p. 304.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrink H, van der Walt C, van Rensburg G. In: Singh J, editor. Fundamentals of research methodology for healthcare professionals. 4 ed. Cape Town: Juta and Company; 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRafii F, Naeini A, Peyrovi. Hamid. Maternal Role Attainment in Mothers with Term Neonate: A Hybrid Concept Analysis. Iran J Nurs Midwifery Res [Internet]. 2020;(25):304\u0026ndash;13. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijnmr.IJNMR_201_19\u003c/span\u003e\u003cspan address=\"10.4103/ijnmr.IJNMR_201_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTheodorah DZ, Mc'Deline RN. The kind of support that matters to exclusive breastfeeding, a qualitative study. BMC Pregnancy Childbirth. 2021;21(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWitten C, Claasen N, Kruger HS, Coutsoudis A, Grobler H. Psychosocial barriers and enablers of exclusive breastfeeding: lived experiences of mothers in low-income townships, North West Province, South Africa. 2020;1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManggiasih VA, Siwi RPY, Retnaningtyas E. Tarpianie. The Relationship Between Family Support And The Attitudes Of Partworld Mothers In Exclusive Breastfeeding At The Hj Clinic. Tarpianie Amd. Keb Prambon Sidoarjo. J Heal Sci Community. 2024;4(3):195\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eModak A, Ronghe V, Gomase KP. The Psychological Benefits of Breastfeeding: Fostering Maternal Well-Being and Child Development. Cureus. 2023;15(10).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrani P, Mrvoljak-theodoropoulou I, Pechlivani F, Gourounti K, Iliadou M, Palaska E et al. Mothers \u0026rsquo; Breastfeeding Self-Efficacy after a High-Risk or Normal Pregnancy: A Greek Longitudinal Cohort Study. 2024;1803\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpjeldn\u0026aelig;s IO. Mothering in socioeconomically marginalised communities in South Africa: A conceptual development. J Psychol Afr. 2021;31(4):406\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVetty P, Yati A, Dyah J. A qualitative systematic review of family support for a successful breastfeeding experience among adolescent mothers. Open Access Maced J Med Sci. 2021;9:775\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Exclusive breastfeeding, first-time mothers, maternal role attainment, emotional experience, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7233573/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7233573/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eExclusive breastfeeding (EBF) during the first six months of life is vital to infant health, yet remains as low as 34% in South Africa. While clinical and systemic challenges to EBF are well documented, emotional experiences particularly among first-time mothers are underexplored. Guided by Mercer\u0026rsquo;s Maternal Role Attainment theory, this study aimed to explore the emotional journey of first-time mothers as they initiate and maintain EBF in Buffalo City Municipality, Eastern Cape.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative, exploratory, descriptive, and contextual design study was conducted with ten purposively selected first-time mothers who had chosen to breastfeed exclusively. In-depth semi-structured interviews were conducted in isiXhosa or English. Transcripts were thematically analysed using Tesch\u0026rsquo;s approach. Trustworthiness was enhanced through corroboration with the participants and by engaging with colleagues or experts to review interpretations and findings, minimising researcher\u0026rsquo;s bias.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwo key themes emerged: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the emotional journey during the initiation of EBF and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) emotional dynamics in the maintenance of EBF. Mothers reported both positive emotions (pride, fulfilment, joy) and negative emotions (frustration, guilt, shame, confusion). Perceived milk insufficiency, infant distress, and conflicting advice from healthcare workers and family were major emotional triggers. Emotional resilience was reinforced by peer and professional support. These stages of emotional development reflected Mercer\u0026rsquo;s theory of maternal role attainment.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe emotional fluctuations first-time mothers experience during EBF are real and justified. Mercer\u0026rsquo;s theory confirms that maternal role development is an evolving psychosocial process. EBF support must therefore address not only technical knowledge but also emotional adaptation. Policies should integrate emotional and psychosocial support into breastfeeding promotion frameworks.\u003c/p\u003e","manuscriptTitle":"“Navigating Emotional Turbulence of Exclusive Breastfeeding”: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 15:34:51","doi":"10.21203/rs.3.rs-7233573/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"824e2174-b4f2-4168-bceb-dd53a4488a2e","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T13:38:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-04 15:34:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7233573","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7233573","identity":"rs-7233573","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}