Research Article Addressing barriers to health: Experiences of breastfeeding mothers after returning to work Sousan Valizadeh, PhD, 1 Mina Hosseinzadeh, PhD STUDENT , 2† Eesa Mohammadi, PhD, 3 Hadi Hassankhani, PhD, 4 Marjaneh M. Fooladi, RN, WHNP-BC, FNP-BC, PhD 5 and Virginia Schmied, RN RM PhD 6 Departments of 1 Pediatrics Nursing, Nursing and Midwifery Faculty, 2 Health Nursing, Nursing and Midwifery Faculty, Student Research Committee, and 4 Medical-Surgical Nursing, Center of Qualitative Studies, Tabriz University of Medical Sciences, Tabriz, 3 Department of Nursing, Faculty of Medical Science, Tarbiat Modares University, Tehran, Iran, 5 University of Jordan Amman, Jordan, World Wide Nursing Service Network (WWNSN, PLLC), El Paso, Texas, USA and 6 School of Nursing and Midwifery, University of Western Sydney, Sydney, New South Wales, Australia Abstract Breastfeeding mothers returning to work often feel exhausted as they must feed on demand and attend to family and employment responsibilities, leading to concerns for their personal health. This study was prompted by a desire to understand and identify barriers to mothers’ health. We describe the experiences of 12 Iranian breastfeeding and employed mothers through in-depth and semi-structured interviews and thematic analysis. Two main themes emerged: (i) working and mothering alone and (ii) facing concerns about health. The findings highlight the need for a support system for breastfeeding mothers within the family and in the workplace. Family- friendly policies targeting mothers’ and employers’ views are needed to support working mothers and promote breastfeeding. Key words barriers, breastfeeding, employment, Iran, women’s health. INTRODUCTION Recent global changes in women’s social status and rapid growth in educational advancement for women have generated new employment opportunities with additional responsibilities; however, women are still perceived as the primary family care- givers (Garima & Kiran, 2014). The transition to parenthood is a very stressful life event (Friedman et al., 2003; Tsao et al., 2015), and studies report numerous challenges faced by work- ing mothers who intend to continue breastfeeding (Johnston & Esposito, 2007; Burns et al., 2010; Skafida, 2012). Breastfeeding is an important biophysiological process that is critical to infant and maternal health (Centers for Disease Control and Prevention, 2013). Nevertheless, most mothers discontinue breastfeeding a few weeks after returning to work (Murtagh & Moulton, 2011). Maintaining a healthy lifestyle while working is a major challenge for mothers re-entering the workforce (Timmerman, 2007). Identifying barriers to maternal health could be crucial for continued breastfeeding. Health barriers are defined as a set of internal and external factors that inhibit healthy behavior (Pender et al., 2006). Internal barriers are influenced by per- sonal and cultural factors (Timmerman, 2007), such as maternal knowledge of the health benefits of breastfeeding, motivation, and time-management skills, whereas external barriers consist of environmental factors, such as access to facilities to breastfeed or express milk in the workplace, opportunities to exercise, and support systems (Tsai, 2013). Few studies have focused on maternal health, employment, and the desire to breastfeed beyond the early postpartum period (Alstveit et al., 2011). Although some studies have reported a negative correlation between maternal health and employment because of an imbalance in work and family dynamics (Grice et al., 2008), others have shown a positive relationship between employment and maternal health when children are older, but a negative effect for mothers with infants (Schnittker, 2007; Marshall & Tracy, 2009). Iran is a developing country with a population of over 75 mil- lion, in which women make up 27% of the workforce (Statisti- cal Center of Iran, 2011). Employment during pregnancy and while breastfeeding is a relatively new phenomenon in Iran (Ahmadifaraz et al., 2014), as Islamic principles encourage women and mothers to focus first on family responsibilities to build a strong foundation and later on their career (Rafii et al., 2013). Employed mothers fulfill sociocultural expecta- tions of family affairs while managing working-related chal- lenges (Ahmadi & Taghavi, 2003). Few Iranian studies have focused on the health concerns of breastfeeding mothers who have recently returned to work (Ahmad-Nia, 2002). Some studies have reported that women discontinue breastfeeding soon after returning to work (Murtagh & Moulton, 2011; Johnston & Esposito, 2007). No research has exclusively examined the health concerns of mothers who are committed to both work and breastfeeding. Correspondence address: Mina Hosseinzadeh, Department of Health Nursing, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences Shariati Jonobi Street, Tabriz, Iran. Email: m.hosseinzadeh63@gmail.com Received 31 July 2016; revision 3 November 2016; accepted 4 November 2016 The address of Marjaneh M.Fooladi and Virginia Schmied is different from where the study was performed. © 2017 John Wiley & Sons Australia, Ltd. doi: 10.1111/nhs.12324 Nursing and Health Sciences (2017) ••, ••–••