Comparing barriers to breastfeeding success in the first month for non-overweight and overweight mothers
Breastfeeding confers multiple benefits to both mother and child including reduction of child obesity risk [
1,
2]. However poorer breastfeeding outcomes in terms of initiation, exclusivity and duration are associated with higher maternal body mass index [BMI]); [
3,
4] a characteristic independently associated with increased child obesity risk [
5]. Breastfeeding problems such as issues with latching and concerns about the infant getting enough milk have been associated with early cessation of breastfeeding, particularly during the first month postpartum [
6,
7]. However, it is not clear whether overweight and obese women are necessarily more likely to experience specific breastfeeding problems than their non-overweight counterparts and whether such problems are more likely to adversely impact on exclusive (or any) breastfeeding for overweight and obese women. Thus, understanding reasons for early cessation of exclusive or any breastfeeding particularly in high risk populations (e.g., overweight or obese mothers) is a fundamental step in designing targeted interventions that can support breastfeeding success and potentially reduce risk of childhood obesity.
Reasons for overweight or obese women to cease exclusively breastfeeding have been explored in a number of qualitative studies. Birth complications (caesarean delivery), feeling self-conscious and a perception of low milk supply were cited as reasons for early cessation of exclusive or any breastfeeding [
8,
9]. Although informative, these studies still do not clarify whether these reasons for cessation of breastfeeding are unique to, or more prevalent in, overweight or obese mothers compared to non-overweight mothers and thus can explain differential feeding outcomes.
In a study on breastfeeding outcomes of Australian women enrolled in the
New Beginnings: Healthy Mothers and Babies study, [
10] it was shown that significantly fewer overweight compared to non-overweight women were exclusively breastfeeding at hospital discharge (73% vs 86%) or at 4 months postpartum (50% vs 66%,) despite no difference in breastfeeding initiation between overweight and non-overweight women (98% vs 96%) [
11]. The aim of the present study is to extend on this previous work using data from the
New Beginnings: Healthy Mothers and Babies study to explore whether these differences in breastfeeding outcomes may be related to differences in self-reported breastfeeding problems and reasons for formula use between non-overweight and overweight women. Specifically, this study examined whether overweight and non-overweight women differed in their reporting of (i) a range of specific breastfeeding problems in the first month postpartum; (ii) use of infant formula in response to these specific breastfeeding problems, and (iii) important reasons for use of infant formula in the first month postpartum. Based on these aims it was predicted that (i) overweight women would report be more likely than non-overweight women to report breastfeeding problems in the first month and (ii) be more likely to use formula in response to these problems. The final aim (iii) was mostly exploratory however overweight women were predicted to endorse reasons for using infant formula related to insufficient milk supply and feeling self-conscious feeding in public more than non-overweight women.
Results
Characteristics of the 477 women who provided data on feeding their baby in the first month after delivery are shown in Table
1. Non-overweight and overweight women were similar on the majority of variables with a few notable exceptions. Overweight women were less likely to have a university level of education (
P = .003), more likely to be born in Australia (
P = .005) and less likely to have had a vaginal (including assisted) delivery (
P < .001) compared to non-overweight women. Overall 96.8% of the sample initiated breastfeeding and there was no difference between non-overweight and overweight women: 12 out of 315 (3.8%) non-overweight women and 3 out of 162 (1.9%) overweight women reported that they never breastfed.
Self-reported breastfeeding problems
Ninety percent of women who did initiate breastfeeding (416 out of 462) reported at least one breastfeeding problem in the first month. The average number of breastfeeding problems experienced during the first month was comparable between non-overweight (M = 2.7 ± SD = 1.6) and overweight (M = 2.6 ± SD = 1.5) women,
P = .40. There were no significant differences between the proportion of non-overweight and overweight women who experienced these problems, after adjusting for selected covariates. The proportion of women experiencing breastfeeding problems is presented in Table
2 (see
Appendix for list of “other” breastfeeding problems). The proportion of mothers who gave infant formula (either in combination with breastfeeding or alone) in response to specified breastfeeding problems is shown in Table
3. Again, there were no significant differences between non-overweight and overweight women after adjusting for selected covariates except that more overweight than non-overweight mothers reported giving formula for ‘other’ reasons (OR = 12.68, 95% CI = (1.46, 109.93,
P = .021.
Table 2
Logistic regression analyses comparing proportions of non-overweight and overweight women who reported breastfeeding problems in the first month postpartum
Sore or cracked nipples | 61 (283) | 66 (197) | 55 (86) | .027 | 0.66 (0.44, 0.99) | .046 |
Latching or attachment | 53 (245) | 56 (169) | 48 (76) | .12 | 0.73 (0.49, 1.11) | .14 |
Difficulties positioning | 37 (172) | 39 (115) | 37 (57) | .69 | 1.09 (0.71, 1.68) | .69 |
Too much milk | 26 (121) | 29 (86) | 23 (35) | .15 | 0.76 (0.47, 1.22) | .25 |
Not enough milk | 25 (114) | 23 (67) | 32 (47) | .071 | 1.48 (0.93, 2.37) | .10 |
Delay in milk coming in | 21 (99) | 20 (61) | 25 (38) | .33 | 1.22 (0.74, 2.01) | .43 |
Mastitis | 15 (71) | 16 (48) | 15 (23) | .72 | 1.08 (0.61, 1.90) | .80 |
Baby refused breast | 11 (49) | 10 (30) | 12 (19) | .48 | 1.30 (0.68, 2.45) | .43 |
Baby tongue tie | 8 (36) | 7 (22) | 9 (14) | .54 | 1.52 (0.72, 3.18) | .27 |
Other b | 9 (42) | 9 (27) | 10 (15) | .84 | 1.13 (0.57, 2.27) | .72 |
Table 3
Logistic regression analyses comparing proportions of non-overweight and overweight women who gave formula milk in response to self-reported breastfeeding problems in the first month postpartum
Sore or cracked nipples | 10 (28/283) | 11 (22/197) | 7 (6/86) | .28 | 0.47 (0.16, 1.36) | .17 |
Latching or attachment | 17 (42/245) | 14 (23/169) | 25 (19/76) | .029 | 1.64 (0.76, 3.54) | .21 |
Difficulties positioning | 12 (20/172) | 10 (11/115) | 16 (9/57) | .23 | 1.66 (0.54, 5.13) | .38 |
Too much milk | 3 (4/121) | 2 (2/86) | 6 (2/35) | – | – | – |
Not enough milk | 71 (81/114) | 70 (47/67) | 72 (34/47) | .80 | 0.72 (0.28, 1.83) | .49 |
Delay in milk coming in | 51 (50/99) | 48 (29/61) | 55 (21/38) | .46 | 1.35 (0.51, 3.62) | .55 |
Mastitis | 16 (11/71) | 17 (8/48) | 13 (3/23) | – | – | – |
Baby refused breast | 37 (18/49) | 30 (9/30) | 47 (9/19) | .22 | 1.67 (0.36, 7.77) | .52 |
Baby tongue tie | 22 (8/36) | 23 (5/22) | 21 (3/14) | – | – | – |
Other b | 33 (14/42) | 22 (6/27) | 53 (8/15) | .04 | 12.68 (1.46, 109.93) | .021 |
A greater proportion of overweight women (49%) relative to non-overweight women (32%) used formula during the first month (
P < .001). This difference remained significant after adjusting for selected covariates (adjusted OR = 1.83, 95% CI = 1.21, 2.78,
P = .004). Reasons for use of infant formula are listed in Table
4 in order of the proportion of women who agreed that the reason was important. Overweight women were more likely than non-overweight women to agree that an important reason for why they used formula in the first month was that it was just as good as breastfeeding (adjusted OR = 2.78, 95% CI = 1.31, 5.91). Non-overweight women were more likely than overweight women to agree that health professional advice was an important reason for why they used formula in the first month (adjusted OR = .40, 95% CI = .19, .85).
Table 4
Logistic regression analyses comparing proportions of non-overweight and overweight women who agreed that specific reasons were important in their decision to use infant formula in the first month postpartum
Did not have enough milk | 49 (88) | 48 (48) | 51 (40) | .73 | 1.05 (0.54, 2.16) | .88 |
Baby didn’t put on enough or lost weight | 34 (61) | 31 (31) | 38 (30) | .35 | 1.15 (0.56, 2.37) | .71 |
Health professional advice | 31 (56) | 37 (37) | 24 (19) | .064 | 0.36 (1.63, .81) | .013 |
Formula just as good as breastfeeding | 30 (54) | 22 (22) | 41 (32) | .008 | 2.28 (1.06, 4.92) | .036 |
Tried breastfeeding before and didn’t like it | 16 (29) | 15 (15) | 18 (14) | .60 | 1.06 (0.42, 2.70) | .89 |
Didn’t feel comfortable feeding in public | 16 (29) | 15 (15) | 18 (14) | .60 | 1.80 (0.71, 4.56) | .22 |
Mum sick or on medications | 15 (27) | 14 (14) | 17 (13) | .65 | 1.16 (0.45, 2.95) | .76 |
Baby sick or preterm | 14 (25) | 11 (11) | 18 (14) | .22 | 1.40 (0.54, 3.68) | .49 |
Needed someone else to feed baby | 13 (23) | 15 (15) | 10 (8) | .32 | 0.57 (0.19, 1.71) | .32 |
I wanted to leave baby for hours | 13 (23) | 15 (15) | 10 (8) | .38 | 0.58 (0.19, 1.74) | .33 |
Someone else wanted to feed baby | 11 (19) | 14 (14) | 6 (5) | .10 | 0.37 (0.11, 1.24) | .11 |
Breastfeeding too inconvenient | 7 (12) | 5 (5) | 9 (7) | .31 | 2.16 (0.60, 7.77) | .24 |
I had too many household duties | 6 (11) | 7 (7) | 5 (4) | .58 | 0.83 (0.19, 3.52) | .80 |
Wanted my body back | 4 (7) | 2 (2) | 6 (5) | – | – | – |
Wanted to go on diet | 1 (2) | 2 (2) | 0 (0) | – | – | – |
Wanted to smoke or drink alcohol | 1 (1) | 1 (1) | 0 (0) | – | – | – |
Discussion
The aim of the present study was to examine whether women who were overweight prior to pregnancy would be more likely to self-report a range of breastfeeding problems and be more likely to use formula in response to these problems during the first month postpartum, even after adjusting for covariates. A second aim was to examine whether overweight and non-overweight women differed in their reasons for use of infant formula in the first month postpartum. In this sample it was previously reported that women who entered their pregnancy overweight were more likely to have ceased exclusive breastfeeding by 4 months [
11] and here we show that overweight women were also more likely to report having used formula in the first month compared to non-overweight women. Although almost all mothers reported that they had experienced at least one of a range of specified breastfeeding problems during the first month postpartum, there were no statistically significant differences according to weight status with covariate adjustment. However, overweight mothers were more likely than non-overweight mothers to use infant formula in response to unspecified (i.e., ‘other’) breastfeeding problems and were more like to use infant formula during the first month because they believed it was just as good as breastfeeding. Self-reported problems with milk supply did not differ between weight groups but was the most commonly reported reason for use of infant formula.
No differences in prevalence of a list of specified breastfeeding problems or use of formula to manage these problems was found between weight status groups in the present study, however more overweight than non-overweight women had used infant formula in the first month, and significantly more overweight women than non-overweight women had ceased breastfeeding by the time of the survey (approximately 4 months postpartum). [
11] Over half of overweight women who reported an unspecified (‘other’) breastfeeding problem used formula in response. Further exploration of these problems (in particular thrush and baby being a ‘lazy feeder’) is needed to better understand this finding. Examination of reasons for formula use in the first month provides some insight into a possible reason for the different outcomes between weight status groups. Almost double the proportion of overweight women than non-overweight women who used infant formula in the first month agreed that an important reason for using formula was that it was as good as breastmilk. This finding is particularly concerning given that children of overweight women have higher obesity risk, [
5] which may be compounded by not breastfeeding [
1]. Further qualitative research may assist in understanding the reasoning behind these issues and how best to communicate the range of health, social and economic benefits of breastfeeding and risks associated with formula feeding to women who may be entering pregnancy overweight or obese.
An unexpected finding was that there was no difference in the proportion of overweight and non-overweight women who reported having “not enough milk” in the first month and who used infant formula in response. These findings are inconsistent with conclusions of a recent review paper [
3]. However longer-term impacts on breastfeeding (such as early cessation) were not assessed here and potentially issues with milk supply (real or perceived) may have differential impacts on breastfeeding outcomes for overweight compared to non-overweight women in the longer-term. Nevertheless, we did show that perceived insufficient milk supply was a common problem affecting over two thirds of breastfeeding mothers during the first month; with almost half of these women using infant formula in response. It is important to note that the data reflect mothers’
perceptions rather than actual adequacy of supply to meet infant energy requirements; it has been estimated that only a small minority of women (~ 5%) have physiologic insufficient milk supply [
17]. Previous work has indicated that perceptions of insufficient milk are consistently associated with low maternal self-efficacy [
18,
19]. Thus, antenatal and postnatal breastfeeding guidance and support needs to consider how concerns about milk may be ameliorated through increasing women’s breastfeeding self-efficacy.
The current findings also did not support the notion that overweight women were more likely than non-overweight women to give infant formula because they felt self-conscious about breastfeeding in public [
8]. However feeling uncomfortable feeding in public was a salient concern for a subset of non-overweight (15%) and overweight mothers (18%) who gave formula in the first month. This concern is a potential barrier to successful breastfeeding that may reflect social and cultural perspectives on the acceptability of women breastfeeding. On a societal level, this barrier to breastfeeding can be addressed through legislation and policy that both protects and promotes the rights of women to breastfeed in public places. On an individual level, health professionals could discuss with new (or expectant) mothers that their right to breastfeed in public is protected by law. It may also be helpful to discuss potential strategies to manage feeling self-conscious breastfeeding in public such as the use of dedicated breastfeeding rooms in shopping centres.
The findings described here need to be considered within the cultural context of Australia and the specific limitations of the study. Relative to other Western countries Australia has high rates of breastfeeding initiation however, the rate of initiation in this sample (96.8%) appears higher than nationally representative data (breastfeeding initiation = 87.8% based on data from a 2004–2005 health survey) [
20]. Furthermore, due to attrition between baseline and follow-up the final sample was not representative of the obstetric population of interest and was over-represented by English-speaking women who were older, married and university educated. A major limitation of the study is the reliance on self-report data which may be subject to social desirability bias. Additionally, the use of retrospective self-report measures of breastfeeding problems in the first month and pre-pregnancy weight may also be subject to recall bias. Combining underweight with normal weight and pre-obese with obese to form the “non-overweight” and “overweight” groups, respectively, was necessary for statistical reasons (i.e., power) but may have obscured differences unique to women with very low or very high BMIs. An additional limitation was that some of the analyses reported here involved a smaller subset of the sample (i.e., only those women who had used formula in the first month) and thus potential groups differences may have failed to reach statistical significance due to insufficient power.
Conclusions
The current study adds to previous literature by comparing prevalence of specific breastfeeding-related problems and reasons for use of infant formula between non-overweight and overweight women. Overall the data suggest that the experience of breastfeeding problems in the first month is very common for women regardless of pre-pregnancy weight status. Concerns about milk supply emerged as the main problem associated with use of infant formula in the first month in both weight status groups. Overweight women were more likely than non-overweight women to use infant formula because they believed that it was “as good as breastfeeding”. Further research into why overweight women in particular may hold this belief is warranted and may clarify expectations or attitudes of healthcare staff and level of support for breastfeeding that is offered to overweight compared the non-overweight women. Nevertheless, prenatal and antenatal breastfeeding support and education that addresses concerns around milk supply are likely to benefit all mothers, regardless of weight status.
Acknowledgments
Data used in this paper is from the New Beginnings Healthy Mothers and Babies Study conducted at Queensland University of Technology and the Royal Brisbane and Women’s Hospital. We would like to acknowledge co-investigators on the project: Prof Jan M. Nicholson LaTrobe University and Prof Leonie K. Callaway Royal Brisbane and Women’s Hospital and the University of Queensland.
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