Risk
Factors for Early Termination of Breast-Feeding
in First-time Mothers
.........................................................................................................................
Dr. Farideh Shiva
Associate Professor,
Deptt. of Pediatrics.
Shaheed Beheshti
Medical University Tehran, Iran
Co-Author: Mojgan Padyabm BA
Statistician
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ABSTRACT
Objective:
To identify risk factors for cessation
of breast-feeding before six months in
primiparous women.
Subjects
and Methods: Mother-infant pairs of
primiparous women were recruited for a
period of one year, with infants between
the ages of 6-24 months, visiting outpatient
clinics of a teaching hospital for routine
check-up and mild illnesses. Information
related to infant feeding patterns was
recorded on a structured questionnaire.
Data was analyzed by SPSS software. Analysis
of Variance, was used for comparison of
means and a p-value of <0.05 considered
significant.
Results:
400 mother-infant pairs were enrolled.
At 6 months of age 68.8% of babies were
predominantly breast-feeding, 14% on partial
breast-feeding, and 17.3% were bottle-fed.
Fifty-four percent of mothers, who stopped
breastfeeding by 6 months, did so in the
first 3 months. Salient risk factors identified
for premature termination of breast feeding
were: cesarean delivery, infant's low
birth weight, neonatal hospitalization
for >3 days, and infant hospitalization
between 1 and 6 months of age, (p-values=
0.001, 0.002, 0.03 and 0.001, respectively).
Insufficient milk secretion was stated
as the most common reason for premature
cessation of breast-feeding.
Conclusion:
Identification of risk factors for early
termination of breast-feeding is necessary
before developing strategies to improve
duration of nursing in first-time mothers.
Key words:
Breast-feeding, primipara, infant feeding.
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Breast-feeding has been widely
accepted as the optimal method of nutrition
for young infants. Apart from psychological,
economical, and nutritional benefits, there
is conclusive evidence that breastfeeding confers
significant protection against morbidity and
mortality associated with infectious diseases
in the first year of life1-4. Literature
search reveals that although the majority of
mothers start breast feeding, a large percentage
discontinue during the early months2, 5-10.
Several factors are associated with early cessation
of breast-feeding and differ in different parts
of the world. Numerous studies have researched
this issue in multi-parous mothers, mothers
of twins, and of low-birth weight infants, however
relatively few reports have focused on feeding
patterns in primiparous women7-12.
First time mothers need extra support since
it has been shown that a successful breast-feeding
experience with the first child inclines the
mother to repeat that experience with later
off-spring9,13,14. In view of the
above reasons we have limited our study to risk-factors
involved with early termination of breast-feeding
in mothers rearing their first infants in the
capital city of a Middle-Eastern country. We
did not find a similar report from this region
of the world in our literature search.
Mother-infant pairs were
recruited for this study from all infants brought
to the outpatient clinics of a teaching hospital
for vaccination, routine checkups and minor
childhood ailments during the study period of
one year. Criteria for enrollment were specified
as follows: all women were first-time mothers,
all infants were between the ages of 6 to twenty-four
months, and were normal with no congenital anomalies
or chronic diseases that would interfere with
breast-feeding. A structured questionnaire was
utilized by trained personnel to collect and
document relevant data about the social and
economic demographics together with information
about feeding patterns and relatable peri- and
postnatal factors.
WHO classification was used
to define the method of feeding: Predominant
breastfeeding was defined as an infant being
fed breast milk along with some other non-milk
fluids, for example water or "sugar water",
but not animal milk or infant formula. Infants
who were offered both breast milk and animal
milk or infant formula were labeled as "partially
breastfed", when no breast milk was given
the infant was "bottle fed". Subjects
were classified into 3 groups; group 1 comprised
mothers in whom predominant breast-feeding was
maintained at least for the first six months
of life; in group 2 infants had started partial
breastfeeding, receiving both breast and bottle
milk during the same period, and in group 3
breast-feeding was discontinued before the end
of 6 months. Particulars of the study subjects
were documented; we utilized SPSS software for
analysis and comparison of variables between
the three groups. Analysis of variance, (ANOVA),
was done for comparison of means and a p-value
<0.05 was considered significant.
Data was documented from a total of 400 mother-infant
pairs, who satisfied the criteria for inclusion
in the study. Four mothers had delivered twins,
the rest were singletons. 315 mothers were housewives
and 85, (about 27%), were working mothers.
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Table
1: Comparison
of variables in three groups of infants
[with predominant breast-feeding (1), partial
breast-feeding (2), and bottle-feeding (3),
at 6 months] |
| No |
Variable |
Group
1
No = 275 |
Group
2
No = 56 |
Group 3
No = 69 |
p-value |
| 1 |
Birth
wt <2.5 kg (%) |
3.6 |
16.1 |
13 |
0.002 |
|
2 |
Cesarean
Delivery (%) |
55.6 |
83.9 |
62.3 |
0.001 |
| 3 |
Male
sex (%) |
50.5 |
57.1 |
58 |
0.4 |
| 4 |
Neonatal
hospitalization, positive (%) |
18.9 |
26.8 |
27.5 |
0.01 |
| 5 |
Neonatal
hospitalization for>3days |
8.4 |
10.7 |
17.4 |
BTWgrps1&3
=0.03 |
| 6 |
Infant
hospitalization between 1-6 m |
3.6 |
12.5 |
27.5 |
0.001 |
| 7 |
Father
smoker (%) |
23.2 |
20 |
30.3 |
0.3 |
| 8 |
Mother’s
age, yrs. mean (SD) |
25.18±4.26 |
26.11±4.73 |
24.54±5.7 |
0.16 |
| 9 |
Working
mother (%) |
20 |
37.5 |
13 |
0.03 |
| 10 |
Mother’s
education, yrs. mean (SD) |
11.81±4 |
11.75±4.5 |
10.99±3.5 |
0.3 |
| 11 |
Father’s
education, yrs. mean (SD) |
11.91±4 |
11.91±4.2 |
11.22±3.9 |
0.43 |
| 12 |
Child
care attendance (%) Total=395 |
1.8 |
5.4 |
3 |
0.3 |
Mean age of infants was 15.2 months. At 6 months
of age 68.8% were on predominant breast-feeding,
(group1), 14% on partial breast-feeding, (group2),
and 17.3% were being bottle-fed (group 3). Out
of the 69 mothers who discontinued breastfeeding
before 6 months, 38, (54%), had done so before
their infants were 3 months old. Out of the
other 31, 11 discontinued at 3 months, 9 at
four months and another 11 at 5 months of age.
Specifics of mothers and babies in the three
groups are compared in Table1. In addition,
7 mothers discontinued breast feeding at 6 months,
2 at 7 months and another 7 at 9 months with
1 mother stopping at 10 months, so 86 mothers,
i.e. 21.5% of our sample of 400 primiparas,
had stopped breast-feeding before their infants
were one year old. All infants who were bottle-fed
before 6 months, were given formula and none
was started on pasteurized cows' milk before
the age of 6 months. Out of the 124 infants
for whom formula was introduced during the first
6 months, it was started at birth in 45, (36%),
(Fig.1).
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Fig 1. Formula introducing age
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Reasons stated for early discontinuation of
breast-feeding are given in Table 2.
|
Table 2: Reasons for early discontinuation
of breast-feeding, (no = 69) |
|
No |
Reasons for breast-feeding termination |
No |
% |
|
1 |
Insufficient milk |
33 |
47.8 |
|
2 |
Baby hospitalization |
13 |
18.8 |
|
3 |
Baby rejection |
7 |
10.1 |
|
4 |
Mothers job |
7 |
10.1 |
|
5 |
Maternal illness |
2 |
2.9 |
|
6 |
Twins |
4 |
5.8 |
|
7 |
Reason not clear |
3 |
4.3 |
First-time mothers make-up
a unique group needing special continuous support
with infant care15. Recent studies
show that the improved rates of breastfeeding
are a result of the intervention of health professionals
during the perinatal period, and, women having
their first child benefit most from educational
activities aimed at promoting breastfeeding16.
In this study we have
attempted to assess current breastfeeding practices
in primiparous mothers using standardized breastfeeding
indicators developed by the World Health Organization
and to detect the impact of risk factors for
discontinuation of breastfeeding. Knowledge
of predictive factors would identify mothers
who need particular attention of healthcare
personnel.
Since giving water or
"sugar water" to the infants to alleviate
presumed thirst or relieve "abdominal colic"
is the norm in this part of world, almost all
infants in our study had received these fluids
in addition to breast milk; thus, exclusive
breast feeding, as defined by The World Health
Organization, i.e. an infant being fed only
breast milk and nothing else, not even water,
with the exception of vitamin supplements and
prescribed medicines, was not relevant in our
subjects17. Furthermore, it has been
shown that indicators based on maternal recall
for exclusive breast feeding may be inadequate
and even misleading; studies conducted rigorously
report many infants who are predominantly breastfed
have been classified as exclusively breastfed
during demographic surveys18, 19.
Therefore, we have used the term "predominant"
breast feeding, which is the recommended WHO
terminology for such infants, although some
babies classified as being predominantly breast-fed
may have been exclusively breast-fed.
Our rates for predominant
breast-feeding at 6 months of age are higher
than several comparable surveys2,5,20,21.
In our study, there was
no significant difference in mothers' age or
level of education between the three groups
with different modes of feeding, which is in
contrast to some reports5,8,10,22,23.
Although Lathouwer et al reported that there
were no differences between the group whose
babies were born by caesarean section and those
who had vaginal deliveries, in our subjects
a significantly higher percentage of mothers
with caesarean sections, as compared to normal
deliveries, discontinued breast-feeding before
6 months (p= 0.001)9. Other factors
negatively associated with prolonged duration
of breast-feeding were infant's low birth weight
and neonatal hospitalization for more than 3
days (p= 0.002, and 0.03, respectively). Hospitalization
of the newborn for 3 days or less did not result
in early cessation of breast-feeding. Infant
hospitalization after the neonatal period had
an adverse effect on continuation of breast-feeding
beyond 6 months (p= 0,001). We did not find
any reports about the association of neonatal
or early infant hospitalization with duration
of breast feeding in first-time mothers. In
our subjects, all mothers were non-smokers and
fathers' smoking habits or level of education
had no effect on his spouse's feedingbehavior.
We have scrutinized mothers'
main reasons for stopping breast-feeding, (Table
2). Almost 50% of the mothers who ceased breast-feeding
their infants did so because they thought that
their milk was not enough to satisfy the baby,
so they would either supplement or even replace
it with formula. This fact has been recorded
by other observers as well, although in one
study it was noticed that most commonly, women
did not breastfeed because they "preferred
to bottle feed"12,24.
Infant hospitalization
was quoted as the second most common reason
for termination of breast feeding in our study,
emphasizing the need for breast-feeding support
from trained hospital staff. Although mothers'
employment was cited as the reason for breast-feeding
discontinuation in about 10% of cases, comparison
between the three groups revealed an interesting
pattern which was unlike other studies.10 Working
mothers tended to have a higher rate of feeding
their babies with both bottle and breast, as
compared to the other two groups, (p= 0.03).
Reason for this discrepancy needs to be explored.
Most probably this group of mothers would have
breast-fed their infants if they did not have
to go to work. While Taylor et al report "Physical
or medical problem" in 14.9% of women who
did not breastfeed and 26.9% of women who had
stopped breastfeeding, making it the second
most common reason for not breastfeeding, in
our study only 2 mothers, named maternal illness
as the cause for discontinuing to nurse their
babies12.
Out of the mothers who
stopped nursing before 6 months, more than half
discontinued breast-feeding before their off-spring
were 3 months old, emphasizing the necessity
for support during early months of infant rearing
to help the first time mother acquire expertise
and confidence with breast-feeding.
Figure 1 illustrates,
that most women who started the bottle in young
infants did so either shortly after birth, or
around 4 months of age. These findings underscore
the need for intervention at two critical periods,
immediate postnatal, and again when the infant
has grown and the mother feels that breast milk
may not be enough to satisfy the baby.
In our study, caesarean
section, low birth weight, neonatal hospitalization
for more than 3 days, infant hospitalization
between 1 and 6 months of age, and perceived
insufficient milk secretion were identified
as leading risk factors for premature termination
of breast feeding. In addition, early postnatal
weeks were critical, since the highest percentage
of first time mothers who introduced the formula
or who stopped to breastfeed, did so during
this period.
Findings in this study
reveal some similarities with reports from other
parts of the world in patterns of infant feeding,
and also unveil some important differences in
associated factors, and in reasons for early
discontinuation of breast feeding. These results
reiterate the fact that interventions that seek
to increase breastfeeding should focus on women
who are at high risk of early discontinuation
and provide educational support within the framework
of local customs.
- Arifeen S, Black
RE, Antelman G, Baqui A, Caulfield L,
Becker S.: Exclusive breastfeeding reduces
acute respiratory infection and diarrhea
deaths among infants in Dhaka slums. Pediatrics.
2001 Oct;108(4):E67.
- Oddy WH, Sly PD, de Klerk NH, Landau
LI, Kendall GE, Holt PG and Stanley FJ:
Breast feeding and respiratory morbidity
in infancy: a birth cohort study. Arch
Dis Child 2003;88:224-228.
- Bahl R, Frost C, Kirkwood BR, Edmond
K, Martines J, Bhandari N, Arthur P: Infant
feeding patterns and risks of death and
hospitalization in the first half of infancy:
multicentre cohort study. Bull World Health
Organ vol.83 no.6 Genebra June 2005.
- Maria Beatriz Reinert do Nascimento;
Hugo Issler: Breastfeeding: making the
difference in the development, health
and nutrition of term and preterm newborns.
Rev. Hosp. Clin. vol.58 no.1 São
Paulo 2003.
- Engebretsen IM, Wamani H, Karamagi
C, Semiyaga N, Tumwine J, Tylleskär
T: Low adherence to exclusive breastfeeding
in Eastern Uganda: A community-based cross-sectional
study comparing dietary recall since birth
with 24-hour recall. BMC Pediatr. 2007
Mar 1;7:10.
- Haiek LN, Gauthier DL, Brosseau D,
Rocheleau L: Understanding breastfeeding
behavior: rates and shifts in patterns
in Quebec. J Hum Lact. 2007 Feb;23(1):24-31.
- Venancio SI, Monteiro CA: Individual
and contextual determinants of exclusive
breast-feeding in Sao Paulo, Brazil: a
multilevel analysis. Public Health Nutr.
2006 Feb; 9(1): 40-6.
- Ego A, Dubos JP, Djavadzadeh-Amini
M, Depinoy MP, Louyot J, Codaccioni X.:
Premature discontinuation of breastfeeding.
Arch Pediatr. 2003 Jan;10(1):11-8.
- De Lathouwer S, Lionet C, Lansac J,
Body G, Perrotin F.: Predictive factors
of early cessation of breastfeeding. A
prospective study in a university hospital.
Eur J Obstet Gynecol Reprod Biol. 2004
Dec 1;117(2):169-73.
- Forster DA, McLachlan HL, Lumley J.:
Factors associated with breastfeeding
at six months postpartum in a group of
Australian women. Int Breastfeed J. 2006
Oct 12;1:18.
- Dodgson JE, Tarrant M, Fong DY, Peng
XH, Hui WH: Breastfeeding patterns of
primiparous mothers in Hong Kong. Birth.
2003 Sep;30(3):195-202.
- Taylor JS, Risica PM, Cabral HJ.:
Why primiparous mothers do not breastfeed
in the United States: a national survey.
Acta Paediatr. 2003 Nov;92(11):1308-13.
- Kronborg H, Vaeth M: The influence
of psychosocial factors on the duration
of breastfeeding. Scand J Public Health.
2004;32(3):210-6.
- Shiva F, Nasiri M.: A study of feeding
patterns in young infants. J Trop Pediatr.
2003 Apr;49(2):89-92.
- Moore ER, Coty MB: Prenatal and postpartum
focus groups with primiparas: breastfeeding
attitudes, support, barriers, self-efficacy,
and intention. J Pediatr Health Care.
2006 Jan-Feb;20(1):35-46.
- Maria LF Vieira, João LC Pinto
e Silva, Antônio A Barros Filho:
Are breastfeeding and complementary feeding
of children of adolescent mothers different
from those of adult mothers? J Pediatr
(Rio J) 2003;79(4):317-24.
- World Health Organization, Division
of Child Health and Development. Indicators
for assessing breastfeeding practice:
reprinted report of an informal meeting
11-12 June, 1991. Geneva: WHO; 1991.
- Bland RM, Rollins NC, Solarsh G, Van
Den Broeck J, Coovadia HM: Maternal recall
of exclusive breast feeding duration.
Arch Dis Child 2003;88:778-783.
- Aarts C, Kylberg E, Hornell A, Hofvander
Y, Gebre-Medhin M, Greiner T: How exclusive
is exclusive breastfeeding? A comparison
of data since birth with current status
data. Int J Epidemiology 2000;29:1041-1046.
- Batal M, Boulghourjian C, Abdallah
A, Afifi R: Breast-feeding and feeding
practices of infants in a developing country:
a national survey in Lebanon. Public Health
Nutr. 2006 May;9(3):313-9.
- J Sikorski, F Boyd, C Dezateux, A
Wade, and J Rowe: Prevalence of breastfeeding
at four months in general practices in
south London. Br J Gen Pract. 2001 June;
51(467): 445-450.
- Ekstrom A, Widstrom AM, Nissen E:
Duration of breastfeeding in Swedish primiparous
and multiparous women. J Hum Lact. 2003
May;19(2):172-8.
- Lande B, Andersen LF, Baerug A, Trygg
KU, Lund-Larsen K, Veierod MB, Bjorneboe
GE.: Infant feeding practices and associated
factors in the first six months of life:
the Norwegian infant nutrition survey.
Acta Paediatr. 2003;92(2):152-61.
- Sacco LM, Caulfield LE, Gittelsohn
J, Martínez H: The Conceptualization
of Perceived Insufficient Milk Among Mexican
Mothers. Journal of Human Lactation, 2006
Vol. 22, No. 3, 277-286.
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