Factors associated with breast-feeding duration

NUTRITION RESEARCH, Vol. 6, pp. 1121-1129, 1986 0271-5317/86 $3.00 + .00 Printed in the USA. Copyright (c) 1986 Pergamon Journals Ltd. All rights reserved.

FACTORS ASSOCIATED WITH BREAST-FEEDING DURATION Nancy M. Lewis, Ph.D. and Hazel M. Fox, Ph.D. Dept. of Human Nutrition and Food Service Management University of Nebraska Lincoln, Nebraska 68583-0806

ABSTRACT

A telephone survey of 45 WIC mothers was conducted to identify factors related to breastfeeding duration. Mothers who breastfed longer than 2 months were compared with those who were not breastfeeding at 2 months postpartum. Factors associated with increased breastfeeding duration were: having previous breastfeeding experience and a positive attitude toward breastfeeding, having agreement with the decision to breastfeed from the baby's father and help in the home from best friends and obtaining breastfeeding information from hospital nurses and classes and films. Mothers who breastfed longer than 2 months introduced formula during the third month while mothers who breastfed less than 2 months introduced formula during the first month. Inadequate milk supply was the reason for stopping breastfeeding given most often by mothers who breastfed longer than 2 months; whereas, nipple discomfort was the reason given most often by mothers who were not breastfeeding at 2 months postpartum. KEY WORDS:

Breastfeed duration

Attitude

Knowledge

WIC

INTRODUCTION The incidence of breastfeeding among mothers participating in the Special Supplemental Food Program for Women, Infants and Children (WIC) has increased to approximately 55% in some areas of the country, and is approaching the national average of 61% (1,2). However, the proportion of low-income mothers who breastfeed declines sharply during the first 2 months postpartum. More than 50% of WIC mothers who start breastfeeding stop during the first 2 months (1,3). The majority of mothers who stop breastfeeding within 2 months want to breastfeed longer (4). Breastfed infants have fewer illnesses than bottlefed infants, and it has been suggested that this protection extends through the first 6 months of life (5,6). Identification of factors associated with increased breastfeeding duration might make it possible to design programs that would enable mothers to breastfeed longer and therefore benefit both mothers and babies. Lack of breastmilk is given most often as the reason mothers stop breastfeeding (1,7). Whether the lack of breastmilk is actual or perceived and to what extent breastmilk production can be altered is not well known. Other reasons mentioned frequently by mothers when they stop breastfeeding are "frequent feedings required", "breastfeeding was too tiring" and "sore nipples". Previous research has indicated that fathers' support of breastfeeding, prenatal education, breastfeeding information, and delayed introduction of formula are positively associated with breastfeeding

1121

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N.M. LEWIS and H.M.FOX

duration, whereas formula samples given at hospital discharge reduce breastfeedlng duration (1,8,9). Mothers' feeding practices at two weeks postpartum are more related to introduction of infant formula products during their hospital stay than to positive nursing attitudes and instruction in breast feeding techniques (I0). Behavioral theory suggests that attitudes are a determinant of behavior and that knowledge acquisition either precedes or follows attitude change and therefore is also related to behavior (11,12,13). Whether specific knowledge and attitudes influence breastfeedlng duration is not clear. Kaplowitz and Olson (3) found that improving knowledge about breastfeeding did not increase breastfeedlng duration. The objective of the present research was to identify knowledge, attitudes and other factors associated with the duration of breastfeedlng.

METHODS Subjects and Experimental Design All of the pregnant mothers who applied to an urban WIC program during a one year period beginning August I, 1983, and who stated that they planned to breastfeed were identified as possible participants. Of the 107 mothers identified, 45 could be contacted by telephone and were surveyed within one year after their babies were born. Development of the Survey Instrument and Data Collection The questionnaire contalned 9 sections: demographic characteristics, breastfeeding knowledge, attitude toward breastfeeding, identity of people who agreed with the mother's decision to breastfeed (support), identity of people who helped in the home during the first 2 weeks after the baby was born (help), sources of information about breastfeeding, reasons mothers introduced formula, reasons they stopped hreastfeeding, and factors they believed would have helped them to have breastfed longer. We evaluated the mothers' knowledge of breastfeeding by giving 5 true-false knowledge questions. Mothers responded to each statement by selecting true, false, or don't know. We developed a set of I0 attitude statements based on previous research which identified attitudes associated with breastfeedlng duration (7). For the 10 attitude statements, women were asked to indicate if they strongly agreed, agreed, had no opinion, disagreed, or strongly disagreed with the statement. To avoid a response set, some attitude statements were phrased so that disagreement indicated a positive attitude. The support section of the questionnaire included a list of I0 people or groups. Mothers were asked how likely it was that the person or group would agree or disagree with their decision to breastfeed. Similarly, the help section of the questionnaire included a list of 8 people and the mothers were asked if these people helped in the home during the first 2 weeks postpartum. From a list of 9 potential information sources mothers were asked which sources provided them with information. The remaining 3 sections of the questionnaire were open-ended questions. Content validity, or the appropriateness of the questions for measuring knowledge, attitudes, support, help and information sources was evaluated by 8 reviewers including nutrition faculty, WIC staff and breastfeeding mothers. Based on reviewers comments, items were revised to insure accuracy and to improve clarity. The questionnaire was then pilot tested with one nutrition faculty member and three WIC mothers. Based on the pilot test, we made final revisions for clarity.

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We compared mothers who were breastfeeding at 2 months postpartum ~ 2 months group, N=29) with women who were not breastfeeding at 2 months postpartum (<2 months group, Nffil6). Chl-square tests were used to identify differences between the groups of mothers on each item within the 9 sections of the questionnaire.

RESULTS AND DISCUSSION Subjects Fifty-eight percent of the mothers were 25 years of age or less and 80% of them were Caucasian (Table i). Fifty-eight percent of the mothers had 12 years of education or less and 67% of them were from families with annual incomes of less than $i0,000. Thirty-slx percent of the mothers were employed when they became pregnant and 60% of them did not have previous breastfeedlng experience. TABLE i Demographic Characteristics of Mothers Who Breastfed More Than or Less Than 2 Months

Characteristic

Age (years) <25 >25 Ethnic Background Black Caucasian Other Years of Education <12 >12 Income <$i0,000 >$i0,000 Employed Father in the home Number of children breastfed (including this one) 0 1 >i ***P < 0.001

>2 months

<2 months

(Nffi29)

(Nffil6)

(N=45)

55 45

62 38

58 43

7 76 17

6 88 6

7 80 13

45 55

81 18

58 42

62 38 41 86

75 25 25 62

67 33 36 78

0 48 52***

37 44 19

13 47 40

Factors Related to Breastfeeding Duration:

Total

Demographic Characteristics

Previous breastfeeding experience (P
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N.M. LEWIS and H.M.FOX

education and income levels represented were narrower than in U.S. mothers in general. Within this group of WIC mothers factors other than education and income accounted for the differences in breastfeeding duration. Six of the mothers in the <2 months group changed their minds about breastfeeding, and left the hospital bottlefeeding. N o n e of these mothers had breastfed before although 4 of them had a preschool child. It appeared that for this group of WIC mothers previous breastfeeding experience was associated with the likelihood of following through with the decision to breastfeed as well as with the probability of breastfeeding longer than 2 months. Thirteen percent of the WIC mothers in our study did not fulfill plans to breastfeed. Knowledge,

Attitude and Decision

Reliability (a measure of whether the instrument would yield a similar score upon repeated administrations) of the knowledge section of the questionnaire using the Spearman Brown Prophecy Formula was rffi0,67. Mothers who hreastfed longer than 2 months were more likely than mothers in the <2 months group to know that feeding supplemental formula to a one month old infant might reduce breastmilk production (Table 2). Other aspects of knowledge did not differ between the two groups of mothers; however, the fewest number of correct responses were obtained on question number one. Only about one third of the mothers knew that most newborn infants need to breastfeed more often than once every 4 hours. Lack of breastmilk is given most often as the reason mothers stop breastfeeding. Both knowledge questions one and five could be related to inadequate hreastmilk production. One mechanism which maintains lactation is sucking stimulation. Therefore either infrequent breastfeeding or the feeding of supplemental formula could result in reduced sucking stimulation and reduced breastmilk production. TABLE 2 Knowledge About Breastfeeding

Question

of Mothers Who Breastfed More or Less Than 2 Months

>2 months (Nffi29)

<2 months

Total

(Nffil6) (Nffi45) % answering correctly

Most newborn infants need to 38 31 breastfeed more often than once every 4 hours.# It is usually necessary to breastfeed 79 75 more often during an infant's growth spurts. It is helpful to begin toughening the 93 94 nipples i-2 months before the baby is born. Most women can produce enough breast79 81 milk to feed their babies.# Feeding supplemental formula to a 79*** 31 1 month old baby may reduce the amount of breastmilk produced by the mother. #Question worded in opposite direction on questionnaire. ***P < 0.001

36

78

93

80 62

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TABLE 3 Attitudes Toward Breastfeeding Expressed by Mothers Who Breastfed More o r Less Than 2 Months

> 2 months (N=29)

< 2 months (N=I6)

Total (N=45)

%a Breastfeedlng is the best way to feed a baby.

I00"**

69

89

Breastmilk is better for the baby than formula.

97*

75

89

It is not easier to bottlefeed than to breastfeed.#

79***

31

62

Breastfeeding does not take more of my time than bottlefeedlng.#

52

44

49

The baby gets all the milk it needs from breastfeeding.

97***

50

80

Breastfeedlng makes me feel more caring toward the baby than bottlefeedlng.

93**

50

78

There is a difference between breast milk and formula.#

93

94

93

Breastfeeding is not more tiring than bottlefeeding.#

62

56

60

The most desirable way to feed my baby is to breastfeed.

93**

56

80

Painful nipples would not cause me to stop breastfeedlng.#

90*

56

78

apercent of mothers who agreed with the statement. #Statement worded in opposite direction on questionnaire. ***P < 0.001 **P < 0.01 *P < 0.05

Mothers who breastfed longer than 2 months responded more positively than mothers in the <2 months group to 7 of the I0 attitude statements (Table 3). When asked about persons who agreed with their decision to breastfeed, mothers who breastfed longer than 2 months had greater support from the fathers of their babies (P<0.05) than mothers in the <2 months group. These findings agree with the behavioral theory of Ajzen and Fishbein (13), which identifies the attitude toward a behavior and the subjective norm (a person's belief that important others consider the behavior desirable or undesirable) as the most important factors influencing behavior. Among all of

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the mothers surveyed, the largest supporters of the decision to breastfeed were the WIC staff; 98% of the women stated that the WIC staff agreed with their decision, 90% indicated agreement from the fathers of their babies, and 90% stated that their doctors agreed with their decision. Mothers and hospital nurses were also strong supporters (about 80% agreed with the decision to breastfeed) and employers and neighbors were the least supportive (33% and 42% agreed, respectively). Help in the Home and Information Sources Nearly two-thlrds of the mothers received daily help in their homes from the fathers of their babies within the first 2 weeks postpartum (Table 4). Women in the >2 months group received more help from best friends (P<0.05) than women in the <2 months group. When asked from whom breastfeeding information was obtained, more mothers indicated the WIC staff than any other source; eighty percent of the mothers stated that the WIC staff provided information about breastfeeding. Books about breastfeeding (58%), doctors (40%) and hospital nurses (40%) were also important sources of information. Mothers who breastfed longer than 2 months received more information from hospital nurses and from classes or films than mothers in the 2 months group (P
>2 months (N=29)

<2 months (N=I6)

Total (N=45)

Persons who provided help Husband/baby's father Mother Best friend

72 38 17*

50 12 6

64 29 13

Sources of information Doctor Books Hospital nurses WIC staff Classes, films

34 62 55** 76 17"*

50 50 13 87 --

40 58 40 80 II

**P <0.01 *P <0.05

Specific sources of help and information beyond that provided by the WIC program contributed to increased breastfeeding duration. Overall, less than 15% of these WIC mothers received help from best friends or attended classes and films and less than one-half of the mothers considered hospital nurses important information sources. Since these three specific sources of help and information appear to contribute to increased breastfeeding duration, WIC mothers might be encouraged to seek assistance from these sources. Reasons Mothers Introduced Formula or Stopped Breastfeeding "Return to work", "lack of breastmilk" and "painful nipples" were the

BREASTFEEDING DURATION

1127

three reasons mothers gave most often for either introducing formula or stopping breastfeeding (Table 5). Mothers who breastfed longer than 2 months were most likely to introduce formula when they returned to work; however, they were most likely to stop hreastfeeding due to a lack of breastmilk. In contrast, mothers in the <2 months group were most likely to introduce formula and stop breastfeedlng due to painful nipples. Although previous research has indicated that inadequate milk supply is the reason given most often by mothers when they stop breastfeedlng, this study indicates that an inadequate milk supply is more often a problem later in the hreastfeeding experience; whereas, nipple discomfort is the major problem for mothers who stop breastfeeding early. Mothers who breastfed longer than 2 months introduced formula at a mean of 66.5 days while those who breastfed less than 2 months introduced formula at a mean of 25.4 days (P<0.05). TABLE 5 Reasons Mothers Introduced Formula or Stopped Breastfeeding

Reason

Introduced Formula >2 months <2 months Total

Return to work

42***

Lack of breastmilk

16

Painful nipples

5

--

Stopped Breastfeeding >2 months <2 months Total

23

27

19

23

6

ii

40*

6

23

31"

17

--

31"*

16

***P < 0. 001 **P < 0.01 *P <0.05

Although 40% of mothers in the >2 months group stopped hreastfeeding due to an inadequate milk supply, only 16% of women in this group started bottlefeeding for this reason. It appears that mothers in the >2 months group introduced formula for reasons other than lack of hreastmilk which may have resulted in reduced breastmilk production. Lack of breastmilk then became the stated reason for stopping breastfeeding, even though the introduction of formula may have been a contributing factor. Return to work was the second most frequent reason given by mothers i n both groups as the reason for stopping hreastfeeding. When t h e m o t h e r s w e r e a s k e d w h a t would h a v e h e l p e d them m o s t t o h a v e h r e a s t f e d l o n g e r , 32% o f t h e s e m o t h e r s s t a t e d t h a t k n o w i n g how t o c o m b i n e b r e a s t f e e d i n g with work would have helped them most. At t h e same t i m e , t h e women i d e n t i f i e d employers as the least supportive of their decision to breastfeed. Education of both mothers a n d e m p l o y e r s m i g h t make i t p o s s i b l e f o r more women t o c o m b i n e b r e a s t f e e d i n g w i t h work a n d t h e r e f o r e e x t e n d t h e l e n g t h o f t i m e t h a t t h e y b r e a s t f e e d . The C o m m i t t e e on N u t r i t i o n o f t h e A m e r i c a n Academy o f P e d i a t r i c s (15) recommends that 3 or 4 month postdelivery p r e g n a n c y l e a v e s h e m a n d a t e d by g o v e r n m e n t legislation so t h a t women c a n b r e a s t f e e d during the early months postpartum without losing their Jobs. This legislation w o u l d h e h e l p f u l f o r t h e s e WIC mothers because only 21% of the mothers' employers provided paid maternity leave. This research indicates that knowledge, attitude, agreement with the

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decision to breastfeed, help in the home, access to information sources and introduction of formula during the third month may all contribute to breastfeeding duration. Future research might utilize information from this project to design education and support programs that will further meet the needs of mothers who choose to breastfeed.

ACKNOWLEDGMENTS Published as Paper Number 7895, Journal Series, Nebraska Agricultural Research Division.

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2.

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3.

Kaplowitz DD, Olson, CM. The effect of an education program on the decision to breastfeed. J. Nutr. Ed. 1983; 15(2):61-65.

4.

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6.

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7.

West CP. Factors influencing the duration of breastfeeding. Biosoclal Science 1980; 12:325-331.

8.

Bergevin Y, Dougherty C, Kramer, MB. Do infant formula samples shorten the duration of breastfeeding? Lancet, 1983; May 21: 1148.

9.

Brogan B, Fox, HM. Infant feeding practices of low-and middleincome families in Nebraska. J. Amer. Dieter. Assoc. 1984; 84(5):560563.

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I0. Relff MI, Essock-Vitale SM. Hospital influences on early infant feeding practices. Pediatrics 1985; 76:872-879. ii. Sims LS. Dietary status of lactating women. 1978; 73:147-154.

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12. Sims LS. Toward an understanding of attitude assessment in nutrition research. J. Amer. Dieter. Assoc. 1981; 78:460-466. 13. Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior, Englewood Cliffs, NJ: Prentice-Hall, Inc., 1980: 53-77.

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14. Martlnez GA, Krieger, FW. 1984 milk-feedlng patterns in the United States. Pediatrics 1985; 76:1004-1008. 15. American Academy of Pediatrics. 591-601.

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