Mothers’ postpartum concerns predict failure to meet breastfeeding goals



First-time mothers’ widely reported breastfeeding problems or concerns predicted the likelihood that they would stop breastfeeding or give their infants formula within the first 2 months after giving birth, a study showed.

The 92% of mothers with any concerns at 3 days post partum were nine times more likely to stop breastfeeding before 2 months post partum, primarily because of infant feeding difficulties or concerns about milk quantity.

"Breastfeeding problems were a nearly universal experience in this cohort of first-time mothers," reported Erin A. Wagner of Cincinnati Children’s Hospital Medical Center and her colleagues in Pediatrics (2013 Sept. 23 [doi:10.1542/peds.2013-0724]). The concerns were "highly prevalent, persistent, and associated with not meeting breastfeeding goals," the investigators said.

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The 92% of mothers with any concerns at 3 days post partum were nine times more likely to stop breastfeeding before 2 months post partum.

Meanwhile, the lack of association between early breastfeeding cessation and prenatal breastfeeding concerns (as opposed to postpartum concerns) implies that the women’s failure to meet breastfeeding goals "do not appear to be simply the ‘self-fulfillment’ of anticipated problems," the researchers added.

The investigators conducted 2,946 interviews, starting with 532 primiparous expectant mothers, about half of whom (49%) were younger than 25. Just over a quarter (27%) were older than 30. Approximately half had private insurance and half had public insurance.

Ms. Wagner and her colleagues then followed up post partum with 447 of the participants, beginning within 24 hours of delivery and conducting additional interviews on days 3, 7, 14, 30, and 60 days post partum. After those lost to follow-up, 418 mothers comprised the final sample of participants with infant feeding information at 2 months post partum.

From that final sample, 47% of the 354 mothers who intended to feed their babies only breast milk for at least 2 months ended up feeding any formula to their child between 30 and 60 days post partum. Among the 406 mothers who intended to breastfeed for at least 2 months, 21% stopped breastfeeding by 60 days post partum.

To qualify the women’s breastfeeding concerns, the researchers categorized the women’s 4,179 open-ended answers involving concerns into nine main categories with a total of 49 subcategories. The most prevalent concern on delivery day was infant feeding difficulties, reported by 44% of the mothers. Three days post partum, 54% of mothers reported infant feeding difficulties, 42% reported breastfeeding pain, and 42% reported concerns about milk quantity. Infant feeding difficulties included latch problems, sleepy infants, nipple confusion or infant feeding refusal, fussy or frustrated infants, poor infant feeding, and problems with the baby’s length or frequency of breastfeeding sessions.

After taking into account women’s education and their breastfeeding intentions in prenatal interviews, the researchers identified two breastfeeding concerns that contributed most to early cessation of breastfeeding. Thirty-two percent of those who stopped were estimated to have continued if not for infant feeding difficulties reported 7 days post partum (population attributable risk (PAR) = 32%).

"Most notably, the predominant subcategories at day 7 contributing to stopping breastfeeding under the infant feeding difficulty main category were ‘fussy or frustrated at the breast,’ ‘infant refusing to breastfeed/nipple confusion,’ and ‘problems with latch,’ " the researchers wrote. The second highest PAR was 23% for reporting concerns about milk quantity 2 weeks post partum. Accounting for the women’s age, ethnicity, health insurance status, or prenatal perceptions about breastfeeding ability did not significantly alter these findings.

Although 79% of the mothers reported at least one breastfeeding concern during prenatal interviews, the peak of concerns occurred on the third postpartum day, with 92% of women reporting at least one concern. The peak for reporting pain while breastfeeding occurred 1 week post partum with 47% of mothers.

Concerns about breastfeeding during the first week post partum appeared to contribute the most toward women’s using formula or stopping breastfeeding by 2 months post partum. Mothers reporting any breastfeeding concerns at 3 days after giving birth were three times more likely to feed their child formula between 1 and 2 months post partum (ARR = 3.3; 95% CI, 1.7-15.0). They were nine times more likely to stop breastfeeding within 60 days post partum (ARR 9.2, 95% CI, 3.0 to infinity).

The researchers identified 34 outliers who reported no breastfeeding concerns three days post partum; all but one of these women continued breastfeeding past 60 days post partum. These women were more likely to be younger than 30, to be Hispanic, to have confidence prenatally of their ability to breastfeed, to have an unmedicated vaginal delivery, and to report having strong breastfeeding support.


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