The Interrelationship Between Repeat Cesarean Section, Smoking Status, and Breastfeeding Duration

Variation in Breastfeeding Initiation and Duration by Mode of Childbirth: A Prospective, Population-Based Study

Introduction: Despite known benefits of breastfeeding, including prevention against infections for infants, in the presence of numerous barriers, less than half of infants in high-income countries breastfeed for 6 months. One potential barrier to breastfeeding is birth by cesarean section (C-Section), which can invoke long-term difficulties. However, our structured literature review found that existing empirical research does not fully elucidate this relationship due to differences in operationalization of C-section and breastfeeding, omission of important confounders, and failure to exclude those who did not initiate breastfeeding (or use time-to-event analyses). In this article, we attempt to overcome these limitations. Methods: We analyzed data from 14,414 mother-infant dyads enrolled in the United Kingdom-based prospective Millennium Cohort Study, beginning in 2001. Using multivariable logistic regression, we examined the association between mode of birth (vaginal, emergency C-section, and elective C-section) and likelihood of breastfeeding initiation. We then applied adjusted Accelerated Failure Time survival models to examine the associations between mode of birth and duration of any and exclusive breastfeeding. Results: Those with planned (but not emergency) C-section were less likely to initiate breastfeeding (odds ratio: 0.84, 95% confidence interval [CI]: 0.71-0.99) relative to vaginal births. However, those with either planned or unplanned C-section discontinued both any and exclusive breastfeeding sooner than vaginal births. This effect was more pronounced for those with planned C-section (time ratio [TR]: 0.75, 95% CI: 0.64-0.89) than unplanned C-section (TR: 0.85, 95% CI: 0.74, 0.97) compared with vaginal births. Conclusions: Through application of rigorous methods, this study provides compelling evidence that breastfeeding duration may be impeded by C-section birth. The findings suggest that additional support for mothers who intend to breastfeed and have a C-section birth may be warranted.

Predictors of Breastfeeding Duration in the New Hampshire Birth Cohort Study

INTRODUCTION

Breastfeeding has significant health benefits for infants and birthing persons, including reduced risk of chronic disease. The American Academy of Pediatrics recommends exclusively breastfeeding infants for 6 months and recently extended its recommendation for continuing to breastfeed with supplementation of solid foods from one to two years. Studies consistently identify lower breastfeeding rates among US infants, with regional and demographic variability. We examined breastfeeding in birthing person-infant pairs among healthy, term pregnancies enrolled in the New Hampshire Birth Cohort Study between 2010 and 2017 (n = 1176).

METHODS

Birthing persons 18-45 years old were enrolled during prenatal care visits at ~ 24-28 weeks gestation and have been followed since enrollment. Breastfeeding status was obtained from postpartum questionnaires. Birthing person and infant health and sociodemographic information was abstracted from medical records and prenatal and postpartum questionnaires. We evaluated the effects of birthing person age, education, relationship status, pre-pregnancy body mass index, gestational weight gain (GWG), smoking and parity, and infant sex, ponderal index, gestational age and delivery mode on breastfeeding initiation and duration using modified Poisson and multivariable linear regression.

RESULTS

Among healthy, term pregnancies, 96% of infants were breastfed at least once. Only 29% and 28% were exclusively breastfed at 6-months or received any breastmilk at 12-months, respectively. Higher birthing person age, education, and parity, being married, excessive GWG, and older gestational age at delivery were associated with better breastfeeding outcomes. Smoking, obesity, and cesarean delivery were negatively associated with breastfeeding outcomes.

CONCLUSIONS

Given the public health importance of breastfeeding for infants and birthing persons, interventions are needed to support birthing persons to extend their breastfeeding duration.

The Association of Maternal Smoking and Drinking Changes During Pregnancy and Postpartum Breastfeeding Pattern and Duration

Objectives: To conduct a secondary data analysis of how changes in smoking and drinking during pregnancy impact status of any breastfeeding and breastfeeding duration in a national cohort. Materials and Methods: A cross-sectional study was conducted using Pregnancy Risk Assessment Monitoring System (PRAMS) data between 2009 and 2017 (n = 334,203). Univariate and multivariate analyses were conducted on the status of any breastfeeding and breastfeeding duration. Results: A dose-dependent inverse relationship was found in which women who smoked the same or more or resumed smoking during pregnancy showed the lowest likelihood and shortest duration of breastfeeding, followed by reduced smokers, quitters, and nonsmokers. Women with a history of alcohol use were significantly more likely to breastfeed compared with women without a history of alcohol use. Conclusions: The profile of smoking change during pregnancy impacts the likelihood and duration of breastfeeding in a dose-dependent and inverse manner. No such relationship was found with drinking change during pregnancy. Public Health Implications: Significant public health efforts should focus on implementing and sustaining evidence-based interventions for prenatal smoking cessation and educating providers and maternal populations on the adverse effect of postpartum alcohol exposure.

Association Between a History of Hookah Use and Breastfeeding Duration

Background: There is limited evidence on the relationship between hookah use and breastfeeding. This study examines the association between a history of hookah use and breastfeeding duration among women in the United States. Materials and Methods: This cross-sectional study examined 96,392 women from the Pregnancy Risk Assessment and Monitoring System (PRAMS) 2016-2019 data. The main outcome of interest was any breastfeeding for at least 3 months. Descriptive statistics, chi-square test, and multivariable regression analyses were performed. Results: Overall, 68.3% of women breastfed for at least 3 months and 4.6% reported using hookah in the last 2 years. Women who reported using hookah in the last 2 years were significantly less likely to breastfeed for at least 3 months compared with women who did not report using hookah in the last 2 years (56.0% versus 68.9%; p < 0.001). In the multivariable model, the odds of breastfeeding for at least 3 months were significantly lower in women who used hookah in the last 2 years compared with those who did not use hookah; odds ratio (95% confidence interval) 0.82 (0.74-0.92; p < 0.001). Additionally, the odds of breastfeeding for at least 3 months were significantly lower for dual users of hookah and cigarettes 0.48 (0.33-0.68; p < 0.001). Conclusion: A history of hookah use is associated with early weaning, independent of potential confounders. This finding suggests the need for educating women about the negative consequences of hookah use on breastfeeding during preconception, prenatal, and postpartum care encounters.

Breastfeeding and complementary feeding in fragile settings: the case of Syrian refugees and their host communities in North Lebanon

BACKGROUND

Adequate breastfeeding and complementary feeding practices are paramount in fragile situations where access to food and healthcare is limited. The objectives of this study are to examine breastfeeding and complementary feeding practices among Syrian refugees and their Lebanese host communities and to investigate the correlates of exclusive breastfeeding (EBF) at four and 6 months in these communities.

METHODS

Using two-stage stratified sampling, a cross-sectional survey was conducted in Akkar, a region with a high density of Syrian refugees in Lebanon, between April and November 2019. In one-to-one interviews, mothers of children (6-24 months) completed a questionnaire including specific questions about breastfeeding and complementary feeding practices, a 24-h recall, and socio-demographic characteristics for 189 Syrian refugees and 182 Lebanese host community households. Descriptive statistics, simple and multiple logistic regression were used in data analysis.

RESULTS

Among breastfeeding practices, ever-breastfeeding was most prevalent (90%), followed by early initiation of breastfeeding (64.8%), EBF at four (49.6%), and six (36%) months. One in four children was introduced to solids before 6 months of age, and less than a third was given iron-fortified baby cereals as the first complementary foods. Only 24.4% and 9.2% of children met the minimum dietary diversity and minimum acceptable diet requirements, respectively. Compared to children of the Lebanese host communities, those of Syrian refugees had higher rates of EBF at four and 6 months as well as continued breastfeeding at 1 year, whereas only 17.9% of Syrian refugees' children met minimum dietary diversity compared to 30.9% of Lebanese host community children (p <  0.05). Among refugees, education and spouse's employment status were associated with higher odds of EBF at 4 months. As for Lebanese households, female children were less likely to be exclusively breastfed at 4 months and 6 months, while a natural delivery increased the odds of EBF at 6 months.

CONCLUSION

Breastfeeding and complementary feeding practices are suboptimal among children of Syrian refugees and their Lebanese host communities in North Lebanon. There is a need for intervention strategies to tackle gaps in services and assistance delivery programs to enhance infant and young child feeding practices among both communities.

Is maternal cigarette or water pipe use associated with stopping breastfeeding? Evidence from the Jordan population and family health surveys 2012 and 2017-18

Background

Maternal smoking is suspected to have negative impacts on breastfeeding, such as decreasing the quantity of breast milk, and reducing vitamin and fat concentrations in the milk in the late lactation period. Cigarette and water pipe tobacco products are widely used in Jordan. We aimed to estimate the association between use of different tobacco products and the rates of current breastfeeding.

Methods

Data from Jordan’s Population and Family Health Surveys 2012 and 2017–18 were examined. Last-born, living children, aged < 25 months, from singleton births, ever breastfed, and living with their mother were included. The key outcome variables were the current breastfeeding (during last 24 h) and tobacco usage status [water pipe tobacco (hookah or narghile) and/or cigarette tobacco]. Complex sample multivariate logistic regression analysis was used to evaluate the association of the current breastfeeding with maternal smoking status.

Results

Overall, 6726 infants were included in the study. The current breastfeeding rate in infants aged 0–6 months was 87%, compared with 43.9% in infants aged 12–17 months and 19.4% in infants aged 18–24 months. Overall, 4.4% had mothers who smoked cigarettes, 5.4% smoked water pipe, and 1.6% both cigarettes and water pipe. The proportion of breastfed infants in non-smoking mothers was 57.7% and, those in smoke water pipe, cigarette and both tobacco products were 55.4, 44.9, and 51.0% respectively. Univariate analysis revealed that women cigarette smokers had a lower odds ratio (OR) for current breastfeeding (OR 0.60, 95% Confidence Interval [CI] 0.39, 0.92). Multivariate analysis revealed that maternal cigarette smoking was associated with a lower odds ratio for current breastfeeding compared with mothers who smoked neither water pipe nor cigarettes (AOR 0.51, 95% Cl 0.30, 0.87).

Conclusions

These results indicate that maternal smoking is associated with termination of breastfeeding, suggesting that structured training should be organized for healthcare professionals, expectant mothers and the general public about the association between maternal smoking and cessation of lactation.

Caesarean delivery associated with adverse breastfeeding practices: a prospective cohort study

Caesarean delivery rates are increasing in many Asian countries. This study investigated the effects of caesarean section on breastfeeding practices from delivery to twelve months postpartum. A prospective cohort study was conducted on 2030 pregnant women recruited from three cities in Vietnam during 2015-2017. The overall caesarean rate was 38.1%. Mothers who underwent caesarean section were more likely to give prelacteal feeds to their infants (adjusted odds ratio (OR) 13.91, 95% confidence interval (CI) 10.52-18.39) and as a result have lower rates of early initiation of breastfeeding (adjusted OR 0.04, 95%CI 0.02-0.05). Having a caesarean section reduced the likelihood of (any, predominant and exclusive) breastfeeding from discharge to 6 months postpartum. After 1 year, the any breastfeeding rate was still lower in the caesarean delivery (70.2%) compared with the vaginal delivery group (72.9%), p = .232. Vietnamese women who give birth by caesarean section need extra support to initiate and maintain breastfeeding.IMPACT STATEMENTWhat is already known on this subject? Early initiation of breastfeeding, and 'exclusive' or 'predominant' breastfeeding rates at discharge are lower in mothers delivering by caesarean section compared to vaginal delivery. Prelacteal feeding rates are higher following caesarean section. However, the association between 'any' breastfeeding duration and caesarean delivery has not been established.What the results of this study add? This study showed that caesarean delivery reduced all breastfeeding rates from discharge to six months and any breastfeeding rate at 12 months postpartum in Vietnamese women.What the implications are of these findings for clinical practice and/or further research? Further breastfeeding interventions are needed during the postpartum period for mothers who deliver by caesarean section.

Workplace support and breastfeeding duration: The mediating effect of breastfeeding intention and self-efficacy

BACKGROUND

Given the large proportion of mothers in the United States work force, understanding the implications of workplace support on breastfeeding outcomes is an important public health priority. The current study investigates if (a) workplace support directly influences the working mothers' breastfeeding intention, self-efficacy, and duration, and (b) workplace support indirectly influences breastfeeding duration through the mediating effect of breastfeeding intention and self-efficacy.

METHODS

Data from the longitudinal Infant Feeding Practices Survey II were analyzed. The main predictor variable, workplace support, was based on a Likert scale from "not at all supportive" to "very supportive." Both mediators, exclusive breastfeeding intention and self-efficacy, were dichotomized (yes; no) while the study outcome, breastfeeding duration, was continuous. Structural equation modeling was used to obtain direct and indirect effects of breastfeeding intention and confidence in attaining breastfeeding goals.

RESULTS

After adjusting for confounders, there was a statistically significant direct effect between self-efficacy, breastfeeding intention, and breastfeeding duration. A statistically significant indirect effect of workplace support on breastfeeding duration through self-efficacy in attaining breastfeeding goals was also observed. The mediation ratios of the indirect effects showed that self-efficacy in attaining breastfeeding goals accounted for 40.8% (P-value=0.032) of the total effect; however, all other mediation ratios did not show statistical significance.

CONCLUSIONS

Self-efficacy is an important predictor for breastfeeding duration. Workplaces may help bolster women's self-efficacy by providing environments that are supportive to breastfeeding working mothers. Future research is needed to identify breastfeeding policies that boost self-efficacy.

Prepregnancy Depression and Breastfeeding Duration: A Look at Maternal Age

Background

In the United States, major depressive disorder affects one in five women aged 20-40 years. During these childbearing years, depression can negatively impact maternal behaviors that are crucial for infant growth and development. This study examined the relationship between prepregnancy depression and breastfeeding duration by maternal age.

Methods

Data from Phase 7 (2012-2013) of the Pregnancy Risk Assessment Monitoring System (N=62,483) were analyzed. Prepregnancy depression was dichotomized while breastfeeding duration was categorized as never breastfed, breastfed 8 weeks or less, and breastfed more than 8 weeks. Maternal age was a significant effect modifier; therefore, results were stratified by maternal age. Multinomial logistic regression was used to obtain odds ratios and 95% confidence intervals (CI).

Results

For women aged 20-24, 25-29, and 30-34 years with prepregnancy depression, the odds of never breastfeeding and breastfeeding 8 weeks or less were significantly higher than in women with no history of prepregnancy depression. Notably, among women aged 25-29 with prepregnancy depression, the odds of never breastfeeding and breastfeeding 8 weeks or less were 93% (adjusted odds ratio (AOR) = 1.93, 95% CI =1.57-2.37) and 65% (AOR = 1.65, 95% CI = 1.37-1.99) higher compared to women with no history of prepregnancy depression, respectively.

Conclusions

Having a history of poor mental health before pregnancy may increase the likelihood of premature breastfeeding cessation. A woman's mental health status before pregnancy should be considered in reproductive and prenatal care models. Efforts should be made to understand challenges women of specific age groups face when trying to breastfeed.

Pregnancy risk factors related to autism: an Italian case-control study in mothers of children with autism spectrum disorders (ASD), their siblings and of typically developing children

This study, carried out in two Italian Institutions, assesses the frequency of 27 potential autism risk factors related to pregnancy and peri- and postnatal periods by interviewing mothers who had children with autism, children with autism and one or two typically developing siblings, or only typically developing children. The clinical sample included three case groups: 73 children and adolescents with autism (Group A), 35 children and adolescents with autism (Group A1) having 45 siblings (Group B) and 96 typically developing children (Group C) matched for gender and age. Twenty-five out of 27 of risk factors presented a higher frequency in Group A in comparison with Group C and for nine of them a statistically significant difference was found. Twenty-one out of 27 of risk factors presented a higher frequency in Group A in comparison with Group B. A higher prevalence of environmental risk factors was observed in 11 risk factors in the Group A1 in comparison with Group B and for nine of them an odds ratio higher than 1.5 was found. For 13 factors there was a progressive increase in frequency going from Group C, B and A and a statistically higher prevalence of the mean number of stressful events per pregnancy was recorded in Group A when compared with Groups B and C. The results suggest that environmental, incidental phenomena and stressful life events can influence pregnancy outcome in predisposed subjects, pointing out a possible threshold effect in women who are predisposed to have suboptimal pregnancies.

Association Between Intimate Partner Violence and Breastfeeding Duration: Results From the 2004-2014 Pregnancy Risk Assessment Monitoring System

BACKGROUND

Intimate partner violence is a major public health problem that disproportionately affects women. Current literature investigating the relationship between intimate partner violence and breastfeeding is inconsistent. Research aim: This study aims to investigate the relationship between physical intimate partner violence that occurs in the preconception or prenatal period and any breastfeeding duration.

METHODS

Data from the retrospective, cross-sectional 2004-2014 Pregnancy Risk Assessment Monitoring System were analyzed ( N = 195,264). The outcome, breastfeeding duration, was categorized as never breastfed, breastfed 8 weeks or less, and breastfeed more than 8 weeks. Multinomial logistic regression was used to obtain crude and adjusted odds ratios and 95% confidence intervals.

RESULTS

Approximately 6% ( n = 11,766) of survey respondents reported preconception and/or prenatal intimate partner violence, and 36.3% ( n = 67,667) of women reported never breastfeeding. The odds of discontinuing breastfeeding before 8 weeks were 18% higher among women who reported experiencing abuse 12 months before pregnancy compared with women who did not report intimate partner violence (adjusted odds ratio = 1.18; 95% confidence interval [1.01, 1.37]). All other estimates showed an overlapping 95% confidence interval.

CONCLUSION

Breastfeeding is essential in improving maternal and child health; however, women in abusive relationships may face additional barriers to breastfeeding. Further research is needed to better understand the impact of violence on breastfeeding behaviors to inform healthcare practices and interventions.

Early feeding, hypoglycemia and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To examine the effects of early breastfeeding (eBF) or early formula feeding (eFF) on hypoglycemia and on BF initiation in infants born to women with pregestational diabetes mellitus (PGDM) who intended to BF.

METHODS

Retrospective cohort investigation of 554 women with PGDM and their infants (IDMs) who delivered during 2008-2016. The first feeding (BF or FF) was considered early if given within 4 hours from birth.

RESULTS

282 (51%) IDMs were admitted to the Well Baby Nursery. Of the 134 IDMs whose early feeding was BF, hypoglycemia affected 30% which was corrected with oral feedings in 78% of the cases. At discharge, 49% BF exclusively while 45% BF partially. Of the 148 IDMs whose early feeding was FF, hypoglycemia affected 40% which was corrected with oral feedings in 69% of the cases. At discharge, 14% BF exclusively while 48% BF partially. There were 272 (49%) IDMs admitted to the NICU. Their early feeding was BF (14%) and FF (86%). Hypoglycemia developed in 50% and 43% of these groups, respectively. Benefits of early feedings on hypoglycemia were masked by the routine use of IV dextrose infusions. At discharge, early BF led to exclusive BF in 45% and partial BF in 50% of the cases. Early FF led to exclusive BF in 17% and partial BF in 42% of the cases.

CONCLUSIONS

Early and continued feeding (BF preferably or FF if BF is not feasible) should be the first line of treatment for hypoglycemia. Early BF is paramount for BF initiation. Early FF is an obstacle, albeit not absolute, to BF initiation, thus it should not deter continued efforts to start or resume BF.

Breastfeeding Initiation in Mothers with Repeat Cesarean Section: The Impact of Marital Status

BACKGROUND

Approximately 90% of mothers with a primary C-section have a subsequent C-section. To date, research has demonstrated that primary C-sections are associated with breastfeeding noninitiation. However, it is unknown if this association persists after the primary C-section. Furthermore, literature has shown a differing relationship between breastfeeding initiations by marital status. Due to the high proportion of women who give birth while unmarried, investigating differences by marital status will add a significant contribution to breastfeeding literature. This study investigates the association between repeat C-section and breastfeeding initiation within marital status groups using a nationally representative cross-sectional survey.

MATERIALS AND METHODS

Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System were analyzed. The sample was restricted to women with a previous singleton live birth who had C-section and whose infant was alive at the time of interview (N = 34,854). Multiple logistic regression analyses were conducted to obtain crude and adjusted odds ratio (AOR) and 95% confidence intervals (CIs).

RESULTS

After adjusting for potential confounders, married women who had a repeat C-section were 2.2 times (AOR = 2.16, 95% CI = 1.69-2.77) more likely to never breastfeed compared to women with vaginal birth after caesarean section (VBAC). Similarly, the odds of breastfeeding noninitiation were 76% (AOR = 1.76, 95% CI = 1.47-2.12) higher among women with a repeat C-section compared to women with VBAC. No significant associations were exhibited among nonmarried women.

CONCLUSIONS

Enhanced educational programs and counseling support may be needed to help families cope with delivery challenges and resulting stressors that may reduce their desire to initiate breastfeeding in the postpartum period.