Benchmark- Capstone Project Change Proposal

Benchmark: Awareness, Intention, and Needs Regarding Breastfeeding: Findings from First-Time Mothers in Shanghai, China

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Hong Jiang,1,2 Mu Li,3 Dongling Yang,1,2 Li Ming Wen,3,4 Cynthia Hunter,3

Gengsheng He,1,2 and Xu Qian1,2



Background and Objectives: Despite efforts, a decline in breastfeeding rates has been documented in China recently. This study explored the awareness of the World Health Organization (WHO) guidelines for breast- feeding and intention to breastfeed among first-time mothers and identified the gap between mothers’ needs and perinatal care provision regarding breastfeeding promotion. Subjects and Methods: In total, 653 women at 5–22 gestational weeks were recruited from four community health centers in Shanghai, China. They completed a self-administered questionnaire at recruitment. Two focus group discussions were held among third-trimester pregnant women who had received prenatal education. Twenty-four in-depth interviews were conducted among postpartum mothers. Results: During early pregnancy, a substantial proportion of mothers were not aware of the nutritional value of breastmilk (40%) or the value of exclusive breastfeeding for 6 months (80%) or any breastfeeding for 24 months (98%). The awareness of the WHO guidelines for breastfeeding was associated with intention to breastfeed (adjusted odds ratio [OR] 2.67, 95% confidence interval [CI] 1.88, 3.78) or intention to breastfeed exclusively (adjusted OR 3.31, 95% CI 1.81, 6.06). In late pregnancy and postpartum, most mothers were still not fully aware of the breastfeeding recommendations and nutritional value of breastmilk. Limited communications with healthcare providers and lack of support for dealing with breastfeeding difficulties were reported. Conclusions: Low awareness of the WHO breastfeeding guidelines was found among first-time mothers in Shanghai. Awareness of breastfeeding guidelines was independently associated with mothers’ intention to breastfeed and intention to breastfeed exclusively. The health benefits of breastfeeding and the recommended duration of breastfeeding should be emphasized in prenatal education programs.

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Table of Contents

Background, Benchmark

Breastfeeding is recommended by the World Health Organization (WHO) as a key measure to ensure the health of mothers and children. In 2002, WHO updated the breastfeeding guidelines and recommended ‘‘all infants should be exclusively breastfed for the first six months of life, and receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond’’ (WHA55 A55/15, paragraph 10, p. 5).1

Efforts have been made to promote breastfeeding in China, where there are more than 10 million live births every year. The Baby Friendly Hospital Initiative has been scaled up in all regions of China since the 1990s.2 The target for breastfeeding promotion was set in the National Program of Action for

Child Development of China in the 1990s and 2000s. Its aim was to promote the ‘‘exclusive breastfeeding’’ rate (defined as ‘‘breastfeeding while giving no other food or liquid, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicine’’)3 for 4 or 6 months and achieve an ‘‘any breastfeeding’’ (defined as ‘‘the child has received breast milk with or without other drinks, formula or other infant food’’)3 rate of 80% by 2000 and of 85% by 2010 (province-based) at 4 months.4,5 Following the WHO’s lead, the China Nutrition Society also updated the national breastfeeding guidelines in 2007. 6

Despite these efforts, a decline in breastfeeding has been documented in China recently. The rate of full breastfeeding (defined as ‘‘while breastfed an infant may also receive small amounts of culturally valued supplements—such as water,

1School of Public Health, Fudan University, Shanghai, China. 2Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China. 3Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia. 4Health Promotion Service, Sydney South West Area, Health Service, Sydney, New South Wales, Australia.

BREASTFEEDING MEDICINE Volume 7, Number 6, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2011.0124


water-based drinks, fruit juice’’)3 for infants 0–5 months was 49% in 2006 and only 28% in 2008.7,8 Data from the 4th Na- tional Health Services Survey (in 2008)9 revealed that the ex- clusive breastfeeding rate in urban areas was only 15.8% for infants £ 6 months. Furthermore, a survey (n = 3,414) con- ducted in 2002 covering five large cities from different regions of China (Guangzhou, Shanghai, Chongqing, Xi’an, and Changchun) showed that the ‘‘any breastfeeding’’ rates at 4, 6, 12, and 24 months were only 61%, 50%, 5%, and 0.4%, re- spectively. These were much lower than in other countries like Australia and the United States.3,10

Breastfeeding decisions and practices are influenced by a wide range of factors, including knowledge, attitudes, beliefs, and sociocultural environments.11–14 A recent study showed that awareness of the WHO breastfeeding recommendations was strongly associated with intention to breastfeed among mothers in southwest Sydney, Australia.15 Other studies have repeatedly found that women’s pre-birth breastfeeding inten- tions are a good predictor of the actual duration of breast- feeding.16,17 However, no studies in China have explored mothers’ awareness of the WHO breastfeeding guidelines and the relationship between this awareness and intention to breastfeed, and none has examined mothers’ perceptions of breastfeeding and whether there is any gap between perinatal health care and mothers’ needs for breastfeeding.

The aims of this study were to explore mothers’ awareness of the WHO guidelines for breastfeeding and their intention to breastfeed. The study also aimed to identify the gap between mothers’ needs and perinatal care provision for breastfeeding.

Subjects and Methods

Study design

This was part of an intervention study (quasi-experimental design) that aimed to investigate the effectiveness of short mobile message health promotion on infant feeding practices. To explore the breastfeeding issues, we analyzed the baseline data collected by mixed quantitative and qualitative methods. The study was approved by the Institutional Review Board of the School of Public Health, Fudan University, Shanghai, China and the Human Research Ethics Committee of the University of Sydney, Sydney, Australia. Written informed consent was obtained from each participant.

Four community health centers (CHCs) were purposively selected as the project sites in two districts of Shanghai, China. In Shanghai, maternal and child health (MCH) care is pro- vided by CHCs and maternity hospitals. Usually, a pregnant woman needs to register and receives the ‘‘Pregnant Women Healthcare Card’’ at around 12 gestational weeks at the health center of the community where her household registration is held. She receives early antenatal care, including the first prenatal education on breastfeeding there. From about 20 weeks of gestation the pregnant woman receives antenatal care and delivery service at the maternity hospital of her choice, where free prenatal education is provided on about four occasions in groups. There is one session delivered by nurses focusing on breastfeeding knowledge, and the educa- tion usually lasts for around 1 hour. After childbirth, most new mothers are encouraged to initiate breastfeeding as soon as possible in the delivery room or operating room by mid- wives or nurses. In maternity ward, a new mother will get detailed guidance for breastfeeding practice from nurses such

as postures for breastfeeding, more sucking by the baby, nipple treatment, etc. The content and quality of breastfeeding guidance vary from delivery hospital to delivery hospital. After discharge from the hospital, the new mother is referred back to the CHC in her household registration area. The mother and baby are followed up by the CHC staff, who understands their overall health status with usually one to three home visits within the first month after delivery. CHCs are also responsible for child healthcare services from age 0 to 6 years.18

Quantitative study

Participants. When mothers attended the CHC for the first time around 12 weeks of their pregnancy, they were approached by MCH staff with a letter of invitation and in- formation about the main study. Mothers were eligible to participate if they were first-time mothers, were older than 20 years, had at least completed junior high school education (9 years), had conceived a singleton fetus, and had no illness that limits breastfeeding after childbirth. From around 1,200 wo- men approached between October 2010 and January 2011, in total, 653 mothers at 5–22 weeks of gestation were recruited.

Data collection. Participating mothers were invited to complete the self-administered questionnaire prior to the first time of prenatal education using the questions adapted from the Healthy Beginning Trial.15 Questions included demograph- ics and health information, access to social support, awareness of the WHO breastfeeding guidelines, intention to breastfeed, knowledge of infant feeding, and awareness of childhood obesity. There were six questions related to the WHO breast- feeding guidelines, including the nutritional value of breastmilk, the health benefits of breastfeeding, the recommended duration for exclusive breastfeeding, and any breastfeeding. Mothers were also asked to provide main reasons for intending or not intending to breastfeed using an open-ended question.

Data analysis. Each of the six questions about the WHO breastfeeding guidelines was graded with one score, with pregnant women receiving 0 for none correct to 6 for all correct answers. Based on the women’s scores they were categorized into the ‘‘high’’ or the ‘‘low’’ awareness groups, depending on their score equal/above or below the medium score.

Statistical analyses were carried out using the Statistical Package for Social Sciences (SPSS) for Windows version 17.0. One-way analysis of variance/t test was used to determine differences for continuous outcomes, whereas the Pearson v2

test was used for categorical outcomes, and Mantel–Haenszel v2 tests were used for trend in proportions. Multiple logistic regression was performed for determining the factors asso- ciated with awareness of breastfeeding guidelines and inten- tion to breastfeed. Unadjusted odds ratios (ORs) and adjusted ORs were calculated for assessing the likelihood of intention to breastfeed.

Qualitative study

Participants. Purposive sampling was applied in recruit- ing participants. Twenty-four new mothers (1–11 months after childbirth) were interviewed using semistructured in- depth interviews and focused group discussions. Among them, nine practiced exclusive breastfeeding or had experi- enced 4–6 months of exclusive breastfeeding, nine used mixed


infant feeding, and six had stopped breastfeeding before the baby turned 4 months.

Two focused group discussions were conducted with pregnant women in the third trimester who had completed the prenatal education programs provided by delivery hos- pitals. Fourteen pregnant women were recruited from two large communities, seven from each, respectively.

Data collection. For the in-depth interviews, postpartum mothers were approached by CHC staff in the child health clinics of each CHC when they brought babies for health check-ups. If they agreed to be interviewed, appointments were set up. The interview guide was piloted before inter- views. All mothers were asked about their experience of breastfeeding, awareness of the WHO breastfeeding guide- lines, problems encountered during breastfeeding, reasons for breastfeeding or not breastfeeding, reflections on breastfeed- ing service during perinatal care, and planned duration of breastfeeding if mothers were breastfeeding.

For the focused discussion groups, the CHC staff contacted potential participants by telephone, verified their eligibility, and arranged a focused discussion group time. The focused discussion group examined mothers’ experiences of prenatal

education and reasons behind their intentions of breastfeed- ing or not.

All interviews were carried out in a private room. Two researchers from the MCH Department of the School of Public Health, Fudan University, who have been trained for quali- tative research conducted all the interviews, one as the facil- itator and the other as the recorder. All qualitative interviews were digitally recorded. Each interview lasted between 30 to 60 minutes.

Data analysis. All recorded materials were transcribed verbatim by the interviewer and the recorder and other re- search assistants. Transcripts were kept as Microsoft Word documents. A de-identification process was applied during data analysis. A content analysis approach was used to cate- gorize the transcript contents.19 Two interviewers carefully reviewed the transcripts to identify emerging themes and coded for themes using Nvivo version 7.0 computer software.


The main characteristics of the participants are shown in Table 1. The mean age of the mothers was 28 years (range,

Table 1. Characteristics of Participants and Factors Associated with Intention to Breastfeed and Exclusively Breastfeed on Bivariate Analysis

Intention to breastfeed Intention to exclusively breastfeed

Characteristic Of total n = 653, n (%) Yes n (row %) p Yes n (row %) p

Age (years) < 25 77 (11.8) 67 (87.0) 0.330a 30 (39.0) 0.755a 25–29 384 (58.8) 350 (91.4) 114 (29.7) ‡ 30 192 (29.4) 176 (91.7) 70 (36.5)

Household registration Non-Shanghai 498 (76.3) 454 (91.3) 0.527 336 (67.5) 0.814 Shanghai 155 (23.7) 139 (89.7) 103 (66.5)

Pregnant women’s education level Junior middle school 21 (3.2) 20 (95.2) 0.522a 16 (76.2) 0.897a

Senior middle school 70 (10.7) 64 (91.4) 44 (62.9) College and above 562 (86.1) 509 (90.7) 379 (67.4)


2212-2672/Copyrightª 2015 by the Academy of Nutrition and Dietetics.


Position Paper

Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding

ABSTRACT It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health protection for the first 6 months of life, and that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants. Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs. Research continues to support the positive effects of human milk on infant and maternal health, as it is a living biological fluid with many qualities not replicable by human milk substitutes. Recent research advancements include a greater understanding of the human gut microbiome, the protective effect of human milk for premature infants and those born to women experiencing gestational diabetes mellitus, the relationship of breastfeeding with hu- man immunodeficiency virus, and the increased ability to characterize cellular com- ponents of human milk. Registered dietitian nutritionists and nutrition and dietetics technicians, registered, should continue efforts to shift the norm of infant feeding away from use of human milk substitutes and toward human milk feeds. The role of regis- tered dietitian nutritionists and nutrition and dietetics technicians, registered, in breastfeeding promotion and support, in the context of the professional code of ethics and the World Health Organization’s International Code of Marketing of Breast-Milk Substitutes, are discussed in the “Practice Paper of the Academy of Nutrition and Di- etetics: Promoting and Supporting Breastfeeding,” published on the Academy website at: J Acad Nutr Diet. 2015;115:444-449.


It is the position of the Academy of Nutrition and Dietetics that exclusive breastfeeding provides optimal nutrition and health pro- tection for the first 6 months of life and that breastfeeding with complementary foods from 6 months until at least 12 months of age is the ideal feeding pattern for infants. Breastfeeding is an important public health strategy for improving infant and child morbidity and mortality, improving maternal morbidity, and helping to control health care costs.


HIS POSITION PAPER technician, registered (NDTR) in breast- mutually desired by mother and infant.3

Treaffirms and updates theAcademy of Nutrition and Di-etetics’ 2009 position paper on breastfeeding1 and supports the “Prac- tice Paper of the Academy of Nutrition andDietetics: PromotingandSupporting Breastfeeding,”2 as well as several other Academy position papers available at the Academy website (www.eatright. org/positions). Additional work has quantified the costs of, and risks related to, not breastfeeding, and federal initia- tives have continued to strengthen ef- forts to increase breastfeeding rates at the national, regional, and local level. The role of the registered dietitian nutri- tionist (RDN) and nutrition and dietetics

feeding promotion and support is touched on here and expanded on in the accompanying practice paper.2

Human milk is considered the optimal form of infant nutrition for nearly all in- fants, as the risks of not receiving human milk include increased rates of infant and maternal morbidity and mortality, increasedhealth care costs, and significant economic losses to families and em- ployers.1,3-6 Therefore, breastfeeding con- tinues to be recommended by multiple national and international health organi- zations and agencies.1,3,7 For example, in the United States, the American Academy ofPediatrics continues to recommend that infants be exclusively breastfed to 6 months of age, atwhich point appropriate complementary foods should be intro- duced and breastfeeding should continue to at least the first birthday or as long as


The World Health Organization extends this for 2years or beyond.7 Several notable advancements have occurred since publi- cation of the 2009 position paper.1 Recent research advancements include a greater understanding of the human gut micro- biome, theprotective effectofhumanmilk for premature infants and those born to womenwith gestational diabetesmellitus (GDM), the relationship of breastfeeding with human immunodeficiency virus, the increased ability to characterize cellular components of humanmilk, and the costs and risks associated with not breastfeed- ing.8-12 Similarly, the role of the RDN/ NDTR remains to promote and support breastfeeding.2

HUMAN MILK COMPOSITION Human milk contains factors that serve both nutritive and non-nutritive

015 by the Academy of Nutrition and Dietetics.


functions,1,3,8,10,11 and it has been well characterized that the relatively low protein content and high bioavailability of essential minerals are optimally suited to the immature digestive sys- tem of the young infant.1,3 Human milk provides maternal immune factors, appetite-regulating hormones, and factors thought to support develop- ment of the healthy infant gut micro- biome.10,11 Mammary-gland�derived stem cells have been discovered recently, and this is considered an extraordinary finding with great po- tential to explain some of the effects on infant health.10 In addition to factors in human milk that provide direct im- munity, milk oligosaccharides are thought to provide indirect immunity, by both serving as substrate for bene- ficial gut bacteria, stimulating infant gut production of secretory immuno- globin A, and by interfering directly with pathogen binding.8 This func- tionality of human milk oligosaccha- rides is a current focus of researchers working to improve outcomes among infants fed with human milk sub- stitutes.8 RDNs/NDTRs will continue to review the latest science to be current when working with breastfeeding families and consider completing coursework as described in the practice paper.2

Although human milk is optimal in most situations, if infant iron stores are found to be inadequate, such as in situations of low birth weight or pre- maturity, in some less-developed countries, or when maternal prenatal iron status was low, it is recommended that the addition of iron drops begin before the introduction of iron-rich complementary foods (at approxi- mately 6 months).3 In addition, breastfed infants should receive sup- plemental fluoride after 6 months of age if living in areas where the local water source is not fluoridated.3

Vitamin K injections are recom- mended for all newborns, but should be delayed until after the first breast- feed (but no more than 6 hours post- partum). Finally, although limited research suggests that relatively high doses of maternal vitamin D supple- mentation (approximately 5,000 IU/ day for 28 days or a one-time dose of 150,000 IU)13 may render direct sup- plementation of the infant unnec- essary, there is currently insufficient evidence to support deviation from

March 2015 Volume 115 Number 3

Institute of Medicine and American Academy of Pediatrics recommenda- tions that breastfed infants receive 400 IU vitamin D per day.3,14 In addition to these micronutrient concerns, guid- ance is required in situations in which mothers are experiencing specific viral illnesses, smoking, using legal and/or illicit drugs, poor nutritional status/di- etary intake, and those who experi- enced gestational diabetes.1,3,15,16

INFANT AND MATERNAL HEALTH OUTCOMES It is important to note that it can be a challenge to rate the strength of breastfeeding research, secondary to inconsistent definitions of breastfeed- ing (eg, exclusivity, frequency, in- tensity, duration), and unethical to conduct the randomized controlled trials necessary to answer many ques- tions.3,17,18 However, systematic re- views and meta-analyses continue to indicate that infant feeding mode is associated with infant and maternal health outcomes.17-23 The Figure out- lines well-established and currently debated health outcomes related to infant feeding mode, framed to convey risks of not breastfeeding instead of benefits of breastfeeding, as it has been noted that this framing may assist with recasting human milk substitutes as being inferior to human milk.4,5 Acute infant health outcomes associated with human milk, including reduced risk of gastrointestinal infections, respiratory infections, and otitis media, are well established and continue to drive breastfeeding initiatives.1,3,18,24-28

Although a relationship between in- fant feeding mode and other health outcomes has been established, many require continued exploration. For example, preterm infants are at

increased risk of developing necro- tizing enterocolitis compared with term infants, and human milk feedings reduce the incidence.9 Studies show an absolute difference of 5% in the risk of necrotizing enterocolitis when comparing outcomes between preterm infants receiving human milk or a substitute. This is considered a mean- ingful clinical difference due to the high case-fatality rate of necrotizing enterocolitis.26 Milk from the infant’s own mother contains bioactive com- ponents and immunomodulatory fac- tors, and is the first choice for feeding


preterm infants.9,29 Although mother’s own milk is desirable, donor milk is recommended when mother’s own milk is not available9,29 (use of donor milk is expanded upon in the practice paper2). Because of the nutritional re- quirements of preterm infants for increased amounts of protein and minerals during periods of rapid growth, it is recommended that human milk provided to very-low-birth- weight infants (<1,500 g) be fortified during the hospital stay.3,9 Although commercial fortifiers are readily avail- able with standardized mixing in- structions, there is increased interest in customizing fortification based on analysis of individual mother’s milk to provide the correct amount of protein and energy for optimal growth.9

Longer-term, but less well- established, effects of not breastfeed- ing include increased risk of type 1 diabetes mellitus, celiac disease, asthma, sudden infant death syn- drome, and development of over- weight or obesity.21,26,27,30 Although unable to show cause and effect, well- designed meta-analyses of time-series data can increase confidence in the stability of associations by evaluating repetition across multiple studies. For example, secondary to the strength of the protective effect of human milk against developing sudden infant death syndrome, illustrated by a recent meta- analysis, it has been recommended that breastfeeding promotion be incorpo- rated into the US sudden infant death syndrome reduction campaign.21,27,30

For mothers, immediate and early ef- fects of breastfeeding include reduced risk of hemorrhage after delivery, stress reduction, delay in ovulation, reduced blood pressure, reduced risk of postpartum depression, greater post- partum weight loss, and possibly greater infant bonding.1,4,6,27,31 Long- term effects include reduced risk of breast and ovarian cancers, hyperten- sion, and type 2 diabetes.12,22,32,33

However, the relatively weak study designs used to evaluate some of these outcomes contribute to their continued debate.3,26

Infant Feeding Trends Although monitoring by the Center for Disease Control and Prevention in- dicates that national breastfeeding ob- jectives have not yet been met, the


Health outcomes Strong evidence

Relationship established; needs additional study

Infant health outcomes

Nonspecific gastrointestinal infections, upper and lower respiratory tract infections


Otitis media X

Atopic dermatitis X

Autoimmune disorders (type 1 diabetes mellitus, celiac disease)


Sudden infant death syndrome X

Necrotizing enterocolitis, among premature and low-birth- weight infants


Cognitive development X

Asthma X

Later overweight or obesity X

Comorbidities of excess weight (type 2 diabetes, cardiovascular disease, heart disease, hypertension, high cholesterol)


Maternal health outcomes

Postpartum hemorrhage X

Delayed ovulation X

Hypertension X

Postpartum weight status X

Infant bonding X

Postpartum depression X

Cancer (postmenopausal breast/ovarian) X

Premenopausal breast cancer X

Comorbidities of excess weight (hypertension, type 2 diabetes mellitus)


Figure. Risks associated with suboptimal breastfeeding (lack of any breastfeeding, partial breastfeeding, or short duration of any breastfeeding).


nation continues to move in a positive direction, and federal-level initiatives, such as the Break Time for Nursing Mothers law and breastfeeding-related preventative services included in the Affordable Care Act and the breast- feeding peer counselor program offered by the Special Supplemental Nutrition Program for Women, Infants, and Children, have continued to target increasing breastfeeding rates.24,25,28

The Table outlines several Healthy People 2020 breastfeeding objectives, along with the most current national rates. Although these recent data


reflect continued improvements in breastfeeding behaviors, disparities in initiation, duration, and exclusivity remain of concern, and RDNs/NDTRs continue to play a critical role in sup- port and promotion.2,28

Social Determinants Determinants of breastfeeding initia- tion, and continuation, remain largely unchanged since publication of the previous position paper.1 Women without a high school diploma, younger women, those who are obese,


low-income women, and those living in certain regions of the United States, continue to be less likely to initiate breastfeeding as compared with their peers, and are less likely to maintain breastfeeding if initiated.28 Those mothers least likely to breastfeed are also those most likely to suffer from many of the acute and chronic diseases associated with a lack of breastfeeding (Figure). For example, non-Hispanic black women are least likely to initiate breastfeeding, but they, and their children, are at higher risk for developing overweight/obesity, type 2

March 2015 Volume 115 Number 3

Table. Healthy People 2020 breastfeeding objectives and most recent national rates

Increase the proportion of infants who are breastfed

2020 Target rates24 (%)

National breastfeeding rates, 201125 (%)

Ever 81.9 79.2

At 6 mo 60.6 49.4

At 12 mo 34.1 26.7

Exclusively through 3 mo 46.2 40.7

Exclusively through 6 mo 25.5 18.8


diabetes, cardiovascular disease, and some cancers.24

The literature is replete with exam- ples of the multiple influences on a mother’s decision to breastfeed, and evidence of these continued disparities in breastfeeding rates suggest that these influences often outweigh maternal desire.28,34 However, eme- rging research is revealing areas for targeted intervention within specific populations.35 For example, maternity care practices that align with the Baby- Friendly Hospital Initiative, a joint initiative of the World Health Organi- zation and the United Nations Chil- dren’s Fund targeting excellence in mother�baby care, were found to be differentially effective, depending on maternal race/ethnicity.35 Mothers who breastfed for at least 10 weeks were more likely to have experienced breastfeeding within the first hour postpartum, have been allowed to feed on demand, and have infants who received only human milk while in the hospital. However, when evaluating these relationships by maternal race/ ethnicity, the authors found that feeding within an hour postpartum was only associated with breastfeeding duration among black and white mothers, but not Hispanic women. Maternity practices are discussed in greater detail in the practice paper.2

Increasing breastfeeding rates by creating successful culturally relevant interventions remains a critical component of initiatives designed to address many of the nations’ health disparities. The Surgeon General’s Call to Action to Support Breastfeeding presents a set of actions developed from a body of literature that describes

March 2015 Volume 115 Number 3

breastfeeding in the context of the socioecological model and calls for ef- forts targeting immediate family members, community groups, health care workers, employers, and mar- keters of human milk substitutes, among others.28 Specifically, initiatives that increase the acceptance of breast- feeding as the social norm and present feeding of human milk substitutes as subpar will continue to be needed to move the nation in a positive direction (see practice paper).2

Perceived Insufficient Milk Supply Prenatal maternal self-efficacy has been linked to positive breastfeeding outcomes.36 Research conducted among primiparas who initiated bre- astfeeding demonstrates the impact of critical early maternal postpartum fac- tors that can disrupt this association, including concerns about milk volume and the ability for both mothers and infants to breastfeed.36 Although it is believed that only 5% of women are physiologically incapable of producing adequate amounts of milk, approxi- mately 50% of US mothers report perceptions of insufficient milk pro- duction, leading to supplementation with human milk substitutes or to weaning completely.27 This supple- mentation reduces infant suckling at the breast, which leads to an actual reduction in milk production. Educa- tion regarding how to accurately assess insufficient milk supply, as well as encouragement to seek expert assis- tance (such as an International Board Certified Lactation Consultant) when faced with lactation issues, should continue, with efforts amplified in at-


risk populations. The practice paper expands on these and other education- related concepts.2

Gestational Diabetes Mellitus GDMisanationalpublichealth issue that is compoundedby thehighprevalenceof maternal overweight/obesity in the United States.37 In addition, GDM is present at higher rates in populations already at elevated risk for not breast- feeding (eg, non-Hispanic black women and low-income women).24 Epidemio- logic evidence indicating a protective effect of breastfeeding on later develop- ment of type 2 diabetes among women experiencing GDM has drawn attention to breastfeeding as a critical intervention in these populations.37 Limited research suggests that blood glucose levels of in- fants born to women with GDM may be more readily stabilized by breast- feeding as compared with feeding human milk substitutes, at least in the immediate postpartum period.38

Therefore, breastfeeding is recom- mended regardless of the presence of a GDM pregnancy.

COST OF NOT BREASTFEEDING A recent pediatric cost analysis was conducted to evaluate the economic burden of suboptimal breastfeeding practices.5 Both direct and indirect costs for disease and the cost of pre- mature death were included. It was determined that if 90% of families in the United States breastfed exclusively for 6 months, $13 billion per year could be saved. A similar study focused on maternal outcomes.4 In this study, direct and indirect health costs and the economic costs of premature death associated with maternal cases of pre- menopausal breast cancer, ovarian cancer, hypertension, type 2 diabetes, and myocardial infarction were considered.4 Comparing current breastfeeding rates at 1 year (23%) with a goal of 90% indicated that suboptimal breastfeeding rates might result in a cost of $17.4 billion. RDNs/NDTRs who have completed relevant course work and/or who are certified as an Inter- national Board Certified Lactation Consultant are well placed to support families to successfully establish and maintain optimal breastfeeding prac- tices, as outlined in the accompanying practice paper.2



EMERGENT TOPICS Several issues concerning breastfeed- ing and the feeding of human milk have emerged that will require addi- tional study. For example, a trending increase in providing human milk exclusively as pumped milk may in- crease the prevalence of infants receiving human milk for the optimal duration.39 However, little is known about the impact refrigeration/freezing and subsequent thawing might have on the immunologic properties of human milk. In addition, research to tease out the benefits of breastfeeding provided by human milk itself, by the direct contact with the mother, or some combination of the two, has yet to be exhaustively conducted.39 Despite these unknowns, if expressed human milk is offered in lieu of a human milk substitute, it is likely to provide sig- nificant benefit and this behavior should continue to be monitored by professionals working with this population.39

Additional emergent topics include optimal levels of maternal vitamin D supplementation to support the breastfeeding infant, the provision of human milk during disaster situations, guidelines for the use of human milk in child care settings, informal milk sharing, and social media and infant feeding (see the practice paper for discussion of these emergent issues).2

CONCLUSION/FUTURE NEEDS Research continues to support the impact of human milk on infant and maternal health outcomes and, as such, federal initiatives supporting the effort to increase national, regional, and local breastfeeding rates continue to be strengthened. Since publication of the 2009 position paper, an effort has been made to quantify the risks of not breastfeeding and to detail the eco- nomic costs associated with suboptimal breastfeeding behaviors. Information presented here and in the accompa- nying practice paper2 provides rationale for continued efforts to shift the norm away from use of human milk sub- stitutes and toward human milk feeds. Research continues to show the impor- tance of breastfeeding and the use of human milk to infant and maternal health outcomes and RDNs/NDTRs should promote and support these practices bymaintaining a current basic


level of knowledge about lactation management, as described in the accompanying practice paper.2

References 1. American Dietetic Association. Position of

the American Dietetic Association: Pro- moting and supporting breastfeeding. J Am Diet Assoc. 2009;109(11):1926-1942.

2. Academy of Nutrition and Dietetics. Prac- tice Paper of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding. resources/practice/position-and-practice- papers/practice-papers. Accessed February 2, 2014.

3. Eidelman AI, Schanler RJ, Johnston M, et al. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):E827-E841.

4. Bartick M. Mothers’ costs of suboptimal breastfeeding: Implications of the maternal disease cost analysis. Breastfeed Med. 2013;8(5):448-449.

5. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics. 2010;125(5):E1048-E1056.

6. Bartick MC, Stuebe AM, Schwarz EB, Luongo C, Reinhold AG, Foster EM. Cost analysis of maternal disease associated with suboptimal breastfeeding. Obstet Gynecol. 2013;122(1):111-119.

7. World Health Organization and the United Nations Children’s Fund. Global Strategy for Infant and Young Child Feeding. publications/infantfeeding/9241562218/ en. Published 2003. Accessed October 11, 2014.

8. Donovan SM, Wang M, Li M, Friedberg I, Schwartz SL, Chapkin RS. Host-microbe interactions in the neonatal intestine: Role of human milk oligosaccharides. Adv Nutr. 2012;3(3):450S-455S.

9. Bertino E, Giuliani F, Baricco M, et al. Benefits of donor milk in the feeding of preterm infants. Early Hum Dev. 2013;89(suppl 2):S3-S6.

10. Hassiotou F, Geddes DT, Hartmann PE. Cells in human milk: State of the science. J Hum Lact. 2013;29(2):171-182.

11. Neville MC, Anderson SM, McManaman JL, et al. Lactation and neonatal nutrition: Defining and refining the critical questions. J Mammary Gland Biol Neoplasia. 2012;17(2):167-188.

12. Schwarz EB, Brown JS, Creasman JM, et al. Lactation and maternal risk of type 2 diabetes: A population-based study. Am J Med. 2010;123(9):863.e1-863.e6.

13. Oberhelman SS, Meekins ME, Fischer PR, et al. Maternal vitamin D supplementa- tion to improve the vitamin D status of breast-fed infants: A randomized controlled trial. Mayo Clin Proceed. 2013;88(12):1378-1387.

14. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. http:// rence-Intakes-for-Calcium-and-Vitamin- D.aspx. Published 2011. Accessed October 11, 2014.

15. Chapman DJ, Nommsen-Rivers L. Impact of maternal nutritional status on breast


milk quality and infant outcomes: An update on key nutrients. Adv Nutr. 2012;3(3):350-352.

16. Allen LH. B vitamins in breast milk: Rela- tive importance of maternal status and intake, and effects on infant status and function. Adv Nutr. 2012;3(3):362-369.

17. Horta BL BR, Martines JC, Victora CG. Ev- idence on the long-term effects of breastfeeding. Systematic reviews and meta-analyses. publications/2007/9789241595230_eng. pdf. Published 2007. Accessed March 14, 2014.

18. Ip S, Chung M, Raman G, et al. Breast- feeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess 2007;(153):1-186.

19. Anothaisintawee T, Wiratkapun C, Lerdsitthichai P, et al. Risk factors of breast cancer: A systematic review and meta-analysis. Asia Pac J Public Health. 2013;25(5):368-387.

20. Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE. Breastfeeding and childhood asthma: Systematic review and meta-analysis. Am J Epidemiol. 2014;179(10):1153-1167.

21. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: A meta-analysis. Pediatrics. 2011;128(1):103-110.

22. Luan NN, Wu QJ, Gong TT, Vogtmann E, Wang YL, Lin B. Breastfeeding and ovarian cancer risk: A meta-analysis of epidemi- ologic studies. Am J Clin Nutr. 2013;98(4): 1020-1031.

23. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012;97(12):1019-1026.

24. US Department of Health and Human Ser- vices.HealthyPeople2020Maternal, Infant, and Child Health Objectives. HealthPeople. gov website. http://www.healthypeople. gov/2020/topics-objectives/topic/matern al-infant-and-child-health. Publishesd 2012. Accessed October 11, 2014.

25. Centers for Disease Control and Preven- tion. Breastfeeding Report Card 2014. reportcard.htm. Published 2013. Accessed October 11, 2014.

26. Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality’s Evi- dence Report on Breastfeeding in Devel- oped Countries. Breastfeed Med. 2009;4(suppl 1):S17-S30.

27. Dieterich CM, Felice JP, O’Sullivan E, Rasmussen KM. Breastfeeding and health outcomes for the mother-infant dyad. Pediatr Clin N Am. 2013;60(1):31-48.

28. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. http:// astfeeding. Published 2011. Accessed October 11, 2014.

29. Menon G, Williams TC. Human milk for preterm infants: Why, what, when and how? Arch Dis Child Fetal Neonatal Ed. 2013;98(6):F559-F562.

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30. Vennemann MM, Bajanowski T, Brinkmann B, et al. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics. 2009;123(3):e406- e410.

31. Figueiredo B, Canário C, Field T. Breast- feeding is negatively affected by prenatal depression and reduces postpartum dep- ression. Psychol Med. 2014;44(5):927- 936.

32. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-982.

33. Turkoz FP, Solak M, Petekkaya I, et al. Association between common risk factors

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and molecular subtypes in breast cancer patients. Breast. 2013;22(3):344-350.

34. Bai Y, Middlestadt SE, Peng CYJ, Fly AD. Predictors of continuation of exclusive breastfeeding for the first six months of life. J Hum Lact. 2010;26(1):26-34.

35. Ahluwalia IB, Morrow B, D’Angelo D, Li RW. Maternity care practices and breastfeeding experiences of women in different racial and ethnic groups: Preg- nancy risk assessment and monitoring system (PRAMS). Matern Child Health J. 2012;16(8):1672-1678.

36. Wagner EA, Chantry CJ, Dewey KG, Nommsen-Rivers LA. Breastfeeding con- cerns at 3 and 7 days postpartum and


feeding status at 2 months. Pediatrics. 2013;132(4):E865-E875.

37. Trout KK, Averbuch T, Barowski M. Pro- moting breastfeeding among obese women and women with gestational diabetes mellitus. Curr Diab Rep. 2011;11(1):7-12.

38. Chertok IRA, Raz I, Shoham I, Haddad H, Wiznitzer A. Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. J Hum Nutr Diet. 2009;22(2):166-169.

39. Rasmussen KM, Geraghty SR. The quiet revolution: Breastfeeding transformed with the use of breast pumps. Am J Public Health. 2011;101(8):1356-1359.

This Academy of Nutrition and Dietetics position was adopted by the House of Delegates Leadership Team on March 16, 1997, and reaffirmed on September 12, 1999; June 6, 2003; May 20, 2007; and March 23, 2012. This position is in effect until December 31, 2019. Requests to use portions of the position or republish in its entirety must be directed to the Academy at

Authors: Rachelle Lessen, MS, RD, IBCLC, LDN, The Children’s Hospital of Philadelphia, Philadelphia, PA; Katherine Kavanagh, PhD, RD, LDN (The University of Tennessee at Knoxville, Knoxville, TN).

Reviewers: Virginia Carney, MPH, RD, IBCLC, FILCA, FADA (St Jude Children’s Research Hospital, Memphis, TN); Public Health Community Nutrition dietetic practice group (DPG) (Phyllis Stell Crowley, MS, RD, IBCLC, Utah Department of Health/WIC, Salt Lake City, UT); Claire Dalidowitz, MS, MA, RD, CD-N (Connecticut Children’s Medical Center, Hartford, CT); Sharon Denny, MS, RD (Academy Knowledge Center, Chicago, IL); Women’s Health DPG (Heather Goesch, MPH, RDN, LDN, Heather Goesch Nutrition, Holly Ridge, NC); Pediatric Nutrition DPG (Stephanie Howard, MPH, RDN, LD, IBCLC Saint Luke’s Hospital, Kansas City, MO); Mary Pat Raimondi, MS, RD (Academy Policy Initiatives & Advocacy, Washington, DC).

Academy Positions Committee Workgroup: Denise A. Andersen, MS, RDN, LD, CLC (Chair) (Business Consultant in Private Practice, Mendota Heights, MN); Mindy G. Hermann, MBA, RDN (The Hermann Group, Inc, Mount Kisco, NY); Alena M. Clark, PhD, MPH, RD, CLC (Content Advisor) (University of Northern Colorado, Greeley, CO).

We thank the reviewers for their many constructive comments and suggestions. The reviewers were not asked to endorse this position or the supporting paper.


  • Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding
    • Human Milk Composition
    • Infant and Maternal Health Outcomes
      • Infant Feeding Trends
      • Social Determinants
      • Perceived Insufficient Milk Supply
      • Gestational Diabetes Mellitus
    • Cost of Not Breastfeeding
    • Emergent Topics
    • Conclusion/Future Needs
    • References

Partner’s education level Junior middle school 14 (2.1) 13 (92.9) 0.788a 9 (64.3) 0.969a

Senior middle school 58 (8.9) 53 (91.4) 40 (69.0) College and above 581 (89.0) 527 (90.9) 390 (67.1)

Family income per month < 4,000 RMB 47 (7.2) 6 (12.8) 0.337 19 (40.4) 0.233 ‡ 4,000 RMB 604 (92.5) 52 (8.6) 193 (32.0)

Women’s employment status Unemployed 106 (16.2) 93 (87.7) 207 64 (60.4) 0.101 Employed 547 (83.8) 500 (91.6) 375 (68.6)

Intended time back to work < 6 months 496 (76.0) 450 (90.9) 0.049 329 (66.3) 0.094 ‡ 6 months or don’t plan to go back 83 (12.7) 80 (96.4) 64 (77.1) Don’t know 74 (11.3) 63 (85.1) 46 (62.2)

Rented accommodation No 152 (23.3) 49 (9.8) 0.138 328 (65.7) 0.127 Yes 499 (76.4) 9 (5.9) 110 (72.4)

Awareness of breastfeeding guidelinesb

Lower 289 (44.3) 248 (85.8) < 0.001 162 (56.1) < 0.001 Higher 364 (55.7) 345 (95.0) 127 (43.9)

aBy Mantel–Haenszel v2 test. bMean score, 3.6; median score, 4.0.


20–41 years). Nearly 90% of mothers were employed and re- ported their monthly family income as 4,000 RMB (*USD $615, middle–low living condition) or more. About 76% of women planned to return to work within 6 months after childbirth. The average gestational age of mothers was 11 weeks (range, 5–22 weeks) at the time of the baseline study.

Mother’s awareness of the breastfeeding guidelines prior to receiving prenatal education

The median score of awareness of the WHO breastfeeding guidelines was 4.0 (range, 1.0–6.0). Although almost all mothers (99%) knew breastfeeding was good for the baby’s health, 22% of mothers did not think breastfeeding was ben- eficial to the mother’s health. Close to 80% and nearly all mothers (98%), respectively, were not aware of the WHO- recommended duration for exclusive breastfeeding or any breastfeeding. In addition, approximately 40% of mothers did not think breastmilk could meet all the nutritional needs for babies less than 6 months old.

Mother’s intention to breastfeed in early pregnancy prior to receiving prenatal education

Prior to receiving any prenatal education, 91% of expectant mothers planned to breastfeed their babies, and the remaining 9% had yet to decide. Only two women claimed that they would not breastfeed. Sixty-seven percent of mothers planned

to exclusively breastfeed their babies, only 9% planned not to exclusively breastfeed, and 24% had not decided. Table 1 shows the factors associated with intention to breastfeed on bivariate analysis.

After multivariate analyses, the only factor associated with the mother’s intention to exclusive breastfeeding was the mother’s awareness of the breastfeeding guidelines (Table 2). Mothers who had a higher awareness score intended to breastfeed (OR 2.67, 95% confidence interval [CI] 1.88, 3.78, p < 0.001) and intention to breastfeed exclusively (OR 3.31, 95% CI 1.81, 6.06, p < 0.001). In addition, compared with mothers intending to go back to work within 6 months after childbirth, mothers who intended to stay at home for ‡ 6 months were more likely to breastfeed (OR 1.89, 95% CI 1.03, 3.47, p = 0.039).

Reasons of breastfeeding intention among mothers in early pregnancy

The main reasons given by the 537 mothers to the open- ended question on the intention to breastfeed in the survey were for the health benefits of the child and mother, for ex- ample: ‘‘.to ensure baby’s health. Baby will have better im- munity’’ and ‘‘Safe, natural, nutritional, good for both baby and mother.’’

Among the 43 mothers who had not decided whether to breastfeed or not, the main issues are revealed in Table 3. The

Table 2. Factors Associated with Intention to Breastfeed and Exclusively Breastfeed in Multiple Logistic Analysis (n = 653)

Intention to breastfeed Intention to exclusively breastfeed

Variable OR 95% CI p OR 95% CI p

Age (years) < 25 1 1 25–29 1.774 0.9783.220 0.059 2.095 0.884–4.966 0.093 ‡ 30 1.234 0.652–2.336 0.519 2.077 0.795–5.424 0.136

Household registration Non-Shanghai 1 1 Shanghai 1.006 0.659–1.563 0.979 0.885 0.456–1.721 0.720

Pregnant women’s education level Junior middle school 1 1 Senior middle school 0.362 0.109–1.203 0.097 0.348 0.036–3.408 0.365 College and above 0.321 0.097–1.065 0.063 0.187 0.019–1.824 0.149

Family income per month < 4,000 RMB 1 1 ‡ 4,000 RMB 1.484 0.744–2.959 0.263 1.499 0.510–4.408 0.462

Women’s employment status Unemployed 1 1 Employed 1.612 0.942–2.758 0.081 1.657 0.706–3.888 0.246

Intended time back to work < 6 months 1 1 ‡ 6 months or don’t plan to go back 1.894 1.033–3.471 0.039a 2.707 0.756–9.697 0.126 Don’t know 1.071 0.578–1.986 0.828 0.683 0.275–1.695 0.411

Rented accommodation No 1 1 Yes 1.438 0.910-2.271 0.119 1.887 0.824-4.321 0.133

Awareness of breastfeeding guidelines Lower 1 1 Higher 2.666 1.878–3.784 < 0.001a 3.307 1.805–6.059 < 0.001a

aSignificant difference. CI, confidence interval; OR, odds ratio.


main reasons for not having decided to breastfeed included the reasons ‘‘concerns about insufficient milk supply,’’ ‘‘ had not yet thought about it,’’ ‘‘concerns about HBV [hepatitis B virus] transmission to the baby,’’ ‘‘concerns about their own figure,’’ ‘‘felt lack of sufficient knowledge,’’ etc.

There were two mothers who did not plan to breastfeed: One responded, ‘‘Just do not want breastfeeding,’’ and the other one did not give any reason.

Perceptions on breastfeeding among mothers in late pregnancy and postpartum

The qualitative study revealed that mothers in their late pregnancy or postpartum period had some knowledge about the health benefits of breastfeeding and the recommended duration of exclusive breastfeeding. However, they still did not know the key components of the WHO breastfeeding guidelines. Some mothers considered that mixed feeding could provide more nutrition to their babies and that it was convenient for weaning. No mothers knew the recommended

duration for any breastfeeding. Many were misinformed by traditional perceptions, for example, that breastmilk would not have any nutritional value after the mother resumed menstruation and therefore breastfeeding should be stopped.

As shown in Table 4, although mothers would trust the information provided by health professionals, they reported that MCH doctors were often too busy to deliver sufficient information on breastfeeding during perinatal care visits. Consequently, the Internet, books, families, and friends be- came the major sources of information on breastfeeding. Furthermore, the prenatal education programs were only of- fered during business hours, which prevented most mothers from attending.


This study found that prior to receiving prenatal educa- tion, a substantial proportion of mothers were not aware of the nutritional value of breastmilk (40%) or the WHO- recommended duration of exclusive breastfeeding (80%) or any breastfeeding (98%). Mothers’ intention to breastfeed or intention to breastfeed exclusively was significantly associ- ated with their awareness of the WHO breastfeeding guide- lines in early pregnancy. In late pregnancy and postpartum, the majority of mothers still did not fully understand the nutritional values of breastmilk or the recommended duration of breastfeeding. Lack of communication and support from the healthcare providers has been identified. These results highlight the importance of promotion and support of breast- feeding in perinatal care services to address the unmet needs.

The strength of this study was that we used a concurrent design with quantitative and qualitative mixed methods to explore breastfeeding issues among first-time mothers in Shanghai, China, in order to tackle the recent decline of breastfeeding in China, particularly in large cities. The quantitative component of our study provided the empirical evidence of the link between mothers’ awareness and their intention of breastfeeding. The qualitative component al- lowed participants to play an active role in identifying prob- lems through voicing their opinions and perceptions in relation to breastfeeding. In addition, the participants of the study were at the different stages of receiving MCH services in the health system (i.e., early and late pregnancy and post- partum), which allowed us to gather information on services provided particularly in relation to breastfeeding promotion across different services. Thus, the qualitative component al- lowed for the emergence of contextual meaning, as a com- plement to the quantitative data. Our findings about mothers’ awareness, intention, and needs regarding breastfeeding will significantly contribute to the body of evidence that supports the promotion of the WHO breastfeeding guidelines and ad- dresses mothers’ needs in relation to breastfeeding.

The positive association between the awareness of the WHO breastfeeding guidelines and the intention to breastfeed or intention to breastfeed exclusively suggests that breast- feeding promotion and education should be initiated early, when mothers have their first visit to the CHC (around 12 gestational weeks). This association was consistent with the study by Wen et al.15 in which participants were recruited from Week 24 to 34 of gestation. Our study showed that the positive relationship between awareness and intention ex- isted even among women in relatively early pregnancy,

Table 3. The Main Reasons Given by the Women Without Intention to Breastfeed

at Early Pregnancy

Reasons for not having decided to breastfeed

Number (%) of total n = 43

Examples of what women said

Concerns about insufficient milk supply

16 (37) ‘‘Not sure whether I will have enough breastmilk because my breasts looked small’’

Had not yet thought about it

10 (23) ‘‘Have not yet thought about it’’

Concerns about HBV transmission to the baby

6 (14) ‘‘I have hepatitis B and don’t know whether baby would have it through breastfeeding’’

Concerns about their own figure

4 (9) ‘‘Breastfeeding will influence my breast figure’’

Felt lack of sufficient knowledge

3 (7) ‘‘Not know too much about breastfeeding, will decide after know more about it’’

Other reasons included lack of freedom, time conflict with work, and cracked nipples

4 (9) ‘‘I will be occupied by the baby all the time if breastfeed’’

Not planning to breastfeed

Number (%) of total n = 2

Do not want breastfeeding

1 (50) ‘‘Just do not want breastfeeding’’

HBV, hepatitis B virus.


Table 4. Themes and Supporting Quotes About the Understanding of Breastfeeding Among Pregnant Women at the Third Trimester and Postpartum Mothers

Selected quotes

Themes Pregnant women

(focused group discussion) Postpartum mothers (in-depth interview)

Awareness of some components of breastfeeding guidelines 1. Know the general health benefit

of breastfeeding ‘‘[Breastfeeding is] good for baby’s,

especially the foremilk very good for baby’s immune system. In addition, breastfeeding could improve the mother–baby relationship’’ (28 years old, 34th gestational week, teacher)

‘‘Breastfeeding is the best. It is safe. You know the ‘melamine infant formula contamination incidentsa

in 2008,’ I worry about the quality of formula’’ (28 years old, 6 months postpartum, mixed breastfeeding, company employee)

2. Know the recommended duration for exclusive breastfeeding

‘‘In the prenatal education, I knew exclusive breastfeeding should last for 6 months’’ (30 years old, 37th gestational week, dentist)

Misunderstanding of breastfeeding 3. Don’t actually know the difference

between breastmilk and formula; regard mixed feeding as the ideal way to ensure nutrition and convenience of weaning

‘‘If baby is fed by a mixed way, the nutrition would be better. I know foremilk would help baby’s immune system, but how about other nutrients? Formula has many nutritional elements.Furthermore, it would be easy for weaning.’’ (34 years old, 35th week gestational, teacher /dancer)

‘‘Although I know breastfeeding is good, but what’s the difference between breastmilk and infant formula? Formula includes many nutrients. Does breastmilk have enough [nutrients] too? I don’t know’’ (34 years old, 2 months postpartum, mixed feeding, company employee)

4. Unawareness of the recommended duration for breastfeeding and traditional idea about discontinuing breastfeeding

‘‘Usually breastfeeding would last for 9–10 months, at most 1 year’’ (31 years, 36th week, teacher)

‘‘I know from my doctor that breastfeeding should last for 10–12 months’’ (30 years old, 7 months postpartum, mixed breastfeeding, physician)

‘‘After menstruation resumed, breastmilk would have no any nutrition value, just like water’’ (34 years old, 35th gestational week, teacher/dancer)

‘‘Many people told me that after the menstruation resumed, breastmilk would have no any nutritional value’’ (31 years old, 4 months postpartum, exclusively breastfeeding, company employee)

Feedback on breastfeeding service through perinatal care 5. Don’t have time to join in the

prenatal education ‘‘[I did not join in the prenatal

education] since I have to work’’ (28 years old, 34th gestational week, company employee)

‘‘There were prenatal classes in hospitals, but I just didn’t have time to attend.I needed to work’’ (28 years old, 2 months postpartum, exclusively breastfeeding, physician)

6. Don’t have enough communication with MCH care providers

During prenatal care: ‘‘It was very fast for each antenatal check-up, less than 10 minutes. But I had to wait for [the doctor] more than 3 hours’’ (27 years old, 36th gestational week, company employee)

During childbirth in hospitals: ‘‘No specific guidance on breastfeeding when I lived in hospital after childbirth. They (health staff) just told us not to bring bottle milk to the



before 22 gestational weeks, prior to receiving prenatal edu- cation. A recent review concluded that breastfeeding inten- tion was a strong indicator for breastfeeding initiation and duration.20 Therefore, improving mothers’ awareness and addressing mothers’ intention to breastfeed will help to im- prove breastfeeding practice.

In this study, planned longer maternal leave was shown to be associated with stronger intention to breastfeed. However,

more than 75% of mothers revealed that they would need to return to work within 6 months after childbirth. Thus, the appropriate public policies are required to remove barriers and to create enabling environments at the workplace for women to continue breastfeeding and facilitate mothers to meet the WHO recommendations.

Consistent with other studies,21 we found that the health benefits of breastfeeding served as a strong incentive for

Table 4. (Continued)

Selected quotes

Themes Pregnant women

(focused group discussion) Postpartum mothers (in-depth interview)

hospital. Every day, nurses asked me whether I had breastmilk. If I had not, she then gave us a cup with a fixed quantity of formula to feed the baby every 4 hours. They didn’t require me to breastfeed my baby and didn’t teach me how to breastfeed the baby’’ (35 years old, 2 months postpartum, formula feeding, company employee)

‘‘There are always a lot of patients. Doctors must be bored since every woman has a lot of questions’’ (28 years old, 34th gestational week, company employee)

During child health care: ‘‘At the kid health check-up, doctors just asked me whether my baby was having breastmilk or formula. They didn’t say any others’’ (30 years old, 8 months postpartum, mixed feeding, unemployed)

7. Get the knowledge and information of breastfeeding mainly from Internet, books, friends, and families

‘‘Some prenatal education will have charge. Internet is very convenient to get all information. No need to take the class’’ (29 years old, 35th gestational week, company employee)

‘‘Usually I know [breastfeeding] from the Internet and one book. I was encouraged and decided to breastfeed by one book’’ (27 years old, 1 months postpartum, mixed feeding, company employee)

8. Need support to deal with the difficult during breastfeeding

‘‘No any health staff member told me how to deal with the insufficient breastmilk production. How can I produce enough breastmilk?’’ (34 years old, 2 months postpartum, mixed feeding, company manager)

‘‘The baby had a disease 1 month ago and he stopped breastfeeding himself’’ (29 years old, 8 months postpartum, having ceased breastfeeding, accountant)

aInfant formula contamination incidents. A food safety incident in China revealed in September 2008 that powdered formula, fresh milk, and other products in China were found to be adulterated with melamine, a synthetic nitrogenous product, to confound a test for determining crude protein content.

MCH, maternal and child health.


mothers’ intention to breastfeed. We also found that mothers’ hesitation in breastfeeding their babies was due to the concern about insufficient breastmilk supply, which has been reported by other studies.12,15,22 Furthermore, concerns about mother- to-child hepatitis B transmission were also expressed by those mothers who were hepatitis B positive.23 Targeted health promotion efforts should be directed to address the concerns of these mothers.

This study also revealed that the infant formula contami- nation incidents that occurred in China in 2008 greatly weak- ened mothers’ trust in the quality of infant formula. The event had motivated mothers to breastfeed their babies, which is a window of opportunity to accelerate the promotion of breast- feeding in China. As a study had shown the incidents had a significant positive impact on breastfeeding among Chinese mothers,24 it is promising to translate mothers’ intention to successful breastfeeding practice through appropriate support. As indicated in this study, however, the current perinatal care model does not provide sufficient support for breastfeeding. The perception of the superior nutritional value of formula could be the result of inadequate information provision about breastmilk during perinatal care and the successful marketing of infant formula. The misunderstanding of mixed infant feeding among mothers in this study was similar to the find- ings of Holmes et al.,25 who showed the inadequate advocacy on exclusive breastfeeding by health professionals and lack of supportive social environment for breastfeeding. The extensive impact of traditional perceptions on breastfeeding duration among mothers, newly reported by this study, further high- lights the inadequate provision of health promotion in the current MCH service. Young mothers obtained breastfeeding information mainly from their own mothers or mothers-in-law, colleagues or friends, the Internet, and books, rather than from health professionals. This indicates that health professionals had not played an active role in providing correct information. The difficulties and concerns raised by mothers in this study, such as ‘‘insufficient breastmilk,’’ what to do in situations with ‘‘mother or child being sick,’’ and ‘‘cracked nipples,’’ have been reported by many other studies.6,26–29 This further suggests inadequate guidance on breastfeeding practice. One study has shown that professional support had the most important influence on breastfeeding intentions and behaviors.30 Health professionals’ support could either increase exclusive breastfeeding31 or pro- long any breastfeeding.32 Thus, approaches to enhance profes- sional supports should be explored as an important component for breastfeeding promotion in the next step.

This study has several limitations. First, because of its cross- sectional design, no causal relationships can be concluded in relation to the study findings. Second, the study sample had a large proportion of well-educated women, which could lead to selection bias and limit its generalizability, although it may be a true reflection of Chinese urban areas where young people have more opportunities to study in colleges and universities since the expansion of high education in the 1990s. In addition, further studies are needed to explore whether awareness and intention of breastfeeding can be translated to future breastfeeding practice.


Low awareness of the WHO breastfeeding guidelines was found among first-time mothers in Shanghai. Awareness of

the breastfeeding guidelines was independently associated with their intention to breastfeed and intention to breastfeed exclusively. The health benefits of breastfeeding and re- commended breastfeeding duration should be emphasized in prenatal education programs when encouraging mothers to comply with the WHO breastfeeding guidelines. Specific concerns about breastfeeding and breastfeeding difficulties encountered by mothers should be addressed by health pro- viders in a more supportive manner. It is important to ad- vocate for appropriate public policy on maternal leave and for a workplace breastfeeding-friendly environment to support mothers returning to work.


The authors are grateful to the staff at Longhua, Caohejing, Meilong, and Xinzhuang Community Health Centers of Shanghai, China for their support during data collection. We thank all the participants for their collaboration. This study was funded by the Nestle Foundation.

Disclosure Statement

No competing financial interests exist.


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25. Holmes AV, Chin NP, Kaczorowski J, et al. A barrier to excusive breastfeeding for WIC enrollees: Limited use of exclusive breastfeeding food package for mothers. Breastfeed Med 2009;4:25–30.

26. Gui F. Reasons for stopping breastfeeding [in Chinese]. J North Sichuan Med Coll 2002;17:52–53.

27. Chen SN, Liu NN. The investigation of breastfeeding knowledge and practice among primiparas. Today Nurse (Academic) 2010;1:68–70.

28. Li XY, Xu YQ, Xie HH, et al. The reasons of breastfeeding cessation in the past 5 years of Nanjing city [in Chinese]. Acta Univ Med Nanjing (Nat Sci) 2005;25:359–360.

29. Tian G, Xie H. Breastfeeding and associated factors in Nanjing city [in Chinese]. Jiangsu Med J 2003;29:612–613.

30. Kervin BE, Kemp L, Pulver LJ. Types and timing of breast- feeding support and its impact on mothers’ behaviours. J Paediatr Child Health 2010;46:85–91.

31. Garg R, Deepti S, Padda A, et al. Breastfeeding knowledge and practices among rural women of Punjab, India: A community-based study. Breastfeed Med 2010;5:303–307.

32. Britton C, McCormick FM, Renfrew MJ, et al. Support for breastfeeding mothers. Cochrane Database Syst Rev 2007; (1):CD001141.

Address correspondence to: Xu Qian, M.D., Ph.D. School of Public Health

Fudan University Mailbox 175, 138 Yixueyuan Road

Shanghai 200032, China



Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective Analysis Katy B. Kozhimannil1*, Judy Jou1, Laura B. Attanasio1, Lauren K. Joarnt2, Patricia McGovern3

1 Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America, 2 Harvard University,

Cambridge, Massachusetts, United States of America, 3 Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis,

Minnesota, United States of America


Background: Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor- related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.

Methods: We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011–2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status.

Results: More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with .30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81– 8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively).

Conclusions: Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

Citation: Kozhimannil KB, Jou J, Attanasio LB, Joarnt LK, McGovern P (2014) Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective Analysis. PLoS ONE 9(8): e104820. doi:10.1371/journal.pone.0104820

Editor: Katariina Laine, Oslo University Hospital, Ullevål, Norway

Received April 2, 2014; Accepted July 16, 2014; Published August 13, 2014

Copyright: � 2014 Kozhimannil et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. The authors obtained the Listening to Mothers III data from the Childbirth Connection program that commissioned the survey. Prior versions of this survey are freely available for analysis through the Odum Institute Dataverse Network at the University of North Caroline at this location: The data that the authors used for this analysis come from the third wave of the survey which is currently being placed in this public repository.

Funding: This research was supported by a grant from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD; grant number R03HD070868) and the Building Interdisciplinary Research Careers in Women’s Health Grant (grant number K12HD055887) from NICHD, the Office of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

* Email:


Breastfeeding has many advantages to infants [1]. In 2010,

approximately 77% of US infants were breastfed at least once, a

substantial increase from 64% in 1998 [2,3]. Despite this progress,

breastfeeding continues to fall short of national goals for duration

and exclusivity set in initiatives such as Healthy People 2020 [2,4].

One possible reason for failure to consistently meet these goals is

the rise in complications women face as they enter pregnancy,

including diabetes, obesity, and hypertension. Breastfeeding

initiation rates are lower and breastfeeding duration is generally

shorter among women with these conditions [5–8]. Six percent of

births are complicated by diabetes [9], 3%–5% of pregnant

women have hypertensive disorders [10–12], and 19%–39% of are

obese when they become pregnant [13]. Clinical management of

these conditions and associated complications may necessitate

greater intrapartum or neonatal intervention, which could affect

care for the woman or infant in the immediate postpartum period,

including breastfeeding [14–19].

The decision to breastfeed is highly personal and affected by

many factors, including anticipated barriers to or support for

breastfeeding, hospital practices, medical issues occurring either

PLOS ONE | 1 August 2014 | Volume 9 | Issue 8 | e104820

before or during pregnancy, and complications during labor and

delivery [1,20–26]. One program that has been successful in

encouraging breastfeeding is the Baby-Friendly Hospital Initiative

(BFHI), a global program to encourage and recognize hospitals

that have policies to provide evidence-based care to support infant

feeding and mother-baby bonding [1,20,24,25,27]. The program,

for example, instructs mothers on breastfeeding, allows babies to

spend the first hour after birth in their mothers arms; provides

newborns no food or drink other than breast milk, unless medically

indicated; practices ‘‘rooming in’’ by allowing mothers and infants

to remain together 24 hours per day; gives no pacifiers or artificial

nipples to breastfeeding infants; and refer mothers to breastfeeding

support groups on discharge from the hospital or clinic. Greater

adoption of these practices is also a focus of Healthy People 2020

[28]. Yet despite the success of these measures, fewer than 7% of

U.S. births currently occur in facilities with an official BFHI

designation [28]. This study examines the relationship between

entering pregnancy with complicating health conditions and early

infant feeding behaviors, focusing on women’s breastfeeding

intentions and supportive hospital practices as potential mediators.

Materials and Methods

Conceptual Model Figure 1 presents the conceptual model for the analysis. The

model focuses on women’s breastfeeding intentions and hospital

support practices during the intrapartum period and how these

factors and their effects may differ for women who enter

pregnancy with diabetes, hypertension or obesity.

Data Data are from the Listening to Mothers III survey, a nationally

representative sample of women who gave birth to a singleton in a

US hospital between July 1, 2011, and June 30, 2012 (N = 2400).

The survey was commissioned by Childbirth Connection and

conducted by Harris Interactive between October and December

2012. The survey documented pregnancy, labor, and birth

experiences in US hospitals, including information about breast-

feeding decisions and pre-existing medical conditions. Data from

this survey have been widely used in clinical and public health

research, including studies of breastfeeding and the role of

supportive hospital practices [26,29,30]. However, this was the

first wave of the survey to include information about medical

conditions prior to pregnancy. Detailed information about the

survey’s methodology, implementation, and questionnaires is

available at

The data used in this analysis were de-identified. Therefore, the

University of Minnesota Institutional Review Board granted this

study exemption from review (Study No. 1011E92983).

Variable Measurement Pregnancy Complexity. We defined pregnancy complexity

from available survey data relating to 3 common medical risk

factors: (1) taking prescription medication for blood pressure

during the month before pregnancy, (2) having either type 1 or

type 2 diabetes before pregnancy or gestational diabetes, or (3)

having a prepregnancy body mass index higher than 30. Our main

analysis included a dichotomous measure of pregnancy complexity

for women reporting any of these 3 conditions. We also

constructed indicators for each of the conditions for separate

analysis (see following description of sensitivity analyses).

Breastfeeding Intention. Women were asked at the time of

the survey to recall their intentions about infant feeding at the end

of pregnancy. We created dichotomous variables indicating (1) any

intent to breastfeed (exclusively or not) and (2) women’s intent to

breastfeed exclusively. Supportive hospital practices and infant

feeding status were assessed among women who reported any

intention to breastfeed (n = 1990), and exclusive breast milk

feeding status at 1 week postpartum was assessed among women

who intended to exclusively breastfeed (n = 1418).

Supportive Hospital Practices. Among women who in-

tended to breastfeed, we examined supportive hospital practices

consistent with BFHI standards. We measured supportive hospital

practices using an 8-point composite measure corresponding to 7

of the 10 BFHI steps. Measures for the remaining 3 steps were not

assessed in the Listening to Mothers surveys because they require

knowledge of hospital administrative policies beyond the scope of

women’s knowledge and experiences. However, data from these

Figure 1. Conceptual Model. doi:10.1371/journal.pone.0104820.g001

Medically Complex Pregnancies and Early Breastfeeding

PLOS ONE | 2 August 2014 | Volume 9 | Issue 8 |

surveys have previously been used to successfully approximate

BFHI hospital practices [26,30]. See Table 1 for detailed

information about the 10 BFHI steps and the 8 items assessed in

the data and used in this analysis.

To assess general concordance with supportive breastfeeding

practices in the hospital, we created a composite measure in which

higher scores indicate that the woman perceived a higher level of

breastfeeding-supportive hospital practices. Scores were not

normally distributed, so we constructed a dichotomous variable

on the basis of the top quintile of responses. Scores of 7 to 8 were

categorized as ‘‘high hospital support,’’ indicating practices

broadly consistent with BFHI standards. We also assessed the

distribution of the items in the composite measure and tested the

stability of the measure by modeling hospital support as a

continuous variable (0–8) and by using a lower threshold (i.e.,

scores of 6–8 for high levels of support from the hospital). Results

were robust to alternative specifications.

Feeding Status 1 Week Postpartum. Two dichotomous

measures of infant feeding status were based on women’s responses

to questions regarding (1) whether they were feeding their

newborn any breast milk (either exclusively or in combination

with formula) 1 week postpartum, and (2) whether they were

feeding their newborn breast milk only 1 week postpartum. This

definition allows for both direct breastfeeding and feeding

expressed breast milk to infants.

Control Variables. We controlled for labor and delivery

factors that may affect the initiation of breastfeeding, including

cesarean delivery, epidural use, and admission to a neonatal

intensive-care unit [31–34]. We assessed these variables from

maternal self-report. We also included several self-reported

sociodemographic and birth-related covariates, including age;

race/ethnicity (white, black, Hispanic, or other/multiple race);

education (high school or less, some college, bachelor’s degree, or

graduate education); 4-category census region (Northeast, South,

Midwest, West); nativity (foreign- or US-born); partnership status

(unmarried with no partner, unmarried with partner, or married);

parity (first-time pregnancy); pregnancy intention (unintended or

intended pregnancy); agreement with the statement ‘‘birth is a

process that should not be interfered with unless medically

necessary;’’ doula support; and primary payer for maternity care

(private, public, or out-of-pocket).

Analysis We first explored associations between the predictors, outcomes,

and covariates for the overall sample using 1- and 2-way

tabulation. We used Pearson’s x2 tests to determine whether differences based on pregnancy complexity were statistically

significant. We used logistic regression to estimate the adjusted

odds of breastfeeding intention based on pregnancy complexity.

Among women intending to breastfeed, we estimated the adjusted

odds of breastfeeding status 1 week postpartum. To test for

mediation by hospital support, we added a variable indicating high

levels of support for breastfeeding at the hospital. In the final

multivariate models of breastfeeding status 1 week postpartum, we

included only covariates that were statistically significantly

associated with the outcomes. We conducted sensitivity analyses,

estimating the same regression models using indicator variables for

prepregnancy obesity, hypertension, and diabetes as the predictors

rather than the combined ‘‘complex pregnancy’’ variable; results

were substantively unchanged. All analyses used a p-value of 0.05

to determine statistical significance, were conducted using Stata

v.12, and weighted to be nationally representative.


Table 2 presents the characteristics of the study population by

pregnancy complexity. Overall, 36.3% of respondents had 1 or

more conditions indicating a complex pregnancy (n = 871). About

8% of women were taking blood pressure medications in the

month before pregnancy, 19.7% were obese, and 20.4% were

diagnosed with diabetes prior to or during pregnancy. There was

some overlap between conditions, particularly for diabetes and

hypertension (r = 0.25), diabetes and obesity, (r = 0.09), and for hypertension and obesity (r = 0.04).

Table 3 shows the distribution of breastfeeding intentions,

supportive hospital practices, and infant feeding outcomes by

Table 1. Baby Friendly Health Initiative Composite Measure Components.

Baby Friendly Hospital Practices Corresponding question(s) used to construct Baby Friendly Hospital Initiative Composite measure

Help mothers initiate breastfeeding within 1 hour of birth. Baby spent 1st hour in mother’s arms.

Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

Hospital staff helped get started breastfeeding.

Hospital staff showed how to position baby for breastfeeding.

Give newborn infants no food or drink other than breast milk, unless medically indicated.

Hospital staff did not provide water or formula supplements.

Practice ‘‘rooming in’’—allow mothers and infants to remain together 24 hours per day.

Baby roomed with mother.

Encourage breastfeeding on demand. Hospital staff encouraged breastfeeding on demand.

Give no pacifiers or artificial nipples to breastfeeding infants. Hospital staff did not give baby a pacifier.

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Hospital staff told about breastfeeding resources in the community.

Inform all pregnant women about the benefits and management of breastfeeding.

Not Applicable

Have a written breastfeeding policy that is routinely communicated to all health care staff.

Not Applicable

Train all health care staff in skills necessary to implement this policy. Not Applicable


Medically Complex Pregnancies and Early Breastfeeding

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pregnancy complexity. In bivariate associations, women with

complex pregnancies were less likely to report that they intended

to breastfeed (77.2% intended to do so) than women without

complex pregnancies, (83.3%; P = .012) but there was no difference between groups in intention to exclusively breastfeed

(55.7% vs. 51.0%). Overall levels of hospital breastfeeding support

among women who intended to breastfeed differed by pregnancy

complexity, with 14.8% of women with complex pregnancies

reporting high levels of hospital support, compared with 20.4% of

women without complex pregnancies (P = .030). The only two statistically significant findings among the specific support

measures were that women with complex pregnancies were less

likely to report that their baby had spent the first hour after birth

in their arms (P = .017) and that the hospital staff had helped them to start breastfeeding (P = .008). Among women planning to breastfeed, about 90% reported feeding their newborn either

partially or exclusively breast milk 1 week postpartum, regardless

of pregnancy complexity. Of those who intended to breastfeed

exclusively, 79.5% of those without complex pregnancies and

69.4% of those with complex pregnancies were doing so

(P = .002).

Table 2. Percentage of Women in the Study Sample (N = 2400), With a Specific Characteristic, by Pregnancy Complexity.

Complex Pregnancy

No Yes P Value

Total 63.7 36.3 —

Sociodemographic Characteristics

Age category .667

18–24 31.9 31.6

25–29 27.3 30.1

30–34 25.7 23.1

35+ 15.0 15.2

Race .023

White 57.8 48.8

Black 13.9 17.9

Hispanic 22.2 24.8

Other/multiple race 6.2 8.5

Education .040

High school or less 40.0 46.2

Some college/associate’s degree 28.9 28.0

Bachelor’s degree 18.4 16.9

Graduate education/degree 12.8 8.9

Region .520

Northeast 14.5 16.4

Midwest 23.5 21.2

South 38.8 41.2

West 23.2 21.2

Foreign born 8.0 5.4 .107

Partnership status .003

Unmarried with no partner 5.9 11.5

Unmarried with partner 32.7 29.7

Married 61.4 58.8

Pregnancy Characteristics

First-time mother 39.5 42.9 .249

Unintended pregnancy 36.1 34.1 .487

Belief that childbirth is a process that should only be interfered with if medically necessary 58.7 57.9 .797

Had doula support during labor 5.3 7.0 .281

Health Insurance Status .045

Private 48.2 40.6

Public 44.3 50.5

Out-of-pocket 7.5 8.8

Note: Percentages are weighted to be nationally representative. Bold values indicate statistically significant difference (P#.05). P values are based on Pearson’s x2 tests. doi:10.1371/journal.pone.0104820.t002

Medically Complex Pregnancies and Early Breastfeeding

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After controlling for sociodemographic and other factors

(Table 4), women with more complex pregnancies were approx-

imately 30% less likely to intend to breastfeed at all (adjusted odds

ratio [AOR] = 0.71; 95% confidence interval [CI], 0.52–0.98),

compared with women who had no complications entering

pregnancy. However, pregnancy complexity had no independent

association with intention to breastfeed exclusively.

In multivariate analysis we found no relationship between

complex pregnancy and whether the infant was being fed breast

milk exclusively or partially 1 week postpartum (Table 5) after

controlling for the same sociodemographic and clinical covariates.

In subsequent models, we also controlled for supportive hospital

practices to examine potential mediation. Babies whose mothers

received high levels of hospital support for breastfeeding were 4

times more likely to receive at least some breast milk 1 week

postpartum. Among women who intended to exclusively breast-

feed, those with complex pregnancies had more than 30% lower

odds of feeding their infants breast milk only (AOR = 0.68; 95%

CI, 0.47–0.98). High levels of hospital support for breastfeeding

were associated with nearly 3 times the odds of exclusive

breastfeeding 1 week postpartum (AOR = 2.79; 95% CI, 1.77–

4.39). When these factors were included simultaneously, the

association between pregnancy complexity and lower odds of

exclusive breastfeeding remained similar (AOR = 0.69; 95% CI,



The study examined the effect of entering pregnancy with

medical complications on infant feeding practices among those

who intended to breastfeed either at all or exclusively, and the

influence of hospital practices on those decisions. Women with

hypertension or diabetes or those who were obese when they

became pregnant were less likely to intend to breastfeed than

women whose pregnancies were not complicated by these

Table 3. Percentage of Women in the Study Population (N = 2400) With Specific Breastfeeding Behaviors, as Well as Intentions and Hospital Support, by Pregnancy Complexity.

Complex Pregnancy

No Yes P Value

Breastfeeding intentions (among all women n = 2400)

Intention to breastfeed, any 83.3 77.2 .012

Intention to breastfeed, exclusive 55.7 51 .115

Hospital Breastfeeding Support Composite Measure (among women planning to breastfeed, n = 1990)

Low (0–6 steps) 79.6 85.2

High (7–8 steps) 20.4 14.8 .030

Hospital Breastfeeding Support Composite Measure Components

Baby in mother’s arms during 1st hour after birth 51.4 43.4 .017

Baby roomed in with mother 63.6 59.4 .193

Hospital staff helped start breastfeeding 81.6 74.4 .008

Hospital staff showed how to position baby for breastfeeding 64.8 62.4 .432

Hospital encouraged breastfeeding on demand 66.4 64.6 .570

Hospital staff did NOT provide water or formula supplements 65.6 61.2 .298

Hospital staff gave information on community resources 52.2 48.7 .294

Hospital staff did NOT give baby a pacifier 58.4 62.2 .245

Outcomes: Infant Feeding 1 Week Postpartum (among women intending to breastfeed)

Breastfeeding at 1 week, any (n = 1990) 91.9 89.0 .156

Breastfeeding at 1 week, exclusive (n = 1418) 79.5 69.4 .002

Note: Percentages are weighted to be nationally representative. Bold values indicate statistically significant difference (P#.05). P values are based on Pearson’s x2 tests. doi:10.1371/journal.pone.0104820.t003

Table 4. Controlled Odds of Breastfeeding Intentions by Pregnancy Complexity (N = 2400).

Any intention to breastfeed

AOR 95% CI

Complex pregnancy 0.71 (0.52–0.98)

Intention to exclusively breastfeed

AOR 95% CI

Complex pregnancy 0.90 (0.70–1.16)

Note: Models are weighted to be nationally representative. Models control for age, race/ethnicity, education, census region, nativity, partnership status, parity, unintended pregnancy, birth attitudes, and health insurance status. Bold text indicates statistically significant (P#.05). doi:10.1371/journal.pone.0104820.t004

Medically Complex Pregnancies and Early Breastfeeding

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conditions. Our results also show that women with complex

pregnancies who planned to exclusively breastfeed were substan-

tially less likely to do so 1 week postpartum than women without

pregnancy complications, even after accounting for supportive

hospital practices.

The findings point to clear opportunities for intervention and

support during pregnancy and immediately after giving birth.

Obstetricians, midwives, family physicians, and pediatricians

should be aware that women with complex pregnancies are less

likely to plan to breastfeed and are less likely to receive

recommended hospital-based support.

Multiple research studies and systematic reviews confirm that

simply counseling women to breastfeed is not sufficient for

encouraging women to breastfeed; rather, tailored support offered

both prenatally and postpartum is most effective in supporting

pregnant women to set and attain breastfeeding goals [35–37].

Clinicians should discuss breastfeeding intentions when establish-

ing relationships with patients prenatally, including consultation

on plans for the use of anti-diabetic or anti-hypertensive

medications compatible with a mother’s intentions, and follow

up to ensure that women with complicated pregnancies have

access to breastfeeding support in the hospital [38]. It is also

important to address breastfeeding intentions and provide

encouragement and support at the time of delivery, given that

delivery third of US women lack a prior relationship with the

clinician attending their delivery [39]. Providing encouragement

and support at the time of delivery may be particularly important

for women with complex pregnancies who may be transferred to

higher acuity care teams at delivery [40–42]. The results of our

analysis suggest that women who are nonwhite, less educated,

unmarried with no partner, and using public health insurance are

more likely to be obese or to develop hypertension or diabetes

prior to pregnancy, so it may be helpful to target outreach and

support efforts to these groups.

Our findings are consistent with prior research showing that

BFHI-consistent hospital practices help to promote early breast-

feeding success [24–27]. Women who reported a high number of

BFHI-consistent hospital practices were 3 times more likely to

exclusively breastfeed than were those who reported a lower

number of BFHI-consistent practices. Women who entered

pregnancy with hypertension, diabetes, or obesity were signifi-

cantly less likely to report experiencing the BFHI-consistent

hospital practices of having their baby in their arms during the first

hour after birth and having hospital staff help them start

breastfeeding. Therefore, hospitals and clinicians alike should

pay particular attention to showing women with complex

pregnancies how to breastfeed (including expressing breast milk

for bottle or syringe feeding [43]) and supporting early breastfeed-

ing efforts, including after cesarean delivery [44,45].

Breastfeeding support should be incorporated into clinical and

hospital policies, with emphasis on women with complex

pregnancies [46]. Postpartum care management or obstetric/

neonatal discharge guidelines for obese women and those with

diabetes or hypertension could explicitly include discussions of

breastfeeding and information about community-based resources.

In addition, compliance with BFHI steps should be promoted in

more hospitals, consistent with the federal Healthy People 2020

goals, as should practices that have been shown to improve

breastfeeding outcomes despite not being part of the BFHI scale,

such as skin-to-contact between women and their infants

immediately after birth [47,48]. Hospital should also be aware

of well-intentioned practices to support breastfeeding that women

may in fact experience negatively. Hands-on-breast approaches to

breastfeeding support, for instance, may be considered unpleasant

and disrespectful by some women [49]. Hospitals and staff should

continue to maintain open communication with women about the

best ways to support their breastfeeding intentions.

Limitations Although providing a rich source of data on breastfeeding from

a patient perspective, the Listening to Mothers surveys have

certain limitations that warrant discussion. These data are based

on retrospective self-reports, leaving room for potential recall bias

and social desirability bias. Although the survey contained some

information about health conditions, assessment of these condi-

tions is based on maternal self-report. In addition to the

complications we included in our analysis, other maternal, fetal,

and neonatal medical conditions or complications that arise during

labor and delivery could also be associated with breastfeeding

intention and practices. Finally, our construction of the BFHI

composite measure relied on maternal perception of proxies for 7

of the 10 BFHI steps. However, several of the 10 BFHI steps

include questions about hospital policy, of which many women

may not be aware.


Breastfeeding is beneficial for women and infants, and medical

contraindications are rare. Complications that occur during

pregnancy, labor, and delivery may hinder breastfeeding, but

Table 5. Controlled Odds of Infant Feeding Status at 1 Week by Pregnancy Complexity and Supportive Hospital Practices.

Any Breastfeeding 1 Week Postpartum (n = 1990)

AOR 95% CI AOR 95% CI

Complex pregnancy 0.81 (0.49–1.34) 0.82 (0.50–1.36)

High supportive hospital practices 4.03 (1.81–8.94)

Exclusive Breastfeeding 1 Week Postpartum (n = 1418)

AOR 95% CI AOR 95% CI

Complex pregnancy 0.68 (0.47–0.98) 0.69 (0.48–1.00)

High supportive hospital practices 2.68 (1.70–4.23)

Note: Models are weighted to be nationally representative. Models control for age, race/ethnicity, education, census region, nativity, partnership status, parity, unintended pregnancy, birth attitudes, health insurance status, cesarean delivery and doula support. Bold text indicates statistically significant (P#.05). doi:10.1371/journal.pone.0104820.t005

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PLOS ONE | 6 August 2014 | Volume 9 | Issue 8 | e104820

supportive hospital practices may facilitate breastfeeding for

women who intend to breastfeed.

We distinguished breastfeeding intentions and early feeding

patterns for women with complex pregnancies and found lower

odds of intending to breastfeed and decreased chances of early

exclusive breastfeeding, even after accounting for supportive

hospital practices, which were associated with greater breastfeed-

ing success. Therefore, it is important to support women with

medically complex pregnancies in overcoming potential challenges

to breastfeeding.


The authors are grateful for helpful input provided by Eugene Declercq,

PhD; Valerie Flaherman, MD, MPH; Dwenda Gjerdingen, MD; Pamela

Jo Johnson, PhD, MPH; and Carol Sakala, PhD.

Author Contributions

Conceived and designed the experiments: KBK LBA PM. Performed the

experiments: LBA JJ LKJ. Analyzed the data: LBA JJ KBK. Contributed

reagents/materials/analysis tools: KBK PM. Contributed to the writing of

the manuscript: KBK LBA JJ LKJ.


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Medically Complex Pregnancies and Early Breastfeeding

PLOS ONE | 7 August 2014 | Volume 9 | Issue 8 | e104820

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