Discontinuation Clinician Support and Psychosocial Risk Factors Associated With Breastfeeding

Objective. Breastfeeding rates fall short of goals set in Healthy People 2010 and other national recommendations. The current, national breastfeeding continuation rate of 29% at 6 months lags behind the Healthy People 2010 goal of 50%. The objective of this study was to evaluate associations between breastfeeding discontinuation at 2 and 12 weeks postpartum and clinician support, maternal physical and mental health status, workplace issues, and other factors amenable to intervention. Methods. A prospective cohort study was conducted of low-risk mothers and infants who were in a health maintenance organization and enrolled in a randomized, controlled trial of home visits. Mothers were interviewed in person at 1 to 2 days postpartum and by telephone at 2 and 12 weeks. Logistic regression modeling was performed to assess the independent effects of the predictors of interest, adjusting for sociodemographic and other confounding variables. Results. Of the 1163 mother–newborn pairs in the cohort, 1007 (87%) initiated breastfeeding, 872 (75%) were breastfeeding at the 2-week interview, and 646 (55%) were breastfeeding at the 12-week interview. In the final multivariate models, breastfeeding discontinuation at 2 weeks was associated with lack of confidence in ability to breastfeed at the 1to 2-day interview (odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.02–7.6), early breastfeeding problems (OR: 1.5; 95% CI: 1.1–1.97), Asian race/ ethnicity (OR: 2.6; 95% CI: 1.1–5.7), and lower maternal education (OR: 1.5; 95% CI: 1.2–1.9). Mothers were much less likely to discontinue breastfeeding at 12 weeks postpartum if they reported (during the 12-week interview) having received encouragement from their clinician to breastfeed (OR: 0.6; 95% CI: 0.4–0.8). Breastfeeding discontinuation at 12 weeks was also associated with demographic factors and maternal depressive symptoms (OR: 1.18; 95% CI: 1.01–1.37) and returning to work or school by 12 weeks postpartum (OR: 2.4; 95% CI: 1.8–3.3). Conclusions. Our results indicate that support from clinicians and maternal depressive symptoms are associated with breastfeeding duration. Attention to these issues may help to promote breastfeeding continuation among mothers who initiate. Policies to enhance scheduling flexibility and privacy for breastfeeding mothers at work or school may also be important, given the elevated risk of discontinuation associated with return to work or school. Pediatrics 2003;112:108–115; breastfeeding, neonatal, health services, clinician support, maternal depression. ABBREVIATIONS. KPMCP, Kaiser Permanente Medical Care Program; CES-D, Center for Epidemiologic Studies Depression Scale; OR, odds ratio; CI, confidence interval; HMO, health maintenance organization. The promotion and support of breastfeeding has emerged as a national public health priority in recent years. The American Academy of Pediatrics has recommended exclusive breastfeeding for 6 months, continuing to 1 year or beyond.1 In its Healthy People 2010 recommendations, the US Department of Health and Human Services set goals of 75% of mothers to breastfeed exclusively in the early postpartum period, 50% to continue to 5 to 6 months, and 25% to continue to 1 year.2 National statistics show large gaps between the reality and the goals, particularly for breastfeeding continuation. In 1998, 64% of mothers initiated breastfeeding in-hospital, but rates of any breastfeeding were only 29% by 6 months and 16% by 1 year.3 Studies have found elevated risk of breastfeeding discontinuation among mothers who are older, have lower educational attainment, and return to work full-time.4–7 Lack of support from family and friends, insufficient prenatal breastfeeding education, and hospital discharge packs that contain infant formula have also been associated with breastfeeding discontinuation.8,9 Among the many studies of breastfeeding continuation, few have evaluated factors amenable to intervention by clinicians in office settings.10 During the first 12 weeks postpartum, mothers must adjust to many new physical, psychological, and social demands. They and their newborns also regularly see health care providers for routine preventive visits, which are an opportunity for support of breastfeeding. This study was designed to address gaps in existing knowledge about clinician support and maternal mental health status as influences on breastfeeding continuation. Our aims were 1) to describe reasons for breastfeeding discontinuation during the first 12 From the *Harvard Pediatric Health Services Research Fellowship Program, Boston, Massachusetts; ‡Division of Research, Kaiser Permanente, Oakland, California; §Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California; and Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massa-