The Moms Who Breastfeed Without Being Pregnant

i. Domperidone (92%)

Experiences of women who underwent induced lactation: A literature review

1 MBBS (Adelaide), MMed (Comm Med) (USM), PhD (La Trobe), IBCLC, Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Email: [email protected], [email protected]

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Tengku Alina Tengku Ismail

3 MD (USM), MMed (Comm. Med) (USM), PhD (USM), Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

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1 MBBS (Adelaide), MMed (Comm Med) (USM), PhD (La Trobe), IBCLC, Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Email: [email protected], [email protected]

2 MBBS (University Malaya), IBCLC, Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

3 MD (USM), MMed (Comm. Med) (USM), PhD (USM), Department of Community Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

(Corresponding author) MBBS (Adelaide), MMed (Comm Med) (USM), PhD (La Trobe), IBCLC, Women’s Health Development Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia. Email: [email protected] , [email protected]

Collection date 2021 Mar 25.

© Academy of Family Physicians of Malaysia
PMCID: PMC8088744 PMID: 33948139

Abstract

Objective:

This article aims to review the literature published over the past five decades related to the experiences of women who have undergone induced lactation.

Methods:

A comprehensive electronic search was conducted using PubMed, the Library of Congress, Google Scholar, SAGE, and ScienceDirect. The following search keywords were used: adoptive breastfeeding, induced lactation, non-puerperal lactation, extraordinary breastfeeding, and milk kinship. The search was restricted to articles written in English and published from 1956 to 2019. All study designs were included except for practice protocols.

Results:

A total of 50 articles about induced lactation were retrieved. Of these, 17 articles identified the experiences of women who underwent induced lactation. The articles included original papers (n=7), reviews (n=5), and case reports (n=5). Four articles were specifically related to Malaysia, and the others were international. These 17 articles concerning the experiences of women who induced lactation will be reviewed based on four themes related to inducing lactation: (a) understanding women’s perception of satisfaction, (b) emotional aspects, (c) enabling factors, and (d) challenges.

Conclusion:

Identifying a total of only 17 articles on induced lactation published over the last 53 years suggests that the subject is understudied. This review provides emerging knowledge regarding the experiences of women who have induced lactation in terms of satisfaction, emotions, enabling factors and challenges related to inducing lactation.

Keywords: adoptive breastfeeding, induced lactation, milk kinship

Introduction

Adoptive breastfeeding, referred to as induced lactation, is relevant in non-puerperal cases. Induced lactation is the process by which a non-puerperal woman is stimulated to lactate; more simply, the term refers to breastfeeding without prior pregnancy. 1,2 Induced lactation has been described as the process of breastmilk production in a mammal (woman) without recent pregnancy and/or birth and may involve the use of herbs, supplements, medications, mechanical stimulation, and/or the infant to facilitate breastmilk production. 2

Healthcare practitioners must comprehend the experiences of women who induce lactation to be able to provide unique, customized support for each individual. 3 The American Academy of Pediatrics (AAP) supports this stance in its policy statement on “Breastfeeding and the Use of Human Milk,” noting that pediatricians should provide counseling to adoptive mothers who decide to breastfeed through induced lactation, a process that requires professional support and encouragement. 4

Malaysia is a Muslim country, which has a bearing on the topic as a motivating factor for Muslim adoptive parents to induce lactation is to establish religious milk kinship. Saari et al. reported a lack of research on induced lactation in Malaysia, particularly involving the Muslim community, regarding why women might induce lactation and the factors that motivate them to do so. 5 Rahim et al. recommended that future investigations develop a practical model for induced lactation in Malaysia to explore maternal views related to the mothers’ needs, obstacles, experiences, perceptions, and motivations. 6

The objective of this article is to review the literature that has been published over the past five decades regarding the experiences of women who have undergone induced lactation. Therefore, this review covers perceptions of satisfaction, emotional aspects, enabling factors, and the challenges that women who underwent induced lactation have experienced. It is hoped that this review will provide healthcare professionals insight into women’s experience of induced lactation and acknowledge the vital role they play in assisting women in this process.

Methods

A comprehensive electronic search was conducted using PubMed, the Library of Congress, Google Scholar, SAGE, and ScienceDirect. The inclusion criteria were articles written in English, published from 1956 to 2019, and reporting outcomes related to satisfaction, emotions, enablers, and challenges in induced lactation. The search included the following study designs: reviews, original papers, and case reports. The exclusion criteria were articles in languages other than English, articles without access to the full paper, and outcomes not related to satisfaction, emotions, enablers, and challenges in induced lactation. Studies with a practice protocol design were also excluded. The following search keywords were used: adoptive breastfeeding, induced lactation, non-puerperal lactation, extraordinary breastfeeding, and milk kinship. The retrieved articles were compiled and managed using EndNote X8 software according to the respective topics. The search was conducted with multiple databases, which resulted in retrieving some duplicate citations, which were deleted using the EndNote X8 software. After deduplication, the search results were screened by title and abstract, followed by reading the full texts and removing the articles that did not meet the inclusion criteria. Based on the repetition of the themes that emerged when reading the full texts, four aspects were chosen for consideration: satisfaction, emotions, enablers, and challenges in inducing lactation. Figure 1 shows the flowchart of the screening and reviewing process.

Figure 1. Screening process for the literature review.

Results

A total of 73 potential papers about induced lactation were retrieved. During the screening process, papers that were excluded were those lacking access to the full text (n=4), duplicates (n=7), and articles with titles and abstracts that did not match the review’s objective (n=12). Consequently, 50 full-text papers were assessed for eligibility, from which full-text papers with no outcome of interest (n=33) were excluded. The content of the papers that offered no outcome of interest included folklore, religious views, and using galactogogues to induce lactation. Finally, 17 papers were included in the review. Four articles were specifically related to Malaysia, and the others were international. The resulting studies comprised seven original papers, five reviews, and five case reports. Based on the themes that repeatedly emerged when reading the full-text papers, the women’s experiences were reviewed based on the following topics related to inducing lactation: (a) understanding women’s perception of satisfaction, (b) emotional aspects, (c) enabling factors, and (d) challenges.

Understanding Women’s Perception of Satisfaction in Inducing Lactation

Auerbach et al. conducted a study in which 240 women who experienced adoptive nursing were asked about the parameters that led to success in a self-report questionnaire comprising closed-ended questions. 7 The study reported that most of the women were satisfied with their experiences. 7 Along the same lines, Goldfarb asked 228 participants how satisfied they were with their efforts to induce lactation. In this case, most of the women who induced lactation reported being satisfied with the overall experience and, given the opportunity, 83% said they would repeat the process. 2

Most of the participants in Saari et al.’s study did not experience pregnancy or childbirth, yet they expressed the desire to enjoy motherhood by breastfeeding their adopted child. 5 In that study, 67% of the mothers claimed that they enjoyed breastfeeding their child. The researchers noted repeated mentions of the words “satisfied,” “relieved,” “enjoy,” “pleasure,” and “indescribable feeling.” 5 In contrast to the papers that focused on understanding the mothers’ perspectives, Bryant 8 and Wittig et al. 3 published systematic reviews focusing on pharmacological and non-pharmacological methods to induce lactation. Both reviews reported that the maternal-infant bonding that resulted from induced lactation was the main source of satisfaction among the participants despite the rigorous process and their inability to produce an adequate milk supply to breastfeed exclusively. 3,8

Table 1 summarizes the findings on understanding women’s perception of satisfaction in inducing lactation in chronological order by year of publication. Based on the publications mentioned above, it is evident that the satisfaction of inducing lactation helps establish the maternal-infant bond, which is promoted by the process of inducing lactation.

Table 1. Findings on the perceptions of satisfaction in inducing lactation.

Study design Number of participants/articles

Summary of the findings on the perceptions of satisfaction in inducing lactation

Auerbach et al. 7 (1981)

Original paper (quantitative design) 240 participants

Most of the participants felt that the mother-infant relationship was important, and 76% evaluated adoptive nursing “positively.”

No clarification of the term “positively.”

Review 26 articles as references

The primary goal was not milk production but establishing an emotional bond with the infant.

Wittig et al. 3 (2008)

Review 18 articles as references

Based on information drawn from the articles in the review, it can be concluded that most women who induce lactation cannot produce enough breastmilk to exclusively breastfeed their infant, but they find satisfaction in this process because of the maternal-infant bonding it promotes.

Original paper (mixed qualitative and quantitative design) 228 participants

The author reported that 76% of the women were “satisfied” with no clarification of the term “satisfied” because that part of the study was quantitative.

Saari et al. 5 (2015)

Original paper (qualitative design) 12 participants

The findings showed that 67% of the mothers enjoyed breastfeeding their child, with repeated mentions of the words “satisfied,” “relieved,” “enjoy,” “pleasure,” and “indescribable feeling.”

Emotional Aspects of Inducing Lactation

Gribble reviewed the evidence in physiological and behavioral research studies regarding how breastfeeding plays a significant role in developing the attachment relationship between an adopted child and mother. 9 The results revealed that breastfeeding an adopted child is an attempt to ensure the quality of attachment between the mother and baby, whereby physical contact between them through breastfeeding enables a baby suffering from the trauma of separation from his/her birth mother to feel secure. 9

In the qualitative section of Goldfarb’s paper, the participants were asked to describe how they felt during the process of inducing lactation 2 The text was analyzed for repeated words, phrases, and themes. The prevalent comments were feelings of awe, wonder, and amazement, followed by love. Mothers reported healing from grief due to infertility as an essential motivation for inducing lactation. 2

Saari et al. asserted that induced lactation undertaken by participants elicited maternal instincts in adoptive mothers. 5 After experiencing induced lactation, all participants agreed that the process prepared them to be mothers and that breastfeeding was a pleasurable experience. All the participants also agreed that breastfeeding entailed affection and touch, exerting a positive impact on the adoptive mothers and the babies they were nursing. 5

Table 2 presents a summary of the findings on the emotional aspects of inducing lactation in chronological order by year of publication. Both positive and negative emotions were associated with induced lactation, as addressed by Goldfarb. 2 Positive emotions were viewed as a source of motivation to induce lactation, and negative emotions were associated with challenges to inducing lactation. 2

Table 2. Findings on the emotional aspects of inducing lactation.

Study design Number of participants/articles

Summary of the findings on the perceptions of satisfaction in inducing lactation

Review 163 articles as references

Breastfeeding an adopted child was an attempt to ensure the quality of attachment between the mother and baby.

Physical contact between the mother and baby through breastfeeding helped a baby suffering from the trauma of separation from his/her birth mother feel secure.

Saari et al. 5 (2015)

Original paper (qualitative design) 12 participants

Induced lactation led to a unique feeling, i.e., maternal instinct in adoptive mothers.

All the participants agreed that breastfeeding prepared them to be mothers and was a pleasurable experience.

All the participants also agreed that the affection and touch associated with breastfeeding had a positive impact.

Original paper (mixed qualitative and quantitative design) 228 participants

Mothers reported that healing from grief due to infertility was the most significant motivation to induce lactation.

Positive emotions were related to the mother-infant relationship, whereas negative emotions were related to technical challenges in inducing lactation, such as concerns about breastmilk supply, finding time to pump, and issues related to breast pumps.

Enabling Factors in Inducing Lactation

In this paper, enabling factors make it possible (or easier) for a woman to induce lactation. Based on an international article, this sub-topic is divided into psychosocial and technical factors, including the regimes and tools used to induce lactation. 3

Psychosocial Factors Enabling Induced Lactation

Szucs et al. published a case report of premature twins whose adoptive mother induced lactation. 10 Both infants received their adoptive mother’s milk exclusively at the age of two months. This approach reflects careful planning by the adoptive mother beginning in the prenatal period, her active role during the infants’ hospital stay, and the support she received from healthcare personnel and family members. 10

Lakhkar 11 and Nemba 12 maintained that the mothers’ motivation was the primary factor that enabled them to induce lactation, followed by family support. The researchers concluded that a mother who was motivated, confident, and knowledgeable about induced lactation had the best chance to succeed. 11,12 Goldfarb 2 and Auerbach et al. 7 found that enhancing the bond between the mother and baby was a key factor in breastfeeding an adopted child.

Women in Malaysia are driven to breastfeed their adopted babies through cultural exposure and religious beliefs to obtain milk kinship. 5 Saari et al. developed a model for adoptive breastfeeding that integrated both the Fiqh and scientific perspectives of adoptive breastfeeding. 5 Research has reported that the psychosocial enablers to induce lactation help fulfill religious milk kinship (Shariah-based) and, from a humanitarian perspective, foster compassion (science-based). 13 Table 3 presents a summary of the findings on the psychosocial factors enabling induce lactation in chronological order by year of publication.

Table 3. Findings on the psychosocial factors enabling induced lactation.

Study design Number of participants/articles

Summary of the findings on the perceptions of satisfaction in inducing lactation

Auerbach et al. 7 (1981)

Original paper (quantitative design) 240 participants

Factors reported as psychosocial enablers for inducing lactation:

i. Mother-infant bonding

ii. Fulfilling emotional needs of babies

iii. Body contact with baby

iv. Nutritional benefits of infants

v. Care by the mother

vi. Ability to produce breastmilk

vii. Breastfeeding as a reflection of femininity

viii. Mother’s physical changes

Case report 37 participants

A mother who was motivated, confident, and knowledgeable on the topic experienced the best chance of successfully inducing lactation.

Case report 23 participants

A mother’s motivation and family support acted as psychosocial enablers to induce lactation.

Review 87 articles as references

Suggested that adoptive mothers in developing countries might have greater milk production than mothers in Western countries because the former were more knowledgeable about breastfeeding, practiced frequent breastfeeding, had close physical contact with children, and lived in cultures that supported breastfeeding.

Original paper (qualitative and quantitative design) 228 participants

Inducing lactation fulfilled the emotional needs of babies and healed the mothers’ grief due to infertility.

Szucs et al. 10 (2010)

Case report 1 participant

Support from healthcare professionals and family members played a role in ensuring that premature twins received their adoptive mother’s milk exclusively at the age of 2 months.

Saari et al. 5 (2015)

Original paper (qualitative design) 12 participants

The themes outlined with regard to these psychosocial factors included “mahram,” “maternal instinct,” “psychology,” “offspring,” and “obligation.” These themes are briefly summarized as follows:

i. “Mahram” and “Obligation”: To establish religious milk kinship

ii. “Maternal instinct”: To satisfy the maternal instincts of adoptive mothers who have not experienced childbirth

iii. “Psychology”: Fulfill the desire to establish a bond between the adoptive mother and child

iv. “Offspring”: To overcome grief from not being able to conceive

Saari et al. 13 (2017)

Original paper (qualitative design) 12 participants

This study developed a Guideline Model of Breastfeeding Adopted Child alligned with the Fiqh and science perspective. Psychosocial enablers for inducing lactation included obligation to fulfill religious milk-kinship (shariah-based) and compassion (science-based).

Technical Factors: Different Regimes that Enable Inducing Lactation

Common approaches to inducing lactation include pharmacologic (hormonal stimulation) and non-pharmacologic (breast stimulation) methods, often used in combination. 3 Non-pharmacologic methods may involve women inducing lactation via breast stimulation through hand expression, using a breast pump, via direct suckling at the breast, or using a supplemental nursing system. 2,3,7,15

Table 4 summarizes the reported technical factors, including pharmacologic and non-pharmacologic approaches, that enable women to induce lactation in chronological order by year of publication. Auerbach et al. 7 and Goldfarb 2 described various regimes used to induce lactation. Patel also demonstrated that a back massage is a simple method that can be implemented in a regime to induce lactation without straining resources. 16 Cheales-Siebenaler et al. described an adoptive mother who produced breastmilk for her infant via various regimes, which resulted in adequate weight gain for her infant. 17

Table 4. Technical factors enabling induced lactation.

Study design Number of participants/articles

Summary of the findings on the perceptions of satisfaction in inducing lactation

Wittig et al. 3 (2008)

Review 18 articles as references

Procedures commonly used to induce lactation include pharmacologic (hormonal stimulation) and non-pharmacologic (breast stimulation) methods, often in combination.

Original paper (mixed-methods design) 228 participants

This paper described various regimes and their popularity (by percentage) in terms of being used to induce lactation, summarized below:

i. Domperidone (92%)

ii. Fenugreek (78%)

iii. Birth control pill (63%)

iv. Blessed thistle (68%)

vi. Metoclopramide (4%)

vii. Expressed breastmilk before infant’s arrival via pumping (75%) or hand expression (14%)

viii. Pumped after most feeds for 10 minutes (40%)

ix. Pumped after baby arrived, but not yet suckling on the breast (32%)

x. Put baby to the breast with a supplemental nursing system (51%)

Maximum milk supply was reported by the participants using the following protocols:

i. Domperidone, birth control, and pumping (45%)

ii. Domperidone and pumping (12%)

iii. Domperidone and supplemental nursing system (12%)

Rahim et al. 6 (2017)

Review 19 articles as references

No previous research has revealed any effective guidelines in place for induced lactation in Malaysia.

Establishing these guidelines is essential in Malaysia, given the recent expansion in Malaysians’ awareness of breastfeeding adopted children.

Auerbach et al. 7 (1981)

Original paper (quantitative design) 240 participants

This paper reported that most of the respondents practiced one or more of the following to induce lactation:

i. Read three or four books about breastfeeding or two or more articles on adoptive nursing before the arrival of their adopted infant

ii. Improved or supplemented maternal diet

iii. Practiced nipple stimulation before or after infant’s arrival

iv. Occasionally used hormone preparations to simulate pregnancy or increase milk ejection reflex

Abejide et al. 15 (1997)

Case report 6 participants

All six women in the case study produced breastmilk by breast-suckling alone; however, no details were included indicating how long they breastfed.

Cheales-Siebenaler et al. 17 (1999)

Case report 1 participant

An adoptive mother induced lactation by bilateral pumping, metoclopramide, and oxytocin nasal spray. She did not use oral or parenteral hormones to induce lactation.

She supplemented her adopted infant at the breast with the help of a supplementary feeding-tube device. She began to produce breastmilk when the infant was 4 months old (suddenly began to express four ounces of breastmilk per breast). The mother stopped her protocol at this time (stopped pumping and taking medications) and proceeded to direct-feed her infant without supplementation throughout the fourth and fifth months, with the infant gaining adequate weight.

Patel et al. 16 (2013)

Original paper (quantitative design) 220 participants

Back massage was effective in improving lactation in all the parameters assessed regarding the baby’s well-being, which was significantly progressive in the study group in comparison to the control group.

Challenges in Inducing Lactation

In 2015, Saari et al. described the challenges of breastfeeding an adopted child in Malaysia. 5 For example, some people may remain skeptical about breastfeeding an adopted child and consider the practice to be against human nature. 5 Four years later, Cazorla et al. reported the challenges faced by mothers inducing lactation and divided them into three categories: challenges during induction of lactation, challenges during breastfeeding, and difficulties during breastfeeding cessation. 18

Nemba conducted a study in Africa with 37 non-puerperal women ranging in age from 19 to 55. 12 A total of 27 women completed the lactation induction program, 24 (89%) of whom successfully breastfed their well-nourished children. All the women who had never previously lactated were successful. Of the three mothers in whom induction was unsuccessful, two obtained a bottle from other sources; their children were malnourished. This study indicates that given a high degree of motivation combined with medication, support, and encouragement, lactation induction is likely to be highly successful and a critical factor in child survival. 12

Table 5 presents a summary of the findings on the challenges in inducing lactation in chronological order by year of publication.

Table 5. Challenges in inducing lactation.

Study design Number of participants/articles

Summary of the findings on the perceptions of satisfaction in inducing lactation

Case report 37 participants

Internal factor: i. Demotivated

i. Lack of support and encouragement

Review 163 articles as references

i. Emotional instability in adoptive infants characterized by the cycle of progression-regression-progression of trying to directly breastfeed an adopted child.

Review 26 articles as references

i. Difficulty in committing time to frequently pump or breastfeed

i. Lack of support from the public, which views inducing lactation as odd or not worth the effort

Original paper (qualitative and quantitative design) 228 participants

i. Worrying about the baby getting enough milk

ii. Sore nipples/breasts

iv. Getting baby to breastfeed

v. Lack of preparation time

i. Equipment difficulties

Saari et al. 5 (2015)

Original paper (qualitative design) 12 participants

i. Lack of commitment

ii. Health problems

ii. Lack of support

iii. Non-conducive work environment

iv. Career setback

Original paper (qualitative design) 9 participants

i. Hardship to endure induced-lactation protocols

ii. Doubts and fears while inducing lactation, such as not being able to produce milk or producing an insufficient amount of milk

iii. Problems with breasts, such as cracked nipples, nipple blebs, blocked ducts, pain, and suction problems

iv. Doubts if amount of milk supplied was sufficient during breastfeeding period

v. The end of shared responsibility for breastfeeding with the partner during breastfeeding cessation

vi. Reduced feeling of closeness to the child during breastfeeding cessation

i. Difficulty obtaining information from health professionals

Discussion

Understanding Women’s Perception of Satisfaction in Inducing Lactation

An adoptive mother seeking to induce lactation is a unique client in need of customized and personalized care. Although understanding the perception of satisfaction in inducing lactation is vital, 3 the studies reviewed on this subject failed to clarify the term “satisfaction” in inducing lactation. 2,3,5,7,8

Saari et al. 5 and Goldfarb 2 produced original papers that reported the outcome of experiences of induced lactation. For their part, Wittig et al. 3 and Bryant 8 presented reviews that reported conclusions drawn by reviewing previous studies. Several studies reported that satisfaction in women who induced lactation arose from the bond the practice established between the mother and the infant. 3,5,7,8

In light of this factor, healthcare professionals helping mothers induce lactation should ask the mothers beforehand about their perceptions of satisfaction in inducing lactation. Practicing this approach will allow healthcare professionals to work with these mothers to achieve their goals. 7 Because inducing lactation is an ongoing process, the perception of satisfaction might change as the process unfolds. It is recommended that healthcare professionals continually ask women who are inducing lactation about how they perceive satisfaction before they induce lactation and during follow-up visits. Such ongoing communication will enable professionals to develop the most realistic plan for an individual woman to achieve lactation. 3

Emotional Aspects of Inducing Lactation

The studies that mentioned positive emotions associated with inducing lactation reported that the practice healed grief due to infertility, increased a woman’s maternal instincts, and benefited the adopted babies by ensuring a secure feeling after the trauma of being separated from their birth mother. In support of this idea, Goldfarb 2 and Saari et al 5 wrote original papers that reported on the outcome of experiences of induced lactation, and Gribble 9 published a review based on the conclusions reported in previous studies.

The emotions reported from the studies mentioned above correlate with a recommendation rooted in dependency theory (Attachment Theory), which was developed by John Bowlby and Mary Ainsworth in 1950. According to this theory, a baby’s dependency on the mother or mother figure is predicated on acceptance, protection, security, and caring. 19 Based on these phenomena, love between a mother and child can be nurtured as early as the birth of the baby through such acts as breastfeeding. The positive effects that inducing lactation can have on women’s emotions support the recommendation that healthcare professionals should always take time to ask the women they are assisting about their emotional well-being during different phases of the lactation-inducing process. This approach provides healthcare professionals with both an opportunity to document the emotional changes that mothers go through when inducing lactation and additional insight about how women feel during different phases of that process. Thus, healthcare professionals will be better able to understand how to assist mothers in inducing lactation. The importance of this recommendation is underlined by the fact that over the course of 53 years, only three studies have addressed this subject, suggesting that more research on this topic is needed. 2,5,9

Women who induce lactation may experience both positive and negative emotions. The negative emotions are related to the technical challenges, such as being concerned about breastmilk supply, finding time to pump, and issues related to breast pumps. 2 Healthcare professionals can assist women with these aspects by offering regular follow-ups to identify the triggers that lead to negative emotions and discuss a plan to avoid those triggers and reduce or eliminate those emotions. Women going through induced lactation should be well supported emotionally because negative emotions will impair the autocrine process of lactation. 20 Consultation sessions should also be attended by family members, a friend, a spouse, or a partner so that they can form a support system for the women inducing lactation to help them avoid emotional breakdowns.

Psychosocial and Technical Factors that Enable Inducing Lactation

Information regarding the social norms that positively affect a woman’s ability to induce lactation in developing countries is somewhat similar to breastfeeding in general. In developing countries, mothers are knowledgeable about breastfeeding because they have observed the practice from a young age. 14,21 This familiarity results in increased confidence in breastfeeding and fewer breastfeeding problems. 22,23 Some women also have beliefs about child care that optimize breastfeeding. For example, they allow unrestricted breastfeeding and keep their babies in close physical contact, day and night. 24,25 This technique maximizes prolactin secretion and breast emptying, accelerating breast development and increasing milk production. 26

The participants in the studies by Goldfarb 2 and Auerbach et al. 7 highly valued the development of love and an affectionate relationship between an adoptive mother and her adopted child because the adoptive woman did not carry the child in her womb. Efforts to establish a bond between an adoptive mother and her adopted child are unequivocally important as a Muslim in a local community in order to establish a mahram relationship. Both motivations act as psychosocial enablers to induce lactation, albeit from different perspectives. The goals are similar, involving an attempt to accept an adopted child as a part of one’s family to avoid any issue of segregation despite the lack of a biological connection. 2,5,7 It is recommended that healthcare professionals understand the psychosocial factors that help women to induce lactation. While the reports regarding these psychosocial factors acknowledged their role in enabling induced lactation, it is recommended that healthcare professionals seek more in-depth information on this subject throughout the different phases of inducing lactation and during follow-ups. Each adoptive mother and breastfeeding baby has their own unique experience, and the psychosocial aspect has received less priority than the nutritional and immunity-enhancing aspects of breastfeeding. 9 Seven articles on this subject over the past 53 years suggests that this topic is severely understudied and deserves further investigation. Gaining insight into the psychosocial enablers in inducing lactation will help healthcare professionals assist women in making practical management plans and managing their expectations. 8

Moreover, many technical factors should be considered in induced lactation programs due to variations in the adoptive mothers’ religious and ethnic backgrounds, health status, and financial and environmental challenges. 2,3,6,7,15–17 Figure 2 presents a summary of the technical factors that enable women to induce lactation.

Figure 2. Summary of the technical factors that enable a woman to induce lactation.

Challenges in Inducing Lactation

Although a review of the challenges to inducing lactation is limited in light of the lack of previous research in this area, women who induce lactation face internal challenges and external challenges. In general, internal challenges include a mother’s lack of motivation, difficulty maintaining the stimulation protocol while inducing lactation, encountering breast problems while pumping or breastfeeding, and the lack of confidence in the ability to produce breastmilk. 2,5,8,12,13,18 External challenges are the lack of support from people, the lack of efficient tools for stimulation, and the emotional instability of the adopted child causing latching difficulties. 5,9,12,18

Bandura’s 27 social cognitive theory serves to summarize the challenges women go through when inducing lactation. Social cognitive theory is founded on a model of causation involving triadic reciprocal determinism. In reciprocal causation, behavior, cognition, personal factors, and environmental influences are interacting determinants that influence each other bidirectionally. 27 Figure 3 describes how social cognitive theory can be incorporated into the results from the review considering the challenges of inducing lactation. As an elaboration of the theory, consider an example from the results that demonstrates the role of environmental factors, personal factors, and behavioral factors. A woman who lacks support from the people around her may be demotivated to induce lactation and have difficulty adhering to the stimulation schedule. For example, breastfeeding equipment difficulties (environmental factor) could lead her to have difficulty adhering to the stimulation schedule (behavioral factor) and cause her to worry about the quantity of breastmilk production (personal factor).

Figure 3. Social cognitive theory used to summarize the challenges faced when inducing lactation.

Conclusion

The review presented in this paper summarized the experiences of women who have induced lactation. The discussion enables a better understanding of participants’ perception of satisfaction, their emotions when inducing lactation, the enablers to inducing lactation, and the challenges in doing so. The information gathered from the articles on induced lactation in the past 53 years supports the conclusion that women seeking to induce lactation perceive satisfaction in terms of the maternal-infant bonding that develops as the process unfolds. 3,8 Women who induced lactation also experienced positive and negative emotions. Positive emotions were related to the mother-infant relationship, while negative emotions stemmed from the technical challenges faced when inducing lactation, such as concerns about the breastmilk supply, finding time to pump, and issues related to breast pumps. 2,5,9

Enablers for inducing lactation can be psychosocial or technical. Psychosocial enablers are related to bonding, nutritional benefits, feelings of self-competency when producing breastmilk, support from people in one’s surroundings, and the obligation to fulfill religious milk kinship. 2,5,7,11,12 Technical enablers include pharmacologic (hormonal stimulation) and non-pharmacologic (breast stimulation) methods. 3,6,7,15–17 used to induce lactation. The challenges associated with induced lactation encompass a variety of internal and external factors, reciprocally influenced by personal, behavioral, and environmental factors (one’s surroundings). 2,5,8,9,12,18

Conflict of Interest

The authors declare that they have no conflicts of interest regarding this manuscript.

Ethical approval

The study was approved by the Human Research Ethics Committee, Universiti Sains Malaysia (USM/JEPeM/18040194).

Informed consent

The writing of this manuscript did not involve any respondents; therefore, informed consent was not required.

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The Moms Who Breastfeed Without Being Pregnant

Hormones and pumping are allowing some parents to induce lactation—and rewrite the rules of caring for a baby.

Bettmann / Getty
April 11, 2023

While her wife was pregnant with their son, Aimee MacDonald took an unusual step of preparing her own body for the baby’s arrival. First she began taking hormones, and then for six weeks straight, she pumped her breasts day and night every two to three hours. This process tricked her body into a pregnant and then postpartum state so she could make breast milk. By the time the couple’s son arrived, she was pumping 27 ounces a day—enough to feed a baby—all without actually getting pregnant or giving birth.

And so, after a 38-hour labor and emergency C-section, MacDonald’s wife could do what many mothers who just gave birth might desperately want to but cannot: rest, sleep, and recover from surgery. Meanwhile, MacDonald tried nursing their baby. She held him to her breast, and he latched right away. Over the next 15 months, the two mothers co-nursed their son, switching back and forth, trading feedings in the middle of the night. MacDonald had breastfed her older daughter the usual way—as in, by herself—a decade earlier, and she remembered the bone-deep exhaustion. She did not want that for her wife. Inducing lactation meant they could share in the ups and the downs of breastfeeding together.

MacDonald, who lives in a small town in Nova Scotia, had never met anyone who had tried this before. People she told were routinely shocked to learn that induced lactation—making milk without pregnancy—is biologically possible. They had so many questions: Was it safe? Did she have side effects? How did it even work? But when she described how she and her wife shared nursing duties, many women told her, “I wish I had had that.”

Induced lactation wasn’t initially developed for co-nursing. Mothers who wanted to breastfeed their adoptive babies were the first to experiment with hormones and pumping. But over time, the few experts who specialize in induced lactation told me, that has given way to more queer couples who want to share or swap nursing duties. Early in her career, Alyssa Schnell, a lactation consultant in St. Louis who herself breastfed her adopted daughter 17 years ago, found that when she suggested to same-sex couples that the non-birthing partner might try nursing, “they would be horrified.” The idea that a woman would nurse a baby she did not give birth to—common in the era of wet nurses—had become strange in our era of off-the-shelf formula. Now parents are coming to her asking to induce lactation, and more of them are interested in co-nursing.

About a quarter of all babies in the U.S. are breastfed exclusively for six months; more than half are breastfed at least some of the time. The statistics don’t say by whom, but that’s because they don’t need to. We can assume it’s virtually always their birthing mother. Even with the help of formula, the pressure around or preference for breastfeeding means that, in many families, the work of feeding falls disproportionately on one parent. But induced lactation decouples breastfeeding from birth. By manipulating biology, parents who co-nurse are testing the limits of just how equal a relationship can truly be.

Breastfeeding is hard work, even when it’s “natural.” Adding induced lactation is harder work still. MacDonald was putting herself on a newborn schedule weeks before her baby was even born. She pumped at home. She pumped at work. She even pumped while her wife was in labor, because skipping sessions can cause milk supply to drop. As Diane Spatz, a lactation expert at the University of Pennsylvania and Children’s Hospital of Philadelphia, puts it, “You have to start pumping like a wild person.”

MacDonald followed a version of the Newman-Goldfarb protocol, named after a pediatrician and an adoptive mother who documented and shared the process in 2000. In addition to pumping, the protocol includes birth control, which causes a surge of progesterone and estrogen akin to pregnancy hormones, and a drug called domperidone, which boosts the milk hormone prolactin. Together they biochemically prime the body for milk production. It’s unusual, Schnell told me, for a woman inducing lactation to make enough milk to feed a baby all on her own—unless she’s breastfed before, like MacDonald had—but it’s also unusual to make no milk at all.

In the U.S., getting domperidone can be a challenge. Though the drug is widely available in Canada, Australia, and Europe, the FDA has banned it in the United States, citing the risk of abnormal heart rhythms and even death. But these heart problems have shown up only in the elderly, foreign experts have noted, and Australian scientists concluded in a 2019 review that domperidone is safe for lactation, as long as women are screened for heart conditions. But in the U.S., parents usually aren’t taking it under the supervision of a doctor. They might buy pills with a prescription at a Canadian pharmacy or surreptitiously order the drug online through overseas pharmacies. “There was a brief moment when you could only buy it in bitcoin,” says Lauren Vallone, whose partner, Robin Berryman, induced lactation so that they could co-nurse their daughter, who was born in 2020.

Inducing lactation felt like a DIY project to Vallone and Berryman. As a queer couple trying to start a family, though, they were also used to doing things a different way. They eventually reached out to Schnell for guidance, but they also swapped tips in a Facebook support group that had a wealth of anecdotal advice. Not that most doctors would have been helpful. Even the idea that one can breastfeed without having been pregnant isn’t widely known, Spatz told me. “Nurses are surprised about that,” she said. “Physicians don’t know that.”

Vallone and Berryman planned to divide nursing duties 50/50, but they didn’t know exactly what that would look like. Would they trade off every other feeding? Would one nurse while the other pumped? What about when one parent went back to work? “There’s stories of people who have induced lactation, but then there’s no, like, ‘Well, what does your day look like?’” Vallone told me. They had no script to follow, so they could write their own. They envisioned giving themselves equal roles from the start, much like how many same-sex couples share a more equal division of labor, because they do not come in with the gender baggage of a heterosexual relationship.

What Vallone and Berryman did not want was to lapse into the roles that they watched their friends fall into, where the birthing parent becomes the breastfeeding parent becomes the default parent. The arrival of a new baby is a delicate time in any relationship—for many reasons, but in no small part because it disrupts whatever division of labor was previously agreed upon. Here is a tiny helpless human, along with a mountain of new tasks necessary to keep them alive. If the baby is breastfed, now a large share of that labor can be done by only one parent. In her case against breastfeeding in The Atlantic in 2009, Hanna Rosin described how that initial inequality persists and festers over the years: “She alone fed the child, so she naturally knows better how to comfort the child, so she is the better judge to pick a school for the child and the better nurse when the child is sick, and so on.” But what if—under very specific circumstances at least—breastfeeding did not fall solely on one parent? What if instead of parenthood starting off on unequal footing, it could be perfectly equal from the very beginning?

For a while, Vallone and Berryman did trade off feedings, and both continued to pump, because they worried that their milk supplies would drop. They tracked every ounce in a shared spreadsheet. (This careful data logging actually allowed Schnell to write a case study about the couple.) The pumping eventually became too much—they couldn’t sleep if they were pumping!—but they have kept co-nursing for two years now.

From the early days, they saw that nursing not only nourished their baby but also soothed her when she cried, made her sleepy when she was tired but fussy. So the work of not just feeding but all-round caregiving fell on them more equally. In the morning, they could alternate one person waking up early with the baby, the other sleeping in. At night, one parent could go out with friends without racing home for bedtime or pumping a bottle of breast milk for the other to feed. Because they could each provide everything their baby wanted, they were also each freer. Breastfeeding simultaneously deepened their relationships with their baby and allowed them a life outside of that. “You really get a sense of how radical it is to have caretaking split so evenly,” Vallone said. The couple is now trying for their second child, which Berryman plans to carry. They plan to co-nurse again.

Vallone and Berryman did, however, run into an unexpected obstacle to their co-nursing: their baby. She at one point refused to nurse on Vallone, the birthing parent, and wanted to nurse only on Berryman. Any parent is probably familiar with how babies can develop seemingly arbitrary preferences: breast over bottle, left breast over right breast, even. As they get older, toddlers, too, go through periods of wanting only one parent or another to feed, clothe, bathe, or comfort them. In this case—as in many cases—Vallone and Berryman had to be deliberate about returning to a more even state. At its most intense, Berryman would sleep away from the baby in another room; it got better over time, but it also sometimes got worse. Equality did not come easily even with two nursing parents, which perhaps isn’t surprising. The advent of formula did not magically render all marriages equal. Vallone and Berryman still had to work toward keeping their co-nursing relationship as balanced as possible. Dividing work is also, well, work.

Not all couples who induce lactation end up splitting breastfeeding evenly. Some are not able to, and some don’t even want to. For example, one parent might choose to carry the baby while the other takes on breastfeeding. Some of the women I spoke with were primarily motivated to induce lactation to pass along their antibodies in breast milk, or to physically bond with a baby they did not carry. Even for those who never made more than a few of the roughly 25 ounces a baby typically needs every day, being able to comfort nurse—when a baby sucks more for soothing than for nourishment—was meaningful. They could nurse their baby to sleep or calm them when upset. It brought the parents closer together too: Although inducing lactation is not equivalent to pregnancy, both parents felt like their bodies were preparing for a baby together. And later, they could troubleshoot a bad latch or clogged duct together. Breastfeeding can be an isolating experience when one parent is attached to a baby eight times a day and the other looks on a bit helplessly; co-nursing made it less so.

Because induced lactation has flown under the radar of mainstream science for so long, a lot remains unknown. A couple of small studies suggest that the protein and sugar content of induced breast milk is in the normal range, but detailed experiments into, for example, the mix of antibodies have never been done. And why are some women inducing lactation able to produce more than others? Schnell has noticed that those who have struggled with infertility or hormonal balances usually make less milk. She has worked with trans women, too, who are able to make milk, though usually not in large amounts. Men, theoretically, could lactate as well; early studies into domperidone actually noted this as a side effect. There are anecdotal reports of men breastfeeding infants, but there’s virtually no research into the phenomenon.

One mother I interviewed, Morgan Lage, told me that her experience inducing lactation to breastfeed her daughter inspired her to train as a lactation consultant, and she hopes now to fill in some of the many unknowns. The Newman-Goldfarb protocol is widely used as the template for anyone attempting induced lactation, but no one has rigorously studied the optimal time to initiate pumping or birth control. Lage started pumping earlier than the protocol suggested, and she wonders if that’s why she was able to have a full milk supply despite never having breastfed before. She loved nursing her daughter. She loved feeling “just as important and needed” in the fleeting, precious period of infancy.

I know what Lage means about feeling needed, though perhaps because I breastfed solo—as most mothers do—I did not always love it. Still, I remember staring at my baby’s eyelashes and toes, marveling at how nearly every molecule in her body came from mine. We did supplement with formula, too, in part because we wanted my husband to be involved in her feeding. Although the bottle satisfied her hunger, it did not always satisfy some primal need for comfort. During her most inconsolable nights, my husband would spend hours trying to soothe her with every trick in the book, only for her to fall quiet and asleep the minute I nursed her. This frustrated us both. To be needed this way was a burden and a joy. I was sorry, for both of us, that we could not share it.