Secular trends in breastfeeding and parental smoking

Postpartum Changes in Mood and Smoking-Related Symptomatology: An Ecological Momentary Assessment Investigation

Introduction

Postpartum smoking relapse is a highly prevalent public health problem. Mood and breast feeding are significantly associated with smoking relapse, although less is known about the temporality of these relationships. Therefore, this study utilized ecological momentary assessments (EMA) to prospectively examine changes in mood and smoking-related symptomatology in relationship to three events-childbirth, termination of breast feeding, and smoking relapse. We expected all three events to significantly alter mood and smoking-related symptomatology.

Methods

We enrolled a sample of pregnant women who had recently quit smoking and intended to remain quit during the postpartum. Participants were randomized to active/placebo progesterone to prevent postpartum relapse. Participants also completed daily EMA to collect data mood and smoking-related symptomatology as well as our three events of interest.

Results

Participants (n = 46) were, on average, 26.5 ± 0.8 years old and, prior to pregnancy, smoked 10.1 ± 0.7 cigarettes/day. We noted a number of significant within- and between-subject relationships. For example, participants reported a 24% decline in negative affect after childbirth (p = .0016). Among those who relapsed to smoking (n = 23), participants randomized to placebo had a significant increase in cigarette craving after relapse (β = 1.06, 95% confidence interval [CI] = 0.62 to 1.49, p value = .0003), whereas participants randomized to active progesterone did not (β = 0.63, 95% CI = -0.35 to 1.62, p value = .1824).

Conclusions

These observations suggest that mood and smoking-related symptomatology are influenced by childbirth, breast feeding, smoking relapse, and use of exogenous progesterone. Future research should explore how these observations may inform novel postpartum smoking relapse-prevention interventions.

Implications

Postpartum smoking relapse has been a persistent public health problem for more than 40 years. Although a number of significant predictors of postpartum smoking relapse have been identified (eg, depression and breast feeding), much of these analyses have relied on cross-sectional and/or self-reported retrospective data. Therefore, for the first time, we utilized ecological momentary assessment to explore the effect of childbirth, termination of breast feeding, and smoking relapse on mood and smoking-related symptomatology (eg, craving). Numerous significant relationships were observed, including a 96% increase in craving after smoking relapse. These novel observations can inform new and effective postpartum smoking relapse-prevention programs.

Maternal smoking and newborn sex, birth weight and breastfeeding: a population-based study

OBJECTIVE

Today, it is acknowledged that smoking during pregnancy and/or the postnatal period has significant risks for a foetus and newborn child. This research examines the relationship between smoking only postnatally, both during pregnancy and postnatally, and the newborn sex, birth weight and breastfeeding.

METHODS

Total 664 women of randomly selected five primary healthcare centres between the dates 20 February 2010 and 20 July 2010 were included in the research. Statistical analyses were performed with SPSS for Windows 19.0 (Statistical Package for Social Sciences software package). Data were described as mean, standard deviation, percentages and Chi-square tests and backward stepwise logistic regression were analysed.

RESULTS

It was found that the percentage of smoking women with daughters is 2.5 times higher than women with sons. Women who smoke are 3.9 times more likely to start feeding their baby with supplementary infant foods at 4 months or earlier than those who do not smoke. Finally, the risk of a birth weight under 2500 g is 3.8 times higher for maternal smokers.

CONCLUSIONS

This study suggests that women who expect a girl smoke more heavily than those who expect a boy. The birth weight of maternal smokers' newborns is lower. Those women who smoke while breastfeeding start feeding their babies with supplementary infant foods at an earlier age.

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

BACKGROUND

The rate of breastfeeding duration is staggeringly low with only one-quarter of infants in the United States being exclusively breastfed at 6 months. Maternal smoking and mode of delivery have been identified as independent risk factors for shorter breastfeeding duration. This study aims to evaluate the effect of repeat cesarean delivery on breastfeeding duration, taking into account smoking status.

MATERIALS AND METHODS

Data from the U.S. population-based Pregnancy Risk Assessment Monitoring System survey, 2004-2011, were analyzed. Women who delivered a live singleton baby, had a previous birth through cesarean delivery, and provided mode of delivery and breastfeeding information were included in the analysis. Multinomial logistic regression models provided crude and adjusted odds ratios (AORs) and 95% confidence intervals (CIs). All models were stratified by smoking status.

RESULTS

Among smokers, women who had repeat cesarean section had a 2-fold higher odds of never breastfeeding (AOR = 2.43, 95% CI = 1.38-4.29) and a 4-fold higher odds of breastfeeding 8 weeks or less (AOR = 4.11, 95% CI = 2.08-8.11) compared with women who gave birth vaginally after cesarean section. Among nonsmokers, the odds of never breastfeeding and breastfeeding 8 weeks or less were 2.4 times (AOR = 2.36, 95% CI = 1.84-3.03) and 1.4 times (AOR = 1.44, 95% CI = 1.15-1.80) higher in women who had repeat cesarean section compared with women who had vaginal birth after cesarean section, respectively.

CONCLUSIONS

Among women who smoke during pregnancy, the results suggest that repeat cesarean delivery negatively affects breastfeeding duration. Interventions are needed for mothers who smoke during pregnancy and undergo repeat cesarean delivery.

Factors affecting breastfeeding duration in Greece: What is important?

AIM: To investigate factors associated with breastfeeding duration (BD) in a sample of mothers living in Greece.

METHODS: Four hundred and twenty-eight mothers (438 infants) were initially recruited in a tertiary University Hospital. Monthly telephone interviews (1665 in total) using a structured questionnaire (one for each infant) were conducted until the sixth postpartum month. Cox regression analysis was used to assess factors influencing any BD.

RESULTS: Any breastfeeding rates in the first, third, and sixth month of the infant’s life reached 87.5%, 57.0% and 38.75%, respectively. In the multivariate analysis, maternal smoking in the lactation period [hazard-ratio (HR) = 4.20] and psychological status (HR = 1.72), and the introduction of a pacifier (HR = 2.08), were inversely associated, while higher maternal education (HR_{university/collegevsprimary/high school} = 0.53, HR_{master’svsprimary/high school} = 0.20), and being an immigrant (HR = 0.35) were positively associated with BD.

CONCLUSION: Public health interventions should focus on campaigns against smoking during lactation, target women of lower educational status, and endorse the delayed introduction of pacifiers.

Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants

AIM

To examine the rate and duration of breastfeeding in a cohort of women in opioid maintenance treatment (OMT) in Norway, as well as the effect of breastfeeding on the incidence and duration of neonatal abstinence syndrome (NAS).

METHODS

A national cohort of 124 women treated with either methadone or buprenorphine during pregnancy, and their neonates born between 1999 and 2009, was evaluated in three study parts. A standardized questionnaire was administered, and medical information from the hospitals and municipalities were collected to confirm self-reported data.

RESULTS

There were high initiation rates of breastfeeding (77%) for women in OMT, but also high rates of early cessation of breastfeeding. Breastfed neonates exposed to methadone prenatally had significantly lower incidence of NAS requiring pharmacotherapy (53% vs. 80%), and both the whole group of infants and the methadone-exposed neonates needed shorter pharmacological treatment of NAS (p < 0.05) than neonates who were not breastfed.

CONCLUSION

Breastfed neonates exposed to OMT medication prenatally, and methadone-exposed newborns in particular, have lower incidence of NAS and require shorter pharmacotherapy for NAS than infants who are not breastfed. The results add to the evidence regarding the benefits of breastfeeding for neonates prenatally exposed to OMT medications.

Longer previous smoking abstinence relates to successful breastfeeding initiation among underserved smokers

OBJECTIVES

The purpose of this study was to examine sociodemographic and behavioral factors related to successful breastfeeding initiation among medically underserved maternal smokers-a population with persistently low rates of initiation.

SUBJECTS AND METHODS

Pretreatment data from a larger randomized behavioral counseling, secondhand smoke reduction trial was examined for this study. Maternal smokers with babies younger than 4 years old reported breastfeeding behaviors. Mothers who breastfed for >4 weeks (n = 50) were matched with mothers who never initiated breastfeeding based on infant age, gender, and maternal race. Multinomial logistic regression analysis tested the hypothesis that a greater duration of mothers' longest previous smoking abstinence would predict successful breastfeeding initiation in the context of other sociodemographic and behavioral factors known to relate to breastfeeding (e.g., education level, income, and maternal age).

RESULTS

The sample consisted of current maternal smokers with a mean age of 28.8 ± 7.1 years. Among participants, 94% were African American, 81% were single, 63% reported an annual family income less than $15,000, and 76% had completed a high school education or less. Logistic regression demonstrated that a longer duration of previous smoking abstinence and education beyond high school predicted breastfeeding initiation.

CONCLUSIONS

Maternal smokers' previous success at smoking abstinence may increase the likelihood of successful breastfeeding initiation. To improve prenatal health education for maternal smokers with low education levels, researchers should explore the utility of merging smoking cessation and postpartum relapse prevention advice within the context of lactation counseling to maximize success of smokers' efforts to initiate breastfeeding.

Paternal smoking and breastfeeding in Xinjiang, PR China

A cohort of 1088 couples in Xinjiang, PR China, were recruited to study infant feeding practices and paternal smoking. Mothers were interviewed in hospital and at 0.5, 1.5, 2.5, 3.5, 4.5, and 6 months. Survival analysis was used to calculate breastfeeding rates in smokers and nonsmokers. The paternal smoking rate was 64.8% and maternal smoking rate 1.7% (P < .01). The rates for any breastfeeding in the smoking group were significantly lower than in the nonsmoking group from 3.5 months to 6 months (P < .05). The rates for exclusive breastfeeding in the paternal smoking group were lower than in the nonsmoking group from discharge to 6 months (P < .05). The median duration of exclusive breastfeeding in the paternal smoking group was shorter than in the nonsmoking group. Paternal smoking was a risk factor for stopping any breastfeeding (hazard risk, 1.84; 95% confidence interval, 1.11-3.04) and exclusive breastfeeding (hazard risk, 1.33; 95% CI, 1.09-1.64) compared with nonsmokers.

Maternal cigarette smoking and breastfeeding duration

AIM

To examine the relationship between cigarette smoking and breastfeeding duration at 2 wk, 6 mo, and longer.

METHODS

Design. A 12-mo longitudinal study. Setting. Two public maternity hospitals in the Perth metropolitan area (Western Australia). Subjects. Eligible mothers of healthy newborn infants. Interventions. Participants completed a self-administered baseline questionnaire while in hospital or shortly after discharge. All women regardless of their chosen infant feeding method were followed up by telephone interview at 4, 10, 16, 22, 32, 40 and 52 wk postpartum. Main outcome measures. Prevalence of breastfeeding at 2 wk, 2 wk to 6 mo and >6 mo in women who smoked during pregnancy, and breastfeeding duration.

RESULTS

Women who smoked during pregnancy had a lower prevalence and shorter duration of breastfeeding than non-smoking mothers (28 vs 11 wk, 95% CI 8.3-13.7). This effect remained even after adjustment for age, education, income, father's smoking status, mother's country of birth, intended duration of breastfeeding >6 mo and birthweight (risk ratio 1.59, 95% CI 1.22-2.08).

CONCLUSION

Women who smoke during pregnancy are at greater risk of not achieving national and international targets for breastfeeding. Encouraging smoking cessation in the antenatal setting is an area for considerable public health gain.

Determinants of breast-feeding and weaning in Alberta, Canada

OBJECTIVE

To assess the determinants of breast-feeding initiation and duration at the population level in Alberta, Canada.

METHODS

Determinants of breast-feeding were assessed based on data from a sample of 1113 women, who represented 150,898 fertile women in Alberta, in the second cycle of the National Population Health Survey conducted 1996-97. Logistic regression analysis was used to estimate the independent effects of various determinants of breast-feeding initiation and duration dichotomized at 4 weeks, 8 weeks, 12 weeks, and 6 months postpartum. All analyses used analytic weights to take both the average design effect and population weights for the complex survey design into account.

RESULTS

The proportion of breast-feeding initiation was 85.6%. It was observed that 71.3% of mothers continued breast-feeding for at least 3 months, and 37.2% of mothers breast-fed their infants for more than 6 months. Determinants of breast-feeding initiation were marital status, education, maternal smoking behaviour, and annual family income. White women and women who were older than 35 years of age were more likely to continue breast-feeding for longer periods, whereas those who smoked during pregnancy were less likely to breast-feed their infants for extended periods. The primary reasons for weaning were breast problems at less than 1 week, insufficient milk production during weeks 1 to 12, and infants who weaned themselves after 3 months.

CONCLUSIONS

Smoking cessation during pregnancy, adequate treatment of early breast problems, and breast-feeding promotion campaigns targeting socioeconomically disadvantaged populations could serve to increase breast-feeding in Canada.

A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants

Breastfeeding benefits preterm infants from a nutritional, gastrointestinal, immunological, developmental, and psychological perspective. Despite the benefits, the incidence and duration of breastfeeding preterm infants continues to be less than that of full-term infants. The lower incidence is probably related to breastfeeding challenges that preterm infants and parents face, including establishing and maintaining a milk supply and transitioning from gavage feeding to breastfeeding. In order to increase the incidence and duration of breastfeeding preterm infants, researchers must examine breastfeeding experiences longitudinally. This way, researchers and clinicians can begin to understand the barriers to breastfeeding at various time periods in the breastfeeding experience and begin implementing strategies to remove these barriers.

Maternal education and the incidence and duration of breast feeding: a prospective study

INTRODUCTION

Duration of breast feeding and factors possibly affecting duration were studied in a population of 2174 newborn infants, with gestational age of >37 weeks, who were born in the Department of Obstetrics and Gynaecology at the University of Florence Hospital between November 15, 1997, and November 14, 1998.

PATIENTS AND METHODS

Nine hundred mothers agreed to participate in the study. Five questionnaires were completed at the end of the 1st, 3rd, 6th, 9th, and 12th postpartum month. These dealt with infant feeding practices, including breast feeding during the previous week. Breast feeding duration was defined as short (1 month); medium-short (>1 month-<3 months); medium (>3-<6 months); medium-long (>6-<9 months), and long (>9 months).

RESULTS

The authors found that 76.3%, 64.7%, 42.3%, 26.4%, and 17% of mothers were still breast feeding at 1, 3, 6, 9, and 12 months after delivery, respectively. The multivariate analysis of the correspondence shows that lack of breast feeding is associated with a birth weight of less than 3000 g, a low level of maternal education, and maternal profession as a housewife or blue collar worker in the commercial sector. A period of breast feeding defined as short or medium-short is associated with mothers who smoke, primiparous mothers, and absence of maternal allergy. The survival curves highlight how the single factor of smoking is an element that leads to a significant difference in the duration of breast feeding. The multiple Cox regression analysis shows a significant negative influence associated with birth weight of less than 3000 g, maternal smoking, and first parity. Above all, among low-birth-weight infants of mothers who smoke, there is a strong correlation with a shorter duration of breast feeding.

DISCUSSION

There is still a need for programs that support and encourage breast feeding, focusing particularly on mothers with a low level of education who give birth to a low-weight infant, primiparous mothers, and smokers.

Infant feeding practices and associated factors in the first six months of life: the Norwegian infant nutrition survey

AIM

To describe and evaluate infant feeding practices during the first 6 mo of life in relation to recommendations, and to study infant feeding practices in relation to maternal and infant characteristics.

METHODS

Data from 2383 Norwegian infants aged 6 mo were collected by a self-administered semi-quantitative food-frequency questionnaire measuring feeding practices at 6 mo and feeding practices retrospectively at < or = 5.5 mo of age.

RESULTS

Only 1% of the infants had never been breastfed. The proportion of breastfed infants was 96% at 1 mo, 85% at 4 mo and 80% at 6 mo. The proportion of exclusively breastfed infants was 90% at 1 mo, 44% at 4 mo and 7% at 6 mo. Twenty-one percent of the infants were introduced to solid foods before the age of 4 mo. For exclusive breastfeeding at 4 mo, breastfeeding at 6 mo and timely introduction of solid foods (not before 4 mo) significant positive trends were found for maternal age, education and degree of urbanization. Negative associations were found for maternal smoking. Furthermore, exclusive breastfeeding at 4 mo was associated with infant gender and marital status, and the odds of breastfeeding at 6 mo significantly decreased with decreasing infant birthweight. Finally, both the odds of exclusive breastfeeding at 4 mo and of breastfeeding at 6 mo increased with increasing numbers of children.

CONCLUSION

These results indicate that a majority of Norwegian infants are fed in accordance with infant feeding recommendations during their first 6mo of life. However, the duration of exclusive breastfeeding is shorter than recommended. Infant feeding practices are significantly associated with maternal and infant characteristics.

Child care decisions: parental choice or chance?

AIM

A study of the context of child care decision making by inner city and suburban mothers, using parents to help develop and administer a semi-structured questionnaire.

METHODS

A total of 131 mothers were interviewed (73 inner city and 58 suburban) at home.

RESULTS

Inner city mothers were more likely to bottle feed, smoke and adopt risky infant sleeping positions, for example the settee. Virtually all babies (98%) were fully vaccinated and placed prone (95%) to sleep at night. Inner city mothers smoked (71%) despite the known health risks and continued postnatally (55%), mainly as a means of relieving stress. In total, 30% of inner city mothers wanted to breast feed; 19% had succeeded to 6-8 weeks postnatally. Bottle feeding helped both mother and baby to have uninterrupted nights of sleep. Suburban mothers (59%) succeeded in breast feeding, with others choosing bottle feeding mostly because of returning to work. The average weekly alcohol consumption, 32 units inner city and 15 units suburban, was taken in weekend binges by inner city parents, but in daily small amounts by suburban mothers.

CONCLUSIONS

The well-being of the baby was the prime concern of all mothers, irrespective of social background. However, inner city mothers made rational decisions to smoke and bottle feed to reduce the impact of stress and allow the mother much needed respite for the good of the entire family.

Maternal, paternal and environmental tobacco smoking and breast feeding

The effects of environmental tobacco smoke (ETS) on breast-feeding patterns are poorly understood, while those of parental smoking on breast-feeding initiation vs. duration have not been clearly delineated. We conducted a prospective, population-based birth cohort study to examine the independent effects of maternal, paternal and ETS on breast-feeding initiation and duration. A total of 6747 Hong Kong Chinese infants were recruited and followed up in 1997-8. We obtained detailed household smoking history and recorded breast-feeding patterns in three follow-up interviews over 9 months. We found that both maternal and paternal smoking were associated with not initiating breast feeding (odds ratio [OR] for ever maternal smoking = 2.51, 95% confidence interval [CI] = 1.63, 3.86; OR for ever paternal smoking = 1.22, 95% CI = 1.08, 1.39). Exposure to ETS in utero and post partum were also related to not starting breast feeding (OR(ETS in utero) = 1.10, 95% CI = 0.99,1.24; OR(ETS post partum) = 1.21, 95% CI = 1.08, 1.36). These effects, however, did not persist for breast-feeding duration of < or = 4 months. Cox proportional hazards modelling confirmed the lack of association between any form of smoking and breast-feeding duration. Our findings suggest that smoking of any kind, during or after pregnancy, is a strong risk indicator for not initiating breast feeding. Smoking as a risk indicator for underlying socio-economic, demographic and psychosocial factors is probably responsible for most of the observed adverse effects, although we cannot rule out direct contributions from pathophysiological mechanisms. Public health strategies directed at these underlying factors should be vigorously pursued to reduce the adverse effects of tobacco on breast feeding and infant health in general.

Breastfeeding initiation and duration: a 1990-2000 literature review

OBJECTIVE

To review the literature on breastfeeding initiation and duration and to delineate effective strategies for promoting positive breastfeeding behaviors.

DATA SOURCES

Computerized searches on MEDLINE, CINAHL, and the Cochrane Library.

STUDY SELECTION

Articles from indexed journals relevant to the objective and published after 1990 (except for classic findings) were reviewed. Although a myriad of pertinent articles was located, referenced citations were limited to three per point. When article selection was required for a specific point, preferences were given to (a) randomized controlled trials; (b) meta-analyses; (c) studies with the largest, most representative samples; and (d) investigations conducted in North America.

DATA EXTRACTION

Data were extracted and organized under the following headings: benefits of breastfeeding, breastfeeding initiation and duration, personal characteristics, attitudinal and intrapersonal characteristics, hospital policies and intrapartum experience, sources of support, breastfeeding interventions, and review implications.

DATA SYNTHESIS

Although the health benefits of breastfeeding are well documented and initiation rates have increased over the past 20 years, most mothers wean before the recommended 6-months postpartum because of perceived difficulties with breastfeeding rather than due to maternal choice. Women least likely to breastfeed are those who are young, have a low income, belong to an ethnic minority, are unsupported, are employed full-time, decided to breastfeed during or late in pregnancy, have negative attitudes toward breastfeeding, and have low confidence in their ability to breastfeed. Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors. Health care professionals can be a negative source of support if their lack of knowledge results in inaccurate or inconsistent advice. Furthermore, a number of hospital routines are potentially detrimental to breastfeeding. Although professional interventions that enhance the usual care mothers receive increase breastfeeding duration to 2 months, these supportive strategies have limited long-term effects. Peer support interventions also promote positive breastfeeding behaviors and should be considered.

CONCLUSIONS

A promising intervention is the complementation of professional services with peer support from a mother experienced in breastfeeding. This lay support appears to be an effective intervention with socially disadvantaged women.

Independent predictors of breastfeeding intention in a disadvantaged population of pregnant women

BACKGROUND

Breastfeeding rates in Scotland are very low, particularly in the more disadvantaged areas. Despite a number of interventions to promote breastfeeding very few women actually intend to breastfeed their baby. The aim of this study was to identify personal and social factors independently associated with intention to breastfeed.

METHODS

Nine hundred and ninety seven women from two socio-economically disadvantaged housing estates located on the outskirts of Glasgow participated in a study that aimed to increase the prevalence of breastfeeding. Self-administered questionnaires completed by each participant collected information in early pregnancy, prior to exposure to the study intervention, on feeding intention, previous feeding experience and socio-demographic data.

RESULTS

Five factors were independently predictive of breastfeeding intention. These were previous breastfeeding experience, living with a partner, smoking, parity and maternal age. After adjusting for these five factors, neither deprivation nor receipt of milk tokens provided useful additional predictive information.

CONCLUSION

In this population of socially disadvantaged pregnant women we identified five variables that were independently predictive of breastfeeding intention. These variables could be useful in identifying women at greatest risk of choosing not to breastfeed. Appropriate promotional efforts could then be designed to give due consideration to individual circumstances.

Maternal smoking and reduced duration of breastfeeding: a review of possible mechanisms

AIM

To systematically review the possible mechanisms by which maternal smoking affects lactation.

METHODS

Databases (Medline, CINAHL, Current Contents, Psychinfo, Sociological Abstracts and the Cochrane Library) were searched for smoking and breastfeeding or infant feeding. The Journal of Human Lactation and Birth were hand-searched, searches were also conducted at NMAA's Lactation Resource Centre and references cited were located where appropriate. Articles were divided into the various ways that smoking could affect breastfeeding and were tabulated.

RESULTS

Most studies were conducted on small samples of animals or humans; the majority were prior to 1985. Most animal studies exposed the animals to much greater levels of nicotine than those to which humans are exposed. Most studies did not examine if breastfeeding behaviour was similar in smokers and non-smokers, and did not consider that any physiological difference found could be the result of poor lactation practices, rather than the cause of poor lactation in smokers. The definition of breastfeeding infants was also problematic in many studies. The effect of smoking on oxytocin in women was only examined in one study, and no effect was found, yet a negative effect of smoking on oxytocin release is reported in the breastfeeding literature.

CONCLUSION

Although there is consistent evidence that women who smoke breastfeed their infants for a shorter duration than non-smokers, the evidence for a physiological mechanism is not strong.