Obese Mothers have Lower Odds of Experiencing Pro-breastfeeding Hospital Practices than Mothers of Normal Weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024)

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Maternal metabolic conditions as predictors of breastfeeding outcomes: Insights from an Australian cohort study

INTRODUCTION

Breastfeeding represents an important opportunity to optimize health outcomes for both mother and infant, particularly in the context of maternal metabolic conditions such as diabetes and polycystic ovary syndrome. However, evidence suggests that women affected by these conditions breastfeed at reduced rates and durations. Our aim was to use the large, prospective, community-based Australian Longitudinal Study on Women's Health (ALSWH) to conduct an in-depth exploratory analysis of breastfeeding outcomes in Australian women affected by key maternal metabolic conditions.

MATERIAL AND METHODS

Data from 12 920 pregnancies to 5605 women from the 1973-1978 birth cohort of the ALSWH were examined. Univariable and multivariable regression using generalized estimating equation models were applied to assess breastfeeding initiation and duration (outcome measures) in relation to key self-reported maternal metabolic diagnoses (pre-gestational type 1 and type 2 diabetes, gestational diabetes, and polycystic ovary syndrome; main explanatory variables). Key sociodemographic and clinical covariates were also considered.

RESULTS

Results showed no significant association between specific maternal metabolic diagnoses (pre-gestational or gestational diabetes, or polycystic ovary syndrome) and breastfeeding outcomes. However, maternal body mass index emerged as a key predictor of suboptimal breastfeeding outcomes. Pregnancies affected by maternal obesity were associated with a 2.1-fold increase in the odds of not initiating breastfeeding, after adjusting for other key variables (95% CI 1.67 to 2.60, p < 0.01). Maternal overweight and obesity were, respectively, associated with an adjusted 1.4-fold (95% CI 1.20 to 1.55, p < 0.01) and 1.8-fold increase (95% CI 1.60 to 2.10, p < 0.01) in the odds of a breastfeeding duration less than 6 months.

CONCLUSIONS

Maternal obesity, rather than any specific maternal metabolic condition, appears to be a key predictor of breastfeeding outcomes in Australian women.

A longitudinal investigation of breastfeeding planning, initiation, and duration among individuals with pre-pregnancy overweight or obesity

Individuals with a body mass index (BMI)≥25 kg/m2 are less likely to initiate and continue breastfeeding than are those with BMIs<25. Given the intergenerational health benefits of breastfeeding, it is important to understand breastfeeding behaviors and their correlates among individuals with BMIs≥25. Thus, in an observational cohort with BMI≥25 (N = 237), we aimed to characterize longitudinal relationships among breastfeeding planning, initiation, and duration and their sociodemographic/clinical correlates and determine if pre-pregnancy BMI predicts breastfeeding planning, initiation, and duration. Breastfeeding behaviors, weight/BMI, and sociodemographic/clinical characteristics were assessed in early, mid, and late pregnancy, and at six-months postpartum. Most participants planned to (84%) and initiated (81%) breastfeeding, of which 37% breastfed for ≥6 months. Participants who were married, first-time parents, higher in education/income, and had never smoked tobacco were more likely to plan, initiate, and achieve ≥6 months of breastfeeding. Higher pre-pregnancy BMI was not associated with breastfeeding planning or initiation but was associated with lower adjusted odds of breastfeeding for ≥6 months relative to <6 months. Findings suggest that support aimed at extending breastfeeding among those with elevated pre-pregnancy BMI may be warranted. Future interventions should also address sociodemographic and clinical inequities in breastfeeding.

The mediation effect of breastfeeding duration on the relationship between maternal preconception BMI and childhood nutritional risk

BACKGROUND

Higher maternal preconception body mass index (BMI) is associated with lower breastfeeding duration, which may contribute to the development of poor child eating behaviours and dietary intake patterns (components of nutritional risk). A higher maternal preconception BMI has been found to be associated with higher child nutritional risk. This study aimed to determine whether breastfeeding duration mediated the association between maternal preconception BMI and child nutritional risk.

METHODS

In this longitudinal cohort study, children ages 18 months to 5 years were recruited from The Applied Research Group for Kids (TARGet Kids!) in Canada. The primary outcome was child nutritional risk, using The NutriSTEP®, a validated, parent-reported questionnaire. Statistical mediation analysis was performed to assess whether total duration of any breastfeeding mediated the association between maternal preconception BMI and child nutritional risk.

RESULTS

This study included 4733 children with 8611 NutriSTEP® observations. The mean (SD) maternal preconception BMI was 23.6 (4.4) and the mean (SD) breastfeeding duration was 12.4 (8.0) months. Each 1-unit higher maternal preconception BMI was associated with a 0.081 unit higher nutritional risk (95% CI (0.051, 0.112); p < 0.001) (total effect), where 0.011(95% CI (0.006, 0.016); p < 0.001) of that total effect or 13.18% (95% CI: 7.13, 21.25) was mediated through breastfeeding duration.

CONCLUSION

Total breastfeeding duration showed to mediate part of the association between maternal preconception BMI and child nutritional risk. Interventions to support breastfeeding in those with higher maternal preconception BMI should be evaluated for their potential effect in reducing nutritional risk in young children.

Association Between Prepregnancy Body Mass Index and Newborn Breastfeeding Initiation

Background: The benefits of breastfeeding a newborn are well documented. Identification of mothers who do not initiate breastfeeding is essential for developing initiatives to improve breastfeeding initiation. Methods: The study used data from the National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS) birth certificate data (2014-2021) to identifying 15,599,930 in-hospital deliveries. We used multivariable logistic regression to assess the association between seven body mass index (BMI) categories and initiation of breastfeeding before hospital discharge. Prepregnancy BMI (weight in kilograms/height in meters2) included underweight (<18.5), healthy weight (18.5-24.9), overweight (25.0-29.9), Obesity Class I (30-34.9), Obesity Class II (35-39.9), and Obesity Class III (40-49.9) classes, in addition to a class newly identified in the literature as super obese (≥50), hereafter "Obesity Class IV." "This project was deemed non-human subjects research." Results: Approximately, 83% of mothers initiated breastfeeding before hospital discharge. Compared to mothers with a healthy prepregnancy BMI, the likelihood of breastfeeding initiation before hospital discharge decreased with increasing prepregnancy BMI. Specifically, we found reduced likelihood of initiation for mothers who were overweight (adjusted odds ratio [aOR]: 0.952, 95% confidence interval [CI]: [0.948-0.955]), Obesity Class I (aOR: 0.884, 95% CI: [0.880-0.888]), Obesity Class II (aOR: 0.816, 95% CI: [0.811-0.820]), Obesity Class III (aOR: 0.750, 95% CI: [0.745-0.755]), and Obesity Class IV (aOR 0.672: 95% CI: [0.662-0.683]). Conclusions: Mothers with prepregnancy BMI above the healthy range had reduced likelihood of initiating breastfeeding prior hospital discharge. This information should be used to develop and initiate interventions for mothers who wish to breastfeed but may need additional lactation assistance support.

Obesity and Prenatal Intention as Predictors of Meeting Breastfeeding Recommendations in an Urban Birth Cohort

Background and Objectives: Few U.S. women meet the public health recommendations to exclusively breastfeed for 6 months and continue breastfeeding for at least 1-2 years. We compared prenatally collected demographic, health, and breastfeeding support/intention variables to examine how these factors intersect to predict meeting breastfeeding recommendations. Methods: PREVAIL, a CDC-funded birth cohort in Cincinnati, OH, was approved by the IRB at CDC, Cincinnati Children's Hospital, and the hospitals where enrollment (third trimester, 2017-2018) occurred. The prenatal questionnaire captured sociodemographics, pre-pregnancy weight and height, breastfeeding environment, and breastfeeding intention, while health factors were obtained from obstetrical records. Body mass index (BMI) (kg/m2) was categorized as healthy (18.5-24.9), overweight (25-29.9), obesity 1 (30-34.9), and obesity 2+ (≥35). Mothers self-reported date of exclusive and any breastfeeding cessation through quarterly postnatal questionnaires. Random forest was used for variable selection, cross-validated in multivariable logistic models. Results: Analysis included n = 237 mothers with BMI ≥18.5. Random forest identified BMI category, prenatal intention, and insurance type as the most important predictors of meeting breastfeeding recommendations. The resulting logistic models explained >40% of the variance with an area under the curve of ≥0.89 for both recommendations. More than 73% of the risk of not meeting breastfeeding recommendations was attributable to having an elevated BMI or lacking strong breastfeeding intention. Conclusions: In PREVAIL, maternal BMI and prenatal intention explained most risks of not meeting breastfeeding exclusivity and duration recommendations. Our findings suggest efforts to improve breastfeeding exclusivity and duration should focus on strengthening prenatal breastfeeding intention and identifying effective interventions for supporting breastfeeding among mothers with higher BMI.

Utility of the capability, opportunity, and motivation behaviour (COM-B) model in explaining the negative association between pre-pregnancy body mass index and exclusive breastfeeding at six weeks postpartum

The mechanisms underlying the negative associations between pre-pregnancy body mass index (BMI) and exclusive breastfeeding remain poorly understood. Thus, the study aimed to determine whether the negative associations between high pre-pregnancy BMI and exclusive breastfeeding at six weeks postpartum are mediated by components of the capability, opportunity, and motivation behaviour (COM-B) model. In this prospective observational study, we assigned 360 primiparous women to a pre-pregnancy overweight/obese group (n = 180) and a normal-BMI group (n = 180). A structural equation model was designed to study how capabilities (onset of lactogenesis II, perceived milk supply, breastfeeding knowledge, and postpartum depression), opportunities (pro-breastfeeding hospital practices, social influence, social support), and motivations (breastfeeding intention, breastfeeding self-efficacy, and attitudes towards breastfeeding) affected exclusive breastfeeding at six weeks postpartum in groups of women with different pre-pregnancy BMIs. In all, 342 participants (95.0%) possessed complete data. Women with high pre-pregnancy BMI were less likely to exclusively breastfeed at six weeks postpartum than women with a normal BMI were. We observed a significant negative direct effect of high pre-pregnancy BMI on exclusive breastfeeding at six weeks postpartum and a significantly negative indirect effect of high pre-pregnancy BMI via the explanatory mediating variables of capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy) on exclusive breastfeeding at six weeks postpartum. Our findings support certain capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy), partially explaining the negative association between high pre-pregnancy BMI and exclusive breastfeeding outcome. We suggest that interventions aimed at promoting exclusive breastfeeding among women with high pre-pregnancy BMI should address the capacity and motivation factors specific to this population.

Women's Reproductive Milestones and Cardiovascular Disease Risk: A Review of Reports and Opportunities From the CARDIA Study

In 1985 to 1986, the CARDIA (Coronary Artery Risk Development in Young Adults) study enrolled 5115 Black or White participants, including 2788 women, aged 18 to 30 years. Over the following 35 years, the CARDIA study amassed extensive longitudinal data on women's reproductive milestones, spanning menarche to menopause. Although not initially conceived as a study of women's health, >75 CARDIA study publications address relationships between reproductive factors and events with cardiovascular and metabolic risk factors, subclinical and clinical cardiovascular disease, and social determinants of health. The CARDIA study was one of the earliest population-based reports to note Black-White differences in age at menarche and associations with cardiovascular risk factors. Adverse pregnancy outcomes, particularly gestational diabetes and preterm birth, have been assessed along with postpartum behaviors, such as lactation. Existing studies have examined risk factors for adverse pregnancy outcomes and lactation, as well as their relationship to future cardiovascular and metabolic risk factors, diagnoses, and subclinical atherosclerosis. Ancillary studies examining components of polycystic ovary syndrome and ovarian biomarkers, such as anti-Müllerian hormone, have facilitated examination of reproductive health in a population-based cohort of young adult women. As the cohort transitioned through menopause, examination of the importance of premenopausal cardiovascular risk factors along with menopause has improved our understanding of shared mechanisms. The cohort is now aged in the 50s to mid-60s, and women will begin to experience a greater number of cardiovascular events as well as other conditions, such as cognitive impairment. Thus, in the next decade, the CARDIA study will provide a unique resource for understanding how the women's reproductive life course epidemiology informs cardiovascular risk, as well as reproductive and chronological aging.

Exploring Successful Breastfeeding Behaviors Among Women Who Have High Body Mass Indices

BACKGROUND

Women with high body mass indices are at risk of lower breastfeeding rates but the drivers of successful breastfeeding in this population are unclear.

RESEARCH AIM

We aimed to (a) explore the barriers and enablers to breastfeeding among women with high body mass indices and (b) map specific behaviors suitable for intervention across the antenatal to postpartum periods.

METHODS

This was a prospective, cross-sectional qualitative study. We conducted semi-structured interviews with women with high body mass indices who successfully breastfed for 6 months or more (n =20), partners (n = 22), and healthcare professionals (n =19) in Ireland during 2018. Interviews were audio recorded, and transcribed verbatim. Data were inductively coded using reflexive thematic analysis and deductively mapped within the Capability, Opportunity, Motivation-Behavior model.

RESULTS

The three themes developed were knowledge, support, and self-efficacy. Knowledge supported a participant's psychological and physical capability to engage in breastfeeding. Support was related to the social and physical opportunity to enable performance of breastfeeding behaviors. Self-efficacy influenced reflective and automatic motivation to perform breastfeeding behaviors. A multifactorial intervention design is needed to support successful breastfeeding.

CONCLUSION

The barriers and enablers identified for participants with high body mass indices were similar to those for the broader population; however, the physicality and associated social bias of high body mass indices mean that additional support is warranted. Antenatal and postpartum breastfeeding services need a multifaceted, inclusive, and high-quality program to provide the necessary support to women with higher body mass indices.

Preconception care utilization and associated factors among reproductive age women in Mizan-Aman town, Bench Sheko zone, Southwest Ethiopia, 2020. A content analysis

Background

Preconception care is highly important in reducing a number of adverse pregnancy outcomes and helps to improve maternal health. Preconception care optimizes women’s health and improves pregnancy outcomes. It is a cost-effective first-line preventive strategy for birth defects. However, preconception care utilization in Ethiopia was very low. Studies on these issues are limited in Ethiopia in general and in Mizan-Aman town in particular.

Objective

To assess preconception care utilization and associated factors among reproductive age women in Mizan-Aman town, Bench-Sheko Zone, Southwest Ethiopia.

Methods

A community based cross-sectional study design was employed from April 16 to May 26, 2020 in Mizan-Aman town. The total study participants were 624 reproductive age women. Data were collected by using pre-tested interviewer administered questionnaires and entered into Epi-data version 3.1 then exported to STATA version 14 and analyzed accordingly. Univeriate and Bivariable analysis was done by analysis of variance (ANOVA) and independent t-test. Multivariable statistical analysis using generalized linear regression model (GLM) approach was used to classify factors of preconception care utilization. Since our response variable is measured in terms of count variable, we used a Poisson regression model with a log link function. Finally, Statistical significance between dependent and independent variables were assessed by odds ratios and 95% confidence intervals.

Results

Overall, 28.6% of the women receipt atleast one item of preconception care while only 1.5% were taken the whole recommended components of preconception care services. The most common item received in the study area was taking micronutrient supplementation (18.5%). Age of women, educational status, husbands educational status, husbands occupation, wealth status, distance from the health facility, waiting time to get services, planning to pregnancy, age at first pregnancy, previous ANC use, Previous PNC use, adverse pregnancy experience, women’s knowledge of preconception care, and attitude on preconception care were determinants of preconception service utilization.

Conclusions

Preconception care component utilization was lower as compare with recommended service with different disparities. Multipurpose tailored strategies which incorporate a woman with no formal education, poor knwledge on preconception care,never take maternal services previously and distant from health facility could improve preconception care service utilization. Advocative strategies on preconception care component and planning pregnancy may elicite more women to use the services of preconception care.

Early Postpartum Patterns of Breastfeeding Exclusivity and Perceived Insufficient Milk by Prepregnancy Body Mass Index

OBJECTIVE

To explore trajectories of breastfeeding exclusivity and perceived insufficient milk (PIM) over the first 8 weeks postpartum among primiparous women and the association of these trajectories with prepregnancy body mass index (BMI).

DESIGN

Secondary analysis of data from a randomized controlled trial.

SETTING

Recruitment for the primary study was conducted in Pittsburgh, Pennsylvania.

PARTICIPANTS

One hundred twenty-two primiparous women with intention to exclusively breastfeed.

METHODS

We used group-based trajectory modeling to classify participants into breastfeeding exclusivity and PIM trajectory groups. We used logistic regression to explore the predictive relationship between prepregnancy BMI and breastfeeding exclusivity and PIM trajectory group memberships.

RESULTS

We identified two trajectories each for breastfeeding exclusivity and PIM over the first 8 weeks postpartum. For breastfeeding exclusivity, one group (n = 60, 49%) had low initial probability of exclusive breastfeeding with linear decline in likelihood of exclusivity over time. The other group (n = 62, 51%) had greater initial probability of exclusive breastfeeding, which remained constant over time. For PIM, one group (n = 41, 34%) had consistently greater probability of endorsing PIM at each time point, whereas the other group (n = 81, 66%) had consistently low probability of endorsing PIM over time. Prepregnancy BMI did not predict group membership in breastfeeding exclusivity, χ2(1) = 2.8, p = .094, or PIM, χ2(1) = 0.72, p = .397.

CONCLUSION

Breastfeeding exclusivity and PIM appeared to be relatively stable phenomena in the postpartum period among a sample of predominately White primiparous women who intended to breastfeed. We did not find a clear association with prepregnancy BMI.

Exposure to Baby-Friendly Hospital Practices and Breastfeeding Outcomes of WIC Participants in Maryland

BACKGROUND

The Baby-Friendly Hospital Initiative is an effective intervention to support maternal practices around breastfeeding. However, adherence of hospitals to the Baby-Friendly 10 Steps, as determined from the perspective of women participating in the United States Special Supplemental Nutrition Program for Women, Infants, and Children, has not been assessed.

RESEARCH AIMS

(1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months.

METHODS

This study was a cross-sectional 2 group comparison, using prospective data collected through a self-report telephone survey and retrospective data gathered from participants' records. Women (N = 182) participating in four Maryland Special Supplemental Nutrition Program for Women, Infants and Children agencies were recruited. One hundred and eight (59%) participants delivered at designated Baby-Friendly Hospitals; 74 (41%) delivered in non-Baby-Friendly designated hospitals. Logistic regression models were utilized to determine the influence of perceived Step adherence on exclusive breastfeeding.

RESULTS

Reported adherence to 10-Steps policies ranged from 10%-85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months.

CONCLUSION

Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Prepregnancy Body Mass Index Is Associated with Time-Dependent Changes in Secretory Activation Measures During the First 7 Days Postpartum in Breast Pump-dependent Mothers of Premature Infants

Background: Little is known about the biology of secretory activation (SA) in overweight and obese (OW/OB) mothers who are breast pump dependent with a premature infant in the neonatal intensive care unit. Objective: To compare time-dependent changes in daily pumped milk volume, maternal milk sodium (Na) concentration, and Na-to-potassium (K) ratios (Na:K) in the first 14 days postpartum in breast pump-dependent mothers with prepregnancy body mass index (BMI) <27 and BMI ≥27 kg/m². Design/Methods: This secondary analysis for 39 subjects, 44% (n = 17) with prepregnancy BMI <27 and 56% (n = 22) with BMI ≥27, included transformed data of outcome measures, chi-square, t-tests, and growth curve models. Results: For days 1-7, daily pumped milk volume increased significantly more rapidly for mothers with BMI <27 (65.82 mL/d) versus BMI ≥27 (33.08 mL/d), but the daily rate of change in pumped milk volume during days 8-14 was not statistically different. Daily milk Na concentration decreased significantly faster in BMI <27 (-3.93 mM/d) versus BMI ≥27 (-2.00 mM/day) during days 1-7, but was not significantly different for days 8-14. No statistical differences were noted for Na:K ratio for either time period. Conclusion: These data add biologic evidence to previous research, suggesting delayed or impaired SA in OW/OB mothers, and suggest that the window of opportunity for research and clinical interventions is days 1-7 postpartum in this population.

The WOMBS Framework: A review and new theoretical model for investigating pregnancy-related weight stigma and its intergenerational implications

As the growing weight stigma literature has developed, one critically relevant and vulnerable population has received little consideration-pregnant and postpartum women. Because weight fluctuations are inherent to this life phase, and rates of prepregnancy overweight and obesity are already high, this gap is problematic. More recently, however, there has been a rising interest in pregnancy-related weight stigma and its consequences. This paper therefore sought to (a) review the emerging research on pregnancy-related weight stigma phenomenology and (b) integrate this existing evidence to present a novel theoretical framework for studying pregnancy-related weight stigma. The Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) Framework proposes psychophysiological mechanisms linking pregnancy-related weight stigmatization to increased risk of weight gain and, in turn, downstream childhood obesity risk. This WOMBS Framework highlights pregnant and postpartum women as a theoretically unique at-risk population for whom this social stigma engages maternal physiology and transfers obesity risk to the child via social and physiological mechanisms. The WOMBS Framework provides a novel and useful tool to guide the emerging pregnancy-related weight stigma research and, ultimately, support stigma-reduction efforts in this critical context.

The Association of Lactation Duration with Visceral and Pericardial Fat Volumes in Parous Women: The CARDIA Study

BACKGROUND

Lactation is associated with lower risks for cardiovascular disease in women. Organ-related adiposity, which plays significant roles in the development of cardiometabolic diseases, could help explain this observation. We evaluated the association of lactation duration with visceral (VAT) and pericardial (PAT) fat volumes in women.

METHODS

Data were obtained from 910 women enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study (1985-1986) without diabetes prior to pregnancy who had ≥1 birth during 25 years of follow-up and had VAT and PAT measured from computed tomographic scans in 2010-2011. Cumulative lactation duration across all births since baseline was calculated from self-reports collected at periodic exams.

RESULTS

At baseline, the average age of women (48% black, 52% white) was 24 ± 3.7 years. After controlling for baseline age, race, smoking status, body mass index, fasting glucose, family history of diabetes, fat intake, total cholesterol, physical activity, and follow-up covariates (parity, gestational diabetes), the mean fat volumes across categories of lactation [none (n = 221), 1-5 months (n = 306), 6-11 months (n = 210), and ≥12 months (n = 173)] were 122.0, 113.7 105.0, and 110.1 cm3 for VAT and 52.2, 46.7, 44.5, and 43.4 cm3 for PAT, respectively. Changes in body weight from the first post-baseline birth to the end of follow-up mediated 21% and 18% of the associations of lactation with VAT and PAT, respectively.

CONCLUSIONS

In this prospective study, longer cumulative lactation duration was associated with lower VAT and PAT volumes, with weight gain partially mediating these associations.

The Relationship Between Internalized Weight Stigma During Pregnancy and Breastfeeding: A Prospective Longitudinal Study

OBJECTIVE

This study aimed to examine the relationship between internalized weight stigma during pregnancy and breastfeeding outcomes at 1 month post partum among individuals with prepregnancy overweight or obesity. Secondarily, the study explored the temporal stability of internalized weight stigma from the third trimester to 1 month post partum via the Weight Bias Internalization Scale (WBIS).

METHODS

A total of 103 pregnant individuals with overweight or obesity were recruited for this study. Participants completed the WBIS during the third trimester and self-reported breastfeeding initiation, continuation, and exclusivity outcomes at 1 month post partum. A paired t test and binomial logistic regression were conducted with covariates hierarchically added to the model.

RESULTS

The average prepregnancy BMI was 33.53 (SD 7.17) kg/m² (range = 25.4-62), and average prenatal WBIS scores were 25.95 (SD 11.83). No difference was found in mean prenatal and postpartum scores (25.95 [SD 11.83]; 26.86 [SD 13.03], respectively; t₉₄ = -0.83, P = 0.41), evidencing temporal stability in WBIS scores from pre to post partum. Prenatal WBIS scores did not predict breastfeeding initiation, continuation, or exclusivity at 1 month post partum in either unadjusted or adjusted models.

CONCLUSIONS

Collectively, this sample displayed low weight bias internalization, which was not predictive of breastfeeding initiation, continuation, or exclusivity at 1 month post partum. Future research is needed to develop a pregnancy-specific weight stigma measure.

Two-Year Test-Retest Reliability of the Breastfeeding Duration Question Used By the Pregnancy Risk Assessment Monitoring System (PRAMS): Implications for Research

INTRODUCTION

A large literature exists on positive sequelae of breastfeeding, relying heavily on maternal self-reported infant feeding behaviors. Many such studies use PRAMS data, though estimates of reliability for the breastfeeding duration question on PRAMS have not been published.

METHODS

We used data from Oregon PRAMS (respondents are a median 3.5 months postpartum) and PRAMS-2 (median 25 months) to assess test-retest reliability of maternal self-reported breastfeeding duration, among women who had weaned prior to completing the PRAMS survey.

RESULTS

The sample-wide kappa for the paired, self-reported breastfeeding duration was 0.014, and the intraclass correlation coefficient was 0.17, both of which indicate poor agreement. More than 80% of women reported a longer duration on PRAMS-2; the median (interquartile range) difference was +1.0 (0.31 - 2.1) months.

DISCUSSION

Recent literature on this topic from high-income countries falls into two categories: entirely retrospective versus "prospective" reliability assessments. Entirely retrospective assessments (both inquiries occur well after weaning) universally report exceedingly high reliability, whereas "prospective" assessments (women report infant feeding behavior during infancy, immediately after weaning, and some years later are asked to replicate their original answer) universally report poorer reliability. Interestingly, all "prospective" reliability studies, including ours, found that women over-report past breastfeeding durations by about 1 month upon the second inquiry. Researchers need not refrain from using maternal self-reported breastfeeding durations, because participants are largely still ranked correctly, relative to each other. However, such research efforts must avoid attempting to determine any optimal threshold duration.

Communication practices of healthcare professionals when caring for overweight/obese pregnant women: A scoping review

OBJECTIVE

To synthesize existing research on communication practices between healthcare professionals and overweight and obese pregnant women.

METHODS

Following PRISMA guidance on conducting scoping reviews, we included original research addressing communication/counseling practices of healthcare professionals with overweight and/or obese pregnant women, published between 2008-2018, and available in English. Fourteen articles are included in this review.

RESULTS

Study findings were organized into three themes: (a) topics addressed during encounters, (b) providers' comfort/confidence, knowledge and methods in communicating with overweight/obese pregnant women, and (c) overweight/obese pregnant women's experiences in communicating with healthcare providers. The most prevalent topics addressed were gestational weight gain, physical activity, and nutrition. Healthcare professionals experience discomfort and are reluctant to address weight status with overweight/obese pregnant patients, use vague statements about weight gain and weight-related obstetric risks, and report low confidence when counseling obese pregnant women. Overweight/obese pregnant women perceive weight stigma when interacting with providers.

CONCLUSION

Weight-related counseling in obstetric care is suboptimal. Providers may benefit from training to more confidently and effectively counsel overweight and obese pregnant women about gestational weight gain, physical activity, and nutrition.

PRACTICE IMPLICATIONS

Patients perceive weight stigma in the obstetric setting, which may be prevented by effective, patient-centered communication.

Parity and the Association Between Maternal Sociodemographic Characteristics and Breastfeeding

Objective: Although clinicians recognize the importance of breastfeeding for child health, breastfeeding initiation can be limited by maternal characteristics such as race/ethnicity, age at first birth, and educational attainment. We hypothesized that the strong influence of prior infant feeding experiences on multiparous women's decision to initiate and continue breastfeeding may mean that these maternal characteristics influence breastfeeding more strongly for primiparas than multiparas. Materials and Methods: Using Pregnancy Risk Assessment and Monitoring System (PRAMS) (Phase 8) survey data from 2016 to 2017, we analyzed mothers' responses to the supplemental question about parity, "Before you got pregnant with your new baby, did you ever have any other babies who were born alive?" Study variables were summarized by using weighted means and proportions and compared according to parity by using Wald tests. In the overall cohort, we evaluated the interaction between parity and each covariate by using logistic regression. Results: In our sample (N = 20,694), 40% of respondents were first-time mothers, and 88% had initiated breastfeeding. Primiparas were more likely to breastfeed than multiparas (92% versus 86%; p < 0.001), but they had shorter mean breastfeeding duration. On unadjusted analysis, four covariates were more strongly associated with breastfeeding initiation among primiparas than multiparas (maternal age, educational attainment, receiving breastfeeding information from a nurse or other medical professional, and receiving breastfeeding information from family or friends). Conclusions: Breastfeeding initiation is impacted more strongly by maternal characteristics for primiparas than multiparas.

Social support modifies the association between pre-pregnancy body mass index and breastfeeding initiation in Brazil

BACKGROUND

Many biological, social and cultural barriers for suboptimal breastfeeding practices have been identified in literature. Among these, excessive pre-pregnancy weight has been identified as a risk factor for not initiating breastfeeding early. Social support, coming from social networks (e.g. a partner, family or friends) or health care providers, has been positively associated with breastfeeding. This study aimed to examine the association between pre-pregnancy excessive weight and breastfeeding within the first hour after birth and if social support modifies this association.

DESIGN

National population-based study conducted with 21,086 postpartum women from February 1, 2011 to October 31, 2012 in 266 hospitals from all five regions of Brazil. Social support was defined as having a companion at the hospital. Main effects and interactions were tested with multivariable regression analyses.

RESULTS

Multivariate regression analyses indicated that class I and class II obese women had lower odds of breastfeeding within the first hour when a companion was not present (AOR = 0.59, 95% CI 0.42-0.82 and AOR = 0.59, 95% CI 0.36-0.97, respectively), but there was no association when the companion was present. Among overweight and obese women, the predicted probability of breastfeeding within the first hour was lower for those without a companion. This association was not found among those with normal pre-pregnancy BMI.

CONCLUSIONS

Social support modifies the relationship between pre-gestational BMI and breastfeeding initiation among women who are overweight or obese, specifically it reduces the risk of delayed breastfeeding initiation.

Breastfeeding experiences and support for women who are overweight or obese: A mixed-methods systematic review

Women who are overweight or obese have increased health risks during and beyond pregnancy, with consequences for their infants' shorter and longer term health. Exclusive breastfeeding to 6 months has many benefits for women and their infants. However, women who are overweight or obese have lower rates of breastfeeding intention, initiation, and duration compared with women with normal weight. This systematic review aimed to examine evidence of (a) breastfeeding barriers and support experienced and perceived by women who are overweight or obese, (b) support shown to be effective in increasing breastfeeding initiation and duration among these women, and (c) perceptions of health care professionals, peer supporters, partners, and family members regarding providing breastfeeding support to these women. Sixteen quantitative and qualitative papers were included and critically appraised. Thematic synthesis was undertaken to obtain findings. Maternal physical barriers such as larger breasts, difficulties of positioning to breastfeed, delayed onset of lactation, perceived insufficient supply of breast milk, and impact of caesarean birth were evident. Maternal psychological barriers including low confidence in ability to breastfeed, negative body image, embarrassment at breastfeeding in public, and experiencing stigma of obesity were also described. Support from health care professionals and family members influenced breastfeeding outcomes. Education for maternity care professionals is needed to enable them to provide tailored, evidence-based support to women who are overweight or obese who want to breastfeed. Research on health care professionals, partners, and family members' experiences and views on supporting this group of women to breastfeed is needed to support development of appropriate interventions.

Contribution of Maternal Obesity to Medically Indicated and Elective Formula Supplementation in a Baby-Friendly Hospital

Objective: Determine if maternal obesity increases use of medically indicated or elective formula in the context of a Baby-Friendly Hospital with high prevalence of obesity. Study Design: We conducted a secondary analysis of mothers who initiated breastfeeding of their term, singleton infant born at a Baby-Friendly community hospital in 2016. We defined medically indicated as formula given per physician order; and elective as formula given per maternal request. We used multinomial logistic regression to determine the odds ratio (OR) and 95% confidence interval (95% CI) for medically indicated and elective formula (each versus exclusive breastfeeding) by obesity status. We adjusted for available covariates and mediating conditions that may be exacerbated by obesity. Results: A total of 1,245 mothers met inclusion criteria, of which 41% were obese. Exclusive breastfeeding, medically indicated formula, and elective formula were 84% versus 70%, 5% versus 12%, and 11% versus 18%, in nonobese versus obese women, respectively. After adjusting for covariates, obesity significantly increased the risk for medically indicated (OR 2.6 [95% CI 1.7-4.1]) and elective (OR 2.0 [95% CI 1.5-2.8]) formula. After additionally adjusting for conditions exacerbated by obesity, the risk of medically indicated formula was attenuated by 48% (OR 1.7 [95% CI 1.02-2.7]), and there was little attenuation of the risk of elective formula (OR 1.8 [95% CI 1.3-2.6]). Conclusions: In a setting with high obesity prevalence and strong support for exclusive breastfeeding, obesity accounted for 36% of medically indicated formula and 21% of elective formula use. In this era of globally increasing maternal obesity prevalence, there is an urgent need to develop successful strategies for supporting breastfeeding that goes above and beyond standard Baby-Friendly approaches.

Hospital breastfeeding support and exclusive breastfeeding by maternal prepregnancy body mass index

Overweight and obese mothers in the United States have disproportionately lower rates of exclusive breastfeeding than mothers of normal weight. The Ten Steps to Successful Breastfeeding (Ten Steps), a series of evidence-based practices designed to support breastfeeding initiation, duration, and exclusivity, demonstrate effectiveness at the population level. It is unknown, however, whether they are consistently provided to women across all maternal body mass index (BMI) categories. We sought to determine whether pre-pregnancy BMI is associated with the implementation and effectiveness of the Ten Steps. We used data from Listening to Mothers III, a cross-sectional survey administered to a sample of mothers who delivered in U.S. hospitals between July 2011 and June 2012. Measures of the Ten Steps were based on maternal self-report on Listening to Mothers III. Our analytic sample was limited to mothers of term infants intending to breastfeed (N = 1,506, weighted). We conducted chi-square testing and constructed weighted multivariable logistic regression models to account for potential confounders. Results suggest that two practices (i.e., holding their babies skin-to-skin for the first time and being encouraged to breastfeed on demand) were more strongly associated with exclusive breastfeeding among mothers with obesity than other mothers. Additionally, mothers with obesity reported holding babies skin-to-skin significantly less often than other mothers. Thus, interventions aimed at helping mothers with obesity to hold their babies skin-to-skin in the first hour and teaching them to breastfeed on demand have the potential to decrease the breastfeeding disparities in this population.

Infant Feeding Practices In a Diverse Group of Women: The Healthy Start Study

Background

To describe infant feeding practices among a diverse group of mother-offspring pairs and identify factors associated with adherence to the American Academy of Pediatrics (AAP) recommendations.

Methods

Data were analyzed from 835 mother-offspring dyads in The Healthy Start Study, an ongoing longitudinal prebirth cohort in Denver, Colorado. Maternal report of infant feeding practices was obtained at 4 to 6 months and 18 to 24 months postnatally. Practices were classified according to the following AAP recommendations: exclusive breastfeeding for first 6 months, continued breastfeeding through 12 months, and introduction of solid foods around 6 months of age. Participants who met all 3 recommendations were categorized as "adherent." All others were categorized as "not adherent."

Results

About 77% of dyads did not adhere fully to the AAP recommendations. Women who worked ⩾35 hours/week or had a higher prepregnancy body mass index were more likely to be nonadherent. Women who were older, college educated, or had offspring with greater weight for gestational age at birth were less likely to be nonadherent.

Conclusions

Most of the women in a large contemporary cohort are not adhering to AAP infant feeding recommendations. Our results highlight the specific subgroups of women who may need additional support to optimize infant feeding practices.

Is Exclusive Breastfeeding Dangerous?

Social media has been alight with descriptions of exclusive breastfeeding being dangerous, resulting in significant and severe negative outcomes in infants whose mothers wished to breastfeed. This backlash has been led by a campaign that uses inflammatory anecdotes and misleading and inaccurate interpretation of research to bolster its assault on breastfeeding. However, poor breastfeeding outcomes can and do happen. The narratives identify areas where clinicians can improve their delivery of care. A closer look at risk factors and interventions may help reduce the risk of poor outcomes and increase the likelihood of mothers meeting their breastfeeding goals.

Is It Really Mothers’ Choice?

Much of the debate about breastfeeding is framed as the “mother’s choice.” As providers, we must always respect mothers’ choices about how they feed their babies. However, there are provider-level barriers that undermine breastfeeding and, therefore, limit mothers’ feeding choices. We address two systemic/provider-level barriers: birth interventions and providers’ attitudes. Both birth interventions and negative provider attitudes about breastfeeding undermine the oxytocin system, making breastfeeding more difficult. Becoming aware of these barriers, providing mothers with effective support during labor and postpartum and changing provider attitudes are essential for increasing exclusive breastfeeding rates.

Breastfeeding Practices Among Hispanic and Non-Hispanic Women at the Postpartum Visit

BACKGROUND

Breastfeeding is an active area in public health advocacy. Despite documented benefits for infants and mothers, exclusive breastfeeding is not universal. Ethnicity, among other variables, has been shown to influence breastfeeding practice. Research aim: Our study aimed to determine which variables are associated with infant feeding patterns at the postpartum visit; compare the sociodemographic variables associated with infant feeding patterns between Hispanic and non-Hispanic mothers; and determine the odds of exclusive breastfeeding, mixed feeding, and exclusive formula feeding associated with sociodemographic characteristics.

METHODS

A retrospective, cross-sectional two-group comparison design was used. Hispanic and non-Hispanic women's ( N = 666) infant feeding patterns at 6-week postpartum were analyzed. Group comparisons were made of the demographic characteristics and infant feeding practice.

RESULTS

Thirty-four percent of Hispanic participants reported exclusive breastfeeding compared with 59% of non-Hispanic White participants. Language and body mass index were significantly associated with infant feeding patterns among Hispanic participants. Compared with non-Hispanic White participants, Hispanic participants had increased odds of reporting mixed feeding and exclusive formula feeding.

CONCLUSION

Breastfeeding initiatives should target English-speaking Hispanic mothers and obese Hispanic mothers to align breastfeeding rates with medical recommendations. Healthcare providers may benefit from additional training to address barriers to breastfeeding among obese women and to provide culturally sensitive support that encourages continued breastfeeding in this population.

Maternal pre-pregnancy overweight/obesity and gestational diabetes interaction on delayed breastfeeding initiation

Background

Cumulative evidence indicates an association between maternal overweight and gestational diabetes with delayed breastfeeding initiation; however, the presence of both conditions simultaneously has been little explored. This study aims to investigate the interaction between maternal overweight/obesity and gestational diabetes on breastfeeding initiation.

Methods

This study comprises data from the IVAPSA Birth Cohort, a prospective follow-up of mothers and their newborns. Two of the five groups from IVAPSA were evaluated, considering women with and without gestational diabetes. These women were further categorized according to their pre-pregnancy body mass index as normal weight or overweight/obese.

Results

219 women were evaluated, 53.4% of them had pre-pregnancy overweight/obesity and 32% had gestational diabetes. Most women were able to initiate breastfeeding within 12 hours from delivery (92.7%) and only eight (3.7%) women had not breastfed in the first 24 hours postpartum. Of these, seven were overweight/obese (77.8%) and five had gestational diabetes (66.7%), with four of them having overweight/obesity and gestational diabetes concomitantly. Women with both adverse conditions had an adjusted relative risk of delayed breastfeeding initiation of 1.072 (95% CI 1.006; 1.141), p = 0.032.

Conclusions

The results indicate an additive interaction between maternal pre-pregnancy overweight/obesity and gestational diabetes on delayed breastfeeding initiation.

Lactation Duration and Progression to Diabetes in Women Across the Childbearing Years: The 30-Year CARDIA Study

Importance

Lactation duration has shown weak protective associations with incident diabetes (3%-15% lower incidence per year of lactation) in older women based solely on self-report of diabetes, studies initiated beyond the reproductive period are vulnerable to unmeasured confounding or reverse causation from antecedent biochemical risk status, perinatal outcomes, and behaviors across the childbearing years.

Objective

To evaluate the association between lactation and progression to diabetes using biochemical testing both before and after pregnancy and accounting for prepregnancy cardiometabolic measures, gestational diabetes (GD), and lifestyle behaviors.

Design, Setting, and Participants

For this US multicenter, community-based 30-year prospective cohort study, there were 1238 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study of young black and white women ages 18 to 30 years without diabetes at baseline (1985-1986) who had 1 or more live births after baseline, reported lactation duration, and were screened for diabetes up to 7 times during 30 years after baseline (1986-2016).

Exposures

Time-dependent lactation duration categories (none, >0 to 6 months, >6 to <12 months, and ≥12 months) across all births since baseline through 30 years.

Main Outcomes and Measures

Diabetes incidence rates per 1000 person-years and adjusted relative hazards (RH) with corresponding 95% CIs, as well as proportional hazards regression models adjusted for biochemical, sociodemographic, and reproductive risk factors, as well as family history of diabetes, lifestyle, and weight change during follow-up.

Results

Overall 1238 women were included in this analysis (mean [SD] age, 24.2 [3.7] years; 615 black women). There were 182 incident diabetes cases during 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6); and rates for women with GD and without GD were 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively (P for difference < .001). Lactation duration showed a strong, graded inverse association with diabetes incidence: adjusted RH for more than 0 to 6 months, 0.75 (95% CI, 0.51-1.09); more than 6 months to less than 12 months, 0.52 (95% CI, 0.31-0.87), and 12 months or more 0.53 (0.29-0.98) vs none (0 days) (P for trend = .01). There was no evidence of effect modification by race, GD, or parity.

Conclusions and Relevance

This study provides longitudinal biochemical evidence that lactation duration is independently associated with lower incidence of diabetes. Further investigation is required to elucidate mechanisms that may explain this relationship.

Breastfeeding and Exposure to Past, Current, and Neighborhood Violence

Objectives Breastfeeding has short- and long-term health benefits for children and mothers, but US breastfeeding rates are suboptimal. Exposure to violence may contribute to these low rates, which vary by race/ethnicity. We studied: (1) whether patterns of violence exposure differ by race/ethnicity and (2) whether these patterns are associated with breastfeeding outcomes. Methods We conducted a secondary analysis of data drawn from self-report surveys completed by a convenience sample of low-income postpartum women (n = 760) in upstate New York. Latent class analysis was used to identify groups of women with similar responses to seven violence measures, including childhood physical and/or sexual violence, experience of partner violence during or just after pregnancy (physical, emotional, verbal), and neighborhood violence (perceived or by ZIP code). Logistic regression and survival analysis were utilized to determine if classes were associated with breastfeeding initiation, duration, and exclusivity, controlling for demographics. Results Exposure to at least one form of violence was high in this sample (87%). We identified 4 classes defined by violence exposure (combining current and historical exposures). Violence exposure patterns differed between racial/ethnic groups, but patterns were inconsistently associated with breastfeeding plans or outcomes. For White women, history of violence exposure increased the likelihood of earlier breastfeeding cessation. By contrast, among Black women, history of violence exposure increased the likelihood of having a breastfeeding plan and initiating breastfeeding. Conclusions for Practice Some differences between violence exposure classes are likely due to the correlation between race/ethnicity and socioeconomic status in the community studied. Additional studies are warranted to better understand how exposure to violence is related to breastfeeding and how best to support women making decisions about intention, initiation, and duration of breastfeeding.

Prenatal Exposure to Stressful Life Events and Infant Breastfeeding

BACKGROUND

Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum.

MATERIALS AND METHODS

Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission).

RESULTS

Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91).

CONCLUSION

This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.

Obesity as a Predictor of Delayed Lactogenesis II

BACKGROUND

Lactogenesis II is the onset of copious milk production. A delay in this has been associated with an increased risk of formula supplementation and early cessation of breastfeeding. Prepregnancy obesity has also been associated with decreased breastfeeding rates and early cessation. Research aim: This study aimed to evaluate the effect of prepregnancy obesity on self-reported delayed lactogenesis II.

METHODS

We conducted a prospective observational cohort study of 216 women with a singleton pregnancy and who planned to breastfeed. We compared the onset of lactogenesis II between women with a body mass index (BMI) < 30 kg/m² and women with a BMI ≥ 30 kg/m². Using multivariate logistic regression analyses, we assessed the relationship between maternal BMI and delay of lactogenesis II.

RESULTS

The prevalence of delayed lactogenesis II among women with prepregnancy BMI < 30 kg/m² and BMI ≥ 30 kg/m² was 46.4% and 57.9%, respectively. Delayed lactogenesis II occurred more frequently among women who were obese at the time of delivery ( p < .05). After controlling for the covariates, age, prepregnancy BMI, and gestational weight gain were positively associated with delayed lactogenesis II.

CONCLUSION

Prepregnancy obesity and excessive gestational weight gain are associated with an increased risk of delayed lactogenesis II. Women who are at risk for delay in lactogenesis II and early breastfeeding cessation will need targeted interventions and support for them to achieve their personal breastfeeding goals.

Hospital practices to promote breastfeeding: The effect of maternal age

BACKGROUND

Breastfeeding rates are disproportionately low among young mothers in the United States. Although the use of hospital practices to promote breastfeeding is widely supported, the extent to which these practices help explain breastfeeding disparities by maternal age is unclear. Accordingly, we aimed to explore how maternal age may affect (1) receipt of hospital practices and (2) associations between these practices and exclusive breastfeeding.

METHODS

Data were derived from participants (n = 1598) of Listening to Mothers III, a national survey administered to mothers of singleton births in United States hospitals from July 2011 to June 2012. We used multivariable logistic regression models and interaction terms to examine maternal age as an effect modifier.

RESULTS

Compared with mothers aged 30 and older, mothers aged 18-19 had lower odds of reporting that nurses helped them initiate breastfeeding when ready (OR 0.59 [95% CI 0.35-0.99]), they roomed-in with their baby (OR 0.32 [95% CI 0.19-54]) and they did not receive a pacifier (OR 0.53 [95% CI 0.32-0.90]). Many associations with breastfeeding were stronger among mothers aged 18-19 and 20-24 than mothers aged 25-29 and 30 and older. Additionally, compared with receiving a pacifier, not receiving a pacifier was associated with greater odds of exclusive breastfeeding at 1 week among mothers aged 30 and older (OR 1.47 [95% CI 1.02-2.11]) but lower odds among mothers aged 18-19 (OR 0.26 [95% CI 0.10-0.70]).

CONCLUSIONS

Hospital practices to promote breastfeeding may be differentially implemented by maternal age. Encouraging teenage mothers to room-in with their babies may be particularly important for reducing breastfeeding disparities. Pacifier use among babies of teenage mothers requires further exploration.

In-Hospital Breastfeeding Experiences Among Women with Gestational Diabetes

BACKGROUND

In-hospital experiences among women with gestational diabetes mellitus (GDM) could impact breastfeeding success. We sought (1) to determine changes in the prevalence of hospital breastfeeding experiences between 2004-2008 and 2009-2011 among women with GDM and women without diabetes; (2) to determine whether GDM is associated with higher occurrence of experiencing Baby-Friendly hospital practices because of their known higher rates of breastfeeding difficulties.

MATERIALS AND METHODS

Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System, a survey of women with a recent live birth from 16 states and New York City, were used based on inclusion of an optional survey question about hospital breastfeeding experiences. We examined the association of in-hospital experiences with GDM within each survey phase using chi-square tests. Weighted multivariable logistic regression was used to determine the association between GDM and hospital breastfeeding experiences.

RESULTS

Among 157,187 (8.8% GDM), there were crude differences by GDM status for at least 60% of hospital experiences despite increases in positive hospital experiences between time periods. Women with GDM were less likely to report breastfeeding in the first hour (adjusted odds ratio: 0.83, confidence interval [95% CI] 0.73-0.94), feeding only breast milk in the hospital (0.73, 0.65-0.82), and feeding on demand (0.86, 0.74-0.99) compared with women without diabetes. Women with GDM were significantly more likely to report receiving a pump (1.28, 1.07-1.53) and a formula gift pack (1.17, 1.03-1.34) compared with women without diabetes.

CONCLUSIONS

Although women with GDM experienced improvements in-hospital breastfeeding experiences over time, disparities in breastfeeding practices remained for five in-patient (hospital) practices that included four negative practices (breastfeeding in the first hour, feeding only breast milk in the hospital, told to feed per mother's preference, receiving a formula gift pack) and one positive practice (receiving a pump).

Breastfeeding Continuation Among Late Preterm Infants: Barriers, Facilitators, and Any Association With NICU Admission?

BACKGROUND AND OBJECTIVES

Late preterm birth (at 34-36 6/7 weeks' gestation) is a risk factor for early breastfeeding cessation. The objective of this study was to determine barriers to and facilitators of breastfeeding continuation among late preterm infants (LPI) and to compare the barriers faced by LPI admitted to the well nursery versus the NICU.

METHODS

The SAS Complex Survey was used to perform multivariable logistic regression analysis by using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System. Data from 3 states (Illinois, Maine, and Vermont) for the years 2004 to 2008 were used.

RESULTS

A total of 2530 mothers of LPI were surveyed. Odds of breastfeeding initiation were similar among LPI admitted to the NICU versus the well nursery (adjusted odds ratio, 1.24 [95% confidence interval, 0.88-1.73]; P = .209). Odds of breastfeeding for ≥ 10 weeks were no different between LPI admitted to the NICU versus those admitted to the well-nursery (adjusted odds ratio, 1.02 [95% confidence interval, 0.73-1.43]; P = .904). Factors associated with increased odds of breastfeeding for ≥ 10 weeks among LPI were higher maternal education, mother being married, and normal maternal BMI. Regardless of NICU admission, the top reasons cited by mothers of LPI for early breastfeeding discontinuation were perceived inadequate milk supply and nursing difficulties.

CONCLUSIONS

Among LPIs, NICU admission was not associated with early breastfeeding cessation. Mothers of LPIs with lower odds of sustaining breastfeeding for at least 10 weeks were single mothers, those with a high school education only, and those who were obese. Breastfeeding support should be enhanced for LPIs and should address perceived maternal milk supply concerns and nursing difficulties.

Post-disaster reproductive health outcomes

We examined methodological issues in studies of disaster-related effects on reproductive health outcomes and fertility among women of reproductive age and infants in the United States (US). We conducted a systematic literature review of 1,635 articles and reports published in peer-reviewed journals or by the government from January 1981 through December 2010. We classified the studies using three exposure types: (1) physical exposure to toxicants; (2) psychological trauma; and (3) general exposure to disaster. Fifteen articles met our inclusion criteria concerning research focus and design. Overall studies pertained to eight different disasters, with most (n = 6) focused on the World Trade Center attack. Only one study examined pregnancy loss, i.e., occurrence of spontaneous abortions post-disaster. Most studies focused on associations between disaster and adverse birth outcomes, but two studies pertained only to post-disaster fertility while another two examined it in addition to adverse birth outcomes. In most studies disaster-affected populations were assumed to have experienced psychological trauma, but exposure to trauma was measured in only four studies. Furthermore, effects of both physical exposure to toxicants and psychological trauma on disaster-affected populations were examined in only one study. Effects on birth outcomes were not consistently demonstrated, and study methodologies varied widely. Even so, these studies suggest an association between disasters and reproductive health and highlight the need for further studies to clarify associations. We postulate that post-disaster surveillance among pregnant women could improve our understanding of effects of disaster on the reproductive health of US pregnant women.