Factors associated with early cessation of breastfeeding in women with gestational diabetes mellitus

Explaining the experience of breastfeeding in women with gestational diabetes and designing and implementing an educational program based on planned behavior theory: a combined exploratory study protocol

BACKGROUND

Gestational diabetes is a type of carbohydrate intolerance that is diagnosed for the first time during pregnancy. Researches have shown that gestational diabetes is associated with many negative prenatal and birth outcomes. Because of the complications such as infant death, several diabetics' mothers plan to stop breastfeeding. Research findings indicate a decrease in breastfeeding in mothers with gestational diabetes/ or contradictory tissues regarding the factors affecting the breastfeeding behavior of mothers with gestational diabetes and a special program to promote breastfeeding for these mothers based on the social and cultural conditions of Iranian society. The present study aims to design an interventional program with a mixed qualitative study based on the theory of planned behavior (PBT) to prevent the decrease of breastfeeding in diabetic mothers.

METHODS/DESIGN

A mixed methods exploratory design will be used to conduct this study in 3 phases. The first phase (qualitative): The purpose of the first phase is to understand the experience of breastfeeding mothers who had gestational diabetes, which will be done using the directed content analysis method. The purposive sampling will be used on pregnant mothers with gestational diabetes 30-34 weeks and mothers with infants (up to 6 months) with a history of gestational diabetes. The second phase include designing and implementing an educational program based on the PBT: Education will be conducted based on the needs assessment of the qualitative phase, the opinions of the focus group, and the literature review, then the breastfeeding behavior will be measured using the survey tool of "breastfeeding drop". The third phase: Interventional quantitative phase: The sample size will be carried out by a pilot study, then a designed program as an educational intervention for teaching breastfeeding behavior based on the PBT for 30-34 weeks pregnant mothers with gestational diabetes will be implemented during 3-4 sessions and breastfeeding behavior will be evaluated after delivery.

DISCUSSION

This is the first mixed-method study in Iran that led to implement an interventional program based on the theory of planned behavior. Because of the complications such as infant death, several diabetics' mothers plan to stop breastfeeding. We hope that the result of this research will be a step in solving breastfeeding problems in mothers with gestational diabetes.

Promoting breastfeeding in women with gestational diabetes mellitus in high-income settings: an integrative review

BACKGROUND

Breastfeeding provides many short- and long-term health benefits for mothers and their infants and is a particularly relevant strategy for women who experience Gestational Diabetes Mellitus (GDM) during pregnancy. However, breastfeeding rates are generally lower amongst this group of women than the general population. This review's objective is to identify the factors that influence breastfeeding by exploring the experiences and outcomes of women in in high-income health care contexts when there is a history of GDM in the corresponding pregnancy.

METHODS

A comprehensive search strategy explored the electronic databases Medline, CINAHL, Web of Science and Scopus for primary studies exploring breastfeeding practices for papers published between January 2011 and June 2023. All papers were screened independently by two researchers with included papers assessed using the Crowe Critical Appraisal tool. Findings were analysed using a narrative synthesis framework.

RESULTS

From an initial search result of 1037 papers, 16 papers representing five high-income nations were included in this review for analysis - the United States of America (n = 10), Australia (n = 3), Finland (n = 1), Norway (n = 1), and Israel (n = 1). Fifteen papers used a quantitative design, and one used a qualitative design. The total number of participants represented in the papers is 963,718 of which 812,052 had GDM and 151,666 did not. Women with an immediate history of GDM were as likely to initiate breastfeeding as those without it. However, they were more likely to have the first feed delayed, be offered supplementation, experience delayed lactogenesis II and or a perception of low supply. Women were less likely to exclusively breastfeed and more likely to completely wean earlier than the general population. Maternity care practices, maternal factors, family influences, and determinants of health were contextual and acted as either a facilitator or barrier for this group.

CONCLUSION

Breastfeeding education and support need to be tailored to recognise the individual needs and challenges of women with a history of GDM. Interventions, including the introduction of commercial milk formula (CMF) may have an even greater impact and needs to be very carefully considered. Supportive strategies should encompass the immediate and extended family who are major sources of influence.

Breastfeeding outcomes at 3 months for women with diabetes in pregnancy: Findings from the Diabetes and Antenatal Milk Expressing randomized controlled trial

BACKGROUND

Women with diabetes in pregnancy have decreased exclusivity and duration of breastfeeding compared with women without diabetes, and their infants are at increased risk of hypoglycemia. Clinicians often suggest pregnant women with diabetes to express breastmilk, and studies have reported increased breastfeeding exclusivity in the early postnatal period for patients who have expressed. Little is known about longer term outcomes. We investigated whether advising low-risk women with diabetes in pregnancy to express beginning at 36 weeks of pregnancy increased exclusivity and maintenance of breastfeeding at 3 months.

METHODS

We conducted a multicenter, two-group, randomized controlled trial at six hospitals in Melbourne, Australia, between 2011 and 2015. Women were randomized to either standard maternity care or advised to hand express for 10 min twice daily, in addition to standard care. Women were telephoned at 12-13 weeks postpartum and asked a series of questions about feeding their baby, perceptions of their milk supply, and other health outcomes.

RESULTS

Of 631 women in the study, data for 570 (90%) were analyzed at 12-13 weeks. After adjustment, we found no evidence that women allocated to antenatal expressing were more likely to be giving only breastmilk (aRR 1.07 [95% CI 0.92-1.22]) or any breastmilk (aRR 0.99 [95% CI 0.92-1.06]) at 12-13 weeks postpartum compared with women in the standard care group.

CONCLUSION

While the practice of antenatal expression for low-risk women with diabetes during pregnancy is promising for increasing exclusivity of breastmilk feeding in hospital, at 12-13 weeks, there was no association with breastfeeding outcomes.

Decision-making process of breastfeeding behavior in mothers with gestational diabetes mellitus based on health belief model

BACKGROUND

Gestational diabetes mellitus (GDM) threatens GDM mothers and their offspring's health and breastfeeding is one of the most effective ways to decrease the risk. However, the prevalence of breastfeeding among GDM mothers is far from optimal and how GDM mothers develop their feeding behavior is still unclear. Thus, this study aimed to explore the formation of GDM mothers' breastfeeding behaviors based on the health belief model (HBM).

METHODS

A questionnaire survey was conducted on 324 GDM mothers who have given birth within 6 months from January 1 to February 6, 2022. According to HBM, GDM mothers' knowledge, the perceived threat from GDM, the perceived value of breastfeeding, self-efficacy, social support and GDM mothers' breastfeeding behavior were measured. Exclusive breastfeeding (EBF) was defined as an infant who received only breast milk in the past 24 h before the survey. Structural equation modeling (SEM) was applied to explore how GDM mothers form their breastfeeding behaviors based on HBM.

RESULTS

The prevalence of EBF among GDM mothers was 33.95%. GDM mothers had limited knowledge of GDM (average 63.14% correct answer to 7 questions), especially poor on the long-term effect of GDM (39.81%) and protective effect of breastfeeding (34.57%-45.99%). Although GDM mothers showed high perceived benefits (Mean: 3.35, SD: 0.46), high self-efficacy (Mean: 3.43, SD: 0.97) and high level of social support for breastfeeding (Mean: 3.74, SD: 0.74), the various barriers (Mean: 2.20, SD: 0.47) hindered their success in EBF. The SEM results showed that a higher level of social support and more self-efficacy of breastfeeding resulted in a higher likelihood of EBF, while the higher level of knowledge of GDM, perceived higher barriers and benefits of breastfeeding and higher susceptibility to GDM consequences led to less EBF.

CONCLUSION

To promote EBF, physicians' education, emphasizing the protective effect of breastfeeding and how to correct breastfeeding, is highly recommended. In addition, social support for GDM mothers is also important to reduce their barriers to breastfeeding and help enhance self-efficacy in breastfeeding.

Self-Efficacy and Outcomes in Women with Diabetes: A Prospective Comparative Study

Background: Breastfeeding is especially beneficial to women with diabetes and their infants, yet diabetic mothers frequently experience less favorable breastfeeding outcomes. Objectives: To identify facilitators and barriers to breastfeeding for women with diabetes by comparing cognitive and social factors, health and hospital-related factors, and breastfeeding outcomes between women with and without diabetes. Design/Methods: Women with any type of diabetes (n = 28) and without diabetes (n = 29) were recruited during pregnancy. Data were collected from the electronic medical record and maternal surveys at 24-37 weeks' gestation, birth hospitalization, and 4 weeks' postbirth. We compared differences in mother's regard for breastfeeding, breastfeeding intention, and birth hospital experience by diabetes status, and estimated odds ratios for exclusive breastfeeding (EBF) and unmet intention to breastfeed. Results: Women with and without diabetes had similar breastfeeding intentions, attitudes, and self-efficacy. Women with diabetes were less likely to EBF, and more likely to have unmet intentions to EBF at hospital discharge, compared to women without diabetes. At 4 weeks' postpartum, there was no difference in breastfeeding by diabetes status, although EBF at hospital discharge was strongly associated with EBF at 4 weeks. Infant neonatal intensive care unit (NICU) admission and hypoglycemia were significantly associated with diabetes status, reduced EBF rates, and unmet breastfeeding intentions. Conclusions: Despite having a strong intent to breastfeed, women with diabetes experienced less favorable early breastfeeding outcomes and were less likely to meet their own breastfeeding goals. These differences may be driven by neonatal complications, such as infant hypoglycemia and NICU admissions, rather than maternal cognitive and social factors.

'Is there any point in me doing this?' Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.

Women's experiences of antenatal expressing were both positive and negative; it is important to understand the range of experiences.

Women should be advised that some women express little or no breast milk antenatally and therefore be reassured if they are concerned.

For women with diabetes in pregnancy, their diabetes management is a significant time burden, and should be considered when discussing antenatal expressing with women.

Maternity care providers need to follow‐up with pregnant women advised to express, to provide education, reassurance, and reassess expressing techniques.

Maternity care providers need to manage and prioritise the use of expressed breast milk.

How breastfeeding behavior develops in women with gestational diabetes mellitus: A qualitative study based on health belief model in China

BACKGROUND

Gestational diabetes mellitus (GDM) is a condition in which women develop hyperglycemia during pregnancy, and is associated with long-term health burden on both mother and their offspring, such as future type 2 diabetes mellitus (T2DM). Although breastfeeding was expected to mitigate metabolic sequelae for both mothers and their newborns, the prevalence of breastfeeding in GDM mothers are sub-optimal worldwide.

OBJECTIVE

To explore the experience of disease among mothers with GDM and how they develop feeding behaviors.

METHODS

This study was conducted in three branches of an integrated tertiary hospital in the central area of China. Mothers who were diagnosed with GDM, had no other complications, and gave birth before no more than 6 months were approached based on a purposive sampling. GDM mothers' experience of the disease and breastfeeding were collected via in-depth interviews. A theory-driven thematic analysis based on Health Belief Model (HBM) was applied for data analysis. Inductive reasoning was used to identify emerging themes which were not included in HBM.

RESULTS

16 GDM mothers were included in the current study, with nine using breastfeeding, six mixed feeding and one artificial feeding, respectively. Nine themes were identified, including: 1) GDM diagnosis and severity; 2) information searching and GDM knowledge;3) GDM management; 4) perceived susceptibility of future diabetes;5) perceived severity of future diabetes;6) perceived benefits of breastfeeding;7) perceived barriers of breastfeeding;8) decision making process of feeding and social support. Generally, mothers with GDM lack reliable sources of information, considered the disease as a minor and transient illness during pregnancy, and failed to realize the long-term risk of GDM and the protective effect of breastfeeding to themselves and their babies. They rarely considered GDM in their feeding decision. Instead, the formation of feeding behaviors depends on the balance between the benefits and barriers of breastfeeding as well as the level of social support.

CONCLUSION

To promote breastfeeding, a multi-facet intervention targeted on healthcare providers (HCPs), GDM mothers and their networks was important to help GDM mothers better and correctly understand the disease and breastfeeding, and increase their capacity of breastfeeding.

Impaired Lactation: Review of Delayed Lactogenesis and Insufficient Lactation

It is estimated that as many as 1 in 20 women worldwide are unable to successfully breastfeed or provide adequate nutrition for their infants through their breast milk alone. Compromised nutrition in the early stages of life places the infant at risk for insufficient growth as well as serious and potentially disabling or life-threatening complications. This review summarizes risk factors associated with impaired lactation that may result in either delayed lactogenesis or insufficient lactation. The risk factors for insufficient lactation are categorized into preglandular, glandular, and postglandular causes. Impaired lactation can occur despite maternal motivation, knowledge, support, and appropriate breastfeeding technique. Although there is no clear way to predict who will experience impaired lactation, knowledge about the risk factors can enable health care professionals to better identify at-risk mother-infant dyads. Early intervention may help prevent infant complications associated with inadequate nutritional intake.

Exploring psychological factors associated with breastfeeding in women with a BMI ≥ 30 kg/m2

OBJECTIVE

Women with a BMI ≥ 30 kg/m² are less likely to initiate and maintain breastfeeding compared to normal-weight women. Psychological factors have been linked with breastfeeding, but their influence on women with a BMI ≥ 30 kg/m² experiences needs further exploration. The aim of this study was to investigate whether psychological factors are voiced by women with a BMI ≥ 30 kg/m², and how these factors influence their breastfeeding.

DESIGN

A secondary analysis of eighteen semi-structured interviews with women with a BMI ≥ 30 kg/m² who had breastfed.

MAIN OUTCOME MEASURES

Deductive thematic analysis was used to apply a framework of psychological factors to the data, and investigate the extent to which they feature within the women's breastfeeding experiences.

RESULTS

All psychological factors were reported as part of women's experiences. Planning to breastfeed, planning short durations and having high confidence, factual and social knowledge positively influenced initiation and maintenance. Believing in their ability to produce nutritionally adequate and sufficient milk, that breastfeeding would assist weight loss, and that others around them approved of breastfeeding also had a positive impact. Novel relationships between psychological factors were found.

CONCLUSIONS

Psychological factors influence women's breastfeeding experiences. A model of breastfeeding in women with a BMI ≥ 30 kg/m² has been developed, and can inform future intervention development.

Factors Associated with the Need for Breastfeeding Information Among Women with Gestational Diabetes Mellitus: A Cross-sectional Study

PURPOSE

Analyzing information based on individual needs can maximize the effectiveness of education, leading to changes in personal health behaviors. This cross-sectional descriptive survey study aimed to identify the characteristics of mothers who experienced gestational diabetes mellitus and correlate the factors associated with their information needs.

METHODS

The participants were 298 women between the ages of 20 and 49 years who were pregnant and diagnosed with gestational diabetes at the time of the study, or who were diagnosed with gestational diabetes mellitus within five years after delivery. The average age of the participants was 34.28 years. After comparing participants' demographics, diabetes, and breastfeeding-related characteristics according to their need for information on breastfeeding, a multiple logistic regression analysis was performed.

RESULTS

Factors associated with participants' need for information on breastfeeding were economic conditions, usual body mass index, current pregnancy, and experience of breastfeeding.

CONCLUSION

The findings can be used to implement programs that meet the needs of these women and help improve maternal and pediatric health and quality of life.

Factors that positively influence in-hospital exclusive breastfeeding among women with gestational diabetes: An integrative review

PROBLEM

Women with gestational diabetes have higher rates of introducing infant formula before leaving hospital.

BACKGROUND

Despite health professional support, less women with gestational diabetes exclusively breastfeed in hospital.

AIM

To find factors that positively influence in-hospital exclusive breastfeeding practices among women with gestational diabetes.

METHODS

An online search was performed in Medline, Scopus, Pubmed, CINAHL and Cochrane databases. Studies containing the keywords gestational diabetes and breastfeeding were retrieved.

FINDINGS

Authors identified 1935 papers from search criteria. Twenty-six papers with no restrictions on research design met inclusion criteria and were included in the review. Factors were divided into personal, antenatal, intrapartum and postnatal factors. The main modifiable factors that were associated with improved in-hospital exclusive breastfeeding rates were having a strong intention to breastfeed, being confident, feeling supported and having continuity of education and support. Women's main reasons to introduce formula were related to baby's hypoglycaemia, delayed lactogenesis II and perceived low milk supply. Skin-to-skin contact after birth combined with frequent breastfeeds were effective ways to improve in-hospital exclusive breastfeeding rates.

CONCLUSION

Influencing factors such as women's breastfeeding intention, confidence and ongoing support are no different to the general population of women. However, promoting skin-to-skin contact after birth combined with frequent feeds are crucial for women with gestational diabetes who are more likely to introduce formula due to delayed lactogenesis II and fear of neonatal hypoglycaemia. There is a need for developing educational and supportive interventions that are tailored specifically for women who have gestational diabetes.

Barriers and benefits to breastfeeding with gestational diabetes

Gestational diabetes mellitus (GDM) is a disease of glucose intolerance during pregnancy and is associated with infant macrosomia, infant hypoglycemia, and increased risk of type 2 diabetes development for both mother and infant. Although breastfeeding potentially mitigates metabolic sequelae for both mother and her offspring, women with GDM are more likely to introduce formula and, therefore, are less likely to exclusively breastfeed, and some studies show less initiation and shorter breastfeeding duration as well. Therefore, women with GDM and their infants warrant investigation of methods by which to increase breastfeeding exclusivity and duration. Exploration of the barriers to breastfeeding for women with GDM demonstrate not only biologic complications such as maternal obesity, increased prevalence of cesarean section, and infant hypoglycemia, but also maternal report of less provider support of breastfeeding and reduced breastfeeding self-efficacy. Consequently, interventions designed to optimize breastfeeding outcomes in this high-risk population should not only focus on the biology but also on provider behavior and maternal social factors.

Factors Associated With Breastfeeding Among Women With Gestational Diabetes

BACKGROUND

Breastfeeding offers benefits to mother and child but is frequently not practiced among women whose pregnancy is complicated by gestational diabetes mellitus. Factors associated with not initiating or not maintaining breastfeeding among these women have been little investigated.

RESEARCH AIMS

(1) To evaluate the frequency of breastfeeding for 30 days among women with a recent pregnancy complicated by gestational diabetes and (2) to determine factors associated with not initiating or not maintaining breastfeeding.

METHODS

Between January 2014 and July 2017 we enrolled women with gestational diabetes at high-risk prenatal services in three Brazilian cities. We collected baseline sociodemographic and health data and followed up with participants by telephone. Using Kaplan-Meier curves, we calculated the proportions of participants not initiating breastfeeding or not maintaining it for at least 30 days. We used Poisson regression with robust variance to identify factors related to this outcome.

RESULTS

Of the 2328 participants with complete information, 2236 (96.1%) initiated breastfeeding, and 2166 (93.1%) maintained breastfeeding for 30 days. Not having breastfed the previous infant (relative risk [RR] = 5.02, 95% CI [3.39, 7.45]), smoking during pregnancy (RR = 2.37, 95% CI [1.48, 3.80]), infant with health problems (RR = 2.25, 95% CI [1.27, 3.99]), early preterm birth (RR = 2.49, 95% CI [1.07, 5.77]), and not intending to breastfeed (RR = 3.73, 95% CI [1.89, 7.33]) were related to not maintaining breastfeeding for at least 30 days.

CONCLUSIONS

Breastfeeding initiation was nearly universal among participants, and most maintained breastfeeding for 30 days. Factors relating to not breastfeeding at 30 days were easily identifiable.

In-Hospital Feeding Practices of Infants Born to Mothers With Gestational Diabetes Mellitus or Type 2 Diabetes Mellitus: Evaluating Policy Implementation Effectiveness

OBJECTIVES

Women with diabetes in pregnancy may experience unique breastfeeding challenges. Few studies have examined the effectiveness of hospital policy to support breastfeeding in this patient population. This study aimed 1) to describe infant feeding practices of mother-infant pairs with gestational diabetes mellitus (GDM) or type 2 diabetes in pregnancy before and after introduction of an in-hospital policy and, 2) to compare feeding practices before and after policy introduction.

METHODS

A retrospective chart audit of mother-infant pairs (n=120) was performed: 60 at 1 year before and 60 after policy introduction. The primary outcome was provision of breast milk at discharge; a chi-square test was completed to compare pre- and postpolicy groups. Secondary outcomes included participant and infant feeding characteristics.

RESULTS

There was no significant difference in the number of infants receiving breast milk at discharge between pre- (58% [35 of 60]) and postpolicy (58% [35 of 60]) groups (p=0.64). The number of infants receiving breast milk exclusively throughout the hospital stay also did not differ by group (37% [22 of 60] before; and 43% [26 of 60] after; p=0.39). Information for each feed was infrequently recorded in charts for the method of feeding (34% [704 of 2,064]), infant state (96% [1,991 of 2,064]) and feeding description (96% [1,987 of 2,064]).

CONCLUSIONS

This practice-based research has highlighted a need for continuation of this work, examining an in-hospital policy to support breastfeeding in those with GDM or type 2 diabetes in pregnancy. Initially, feedback could be collected from health-care providers to understand perceived facilitators and barriers to policy application and the use of job aids (e.g. record keeping tools).

The Effect of Interactive Web-Based Monitoring on Breastfeeding Exclusivity, Intensity, and Duration in Healthy, Term Infants After Hospital Discharge

OBJECTIVE

To determine whether a Web-based interactive breastfeeding monitoring system increased breastfeeding duration, exclusivity, and intensity as primary outcomes and decreased symptoms of postpartum depression as a secondary outcome.

DESIGN

Two-arm, randomized controlled trial.

SETTING

Three hospitals in the Midwestern United States.

PARTICIPANTS

One hundred forty one (141) mother-newborn dyads were recruited before discharge.

METHODS

Postpartum women were randomly assigned to the control or intervention groups. Women in the control group (n = 57) followed the standard hospital protocol, whereas women in the intervention group (n = 49) were given access to an online interactive breastfeeding monitoring system and were prompted to record breastfeeding and infant output data for 30 days. A follow-up online survey was sent to both groups at 1, 2, and 3 months to assess breastfeeding outcomes and postpartum depression.

RESULTS

For mothers and infants, there were no significant differences in demographics between groups. No significant differences in breastfeeding outcomes were found between groups at discharge (p = .707). A significant difference in breastfeeding outcomes was found between groups at 1, 2, and 3 months (p = .027, p < .001, and p = .002, respectively). Members of the intervention group had greater exclusive breastfeeding rates at 1, 2, and 3 months. By the end of the third month, 84% of the intervention group was breastfeeding compared with 66% of the control group. Postpartum depression symptom scores decreased for both groups at 1, 2, and 3 months (control group: 4.9 ± 3.9, 4.3 ± 4.9, and 3.2 ± 3.9, respectively; intervention group: 4.7 ± 4.5, 3.0 ± 3.4, and 2.8 ± 3.6, respectively). However, there was no significant difference between groups at 1, 2, and 3 months (p = .389, .170, and .920, respectively) for depression.

CONCLUSION

The Web-based interactive breastfeeding monitoring system may be a promising intervention to improve breastfeeding duration, exclusivity, and intensity.