Background

Supporting breastfeeding is a public health priority, based on the well-established benefits of breastfeeding for maternal and child health [1,2]. Although there are very high rates of initiation of breastfeeding worldwide (>80% of mothers in most countries), rates of breastfeeding decline markedly in the first few months after birth [2], most notably in high-income countries. This occurs for a multitude of reasons, reflecting breastfeeding difficulties and insufficient access to lactation support and postnatal care, as well as broader family and social support, access to paid maternity leave and social and cultural norms about infant feeding [3]. For some women, ceasing breastfeeding earlier than initially desired leaves them feeling stigmatised [4] and can be a source of shame, grief, guilt, distress and anxiety [5,6], contributing to a reduced sense of agency to achieve breastfeeding goals and poor psychological wellbeing [7,8]

One of the most common reasons cited for early cessation of breastfeeding is perceived low or insufficient milk supply [9–12]. This should be managed initially by the provision of breastfeeding counselling and support [13], however, when concerns persist, substances known as galactagogues are often recommended [13,14]. Galactagogues are foods, herbal supplements or medications believed to assist initiation, maintenance, or augmentation of breast milk supply [15]. For centuries, women have used herbal or food preparations such as fenugreek, fennel, oats and brewer’s yeast and other local botanicals, in this way [16–18].

Recently, there has been an increase in the direct marketing of herbal galactagogues and food and beverage products such as ‘lactation cookies’ and breastfeeding teas/tisanes [19]. In addition, a growing number of pharmacological agents to support lactation have been evaluated in clinical trials [14]. Of these, the medication domperidone is the most widely studied, and has been shown to result in modest increases in breast milk volume among mothers who have given birth prematurely–a group at high risk of lactation difficulties [20]. However, the generalisability of these findings to all women who give birth is unclear and there are ongoing concerns about rare but serious adverse effects associated domperidone, including cardiac arrhythmias [21]. Such concerns have led to regulatory warnings against its use during lactation by the Food and Drug Administration in the United States [15,22].

Evidence about the safety and efficacy of herbal and food products marketed as galactagogues is inconsistent, with both positive and negative impacts on milk supply reported for some products (e.g. fenugreek), as well possible maternal and infant side effects [15,16]. As a result of inconclusive evidence, peak professional societies such as the Academy of Breastfeeding Medicine, do not recommend use of any specific galactagogues during lactation [15,22].

Despite limited evidence to support use, current research indicates that the number of women using galactagogue is increasing [23–26]. In high- and middle-income countries, prescribed pharmacological galactagogues are now a common treatment for insufficient milk supply [19,27–29]. In a recent study of over 200,000 mothers in British Columbia, Canada, 1 in 5 were prescribed domperidone in the first six months after birth, with reported use doubling between 2002 and 2011 [29]. While information about utilisation patterns of other galactagogues is limited, a recent US study found that approximately 50% of breastfeeding women reported using a herbal preparation postpartum to increase milk supply [19].

Within academic research, there has been little prior exploration of the reasons why women are increasingly seeking out or being prescribed substances to increase breast milk supply. The limited available research has focussed on herbal galactagogues only [24–26] or has been undertaken in regions where access to pharmaceutical galactagogues is restricted [19]. Nevertheless, the findings indicate that when taking a herbal product, some women report feelings of increased confidence and reassurance in their ability to breastfeed [25,26]. This suggests that there may be important social and emotional aspects surrounding galactagogue use that are not well understood. Further, there is some evidence that women perceive herbal galactagogues to be ‘safer’ than pharmacological agents, and in the absence of clear guidelines for use, appear to be relying on the internet and social media for anecdotal reports about efficacy [19,25,26,30,31].

To date, no studies have examined decision-making about the full range of galactagogue treatment options available. In addition, there has been limited attention paid to the broader factors that may influence decisions about galactagogue use, including cost and accessibility, the level of informal and formal support women engage with, the increased marketing of products (particularly via social media), the degree of social expectations for mothers to provide breast milk [30–32]. The latter is important as some women who stop breastfeeding express feelings of ‘failure’, illustrating how breastfeeding is intrinsically linked to ideals about ‘good mothering’ and is often framed as a moral ‘choice’ and responsibility [33,34]. Thus, pressure to breastfeed and the resulting influence on psychological wellbeing and diminishing of maternal agency may well be contributing to use of galactagogues. The aim of this paper was to undertake an in-depth exploration of the key factors influencing decision-making around the use of a broad range of galactagogues.

Methods

Participants in this study were recruited from a large, national online survey of Australian women’s awareness and use of galactagogues to boost breast milk supply. The survey was promoted through various social media platforms including member pages for the Australian Breastfeeding Association (the leading, national breastfeeding advocacy and mother-to-mother support organisation in Australia) and the Miracle Babies Foundation (an Australian organisation supporting premature and sick newborns, their families and the hospitals that care for them). After anonymously completing the original survey online, women were invited to express their interest in participating in an interview and provide their contact details. The inclusion criteria were intentionally broad, including women who had challenges breastfeeding and/or with supply and women who did not. Participants were recruited from all states and territories however those living outside Australia were excluded. Participants were given the option of participating in person, over the telephone or via video conferencing software. Ethical approval for the project was granted by University of Adelaide Human Research Ethics Committee (Approval number H-2019-167).

Semi-structured interviews were conducted during October and November of 2019 by an interviewer located in Adelaide, South Australia. To align with ethical protocols, prior to the interviews Information Sheets and Consent Forms were distributed providing details including information about audio recording, transcription, data storage and de-identification processes. Signed consent forms were collected at the time of the interview, Author 1 (who conducted all the interviews) confirmed consent and asked permission to begin the audio recording. Following the interview, participants were offered an AUD$30 gift card in acknowledgement of their time.

To encourage participants to discuss the topics or events they considered important to their decision-making about galactagogues interviews followed a semi-structured interview guide (attached). Author 1 conducted all of the interviews. She has a PhD and experience conducting interviews with mothers around breastfeeding. At the time of the project, Author 1 was employed as a Research Fellow. In order to situate the research and the researcher, the interviews began with a preamble and a brief introduction to Author 1 including relevant personal details (family background, age, maternal status). The participants were also told about the researcher’s background in this area of inquiry, which was intended to inform the participants of the researcher’s subject position.

The survey was undertaken between September to December 2019. Over 2,000 women participated and of these, 486 women indicated they may be interested in participating in an interview. We approached women in the order that they completed the survey, with the goal of interviewing approximately 20 women. This entailed contacting the first 46 women who expressed interest, and of these, 22 women replied to confirm their interest and scheduled an interview. The number of interviews included two pilot interviews to test and modify the interview guide. Sixteen interviews were conducted over the telephone, four face-to-face in the local public maternity hospital and two via video conference software. Twenty of the interviews were transcribed by a professional transcription service (pilot interviews were not transcribed), de-identified and assigned pseudonyms.

Interviews were analysed thematically informed by the approach to qualitative data analysis in health-related fields endorsed by Braun and Clarke [35]. Following each interview, the researcher recorded brief memos to document key points including findings that were consistent or contradictory. After the interviews were complete, initial fieldnotes and the semi-structured interview guide were used to generate the early coding framework. A first reading of the interview transcripts (familiarisation stage), was used to refine this coding framework further, which was then checked by another member of the project team (senior author). Using NVivo (version 12) software, the data were coded and classified into core themes and subthemes which were revised further in consultation with the wider project team at two different time periods.

Findings

The average age of the participants was 34 years (range 29–50), giving birth between 2009 and 2019. Twelve participants reported having a degree level education, eight a higher degree and around a third of participants were employed in a health profession or research role. Ten of the participants were first time mothers, four reported giving birth prematurely and nine reported having a caesarean section. One participant identified as being born outside of Australia (New Zealand), one identified as Aboriginal and Torres Strait Islander (First Nation), and all spoke English as the primary language in the home.

All twenty-two participants initiated breastfeeding, and at the time of the interviews, nine were still breastfeeding or supplying expressed breast milk. Domperidone was the most commonly used pharmaceutical galactagogue (n = 15, 68%), but in most cases was used in combination with a non-pharmaceutical galactagogue. Twenty participants (91%) reported taking at least one non-pharmaceutical substance, including fenugreek, lactation cookies, brewer’s yeast, and various combinations of products.

Fig 1 provides a summary of the core themes that emerged during analysis regarding the factors that influenced women’s decisions to use galactagogues. As depicted, following a trigger–a real or perceived concern about breast milk supply–their decisions to use a galactagogue/s were underpinned by the core domains of: access to and quality of breastfeeding support available, maternal agency, and determination to provide breast milk. Outside of the core domains, important broader dimensions of decision-making were revealed, indicative of the complexity of women’s deliberations concerning galactagogues. These dimensions reflected a range of maternal experiences, external factors and processes that had an overarching influence on decision-making. The dimensions were separated into categories that emphasise distinctions relating to breast milk supply (left of outer ring) which included maternal emotional wellbeing, social norms and pressures, concerns about infant development, maternal physical health and lactation history, as well as distinctions relating to galactagogue use (right of outer ring) which included desire for a guaranteed/urgent response, risk-risk trade-off, acceptance and trust, and accessibility and cost. The bi-directional arrows in Fig 1 are indicative of the dynamic nature of these influences throughout the decision-making process with many factors interrelated. The dimensions were not equal in influence, as the value attributed to each was highly individualised and situational, and many women were drawing on more than one dimension to make their decisions about what to use to boost breast milk supply. These decisions were not final with many recycling through the process of seeking more advice, support or information if the expected outcome did not occur.

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Fig 1. Domains and dimensions influencing women’s decision-making regarding the use of galactagogues.

https://doi.org/10.1371/journal.pone.0249599.g001

Discussion

This study provides insights into the complexity of factors underpinning decisions about the use of galactagogues as women navigate new and expanding motherhood. Our findings reveal three core domains influencing decision making, reflecting the availability and quality of breastfeeding support, attempts to restore or maintain maternal agency and the underlying determination to breastfeed. These domains are interrelated, such that experiences in one domain influence how women draw on the other domains to make decisions. A key finding is the range of problematic interactions women had with health care professionals regarding breastfeeding support, that resulted in feelings of being dismissed and the provision of conflicting information, that was sometimes at odds with beliefs about breastfeeding. From these experiences’ women felt undermined and some turned to galactagogues to regain agency to achieve their breastfeeding goals.

Our findings also reveal a range of broader dimensions influencing decision making which are highly individualised and interlinked with other dimensions as well as the core domains. We found decisions about galactagogues were often underpinned by high levels of stress, which were often be amplified by social norms about breastfeeding being ‘natural’ and feelings of maternal failure when difficulties arise. Interpretations of these findings suggest that some women felt they did not see the use of galactagogues as a ‘choice’, indicative of a diminished sense of agency.

The experiences of stress and resultant effects on wellbeing in this study often impinged on women’s ability to balance risks associated with galactagogue use against their own physical and mental health and the consequences of different feeding options for the health of their infant. The prioritising of the benefits to baby over mother may be interpreted as evidence that women are denying their own agency [8] as they had no choice but to take them, in order to avoid stigma and shame around not breastfeeding. However, it is critical to emphasise that the range of factors identified in this study that influence decisions about galactagogues illustrate that women are not simply docile in making decisions about using a substance to boost their supply. Instead, they are deliberating on galactagogues with regard to the consequences for their identity as a mother, often as a way to ‘restore lost agency’ [8] in the face of inadequate breastfeeding support including insufficient information about risks, in a context of high emotions, stress and sleep deprivation [8].

The findings of this study relating to the large volume of information women receive emphasises the multiple and frequently contrasting details that at times was difficult to navigate. At a time when some women admitted feeling overwhelmed, sleep deprived, hormonal and not being able to rationalise, the presentation of contradictory information complicated the informed decision-making process. Moreover, the inconsistent information was often not only at odds with the predominant ‘breast is best’ messaging in health care but also signals that women’s values and beliefs (including their breastfeeding goals) may not always be factored into the information and support they receive, which has been demonstrated in research in other high income country settings [36,37].

We argue that simply improving the provision and volume of information about galactagogues will not be sufficient to support women in their decision-making. This aligns with previous research regarding infant feeding decisions, which Sheehan and colleagues [38] argue can only be adequately supported when they are viewed in relation to individual experiences and immediate sociocultural contexts. We argue that support must include consideration of the moral aspects of the ‘breast is best’ messaging, and the implications that has for maternal psychological wellbeing and agency when breastfeeding difficulties are experienced. For many participants in this study, ideologies about being a good mother and breastfeeding as a moral imperative were important factors in their decision to use galactagogues and contributed to feelings of stress. These emotional aspects underscore the need for access to high quality postnatal care that includes psychological support that offers practical information and communication approaches that work to enhance or restore women’s agency [8].

The urgency and need for a guaranteed solution was exemplified by women’s practices of using multiple combinations of substances and by initiating galactagogues concurrently with other techniques. These practices may obscure the need to address possible underlying supply issues through non-pharmacological breastfeeding support strategies. As well, it may also suggest that some women have unrealistic expectations about the effectiveness of galactagogues. To address these issues, we argue that breastfeeding advice and support would be more beneficial if it contained clearer and concise information about the effectiveness of galactagogues and the reasons they are used, in order to manage expectations and avoid possible negative impacts on maternal agency, confidence, anxiety and self-efficacy, which can have negative psychological effects {Henderson, 2016, The price mothers pay`, even when they are not buying it: Mental health consequences of idealized motherhood} [36,37].

In the context of breastfeeding and postnatal support that is alarming, dismissive and judgemental, conflicting or missing information has the potential to damage trust in health professionals and may be influencing women to seek out and value alternative sources of information. Although many participants indicated their preference for evidence-based information, this may reflect the high level of education and the employment background of this particular participant cohort. Whilst some women trusted health professionals as experts, others regarded the subjective experiences of other women as ‘expert’ advice. The growing relevance, influence and access to information drawn from lived experiences and anecdotes discussed in the interviews offers an interesting contrast to the value of evidence-based information and is an important finding in this research. Anecdotes were featured in stories shared on social media, the commercial and marketing material women were exposed to and attached to gifts supplied by well-intentioned family and peers.

Existing research verifies that women are more frequently engaging with Google searches and social media specifically seeking information about breastfeeding concerns [30,39], suggesting a shift away from the influence of experts. For example, websites selling foods and herbal substances (i.e. commercial lactation cookies) feature testimonials advertising instant results, influencing women’s assumptions about how off-the-shelf products work. The value and reliance women placed on the information tied to product promotion suggests that when information and support from professionals was inaccessible, dismissive, unhelpful, contradictory or inconsistent women actively sought out and engaged with popular sources of information and support, unverified claims, and solutions that filled these gaps. The information attached to these commercial products has been carefully crafted to take advantage of these elements of confusion by offering their merchandise as a solution. As well, the gifting of galactagogues may be associated with the increased marketing, promotion and availability of galactagogue products (sold in many gourmet foods stores) that women are using to not only support each other and enhance maternal agency.

In valuing these sources of information as credible and reliable, women may also risk basing decisions on unfounded advice and information [40]. For instance, engaging with anecdote, marketing material or gifting may be encouraging women to self-diagnose or misinterpret the source of the breastfeeding issue (e.g. problematising supply rather than addressing latch). These findings indicate that there is a considerable need to address inconsistencies and evidence gaps regarding the effectiveness and safety of commonly used galactagogues, with an emphasis on the communication styles relied to deliver and support this information [38].

As the evidence presented in this paper indicates, women are not positioned as passive and are highly invested in finding ways to continue and prolong the provision of breast milk. This research has identified that, in the context of experiences associated with insufficient breast milk supply, one of the key elements in the continuation of breastfeeding is high quality, comprehensive lactation support that positively response to women’s goals and values. The importance of empowering breastfeeding support has been widely recognised and is an ongoing and urgent priority requiring increased investment to improve lactation support [1]. Ways of addressing support needs have been explored in a recent study by Blixt et al [36] who provide a comprehensive summary of the type of breastfeeding support women are specifically seeking. They outline five key categories including evidence-based care, earlier preparation for possible breastfeeding challenges during pregnancy, respectful and mutual dialogue, individual solutions to problems or concerns and practical support. The findings of this study align with the recommendations outlined by Blixt and colleagues [36], however, we offer an expansion by recommending that individualised and tailored support could also be improved by involving processes that encourage trust and shared decision-making regarding breastfeeding challenges, which may or may not include recommending galactagogue use. The shared decision-making elements would help to maintain and enhance women’s agency which this research has found is often compromised during the decision-making process.

We argue that breastfeeding support should begin with an assessment of whether milk supply is real or perceived and then ensure other measures are exhausted before considering galactagogue interventions [41]. To ensure women are exhausting non-galactagogue strategies, approaches with professionals may benefit from adopting an individually tailored, shared approach as it is considered a more bidirectional and holistic approach to decision-making [42, see also 43–46]. A shared decision-making approach would enable women to engage with practices to support breastfeeding and/or boost supply which are attuned to the complexity of their situations and individual values.

To support this approach to decision-making, we suggest that women may benefit from the design and implementation of a shared decision-making aid that could be used by health care professionals in conjunction with women [47]. According to Kennedy and colleagues [47], decision aids can help women understand terminology, options and alternatives to care, enable them to express their personal values and reduce decisional conflict. Domains and dimensions of decisions presented in this paper could be factored into the design of a high-quality decision-making aid that enables informed choice and a shared approach that eliminates the possibility of support being dismissive or judgemental. A shared decision-making approach to breastfeeding support is currently being piloted in areas of North America [48, see also 49] and based on these findings similar approaches may be beneficial if adapted in other locations, in conjunction with decision-aids as required.

Finally, as women in this study were seeking breastfeeding support and information from many different sources, there is evidence to suggest that women are not systematically engaging with or being directed to an IBCLC when problems arise [1]. IBCLC professionals are seen to be the best-practice approach to accessing breastfeeding support as they are trained based on globally recognised, evidence-based standards [50]. However, access to IBCLC in this study was mixed, in some cases participants could not say with certainty whether the lactation consultant they engaged with was an IBCLC, and others identified barriers around access including cost (for private consultations) and accessibility which they saw as limited because of high demand for these services (particularly in public health care). As Garner and colleagues [51] argue, these barriers create “discontinuity” in breastfeeding care and support where health care providers rely on others, resulting in gaps in care, inconsistent messages and poor communication. As the findings presented by Garner et al are consistent with the findings of our study, we strongly recommend an urgent investment in and mainstreaming of IBCLCs in order to ensure women receive equitable and consistent support grounded in internationally agreed on strategies. We suggest that these strategies will be more impactful if they are inclusive of a shared decision-making approach to breastfeeding challenges [50]. Due to the critical role of GPs, they may also require further training to best support women in collaboration with trained breastfeeding consultants [52].

Limitations

The group of participants were highly educated and employed in health or health related fields (including research). Information about the household income or other social and cultural practices were not collected but the few demographic details available present a group of participants who were predominantly white, heterosexual, able-bodied group of women who reported high levels of education. This is reflective of the overall characteristics of participants in the online survey (the source of participants for this study), thus recruiting more participants from the survey would not have increased diversity of this sample.

Conclusions

These findings shed light on the complex range of influential factors underpinning decisions to use galactagogues. For many participants, decisions were driven by a strong sense of determination to breastfeed and the need for an urgent ‘fix’, leading to use of multiple concurrent strategies to address breastfeeding challenges. Decisions occurred in a background of inconsistent and sometimes conflicting and unhelpful information and support about breastfeeding, leading some women to actively engage in an assessment of benefits and risks whereas others delegated responsibilities to a health care provider. Women often reported feeling highly stressed during this time, navigating the physiological and emotional changes that accompany motherhood, under a weight of expectation about breastfeeding being the natural and best ‘choice’ for infant feeding. As feelings of being ‘dismissed’ were a key feature of some women’s experiences with health care professionals, the findings shed light on ways that existing breastfeeding support can influence maternal agency. We suggest improvements to breastfeeding support that addressing inconsistent and judgemental messaging and incorporates shared decision-making approaches during this intensive period of early mothering is needed. Improved support strategies must also be accompanied by high quality research that addresses evidence gaps regarding the effectiveness and safety of commonly used galactagogues, to provide reliable information to assist women and health care providers during this time.

Supporting information

Acknowledgments

The project team would like to acknowledge the generous contributions of the women who participated in this research. We thank them for their time and personal stories. The project team would also like to acknowledge Robyn Stevenson who supported participant recruitment. We also acknowledge the collegial support from the Fay Gale Centre for Gender Research, the Robinson Research Institute at the University of Adelaide and staff at the SAHMRI Women’s and Children’s site.