The Timing and Predictors of the Early Termination of Breastfeeding
           Ilgi Ozturk Ertem, Nancy Votto and John M. ...
The Timing and Predictors of the Early Termination of Breastfeeding

                         Ilgi Ozturk Ertem, MD*; Nanc...
Therefore, the purposes of this study were to iden-                    Statistical Analysis
tify the rate, timing, and pre...
not name a source, and only 1 mother identified a            ness, and leaking, were reported by 26.6% of the
WIC consulta...
TABLE 3.      Factors Associated With Early Discontinuation of         similar to that reported by Serwint (72.7%).33 Thes...
less than a high school education and those of Puerto        strengthen confidence may be the provision of finan-
Rican or...
to breastfeed before conventional prenatal breast-                             19. Trado MG, Hughes RB. A phenomenological...
The Timing and Predictors of the Early Termination of Breastfeeding
            Ilgi Ozturk Ertem, Nancy Votto and John M....
Upcoming SlideShare
Loading in …5

The Timing And Predictors Of The Early Termination Of Breastfeeding


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

The Timing And Predictors Of The Early Termination Of Breastfeeding

  1. 1. The Timing and Predictors of the Early Termination of Breastfeeding Ilgi Ozturk Ertem, Nancy Votto and John M. Leventhal Pediatrics 2001;107;543-548 DOI: 10.1542/peds.107.3.543 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2001 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from by on June 2, 2009
  2. 2. The Timing and Predictors of the Early Termination of Breastfeeding Ilgi Ozturk Ertem, MD*; Nancy Votto, RN‡; and John M. Leventhal, MD‡ B ABSTRACT. Objective. To determine the prevalence reastfeeding has been key for the survival of and correlates of the early discontinuation of breastfeed- the human species1 and has been a normative ing by mothers eligible for the Women, Infants, and behavior for all populations until the advent of Children Program (WIC). formula. The widespread behavior of nursing has Methodology. A longitudinal observational study in preceded the knowledge of the benefits of breast- which we enrolled English-speaking mothers who initi- feeding and advantages over formula. Lack of ated breastfeeding after delivering healthy-term infants knowledge regarding breastfeeding and problems of at Yale-New Haven Hospital and planned to bring their lactation may be universally encountered. These fac- infants to the hospital’s primary care center. Data on tors, however, play a minor role in the discontinua- mother’s baseline knowledge, attitudes, beliefs, and tion of breastfeeding in populations around the problems regarding breastfeeding were collected by semistructured interviews within 48 hours after delivery, world that practice prolonged breastfeeding.2–5 at 1 and 2 weeks’ postpartum, and by chart reviews at 2 Knowledge of when and why women discontinue and 4 months. A nonparticipating control group was used breastfeeding is crucial to guide interventions aimed to test the Hawthorne effect. at increasing both the initiation and duration of Results. Of the 64 participating mothers, the majority breastfeeding. The longer women continue nursing, were minority (56% black, 34% of Puerto Rican origin), the more this method of infant feeding will become single (75%), and already enrolled in WIC (91%). The “seen” and the more likely it is to be viewed as rates of discontinuation of breastfeeding were 27%, 37%, normative behavior, rather than just a “try.” 70%, and 89% by 1 week, 2 weeks, 2 months, and 4 The goals of the Department of Health and Human months, respectively. The mother’s knowledge and prob- Services Healthy People 2000 objective regarding lems of lactation were not associated with the early dis- breastfeeding were 75% for the initiation of breast- continuation of breastfeeding. After using logistic regres- feeding, and 50% for the continuation up to 6 months sion to control for potential confounders, mothers who postpartum.6 Although in the United States from lacked confidence at baseline that they would still be 1989 to 1995, the initiation of breastfeeding increased breastfeeding at 2 months (risk ratio: 2.38, 95% confi- from 52.2% to 59.7% and the rate of breastfeeding at dence interval: 1.82– 6.18), and those who believed that 6 months increased from 18.1% to 21.6%, these rates the baby prefers formula (risk ratio: 1.68, 95% confidence are lower for more indigent women.7 Many interven- interval: 1.04 –2.71) were more likely to stop breastfeed- tions have intended to increase the rates of both the ing within the first 2 weeks postpartum. Conclusions. The results of this study demonstrate initiation and continuation of breastfeeding for that interventions aimed at prolonging the duration of women enrolled in the Women, Infants, and Chil- breastfeeding in this population will need to shift focus dren Program (WIC) with limited success.8 –14 Most from increasing knowledge and managing problems of interventions have focused on increasing knowledge lactation to enhancing the mother’s confidence regarding regarding breastfeeding or the management of prob- breastfeeding, while also addressing beliefs regarding an lems of lactation. Where breastfeeding is not the infant’s preferences. Pediatrics 2001;107:543–548; breast- norm, however, it is not known whether the lack of feeding, breastfeeding duration, Women Infants and Chil- knowledge and problems encountered during dren Program. breastfeeding are the reasons for the early discontin- uation of breastfeeding. In the United States, for low-income mothers, re- ABBREVIATIONS. WIC, Women, Infants, and Children Program; NPCG, nonparticipating control group; CI, confidence interval; gional differences seem to play a role in the rates of RR, risk ratio. the initiation and duration of breastfeeding. Al- though there are some data about the correlates of breastfeeding for rural populations11–15 and for women living in Southern,16 –20 Western,21,22 and Midwestern23 United States, specifically for mothers living in urban environments and enrolled in WIC, From the *Department of Pediatrics, Ankara University School of Medicine, Ankara, Turkey and ‡Department of Pediatrics, Yale University School of recent data about the correlates of breastfeeding du- Medicine, New Haven, Connecticut. ration in the Northeastern region are few.10 Further- Received for publication Dec 2, 1999; accepted June 21, 2000. more, although data on the predictors of the early Reprint requests to (I.O.E.) Assistant Professor of Pediatrics, Department of discontinuation of breastfeeding by higher income Pediatrics, Ankara University School of Medicine, Cebeci, 06100, Ankara, Turkey. E-mail: women are present,24 the precise timing and predic- PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- tors for the early discontinuation of breastfeeding are emy of Pediatrics. not available for low-income populations. PEDIATRICS Vol. 107 No. 3 March 2001 543 Downloaded from by on June 2, 2009
  3. 3. Therefore, the purposes of this study were to iden- Statistical Analysis tify the rate, timing, and predictors of the early dis- The rates of discontinuing breastfeeding were calculated by continuation of breastfeeding for women enrolled in dividing the number of women not breastfeeding at all by the WIC and living in an urban Northeastern environ- number of women present in the study at each outcome point. Relative risks and confidence intervals (CIs) were computed to ment. Based on the theory by Fishbein and Ajzen25,26 examine the relationships between the baseline variables, interim that behavioral intentions are the most important problems related to breastfeeding, and the outcome of breastfeed- predictors of behavior and on previous reports that ing at 2 weeks and 2 months separately. Those variables signifi- have shown that intentions related to breastfeeding cantly related to the outcome were entered into a step-wise logistic regression model to identify variables that were independently predict breastfeeding behavior,27–29 we hypothesized related to the discontinuation of breastfeeding at 2 weeks. Because that for those women living in impoverished urban of the low rate of continuation at 2 months, a logistic regression environments 1) the early discontinuation of breast- analysis was not performed on this outcome. Because of the very feeding would not be dependent on the lack of low rate of breastfeeding at 4 months, these data were used only knowledge on breastfeeding or on problems of lac- to provide rates of discontinuation at the 2- to 4-month interval. For all analyses, we used SAS-PC (SAS Institute Inc, Cary, NC).31 tation; but that 2) the early discontinuation of breast- feeding could be predicted during the early postpar- RESULTS tum period by the mother’s beliefs and attitudes, During the time of data collection, information on specifically, her report of a lack of confidence in her 457 mothers was reviewed prospectively. Of these, intention to continue breastfeeding. 125 (27.4%) initiated breastfeeding and 332 (72.6%) bottle-fed their infants during the first 48 hours post- METHODS partum. Of the 125 breastfeeding mothers, 64 (51.2%) Eligibility Criteria were enrolled in the study group, and 61 (48.8%) During a 6-month period, we reviewed the daily postpartum were enrolled in the NPCG. Of the 61 mothers en- logs at Yale-New Haven Hospital (a university-based hospital) rolled in the NPCG, 21 (34.4%) stopped breastfeed- serving an inner-city population and enrolled mothers who met ing by 2 weeks and 72.7% and 83.6% had stopped the following criteria: 1) spoke English and were eligible for WIC; 2) delivered a healthy-term, singleton infant; 3) planned to bring breastfeeding by 2 and 4 months, respectively. There their infant to the hospital’s primary care center for well child care; were no differences between the study group and the and 4) initiated breastfeeding during the first 48 hours postpar- NPCG in any of the baseline sociodemographic char- tum. acteristics that were noted in the medical records or in the outcome of breastfeeding. These results Data Collection showed that participation in this study did not Mothers were told that we were interested in learning about change the rates of breastfeeding. The remainder of breastfeeding in general, and oral consent to participate in the the results focuses on the study group. study was obtained. The study was approved by the Institutional Review Board of Yale University School of Medicine. Baseline data were collected within the first 48 hours after delivery through a Sociodemographic Characteristics of Sample semistructured interview conducted on the postpartum floor. This As seen in Table 1, most mothers were of black interview was developed specifically for the study and included (56.3%) or Puerto Rican (34.4%) origin, and most both closed-ended and precoded, open-ended questions con- taining information on factors related to the discontinuation of were single (75.0%); their median age was 22.0, and breastfeeding. This information included the mother’s: 1) sociode- median years of education was 12.1. The majority of mographic characteristics; 2) knowledge regarding breastfeeding; mothers (90.6%) had already been enrolled in WIC and 3) attitudes and beliefs related to breastfeeding; in particular, before delivery. Most mothers (71.9%) stated that her confidence in her intention to continue breastfeeding. A they would not be going back to work or school mother was considered not confident if she stated at the baseline interview that her probability of still breastfeeding at 2 months within the next 2 months. postpartum was low. Problems related to breastfeeding and outcome data on the Knowledge Regarding Breastfeeding method of feeding were collected by a telephone interview con- The primary source of information on breastfeed- ducted 1-week postpartum, an interview in person conducted at the 2-week well-child visit, and a review of medical records at 2 ing was identified as written material or videotapes and 4 months of the child’s life. If a mother stated that she was no by 49.2% of mothers, medical professionals (includ- longer breastfeeding at all, this was considered discontinuation; ing obstetrician, midwife, pediatrician, or nurse) by any other amount of breastfeeding was considered continuation. 22.1%, and family or friends by 16.9%; 11.9% could The discontinuation of all breastfeeding episodes by 2 weeks or 2 months was referred to as the “very early” or “early” discontin- uation of breastfeeding, respectively. Exclusive breastfeeding was TABLE 1. Sociodemographic Characteristics of Mothers defined as breastfeeding without the introduction of formula or (n 64) solids. Water supplementation was allowed in the definition of exclusive breastfeeding. Sociodemographic Characteristics n (%) Because data collection involved intensive interviewing and Ethnicity patient contact, we also examined the possibility of the Hawthorne Black 36 (56.3) effect. This refers to the effect of study participation on the out- Puerto Rican 22 (34.4) come.30 A nonparticipating control group (NPCG) was used to test White 6 (9.4) the Hawthorne effect. This group consisted of women who ful- Primiparous 33 (51.6) filled the same eligibility criteria but who were purposefully not Marital status: interviewed. The researchers conducted interviews with study Single 48 (75.0) group mothers on alternating days. Women for the NPCG were Median age 22.0 chosen to be those mothers who delivered on days that the re- Median years of schooling 12.1 searchers did not conduct interviews. Baseline sociodemographic Enrolled in WIC before delivery 58 (90.6) data and similar outcome data regarding feeding practices were Not going back to work/school 46 (71.9) collected for this group by medical chart review. 544 EARLY TERMINATION OF BREASTFEEDING Downloaded from by on June 2, 2009
  4. 4. not name a source, and only 1 mother identified a ness, and leaking, were reported by 26.6% of the WIC consultant as a source of information. The pack- mothers; 2) problems related to the baby, such as age of benefits provided by WIC to breastfeeding spitting up, crankiness, and fussing, were reported mothers was correctly known by only 3 mothers. by 35.9%; 3) a perception of insufficient milk supply Almost all mothers (92.3%) noted that the infant’s was reported by 28.1%; 4) inconvenience for the pediatrician was the primary source from whom mother, such as being too tiring or preventing the they would desire to receive information regarding mother from going out, were reported by 28%; and breastfeeding, and the pediatrician was also identi- 5) problems that required medical management, fied by 79.7% as the primary person to turn to, if such as jaundice or maternal illness, were reported problems related to breastfeeding should occur. by 10.9%. Most mothers were knowledgeable about the bene- fits of breastfeeding for the infant (90.2%), naming all Outcome of Breastfeeding 3 types of benefits—nutritional, immunologic, and All 64 mothers participated in the 1-week and psychological. Knowledge related to the practice of 2-week interviews. Feeding methods could be docu- breastfeeding, such as how long exclusive breast- mented for 53 (82.8%) and 51 (79.7%) infants at 2 and feeding is sufficient for the baby, was correctly 4 months, respectively. There were no differences known by 30% of the women only, and only 3 moth- between the 64 mothers or infants enrolled in the ers identified frequent nursing as a means of increas- study and those 13 lost to follow-up by 4 months, ing milk production. with regard to baseline variables or rates of discon- tinuation of breastfeeding at 2 weeks. Attrition was Attitudes and Beliefs Related to Breastfeeding attributable to missing charts or missing data on Primiparous mothers comprised 51.6% of the feeding in the charts. As seen in Table 2, over a study group, and of the 31 multiparous mothers, 14 4-month period, there were 2 time frames during (42.4%) had not breastfed a former child. Thirty-one which mothers most frequently discontinued breast- percent of mothers had not seen anyone nursing, and feeding. The first peak of discontinuation occurred 51.6% had not been breastfed themselves. Benefits during the first week, when 26.6% mothers discon- for the infant, such as protection against illness, best tinued breastfeeding; the second peak was between 2 food, best nutrition, and no artificial products, were weeks and 2 months, when another 32.1% stopped. stated most frequently as the primary reason to By 2 months and 4 months, 77.4% and 88.2% of breastfeed (92.2%). Enhancement of mother-infant mothers had stopped breastfeeding, respectively. In interactions (3.1%) or benefits for the mother (4.7%) addition to these low rates of continuation of any were stated less often. The decision to breastfeed was amount of breastfeeding, as seen in Table 2, exclusive made before pregnancy by 32.8% of the mothers and breastfeeding rates were similarly low and decreased during the first, second, and third trimesters by in time. At 1 week, 2 weeks, 2 months, and 4 months: 46.9%, 12.5%, and 7.5% of the mothers, respectively. 37.5%, 26.6%, 11.3%, and 5.9% of the total number When asked how mothers thought people close to of infants remaining in the study were exclusively them felt about their decision to breastfeed, 70.3% breastfed, respectively. stated that such individuals wanted them to breast- feed. In 62.5% of the cases, the father of the baby was Factors Predicting the Early Discontinuation of perceived as supportive of breastfeeding. Breastfeeding Most mothers did not believe that breastfeeding Table 3 shows the relative risks for those baseline was inconvenient for the mother (81.3%); however, factors that were significantly related to the early 57.8% believed it was easier than formula feeding, discontinuation of breastfeeding at 2 weeks or 2 28.1% felt comfortable nursing in public, and 32.8% months. Although several factors were associated thought it was in fashion. Although most mothers with early discontinuation, only 2 variables—mater- stated that babies enjoy breastfeeding more than for- nal age 20 and lack of confidence about continuing mula feeding, 39.1% stated that babies enjoy formula to breastfeed until the infant was 2 months of age— more. Most mothers (95.3%) stated that they wanted were significantly associated with discontinuing to breastfeed up to 6 months, and 60.9% stated that breastfeeding both at 2 weeks and at 2 months. they wanted to breastfeed exclusively. Their in- Sources of information and knowledge on breast- tended reasons for stopping were related to a natural feeding or the occurrence of breastfeeding problems weaning time indicated by comments like “when during the first 2 weeks were not related to the baby gets teeth,” or “when he is old enough.” When outcome of discontinuation. Mothers who had not asked about their confidence that they would con- breastfed before were more likely to stop breastfeed- tinue breastfeeding until the infant was 2 months of age, 45.3% stated that the chances that they would TABLE 2. Timing and Rates of Termination of Breastfeeding still be breastfeeding were low. Time Period Rate of Rate of Exclusive ( 2 Days) Discontinuation Breastfeeding Problems Experienced During the First 2 Weeks of During During Breastfeeding Time Period Time Period At the 2-week interview, most mothers reported Before 7 d 17/64 (26.6%) 24/64 (37.5%) having experienced problems related to breastfeed- From 7 to 14 d 7/64 (10.9%) 17/64 (26.6%) ing. These were classified into 5 groups: 1) problems From 15 to 60 d 17/53 (32.1%) 6/53 (11.3%) From 61 to 120 d 10/51 (19.6%) 3/51 (5.9%) of nursing, such as cracked and painful nipples, sore- ARTICLES 545 Downloaded from by on June 2, 2009
  5. 5. TABLE 3. Factors Associated With Early Discontinuation of similar to that reported by Serwint (72.7%).33 These Breastfeeding similar rates of discontinuation justify the generaliz- Baseline Factors RR (95% CI) for ability of our results and the need to understand Discontinuation of Breastfeeding better when and why women in low-income popu- At 2 Weeks At 2 Months lations discontinue breastfeeding early. (95% CI) The exact timing of the termination of breastfeed- Maternal age 20 1.86* (1.02–3.41) 1.38* (1.07–1.76) ing has not been previously reported. We found that Puerto Rican ethnicity 2.26** (1.22–4.17) 1.12 (0.84–1.49) during the first 4 months postpartum, there are 2 Single marital status 0.77 (0.32–1.64) 1.74** (1.02–2.98) peaks for the termination of breastfeeding. The first Education 12 y 2.34** (1.31–4.18) 1.29 (1.00–1.65) peak is during the first week postpartum when ap- Decided while 3.41** (1.15–10.18) 1.27 (0.90–1.77) proximately 25% of mothers stop breastfeeding, and pregnant Not confident 2.80** (1.64–4.79) 11.70** (1.79–76.5) the second peak is between 2 weeks and 2 months Believed babies 1.97** (1.36–12.15) 1.15 (0.95–1.59) postpartum when another 40% discontinue. Fewer enjoy formula mothers (approximately 10%) stop breastfeeding be- *P .05; ** P .01. tween 1 and 2 weeks or between 2 months and 4 months. This timing suggests that a 1-week postpar- tum visit for well-child care is too late to intervene ing very early, but this did not reach a level of for many breastfeeding mothers. significance (risk ratio [RR]: 2.53; 95% confidence Our first hypothesis that the early discontinuation interval [CI]: 0.86 –7.42). Attitudes and beliefs that of breastfeeding would not be dependent on prob- were not related to the discontinuation of breastfeed- lems of lactation or on a lack of knowledge about ing included perceived support regarding breast- breastfeeding was confirmed. Although the majority feeding, intended duration of breastfeeding, in- of mothers in our sample reported experiencing tended exclusion of formula, and beliefs of the problems, there was no significant relationship be- convenience or hardship of breastfeeding. tween the very early discontinuation of breastfeed- ing and having problems related to breastfeeding. Independent Variables Predicting the Early This result may help explain why interventions Discontinuation of Breastfeeding aimed at solving problems of nursing have reported To determine the independent predictors of the limited success.10,34 very early discontinuation of breastfeeding, a step- The perception of insufficient milk supply was wise logistic regression analysis model was used. investigated separately, because parallel to other in- The 7 baseline variables shown in Table 3 were en- vestigators35,36 we believed that this would be an tered into the model as independent variables, with important reason why mothers discontinue breast- the termination of breastfeeding at 2 weeks as the feeding. Contrary to our expectations, however, the dependent variable. Two independent predictors of perception of insufficient milk supply was not re- breastfeeding at 2 weeks emerged from the logistic lated to the early termination of breastfeeding. regression model: the mother’s lack of confidence Most mothers were knowledgeable about the ben- about continuing to breastfeed up to 2 months (Man- efits of breastfeeding. They extensively described the tel-Haenszel adjusted RR 2.38, 95% CI: 1.82– 6.18), benefits for the baby, and these were the primary and the belief that the baby enjoys bottle feeding reasons given by mothers for the initiation of breast- (Mantel-Haenszel adjusted RR 1.68, 95% CI: 1.04 – feeding. Information related to the actual practice of 2.71). As seen previously in Table 3, of these 2 factors, breastfeeding was less often known by the mothers. only confidence in the continuation of breastfeeding Although the majority of mothers had decided to was significantly related to that outcome at 2 breastfeed before or during the first trimester of months. Those mothers who were not confident that pregnancy, and although the majority had been en- they would continue nursing up to 2 months were rolled in WIC during the first 2 trimesters of preg- almost 12 times more likely to stop breastfeeding nancy (79.3%), the benefits provided by the WIC before 2 months than those who were confident. program to breastfeeding mothers were primarily unknown. Overall, there was little variation in infor- DISCUSSION mation that was known, and there was no significant This study provides a longitudinal description of relationship between knowledge regarding breast- the rate, timing, and factors affecting the very early feeding and the early termination of nursing. This termination of breastfeeding by mothers eligible for finding has implications for interventions that aim to WIC and living in an urban area. In our study, 27% increase the duration of breastfeeding. Although in- of English speaking mothers who were eligible for formation that is already known by most mothers— WIC and who delivered healthy-term, singleton in- namely, the benefits of breastfeeding—may play a fants initiated breastfeeding. This rate is consistent very important role in the initiation of breastfeeding, with other reports from the Northeast region10,32 and it does not affect the duration of breastfeeding. also rates from urban populations from other re- As indicated by a comprehensive review of the gions.15,16 Although rates of the early discontinua- literature, sociodemographic variables have been tion of breastfeeding have been investigated less in- consistently related to the initiation and discontinu- tensively, our rate of discontinuation at 2 weeks ation of breastfeeding.37 We found younger age to be (37.4%) is similar to that reported by Kistin32 (38.5%), significantly related to the discontinuation of breast- and our rate of discontinuation at 2 months (77.4%) is feeding by 2 weeks and 2 months. Mothers who had 546 EARLY TERMINATION OF BREASTFEEDING Downloaded from by on June 2, 2009
  6. 6. less than a high school education and those of Puerto strengthen confidence may be the provision of finan- Rican origin had higher rates of discontinuation of cial incentives such as additional vouchers for moth- breastfeeding during the first 2 weeks postpartum. ers who choose to breastfeed coupled with support These findings regarding mothers of Puerto Rican to increase confidence. ethnicity are different from those reported for other A mother’s belief that her baby enjoys formula Hispanic mothers.38 Often in the medical literature, feeding more than breastfeeding emerged as a sec- populations of Mexican and Puerto Rican origin are ond independent predictor of the very early discon- both categorized as Hispanic. Our findings support tinuation of breastfeeding. Rephrased, this new find- the need to study additionally the breastfeeding pat- ing implies that the mother’s confidence in the terns of mothers of Puerto Rican origin living in the infant’s confidence that he/she wanted breastfeed- United States, to define ethnicity accurately, and also ing seemed as important as the mother’s confidence to guide interventions specifically to this ethnic in herself that she would continue to breastfeed. group, particularly during the earlier phases of Although these 2 concepts seem to be related and breastfeeding. overlapping, in our study, they were only moder- Perceived support from significant others, a factor ately correlated (Pearson’s R 0.30) and emerged as often found to be related to the initiation of breast- independent predictors of breastfeeding at 2 weeks. feeding,39,40 was not confirmed in our study. We In the study by Loughlin,24 the postpartum nurse’s may not have been able to determine actual support ratings of the newborn’s feeding behaviors also were from our interview. Alternatively, our finding, when predictive of the breastfeeding duration. It may be coupled with results from other studies,41,42 suggests that a newborn’s early behavior at the breast may that support from the father of the baby or other shape a mother’s perception of whether her baby persons close to the mother may not be enough or enjoys breastfeeding. It also may be, as implied by crucial for the continuation of breastfeeding. Loughlin, that the mother-infant interaction, which Our results supported our second hypothesis that may be guided by the mother’s confidence, is shap- confidence in the intention to breastfeed would be ing the nurse’s ratings. Our findings suggest that the the strongest predictor of breastfeeding outcome. mother’s perception of the infant’s response to The discontinuation of breastfeeding could be pre- breastfeeding is separate from the mother’s confi- dicted by the mother’s own prediction shortly after dence in breastfeeding. These preliminary findings birth that she would not likely breastfeed for long. highlight that the infant is an active participant in the This information, which was obtained before the outcome of breastfeeding. The infant’s cues and what mother had actually experienced breastfeeding for the infant wants need to be discussed to dispel the long or before she had encountered problems, sug- myth that infants like formula better. gests strongly that the discontinuation of breastfeed- Mothers identified their pediatrician as the desired ing is determined very early. Our findings are simi- source of information regarding breastfeeding and lar to those of Loughlin et al in a more affluent problems with breastfeeding. These findings place population of mostly white mothers followed in a pediatricians serving low-income, urban populations private practice.24 These mothers also were asked in a key position to promote breastfeeding. Recent how confident they were in breastfeeding, and this information regarding the importance of a physi- variable emerged as a significant predictor of the cian’s confidence about breastfeeding counseling44 early termination of breastfeeding. Interestingly, in and the educational needs of pediatricians about our study, when asked about how long they wished breastfeeding45 suggests ways to influence how phy- to continue breastfeeding, the vast majority stated sicians promote breastfeeding. that they would continue until the baby was old Our results reflect mothers enrolled in WIC at 1 enough to wean. It was only when mothers were center, therefore, the generalizability is limited. Fur- asked about their confidence or certainty that they thermore, because the rate of continuation is low, a would continue that mothers were able to express greater number of participants are needed to exam- their doubts and lack of confidence. ine the predictors of continuation of breastfeeding Based on our results, we believe that the concept of beyond 2 months. Interviews in person would have confidence in breastfeeding should be addressed in been desirable to obtain information about breast- any program aimed at promoting breastfeeding, and feeding at 2 and 4 months. Because of limitations of the mother should be allowed open discussion of this resources for such a follow-up, we relied on chart doubt or confidence. This method of intervention reviews. Despite these limitations, we believe that may help a woman to find the reasons behind the we have been able to determine attitudinal factors discrepancies between her idealized desire to con- associated with the duration of breastfeeding, and tinue breastfeeding and her lack of confidence that that our results add to the literature concerning the she actually will continue. Understanding these dis- sociodemographic characteristic. Attitudinal factors crepancies, in turn, may help to increase her confi- and beliefs involve intensive interviewing; we be- dence in her intended behavior. We believe that for lieve that the inclusion of a NPCG to test the Haw- populations where breastfeeding is not a normative thorne effect has strengthened the validity of our behavior, questions related to why it is not and why results. people have doubt should be posed early in life, such as in school programs or through mass media, or at CONCLUSION least very early in pregnancy. As implied earlier in We have demonstrated that breastfeeding women the literature,43 another approach that might in an underserved population make up their minds ARTICLES 547 Downloaded from by on June 2, 2009
  7. 7. to breastfeed before conventional prenatal breast- 19. Trado MG, Hughes RB. A phenomenological study of breast feeding WIC recipients in South Carolina. Adv Pract Nurs Q. 1996;2:31– 41 feeding promotion programs can reach them, and 20. Barron SP, Lane HW, Hannan TE, Struempler B, Williams JS. Factors that usually such women have made up their minds influencing duration of breast feeding among low-income women. J Am previously to stop breastfeeding sooner than conven- Diet Assoc. 1988;88:1557–1561 tional well-child care programs can reach them. We 21. Tuttle CR, Dewey KG. WIC programs associated with increasing breast conclude that to make breastfeeding the norm for a feeding among low-income among women in California. J Am Diet population where this is an infrequent event, inter- Assoc. 1996;96:885– 890 22. Tuttle CR, Dewey KG. Determinants of feeding choices among South- ventions should focus on increasing a mother’s con- east Asian immigrants in northern California. J Am Diet Assoc. 1994;94: fidence in breastfeeding; in addition, the role of the 282–286 infant on the duration of breastfeeding should be 23. McClurg-Hitt D, Olsen J. Infant feeding decisions in the Missouri WIC taken into account. Program. J Hum Lact. 1994;10:253–256 24. Loughlin HH, Clapp-Channing NE, Gehlbach SH, Pollard JC, Mc- ACKNOWLEDGMENT Cutchen TM. Early termination of breast feeding: identifying those at risk. Pediatrics. 1985;75:508 –513 Dr. Leventhal was supported in part by a Training Grant in 25. Ajzen I, Fishbein M. Attitude-behavior relations: a theoretical analysis Behavioral Pediatrics from the Bureau of Maternal and Child and review of empirical research. Psychol Bull. 1977;84:888 –918 Health. 26. Gabriel A, Gabriel KR, Lawrence RA. Cultural values and biomedical knowledge: Choices in infant feeding. Soc Sci Med. 1986;23:501–509 REFERENCES 27. Buxton KE, Gielen AC, Faden RR, Brown CH, Paige DM, Chwalow AJ. 1. Greer FR, Apple RD. Physicians, formula companies and advertising. A Women intending to breastfeed: predictors of early infant feeding ex- historical perspective. Am J Dis Child. 1991;145:282–286 periences. Am J Prev. Med. 1991;7:101–106 2. Nath DC, Goswami G. Determinants of breast feeding patterns in an 28. Manstead AS, Plevin CE, Smart JL. Predicting mothers’ choices of infant urban society of India. Hum Biol. 1997;69:557–573 feeding method. Br J Soc Psychol. 1984;23:223–231 3. Tessema T, Hailu A. Childhood feeding practice in north Ethiopia. East 29. Manstead AS, Proffitt C, Smart JL. Predicting and understanding moth- Afr Med J. 1997;74:92–95 ers’ infant-feeding intentions and behavior: testing the theory of rea- 4. Marquis GS, Diaz J, Bartolini R, Creed de Kanashiro H, Rasmussen KM. soned action. J Pers Soc Psychol. 1983;44:657– 671 Recognizing the reversible nature of child feeding decisions: breast 30. Homans G. Group Factors in Worker Productivity. In: H Proshansky, B feeding, weaning, and relactation patterns in a shanty town community Seidenberg, eds. Basic Studies in Social Psychology. New York, NY: Holt, of Lima, Peru. Soc Sci Med. 1998;47:645– 656 Rinehart, and Winston; 1965:592– 604 5. Jakobsen MS, Sodemann M, Molbak K, Aaby P. Reason for termination 31. SAS System for Elementary Statistical Analysis. 2nd ed. Cary, NC: SAS of breast feeding and the length of breast feeding. Int J Epidemiol. Institute Inc; 1997 1996;25:115–121 32. Kistin N, Benton D, Rao S, Sullivan M. Breast feeding rates among black 6. US Department of Health and Human Services. Healthy People 2000: urban low-income women: effect of prenatal education. Pediatrics. 1990; National Health Promotion and Disease Prevention Objectives-Full Report, 86:741–746 with Commentary. Washington DC: US Government Printing Office. 33. Serwint JR, Wilson ME, Vogelhut JW, Repke JT, Seidel HM. A random- 2000;1990:379 ized controlled trial of prenatal pediatric visits for urban, low-income 7. Ryan AS. The resurgence of breast feeding in the United States. Pediat- families. Pediatrics. 1996;98:1069 –1075 rics. 1997;99(4). 34. Grossman LK, Harter C, Sachs L, Kay A. The effect of postpartum 8. Young SA, Kaufman M. Promoting breast feeding at a migrant health lactation counseling on the duration of breast feeding in low income center. Am J Public Health. 1988;78:523–525 populations. Am J Dis Child. 1990;144:471– 474 9. Arlotti JP, Cottrell BH, Lee SH, Curtin JJ. Breast feeding among low- 35. Hill PD, Aldog J. Potential indicators of insufficient milk supply syn- income women with and without peer support. J Community Health drome. Res Nurs Health. 1991;14:11–19 Nurs. 1998;15:163–178 36. Hill PD, Humenick SS. Development of the H & H Lactation Scale. Nurs 10. Caulfield LE, Gross SM, Bentley ME, et al. WIC based interventions to Res. 1996;45:136 –140 promote breast feeding among African-American women in Baltimore: 37. Losch M, Dungy Claibourne ID, Russell D, Dusdieker LB. Impact of effects on breast feeding initiation and continuation. J Hum Lact. 1998; attitudes on maternal decisions regarding infant feeding. J Pediatr. 1995; 14:15–22 125:507–514 11. Schafer E, Vogel MK, Viegas S, Hausafus C. Volunteer peer counselors 38. Ryan AS, Rush D, Krieger FW, et al. Recent declines in breast feeding in increase breast feeding duration among rural low-income women. Birth. the United States, 1984 through 1989. Pediatrics. 1991;88:719 –727 1998;25:101–106 39. Matich JR, Sims LS. A comparison of social support variables between 12. Reifsner E, Eckhart D. Prenatal breast feeding education: its effect on breast feeding among WIC recipients. J Hum Lact. 1997;13:121–125 women who intend to breast or bottle feed. Soc Sci Med. 1992;34:919 –927 13. Long DG, Funk Archuleta MA, Geiger CJ, Mozar AJ, Heins JN. Peer 40. Raj VK. The role of social support in breast feeding promotion: A counselor program increases breast feeding rates in Utah Native Amer- literature review. J Hum Lact. 1998;14:41– 45 ican WIC population. J Hum Lact. 1995;11:279 –284 41. Freed GL, Jones TM, Schandler RJ. Perinatal determination of demo- 14. Young SA, Kaufman M. Promotion of breast feeding at a migrant health graphic and attitudinal factors regarding feeding practice in the indi- center. Am J Public Health. 1988;78:523–525 gent population. Am J Perinatol. 1992;9:420 – 424 15. Gielen AC, Faden RR, O’Campo P, Paige DM. Determinants of breast 42. Barron SP, Lane HW, Hannon TE, Struempler B, Williams JC. Factors feeding in a rural WIC population. J Hum Lact. 1992;8:11–15 influencing duration of breast feeding among low income women. J Am 16. MacGowan RJ, MacGowan CA, Serdula MK, Lane JM, Joesoef RM, Diet Assoc. 1988;88:1557–1561 Cook FH. Breast feeding among women attending women, infants and 43. Kramer MS. Poverty, WIC, and promotion of breast feeding. Pediatrics. children clinics in Georgia 1987. Pediatrics. 1991;87:361–366 1991;87:399 – 400 17. Black RF, Blair JP, Jones VN, Durant RH. Infant feeding decisions 44. Burglehaus MJ, Smith LA, Sheps SB, Green LW. Physicians and breast among pregnant women from a WIC population in Georgia. J Am Diet feeding: beliefs, knowledge, self-efficacy and counseling practices. Can Assoc. 1990;90:255–259 J Public Health. 1997;88:383–387 18. Bagwell JE, Kendrick OW, Stitt KR, Leeper JD, Espy ML, Gedel ML. 45. Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians practices and Breastfeeding among women in the Alabama WIC Program. J Hum Lact. attitudes regarding breast feeding promotion. Pediatrics. 1999; 103(3). 1992;8:205–208 URL: 548 EARLY TERMINATION OF BREASTFEEDING Downloaded from by on June 2, 2009
  8. 8. The Timing and Predictors of the Early Termination of Breastfeeding Ilgi Ozturk Ertem, Nancy Votto and John M. Leventhal Pediatrics 2001;107;543-548 DOI: 10.1542/peds.107.3.543 Updated Information including high-resolution figures, can be found at: & Services References This article cites 32 articles, 15 of which you can access for free at: Citations This article has been cited by 20 HighWire-hosted articles: s Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Nutrition & Metabolism m Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: Reprints Information about ordering reprints can be found online: Downloaded from by on June 2, 2009