A comparison of the incidence of breast feeding two and four months after delivery in mothers discharged within 72 hours and after 72 hours post delivery

A comparison of the incidence of breast feeding two and four months after delivery in mothers discharged within 72 hours and after 72 hours post delivery Cecilia I. E. Svedulf, Ingegerd L. Bergbom Engberg, Harriet Berthold and Ingela E. H6glund Objective: to compare breast feeding at two and four months after delivery in mothers discharged early (ED -- before 72 hours post delivery) and late (LD -- after 72 hours post delivery), and to explore the factors of greatest importance to the successful practice of breast feeding.

Design: ex-post facto design. Setting: in the county of Hiirryda, Sweden. Participants: all Swedish speaking women in the county of Hiirryda whose babies were born between 01.01.94 and 31.05.94 and who were registered at the Child Health Station (CHS) by the age of three months. One hundred and ninety women were invited to participate and 157 (83%) accepted.

Measurements and findings: no significant difference was found in the breast feeding rates Cecilia I. E. Svedulf BSc, RN, District Nurse, Av~gen 4, S-430 65 R~ivlanda,Sweden Ingegerd L. Bergbom Engberg EdD, DMSc, RN, Associate Professor, Bor~s University College of Health Science, Box 55140, S-50 404 Bor~s, Sweden Harriet Berthold EdD, DMSc, RN, Assistant Professor, Bor~s University College of Health Science, Box 55140, S-50 404 Bor~s, Sweden Ingela E. H6glund BSc, EdD, PuN,Senior Lecturer, Bor~s University College of Health Science, Box 55140, S-50 404 Bor~s, Sweden (Correspondence to CIES) Manuscript accepted 7 October 1997

between the ED and LD group. However, ED mothers breast fed exclusively to a higher extent at two and at four months (exclusive breast feeding: at two months 89% and 86% respectively, and at four months 84% and 74% respectively, partial breast feeding: at two months 6% and 10% respectively, and at four months 5% and 12% respectively). If the woman considered that she had received encouragement and support while breast feeding for the first time, the probability of her breast feeding at two and at four months were about six times as great (Exp(B) 5.7594, df = I, p = 0.0270; (Exp(B) 5.9781 df = I, p = 0.0005 respectively).

Key conclusions: the length of the hospital stay had no significant effect on the incidence of breast feeding at two and four months post delivery. The most predominant factors influencing breast feeding were seen to be the mother's first experience of breast feeding and the degree of support, help and encouragement she received. Less than half of the women received a visit from the CHS nurse after t h e i r return home from hospital.

Implications for practice: the findings suggest that it is important that the midwife or nurse should prepare, support and encourage the mother when breast feeding for the first time.

The midwife's or nurse's interventions are important for the incidence of breast feeding, at least during the first four months, and indirectly affect public health. This must also be taken into consideration when caring for mothers in the delivery w a r d and before discharge, i.e. that the breast feeding is working well, that the mother experiences it as working well, and also for planning follow-up after discharge. Midwiferyl1998 ) 14,37~17 © 1998HarcourtBrace& Co. Ltd

38 Midwifery INTRODUCTION During the last two decades, several international efforts have been made by the United Nations (UN) and its organisations to increase the incidence of breast feeding. The goal of the World Health Organization (WHO) and of [he United Nations Children's Fund (UNICEF) concerning breast feeding is to protect, promote and support breast feeding exclusively from the baby's birth to four to six months of age, and thereafter partially for up to two years of age or beyond (Innocenti Declaration 1990). At the 1989 UN convention on children's rights, it was stressed that all convention states should strive to give education about the advantages of breast feeding (R~idda Barnen 1991). The WHO recommendation is that all countries should have set a goal that by the year 2000 80% of newborn babies should be breast fed exclusively for the first four months (WHO 1989). Sweden also participates in the WHO and UNICEF initiated action Baby Friendly Hospitals Initiative, which aims to give care and to promote breast feeding in all delivery and maternity wards (Socialdepartementet 1993). During the same period it has become possible for women and their babies to leave the maternity ward within 72 hours of delivery, so called early discharge.

Influence of hospital stay on the duration of breast feeding Several studies have shown that mothers leaving hospital early had a slightly lower rate of breast feeding at the beginning, but after a period of time they had the same or even a slightly higher rate than those leaving hospital later than 72 hours after delivery (Waldenstrrm et al 1987, Waldenstrrm 1989, Kirkegaard 1993, Mitchell et al 1993, Waldenstrrm & Nilsson 1994). However, Carty and Bradly (1990) report that women discharged within 48 hours of birth breast fed exclusively to a higher extent when the baby was one month old compared with women discharged after four days.

Other factors influencing breast feeding Earlier studies indicate that a wide range of factors appeared to correlate with longer periods of breast feeding, namely: higher education (Florack et al 1984, Buxton et al 1991, Bergman et al 1993, Kirkegaard 1993, Michaelsen et al 1994), marriage (Jones 1987), non-smoking (Bergman et al 1993), higher income (Buxton et al 1991), higher social class (Jones 1987) and higher age (Beske & Garvis 1982, Michaelsen 1994). Women choosing early discharge from hospital post delivery were seen to be less well educated (Waldenstrrm & Lindmark 1987, Mitchell et al 1993) and, on average, were found to be younger and more self-confident with delivery and prospective parenthood; whereas

women from studies in New Zealand and Sweden were often older and multiparae (M~tensson 1993, Mitchell et al 1993). It is usually during pregnancy, or even earlier (Graffy 1992), that a woman decides whethe~ or not to breast feed (Lyon et al 1981, Bergman et al 1993). Other factors which influence breast feeding positively are the mother's confidence in the ability to breast feed and her decisiveness to breast feed (Buxton et al 1991), as well as antenatal education about breast feeding (Wiles 1984). The first contact between mother and baby during the first few hours and early breast feeding result in a longer lactation period (de Chateau 1980, Buxton 1991). Rooming-in (i.e. the mother being together with her baby for 24 hours) and having no rigid time schedule (i.e. where the baby determines the incidence and duration of sucking) are of importance to successful breast feeding (Buxton et al 1991). The father's attitude towards breast feeding plays an important part in the woman's choice of how to feed her baby (Beske & Garvis 1982, Jones 1987). Advice from female relatives and friends, the ways in which they fed their babies, and whether the woman has watched another breast feeding are also important factors (Lyon et al 1981). Previous positive breast-feeding experience is another key factor to successful breast feeding (Kirkegaard 1993). Jones (1987) reported that the most important reasons to breast feed was the opinion that it is the best for the baby and that it is also natural.

Factors having a negative influence on breast feeding The woman's attitude towards breast feeding is adversely influenced by her own or her friends' previous negative experiences of breast feeding, by excessive demands (de Chgteau et al 1977, Jones 1987, Graffy 1992, Bergman et al 1993) and how she regards her breasts (Lyon et al 1981). Weighing babies before and after feeding and the use of dummies/pacifiers also have a negative influence on breast feeding (de Chateau et al 1977, Righard & Alade 1992, Victoria et al 1993). Artificial milk supplements reduce the baby's sucking and thereby reduce milk production and, consequently, cause less breast feeding (Widstr6m 1988, Michaelsen et al 1994). Some obstetric analgesia given to mothers during childbirth as well as gastric suction of babies immediately after birth can also negatively affect breast feeding (Widstrrm 1988). The Swedish Social Department encourages research and development projects concerned with breast feeding and mothers' early discharge from hospital (Socialdepartementet 1993). Several studies on the incidence of breast feeding following early discharge after childbirth have been undertaken (Waldenstrrm et al 1987, Waldenstrtim 1989, Carty et al 1990, Kirkegaard 1993, Mitchell et al 1993, Waldenstr6m & Nilsson 1994). However, no studies of the incidence of breast feeding four

A comparison of breast feeding in mothers discharged within and after 72 hours post delivery

months after delivery were found, and there were no studies comparing mothers' opinions on factors which they had considered to be of importance to breast feeding.

Purpose The purpose of this study was to compare breast feeding at two and four months after delivery in mothers discharged early after delivery with those discharged late, and to explore those factors being of greatest importance to the successful practice of breast feeding.

HETHODS An ex-post facto design was used to describe and compare women who breast fed at two and four months after delivery, and who were discharged either up to 72 hours or after 72 hours from the postnatal ward. A questionnaire was designed by one of the authors, and included four questions from the Swedish Committee in the UNICEF/WHO action 'Baby Friendly Hospitals' (Socialdepartementet 1993). The questionnaire consisted of 45 smactured and semi-structured questions on nine themes. These themes concerned demographic data, previous experiences of breast feeding and close relatives' attitudes to breast feeding. Six questions concerned information, expectations and attitudes to breast feeding during pregnancy. A further six questions concerned breast feeding in conjunction with delivery. Other themes were the length and experienced quality of breast feeding during the first four months after delivery, breast feeding support, and positive as well as negative factors which the mothers considered affected their breast feeding. To test the reliability and validitiy of the questionnaire four expert district nurses, with long professional experience of caring for mothers with newborn babies, assessed it for relevance and meaning. All questions in the questionnaire were considered to be relevant as previous studies have shown their relevance. A pilot study with three mothers was also undertaken and, as a result, some small changes were made. Data collection took place four months after childbirth, when the women answered the questionnaire and mailed it to one of the investigators.

Data analysis The answered questionnaires were processed using the statistical program Statistical Package for the Social Sciences (SPSS). Descriptive statistics, such as mean, standard deviation (SD) and range were applied. For differences between groups ;(2 analyses with Pearson's test for cells more than five and Fisher's exact test for cells up to five were used. The significance level was set at 0.05. Logistic regression was used to determine factors important to breast feeding. The significance level was set at 0.01.

39

In this study the incidences of breast feeding at two and four months after birth, together with demographic data, encouragement and support given, and the mothers' experiences and expectations are presented. The study was approved by the Research Ethical Committee, University of Gothenburg, Sweden, in 1994.

Sample The population (n = 190) comprised all the Swedish speaking women in the county of H/irryda who had just become mothers with babies born between 01.01.94 and 31.05.94 and who were registered at the Child Health Station (CHS) by the age of three months. Of the 190 women having a baby during this time, 145 were given a written invitation to take part in the study by their district nurse at their threemonth health check at the CHS. Of those invited 138 agreed to take part. Written invitations were sent by post to fourteen women because they had already visited the CHS before permission to start the study had been given by the Research Ethical Committee. Nine of these mothers, agreed to take part. Due to pressure of work at the CHS the district nurses forgot to give the invitations to 31 mothers. These subsequently received a written invitation by post, and 26 of them accepted the invitation. In total 173 agreed to participate, but 16 mothers subsequently did not answer the questionnaire. Consequently, 157 women participated in the study, giving a response rate of 83%.

FINDINGS Sample characteristics The women had a mean age of 29.7 years (SD 4.3) with a range of 1 8 4 2 years. The multiparous mothers, comprising 54% of the sample, had a mean age of 30.3 years, whilst the primiparae had a mean age of 28.4 years. Most of the women (98%) were marfled or lived together with the baby's father. A majority of the mothers (52%) lived in a community with more than 5000 inhabitants whilst 26% lived in villages with less than 5000 inhabitants and 21% lived in the countryside. There were as many women with university education as there were those with two years' upper secondary school, 33% each. Twentytwo per cent of the mothers had three to four years' upper secondary school education, whilst 13% only had comprehensive school education (Table 1).

Early and late discharge groups The 157 women were divided into two groups based on the time of discharge from hospital, i.e. discharge within 72 hours after the delivery (ED) (n = 64) or discharge after 72 hours (LD) (n = 92). Less than half of the mothers (64, 41%) chose early discharge (Table 2). There was a difference within the ED

40

Midwifery

Basic data Total number in group, % of total

All mothers n = 157

Primiparae n = 72, 46%

Multiparae n = 85, 54%

Age (yrs) 18to20 21 t o 2 5 26 to 30 31 to 35 36 to 40 41 up Mean Standard deviation Confidence interval

n = 156* 3 20 68 49 13 2 29.7 4.3 29.0-30.4

n = 72 3 13 34 16 5 I 28.6 4.3 27.7-29.6

n = 84* 0 7 34 34 8 I 30.7 3.8 29.9-31.5

Civil status Married or living together Single Divorced

n = 157 154 2 I

Education Comprehensive school 2 years upper secondary school 3 to 4 years upper secondary school University

n = 157 20 13% 51 33% 35 22% 51 33%

8 21 19 24

5% 13% 12% 15%

12 30 16 27

8% 19%o 10% 17%

Dwelling Greater than 5000 inhabitants Less than 5000 inhabitants Countryside

n = 155* 81 52% 41 26% 33 21%

43 15 12

28% 10%0 8%

38 26 21

25% 17% 14°,6

70 I 0

83 I I

* One woman did not answer the question about her age, and two did not answer about their dwelling.

Basic data Total number in group, % o f total

Age (yrs) [8to20 21 to25 26 to 30 31 to 35

Early discharge (6-72 hours) 64 41%o

Late discharge (later than 72 hours) 92 59%

3 8 25 20

0 [2 43 29

7 0 29.6 4.6

6 2 29.8 4. I

64 0 0

89 2 I

14" 22 13 15

6 29 22 35

30 21 12

50 20 2I

n = 155

36 to 40 41 up Mean Standard deviation Civil status Married or living togehter Single Divorced

n = 156

Education Comprehensive school 2 years upper secondary school 3 to 4 years upper secondary school University

n = 156

Dwelling Greater than 5000 inhabitants Less than 5000 inhabitants Countryside

n = 154

Primiparae

n = 72

24

47**

Multiparae

n = 85

40

45

Some women did not answer all questions (n = 4); .%2 = 9.76398, df = 3, p = 0.02068 vs. late discharge; **%2 = 23.9321 I, df = 9, p = 0.00441.

group regarding age. Women discharged earliest (6-24 hours) had a mean age of 28 years compared to 30 for the rest (25-72 hours). A correlation was noticed between the women's educational background and their time of discharge. A greater inci-

dence of early discharge was noticed amongst those with lower educational background 0~2=9.76398, df= 3, P = 0.02068). More primiparae went home late compared to multiparae (Z2= 23.93211, df= 9, P = 0.00441).

A comparison of breast feeding in mothers discharged within and after 72 hours post delivery

Previous breast feeding experiences About half the women (83, 53%) were multiparae with previous experience of breast feeding. Of the women in the ED group 42 (66%) had earlier experience of breast feeding whereas only 47% (41) of the LD group had previously breast fed (Z 2 = 4.71065, df = 1, P = 0.2998). The mean time for breast feeding exclusively was 4.6 months, but varied between 0-10 months. For exclusive plus partial breast feeding the variance was 2.5-27 months. About half the women (n = 44) considered their previous breast feeding to be successful. Of these women 41 were breast feeding this baby at the age of four months. More than half of the mothers (n = 48) had not received help and support from the staff when they breast fed their previous baby. Of those who did, more women left hospital earlier this time.

Breast feeding status at two and four months after delivery When the baby was two months old, 57 (89%) in the ED group breast fed their baby exclusively, four (6%) were partially breast feeding, whilst three (5%) had stopped breast feeding. By comparison in the LD group there were 79 (86%) exclusively breast feeding, nine (10%) partially breast feeding and four (4%) no longer breast feeding (Table 3). Thus, at this point the incidence of breast feeding between the two groups did not differ. Mothers leaving hospital early breast fed exclusively to a higher extent, but the total breast-feeding rate (exclusive plus partial) was higher amongst mothers leaving hospital after 72 hours. When the mothers within the ED group were compared, there was a big variance in breast feeding at two months depending on how many hours after delivery they left hospital (Table 3). All women leaving hospital 6-24 hours after birth were breast feeding at two months. There was a tendency for women who left 25-48 hours after birth to have a lower breast feeding rate than all other mothers. When the baby was four months old the

41

total breast feeding rates were virtually the same in both groups, but on analysing exclusive and partial breast feeding differences appear. Mothers discharged early breast fed exclusively to a higher extent than mothers discharged late. Comparing primiparae and multiparae, it was found that the multiparae in the ED group had a higher breast feeding rate than the primiparae both at two and at four months, whilst the opposite was found in the LD group. The differences at two months were only significant within the ED group amongst women discharged 25-48 hours after delivery (Z2 = 6.25055, df = 2, P = 0.04392). When the babies were four months old all the multiparae who were discharged after 6-24 hours still breast fed their babies exclusively (Z2 = 4.95000, df = 1, P-- 0.02609). One of the two primiparae had stopped breast feeding. When asked whether there was any difference in the experience of breast feeding at two and four months after delivery, more mothers in the LD group thought that there was, 57 women, compared with 24 women in the ED group. For 65 women it was a change for the better, i.e. they had got better routines, the baby ate faster, the mother felt more relaxed, it was easier, breast problems were fewer, and mother and baby had go to know each other better and communicated in a different way when the baby was suckling. Two mothers expressed the change as: There is more time to laugh and chat now. Now when our daughter is older I enjoy breast feeding more because we have an invaluable communciation every time I feed her. Nineteen women said experience was worse; the baby was not satisfied, or needed breast milk or supplementary food more often or was more easily disturbed.

Attitudes towards breast feeding and experiences of the first breast feeding Most women (n = 151) stated that the baby's father had a positive attitude to breast feeding. The opinion

ED group

LD group

Time after childbirth: Total number in group, % of total

6-24 hours II 7%

2 5 4 8 hours 18 12%

49-72 hours 35 22%

> 72 hours 92 59%

Breast feeding at 2 months Exclusively Partially Stopped

II 0 0

14 2 2

32 2 I

79 9 4

Breast feeding at 4 months Exclusively Partially Stopped

I0 0 I

31 I 3

67 II 12

12 2 3

Some women did not answer all questions (n = 4). One did not say when she left hospital and three did not answer whether they breast fed at 4 months.

42

Midwifery

of five fathers was reported to be indifferent or unknown. During pregnancy a majority of the women in both groups thought that breast feeding was going to be successful. In the ED group 31 (48%) of the women were of the opinion that they were going to succeed 'very well' compared with 39 (42%) in the LD group. Mothers leaving hospital earliest, after 6-24 hours, were the most self-confident. Amongst them six thought that they were going to succeed 'very well', while seven of the women discharged 25-48 hours after delivery were of the same opinion. More women in the ED group (n = 35, 55%) reported that the first breast feeding was a very positive experience when compared with the women in the LD group (n = 44, 48%). Mothers whose experience of the first breast feeding was rated 'positive' to 'very positive' were in general also discharged earliest (6-24 hours), whilst mothers whose experience was not so positive, i.e. neither 'positive nor negative' or 'negative' were discharged later after

birth (Table 4). Mothers with a 'positive' to 'very positive' experience of the first breast feeding also thought that the whole breast-feeding period worked 'very well', or 'well', compared with mothers who did not find the first breast feeding positive (Z2 = 29.39, df = 12, P = 0.00345). A seen in Table 5, a positive or negative experience at the first breast feeding after delivery appears to influence the incidence of breast feeding at two and four months. Using logarithmic regression, it was found that the probability of a women breast feeding her baby at the age of two months is 33 times greater (Exp(B) 33.0964, d f = 1, P = 0.0015), and atthe age of four months nearly nine times greater (Exp(B) 8.9344, df = 1, P = 0.0000) if the first breast feeding had been a positive experience, than if breast feeding had been a negative experience. The answer of 'well' to 'very well', to the question on how breast feeding worked when the mother left hospital was the same in both groups (ED 87%,

ED group 6-24 hours I I 7%

Total number in group, % of total

LD group

2 5 4 8 hours 18 12%

49-72 hours 35 22%

> 72 hours 92 59%

Initial breast feeding experience* Very positive Positive Neither positive nor negative Negative Very negative

7 3 0 I 0

9 4 2 3 0

19 I0 4 I I

44 3I I0 3 4

Breast feeding at discharge Working very well Working well Working less well Working badly

4 6 I 0

8 6 4 0

16 15 3 I

39 39 7 4

Breast feeding over whole period Worked very well Worked well Worked less well Worked badly

8 3 0 0

7 6 4 I

1S 17 I I

50 28 9 5

Some women did not answer all questions(n = 4); * Z 2 = 29.39, df = 12, p = 0.00345.

Breast fed at 2 months ED group LD group n = 62 n = 88 n % n %

Breast fed at 4 months ED group LD group n = 56 n = 78 n %0 n %0

Initial breast feeding experience Very positive/positive Neither positive nor negative Very negative/negative

52 5 5

8I 8 8

74 8 6

80 9 7

50 4 2

78 6 3

66 7 3

72 8 3

Support and encouragement Received on maternity ward Not received on maternity ward

51 7

80 II

69 19

75 21

48 7

75 13

64 14

79 15

Some women did not answer all questions (n = 4).

43

A c o m p a r i s o n o f breast feeding in m o t h e r s discharged w i t h i n and after 72 hours post delivery

n = 55; LD 88%, n = 78). A higher percentage of mothers in the group who left hospital 25-48 hours after delivery thought that breast feeding worked less well compared with those who left hospital earlier or later. Women who thought that breast feeding worked 'less well' or 'badly' were discharged later. Four months after delivery there were as many in the ED group as in the LD group who thought that their breast feeding period had worked 'well' to 'very well' (Table 5). Fourteen women gave reasons why breast feeding worked as it did. Mothers who succeeded less well stated that insufficient milk production, sickness or 'thrush' infection in mother or baby were the reasons why their breast feeding did not work better than it did. Reasons for breast feeding working badly were that the baby did not take to the breast or there was 'thrush' infection of the nipples. Two multiparae had difficulties because of older children who disturbed them. Comments mothers made were: Breast feeding was more difficult to learn than I thought. I was a bit shocked. Very hard from time to time. It's not the most comfortable thing to do, but the most important thing is that the baby feels well. Of the women who were breast feeding their babies four months after delivery (n = 135), 114 (84%) stated that they planned to continue to breast feed for between four and 15 months. Six mothers in the ED group and one mother in the LD group felt unsure. Some reported: As long as possible, as long as the baby wants it, as long as I am satisfied with it or until my baby eats normal food. Of those who stated how long they planned to continue, the mean time in the ED group was 7.7 months (SD 2.2), and 7.1 months (SD 1.9) in the LD group. Eighty-four per cent (n = 53) of the mothers who were discharged early thought that the most important factor for successful breast feeding was to believe in one's capacity to breast feed. Seventy per cent (n = 64) in the LD group were of the same opinion. These differences are significant ()C2 = 4.28468, df = 1, P = 0.03846). One fifth in both groups thought that encouragement and support was most important for success with breast feeding. More

Support and encouragement Received on maternity ward Not received on maternity ward

women (n = 17) who were discharged late valued information as being more important to successful breast feeding compared to women who were discharged early ()~2 = 6.42244, df = 1, P = 0.01127). Only seven mothers, of whom five were in the LD group, thought that previous good breast-feeding experiences were most important.

B r e a s t - f e e d i n g s u p p o r t in t h e d e l i v e r y and postnatal wards Fifty-two mothers in the ED group (83%) stated that they received encouragement, support or help at the first breast feeding, while 71 (77%) of the mothers in the LD group reported this. Mothers who left hospital 25--48 hours after delivery, however, received significantly less breast-feeding support than mothers who left before 25 hours or after 48 hours after birth (;(2 = 8.65188, df = 3, P = 0.03430). The probability of the women breast feeding at two and four months after delivery is about six times as large (Exp(B) 5.7495, df = 1, P = 0.0270; Exp(B) 5.9781, df = 1, P = 0.0005 respectively) if the women consider that they have received encouragement and support while breast feeding for the first time when compared with those who reported no such support. In the ED group, 48 (94%) mothers who reported receiving support and help at the first breast feed thought that their breast feeding had worked 'well' or 'very well', compared with seven of those who reported that they did not receive any support and help (Z2 = 9.19354, df = 3, P = 0.02683). In the LD group, 62 mothers (87%) thought that breast feeding had worked 'well' or 'very well', if they received support and help at the first breast feed compared with 16 of those who did not receive any support (Z2 = 10.23711, df = 3, P = 0.01665). Four mothers who left hospital late and who reported that they did not receive help at the first breast feed thought that breast feeding did not work later. In the postnatal ward 47 (77%) mothers in the ED group and 73 mothers (83%) in the LD group reported receiving help and support to continue breast feeding until the baby was two months old (Table 6). Some women (n = 32) commented on whether or not they had received support and encouragement. Nine women did not need any sup-

Breast fed at 2 months ED group LD group n = 62 n = 88

Breast fed at 4 months ED group LD group n = 56 n = 78

n

%

n

%

n

%

n

%

47 4

77 6

73 14

83 15

43 13

72 22

67 I0

75 II

Some women did not answer all questions (n = 6).

44

Midwifery

port or help when breast feeding. Twelve-others did not feel that they had received enough help or support giving as reasons, for instance: Too many different ideas about breast feeding among the staff. Did not receive any real support or the staff didnot have enough time. For some mothers (n = 11) the help was sufficient or even too much.

Breast-feeding support after return home from hospital Within one week of returning home the family should receive a home visit from the CHS nurse and, if they have been discharged early, a visit by the midwife. More than half the mothers (n = 95, 61%) stated that they had not received any home visit by the CHS nurse. Seventy-two women (46%) did not receive a home visit at all, neither from a CHS nurse nor a midwife. Twenty-six mothers stated that they wanted a home visit by the CHS nurse but did not get one. Fifty-one mothers (33%) visited the CHS themselves. However, it was not clear if this was their own choice or whether they were recommended to visit the CHS by the staff. Women in the ED group who received a home visit (n = 47) were, on average, visited two days (SD 1.6) after their return home; women in the LD group (n = 39) were visited on average four day s (SD 2.0) after their return home (~a = 40.69545, df = 24, P = 0.01798). Three quarters of the mothers who were discharged early and received a home visit were visited by a midwife, whilst 35 (95%) of the mothers who were discharged late and received a home visit were visited by the CHS nurse. Information about breast feeding and help to breast feed was reported to be more often given to women in the ED group (n = 43) compared with mothers in the LD group (n = 29) (~2 = 4.36054, df = 1, P = 0.03678). Only a third of the women in both groups, early respectively late discharge, were satisfied with the breast-feeding information given by the CHS. Comparing the findings in the ED group large differences were found. Eight mothers discharged after 6-24 hours found the breast-feeding information and help 'good' or 'very good' compared with five and eleven discharged 25-48 hours and 49-72 hours respectively after delivery. Seven women discharged after 25--48 hours reported that they did not get any breast-feeding information at the CHS, compared with 1, 9 and 27 women discharged after 6-24 hours, 49-72 hours and later than 72 hours respectively. Most mothers in both groups (n =24 ED, n = 40 LD) stated that the best breast-feeding support they had received was in the postnatal ward. The second best support in the ED group was found in literature and the third best support was the baby's father. Pregnancy Care Centre (PCC) and CHS were men-

tioned fourth and fifth by this group. For women in the LD group the child's father was the second best support closely followed by girlfriends and literature. The fifth best breast-feeding support was received from the staff in the delivery ward and sixth best by CHS. Ten mothers (seven ED, three LD) were 'confident' in themselves. Mothers who discharged early after childbirth reported better breast-feeding support at the PCC than women who were discharged later (Z 2 = 4.66117, df = 1, P = 0.03085).

Other factors influencing breast feeding In the study 118 (76%) babies suckled within two hours after delivery. All of the women who left hospital 6-24 hours (n = 11) after delivery had had babies who suckled within two hours. The mothers found that breast feeding worked equally well no matter when the baby suckled for the first time. Rooming-in was practised by three quarters of the mothers (n = 113). For 21 mothers this was impossible because the babies were nursed, or under observation, in the neonatal ward. There was a tendency that women who were together with their babies only during the day breast fed their babies less at four months after delivery when compared both with those practising rooming-in and with those who had their babies in the neonatal ward. However, the differences were not significant (Z2 = 7.71513, d f = 4, P = 0.10259). About a quarter of the babies (n = 36) were given additional fluid in the postnatal ward, principally for medical reasons, significantly more in the LD group (n = 30) than in the ED group (n = 6, Z2 = 13.97040, df = 3, P = 0.00295). But this fact did not seem to have any negative influence upon breast feeding in the LD group. However, in the ED group, babies given additional fluid in the postnatal ward were breast fed less. Forty-four per cent (28) of the babies in the ED group and 51% (47) of those in the LD group were using a dummy/pacifier when the questionnaire was completed. Higher education was correlated with a longer period of breast feeding. Within the LD group significantly more mothers (n=54, 60%) who had higher education breast fed four months after delivery when compared with mothers with lower education (n=24, 31%) (Z2=17.62916, d f = 6 , P=0.00723). The age of the mother was another factor influencing breast feeding; 92% (n = 127) of the women 25 years old or older breast fed their baby four months after delivery, while only seven mothers younger than 25 did so (Z2=85.29045, dr=44, P=0.00019). Smoking influenced breast feeding negatively. Only 12 of the smoking mothers breast fed their baby exclusively and five partially, when the baby was four months of age compared with 108 (83%) exclusively and 10 partially for non-smoking mothers (Z2= 12.96288, d f = 2 , P=0.00153).

A comparison of breast feeding in mothers discharged within and after 72 hours post delivery

DISCUSSION There was an 83% response rate in this study, which is satisfactory. However, it is possible this could have been higher if, as planned, all the women had received a personal invitation at the CHS. As it was, 45 women were sent invitations by post which resulted in a 33% non response compared to a 5% non response amongst those who were personally invited. It would have been better if the study had taken part at another time of the year, not in the holiday period. Furthermore, the distribution and collection of the questionnaires would have been improved, if only one or two (instead of ten) district nurses had invited the mothers to participate in the study. Perhaps some nurses are uninterested in, have no knowledge of, or even have a negative attitude to research? That could lead to bad motivation or 'forgetfulness'. The structured questions were complemented by semi-structured questions in order to allow for fuller responses to some questions. All women, both healthy mothers delivered at an Alternative Birth Care Centre leaving hospital within 24 hours, as well as mothers obliged to have a late discharge because of their own or their baby's illness were included in the study. This fact is both the strength and the weakness of this study. It is the strength compared to other studies where many mother-baby pairs were excluded because of factors such as: illness in mother or child, prematurity, twin birth, caesarean section, low birth weight, or risk factors such as smoking. The weakness is that factors such as illness in the mother or baby could negatively affect breast feeding and thus result in bias. However, it is possible that the findings can be generalised to other communities similar to H~-ryda. In the present study two groups were compared, women discharged from hospital within 72 hours of childbirth and those discharged later. The demographics of the two groups only differed significantly regarding education and whether they were primiparae or multiparae. As in previous studies (Waldenstr0m et al 1987, Mitchell et al 1993) women who left hospital early tended to have a lower educational background than those discharged late. In the present study more multiparae went home early, a pattern that is also found in previous studies (Mitchell et al 1993, Mftrtensson 1993). The role of previous positive breast-feeding experiences as a factor related to successful breast feeding is identified by Kirkegaard (1993) and was confirmed in this study, where 91% of the women who considered their previous breast feeding to be very good still exclusively breast fed this baby at four months of age. The breast feeding rates in this study were high, when compared with the Swedish population in general, in both ED and LD groups, at two and at four months after the delivery (exclusive breast

45

feeding: at two months 89% and 86% respectively, and at four months 84% and 74% respectively, together with partial breast feeding: at two months 6% and 10% respectively, and at four months 5% and 12% respectively). According to the Swedish official health statistics for children born in 1994, 76.3% were breast fed exclusively at the age of two months, and 12.5% partially. At the age of four months 64.1% were breast fed exclusively, and 15.7% partially (Socialstyrelsen 1997). These differences can be explained by the relatively high age of the women in this study, a factor which correlates with longer periods of breast feeding (Beske & Garvis 1982, Michaelsen et al 1994) and by the fact that more than half of the women had at least twelve years of education (Florack et al 1984, Buxton et al 1991, Bergman et al 1993, Kirkegaard 1993, Michaelsen et al 1994). Almost all of the participants were married or living with a partner, something that earlier studies found important for a higher breast-feeding rate (Jones 1987). Over the last years great efforts have been made to promote breast feeding in the delivery and maternity wards, to educate the staff, and a breast-feeding policy has also been drawn up. Together, all these efforts may have had a positive effect on the breast-feeding rates observed. In the invitation to the study it was stated that all answers were equally important, but some mothers might not have answered the questionnaires if they felt they had been unsuccessful in breast feeding, thus we cannot exclude the possibility that the breast-feeding pattern in this group might have been different. The breast-feeding status at two and at four months did not differ significantly in the ED and the LD groups. On leaving hospital, marginally more mothers leaving late experienced breast feeding as working 'very well', and at two months the total breast-feeding rate (exclusive plus partial) was somewhat higher in the LD group. However, women in the ED group breast fed exclusively to a somewhat higher extent at two months and the difference had increased in their favour at four months. This pattern is supported by other studies (Waldenstr6m et al 1987, Waldenstr6m 1989, Kirkegaard 1993, Mitchell et al 1993) where mothers discharged early breast fed to a lesser extent in the beginning, but later on to at least the same level. As in the study by Waldenstr6m (1989), the early discharged multiparae in the present study breast fed for a longer period than the primiparae. The reason could be that multiparae, with self confidence and good experience of previous breast feeding, will do well without prolonged support, whilst women without this confidence, going home early without good support, do not succeed as well. As mentioned in other studies (Waldenstr6m 1987, Waldenstr0m 1989, MSrtensson 1993), mothers leave hospital at different times for different reasons, and not only because they feel that breast feeding is established and working well. It seems as

46

Midwifery

though the primiparae need longer help and support to establish breast feeding, which Wennergren et al (1986) also found. Multiparae staying in hospital more than 72 hours might often stay for reasons other than to be given help and support, reasons such as sickness in the mother or baby, risk factors such as twin-birth, caesarean section, low birth weight or prematurity, or just to rest before going home to older children. In the present study there was a difference between the group of mothers within the ED group who left hospital 25--48 hours after the delivery and all other mothers. At four months only a fifth were still breast feeding. These women had received significantly less encouragement, help and support while breast feeding for the first time, and had experienced the first breast feed as less positive. In the present study we found that the most important factor for a woman, as to whether to breast feed or not, were the experience of the first breast feed. We found that the probability of a woman breast feeding her baby at the age of two months was 33 times greater, and at the age of four months nearly nine times greater, if the first breast feed was a positive experience rather than a negative one. These mothers also received less breast-feeding information at the PCC and the CHS and had received less support in the maternity ward than other women. It was also seen that the probability of the women breast feeding at two and at four months after the delivery was nearly six times as large if the women considered that they had received support, help and encouragement while breast feeding in the maternity ward. Most mothers considered that they had received their best breast-feeding support in the maternity ward, which is in accordance with the findings of Bergman et al (1993). Conflicting advice and lack of time were reasons reported by the women when they did not get enough support. This underlines the importance of having a breast-feeding policy and that this policy is adopted by the staff at different health care units. It is possible that the midwives and nurses were not sensitive enough to give these women the support they needed or did not have satisfactory knowledge, experience or competence. Lack of time as well as lack of commitment for the mothers or not giving breast feeding priority could also be an explanation. There is a need for more communication between the PCC, the delivery and postnatal wards as well as the CHS concerning breast-feeding information, but also to evaluate and ensure that enough staff are available to give the necessary time to help every mother according to her needs. It is remarkable and alarming that only a third of the mothers were satisfied with the breast-feeding information and help given at the CHS, and that approximately a third did not receive any breast-feeding information at all at the CHS, a fact that is supported by Bergman et al (1993). Less than half of the women received a visit by the CHS nurse after their return home from hospital.

That could also be a reason the mothers did not feel that they had received enough help. The home visit is an opportunity to generate contact and confidence, which are important to the provision of adequate support. It also provides an opportunity to see the mother breast feed and to form an opinion as to how the breast feeding is working. It is of fundamental importance that a district nurse should have sufficient time for health work, and give priority to home visits for all first-time parents and to 90% of all parents. Other important factors influencing breast feeding found in the present study and supported by previous studies were the age of the women, the level of the education and smoking, but none of these factors were as important as those mentioned above (Beske & Garvis 1982, Florack et al 1984, Buxton et al 1991, Bergman et al 1993, Kirkegaard 1993, Michaelsen et al 1994). Surprisingly, in the present study, the group of mothers who succeeded best with their breast feeding were mothers discharged 6-24 hours after delivery, who were younger, less well educated and smoked to a higher extent. This indicates that these factors are not necessarily the most important.

CONCLUSION In the present study, no statistically significant relationship was found between breast-feeding rates and the length of stay in hospital after childbirth. If the mother has the opportunity to choose the length of the stay, it may well partially depend on how breast feeding is working for her. The group of mothers who had the highest breast-feeding incidence were younger, less well educated and smoked to a higher extent. That indicates that these factors are not the most important for successful breast feeding. The most predominant factors influencing breast feeding were seen to be the mother's first experience of breast feeding and the degree of support, help and encouragement she received in conjunction with this. Presumably, many factors, such as the experience of the first breast feed, support, help and encouragement, age, education, smoking habits, previous good breast-feeding experiences, self confidence, motivation, and a positive attitude all work together towards successful breast feeding.

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A comparison of breast feeding in mothers discharged within and after 72 hours post delivery

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