Explaining the cultural components of breastfeeding consistency in premature infants: A descriptive exploratory study

Explaining the cultural components of breastfeeding consistency in premature infants: A descriptive exploratory 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 Article Explaining the cultural components of breastfeeding consistency in premature infants: A descriptive exploratory study Maryam Nasrabadi, Mehrosadat mahdizadeh, Hasan boskabadi, jamshid jamali, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8854013/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Preterm birth poses significant challenges in establishing and maintaining breastfeeding. Cultural beliefs and practices and supporting the biological needs of the mother and child can affect the occurrence of breastfeeding issues. The present study sought to explain the cultural factors affecting the consistency of breastfeeding in mothers with premature infants based on the PEN-3 model. The present qualitative exploratory descriptive study was conducted in light of the PEN-3 theoretical framework. The data were collected through in-depth interviews with mothers of premature infants and those influencing the breastfeeding process. They were then analysed using structured qualitative content analysis and Lincoln and Guba’s trustworthiness criteria in MAXQDA. The present study sought to distinguish positive, neutral, and negative cultural beliefs, and to identify social expectations and norms related to breastfeeding. The results of the analysis of 49 interviews conducted with mothers of premature infants and various influential groups included 3 main themes, 9 categories, such as acquiring breastfeeding knowledge to ensure the long-term health of the mother and infant, the mother's ability to dynamically align her lifestyle with the nutritional challenges of the premature infant, cultivating religious beliefs and religious teachings, fundamental health-oriented cultural beliefs, a structural support network, preferred sources of information, valuing financial and time, and promoting breastfeeding education programs, and 21 subcategories based on the dimensions and constructs of the PEN-3 model.The overall findings showed that experiences and other phenomena influenced by deeply rooted health-oriented cultural beliefs such as milk sufficiency, family and community expectations about maternal success, and individual empowerment to cope with social norms affect the consistency of breastfeeding in lactating women with premature infants. There seems to be a strong need to develop family-centred and culturally relevant strategies to increase breastfeeding rates in mothers of premature infants. Social science/Anthropology Humanities/Cultural and media studies Social science/Cultural and media studies Health sciences/Health care Humanities/Health humanities Biological sciences/Psychology Social science/Psychology Humanities/Religion Social science/Sociology Qualitative study Ppremature infants Preterm birth Breastfeeding continuity Descriptive exploratory PEN-3 model Figures Figure 1 Introduction Preterm birth, defined as the birth of a baby before 37 weeks of gestation 1 , is a major global public health challenge, accounting for more than 3% of the global burden of disease 2 , 3 . With an estimated prevalence of 10.6%, premature infants are exposed to a wide range of developmental vulnerabilities 4 , 5 , while this rate in Iran shows an alarming range of 5.5–20% 6,7 . Despite medical advances that have increased the survival of these infants, they remain at a high risk of life-threatening complications such as necrotizing enterocolitis, extrapulmonary dysplasia, and sepsis 8 . Breastfeeding, a vital protective intervention, plays an important role in moderating these outcomes, although physiological and environmental barriers challenge the achievement of exclusive breastfeeding 9 , 10 . This has reduced the adverse clinical outcomes, resulted in economic savings of $ 13 billion and prevented 900 preventable deaths in several countries 11 . However, initiation of breastfeeding in preterm infants is complicated and difficult due to developmental immaturity, inability to coordinate sucking/swallowing, and delayed physical separation in the NICU, which can lower the rates of exclusive breastfeeding (e.g., 20% in Europe and 46.5% in Iran), and lower gestational age acts as a predictor of early cessation of this type of feeding 12 – 16 . Systematic studies on breastfeeding interventions point to the critical role of cultural and contextual factors in designing successful interventions for breastfeeding in preterm infants 17 , as breastfeeding practices strike a balance between culture and biology, and sociocultural support is essential for its continuation. In this regard, there is a research gap in the cultural context of Iranian mothers of preterm infants, which requires an indigenous approaches to research 18 . To develop effective interventions, the PEN-3 model has been employed as an appropriate sociocultural framework that encourages the researcher and the community to find solutions by considering cultural identity, cultural empowerment, and social relationships. As another feature of this model, considerable attention is paid to the positive aspects of culture influencing community health programs and interventions 19 – 21 . This model consists of three dimensions, each represented by a letter in PEN. These three dimensions are internally related and interdependent. The first dimension is cultural identity (health education), which distinguishes three groups, P: person, E: extended family, and N: neighbourhood. Health education is not only concerned about the individual, but also involving community members and their intellectual and religious leaders in health programs fitting the culture of those communities 22 . The second dimension is relationships and expectations (educational diagnosis), which includes P (perceptions) that entail knowledge, attitudes, and self-efficacy, E (enablers), that include the social forces which can support and improve health behaviours or prevent them through barriers, and N: (nurturers), which include people who influence the breastfeeding behaviour of premature infants’ mothers. The third dimension of the PEN-3 model is cultural empowerment, which deals with cultural beliefs, enablers, and nurturers. Here, P is positive, E is existential and N is negative as related to health. In other words, it has to do with the impact of existing cultural beliefs on behaviour in society 23 . Despite conclusive global evidence for the clinical and economic benefits of exclusive breastfeeding for preterm infants, the success rate of breastfeeding consistency in Iran is low. This wide gap is mainly because of ignoring the socio-cultural context and specific beliefs of Iranian mothers, which requires local research to accurately identify supportive and inhibitory cultural elements. Thus, the present study aimed to explain the cultural factors affecting breastfeeding consistency in preterm infants’ mothers in Iran based on the PEN-3 model. Methodology Design of Study . A guided content analysis was used in the present qualitative study to describe breastfeeding consistency based on the PEN-3 cultural model. The study was conducted between December 2023and March 2023. The research method is usually classified as theory-based and inductive. Setting of Study. The study was set in Hakim Hospital, Neyshabur, Comprehensive Health Centres, and Lactation Counselling Clinics of Neyshabur University of Medical Sciences. Neyshabur is located in the northeast of Khorasan Razavi Province, Iran, and is the second most populous city in the province. This city is located on the ancient Silk Road, and a centre of knowledge and birthplace of many Iranian scientists, poets, Sufis, and scholars throughout history, and has been considered a symbol of Iranian history and culture. Hakim Hospital is currently the only women's hospital in the city, and every year, more than 6,755 infants are born in this hospital, among which about 606 cases (9%) are premature (under 37 weeks). Participants. The research population was mothers to premature babies and influential people in premature baby nutrition, including paediatricians and gynaecologists, nurses in departments related to premature babies, health care workers in comprehensive health centres, and breastfeeding consultants living in Neyshabur. Having approved the project and gained permission from Neyshabur University of Medical Sciences and making arrangements with hospital and health centre officials, a list of mothers with premature babies was extracted from the electronic health service system (SIB system). Then, 125 eligible mothers were contacted. Having analysed the mothers' interviews and extracted the initial codes, hospital and comprehensive health centre personnel and specialist physicians were interviewed, and 57 agreed to be interviewed. Eight interviews were excluded for incompleteness and non-compliance with the objectives of study. Interviews were conducted in a quiet room or in the parents' homes (n = 5) or hospitals (n = 6), comprehensive health centres (n = 19), private offices (n = 8), and lactation counselling clinics (n = 11). Inclusion and exclusion criteria . The participants were supposed to be mothers with premature babies having had deliveries at least 15 days earlier, holding Iranian nationality, residing in Neyshabur city, and having no disease or abnormality, such as galactosemia, cleft lip and palate, Down syndrome, Pirrabin syndrome, presence of frenulum and jaw and oral abnormalities, absence of any disease or specific problem in the mother that prohibits breastfeeding or disrupts breastfeeding (diseases such as HIV, HTLV1/2, cancer, drug addiction, psychological disorders that may cause harm to the infant by the mother during breastfeeding, burns of both breasts, breast anomalies, use of certain medications such as radioactive and chemotherapy drugs, phenytoin, Tamoxifen, ergotamine and other medications that prohibit breastfeeding. The exclusion criteria were unwillingness to participate in the interview and incomplete and ambiguous responses. Sample size and sampling procedure. Purposive sampling with maximum diversity was used with the target groups. Initially, participants’ characteristics including their age, type of employment, level of education, marital status, gender and other important demographic information was recorded. The interview guide included a few main questions that allowed the participants to express their views as fully as possible. Following the probes and considering the participants' responses, follow-up questions were used to address all aspects of one section of the topic. For example, they were asked to explain more about their experience and cast views or provide an example. Interviews with the participants continued until data saturation. The main researcher in this study was a 54-year-old woman with 15 years of experience in breastfeeding. The interviews took between 30 and 40 minutes (or more when necessary). At the outset, the researcher introduced herself and stated the objectives of study, and began the interview with open-ended questions appropriate for opening a discussion and establishing communication. Then, a series of questions followed according to the interview guide and based on the PEN-3 model constructs. Data Collection. In this study, semi-structured in-depth interviews were conducted. Sample interview questions are provided in Appendix 1. Interviewers transcribed the recorded interviews verbatim within 48 hours of the interview. When necessary, notes and diaries were taken to adjust the next interview strategy and improve the accuracy and precision of data. Interviewers read and familiarized themselves with the transcripts, then the interviews were fed into MAXQDA. The codes were created for latent and overt content, and then the themes were identified from the codes based on the model constructs. In case there were any conflicts, discussions were made until agreement was reached. After transcribing and coding 49 audio files, the researchers agreed that they may have reached theme saturation. Five more interviews were held yet no new codes or themes emerged, and the theme saturation was confirmed. Data validation . To assess the trustworthiness of qualitative data, Guba and Lincoln introduced items such as credibility, confirmability, transferability, dependability and authenticity, as used throughout the present study (23). These criteria are the quantitative counterparts of validity, reliability, objectivity, and external validity in the positivist paradigm. To avoid bias during the analysis, an expert researcher listened to the tapes, read the transcripts of interviews, and cross-compared them. The reviewers confirmed that the transcripts corresponded to the recorded interviews. Next was the primary identification of themes and subthemes by the main researcher. Two other researchers agreed on the analytic results of a random selection of 50% of manuscripts. Data analysis: Data analysis was performed using structured qualitative content analysis and Shannon formula, in MAXQDA10 (23, 24). According to this approach, the known key concepts of the PEN-3 model were considered as the initial classification. In the next step, operational definitions of the concepts were extracted for each category according to the PEN-3 model. Data analysis began with the repeated reading of the entire interview transcript to obtain an overall sense of the topic. Then, the entire transcript was read carefully word for word. Codes were placed in the previously identified categories of the model based on conceptual similarity, and depending on the scope and logical relationships of the content of categories, the subcategories were formed. Through repeatedly reviewing the data, new categories were named based on the content of codes, and their sub-categories were identified through further analysis. In the next step, the initial operational definitions were clarified. In the research process, and concerning the content of each specific transcript, the initial categories were reviewed, modified, and new categories were added (23, 24). Ethical considerations . This study has been approved by the Research Committee of Mashhad University of Medical Sciences with a project code of 4011912 and ethics code of IR.MUMS.FHMPM.REC.1402.030, and all stages of the study were conducted in accordance with the guidelines and rules of this committee. After receiving a letter of permission from the ethics committee, and visiting the hospital and other comprehensive health centres and clinics for breastfeeding counselling and early thyroid screening of new-borns, the data collection began. The participants were informed about the purpose of study and participation was quite voluntary. All participants were adults and only those who gave their verbal consent were interviewed. Permission was gained from the interviewers to conduct the interviews. Respondents were assured that all information provided would be confidential and that the results and reports of this study would not reveal the respondents’ identity. The researchers did not use any unfair means to influence the participants to obtain information. Results The demographic characteristics of participants are presented in full in Tables 1 and 2 . Most participants in this qualitative study were within the age range of 18–35 years. The gestational age of mothers was between 28–36 weeks. The sample included three mothers who had given birth to twins, one of whom stated that a twin died in one month of birth and hospitalization in the neonatal intensive care unit. 25% of mothers fed their infants exclusively breast milk, 60% both (formula and breast milk), and 16% fed their infants exclusively formula. A total number of 1,477 codes were extracted from the 49 interviews; then, the codes with common and similar themes were merged, and finally 21 sub-subcategories, 9 subcategories, and 3 categories were formed based on the PEN-3 model (Appendex2). Table 1 Frequency distribution of demographic characteristics of participants in the study (N = 25) Variable number percentage Variable number percentage Number of children First child 8 32 Education Undergraduate 8 32 Two children or more 17 68 Diploma 7 28 Sex Daughter 13 52 University 8 32 Son 12 48 Under 18 2 8 Occupation Housewife 19 76 18–35 22 88 Employed 6 24 Over 35 1 4 Residence City 15 60 Pregnancy Status WANTED 20 80 Rural 10 40 Unwanted 5 20 Gestational Age Under 30 weeks 2 8 Type of Delivery Natural 8 32 34–36 weeks 17 68 17 68 History of premature birth Yes 4 16 Age of Child 1–3 months 10 10 No 21 84 4–6 months 12 48 birth weight Under 1000g 2 8 More than 6 months 3 12 1000–1500 3 12 Duration of Hospitalization of Newborn Less than 5 days 5 20 1550–2000 2 8 5–10 days 15 60 2001–3000 13 52 More than a month 5 20 3000 and above 5 20 Economic Situation Poor 7 28 Average 15 60 History of breastfeeding previous children Yes 15 60 Good 3 12 No 12 40 Type of baby nutrition Breast milk 6 24 Formula 4 16 Breast milk and formula 15 60 Table 2 Frequency distribution of demographic characteristics of participants in qualitative study interviews (employees and specialist physicians ,n = 24) Variable number percentage Variable number percentage Occupation history Less than 5 years 5 21 Education Diploma 0 0 5 years and more 19 79 Bachelor's Degree 16 67 Type of specialization Healthcare worker 6 24 Doctorate 8 33 Nurse 3 14 AGE Under 25 years old 0 0 Pediatrician 6 24 25–35 years old 15 63 Gynecologist 2 8 Over 35 years old 9 38 Breastfeeding consultant 3 14 Number of children One child 6 25 Staff managers 4 17 Two or more 18 75 Residence City 24 100 Marriage Yes 24 100 Rural 0 0 No 2 8 Cultural Identity/Health Education (Personalized Education, Family-Centered Education, Neighborhood-Centered Education). The cultural identity dimension of the PEN-3 model identifies internal forces (intrapersonal characteristics) and external forces such as family, extended family networks, and community that may influence breastfeeding consistency and how a child is fed. Personalized education . (Mothers' concerns, individual preferences, increasing breastfeeding motivation, physical and physiological conditions of the mother and infant) This section examines the effects of different layers of society on mothers' understanding and performance, and focuses on individual factors and characteristics and internal coping mechanisms to reduce breastfeeding-related stress, including mothers' concerns such as guilt and remorse, perceived stress, perceived loneliness and unfulfilled dreams, excessive obsession with caring for the baby, feelings of shame and inability to care for the baby, fatigue and despair, mothers' obsession with baby problems, individual preferences such as importance of fitness and beauty, maintaining a job position and responsibility for other children, intrinsic motivation for breastfeeding such as the mother’s positive and negative experiences of previous breastfeeding and perceived benefits of breastfeeding, as well as the physical and physiological conditions of the mother and premature baby, such as fatigue, concerns about milk sufficiency, changes in mother and baby sleep patterns, as well as the baby's inability to latch on and other problems related to baby development. A major source of anxiety for mothers was their concern for the health and safety of infants. With their premature infants hospitalized immediately after birth and limited access to their infants, mothers faced difficulties in trying to establish their maternal role. One mother stated “I felt terribly anxious when my baby was hospitalized. My baby’s condition was unstable. Every time the doctor came for a visit, I anxiously awaited the doctor or nurse’s comments on my baby’s condition ,” while another described the situation as “very difficult.” “Taking care of my baby was strenuous. I had to stand by my baby’s bed, bend over and breastfeed him because he was so small. I was afraid to hold him.” (M 1) Concerns about breast milk adequacy also added to mothers' anxiety, as reflected in comments such as “When I didn't produce milk after delivery, I was worried about my baby going hungry.” Mothers also reported feelings of helplessness due to their inability to participate in feeding and caring for their baby. One mother stated, “I was hospitalized for three days because of bleeding and I couldn't see my baby or breastfeed him.” Another mother expressed her feelings as, “I don't know how I got through those days, I felt ashamed that I couldn't deliver on time like other mothers and produce enough milk for my baby.” (M2) After discharge from the hospital, some parents' over-sensitivity and attention to infant nutrition and growth were concerns that emerged, the lactation consultant explained. "There were instances that the mother went to the clinic and the infant had no problems, but because of the high stress and low self-esteem, the mother would call home and complain that she couldn't breastfeed the baby, as it wouldn't latch on to the breast, and that she couldn't wake it up. The mother insisted that she didn't have any milk and that it was difficult to breastfeed." (C1) One mother also stated: "I pick the baby up and breastfeed it as soon as it cries. I always think I don't have enough milk. When I went to the doctor, I kept saying, 'Check him up and see if he's healthy.' The doctor would say, the problem is with you, you're overly sensitive.' The baby is fine. There's nothing wrong with him.' (M2)" Family-centered education Extended family. The immediate family, especially grandmothers, play a pivotal role in determining the physical and social environment of breastfeeding and its impact on the mother-infant relationship. The grandmother's role in the breastfeeding process is very decisive; she is not only the family's experiential memory, but can also give the new mother emotional and soothing support. If this precious legacy of experience is combined with modern medical knowledge and the grandmother's attitude towards the power of breast milk is positive and deep, the breastfeeding process ends in success and confidence. However, vigilance is required; because traditional beliefs that are far from current science can be a compassionate obstacle. Therefore, synchronizing grandmothers' awareness with medical advice not only strengthens support, but is also a key investment in promoting infant health and strengthening family bonds. These people have their own traditional beliefs about child care and believe that their own ways are the best for the baby. With the support of enablers, this group may support some positive aspects of behaviour, such as continued breastfeeding, but sometimes, the family expectations from the mother are strict and unreasonable, and grandmothers may compare their own mothers or others’ mothers and, instead of supporting them, become a source of frustration and disappointment. They may, thus, lower the mother's self-esteem. In this regard, one of the mothers who served as a nurse in the neonatal intensive care unit admitted: "I myself believe that breast milk meets all my baby's needs until six months of age, and at a certain period, infant colic begins, but when my baby was very bloated and restless, my mother-in-law gave her herbal teas like bergamot and say that there is a problem with your milk, which is causing the baby to develop a stomachache." (M3) The present findings also showed that individuals within the extended family system may resist some aspects of breastfeeding and infant feeding interventions and education. Mothers-in-law, mothers, and husbands may initially be willing to support mothers, however, sometimes these same relatives may not be receptive to change, especially those who adhere to traditional patriarchal beliefs. Childcare and housework are culturally viewed as women's duties. Childcare and housework are considered solely the woman's responsibility, with men viewed solely as responsible for work outside home and earning a living. In some cases, they are even criticized for helping their wives with infant care. Some respondents reported that their husbands did not feel supported in caring for the infant and housework, which led to sleep deprivation, stress, and fatigue. One mother said about the lack of support from her family in caring for the child: "My husband and family believed in breastfeeding and said insisted that I only feed the baby my own milk, but no one helped me with the housework and I didn't have time to express milk. When the baby cried, I had to give it formula." (M4) Furthermore, hospital staff and specialists agreed that as soon as mothers are discharged from hospital, they are bombarded with misinformation from those surrounding them and have no choice but to give in to their insistence. A paediatrician described the influence of family and those surrounding mothers on their behaviour: “While they are in the hospital, they express their milk because the hospital atmosphere is breastfeeding-friendly and they receive enough information and support, but as soon as they go home, they stop breastfeeding and use formula milk as they are pressed by others around them. As soon as a mother is discharged from hospital, many ignorant people, sisters, aunts and uncles, surround her, all mistaking themselves as doctors and insist on conveying whatever wrong experiences they have to the mother.” (P1) Neighborhood-based education: local leaders Neighbourhood . Local social norms that influence the acceptance or rejection of breastfeeding-related behaviours in public spaces can affect breastfeeding in premature infants. The present findings emphasized that social and institutional factors in neighbourhoods, such as health centre workers, neighbours, health volunteers, and health workers as local leaders, can help establish good relationships with mothers and promote or hinder infant feeding practices. In the present study it was observed that health workers sometimes do not deal with this scientific issue and share their wrong beliefs and personal experiences with mothers. Concerning this, a paediatrician did not consider the quality of education in health centres appropriate, and explained: "In general, many health centers provide poor prenatal and postpartum education. Mothers have very little knowledge. If the education in health care is poor and the staff themselves do not have the right skills for practical education and sometimes transfer their personal experiences, the quality of education in the centers must change." (P2) relationships and expectations/diagnosis (perceptions, nurturers, enablers) Gaining knowledge of breastfeeding principles to ensure the long-term health of mother and infant. Most respondents were aware of the benefits of breastfeeding for premature infants and considered breast milk the best type of nutrition for the baby. They mostly pointed out the role of breast milk in increasing the infant’s immunity and intelligence, and stated that breastfeeding is enjoyable, easy, and inexpensive. However, many lacked the required knowledge about the signs of breast milk adequacy and the infant’s satiety and hunger, and only considered the baby crying a sign of hunger. They were not aware of other early signs of hunger such as sucking lips, searching for the breast, and eye movements. Some also stated that the most important sign of breast milk adequacy is the baby's calm state and considered proper maternal nutrition the best way to increase breast milk. A mother commented on the benefits of breastfeeding: "Breast milk is easy to use as there is no need to mix, boil water, and carry a heavy bag to parties or outside home to feed the baby. These are some of the reasons why I prefer breastfeeding to formula.” Another mother commented: “Breastfeeding strengthens my child and doesn’t need a specialist or hospital stay with a weak cold.” (M5) Self-efficacy, mother's ability to dynamically align lifestyle with infant nutritional challenges Self-efficacy means the belief in one's ability to show a health-related behaviour such as breastfeeding. In this study, mothers' self-efficacy was defined by concepts such as the mother's ability to breastfeed (holding the baby to the breast for proper nutrition, preventing problems such as sores and cracks in the breast, the skill of expressing and emptying the breast to increase breast milk, preventing breast problems, ability to recognize the baby's fullness and hunger, and waking the baby, as well as resistance and persistence against the insistence of others to consume formula milk. The ability to adapt and manage life with the conditions of a premature baby was defined by concepts such as managing breastfeeding outside home and coordinating breastfeeding with the daily routine of breastfeeding during the baby's sleep and wakefulness. A resident paediatrician in the neonatal intensive care unit described mothers' self-efficacy for breastfeeding as a necessary condition for success in breastfeeding mothers of premature babies. He added, "I believe when a mother gains the skill needed, she can resist the insistence of others to start formula milk, and this is what I, the doctor and health care workers, can create in mothers by encouraging mothers and teaching them care and breastfeeding skills.” (P3) Nurturers Structured support network, preferred sources of information search/patterns to follow. Most nurturers in the family structure are the husbands and grandmothers of the infant. Extended family is explained in detail in the section. Husband’s support is at heart of breastfeeding success, especially for mothers of premature infants, and it is multi-dimensional. As the findings showed, mothers held different perceptions of support, ranging from helping to earn a living, to relieving maternal stress and creating an emotional space for the secretion of hormones necessary for breastfeeding, and practical assistance in the daily management of the baby and mother. Husband’s active participation in caring for the baby, including learning correct breastfeeding techniques, such as hugging, skin-to-skin contact, and kangaroo care, increased the mother's self-confidence and improved the chances of continuing breastfeeding. The husband plays an important role in defending the mother's choice against peer pressure and ensuring that the mother has enough time and peace to focus on feeding the infant. Conversely, the husband’s indifference causes depression and frustration in the mother and reduces her motivation to continue breastfeeding. A mother who had exclusively breastfed her baby until he was two months old said, “My husband had no idea about my breastfeeding and was not supportive at all in taking care of the baby or doing housework .” In contrast, a working mother who breastfed her premature twins said, “My husband is the reason for my success in breastfeeding. In addition to helping me take care of the babies, she helps me with all the housework so that I can continue breastfeeding safely.” (M6) The interviewees reported that despite their desire to receive information from health professionals and workers, they most often receive information about breastfeeding and feeding babies from their family, especially their husband, peers, television, the Internet, and social networks such as Instagram, Telegram, etc. Two of the mothers viewed their husbands as the most important sources of information because they were meticulous or had a health-related job. One mother stated, “My husband is very studious and when we go to the doctor, he listens carefully and asks good questions.” Another continued, “I follow my friends’ advice on feeding my baby and I usually ask my questions from friends because they are experienced mothers who are successful in caring for their children.” (M7) One of the health care providers believed that mothers tended to get information from unreliable sources instead of asking them and sometimes got confused by the contradictory opinions from different sources on the Internet and social networks. “My wife and I even argued sometimes because our search sources were different. We didn’t know which one was correct, which was truly confusing (H1).” Another mother admitted, “I search on the Internet because it is available whenever needed.” (M8) Several mothers thought that health workers and doctors did not have enough time to answer their questions. One mother emphasized the busyness of nurses and specialists and said, “They do not have the time to answer our questions and are rarely available.” (M1) They were mostly unaware of the existence of a lactation clinic and had never visited one. One mother, whose husband was a health professional, had visited the lactation clinic immediately after discharge from hospital and was grateful for the support of the lactation consultant: “ my daughter was born at 31 months old and weighed 1200 grams. She was discharged after two months in the NICU. She had a very weak suck and would often grab the nipple and feel hungry. When I visited the clinic, the lactation consultant helped me put her on the breast correctly. I breastfed her for the first time without pain.” (M10) Enablers Financial and time investment, development of empowerment programs. Family systems, social groups, religious and spiritual networks, and community organizations (such as organizational support for working mothers) and financial investments, such as the required equipment (including educational resources and appropriate breastfeeding chairs), valuing and allocating time to see a lactation consultant, and developing educational programs to empower health care workers (such as in-service courses for staff and childbirth preparation classes and breastfeeding skills classes before and after childbirth) can be positive agents of change; however, a counterargument can also be made that these same empowering tools can sometimes be a barrier to health-oriented change. A doctor specialized in this matter admitted, "I think some health workers do not have enough knowledge to provide breastfeeding advice for premature babies. When I took my baby to the health center because he had a terrible colic, the health workers would say, 'Well, you tried formula milk, maybe it's because of your own milk,' while I, the doctor, knew that it had nothing to do with breast milk." (P3) A resident physician in the NICU with 10 years of experience in this department stated that the lack of scientific evaluation of educational programs is one reason for the insufficient skills of nurses, saying: "Despite holding regular 20-hour workshops for nurses and midwives, there is no desired outcome in this field because a standardized evaluation is not conducted. Even for mothers, this evaluation needs to be conducted before discharge.” (P4) The existence of milk banks and lactation counselling clinics in the cities of Neyshabur was another enabler, as most mothers were not aware of the presence of such facilities. The paediatrician who was the dean of the medical school of university explained in an interview, "Despite the authorities’ efforts to create facilities such as milk banks and lactation counseling clinics, your public awareness-raising is not good. I mean, these important facilities have not been advertised well. You should act like social marketers and present these facilities well." (P5) Educational media appropriate to the culture and characteristics of mothers can be effective in consolidating education for mothers at the time of discharge. According to the hospital lactation consultant, there are not enough products for financial costs: "Suitable books along with educational CDs have been produced by the Ministry of Health, but we do not have enough to provide to mothers." (C1) Cultural empowerment fundamental health-oriented cultural beliefs, religious teachings, and religious beliefs. Culture and traditions, as well as religious teachings, play a key role in how Iranian women decide to breastfeed their babies. Breastfeeding is an acquired and imitative activity; therefore, how a woman is socialized about breastfeeding, as well as the dominant religious traditions and beliefs in the family, shape her decision to breastfeed or not. Grandmothers staying at the maternity home for the first ten days of delivery and caring for the mother and baby, and believing in the rewards and spiritual value of breastfeeding were mentioned among the positive behaviours expressed by the participating mothers. Respondents who reported having a family member who believed in breastfeeding (mother, mother-in-law, and/or sister) were more likely to exhibit positive behaviours and had a better mental health. One woman who exclusively breastfed her child spoke enthusiastically about how her upbringing and cultural traditions influenced her choice to breastfeed: “I grew up thinking that breastfeeding was an important spiritual and traditional value in our family and that mothers who breastfeed their children were more respected. I never saw a woman in our family welcome formula.” (M9) Unique behaviours . These include neutral behaviours; that is, they have no adverse health effects and do not require change. For example, asking for prayers from social and religious acquaintances, fasting and praying, using blessed clothes and holy water to bless and protect the new born, and breastfeeding with ablution were among the behaviours reported by respondents. Negative behaviours include beliefs and practices that are harmful or likely to act as barriers to breastfeeding, for example, a number of mothers stated that they had consulted a traditional midwife to elevate the palate to relieve their child's refusal, or that they refused to use donated milk from other mothers at the milk bank because it conflicted with some of their beliefs, or that some mothers believed if they expressed their milk, there would be no milk left in their breasts for the baby. It seemed that food prohibitions by grandmothers in the first days after delivery were one of the stressors for mothers. A health worker working in a rural health centre explained: "In the first days of delivery, mothers are prohibited from eating hot foods because of jaundice in the baby, and grandmothers recommend eating rooster meat instead of chicken meat." (HC1) Discussion The present study aimed to explain the cultural components of breastfeeding consistency in premature infants based on the PEN-3 model constructs. Our findings, as described by mothers with premature infants about breastfeeding experiences after the birth of a premature infant based on the model constructs, revealed that the path to breastfeeding success for this group of mothers involves a complex set of clinical, emotional, structural, and traditional beliefs challenges. Cultural identity. The findings clearly showed that physical separation from the premature infant and the inability to provide direct care create a profound challenge to the maternal identity. The interviewed mothers expressed that in the absence of direct care, they do not believe they are properly fulfilling their maternal role. This negative perception directly increased their stress and, as a result, undermined their desired performance at the beginning of the breastfeeding process. This finding is consistent with the results of a qualitative study by Nasrabadi et al. 23 . From a physiological perspective, the mother's efforts to maintain breastfeeding due to the premature infant’s condition become a stressor in themselves. Frequent breastfeeding is associated with physical complications such as fatigue and breast pain. These results are consistent with previous studies. This continuous pressure on mothers whose infants rely on expressed milk significantly increases the risk of experiencing milk deficiency and, ultimately, premature cessation of breastfeeding. The results also emphasize the importance of adequate sleep as a key physiological factor in maintaining milk production. In addition, the mother's individual experience acts as a strong predictor of breastfeeding continuation. Mothers who have previously had successful breastfeeding experiences are significantly more motivated and likely to continue breastfeeding for a long time with subsequent infants 10 , 19 . These results are consistent with the related literature 24 , 25 . In addition, while the new born is hospitalized in the neonatal intensive care unit (NICU), mothers face a double crisis. Acute concerns about the vital condition of the new born and a sense of severe inability to establish a direct care relationship due to multiple connections and the physical weakness of the new born combine a sense of inability with lower self-confidence in the maternal role. A mother who is unable to provide direct care has less confidence in playing her central role, which in itself is a factor that increases stress and reduces optimal performance in initiating breastfeeding. This, along with the technical and physical challenges caused by recurrent pumping, fatigue, and breast pain, leads mothers to a lack of milk supply and ultimately premature cessation of breastfeeding. Perceptions (knowledge, attitudes, self-efficacy. Our findings also showed that mothers who had good knowledge and positive attitudes towards the benefits of breastfeeding fed their infants with formula for various reasons, this was indicative of low self-efficacy and less feeling empowered to breastfeed and manage the life routines associated with breastfeeding. While they believed that breastfeeding their hospitalized infants made them feel motherly and more competent, the challenges these mothers experienced in expressing milk and establishing breastfeeding were very frustrating and exacerbated the sense of helplessness in breastfeeding infants. Similar findings in other studies on low birth weight and premature infants conducted outside Iran 26 . show that if the existing interventions during pregnancy and postpartum are implemented optimally, they can further empower mothers of premature infants and reduce breastfeeding problems by developing the necessary skills in the mother before and after delivery. If mothers are familiar with the specific characteristics of premature infants and care/breastfeeding skills before delivery, they will pursue breastfeeding with greater motivation, higher self-efficacy, and stronger morale because self-efficacy is an important variable in predicting the duration of breastfeeding and identifying mothers who end breastfeeding too early 26 , 27 . Breastfeeding self-efficacy is influenced by certain important factors, including functional achievements, substitution experiences, verbal persuasion, and physiological responses, and health care providers can increase breastfeeding self-efficacy through these factors. Any successful breastfeeding experience increases the mother's perceived ability to breastfeed, and conversely, unpleasant experiences decrease self-efficacy. Nurturers .In the present study, while most mothers received relatively good support from husbands, they each presented different concepts of support. Some considered support simply as a husband’s effort to make ends meet and earn the living, yet most considered emotional support and participation in infant care as real support. In general, similar studies have agreed that paternal support in any form can improve mothers’ confidence, skills, and ability to breastfeed infants 28 – 30 . This study also identified specialist support from healthcare providers as a preferred source for acquiring pumping and breastfeeding skills 26 . Unfortunately, this support faced certain serious barriers in practice 25 , 30 . Limited access to lactation consultants in hospital during their infant’s evening and night shifts and after discharge meant that mothers did not receive the support they needed to establish and maintain their milk supply. Although intensive care unit nurses are usually present during the evening shift but do not have enough time or skills to provide practical assistance to mothers, this finding is consistent with the results of other studies 31 . This lack of professional communication drove mothers to informal sources. Another prominent problem was information inconsistency; the confusion caused by contradictory advice from different sources confused mothers and ultimately led them to social network channels, the Internet, and to follow the experiences of other mothers and traditional midwives 32 . Similar findings have been reported elsewhere. Consequently, there is an urgent need to plan health care education and support for mothers breastfeeding preterm infants in Neyshabur. This support requires training a sufficient number of lactation consultants and establishment of specialized and collaborative preterm infant care teams to support mothers and their families. Enablers . Social and occupational factors also influenced empowerment. Return to work was a common reason for early cessation of breastfeeding; mothers with higher education, due to the importance of professional advancement, were concerned about the negative impact of breastfeeding on their career path 33 . Yet, in Iran, working mothers use nine months of paid leave and receive two hours of paid leave a day after returning to work. Changing jobs or being placed in a lower position caused more stress for them. Therefore, it is necessary to set rules and regulations on job security to support mothers of premature babies to continue breastfeeding. An important factor in this hospital was the existence of a milk bank, which had been established a year ago with the efforts of authorities and the resident physician of the NICU. However, government insurance only covered the cost while the baby was in the hospital. After discharge from hospital, mothers with a milk deficiency had to pay this cost freely, which was not possible for some; therefore, they preferred formula milk to donated milk. Consulting with social security insurance companies to reduce costs for mothers in need of donated milk can be an effective step in reducing the consumption of formula and reducing the mortality of premature babies. In this study, despite regular 20-hour breastfeeding counselling workshops for the new staff in NICU, maternity, and postpartum departments, these staff did not have the required skills for breastfeeding counselling, and the necessary support for mothers was not provided during the night shift. Therefore, the quality of these training workshops and periodic evaluation of staff knowledge and skills after training seem essential. Cultural enablers . The findings clearly showed that the social and cultural environment surrounding the mother plays a decisive role in adopting the infant feeding pattern. According to the findings of the cultural empowerment dimension of the PEN-3 model, this study confirms that in a society that traditionally values ​​breastfeeding, the chances of mothers using formula milk are significantly lower. One of the most striking findings of this study was the strong effect of cultural and traditional beliefs on mothers' intentions. These beliefs sometimes directly contradicted clinical advice. Some mothers considered the breast to be merely a "storage" and considered expressing milk to cause complete depletion and decrease future milk supply, and therefore they refused to go for it. In more severe cases, mothers referred to non-scientific sources such as fortune-tellers and faith-healers to solve biological breastfeeding problems, instead of lactation consultants, and considered observing specific religious rituals such as performing ablution and facing the Qabalah during breastfeeding to cause comfort and success in breastfeeding. Some previous qualitative review studies confirmed the results of the present study 24 , 32 . These results highlight the need for community education to value breastfeeding so that mothers are less under social pressure to choose formula. These findings show an urgent need to review the education process in terms of local culture and beliefs and support at the Neyshabur level. This review should include specialized training of lactation consultants, formation of interdisciplinary specialized teams, and development of integrated clinical guidelines to effectively support mothers of premature infants in the challenging process of establishing and maintaining breast milk supply. Hence, for long-term success, continuous community promotion and education is essential to create a social environment supportive of the benefits of breastfeeding. Strengths and limitations of the study . A qualitative study based on the PEN-3 model allows for an in-depth and rich understanding of the beliefs, customs, and cultural values ​​related to breastfeeding among Iranian mothers of preterm infants. This approach, beyond quantitative data, helps identify the underlying reasons and motivations for health behaviours. Using the PEN-3 provides a systematic theoretical framework for collecting, analysing, and interpreting data. The model helps researchers examine the relationships between culture, beliefs, and breastfeeding behaviours in a structured manner and avoid superficial or irrelevant interpretations. The present findings can help design indigenous and culturally sensitive health interventions. By identifying positive, neutral, and negative aspects of culture, interventions can be specifically effective in enhancing breastfeeding-supportive behaviours and reducing cultural barriers. However, this study has a number of limitations. Since this is a qualitative study, the findings are not directly generalizable to the broader population of Iranian mothers of preterm infants. The results are limited to the specific social and cultural contexts studied. Interpretation of qualitative data may also be influenced by unconscious researcher biases. We used careful coding techniques, peer review, and participant review to reduce this bias, but it is impossible to completely eliminate it. The PEN-3 model, although a useful framework to understand cultural influences, may not capture all the complex and multifaceted dimensions of breastfeeding-related behaviours. Factors such as health policies, access to health services, and socioeconomic factors also play important roles that PEN-3 does not directly address. Conclusion The results of this study, with the help of the PEN-3 model, were able to effectively identify points of cultural empowerment that shape factors affecting the feeding of premature infants, which, if strengthened in their positive aspects and moderated in their negative aspects, can support the consistency of breastfeeding. The results of this study emphasize that breastfeeding-related decisions and behaviours are completely sociocultural processes and cannot be measured solely in biological or medical frameworks. The key findings of this study showed that traditional beliefs about the adequacy of breast milk, family and social networks, and the way professional supports are accepted or rejected play a pivotal role in the acceptance or discontinuation of breastfeeding in mothers of premature infants. In particular, the application of the PEN-3 model managed to more clearly reveal specific cultural elements that act as barriers (negative elements) or facilitators (positive elements). In conclusion, the use of this framework is a valid and efficient method for localizing interventions in the Iranian public health field. Therefore, the results of this study provide a strong basis for designing innovative and culturally sensitive intervention protocols in future that are not only clinically but also culturally effective and acceptable to Iranian mothers. Declarations Data availability All data used and/or analyzed during the study are included within the manuscript or supplementary information files. Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences with ethics code IR.MUMS.FHMPM.REC.1402.030 after obtaining the required permit for the research. Acknowledgements This study is based on the results of the qualitative section of a doctoral thesis at Mashhad University of Medical Sciences. The authors express their deep gratitude to the Vice Chancellor for Research of Mashhad University, the officials and staff of Neyshabur University of Medical Sciences, as well as the pediatricians and mothers who participated in this study. Author Contributions : Dr.Maryam Nasrabadi: Responsible for data collection, analysis and author of the article Dr. Mehralsadat Mehdizadeh: Qualitative data analysis, scientific advisor and author Dr. Noushin Peyman: Scientific advisor and author Dr. Hassan Baskabadi: Author and scientific advisor Dr. Jamshid Jamali: Statistical advisor and author Dr. nasim pooralizadeh: Author and scientific advisor Conflict of Interest The authors declare no conflict of interest. Funding This project is financially supported by the Vice Chancellor for Research of Mashhad University of Medical Sciences. Consent to Participation: All participants in the study were adults and verbal consent was provided Abbreviations : NICU: Neonatal Intensive Care Unit M: Mothers, P: Pediatrics, HC: Healthcare, C: Consulter Additional information : Annex 1 to 4 summarizes all information. (DOC) References Wheeler, B. J. & Dennis, C. L. Psychometric testing of the modified breastfeeding self-efficacy scale (short form) among mothers of ill or preterm infants. J. Obstetric Gynecologic Neonatal Nurs. 42 , 70–80 (2013). Fucile, S., Wener, E. & Dow, K. Enhancing breastfeeding establishment in preterm infants: A randomized clinical trial of two non-nutritive sucking approaches. Early Hum. Dev. 156 , 105347 (2021). Lechner, B. E. & Vohr, B. R. Neurodevelopmental outcomes of preterm infants fed human milk: a systematic review. Clin. Perinatol. 44 , 69–83 (2017). Brockway, M., Benzies, K. M., Carr, E. & Aziz, K. Breastfeeding self-efficacy and breastmilk feeding for moderate and late preterm infants in the Family Integrated Care trial: a mixed methods protocol. Int. Breastfeed. J. 13 , 29 (2018). Brockway, M., Benzies, K. M., Carr, E. & Aziz, K. Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration. J. Clin. Nurs. 29 , 2872–2885 (2022). Chipojola, R., Chiu, H. Y., Huda, M. H., Lin, Y. M. & Kuo, S. Y. Effectiveness of theory-based educational interventions on breastfeeding self-efficacy and exclusive breastfeeding: A systematic review and meta-analysis. Int. J. Nurs. Stud. 109 , 1036750 (2020). Sharifi, N., Khazaeian, S., Pakzad, R. & Chehreh, H. Investigating the prevalence of preterm birth in Iranian population: a systematic review and meta-analysis. J. caring Sci. 6 , 371 (2017). Blencowe, H. et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. lancet 379 , 21622172 (2012). Bai, Y. K., Lee, S. & Overgaard, K. Critical review of theory use in breastfeeding interventions. J. Hum. Lactation . 35 , 478–500 (2019). Cristofalo, E. A. et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J. Pediatr. 163 , 1592–1595 (2013). Bartick, M. & Reinhold, A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 125 , e1048–e10 (2010). Mendez, G. The impact of partner/family influences and family breastfeeding exposure on breastfeeding practices among black/African American women in Pittsburgh, Allegheny County PA (University of Pittsburgh, 2019). Schanler, R., Abrams, S., Motil, K. & Kim, M. Maternal and economic benefits of breastfeeding. UpToDate 18, (2010). Nayebinia, A. S., Faroughi, F. & Asadi, G. Fathnezhad-Kazemi, A. Factors affecting breastfeeding self-efficacy among mothers with preterm infants. Women's Health . 20 (1745 4), 5057241305297 (2024). Vafaee, A., Khabazkhoob, M., Moradi, A. & Najafpoor, A. Prevalence of exclusive breastfeeding during the first six months of life and its determinant factors on the referring children to the health centers in mashhad, northeast of Iran-2007. (2010). Tehreem, S. Frequency of Contributing Factors of Lactation Failure in Infants Presented at Mayo Hospital Lahore. DeVane-Johnson, S., Giscombe, C. W., Williams, R., Fogel, I., Thoyre, S. & C. & A qualitative study of social, cultural, and historical influences on African American women’s infant-feeding practices. J. Perinat. Educ. 27 , 71 (2018). Katsinde, S., Srinivas, S. & Hornby, D. The Need for Culture Sensitive Participatory Health Promotion Activities To Promote Breastfeeding. Indian J. Pharm. Practice 7 (2014). Airhihenbuwa, C. O., Ford, C. L. & Iwelunmor, J. I. Why culture matters in health interventions: lessons from HIV/AIDS stigma and NCDs. Health Educ. Behav. 41 , 78–84 (2014). Iwelunmor, J., Newsome, V. & Airhihenbuwa, C. O. Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethn. Health . 19 , 20–46 (2014). 21, Nsiah-Asamoah, C., Hormenu, T., Pollmann, D. & Schack, T. Managing Overweight and Obesity in Ghana from a Cultural Lens (The Complementary Role of Behaviour Modification, 2018). Assarroudi, A., Heshmati Nabavi, F., Armat, M. R., Ebadi, A. & Vaismoradi, M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. J. Res. Nurs. 23 , 42–55 (2018). Nasrabadi, M., VAHEDIAN, S. M., Esmaily, H., Tehrani, H. & Gholian, A. M. Factors affecting Exclusive breastfeeding in the first six months of birth: An Exploratory-Descriptive Study. (2019). Adama, E. A., Bayes, S. & Sundin, D. Parents' experiences of caring for preterm infants after discharge from neonatal intensive care unit: a meta-synthesis of the literature. J. Neonatal Nurs. 22 , 27–51 (2016). Maleki, M., Mardani, A., Harding, C., Basirinezhad, M. H. & Vaismoradi, M. Nurses’ strategies to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit: a systematic review and meta-analysis. Women's Health . 18 , 17455057221104674 (2022). Alves, A. K. et al. d. S. Social Representations of Bedside Milk Expression Among Mothers of Preterm Newborns in Neonatal Intensive Care Units. Journal of Advanced Nursing (2025). Charoghchian Khorasani, E., Peyman, N. & Esmaily, H. Relations between breastfeeding self-efficacy and maternal health literacy among pregnant women. Evid. Based Care . 6 , 18–25 (2017). Cannon, J., Mwamba, M. & Whembolua, G. L. An Afrocentric Perspective on the Breastfeeding Disparity: The Case of Immigrant Congolese Fathers'. Undergraduate Sch. Showcase 2 (2020). Russell, J. A. & King, R. The challenges of breastfeeding a late preterm or early term infant: Women's and clinician's perceptions of provision of antenatal information when considering early planned birth. Midwifery 143 , 104314 (2025). Mwamba, M. A. What Role do Fathers' Cultural Experiences Play in the Decision to Support Breastfeeding? (The University of North Carolina at Chapel Hill, 2019). Sofolahan-Oladeinde, Y., Iwelunmor, J., Conserve, D., Gbadegesin, A. & Airhihenbuwa, C. Role of healthcare in childbearing decision-making of WLHA in Nigeria: Application of PEN-3 cultural model. Glob. Public Health . 12 , 680–693 (2017). Adama, E. A., Adua, E., Bayes, S. & Mörelius, E. Support needs of parents in neonatal intensive care unit: An integrative review. J. Clin. Nurs. 31 , 532–547 (2022). Van Esterik, P. & Greiner, T. Breastfeeding and women's work: constraints and opportunities. Stud. Fam. Plann. 12 , 184–197 (1981). Additional Declarations No competing interests reported. Supplementary Files suppelmentary.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 May, 2026 Reviewers agreed at journal 18 May, 2026 Reviewers invited by journal 07 May, 2026 Editor assigned by journal 05 May, 2026 Editor invited by journal 16 Feb, 2026 Submission checks completed at journal 14 Feb, 2026 First submitted to journal 14 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8854013","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":641635865,"identity":"ca4aa274-9983-4f1a-a25a-31f673488971","order_by":0,"name":"Maryam Nasrabadi","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Nasrabadi","suffix":""},{"id":641635869,"identity":"65c3dec6-a3b4-4dfa-af04-d948877cb260","order_by":1,"name":"Mehrosadat mahdizadeh","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mehrosadat","middleName":"","lastName":"mahdizadeh","suffix":""},{"id":641635874,"identity":"9c984d95-7e20-4444-bbf0-9be293608fbf","order_by":2,"name":"Hasan boskabadi","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hasan","middleName":"","lastName":"boskabadi","suffix":""},{"id":641635878,"identity":"085f7623-dae0-4b48-8ec4-2a3bf2ea1ad9","order_by":3,"name":"jamshid jamali","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"jamshid","middleName":"","lastName":"jamali","suffix":""},{"id":641635885,"identity":"65e15d9a-c9f3-4d2d-bcda-f07dfa94d38c","order_by":4,"name":"nasim pooralizadeh","email":"","orcid":"","institution":"Neyshabur University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"nasim","middleName":"","lastName":"pooralizadeh","suffix":""},{"id":641635891,"identity":"d99d17c6-5188-4bb1-92d1-7871f74443b6","order_by":5,"name":"Nooshin Peyman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBADOTiLjVgtxqRrSWwgViWDOXuP6YafO+6kr52RnfyBocaOgU/6AH4tlj1nzG72nnmWu+1G7jYJhmPJDGx8Cfi1GNzIMbvB23YYrAXokQMMbDwEHGZw/43Zzb9th9PNbuRu/sDwjxgtN3jMbgNtSQBq2SDB2EaEFsuetLLbsm2HDbedebtNIrEvmYegFnP2w9tuvm07LG92HOiwD9/s5OR7CDmMgcMAwUtgYCBkB0gL+wOCikbBKBgFo2CEAwAsXUOuvJ7muwAAAABJRU5ErkJggg==","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Nooshin","middleName":"","lastName":"Peyman","suffix":""}],"badges":[],"createdAt":"2026-02-11 16:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8854013/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8854013/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109439975,"identity":"c7c3f487-6031-4727-a961-a173cbe8d3eb","added_by":"auto","created_at":"2026-05-18 07:06:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98238,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the introduction section.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8854013/v1/eea918a31b9efdaa8c67823f.png"},{"id":109764063,"identity":"955aacde-2dde-4e86-bc35-455569e33f66","added_by":"auto","created_at":"2026-05-22 07:36:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":413354,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8854013/v1/999b3097-4559-4d64-a694-8fa211a77e06.pdf"},{"id":109760253,"identity":"e0dbff86-3648-4144-926a-4444f3e307bf","added_by":"auto","created_at":"2026-05-22 07:28:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":36695,"visible":true,"origin":"","legend":"","description":"","filename":"suppelmentary.docx","url":"https://assets-eu.researchsquare.com/files/rs-8854013/v1/22d6d77dfc903db86f2b4eec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Explaining the cultural components of breastfeeding consistency in premature infants: A descriptive exploratory study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePreterm birth, defined as the birth of a baby before 37 weeks of gestation \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e, is a major global public health challenge, accounting for more than 3% of the global burden of disease \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. With an estimated prevalence of 10.6%, premature infants are exposed to a wide range of developmental vulnerabilities \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, while this rate in Iran shows an alarming range of 5.5\u0026ndash;20% \u003csup\u003e6,7\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite medical advances that have increased the survival of these infants, they remain at a high risk of life-threatening complications such as necrotizing enterocolitis, extrapulmonary dysplasia, and sepsis \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Breastfeeding, a vital protective intervention, plays an important role in moderating these outcomes, although physiological and environmental barriers challenge the achievement of exclusive breastfeeding \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. This has reduced the adverse clinical outcomes, resulted in economic savings of \u003cspan\u003e$\u003c/span\u003e13\u0026nbsp;billion and prevented 900 preventable deaths in several countries \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, initiation of breastfeeding in preterm infants is complicated and difficult due to developmental immaturity, inability to coordinate sucking/swallowing, and delayed physical separation in the NICU, which can lower the rates of exclusive breastfeeding (e.g., 20% in Europe and 46.5% in Iran), and lower gestational age acts as a predictor of early cessation of this type of feeding \u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSystematic studies on breastfeeding interventions point to the critical role of cultural and contextual factors in designing successful interventions for breastfeeding in preterm infants\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, as breastfeeding practices strike a balance between culture and biology, and sociocultural support is essential for its continuation. In this regard, there is a research gap in the cultural context of Iranian mothers of preterm infants, which requires an indigenous approaches to research \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. To develop effective interventions, the PEN-3 model has been employed as an appropriate sociocultural framework that encourages the researcher and the community to find solutions by considering cultural identity, cultural empowerment, and social relationships. As another feature of this model, considerable attention is paid to the positive aspects of culture influencing community health programs and interventions \u003csup\u003e\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis model consists of three dimensions, each represented by a letter in PEN. These three dimensions are internally related and interdependent. The first dimension is cultural identity (health education), which distinguishes three groups, P: person, E: extended family, and N: neighbourhood. Health education is not only concerned about the individual, but also involving community members and their intellectual and religious leaders in health programs fitting the culture of those communities \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The second dimension is relationships and expectations (educational diagnosis), which includes P (perceptions) that entail knowledge, attitudes, and self-efficacy, E (enablers), that include the social forces which can support and improve health behaviours or prevent them through barriers, and N: (nurturers), which include people who influence the breastfeeding behaviour of premature infants\u0026rsquo; mothers. The third dimension of the PEN-3 model is cultural empowerment, which deals with cultural beliefs, enablers, and nurturers. Here, P is positive, E is existential and N is negative as related to health. In other words, it has to do with the impact of existing cultural beliefs on behaviour in society\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eDespite conclusive global evidence for the clinical and economic benefits of exclusive breastfeeding for preterm infants, the success rate of breastfeeding consistency in Iran is low. This wide gap is mainly because of ignoring the socio-cultural context and specific beliefs of Iranian mothers, which requires local research to accurately identify supportive and inhibitory cultural elements. Thus, the present study aimed to explain the cultural factors affecting breastfeeding consistency in preterm infants\u0026rsquo; mothers in Iran based on the PEN-3 model.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e \u003cb\u003eDesign of Study\u003c/b\u003e. A guided content analysis was used in the present qualitative study to describe breastfeeding consistency based on the PEN-3 cultural model. The study was conducted between December 2023and March 2023. The research method is usually classified as theory-based and inductive.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSetting of Study.\u003c/b\u003e The study was set in Hakim Hospital, Neyshabur, Comprehensive Health Centres, and Lactation Counselling Clinics of Neyshabur University of Medical Sciences. Neyshabur is located in the northeast of Khorasan Razavi Province, Iran, and is the second most populous city in the province. This city is located on the ancient Silk Road, and a centre of knowledge and birthplace of many Iranian scientists, poets, Sufis, and scholars throughout history, and has been considered a symbol of Iranian history and culture. Hakim Hospital is currently the only women's hospital in the city, and every year, more than 6,755 infants are born in this hospital, among which about 606 cases (9%) are premature (under 37 weeks).\u003c/p\u003e \u003cp\u003e\u003cb\u003eParticipants.\u003c/b\u003e The research population was mothers to premature babies and influential people in premature baby nutrition, including paediatricians and gynaecologists, nurses in departments related to premature babies, health care workers in comprehensive health centres, and breastfeeding consultants living in Neyshabur. Having approved the project and gained permission from Neyshabur University of Medical Sciences and making arrangements with hospital and health centre officials, a list of mothers with premature babies was extracted from the electronic health service system (SIB system). Then, 125 eligible mothers were contacted. Having analysed the mothers' interviews and extracted the initial codes, hospital and comprehensive health centre personnel and specialist physicians were interviewed, and 57 agreed to be interviewed. Eight interviews were excluded for incompleteness and non-compliance with the objectives of study. Interviews were conducted in a quiet room or in the parents' homes (n\u0026thinsp;=\u0026thinsp;5) or hospitals (n\u0026thinsp;=\u0026thinsp;6), comprehensive health centres (n\u0026thinsp;=\u0026thinsp;19), private offices (n\u0026thinsp;=\u0026thinsp;8), and lactation counselling clinics (n\u0026thinsp;=\u0026thinsp;11).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion and exclusion criteria\u003c/b\u003e. The participants were supposed to be mothers with premature babies having had deliveries at least 15 days earlier, holding Iranian nationality, residing in Neyshabur city, and having no disease or abnormality, such as galactosemia, cleft lip and palate, Down syndrome, Pirrabin syndrome, presence of frenulum and jaw and oral abnormalities, absence of any disease or specific problem in the mother that prohibits breastfeeding or disrupts breastfeeding (diseases such as HIV, HTLV1/2, cancer, drug addiction, psychological disorders that may cause harm to the infant by the mother during breastfeeding, burns of both breasts, breast anomalies, use of certain medications such as radioactive and chemotherapy drugs, phenytoin, Tamoxifen, ergotamine and other medications that prohibit breastfeeding. The exclusion criteria were unwillingness to participate in the interview and incomplete and ambiguous responses.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSample size and sampling procedure.\u003c/b\u003e Purposive sampling with maximum diversity was used with the target groups. Initially, participants\u0026rsquo; characteristics including their age, type of employment, level of education, marital status, gender and other important demographic information was recorded. The interview guide included a few main questions that allowed the participants to express their views as fully as possible. Following the probes and considering the participants' responses, follow-up questions were used to address all aspects of one section of the topic. For example, they were asked to explain more about their experience and cast views or provide an example. Interviews with the participants continued until data saturation. The main researcher in this study was a 54-year-old woman with 15 years of experience in breastfeeding. The interviews took between 30 and 40 minutes (or more when necessary). At the outset, the researcher introduced herself and stated the objectives of study, and began the interview with open-ended questions appropriate for opening a discussion and establishing communication. Then, a series of questions followed according to the interview guide and based on the PEN-3 model constructs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection.\u003c/b\u003e In this study, semi-structured in-depth interviews were conducted. Sample interview questions are provided in Appendix 1. Interviewers transcribed the recorded interviews verbatim within 48 hours of the interview. When necessary, notes and diaries were taken to adjust the next interview strategy and improve the accuracy and precision of data. Interviewers read and familiarized themselves with the transcripts, then the interviews were fed into MAXQDA. The codes were created for latent and overt content, and then the themes were identified from the codes based on the model constructs. In case there were any conflicts, discussions were made until agreement was reached. After transcribing and coding 49 audio files, the researchers agreed that they may have reached theme saturation. Five more interviews were held yet no new codes or themes emerged, and the theme saturation was confirmed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData validation\u003c/b\u003e. To assess the trustworthiness of qualitative data, Guba and Lincoln introduced items such as credibility, confirmability, transferability, dependability and authenticity, as used throughout the present study (23). These criteria are the quantitative counterparts of validity, reliability, objectivity, and external validity in the positivist paradigm. To avoid bias during the analysis, an expert researcher listened to the tapes, read the transcripts of interviews, and cross-compared them. The reviewers confirmed that the transcripts corresponded to the recorded interviews. Next was the primary identification of themes and subthemes by the main researcher. Two other researchers agreed on the analytic results of a random selection of 50% of manuscripts.\u003c/p\u003e \u003cp\u003eData analysis: Data analysis was performed using structured qualitative content analysis and Shannon formula, in MAXQDA10 (23, 24). According to this approach, the known key concepts of the PEN-3 model were considered as the initial classification. In the next step, operational definitions of the concepts were extracted for each category according to the PEN-3 model. Data analysis began with the repeated reading of the entire interview transcript to obtain an overall sense of the topic. Then, the entire transcript was read carefully word for word. Codes were placed in the previously identified categories of the model based on conceptual similarity, and depending on the scope and logical relationships of the content of categories, the subcategories were formed. Through repeatedly reviewing the data, new categories were named based on the content of codes, and their sub-categories were identified through further analysis. In the next step, the initial operational definitions were clarified. In the research process, and concerning the content of each specific transcript, the initial categories were reviewed, modified, and new categories were added (23, 24).\u003c/p\u003e \u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e. This study has been approved by the Research Committee of Mashhad University of Medical Sciences with a project code of 4011912 and ethics code of IR.MUMS.FHMPM.REC.1402.030, and all stages of the study were conducted in accordance with the guidelines and rules of this committee. After receiving a letter of permission from the ethics committee, and visiting the hospital and other comprehensive health centres and clinics for breastfeeding counselling and early thyroid screening of new-borns, the data collection began. The participants were informed about the purpose of study and participation was quite voluntary. All participants were adults and only those who gave their verbal consent were interviewed. Permission was gained from the interviewers to conduct the interviews. Respondents were assured that all information provided would be confidential and that the results and reports of this study would not reveal the respondents\u0026rsquo; identity. The researchers did not use any unfair means to influence the participants to obtain information.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic characteristics of participants are presented in full in Tables \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Most participants in this qualitative study were within the age range of 18\u0026ndash;35 years. The gestational age of mothers was between 28\u0026ndash;36 weeks. The sample included three mothers who had given birth to twins, one of whom stated that a twin died in one month of birth and hospitalization in the neonatal intensive care unit. 25% of mothers fed their infants exclusively breast milk, 60% both (formula and breast milk), and 16% fed their infants exclusively formula. A total number of 1,477 codes were extracted from the 49 interviews; then, the codes with common and similar themes were merged, and finally 21 sub-subcategories, 9 subcategories, and 3 categories were formed based on the PEN-3 model (Appendex2).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFrequency distribution of demographic characteristics of participants in the study (N\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003enumber\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003enumber\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eNumber of children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eFirst child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eUndergraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eTwo children or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eDaughter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eUniversity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eSon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eUnder 18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e18\u0026ndash;35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eOver 35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eCity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003ePregnancy Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eWANTED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eUnwanted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eGestational Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eUnder 30 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eType of Delivery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eNatural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e34\u0026ndash;36 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eHistory of premature birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eAge of Child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e1\u0026ndash;3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e4\u0026ndash;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\n \u003cp\u003ebirth weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eUnder 1000g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eMore than 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1000\u0026ndash;1500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eDuration of Hospitalization of Newborn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eLess than 5 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e1550\u0026ndash;2000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e5\u0026ndash;10 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2001\u0026ndash;3000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eMore than a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e3000 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eEconomic Situation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eAverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\n \u003cp\u003eHistory of breastfeeding previous children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eType of baby nutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eBreast milk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eFormula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eBreast milk and formula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFrequency distribution of demographic characteristics of participants in qualitative study interviews (employees and specialist physicians ,n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003enumber\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003enumber\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003epercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eOccupation\u003c/p\u003e\n \u003cp\u003ehistory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eLess than 5 years\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5 years and more\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eBachelor\u0026apos;s Degree\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of specialization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare worker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eDoctorate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e33\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNurse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAGE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnder 25 years old\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePediatrician\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u0026ndash;35 years old\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e63\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGynecologist\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eOver 35 years old\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e38\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreastfeeding consultant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne child\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eStaff managers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eTwo or more\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e75\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e100\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarriage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e100\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eRural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003e0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eCultural Identity/Health Education\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e(Personalized Education, Family-Centered Education, Neighborhood-Centered Education).\u003c/strong\u003e The cultural identity dimension of the PEN-3 model identifies internal forces (intrapersonal characteristics) and external forces such as family, extended family networks, and community that may influence breastfeeding consistency and how a child is fed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonalized education\u003c/strong\u003e. (Mothers\u0026apos; concerns, individual preferences, increasing breastfeeding motivation, physical and physiological conditions of the mother and infant)\u003c/p\u003e\n\u003cp\u003eThis section examines the effects of different layers of society on mothers\u0026apos; understanding and performance, and focuses on individual factors and characteristics and internal coping mechanisms to reduce breastfeeding-related stress, including mothers\u0026apos; concerns such as guilt and remorse, perceived stress, perceived loneliness and unfulfilled dreams, excessive obsession with caring for the baby, feelings of shame and inability to care for the baby, fatigue and despair, mothers\u0026apos; obsession with baby problems, individual preferences such as importance of fitness and beauty, maintaining a job position and responsibility for other children, intrinsic motivation for breastfeeding such as the mother\u0026rsquo;s positive and negative experiences of previous breastfeeding and perceived benefits of breastfeeding, as well as the physical and physiological conditions of the mother and premature baby, such as fatigue, concerns about milk sufficiency, changes in mother and baby sleep patterns, as well as the baby\u0026apos;s inability to latch on and other problems related to baby development.\u003c/p\u003e\n\u003cp\u003eA major source of anxiety for mothers was their concern for the health and safety of infants. With their premature infants hospitalized immediately after birth and limited access to their infants, mothers faced difficulties in trying to establish their maternal role. One mother stated \u003cem\u003e\u0026ldquo;I felt terribly anxious when my baby was hospitalized. My baby\u0026rsquo;s condition was unstable. Every time the doctor came for a visit, I anxiously awaited the doctor or nurse\u0026rsquo;s comments on my baby\u0026rsquo;s condition\u003c/em\u003e,\u0026rdquo; while another described the situation as \u003cem\u003e\u0026ldquo;very difficult.\u0026rdquo; \u0026ldquo;Taking care of my baby was strenuous. I had to stand by my baby\u0026rsquo;s bed, bend over and breastfeed him because he was so small. I was afraid to hold him.\u0026rdquo;\u003c/em\u003e (M 1)\u003c/p\u003e\n\u003cp\u003eConcerns about breast milk adequacy also added to mothers\u0026apos; anxiety, as reflected in comments such as \u0026ldquo;When I didn\u0026apos;t produce milk after delivery, I was worried about my baby going hungry.\u0026rdquo; Mothers also reported feelings of helplessness due to their inability to participate in feeding and caring for their baby. One mother stated, \u0026ldquo;I was hospitalized for three days because of bleeding and I couldn\u0026apos;t see my baby or breastfeed him.\u0026rdquo; Another mother expressed her feelings as, \u0026ldquo;I don\u0026apos;t know how I got through those days, I felt ashamed that I couldn\u0026apos;t deliver on time like other mothers and produce enough milk for my baby.\u0026rdquo; (M2)\u003c/p\u003e\n\u003cp\u003eAfter discharge from the hospital, some parents\u0026apos; over-sensitivity and attention to infant nutrition and growth were concerns that emerged, the lactation consultant explained. \u003cem\u003e\u0026quot;There were instances that the mother went to the clinic and the infant had no problems, but because of the high stress and low self-esteem, the mother would call home and complain that she couldn\u0026apos;t breastfeed the baby, as it wouldn\u0026apos;t latch on to the breast, and that she couldn\u0026apos;t wake it up. The mother insisted that she didn\u0026apos;t have any milk and that it was difficult to breastfeed.\u0026quot;\u003c/em\u003e (C1) One mother also stated: \u003cem\u003e\u0026quot;I pick the baby up and breastfeed it as soon as it cries. I always think I don\u0026apos;t have enough milk. When I went to the doctor, I kept saying, \u0026apos;Check him up and see if he\u0026apos;s healthy.\u0026apos; The doctor would say, the problem is with you, you\u0026apos;re overly sensitive.\u0026apos; The baby is fine. There\u0026apos;s nothing wrong with him.\u0026apos;\u003c/em\u003e (M2)\u0026quot;\u003c/p\u003e\n\u003ch3\u003eFamily-centered education\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eExtended family.\u003c/strong\u003e The immediate family, especially grandmothers, play a pivotal role in determining the physical and social environment of breastfeeding and its impact on the mother-infant relationship. The grandmother\u0026apos;s role in the breastfeeding process is very decisive; she is not only the family\u0026apos;s experiential memory, but can also give the new mother emotional and soothing support. If this precious legacy of experience is combined with modern medical knowledge and the grandmother\u0026apos;s attitude towards the power of breast milk is positive and deep, the breastfeeding process ends in success and confidence. However, vigilance is required; because traditional beliefs that are far from current science can be a compassionate obstacle. Therefore, synchronizing grandmothers\u0026apos; awareness with medical advice not only strengthens support, but is also a key investment in promoting infant health and strengthening family bonds. These people have their own traditional beliefs about child care and believe that their own ways are the best for the baby. With the support of enablers, this group may support some positive aspects of behaviour, such as continued breastfeeding, but sometimes, the family expectations from the mother are strict and unreasonable, and grandmothers may compare their own mothers or others\u0026rsquo; mothers and, instead of supporting them, become a source of frustration and disappointment. They may, thus, lower the mother\u0026apos;s self-esteem.\u003c/p\u003e\n\u003cp\u003eIn this regard, one of the mothers who served as a nurse in the neonatal intensive care unit admitted: \u0026quot;I myself believe that breast milk meets all my baby\u0026apos;s needs until six months of age, and at a certain period, infant colic begins, but when my baby was very bloated and restless, my mother-in-law gave her herbal teas like bergamot and say that there is a problem with your milk, which is causing the baby to develop a stomachache.\u0026quot; (M3)\u003c/p\u003e\n\u003cp\u003eThe present findings also showed that individuals within the extended family system may resist some aspects of breastfeeding and infant feeding interventions and education. Mothers-in-law, mothers, and husbands may initially be willing to support mothers, however, sometimes these same relatives may not be receptive to change, especially those who adhere to traditional patriarchal beliefs. Childcare and housework are culturally viewed as women\u0026apos;s duties. Childcare and housework are considered solely the woman\u0026apos;s responsibility, with men viewed solely as responsible for work outside home and earning a living. In some cases, they are even criticized for helping their wives with infant care. Some respondents reported that their husbands did not feel supported in caring for the infant and housework, which led to sleep deprivation, stress, and fatigue. One mother said about the lack of support from her family in caring for the child: \u0026quot;My husband and family believed in breastfeeding and said insisted that I only feed the baby my own milk, but no one helped me with the housework and I didn\u0026apos;t have time to express milk. When the baby cried, I had to give it formula.\u0026quot; (M4)\u003c/p\u003e\n\u003cp\u003eFurthermore, hospital staff and specialists agreed that as soon as mothers are discharged from hospital, they are bombarded with misinformation from those surrounding them and have no choice but to give in to their insistence. A paediatrician described the influence of family and those surrounding mothers on their behaviour: \u003cem\u003e\u0026ldquo;While they are in the hospital, they express their milk because the hospital atmosphere is breastfeeding-friendly and they receive enough information and support, but as soon as they go home, they stop breastfeeding and use formula milk as they are pressed by others around them. As soon as a mother is discharged from hospital, many ignorant people, sisters, aunts and uncles, surround her, all mistaking themselves as doctors and insist on conveying whatever wrong experiences they have to the mother.\u0026rdquo; (P1)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eNeighborhood-based education: local leaders\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eNeighbourhood\u003c/strong\u003e. Local social norms that influence the acceptance or rejection of breastfeeding-related behaviours in public spaces can affect breastfeeding in premature infants. The present findings emphasized that social and institutional factors in neighbourhoods, such as health centre workers, neighbours, health volunteers, and health workers as local leaders, can help establish good relationships with mothers and promote or hinder infant feeding practices. In the present study it was observed that health workers sometimes do not deal with this scientific issue and share their wrong beliefs and personal experiences with mothers. Concerning this, a paediatrician did not consider the quality of education in health centres appropriate, and explained: \u003cem\u003e\u0026quot;In general, many health centers provide poor prenatal and postpartum education. Mothers have very little knowledge. If the education in health care is poor and the staff themselves do not have the right skills for practical education and sometimes transfer their personal experiences, the quality of education in the centers must change.\u0026quot; (P2)\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003erelationships and expectations/diagnosis (perceptions, nurturers, enablers)\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eGaining knowledge of breastfeeding principles to ensure the long-term health of mother and infant.\u003c/strong\u003e Most respondents were aware of the benefits of breastfeeding for premature infants and considered breast milk the best type of nutrition for the baby. They mostly pointed out the role of breast milk in increasing the infant\u0026rsquo;s immunity and intelligence, and stated that breastfeeding is enjoyable, easy, and inexpensive. However, many lacked the required knowledge about the signs of breast milk adequacy and the infant\u0026rsquo;s satiety and hunger, and only considered the baby crying a sign of hunger. They were not aware of other early signs of hunger such as sucking lips, searching for the breast, and eye movements. Some also stated that the most important sign of breast milk adequacy is the baby\u0026apos;s calm state and considered proper maternal nutrition the best way to increase breast milk. A mother commented on the benefits of breastfeeding: \u003cem\u003e\u0026quot;Breast milk is easy to use as there is no need to mix, boil water, and carry a heavy bag to parties or outside home to feed the baby. These are some of the reasons why I prefer breastfeeding to formula.\u0026rdquo; Another mother commented: \u0026ldquo;Breastfeeding strengthens my child and doesn\u0026rsquo;t need a specialist or hospital stay with a weak cold.\u0026rdquo; (M5)\u003c/em\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eSelf-efficacy, mother\u0026apos;s ability to dynamically align lifestyle with infant nutritional challenges\u003c/h2\u003e\n \u003cp\u003eSelf-efficacy means the belief in one\u0026apos;s ability to show a health-related behaviour such as breastfeeding. In this study, mothers\u0026apos; self-efficacy was defined by concepts such as the mother\u0026apos;s ability to breastfeed (holding the baby to the breast for proper nutrition, preventing problems such as sores and cracks in the breast, the skill of expressing and emptying the breast to increase breast milk, preventing breast problems, ability to recognize the baby\u0026apos;s fullness and hunger, and waking the baby, as well as resistance and persistence against the insistence of others to consume formula milk. The ability to adapt and manage life with the conditions of a premature baby was defined by concepts such as managing breastfeeding outside home and coordinating breastfeeding with the daily routine of breastfeeding during the baby\u0026apos;s sleep and wakefulness. A resident paediatrician in the neonatal intensive care unit described mothers\u0026apos; self-efficacy for breastfeeding as a necessary condition for success in breastfeeding mothers of premature babies. He added, \u003cem\u003e\u0026quot;I believe when a mother gains the skill needed, she can resist the insistence of others to start formula milk, and this is what I, the doctor and health care workers, can create in mothers by encouraging mothers and teaching them care and breastfeeding skills.\u0026rdquo; (P3)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eNurturers\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eStructured support network, preferred sources of information search/patterns to follow.\u003c/strong\u003eMost nurturers in the family structure are the husbands and grandmothers of the infant. Extended family is explained in detail in the section.\u003c/p\u003e\n\u003cp\u003eHusband\u0026rsquo;s support is at heart of breastfeeding success, especially for mothers of premature infants, and it is multi-dimensional. As the findings showed, mothers held different perceptions of support, ranging from helping to earn a living, to relieving maternal stress and creating an emotional space for the secretion of hormones necessary for breastfeeding, and practical assistance in the daily management of the baby and mother. Husband\u0026rsquo;s active participation in caring for the baby, including learning correct breastfeeding techniques, such as hugging, skin-to-skin contact, and kangaroo care, increased the mother\u0026apos;s self-confidence and improved the chances of continuing breastfeeding. The husband plays an important role in defending the mother\u0026apos;s choice against peer pressure and ensuring that the mother has enough time and peace to focus on feeding the infant. Conversely, the husband\u0026rsquo;s indifference causes depression and frustration in the mother and reduces her motivation to continue breastfeeding. A mother who had exclusively breastfed her baby until he was two months old said, \u003cem\u003e\u0026ldquo;My husband had no idea about my breastfeeding and was not supportive at all in taking care of the baby or doing housework\u003c/em\u003e.\u0026rdquo; In contrast, a working mother who breastfed her premature twins said, \u003cem\u003e\u0026ldquo;My husband is the reason for my success in breastfeeding. In addition to helping me take care of the babies, she helps me with all the housework so that I can continue breastfeeding safely.\u0026rdquo;\u003c/em\u003e (M6)\u003c/p\u003e\n\u003cp\u003eThe interviewees reported that despite their desire to receive information from health professionals and workers, they most often receive information about breastfeeding and feeding babies from their family, especially their husband, peers, television, the Internet, and social networks such as Instagram, Telegram, etc. Two of the mothers viewed their husbands as the most important sources of information because they were meticulous or had a health-related job. One mother stated, \u003cem\u003e\u0026ldquo;My husband is very studious and when we go to the doctor, he listens carefully and asks good questions.\u0026rdquo; Another continued, \u0026ldquo;I follow my friends\u0026rsquo; advice on feeding my baby and I usually ask my questions from friends because they are experienced mothers who are successful in caring for their children.\u0026rdquo; (M7)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne of the health care providers believed that mothers tended to get information from unreliable sources instead of asking them and sometimes got confused by the contradictory opinions from different sources on the Internet and social networks. \u003cem\u003e\u0026ldquo;My wife and I even argued sometimes because our search sources were different. We didn\u0026rsquo;t know which one was correct, which was truly confusing (H1).\u0026rdquo;\u003c/em\u003e Another mother admitted, \u003cem\u003e\u0026ldquo;I search on the Internet because it is available whenever needed.\u0026rdquo; (M8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral mothers thought that health workers and doctors did not have enough time to answer their questions. One mother emphasized the busyness of nurses and specialists and said, \u003cem\u003e\u0026ldquo;They do not have the time to answer our questions and are rarely available.\u0026rdquo; (M1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey were mostly unaware of the existence of a lactation clinic and had never visited one. One mother, whose husband was a health professional, had visited the lactation clinic immediately after discharge from hospital and was grateful for the support of the lactation consultant: \u003cem\u003e\u0026ldquo; my daughter was born at 31 months old and weighed 1200 grams. She was discharged after two months in the NICU. She had a very weak suck and would often grab the nipple and feel hungry. When I visited the clinic, the lactation consultant helped me put her on the breast correctly. I breastfed her for the first time without pain.\u0026rdquo;\u003c/em\u003e (M10)\u003c/p\u003e\n\u003ch3\u003eEnablers\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial and time investment, development of empowerment programs.\u003c/strong\u003e Family systems, social groups, religious and spiritual networks, and community organizations (such as organizational support for working mothers) and financial investments, such as the required equipment (including educational resources and appropriate breastfeeding chairs), valuing and allocating time to see a lactation consultant, and developing educational programs to empower health care workers (such as in-service courses for staff and childbirth preparation classes and breastfeeding skills classes before and after childbirth) can be positive agents of change; however, a counterargument can also be made that these same empowering tools can sometimes be a barrier to health-oriented change. A doctor specialized in this matter admitted, \u003cem\u003e\u0026quot;I think some health workers do not have enough knowledge to provide breastfeeding advice for premature babies. When I took my baby to the health center because he had a terrible colic, the health workers would say, \u0026apos;Well, you tried formula milk, maybe it\u0026apos;s because of your own milk,\u0026apos; while I, the doctor, knew that it had nothing to do with breast milk.\u0026quot;\u003c/em\u003e (P3)\u003c/p\u003e\n\u003cp\u003eA resident physician in the NICU with 10 years of experience in this department stated that the lack of scientific evaluation of educational programs is one reason for the insufficient skills of nurses, saying: \u003cem\u003e\u0026quot;Despite holding regular 20-hour workshops for nurses and midwives, there is no desired outcome in this field because a standardized evaluation is not conducted. Even for mothers, this evaluation needs to be conducted before discharge.\u0026rdquo; (P4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe existence of milk banks and lactation counselling clinics in the cities of Neyshabur was another enabler, as most mothers were not aware of the presence of such facilities. The paediatrician who was the dean of the medical school of university explained in an interview, \u003cem\u003e\u0026quot;Despite the authorities\u0026rsquo; efforts to create facilities such as milk banks and lactation counseling clinics, your public awareness-raising is not good. I mean, these important facilities have not been advertised well. You should act like social marketers and present these facilities well.\u0026quot; (P5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEducational media appropriate to the culture and characteristics of mothers can be effective in consolidating education for mothers at the time of discharge. According to the hospital lactation consultant, there are not enough products for financial costs: \u003cem\u003e\u0026quot;Suitable books along with educational CDs have been produced by the Ministry of Health, but we do not have enough to provide to mothers.\u0026quot;\u003c/em\u003e (C1)\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCultural empowerment\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003efundamental health-oriented cultural beliefs, religious teachings, and religious beliefs.\u003c/strong\u003eCulture and traditions, as well as religious teachings, play a key role in how Iranian women decide to breastfeed their babies. Breastfeeding is an acquired and imitative activity; therefore, how a woman is socialized about breastfeeding, as well as the dominant religious traditions and beliefs in the family, shape her decision to breastfeed or not. Grandmothers staying at the maternity home for the first ten days of delivery and caring for the mother and baby, and believing in the rewards and spiritual value of breastfeeding were mentioned among the positive behaviours expressed by the participating mothers. Respondents who reported having a family member who believed in breastfeeding (mother, mother-in-law, and/or sister) were more likely to exhibit positive behaviours and had a better mental health. One woman who exclusively breastfed her child spoke enthusiastically about how her upbringing and cultural traditions influenced her choice to breastfeed: \u003cem\u003e\u0026ldquo;I grew up thinking that breastfeeding was an important spiritual and traditional value in our family and that mothers who breastfeed their children were more respected. I never saw a woman in our family welcome formula.\u0026rdquo;\u003c/em\u003e (M9)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eUnique behaviours\u003c/strong\u003e. These include neutral behaviours; that is, they have no adverse health effects and do not require change. For example, asking for prayers from social and religious acquaintances, fasting and praying, using blessed clothes and holy water to bless and protect the new born, and breastfeeding with ablution were among the behaviours reported by respondents.\u003c/p\u003e\n \u003cp\u003eNegative behaviours include beliefs and practices that are harmful or likely to act as barriers to breastfeeding, for example, a number of mothers stated that they had consulted a traditional midwife to elevate the palate to relieve their child\u0026apos;s refusal, or that they refused to use donated milk from other mothers at the milk bank because it conflicted with some of their beliefs, or that some mothers believed if they expressed their milk, there would be no milk left in their breasts for the baby. It seemed that food prohibitions by grandmothers in the first days after delivery were one of the stressors for mothers. A health worker working in a rural health centre explained: \u003cem\u003e\u0026quot;In the first days of delivery, mothers are prohibited from eating hot foods because of jaundice in the baby, and grandmothers recommend eating rooster meat instead of chicken meat.\u0026quot;\u003c/em\u003e (HC1)\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to explain the cultural components of breastfeeding consistency in premature infants based on the PEN-3 model constructs. Our findings, as described by mothers with premature infants about breastfeeding experiences after the birth of a premature infant based on the model constructs, revealed that the path to breastfeeding success for this group of mothers involves a complex set of clinical, emotional, structural, and traditional beliefs challenges.\u003c/p\u003e \u003cp\u003e\u003cb\u003eCultural identity.\u003c/b\u003e The findings clearly showed that physical separation from the premature infant and the inability to provide direct care create a profound challenge to the maternal identity. The interviewed mothers expressed that in the absence of direct care, they do not believe they are properly fulfilling their maternal role. This negative perception directly increased their stress and, as a result, undermined their desired performance at the beginning of the breastfeeding process. This finding is consistent with the results of a qualitative study by Nasrabadi et al. \u003csup\u003e23\u003c/sup\u003e. From a physiological perspective, the mother's efforts to maintain breastfeeding due to the premature infant\u0026rsquo;s condition become a stressor in themselves. Frequent breastfeeding is associated with physical complications such as fatigue and breast pain. These results are consistent with previous studies. This continuous pressure on mothers whose infants rely on expressed milk significantly increases the risk of experiencing milk deficiency and, ultimately, premature cessation of breastfeeding. The results also emphasize the importance of adequate sleep as a key physiological factor in maintaining milk production. In addition, the mother's individual experience acts as a strong predictor of breastfeeding continuation. Mothers who have previously had successful breastfeeding experiences are significantly more motivated and likely to continue breastfeeding for a long time with subsequent infants\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. These results are consistent with the related literature\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eIn addition, while the new born is hospitalized in the neonatal intensive care unit (NICU), mothers face a double crisis. Acute concerns about the vital condition of the new born and a sense of severe inability to establish a direct care relationship due to multiple connections and the physical weakness of the new born combine a sense of inability with lower self-confidence in the maternal role. A mother who is unable to provide direct care has less confidence in playing her central role, which in itself is a factor that increases stress and reduces optimal performance in initiating breastfeeding. This, along with the technical and physical challenges caused by recurrent pumping, fatigue, and breast pain, leads mothers to a lack of milk supply and ultimately premature cessation of breastfeeding.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePerceptions (knowledge, attitudes, self-efficacy.\u003c/b\u003eOur findings also showed that mothers who had good knowledge and positive attitudes towards the benefits of breastfeeding fed their infants with formula for various reasons, this was indicative of low self-efficacy and less feeling empowered to breastfeed and manage the life routines associated with breastfeeding. While they believed that breastfeeding their hospitalized infants made them feel motherly and more competent, the challenges these mothers experienced in expressing milk and establishing breastfeeding were very frustrating and exacerbated the sense of helplessness in breastfeeding infants. Similar findings in other studies on low birth weight and premature infants conducted outside Iran \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. show that if the existing interventions during pregnancy and postpartum are implemented optimally, they can further empower mothers of premature infants and reduce breastfeeding problems by developing the necessary skills in the mother before and after delivery. If mothers are familiar with the specific characteristics of premature infants and care/breastfeeding skills before delivery, they will pursue breastfeeding with greater motivation, higher self-efficacy, and stronger morale because self-efficacy is an important variable in predicting the duration of breastfeeding and identifying mothers who end breastfeeding too early \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Breastfeeding self-efficacy is influenced by certain important factors, including functional achievements, substitution experiences, verbal persuasion, and physiological responses, and health care providers can increase breastfeeding self-efficacy through these factors. Any successful breastfeeding experience increases the mother's perceived ability to breastfeed, and conversely, unpleasant experiences decrease self-efficacy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eNurturers\u003c/b\u003e.In the present study, while most mothers received relatively good support from husbands, they each presented different concepts of support. Some considered support simply as a husband\u0026rsquo;s effort to make ends meet and earn the living, yet most considered emotional support and participation in infant care as real support. In general, similar studies have agreed that paternal support in any form can improve mothers\u0026rsquo; confidence, skills, and ability to breastfeed infants\u003csup\u003e\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. This study also identified specialist support from healthcare providers as a preferred source for acquiring pumping and breastfeeding skills\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Unfortunately, this support faced certain serious barriers in practice \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Limited access to lactation consultants in hospital during their infant\u0026rsquo;s evening and night shifts and after discharge meant that mothers did not receive the support they needed to establish and maintain their milk supply. Although intensive care unit nurses are usually present during the evening shift but do not have enough time or skills to provide practical assistance to mothers, this finding is consistent with the results of other studies \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. This lack of professional communication drove mothers to informal sources. Another prominent problem was information inconsistency; the confusion caused by contradictory advice from different sources confused mothers and ultimately led them to social network channels, the Internet, and to follow the experiences of other mothers and traditional midwives \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Similar findings have been reported elsewhere. Consequently, there is an urgent need to plan health care education and support for mothers breastfeeding preterm infants in Neyshabur. This support requires training a sufficient number of lactation consultants and establishment of specialized and collaborative preterm infant care teams to support mothers and their families.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEnablers\u003c/b\u003e. Social and occupational factors also influenced empowerment. Return to work was a common reason for early cessation of breastfeeding; mothers with higher education, due to the importance of professional advancement, were concerned about the negative impact of breastfeeding on their career path \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Yet, in Iran, working mothers use nine months of paid leave and receive two hours of paid leave a day after returning to work. Changing jobs or being placed in a lower position caused more stress for them. Therefore, it is necessary to set rules and regulations on job security to support mothers of premature babies to continue breastfeeding. An important factor in this hospital was the existence of a milk bank, which had been established a year ago with the efforts of authorities and the resident physician of the NICU. However, government insurance only covered the cost while the baby was in the hospital. After discharge from hospital, mothers with a milk deficiency had to pay this cost freely, which was not possible for some; therefore, they preferred formula milk to donated milk. Consulting with social security insurance companies to reduce costs for mothers in need of donated milk can be an effective step in reducing the consumption of formula and reducing the mortality of premature babies.\u003c/p\u003e \u003cp\u003eIn this study, despite regular 20-hour breastfeeding counselling workshops for the new staff in NICU, maternity, and postpartum departments, these staff did not have the required skills for breastfeeding counselling, and the necessary support for mothers was not provided during the night shift. Therefore, the quality of these training workshops and periodic evaluation of staff knowledge and skills after training seem essential.\u003c/p\u003e \u003cp\u003e\u003cb\u003eCultural enablers\u003c/b\u003e. The findings clearly showed that the social and cultural environment surrounding the mother plays a decisive role in adopting the infant feeding pattern. According to the findings of the cultural empowerment dimension of the PEN-3 model, this study confirms that in a society that traditionally values ​​breastfeeding, the chances of mothers using formula milk are significantly lower. One of the most striking findings of this study was the strong effect of cultural and traditional beliefs on mothers' intentions. These beliefs sometimes directly contradicted clinical advice. Some mothers considered the breast to be merely a \"storage\" and considered expressing milk to cause complete depletion and decrease future milk supply, and therefore they refused to go for it. In more severe cases, mothers referred to non-scientific sources such as fortune-tellers and faith-healers to solve biological breastfeeding problems, instead of lactation consultants, and considered observing specific religious rituals such as performing ablution and facing the Qabalah during breastfeeding to cause comfort and success in breastfeeding. Some previous qualitative review studies confirmed the results of the present study \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. These results highlight the need for community education to value breastfeeding so that mothers are less under social pressure to choose formula. These findings show an urgent need to review the education process in terms of local culture and beliefs and support at the Neyshabur level. This review should include specialized training of lactation consultants, formation of interdisciplinary specialized teams, and development of integrated clinical guidelines to effectively support mothers of premature infants in the challenging process of establishing and maintaining breast milk supply. Hence, for long-term success, continuous community promotion and education is essential to create a social environment supportive of the benefits of breastfeeding.\u003c/p\u003e \u003cp\u003e\u003cb\u003eStrengths and limitations of the study\u003c/b\u003e. A qualitative study based on the PEN-3 model allows for an in-depth and rich understanding of the beliefs, customs, and cultural values ​​related to breastfeeding among Iranian mothers of preterm infants. This approach, beyond quantitative data, helps identify the underlying reasons and motivations for health behaviours. Using the PEN-3 provides a systematic theoretical framework for collecting, analysing, and interpreting data. The model helps researchers examine the relationships between culture, beliefs, and breastfeeding behaviours in a structured manner and avoid superficial or irrelevant interpretations. The present findings can help design indigenous and culturally sensitive health interventions. By identifying positive, neutral, and negative aspects of culture, interventions can be specifically effective in enhancing breastfeeding-supportive behaviours and reducing cultural barriers. However, this study has a number of limitations. Since this is a qualitative study, the findings are not directly generalizable to the broader population of Iranian mothers of preterm infants. The results are limited to the specific social and cultural contexts studied. Interpretation of qualitative data may also be influenced by unconscious researcher biases. We used careful coding techniques, peer review, and participant review to reduce this bias, but it is impossible to completely eliminate it. The PEN-3 model, although a useful framework to understand cultural influences, may not capture all the complex and multifaceted dimensions of breastfeeding-related behaviours. Factors such as health policies, access to health services, and socioeconomic factors also play important roles that PEN-3 does not directly address.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study, with the help of the PEN-3 model, were able to effectively identify points of cultural empowerment that shape factors affecting the feeding of premature infants, which, if strengthened in their positive aspects and moderated in their negative aspects, can support the consistency of breastfeeding. The results of this study emphasize that breastfeeding-related decisions and behaviours are completely sociocultural processes and cannot be measured solely in biological or medical frameworks. The key findings of this study showed that traditional beliefs about the adequacy of breast milk, family and social networks, and the way professional supports are accepted or rejected play a pivotal role in the acceptance or discontinuation of breastfeeding in mothers of premature infants. In particular, the application of the PEN-3 model managed to more clearly reveal specific cultural elements that act as barriers (negative elements) or facilitators (positive elements). In conclusion, the use of this framework is a valid and efficient method for localizing interventions in the Iranian public health field. Therefore, the results of this study provide a strong basis for designing innovative and culturally sensitive intervention protocols in future that are not only clinically but also culturally effective and acceptable to Iranian mothers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data used and/or analyzed during the study are included within the manuscript or supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences with ethics code IR.MUMS.FHMPM.REC.1402.030 after obtaining the required permit for the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is based on the results of the qualitative section of a doctoral thesis at Mashhad University of Medical Sciences. The authors express their deep gratitude to the Vice Chancellor for Research of Mashhad University, the officials and staff of Neyshabur University of Medical Sciences, as well as the pediatricians and mothers who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eDr.Maryam Nasrabadi: Responsible for data collection, analysis and author of the article\u003c/p\u003e\n\u003cp\u003eDr. Mehralsadat Mehdizadeh: Qualitative data analysis, scientific advisor and author\u003c/p\u003e\n\u003cp\u003eDr. Noushin Peyman: Scientific advisor and author\u003c/p\u003e\n\u003cp\u003eDr. Hassan Baskabadi: Author and scientific advisor\u003c/p\u003e\n\u003cp\u003eDr. Jamshid Jamali: Statistical advisor and author\u003c/p\u003e\n\u003cp\u003eDr.\u0026nbsp;nasim pooralizadeh: Author and scientific advisor\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project is financially supported by the Vice Chancellor for Research of Mashhad University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participation:\u003c/strong\u003e All participants in the study were adults and verbal consent was provided \u003cstrong\u003eAbbreviations\u003c/strong\u003e: NICU: Neonatal Intensive Care Unit M: Mothers, P: Pediatrics, HC: Healthcare, C: Consulter\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eAnnex 1 to 4 summarizes all information. (DOC)\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWheeler, B. J. \u0026amp; Dennis, C. L. Psychometric testing of the modified breastfeeding self-efficacy scale (short form) among mothers of ill or preterm infants. \u003cem\u003eJ. Obstetric Gynecologic Neonatal Nurs.\u003c/em\u003e \u003cb\u003e42\u003c/b\u003e, 70\u0026ndash;80 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFucile, S., Wener, E. \u0026amp; Dow, K. Enhancing breastfeeding establishment in preterm infants: A randomized clinical trial of two non-nutritive sucking approaches. \u003cem\u003eEarly Hum. Dev.\u003c/em\u003e \u003cb\u003e156\u003c/b\u003e, 105347 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechner, B. E. \u0026amp; Vohr, B. R. Neurodevelopmental outcomes of preterm infants fed human milk: a systematic review. \u003cem\u003eClin. Perinatol.\u003c/em\u003e \u003cb\u003e44\u003c/b\u003e, 69\u0026ndash;83 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrockway, M., Benzies, K. M., Carr, E. \u0026amp; Aziz, K. Breastfeeding self-efficacy and breastmilk feeding for moderate and late preterm infants in the Family Integrated Care trial: a mixed methods protocol. \u003cem\u003eInt. Breastfeed. J.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e, 29 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrockway, M., Benzies, K. M., Carr, E. \u0026amp; Aziz, K. Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration. \u003cem\u003eJ. Clin. Nurs.\u003c/em\u003e \u003cb\u003e29\u003c/b\u003e, 2872\u0026ndash;2885 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChipojola, R., Chiu, H. Y., Huda, M. H., Lin, Y. M. \u0026amp; Kuo, S. Y. Effectiveness of theory-based educational interventions on breastfeeding self-efficacy and exclusive breastfeeding: A systematic review and meta-analysis. \u003cem\u003eInt. J. Nurs. Stud.\u003c/em\u003e \u003cb\u003e109\u003c/b\u003e, 1036750 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharifi, N., Khazaeian, S., Pakzad, R. \u0026amp; Chehreh, H. Investigating the prevalence of preterm birth in Iranian population: a systematic review and meta-analysis. \u003cem\u003eJ. caring Sci.\u003c/em\u003e \u003cb\u003e6\u003c/b\u003e, 371 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlencowe, H. et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. \u003cem\u003elancet\u003c/em\u003e \u003cb\u003e379\u003c/b\u003e, 21622172 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBai, Y. K., Lee, S. \u0026amp; Overgaard, K. Critical review of theory use in breastfeeding interventions. \u003cem\u003eJ. Hum. Lactation\u003c/em\u003e. \u003cb\u003e35\u003c/b\u003e, 478\u0026ndash;500 (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCristofalo, E. A. et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. \u003cem\u003eJ. Pediatr.\u003c/em\u003e \u003cb\u003e163\u003c/b\u003e, 1592\u0026ndash;1595 (2013).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBartick, M. \u0026amp; Reinhold, A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. \u003cem\u003ePediatrics\u003c/em\u003e \u003cb\u003e125\u003c/b\u003e, e1048\u0026ndash;e10 (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendez, G. \u003cem\u003eThe impact of partner/family influences and family breastfeeding exposure on breastfeeding practices among black/African American women in Pittsburgh, Allegheny County PA\u003c/em\u003e (University of Pittsburgh, 2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchanler, R., Abrams, S., Motil, K. \u0026amp; Kim, M. Maternal and economic benefits of breastfeeding. \u003cem\u003eUpToDate\u003c/em\u003e 18, (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNayebinia, A. S., Faroughi, F. \u0026amp; Asadi, G. Fathnezhad-Kazemi, A. Factors affecting breastfeeding self-efficacy among mothers with preterm infants. \u003cem\u003eWomen's Health\u003c/em\u003e. \u003cb\u003e20\u003c/b\u003e (1745 4), 5057241305297 (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVafaee, A., Khabazkhoob, M., Moradi, A. \u0026amp; Najafpoor, A. Prevalence of exclusive breastfeeding during the first six months of life and its determinant factors on the referring children to the health centers in mashhad, northeast of Iran-2007. (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTehreem, S. Frequency of Contributing Factors of Lactation Failure in Infants Presented at Mayo Hospital Lahore.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeVane-Johnson, S., Giscombe, C. W., Williams, R., Fogel, I., Thoyre, S. \u0026amp; C. \u0026amp; A qualitative study of social, cultural, and historical influences on African American women\u0026rsquo;s infant-feeding practices. \u003cem\u003eJ. Perinat. Educ.\u003c/em\u003e \u003cb\u003e27\u003c/b\u003e, 71 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatsinde, S., Srinivas, S. \u0026amp; Hornby, D. The Need for Culture Sensitive Participatory Health Promotion Activities To Promote Breastfeeding. \u003cem\u003eIndian J. Pharm. Practice\u003c/em\u003e \u003cb\u003e7\u003c/b\u003e (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAirhihenbuwa, C. O., Ford, C. L. \u0026amp; Iwelunmor, J. I. Why culture matters in health interventions: lessons from HIV/AIDS stigma and NCDs. \u003cem\u003eHealth Educ. Behav.\u003c/em\u003e \u003cb\u003e41\u003c/b\u003e, 78\u0026ndash;84 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwelunmor, J., Newsome, V. \u0026amp; Airhihenbuwa, C. O. Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. \u003cem\u003eEthn. Health\u003c/em\u003e. \u003cb\u003e19\u003c/b\u003e, 20\u0026ndash;46 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e21, Nsiah-Asamoah, C., Hormenu, T., Pollmann, D. \u0026amp; Schack, T. \u003cem\u003eManaging Overweight and Obesity in Ghana from a Cultural Lens\u003c/em\u003e (The Complementary Role of Behaviour Modification, 2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssarroudi, A., Heshmati Nabavi, F., Armat, M. R., Ebadi, A. \u0026amp; Vaismoradi, M. Directed qualitative content analysis: the description and elaboration of its underpinning methods and data analysis process. \u003cem\u003eJ. Res. Nurs.\u003c/em\u003e \u003cb\u003e23\u003c/b\u003e, 42\u0026ndash;55 (2018).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNasrabadi, M., VAHEDIAN, S. M., Esmaily, H., Tehrani, H. \u0026amp; Gholian, A. M. Factors affecting Exclusive breastfeeding in the first six months of birth: An Exploratory-Descriptive Study. (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdama, E. A., Bayes, S. \u0026amp; Sundin, D. Parents' experiences of caring for preterm infants after discharge from neonatal intensive care unit: a meta-synthesis of the literature. \u003cem\u003eJ. Neonatal Nurs.\u003c/em\u003e \u003cb\u003e22\u003c/b\u003e, 27\u0026ndash;51 (2016).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaleki, M., Mardani, A., Harding, C., Basirinezhad, M. H. \u0026amp; Vaismoradi, M. Nurses\u0026rsquo; strategies to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit: a systematic review and meta-analysis. \u003cem\u003eWomen's Health\u003c/em\u003e. \u003cb\u003e18\u003c/b\u003e, 17455057221104674 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlves, A. K. et al. d. S. Social Representations of Bedside Milk Expression Among Mothers of Preterm Newborns in Neonatal Intensive Care Units. \u003cem\u003eJournal of Advanced Nursing\u003c/em\u003e (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharoghchian Khorasani, E., Peyman, N. \u0026amp; Esmaily, H. Relations between breastfeeding self-efficacy and maternal health literacy among pregnant women. \u003cem\u003eEvid. Based Care\u003c/em\u003e. \u003cb\u003e6\u003c/b\u003e, 18\u0026ndash;25 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCannon, J., Mwamba, M. \u0026amp; Whembolua, G. L. An Afrocentric Perspective on the Breastfeeding Disparity: The Case of Immigrant Congolese Fathers'. \u003cem\u003eUndergraduate Sch. Showcase\u003c/em\u003e \u003cb\u003e2\u003c/b\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell, J. A. \u0026amp; King, R. The challenges of breastfeeding a late preterm or early term infant: Women's and clinician's perceptions of provision of antenatal information when considering early planned birth. \u003cem\u003eMidwifery\u003c/em\u003e \u003cb\u003e143\u003c/b\u003e, 104314 (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwamba, M. A. \u003cem\u003eWhat Role do Fathers' Cultural Experiences Play in the Decision to Support Breastfeeding?\u003c/em\u003e (The University of North Carolina at Chapel Hill, 2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSofolahan-Oladeinde, Y., Iwelunmor, J., Conserve, D., Gbadegesin, A. \u0026amp; Airhihenbuwa, C. Role of healthcare in childbearing decision-making of WLHA in Nigeria: Application of PEN-3 cultural model. \u003cem\u003eGlob. Public Health\u003c/em\u003e. \u003cb\u003e12\u003c/b\u003e, 680\u0026ndash;693 (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdama, E. A., Adua, E., Bayes, S. \u0026amp; M\u0026ouml;relius, E. Support needs of parents in neonatal intensive care unit: An integrative review. \u003cem\u003eJ. Clin. Nurs.\u003c/em\u003e \u003cb\u003e31\u003c/b\u003e, 532\u0026ndash;547 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Esterik, P. \u0026amp; Greiner, T. Breastfeeding and women's work: constraints and opportunities. \u003cem\u003eStud. Fam. Plann.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 184\u0026ndash;197 (1981).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Qualitative study, Ppremature infants, Preterm birth, Breastfeeding continuity, Descriptive exploratory, PEN-3 model","lastPublishedDoi":"10.21203/rs.3.rs-8854013/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8854013/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePreterm birth poses significant challenges in establishing and maintaining breastfeeding. Cultural beliefs and practices and supporting the biological needs of the mother and child can affect the occurrence of breastfeeding issues. The present study sought to explain the cultural factors affecting the consistency of breastfeeding in mothers with premature infants based on the PEN-3 model. The present qualitative exploratory descriptive study was conducted in light of the PEN-3 theoretical framework. The data were collected through in-depth interviews with mothers of premature infants and those influencing the breastfeeding process. They were then analysed using structured qualitative content analysis and Lincoln and Guba’s trustworthiness criteria in MAXQDA. The present study sought to distinguish positive, neutral, and negative cultural beliefs, and to identify social expectations and norms related to breastfeeding. The results of the analysis of 49 interviews conducted with mothers of premature infants and various influential groups included 3 main themes, 9 categories, such as acquiring breastfeeding knowledge to ensure the long-term health of the mother and infant, the mother's ability to dynamically align her lifestyle with the nutritional challenges of the premature infant, cultivating religious beliefs and religious teachings, fundamental health-oriented cultural beliefs, a structural support network, preferred sources of information, valuing financial and time, and promoting breastfeeding education programs, and 21 subcategories based on the dimensions and constructs of the PEN-3 model.The overall findings showed that experiences and other phenomena influenced by deeply rooted health-oriented cultural beliefs such as milk sufficiency, family and community expectations about maternal success, and individual empowerment to cope with social norms affect the consistency of breastfeeding in lactating women with premature infants. There seems to be a strong need to develop family-centred and culturally relevant strategies to increase breastfeeding rates in mothers of premature infants.\u003c/p\u003e","manuscriptTitle":"Explaining the cultural components of breastfeeding consistency in premature infants: A descriptive exploratory study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-18 07:06:02","doi":"10.21203/rs.3.rs-8854013/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"71113282140735742150101301484704347060","date":"2026-05-21T22:08:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260670235094384909387312796393686640041","date":"2026-05-18T21:48:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-07T13:36:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-05T10:01:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-16T16:28:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-15T01:13:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-02-15T01:09:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e422f2e4-221d-456e-8750-51fbd0b22d9b","owner":[],"postedDate":"May 18th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"71113282140735742150101301484704347060","date":"2026-05-21T22:08:54+00:00","index":139,"fulltext":""},{"type":"reviewerAgreed","content":"260670235094384909387312796393686640041","date":"2026-05-18T21:48:34+00:00","index":135,"fulltext":""},{"type":"reviewersInvited","content":"48","date":"2026-05-07T13:36:40+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":68245922,"name":"Social science/Anthropology"},{"id":68245923,"name":"Humanities/Cultural and media studies"},{"id":68245924,"name":"Social science/Cultural and media studies"},{"id":68245926,"name":"Health sciences/Health care"},{"id":68245928,"name":"Humanities/Health humanities"},{"id":68245930,"name":"Biological sciences/Psychology"},{"id":68245932,"name":"Social science/Psychology"},{"id":68245933,"name":"Humanities/Religion"},{"id":68245934,"name":"Social science/Sociology"}],"tags":[],"updatedAt":"2026-05-18T07:06:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-18 07:06:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8854013","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8854013","identity":"rs-8854013","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}