This study showed that cracked nipples, sore nipples during breastfeeding, insufficient production of milk and breast engorgement were the breastfeeding problems most commonly encountered by lactating mothers. These breastfeeding problems occurred mainly during the first week after birth and throughout the rest of the first month. Breastfeeding problems during a given period negatively impacted on exclusive or predominant breastfeeding continuing beyond that time.
During this study, the highest frequency of breastfeeding problems was noted within the first week after delivery (17.1%) and remained high during the rest of the first month (16.2%) but decreased from the second month (6.7%). At six months, less than one out of twenty breastfeeding mothers (4.7%) reported experiencing breastfeeding problems. These results reinforce the evidence that the first month after childbirth, and especially the first week, is critical for the establishment and the continuation of breastfeeding (15). This observation suggests that the mother should be supported during this period to prevent and overcome breastfeeding difficulties. Higher proportions of breastfeeding problems (40–80%) have been reported during the first week in developed countries (16–18). An explanation for this noticeable difference is the fact that breastfeeding is common in Africa; therefore, African women could be positive thinkers towards breastfeeding. Women who think positively about breastfeeding perceive problems as ‘normal’ while those who lack self-assurance in their capacity to breastfeed are more likely to focus on its negative aspects (19).
With regard to the type of breastfeeding problems encountered, the most reported were: cracked nipples; sore nipples during breastfeeding; insufficient production of breast milk; and breast engorgement. The same problems were also reported during the first month, with almost similar proportions in Denmark (17), the United States of America (USA) (18) and Ethiopia (20). Cracked or sore nipples are mainly a consequence of poor breastfeeding technique (21) that can be prevented with good positioning, optimal attachment of the baby and gentle removal from the breast when the baby is satisfied (16, 22). Therefore, breastfeeding technique should be assessed and taught to each mother at least once by midwives while at the maternity facility and corrected if needed (22).
Apart from cracked or sore nipples, insufficient production of breast milk was the second most common breastfeeding problem reported by mothers during this study. However, this insufficiency is more often secondary than primary (16). The primary glandular insufficiency is rare. More often, insufficient milk production occurs: when the breasts are not emptied sufficiently and frequently for whatever reason, notably poor breastfeeding technique; painful latch on by suckling; mother and infant separation; and illness of mother or infant (22). If the mother and infant are separated or unwell, early and regular milk expression by hand or pump should be started to maintain milk production (23). On the other hand, insufficient production of breast milk is more perceived than real (19). The mother’s perception of not having enough milk is often a misinterpretation of her crying baby or a feeling of soft or empty breasts. Therefore, the mother experiencing insufficient production of breast milk needs to be supported by midwives and relatives to improve her breastfeeding self-efficacy.
The third most common breastfeeding problem reported in this study was breast engorgement that, once again, resulted from a poor emptying of breasts (16). Early initiation of breastfeeding, spending more time to breastfeed during the first 48 hours after childbirth and emptying one breast at each breastfeeding by alternating the breast that is first offered, may help to prevent this problem (22, 24).
This study pointed out that breastfeeding problems during a given period had a negative impact on the continuation of exclusive or predominant breastfeeding beyond this period, except during the third and fourth months. The fact that no association was found during the third and fourth months of life suggests that weaning was probably planned at this age. Indeed, mixed feeding was the norm among older generations which prefer that the current mothers adopt the same infant feeding practices (25). Before 2001, the WHO allowed the introduction of complementary foods from the third to fourth months (26).
Regarding the strength of the association, the highest hazard ratio was noted during the first month after delivery. During this period, the hazard of discontinuing exclusive or predominant breastfeeding was seven times higher among mothers who had experienced breastfeeding problems. This result highlights, once again, that the first weeks after childbirth are critical to the establishment and the continuation of breastfeeding. Similar findings were reported in Sweden (27) and USA (18).
In addition, this study noted also a high hazard ratio during the sixth month of life; mothers who experienced breastfeeding problems were six times more at risk to stop exclusive or predominant breastfeeding. This may suggest that these mothers had planned probably to breastfeed exclusively for the first six months but could not reach their goal due to breastfeeding problems. These results illustrate the importance of breastfeeding counselling, which should begin during the antenatal period and continue throughout the breastfeeding period, particularly the first six months.
4.1 Strengths and limitations
The results of this study should be interpreted taking into account its strengths and limitations.
One of the limitations was that the data used were collected in 2013 and may seem outdated. However, in our opinion, results from this study are still valuable today, given that the rate of mothers achieving the global recommendation on exclusive breastfeeding remained around 50% from 2013 to 2018. This study was prospective; thus, the low reliability of the duration of exclusive breastfeeding determined retrospectively was avoided. However, the recall bias was not completely avoided because the day when foods or drinks other than breast milk were introduced was determined retrospectively. Therefore, mothers could or could not remember precisely that moment. Nonetheless, to our knowledge, this study is the first carried out in Kinshasa to investigate breastfeeding problems experienced by mothers.
4.2 Recommendation for future research
The most common breastfeeding problems reported during this study may be prevented by improving the breastfeeding technique. Furthermore, these problems occurred mainly during the first month after the childbirth, especially during the first week. Future research should be carried out to assess the effect of technical support, offered as early as possible after the childbirth to improve the breastfeeding technique, on the occurrence of these problems.