BREASTFEEDING MEDICINE

Volume 12, Number 4, 2017 Original Paper

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2016.0183

Perception of Not Having Enough Milk and Actual Milk

Production of First-Time Breastfeeding Mothers:
Is There a Difference?

Roseline Galipeau, Louise Dumas, and Mario Lepage

Abstract

Objective: This study aimed to determine the relationship between perceived insufficient milk supply (PIMS)
and actual insufficient milk supply (AIMS) and the relative contributions of physiological and psychosocial
variables on both PIMS and AIMS of first-time breastfeeding mothers.
Participants and Methods: Data were collected among 123 breastfeeding mothers at a Canadian, French-
speaking maternal care hospital. Birth events, breastfeeding practices, infant and maternal capacities, and PIMS
and AIMS were collected at 48 hours after birth, postnatal weeks 2 and 6.
Results: No significant relationship was found between PIMS and AIMS. Maternal breastfeeding self-efficacy
and number of feeds were related to PIMS at week 2, and skin-to-skin contact at birth and number of feeds were
related to AIMS as measured by 24-hour milk production at week 2.
Conclusion: Maternal breastfeeding self-efficacy impacts PIMS. Interventions should be directed to increase
maternal confidence in breastfeeding, which in turn influences breastfeeding duration.

Keywords: perceived insufficient milk, breast milk production, breastfeeding self-efficacy

Introduction dermining this process can decrease the amount of milk

S ubstantial quality evidence confirms the health risks
associated with not breastfeeding both for mother and
child.1 Still, few mothers in Canada as well as in many high-
income countries maintain breastfeeding practices according to
international recommendations.2,3 Indeed, the first 2 to 6 weeks
following birth have been identified as a critical period for
weaning or supplementing breastfeeding, maternal perception
of insufficient milk supply being the most frequently reported
concern.4–6 Although highly prevalent, we do not know if ma-
ternal report of insufficient milk is a maternal perception or an
actual insufficient milk supply (AIMS) or both.4 The relation-
ship between perceived insufficient milk supply (PIMS) and
AIMS needs to be further explored to design evidence-informed
interventions for exclusive breastfeeding duration.4
Insufficient milk supply
Milk production (or supply) refers to the amount of breast
milk transferred to the infant. It relies on three different
components: efficacy of baby’s sucking, breast capacity to
produce milk, and the milk ejection reflex.7 Any factor un-
transferred to the child and, as such, the child’s satisfaction
level.7 Primary insufficiency of breast milk supply is rare and
concerns hypoplasia of mammary gland or breast surgery
such as breast reduction or Sheehan’s syndrome.8 Secondary
insufficiency of breast milk supply or postglandular insuffi-
ciency9 arises when the normal physiological breastfeeding
process has been disrupted by factors that limit frequency or
efficacy of mammary gland stimulation such as breast milk
substitutes at the time of the establishment of lactogenesis
stage II, nonoptimal baby suckling, or an insufficient number
of feedings.10
Perception of insufficient milk supply
Maternal perception of insufficient milk supply occurs
when the mother believes her breast milk is not enough in
quality or in quantity to satisfy her baby.11,12 Indeed, dis-
satisfaction of the child, expressed by crying, is a major
contributing factor to maternal perception of insufficient milk
supply.4 Besides satisfaction of the child, other contributing
factors to PIMS are behavior of the infant at the breast and
increased or decreased number of feedings.4 Child capacities

Nursing Department, University of Quebec in Outaouais, Gatineau, Canada.

1
2 GALIPEAU ET AL.
also influence the mother’s confidence in her capacity to
breastfeed, which has been linked to PIMS and breastfeeding
exclusivity and duration.4,13,14 However, very few studies have
focused on the distinction between PIMS and AIMS.4 In fact,
we cannot confirm if there is a difference between the perception
and the reality of milk insufficiency.15 This limits the develop-
ment and validation of nursing interventions to prevent, assess,
and address both situations.4 The aim of this study was to de-
termine the relationship between PIMS and AIMS and the rel-
ative contributions of physiological and psychosocial variables
on both PIMS and AIMS of first-time breastfeeding mothers.
The study also aimed at documenting the breastfeeding rates and
exclusivity during the first 6 weeks postnatally.
Participants and Methods
This study used a predictive correlational longitudinal de-
sign with three time measurements: 48 hours and postnatal
weeks 2 and 6. A convenience sample was recruited between
June 2012 and January 2014 from the maternity unit at a non-
baby-friendly designated Canadian regional hospital averag-
ing 2300 births annually. Inclusion criteria were (1) first-time
breastfeeding mothers ‡18 years old, (2) birth of an infant at
‡37 weeks of gestation and with a birth weight of ‡2500 g,
and (3) French and/or English language spoken and written.
Exclusion criterion was mother–infant separation ‡24 hours
after birth because of health conditions of mother or baby.
After verification of eligibility, 123 mothers accepted to
participate in the study. After signed consent, the mothers
were given a questionnaire to complete on day 3. Of the 123
mothers who accepted to participate, 98 (79.7%) completed/
returned the day 3 questionnaire to the research assistant and
25 (20.3%) mothers left the hospital without giving back the
questionnaire. At week 2, 62 (50.4%) mothers were reached
by phone for a home visit appointment and the week 2
questionnaire was completed at the time of the home visit.
Sixty-one mothers were not reached by phone after three at-
tempts. In addition, at the time of home visit at week 2, the 24-
hour diary of breastfeeding, which includes milk production
measurement, was completed by 57 (46.3%) mothers. Reason
for noncompletion was cessation of breastfeeding. At week 6,
52 (42.2%) mothers were reached by phone and they
answered the breastfeeding practices assessment (Table 1).
Table 1. Follow-Up Rate and Breastfeeding Practices Upon Study Time Frames
Participants
Breastfeeding practices, n (%)
Timeframe/ Follow-up
measures rate, n (%) Exclusive Nonexclusive No breastfeeding
Baseline (24 hours 123 (100) — —
after birth)
T1—day 3 98 (79.7) 68 (70) 30 (30)
questionnaire
T2—week 2 62 (50.4) 46 (74) 11 (18)
questionnaire
T2—week 2 24-hour 57 (46.3) — —
breastfeeding
diary
T3—week 6 52 (42.2) 46 (88) 5 (10)
phone call
Procedure
Both Research Ethics Committees of the university and
hospital approved the study. Each day, the research assistant
verified about new births in the past 24 hours and mothers’
eligibility for participation in the study. Nurses asked eligible
mothers if they were interested in participating. When they
agreed, the research assistant met them to explain the study
and obtain informed consent. At 48 hours postnatal, mothers
completed a self-reported questionnaire (duration 15 min-
utes) that included measures described below. The research
assistant also reviewed both mother’s and baby’s charts for
pregnancy and birth events. With the phone number provided
at time of recruitment, the research assistant called the mo-
ther to plan a home visit at around 2 weeks. At the time of
home visit, the research assistant brought a baby weighing
scale (precision at 2 g) for breast milk production measure-
ment and explained the use of it as well as the 24-hour
breastfeeding journal. Mothers were asked to weigh their
baby before and after each breastfeeding session for the next
24 hours (1 day) and to complete the breastfeeding journal
accordingly, including baby’s urine and stools at diaper
change as another indicator of adequate milk supply.16 The
same self-reported questionnaire completed at 48 hours,
which included breastfeeding self-efficacy measure, was also
filled at that time by the mother (duration 10 minutes). An-
other home visit was planned for the pickup of the scale. At
postnatal week 6, a phone call (duration 5–10 minutes) was
made by the research assistant to ask about breastfeeding
practices and offer guidance as needed.
Measures
Table 2 summarizes the variables included in this study.
Baseline variable—sociodemographic characteristics.
Sociodemographic characteristics were self-reported by the
mother in the day 3 questionnaire.
Study variables
Birth events. Data collected through chart review by the
research assistant included type of birth (vaginal or cesarean
section), baby’s birth weight, skin-to-skin contact after birth,
and first-hour breastfeeding.
Dropouts/time
frame (n) Reasons for dropouts
— — —
— 25 Left without giving
back questionnaire
5 (8) 36 Not reached by phone
after three attempts
— 5 Breastfeeding cessation
1 (2) 71 Not reached by phone
after three attempts
INSUFFICIENT BREAST MILK, PERCEIVED AND ACTUAL
Table 2. Variables Included in the Study with Measurement Times
Variables/measures T1, 48 hours
Baseline variables
Sociodemographic characteristics
Study variables
Birth events
Infant capacities
Infant Breastfeeding Assessment Tool
Number of feedings/24 hours
Irritability during feeds—MABS
Breastfeeding self-efficacy
Breastfeeding self-efficacy short form
Outcome variables
Perceived insufficient milk supply
Perceived insufficient milk supply scale
Actual insufficient milk supply
Baby weight loss (%)
24-hour milk production
Breastfeeding practices
Infant capacities. Infant capacities included at 48 hours
and postnatal week 2 questionnaires were as follows:
(1) Infant Breastfeeding Assessment Tool (IBFAT) mea-
sures child’s capacity to suckle.17 This instrument as-
sesses four components of effective sucking: eagerness
to attach to the breast, sucking reflex, and latch and
effective suckling, each element being noted by the
mother on a 1 to 3 scale. A score between 10 and 12
indicates optimal child’s capacity. Inter-rater reliability
index of 91% between mothers’ and professionals’
ratings has been reported.17 This instrument was also
used to predict breastfeeding cessation in the first 2
weeks postnatal.17 Cronbach’s alpha was 0.71 from a
previous study on PIM by the main author.13
(2) Infant breastfeeding demand: Number of times the
mother breastfed in the last 24 hours. This measure
was self-reported by the mother at day 3 and week 2
questionnaires by answering the following question:
How many times did you breastfeed your baby in the
last 24 hours?
(3) Irritability during feeds subscale of the Mother and
Baby Scale18 was used to measure infant tempera-
ment during feeds. This scale assessed maternal
perception of how much her baby fretted and cried
during feeds.19 Examples of items were ‘‘My baby’s
overactivity (kicking, turning head, etc.) has been
making it difficult to fix her/him to the breast’’ or
‘‘During feeds, my baby has tended to fuss or cry.’’
Eight items were assessed on a one-dimensional scale
from never apply ( = 0) to very/often apply ( = 5).
Higher scores mean a more irritable infant during
feedings. Cronbach’s alpha was 0.86 among a sample
of mothers and babies in the early postnatal period.18
Maternal capacity as per mother’s perception. Maternal
breastfeeding self-efficacy was measured at 48 hours and post-
natal week 2 questionnaires with the Breastfeeding Self-Efficacy
Scale-Short Form (BSES-SF),20 which has 14 items to measure
3
Measurement times
T2, week 2 T3, week 6
O
O
O O
O O
O O
O O
O O
O —
— O
O O O
mother’s confidence in her capacity to breastfeed. Mother rates
each item on a 5-point Likert scale from (1) not confident to (5)
very confident. Score varies from 14 to 70. Elevated score in-
dicates high level of confidence. Cronbach’s alpha was 0.94
from a previous study on PIM by the main author.13
Outcome variables
Perceived and actual insufficient breast milk supply.
Perceived and actual insufficient breast milk supply was
measured at 48 hours and at postnatal week 2 with ques-
tionnaires as follows:
(1) PIMS is defined by the mother as milk being insufficient
either in quantity or nutritional quality to meet the needs
of her child.11 This instrument first asks for a yes/no
answer on mother’s belief that she can produce suffi-
cient milk to meet the needs of her infant. Then, an open
question invites mother to explain her yes or no from
the previous nominal question. Next five questions are
noted on a 5-point Likert scale on the mother’s per-
ception of the child’s satisfaction. Examples of items
assessed were ‘‘My baby generally appears satisfied
after feedings’’ and ‘‘My breast milk is all the nutrition
my baby needs to thrive.’’ High score indicates high
perception of milk sufficiency. Content validity of PIMS
was assessed by six breastfeeding experts,11 and Cron-
bach’s alpha was 0.70 in a study sample of 60 moth-
ers.11 Cronbach’s alpha was 0.80 from a previous study
on PIM by the main author of this study.13
(2) AIMS was measured by the child’s weight loss at T1
(birth weight minus weight at 48 hours). More than
7% loss is considered significant.21 At T2, milk pro-
duction refers to the volume of milk transferred to the
child within 24 hours as measured by baby’s weight
on a precise scale (2 g precision) before and after each
breastfeed.22 One gram of weight gain is considered
equivalent to 1 mL of breast milk intake.22
Breastfeeding practices. At 48 hours and postnatal weeks
2 and 6, mothers were asked if they were breastfeeding
4 GALIPEAU ET AL.

exclusively (no other type of feed, including water), pre- Table 3. Sociodemographic Characteristics
dominantly (includes only one or two feeds other than breast of Participants (T1, n = 98)
milk), partially (three or more feeds other than breast milk),
or not breastfeeding. For analysis purposes, predominant and Variable n (%) Mean (SD)
partial breastfeeding were combined. Age of the mother 28.18 years
(–0.45)
Data analyses Marital statusa 96a
Data were entered and analyzed using SPSS, version 23. Married or lived with a spouse 83 (86.5)
Descriptive statistical analyses were done. The relationships Single 13 (13.5)
among sociodemographics, pregnancy, birth events, infant/ma- Educationa 97a
ternal factors, actual and perceived milk insufficiency, and Primary 4 (4.1)
breastfeeding practices were analyzed. Pearson correlations Secondary 13 (13.4)
were used to assess continuous variables. Student’s t test anal- Professional diploma 15 (15.5)
College 14 (14.4)
ysis was used to assess ratio variables. Analysis of variance was University’s Certificate 5 (5.2)
used for categorical variables with multiple comparisons. Bachelor 32 (33.0)
Master 11 (11.3)
Results PhD 3 (3.1)
Sociodemographic characteristics Family income (CDN$/ 95a
annual before taxes)a
Table 2 summarizes the sociodemographic characteristics <25,000$ 15 (15.8)
of participants. The mean maternal age was 28.2 years 25,000$–49,999$ 18 (18.9)
(standard deviation [SD] = –0.45 years). In total, 86.5% were 50,000$–74,999$ 14 (14.7)
married or lived with a partner, and almost 70% were at least 75,000$–100,000$ 18 (18.9)
college graduates. Two-thirds (65.2%) reported a family >100,000$ 30 (31.7)
annual income of ‡50,000 CDN$. Among the group, 87.5% Nationalitya 96a
were Canadian and 82.5% spoke French at home. Canadian 84 (87.5)
Others 12 (12.5)
Birth events Language spoken at homea 97a
English 14 (14.4)
Table 3 summarizes birth events as well as baby’s and French 80 (82.5)
mother’s capacities. Almost 75% of the mothers gave birth Others 3 (3.1)
vaginally and had immediate skin-to-skin contact at birth Working statusa 97a
with their baby for as long as 1–2 hours as it is the norm in this Employed 88 (90.7)
hospital for most vaginal births. Most vaginally delivered Unemployed 9 (9.3)
babies had their first suckling during this period.
T1 = day 3 questionnaire.
a
Breastfeeding practices Missing response.
SD, standard deviation.
At 48 hours, almost 70% (68/98) of the mothers breastfed
exclusively and 30% supplemented their child with formula
supplements (30/98). The most frequently reported reasons mothers at T2 answered positively. Reasons most frequently
for supplementation were not enough milk and painful nip- reported for positive perception of milk production were re-
ple. At postnatal week 2, 91.9% (57/62) of the mothers were lated to baby sleeping well or signs of satiety or adequate
breastfeeding, either exclusively (74%; 46/62) or non- urine and stool patterns.16
exclusively (18%; 11/62). Most frequent reasons given for At T1 (48 hours), no significant association was found
introducing formula supplements were fatigue, baby not between the baby’s weight loss and maternal perception of
satisfied, and painful nipples. At postnatal week 6, 88% (46/ insufficient milk supply (PIMS) (r = -0.33; NS). At T2
52) of the mothers were breastfeeding exclusively, 10% (5/ (2 weeks), no significant association was found between
52) gave formula or other liquid to their child, and 2% (1/52) 24-hour milk production and PIMS (r = 0.20; NS).
stopped breastfeeding. The reason most frequently given for
supplements were babysitting needed (Table 4). Factors associated with breast milk production,
actual or perceived
Breast milk production, actual and perceived
Factors related to actual breast milk production at T1 (ba-
At 48 hours, the mean baby’s weight loss was 6.19% by’s weight loss) were skin-to-skin contact (t = -3.359,
(SD = –0.21). The mean baby’s weight loss for exclusive p = 0.001) and breastfeeding at birth (t = -3.652, p < 0.01) and
breastfeeding mothers was 6.469 – 1.894 g and, for nonexclu- at T2 (24-hour milk production) were skin-to-skin contact at
sive, 5.573 – 2.244 g. Following Student’s t test, this difference birth (t = 2.336, p = 0.023) and number of breastfeeds/24 hours
in weight loss was found to be statistically nonsignificant. (r = 0.33, p < 0.05). Factors related to PIMS at T1 were IBFAT
At 2 weeks, the 24-hour breast milk production was (r = 0.538, p < 0.01), I-MABS (r = -0.45, p < 0.01), and BSES-
525.48 mL (SD = 213.97) (Table 4). When asked if they SF (r = 0.38, p < 0.01) and for PIMS at T2 were BSES-SF T1
perceived their breast milk production enough to satisfy their (r = 0.308, p < 0.5) and BSES-SF T2 (r = 0.725, p < 0.01) and
newborn, 82% (73/89) of mothers at T1 and 92.5% (49/53) of number of breastfeeds per 24 hours (r = 0.499, p < 0.01).
 Table 4. Descriptive Statistics of Birth Events, Infant Capacities, Breastfeeding Self-efficacy, Perceived Insufficient
Milk Supply, Actual Insufficient Milk Supply, and breastfeeding practices
Baseline (n = 123), T1 (n = 98), T2 (n = 62),
Variable mean (SD) n (%) mean (SD) n (%) mean (SD) n (%) T3 (n = 52), n (%)
Birth events
Type of deliverya 122a
Vaginal 91 (73.9)
Cesarean 32 (26.1)
Birth weight (g) 3427.70 (–38.37)
Skin-to-skin contact
Yes 85 (69.4)
No 38 (30.9)
Length (minutes) 93.73 (–4.57)
Breastfeeding at birtha 121a
Yes 84 (69.4)
No 37 (30.6)
Infant capacities
IBFAT — 9.43 (–2.28) 10.96 (–1.27)

5
I-MABS — 10.57 (–7.38) 8.88 (–4.83)
Number of feeds — 9.04 (–2.47) 9.18 (–2.25)
Breastfeeding
Self-efficacy — 50.58 (–7.38) 56.91 (–8.20)
PIMS — 20.75 (–4.30) 22.54 (–2.60)
AIMS
% baby’s weight loss — 6.19 (–0.21) —
24-hour milk production (mL)a — — 57a
Number baby’s urine (24 hours)a — — 525.48 (–213.97)
Number baby’s stools (24 hours)a — — 57a
Breastfeeding practices — 8.94 (–4.27)
Breastfeeding 57a
No — 6.12 (–3.44) 5 (8) 1 (2)
Yes 98 (100) 57 (92) 51 (98)
Exclusive 68 (70) 46 (74) 46 (88)
Nonexclusive 30 (30) 11 (18) 5 (10)
Baseline = 24 hours after birth; T1 = day 3 questionnaire, T2 = week 2 questionnaire, and T3 = week 6 phone call.
a
Missing response.
AIMS, actual insufficient milk supply; IBFAT, Infant Breastfeeding Assessment Tool; PIMS, perceived insufficient milk supply; SD, standard deviation.
6 GALIPEAU ET AL.
We further compared these variables among mothers who
reported breastfeeding exclusively versus nonexclusively
(predominant + partial) at both 48 hours and postnatal week
2. Mothers who breastfed exclusively (68/92) were more
likely than mothers who introduced breast milk substitutes
(24/92) to perceive their breast milk production as sufficient
(21.46 – 4.04 versus 18.63 – 4.46; t = 2.87, p = 0.005). Mo-
thers who breastfeed exclusively at 48 hours (65/85) com-
pared with mothers who introduced breast milk substitutes
(20/85) were also significantly different in terms of breast-
feeding self-efficacy (52.17 – 10.06 versus 45.45 – 10.11;
t = 2.61, p = 0.01). At postnatal week 2, mothers who did not
breastfeed exclusively (11/57) were more likely to perceive
milk insufficiency than mothers who breastfed exclusively
(19.45 – 3.42 versus 23.28 – 1.72; t = 3.63, p = 0.004). They
were also more likely to breastfeed less frequently than
mothers who breastfed exclusively (7.45 – 1.29 versus 9.6 –
1.87; t = 3.04, p = 0.004).
Discussion
This study aimed to determine the relationship between
PIMS and AIMS and the relative contributions of physio-
logical and psychosocial variables on both PIMS and AIMS.
To our knowledge, this is the first study that documents, at the
same time points, PIMS and AIMS.4 We also intended to
report breastfeeding and its exclusivity rates.
Maternal perception of insufficient milk supply was not
related to actual milk supply. Indeed, at both time frames,
more than 80% of the mothers at 48 hours and more than 90%
at postnatal week 2 believed their breast milk supply was
enough to satisfy their infants. Actual milk production, both
at 48 hours and at postnatal week 2, was within expected and
published results. The mean percentage of baby’s weight loss
was 6.19% (SD = –0.21) at 48 hours, which parallels the re-
sults of a systematic review where mean weight loss from 11
studies ranged from 5.7% to 6.6% (SD = –2%).23 Our find-
ings also correspond to the expected result of less than 7% of
weight loss between 3 and 5 days.21 The 24-hour milk pro-
duction at 2 weeks was 525.48 mL (–213.97 mL), which is
similar to published results of normal breast milk production
during the first postnatal month.8
Factors associated with PIMS at 48 hours were both in-
fants’ ability to suckle effectively and maternal breastfeeding
self-efficacy. Mothers who perceive positively both mother
and child breastfeeding capacities are more likely to perceive
their supply as sufficient to satisfy their infants. At 2 weeks,
mothers who perceive positively their own breastfeeding
capacity and who breastfeed often perceive their breast milk
supply as adequate to satisfy their infant. These findings
confirm previous results not only on the importance of child’s
capacity to suckle effectively for optimal milk transfer but
also its impact on mother’s breastfeeding confidence.4,7,13,14
Maternal evaluation of the dyad’s capacity contributes to her
perception of breastfeeding self-efficacy and is determinant
to her intention to pursue and to maintain her breastfeeding
practice and the actions required for its success.24 Perception
of a satisfied infant provides a feeling of security to the
mother and enhances her breastfeeding self-efficacy.25 Mo-
ther’s confidence in her breastfeeding capacity influences her
interpretation of the infant’s demands and cues in a positive
way.25,26
Factors associated with actual breast milk production were
different than for the perceived breast milk production at
48 hours, but partly similar at 2 weeks. Skin-to-skin contact at
birth, followed by an early breastfeeding session, was asso-
ciated with baby’s reduced weight loss at 48 hours. This is in
line with evidence from the literature. It has been demon-
strated that immediate and uninterrupted skin-to-skin contact
at birth positively influences the initiation of breastfeeding as
baby is more inclined to attach spontaneously to the breast if
not forced to suckle and oxytocin level is increased by this
contact; feedings are also more effective when skin-to-skin
contact lasts at least 1 hour without interruption.27–34 When
baby suckles spontaneously within the first 2 hours, it is
linked with more feeding episodes at days 3 and 4, more milk
production, more milk ingested, and less engorgement.27,35,36
There is also a demonstrated link between immediate and
uninterrupted skin-to-skin contact at birth and exclusivity of
breastfeeding at discharge and later on.27,37
At postnatal week 2, skin-to-skin contact and number of
breastfeeds were still associated with 24-hour milk produc-
tion. This finding adds to previous results that the frequency
of breast stimulation among nonsupplementing mothers was
related to milk production in the first 3 weeks postpartum.22
However, it seems that frequency of breastfeeds is often re-
ported as an issue by breastfeeding mothers; they expressed
difficulty in determining how often they should breastfeed
their baby.38 In this study, mothers with PIM were less likely
to breastfeed frequently as they believed it meant their baby
was not satisfied. Although informed by health professionals
to breastfeed on baby’s demand, mothers expressed difficulty
in interpreting baby’s cues.26,38 If mothers have skin-to-skin
contact immediately at birth and are supported early on to
recognize their baby’s demand and to immediately respond to
it, mothers seem less preoccupied by the frequency of feeds.
Limitations
There are a few limitations to this study. First, it is a con-
venience sample, therefore self-selection might have oc-
curred. The sociodemographic characteristics of participants
were comparable with regional sociodemographic data ex-
cept for family income, educational level, and marital status,
which are slightly higher than average for the area. These
characteristics have been associated with breastfeeding ex-
clusivity and duration. Lack of variability in our sample of
breastfeeding mothers might have influenced the nonsignifi-
cant relationship between perceived and actual breast milk
supply. Indeed, mothers who experienced breastfeeding dif-
ficulties might have been less likely to participate in this study
or might have stopped breastfeeding or have introduced breast
milk substitutes early. Therefore, mothers with a successful
breastfeeding experience might have been overrepresented.
Second, the breastfeeding assessment measures were self-
administered, obviously subjective in nature. Validity and
reliability of the measures of actual milk supply might have
influenced the results as well as the small sample of mothers
who did measure their milk production at 2 weeks. Not all
mothers provided 24-hour milk production and these missing
data might not have been random. It is also possible that some
measurement error occurred even though actions were taken
to minimize this bias by selecting a precise baby scale—the
research assistant explained the functioning to the mother. It
INSUFFICIENT BREAST MILK, PERCEIVED AND ACTUAL
might also be the case for actual breast milk production
measure such as percentage of baby’s weight loss. This
measure was taken from baby’s chart at 48 hours. We could
not exclude that some babies might have continued to lose
weight when back home.
Conclusion
The aim of this study was to determine the relationship
between PIMS and AIMS and the relative contributions of
physiological and psychosocial variables on both PIMS and
AIMS of first-time breastfeeding mothers. To our knowledge,
this is the first study documenting at the same time points
maternal perception and actual insufficiency of milk supply.
In this sample of primiparous mothers, maternal perception
of not having enough milk was not associated with an actual
insufficiency of milk supply as measured by baby’s weight
loss or 24-hour milk production. Indeed, factors associated
with maternal perception versus actual insufficiency were
deemed different. First-time breastfeeding mothers with
higher breastfeeding self-efficacy were less likely to perceive
their infant as nonsatisfied. Therefore, interventions should
be directed toward promoting early, optimal, and frequent
feedings. Professional support should be directed to inform
and guide parents toward optimal latch-on and signs to rec-
ognize that baby’s suckling is efficacious, as well as re-
sources available if experiencing breastfeeding difficulties.
Acknowledgments
The authors would like to thank all mothers who participated
in this study. They thank Drissa Sia, PhD, for his participation in
statistical analyses. They also thank the ‘‘Naissance-Renaissance
Outaouais,’’ the regional breastfeeding mother-to-mother group,
for their support with renting the baby’s scale.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Roseline Galipeau, PhD
Nursing Department
University of Quebec in Outaouais
Campus de Saint-Jérôme
5, Rue Saint-Joseph
Local J 3211
Gatineau J7Z 0B7
Canada
E-mail: roseline.galipeau@uqo.ca