Medically Complex Pregnancies and Early BreastfeedingBehavio.docx

Medically Complex Pregnancies and Early Breastfeeding
Behaviors: A Retrospective Analysis
Katy B. Kozhimannil1*, Judy Jou1, Laura B. Attanasio1,
Lauren K. Joarnt2, Patricia McGovern3
1 Division of Health Policy and Management, University of
Minnesota School of Public Health, Minneapolis, Minnesota,
United States of America, 2 Harvard University,
Cambridge, Massachusetts, United States of America, 3
Division of Environmental Health Sciences, University of
Minnesota School of Public Health, Minneapolis,
Minnesota, United States of America
Abstract
Background: Breastfeeding is beneficial for women and infants,
and medical contraindications are rare. Prenatal and labor-
related complications may hinder breastfeeding, but supportive
hospital practices may encourage women who intend to
breastfeed. We measured the relationship between having a
complex pregnancy (entering pregnancy with hypertension,
diabetes, or obesity) and early infant feeding, accounting for
breastfeeding intentions and supportive hospital practices.
Methods: We performed a retrospective analysis of data from a
nationally-representative survey of women who gave birth
in 2011–2012 in a US hospital (N = 2400). We used logistic
regression to examine the relationship between pregnancy
complexity and breastfeeding. Self-reported prepregnancy
diabetes or hypertension, gestational diabetes, or obesity

indicated a complex pregnancy. The outcome was feeding status
1 week postpartum; any breastfeeding was evaluated
among women intending to breastfeed (N = 1990), and exclusive
breastfeeding among women who intended to exclusively
breastfeed (N = 1418). We also tested whether breastfeeding
intentions or supportive hospital practices mediated the
relationship between pregnancy complexity and infant feeding
status.
Results: More than 33% of women had a complex pregnancy;
these women had 30% lower odds of intending to breastfeed
(AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to
exclusively breastfeed were similar for women with and without
complex pregnancies. Women who intended to breastfeed had
similar rates of any breastfeeding 1 week postpartum
regardless of pregnancy complexity, but complexity was
associated with .30% lower odds of exclusive breastfeeding 1
week among women who intended to exclusively breastfeed
(AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices
were strongly associated with higher odds of any or exclusive
breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81–
8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively).
Conclusions: Improving clinical and hospital support for women
with complex pregnancies may increase breastfeeding
rates and the benefits of breastfeeding for women and infants.
Citation: Kozhimannil KB, Jou J, Attanasio LB, Joarnt LK,
McGovern P (2014) Medically Complex Pregnancies and Early
Breastfeeding Behaviors: A Retrospective
Analysis. PLoS ONE 9(8): e104820.
doi:10.1371/journal.pone.0104820
Editor: Katariina Laine, Oslo University Hospital, Ullevål,
Norway

Received April 2, 2014; Accepted July 16, 2014; Published
August 13, 2014
Copyright: � 2014 Kozhimannil et al. This is an open-access
article distributed under the terms of the Creative Commons
Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium,
provided the original author and source are credited.
Data Availability: The authors confirm that, for approved
reasons, some access restrictions apply to the data underlying
the findings. The authors obtained the
Listening to Mothers III data from the Childbirth Connection
program that commissioned the survey. Prior versions of this
survey are freely available for analysis
through the Odum Institute Dataverse Network at the University
of North Caroline at this location: http://arc.irss.unc.edu/dvn.
The data that the authors used for
this analysis come from the third wave of the survey which is
currently being placed in this public repository.
Funding: This research was supported by a grant from the
Eunice Kennedy Shriver National Institutes of Child Health and
Human Development (NICHD; grant
number R03HD070868) and the Building Interdisciplinary
Research Careers in Women’s Health Grant (grant number
K12HD055887) from NICHD, the Office of
Research on Women’s Health, and the National Institute on
Aging, at the National Institutes of Health, administered by the
University of Minnesota Deborah E.
Powell Center for Women’s Health. The funders had no role in
study design, data collection and analysis, decision to publish,
or preparation of the manuscript.
Competing Interests: The authors have declared that no
competing interests exist.

* Email: [email protected]
Introduction
Breastfeeding has many advantages to infants [1]. In 2010,
approximately 77% of US infants were breastfed at least once, a
substantial increase from 64% in 1998 [2,3]. Despite this
progress,
breastfeeding continues to fall short of national goals for
duration
and exclusivity set in initiatives such as Healthy People 2020
[2,4].
One possible reason for failure to consistently meet these goals
is
the rise in complications women face as they enter pregnancy,
including diabetes, obesity, and hypertension. Breastfeeding
initiation rates are lower and breastfeeding duration is generally
shorter among women with these conditions [5–8]. Six percent
of
births are complicated by diabetes [9], 3%–5% of pregnant
women have hypertensive disorders [10–12], and 19%–39% of
are
obese when they become pregnant [13]. Clinical management of

these conditions and associated complications may necessitate
greater intrapartum or neonatal intervention, which could affect
care for the woman or infant in the immediate postpartum
period,
including breastfeeding [14–19].
The decision to breastfeed is highly personal and affected by
many factors, including anticipated barriers to or support for
breastfeeding, hospital practices, medical issues occurring
either
PLOS ONE | www.plosone.org 1 August 2014 | Volume 9 | Issue
8 | e104820
http://creativecommons.org/licenses/by/4.0/
http://arc.irss.unc.edu/dvn
http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.
0104820&domain=pdf
before or during pregnancy, and complications during labor and
delivery [1,20–26]. One program that has been successful in
encouraging breastfeeding is the Baby-Friendly Hospital
Initiative
(BFHI), a global program to encourage and recognize hospitals
that have policies to provide evidence-based care to support
infant

feeding and mother-baby bonding [1,20,24,25,27]. The program,
for example, instructs mothers on breastfeeding, allows babies
to
spend the first hour after birth in their mothers arms; provides
newborns no food or drink other than breast milk, unless
medically
indicated; practices ‘‘rooming in’’ by allowing mothers and
infants
to remain together 24 hours per day; gives no pacifiers or
artificial
nipples to breastfeeding infants; and refer mothers to
breastfeeding
support groups on discharge from the hospital or clinic. Greater
adoption of these practices is also a focus of Healthy People
2020
[28]. Yet despite the success of these measures, fewer than 7%
of
U.S. births currently occur in facilities with an official BFHI
designation [28]. This study examines the relationship between
entering pregnancy with complicating health conditions and
early
infant feeding behaviors, focusing on women’s breastfeeding

intentions and supportive hospital practices as potential
mediators.
Materials and Methods
Conceptual Model
Figure 1 presents the conceptual model for the analysis. The
model focuses on women’s breastfeeding intentions and hospital
support practices during the intrapartum period and how these
factors and their effects may differ for women who enter
pregnancy with diabetes, hypertension or obesity.
Data
Data are from the Listening to Mothers III survey, a nationally
representative sample of women who gave birth to a singleton in
a
US hospital between July 1, 2011, and June 30, 2012 (N =
2400).
The survey was commissioned by Childbirth Connection and
conducted by Harris Interactive between October and December
2012. The survey documented pregnancy, labor, and birth
experiences in US hospitals, including information about breast-
feeding decisions and pre-existing medical conditions. Data
from

this survey have been widely used in clinical and public health
research, including studies of breastfeeding and the role of
supportive hospital practices [26,29,30]. However, this was the
first wave of the survey to include information about medical
conditions prior to pregnancy. Detailed information about the
survey’s methodology, implementation, and questionnaires is
available at www.childbirthconnection.org/listeningtomothers/.
The data used in this analysis were de-identified. Therefore, the
University of Minnesota Institutional Review Board granted this
study exemption from review (Study No. 1011E92983).
Variable Measurement
Pregnancy Complexity. We defined pregnancy complexity
from available survey data relating to 3 common medical risk
factors: (1) taking prescription medication for blood pressure
during the month before pregnancy, (2) having either type 1 or
type 2 diabetes before pregnancy or gestational diabetes, or (3)
having a prepregnancy body mass index higher than 30. Our
main
analysis included a dichotomous measure of pregnancy

complexity
for women reporting any of these 3 conditions. We also
constructed indicators for each of the conditions for separate
analysis (see following description of sensitivity analyses).
Breastfeeding Intention. Women were asked at the time of
the survey to recall their intentions about infant feeding at the
end
of pregnancy. We created dichotomous variables indicating (1)
any
intent to breastfeed (exclusively or not) and (2) women’s intent
to
breastfeed exclusively. Supportive hospital practices and infant
feeding status were assessed among women who reported any
intention to breastfeed (n = 1990), and exclusive breast milk
feeding status at 1 week postpartum was assessed among women
who intended to exclusively breastfeed (n = 1418).
Supportive Hospital Practices. Among women who in-
tended to breastfeed, we examined supportive hospital practices
consistent with BFHI standards. We measured supportive
hospital

practices using an 8-point composite measure corresponding to
7
of the 10 BFHI steps. Measures for the remaining 3 steps were
not
assessed in the Listening to Mothers surveys because they
require
knowledge of hospital administrative policies beyond the scope
of
women’s knowledge and experiences. However, data from these
Figure 1. Conceptual Model.
doi:10.1371/journal.pone.0104820.g001
8 | e104820
www.childbirthconnection.org/listeningtomothers/
surveys have previously been used to successfully approximate
BFHI hospital practices [26,30]. See Table 1 for detailed
information about the 10 BFHI steps and the 8 items assessed in
the data and used in this analysis.
To assess general concordance with supportive breastfeeding
practices in the hospital, we created a composite measure in

which
higher scores indicate that the woman perceived a higher level
of
breastfeeding-supportive hospital practices. Scores were not
normally distributed, so we constructed a dichotomous variable
on the basis of the top quintile of responses. Scores of 7 to 8
were
categorized as ‘‘high hospital support,’’ indicating practices
broadly consistent with BFHI standards. We also assessed the
distribution of the items in the composite measure and tested
the
stability of the measure by modeling hospital support as a
continuous variable (0–8) and by using a lower threshold (i.e.,
scores of 6–8 for high levels of support from the hospital).
Results
were robust to alternative specifications.
Feeding Status 1 Week Postpartum. Two dichotomous
measures of infant feeding status were based on women’s
responses
to questions regarding (1) whether they were feeding their
newborn any breast milk (either exclusively or in combination

with formula) 1 week postpartum, and (2) whether they were
feeding their newborn breast milk only 1 week postpartum. This
definition allows for both direct breastfeeding and feeding
expressed breast milk to infants.
Control Variables. We controlled for labor and delivery
factors that may affect the initiation of breastfeeding, including
cesarean delivery, epidural use, and admission to a neonatal
intensive-care unit [31–34]. We assessed these variables from
maternal self-report. We also included several self-reported
sociodemographic and birth-related covariates, including age;
race/ethnicity (white, black, Hispanic, or other/multiple race);
education (high school or less, some college, bachelor’s degree,
or
graduate education); 4-category census region (Northeast,
South,
Midwest, West); nativity (foreign- or US-born); partnership
status
(unmarried with no partner, unmarried with partner, or
married);
parity (first-time pregnancy); pregnancy intention (unintended

or
intended pregnancy); agreement with the statement ‘‘birth is a
process that should not be interfered with unless medically
necessary;’’ doula support; and primary payer for maternity
care
(private, public, or out-of-pocket).
Analysis
We first explored associations between the predictors,
outcomes,
and covariates for the overall sample using 1- and 2-way
tabulation. We used Pearson’s x2 tests to determine whether
differences based on pregnancy complexity were statistically
significant. We used logistic regression to estimate the adjusted
odds of breastfeeding intention based on pregnancy complexity.
Among women intending to breastfeed, we estimated the
adjusted
odds of breastfeeding status 1 week postpartum. To test for
mediation by hospital support, we added a variable indicating
high
levels of support for breastfeeding at the hospital. In the final
multivariate models of breastfeeding status 1 week postpartum,
we

included only covariates that were statistically significantly
associated with the outcomes. We conducted sensitivity
analyses,
estimating the same regression models using indicator variables
for
prepregnancy obesity, hypertension, and diabetes as the
predictors
rather than the combined ‘‘complex pregnancy’’ variable;
results
were substantively unchanged. All analyses used a p-value of
0.05
to determine statistical significance, were conducted using Stata
v.12, and weighted to be nationally representative.
Results
Table 2 presents the characteristics of the study population by
pregnancy complexity. Overall, 36.3% of respondents had 1 or
more conditions indicating a complex pregnancy (n = 871).
About
8% of women were taking blood pressure medications in the
month before pregnancy, 19.7% were obese, and 20.4% were
diagnosed with diabetes prior to or during pregnancy. There was

some overlap between conditions, particularly for diabetes and
hypertension (r = 0.25), diabetes and obesity, (r = 0.09), and for
hypertension and obesity (r = 0.04).
Table 3 shows the distribution of breastfeeding intentions,
supportive hospital practices, and infant feeding outcomes by
Table 1. Baby Friendly Health Initiative Composite Measure
Components.
Baby Friendly Hospital Practices
Corresponding question(s) used to construct Baby Friendly
Hospital Initiative Composite measure
Help mothers initiate breastfeeding within 1 hour of birth. Baby
spent 1st hour in mother’s arms.
Show mothers how to breastfeed and how to maintain lactation,
even if they are separated from their infants.
Hospital staff helped get started breastfeeding.
Hospital staff showed how to position baby for breastfeeding.
Give newborn infants no food or drink other than breast milk,
unless medically indicated.
Hospital staff did not provide water or formula supplements.
Practice ‘‘rooming in’’—allow mothers and infants to remain
together 24 hours per day.
Baby roomed with mother.

Encourage breastfeeding on demand. Hospital staff encouraged
breastfeeding on demand.
Give no pacifiers or artificial nipples to breastfeeding infants.
Hospital staff did not give baby a pacifier.
Foster the establishment of breastfeeding support groups and
refer
mothers to them on discharge from the hospital or clinic.
Hospital staff told about breastfeeding resources in the
community.
Inform all pregnant women about the benefits and management
of breastfeeding.
Not Applicable
Have a written breastfeeding policy that is routinely
communicated
to all health care staff.
Not Applicable
Train all health care staff in skills necessary to implement this
policy. Not Applicable
doi:10.1371/journal.pone.0104820.t001
8 | e104820

pregnancy complexity. In bivariate associations, women with
complex pregnancies were less likely to report that they
intended
to breastfeed (77.2% intended to do so) than women without
complex pregnancies, (83.3%; P = .012) but there was no
difference between groups in intention to exclusively breastfeed
(55.7% vs. 51.0%). Overall levels of hospital breastfeeding
support
among women who intended to breastfeed differed by pregnancy
complexity, with 14.8% of women with complex pregnancies
reporting high levels of hospital support, compared with 20.4%
of
women without complex pregnancies (P = .030). The only two
statistically significant findings among the specific support
measures were that women with complex pregnancies were less
likely to report that their baby had spent the first hour after
birth
in their arms (P = .017) and that the hospital staff had helped
them
to start breastfeeding (P = .008). Among women planning to
breastfeed, about 90% reported feeding their newborn either
partially or exclusively breast milk 1 week postpartum,
regardless

of pregnancy complexity. Of those who intended to breastfeed
exclusively, 79.5% of those without complex pregnancies and
69.4% of those with complex pregnancies were doing so
(P = .002).
Table 2. Percentage of Women in the Study Sample (N = 2400),
With a Specific Characteristic, by Pregnancy Complexity.
Complex Pregnancy
No Yes P Value
Total 63.7 36.3 —
Sociodemographic Characteristics
Age category .667
18–24 31.9 31.6
25–29 27.3 30.1
30–34 25.7 23.1
35+ 15.0 15.2
Race .023
White 57.8 48.8
Black 13.9 17.9

Hispanic 22.2 24.8
Other/multiple race 6.2 8.5
Education .040
High school or less 40.0 46.2
Some college/associate’s degree 28.9 28.0
Bachelor’s degree 18.4 16.9
Graduate education/degree 12.8 8.9
Region .520
Northeast 14.5 16.4
Midwest 23.5 21.2
South 38.8 41.2
West 23.2 21.2
Foreign born 8.0 5.4 .107
Partnership status .003
Unmarried with no partner 5.9 11.5
Unmarried with partner 32.7 29.7
Married 61.4 58.8
Pregnancy Characteristics

First-time mother 39.5 42.9 .249
Unintended pregnancy 36.1 34.1 .487
Belief that childbirth is a process that should only be interfered
with if medically necessary 58.7 57.9 .797
Had doula support during labor 5.3 7.0 .281
Health Insurance Status .045
Private 48.2 40.6
Public 44.3 50.5
Out-of-pocket 7.5 8.8
Note: Percentages are weighted to be nationally representative.
Bold values indicate statistically significant difference (P#.05).
P values are based on Pearson’s x2 tests.
8 | e104820
After controlling for sociodemographic and other factors
(Table 4), women with more complex pregnancies were approx-
imately 30% less likely to intend to breastfeed at all (adjusted
odds

ratio [AOR] = 0.71; 95% confidence interval [CI], 0.52–0.98),
compared with women who had no complications entering
pregnancy. However, pregnancy complexity had no independent
association with intention to breastfeed exclusively.
In multivariate analysis we found no relationship between
complex pregnancy and whether the infant was being fed breast
milk exclusively or partially 1 week postpartum (Table 5) after
controlling for the same sociodemographic and clinical
covariates.
In subsequent models, we also controlled for supportive hospital
practices to examine potential mediation. Babies whose mothers
received high levels of hospital support for breastfeeding were 4
times more likely to receive at least some breast milk 1 week
postpartum. Among women who intended to exclusively breast-
feed, those with complex pregnancies had more than 30% lower
odds of feeding their infants breast milk only (AOR = 0.68;
95%
CI, 0.47–0.98). High levels of hospital support for breastfeeding
were associated with nearly 3 times the odds of exclusive

breastfeeding 1 week postpartum (AOR = 2.79; 95% CI, 1.77–
4.39). When these factors were included simultaneously, the
association between pregnancy complexity and lower odds of
exclusive breastfeeding remained similar (AOR = 0.69; 95% CI,
0.48–1.00).
Discussion
The study examined the effect of entering pregnancy with
medical complications on infant feeding practices among those
who intended to breastfeed either at all or exclusively, and the
influence of hospital practices on those decisions. Women with
hypertension or diabetes or those who were obese when they
became pregnant were less likely to intend to breastfeed than
women whose pregnancies were not complicated by these
Table 3. Percentage of Women in the Study Population (N =
2400) With Specific Breastfeeding Behaviors, as Well as
Intentions and
Hospital Support, by Pregnancy Complexity.
Complex Pregnancy
No Yes P Value
Breastfeeding intentions (among all women n = 2400)

Intention to breastfeed, any 83.3 77.2 .012
Intention to breastfeed, exclusive 55.7 51 .115
Hospital Breastfeeding Support Composite Measure (among
women planning to breastfeed, n = 1990)
Low (0–6 steps) 79.6 85.2
High (7–8 steps) 20.4 14.8 .030
Hospital Breastfeeding Support Composite Measure
Components
Baby in mother’s arms during 1st hour after birth 51.4 43.4 .017
Baby roomed in with mother 63.6 59.4 .193
Hospital staff helped start breastfeeding 81.6 74.4 .008
Hospital staff showed how to position baby for breastfeeding
64.8 62.4 .432
Hospital encouraged breastfeeding on demand 66.4 64.6 .570
Hospital staff did NOT provide water or formula supplements
65.6 61.2 .298
Hospital staff gave information on community resources 52.2
48.7 .294
Hospital staff did NOT give baby a pacifier 58.4 62.2 .245
Outcomes: Infant Feeding 1 Week Postpartum (among women
intending to breastfeed)

Breastfeeding at 1 week, any (n = 1990) 91.9 89.0 .156
Breastfeeding at 1 week, exclusive (n = 1418) 79.5 69.4 .002
Note: Percentages are weighted to be nationally representative.
Bold values indicate statistically significant difference (P#.05).
P values are based on Pearson’s x2 tests.
Table 4. Controlled Odds of Breastfeeding Intentions by
Pregnancy Complexity (N = 2400).
Any intention to breastfeed
AOR 95% CI
Complex pregnancy 0.71 (0.52–0.98)
Intention to exclusively breastfeed
AOR 95% CI
Complex pregnancy 0.90 (0.70–1.16)
Note: Models are weighted to be nationally representative.
Models control for age, race/ethnicity, education, census region,
nativity, partnership status, parity,
unintended pregnancy, birth attitudes, and health insurance
status. Bold text indicates statistically significant (P#.05).
8 | e104820

conditions. Our results also show that women with complex
pregnancies who planned to exclusively breastfeed were
substan-
tially less likely to do so 1 week postpartum than women
without
pregnancy complications, even after accounting for supportive
hospital practices.
The findings point to clear opportunities for intervention and
support during pregnancy and immediately after giving birth.
Obstetricians, midwives, family physicians, and pediatricians
should be aware that women with complex pregnancies are less
likely to plan to breastfeed and are less likely to receive
recommended hospital-based support.
Multiple research studies and systematic reviews confirm that
simply counseling women to breastfeed is not sufficient for
encouraging women to breastfeed; rather, tailored support
offered
both prenatally and postpartum is most effective in supporting

pregnant women to set and attain breastfeeding goals [35–37].
Clinicians should discuss breastfeeding intentions when
establish-
ing relationships with patients prenatally, including
consultation
on plans for the use of anti-diabetic or anti-hypertensive
medications compatible with a mother’s intentions, and follow
up to ensure that women with complicated pregnancies have
access to breastfeeding support in the hospital [38]. It is also
important to address breastfeeding intentions and provide
encouragement and support at the time of delivery, given that
delivery third of US women lack a prior relationship with the
clinician attending their delivery [39]. Providing encouragement
and support at the time of delivery may be particularly
important
for women with complex pregnancies who may be transferred to
higher acuity care teams at delivery [40–42]. The results of our
analysis suggest that women who are nonwhite, less educated,
unmarried with no partner, and using public health insurance
are

more likely to be obese or to develop hypertension or diabetes
prior to pregnancy, so it may be helpful to target outreach and
support efforts to these groups.
Our findings are consistent with prior research showing that
BFHI-consistent hospital practices help to promote early breast-
feeding success [24–27]. Women who reported a high number of
BFHI-consistent hospital practices were 3 times more likely to
exclusively breastfeed than were those who reported a lower
number of BFHI-consistent practices. Women who entered
pregnancy with hypertension, diabetes, or obesity were signifi-
cantly less likely to report experiencing the BFHI-consistent
hospital practices of having their baby in their arms during the
first
hour after birth and having hospital staff help them start
breastfeeding. Therefore, hospitals and clinicians alike should
pay particular attention to showing women with complex
pregnancies how to breastfeed (including expressing breast milk
for bottle or syringe feeding [43]) and supporting early
breastfeed-

ing efforts, including after cesarean delivery [44,45].
Breastfeeding support should be incorporated into clinical and
hospital policies, with emphasis on women with complex
pregnancies [46]. Postpartum care management or obstetric/
neonatal discharge guidelines for obese women and those with
diabetes or hypertension could explicitly include discussions of
breastfeeding and information about community-based
resources.
In addition, compliance with BFHI steps should be promoted in
more hospitals, consistent with the federal Healthy People 2020
goals, as should practices that have been shown to improve
breastfeeding outcomes despite not being part of the BFHI
scale,
such as skin-to-contact between women and their infants
immediately after birth [47,48]. Hospital should also be aware
of well-intentioned practices to support breastfeeding that
women
may in fact experience negatively. Hands-on-breast approaches
to
breastfeeding support, for instance, may be considered
unpleasant

and disrespectful by some women [49]. Hospitals and staff
should
continue to maintain open communication with women about the
best ways to support their breastfeeding intentions.
Limitations
Although providing a rich source of data on breastfeeding from
a patient perspective, the Listening to Mothers surveys have
certain limitations that warrant discussion. These data are based
on retrospective self-reports, leaving room for potential recall
bias
and social desirability bias. Although the survey contained some
information about health conditions, assessment of these condi-
tions is based on maternal self-report. In addition to the
complications we included in our analysis, other maternal, fetal,
and neonatal medical conditions or complications that arise
during
labor and delivery could also be associated with breastfeeding
intention and practices. Finally, our construction of the BFHI
composite measure relied on maternal perception of proxies for
7

of the 10 BFHI steps. However, several of the 10 BFHI steps
include questions about hospital policy, of which many women
may not be aware.
Conclusion
Breastfeeding is beneficial for women and infants, and medical
contraindications are rare. Complications that occur during
pregnancy, labor, and delivery may hinder breastfeeding, but
Table 5. Controlled Odds of Infant Feeding Status at 1 Week by
Pregnancy Complexity and Supportive Hospital Practices.
Any Breastfeeding 1 Week Postpartum (n = 1990)
AOR 95% CI AOR 95% CI
Complex pregnancy 0.81 (0.49–1.34) 0.82 (0.50–1.36)
High supportive hospital practices 4.03 (1.81–8.94)
Exclusive Breastfeeding 1 Week Postpartum (n = 1418)
AOR 95% CI AOR 95% CI
Complex pregnancy 0.68 (0.47–0.98) 0.69 (0.48–1.00)
High supportive hospital practices 2.68 (1.70–4.23)
Note: Models are weighted to be nationally representative.
Models control for age, race/ethnicity, education, census region,
nativity, partnership status, parity,

unintended pregnancy, birth attitudes, health insurance status,
cesarean delivery and doula support. Bold text indicates
statistically significant (P#.05).
8 | e104820
supportive hospital practices may facilitate breastfeeding for
women who intend to breastfeed.
We distinguished breastfeeding intentions and early feeding
patterns for women with complex pregnancies and found lower
odds of intending to breastfeed and decreased chances of early
exclusive breastfeeding, even after accounting for supportive
hospital practices, which were associated with greater
breastfeed-
ing success. Therefore, it is important to support women with
medically complex pregnancies in overcoming potential
challenges
to breastfeeding.
Acknowledgments

The authors are grateful for helpful input provided by Eugene
Declercq,
PhD; Valerie Flaherman, MD, MPH; Dwenda Gjerdingen, MD;
Pamela
Jo Johnson, PhD, MPH; and Carol Sakala, PhD.
Author Contributions
Conceived and designed the experiments: KBK LBA PM.
Performed the
experiments: LBA JJ LKJ. Analyzed the data: LBA JJ KBK.
Contributed
reagents/materials/analysis tools: KBK PM. Contributed to the
writing of
the manuscript: KBK LBA JJ LKJ.
References
1. Eidelman AI, Schanler RJ, Johnston M, Landers S, Nobles L,
et al. (2012)
Breastfeeding and the use of human milk. Pediatrics 129: e827–
e841.
2. Centers for Disease Control and Prevention (2013)
Breastfeeding report card—
United States, 2013. Available:
http://www.cdc.gov/breastfeeding/pdf/
2013breastfeedingreportcard.pdf. Accessed 2014 Mar 27.
3. US Department of Health and Human Services (2000)

Healthy People 2010:
conference edition. Vols. 1, 2. Washington, DC.
4. US Department of Health and Human Services (2010)
Healthy People 2020
topics and objectives: maternal, infant and child health.
Washington, DC: Office
of Disease Prevention and Health Promotion.
5. Taylor JS, Kacmar JE, Nothnagle M, Lawrence R (2005) A
systematic review of
the literature associating breastfeeding with type 2 diabetes and
gestational
diabetes. J Am Coll Nutr 24: 320–326.
6. Yoder SR, Thornburg LL, Bisognano JD (2009) Hypertension
in pregnancy and
women of childbearing age. Am J Med 122: 890–895.
7. Amir LH, Donath S (2007) A systematic review of maternal
obesity and
breastfeeding intention, initiation and duration. BMC Pregnancy
Childbirth 7:
9.
8. Li R, Jewell S, Grummer-Strawn L (2003) Maternal obesity
and breast-feeding
practices. Am J Clin Nutr 77: 931–936.
9. Martin JA, Hamilton BE, Ventura S, Osterman M, Matthews
TJ (2013) Births:
final data for 2011. Natl Vital Stat Rep 62: 1–90.

10. Sibai B (2002) Chronic hypertension in pregnancy. Obstet
Gynecol 100: 369–
377.
11. Gilstrap L, Ramin SM (2001) ACOG practice bulletin no.
29: chronic
hypertension in pregnancy. Obstet Gynecol 98: 177–185.
12. Ferrer RL, Sibai BM, Mulrow CD, Chiquette E, Stevens KR,
et al. (2000)
Management of mild chronic hypertension during pregnancy: a
review. Obstet
Gynecol 96: 849–860.
13. Yogev Y, Catalano PM (2009) Pregnancy and obesity.
Obstet Gynecol Clin
North Am 36: 285–300.
14. Aviram A, Hod M, Yogev Y (2011) Maternal obesity:
implications for pregnancy
outcome and long-term risks: a link to maternal nutrition. Int J
Gynaecol Obst
115 Suppl: S6–S10.
15. Gilmartin AH, Ural SH, Repke JT (2008) Gestational
diabetes mellitus. Rev
Obstet Gynecol 1: 129–134.
16. Wahabi H, Esmaeil S, Fayed A, Al-Shaikh G, Alzeidan R
(2012) Pre-existing
diabetes mellitus and adverse pregnancy outcomes. BMC
Research Notes 5:
496.

17. Metzger BE, Buchanan T, Coustan DR, de Leiva A, Dunger
DB, et al. (2007)
Summary and recommendations of the Fifth International
Workshop-Confer-
ence on Gestational Diabetes Mellitus. Diabetes Care 30 Suppl
2: S251–S260.
18. Feig DS, Palda V (2002) Type 2 diabetes in pregnancy: a
growing concern.
Lancet 359: 1690–1692.
19. Matias SL, Dewey KG, Quesenberry CP, Gunderson EP
(2014) Maternal
prepregnancy obesity and insulin treatment during pregnancy
are independently
associated with delayed lactogenesis in women with recent
gestational diabetes
mellitus 1–4. Am J Clin Nutr 99: 115–121.
20. Baby-Friendly USA: the gold standard of care (2012)
Available: http://www.
babyfriendlyusa.org/. Accessed 2014 Mar 2.
21. Rowe-Murray HJ, Fisher JRW (2002) Baby friendly hospital
practices: cesarean
section is a persistent barrier to early initiation of
breastfeeding. Birth 29: 124–
131.
22. Zanardo V, Svegliado G, Cavallin F, Guistardi A, Cosmi E,
et al. (2010) Elective
cesarean delivery: does it have a negative effect on

breastfeeding? Birth 37: 275–
279.
23. Colaizy TT, Morriss FH (2008) Positive effect of NICU
admission on
breastfeeding of preterm US infants in 2000 to 2003. J Perinatol
28: 505–510.
24. Perrine CG, Scanlon KS, Li R, Odom E, Grummer-Strawn
LM (2012) Baby-
friendly hospital practices and meeting exclusive breastfeeding
intention.
Pediatrics 130: 54–60.
25. DiGirolamo AM, Grummer-Strawn LM, Fein SB (2008)
Effect of maternity-
care practices on breastfeeding. Pediatrics 122 Suppl: S43–S49.
26. Declercq E, Labbok MH, Sakala C, O’Hara MA (2009)
Hospital practices and
women’s likelihood of fulfilling their intention to exclusively
breastfeed.
Am J Pub Health 99: 929.
27. Murray EK, Ricketts S, Dellaport J (2007) Hospital
practices that increase
breastfeeding duration: results from a population-based study.
Birth 34: 202–
211.
28. Baby-Friendly USA. Find Facilities. Available:
www.babyfriendlyusa.org/find-

facilities. Accessed 2013 Nov 25.
29. Kozhimannil KB, Attanasio LB, McGovern PM, Gjerdingen
DK, Johnson PJ
(2012) Reevaluating the relationship between prenatal
employment and birth
outcomes: a policy-relevant application of propensity score
matching. Womens
Health Issues 23: e77–e85.
30. Attanasio LB, Kozhimannil KB, McGovern PM, Gjerdingen
DK, Johnson PJ
(2013) The impact of prenatal employment on breastfeeding
intentions and
breastfeeding status at one week postpartum. J Hum Lact 29:
620–628.
31. Prior E, Santhakumaran S, Gale C, Philipps LH, Modi N, et
al. (2012)
Breastfeeding after cesarean delivery: a systematic review and
meta-analysis of
world literature. Am J Clin Nutr 95: 1113–1135.
32. Wiklund I, Norman M, Uvnäs-Moberg K, Ransjö-Arvidson
A-B, Andolf E
(2009) Epidural analgesia: breast-feeding success and related
factors. Midwifery
25: e31–e38.
33. Kirchner L, Jeitler V, Waldhör T, Pollak A, Wald M (2009)
Long hospitalization

is the most important risk factor for early weaning from breast
milk in premature
babies. Acta Paediatr 98: 981–984.
34. Nyqvist KH, Häggkvist A-P, Hansen MN, Kylberg E,
Frandsen AL, et al. (2013)
Expansion of the Baby-Friendly Hospital Initiative ten steps to
successful
breastfeeding into neonatal intensive care: expert group
recommendations.
J Hum Lact 29: 300–309.
35. Lumbiganon P, Martis R, Laopaiboon M, Ho J, Hakimi M
(2012) Antenatal
breastfeeding education for increasing breastfeeding duration
(review). Cochrane
Database Syst Rev 9: CD006425.
36. Chung M, Ip S, Yu W, Raman G, Trikalanos T, et al. (2008)
Interventions in
primary care to promote breastfeeding: a systematic review.
Rockville, MD:
Agency for Healthcare Research and Quality.
37. Dyson L, Mccormick F, Renfrew M (2008) Interventions for
promoting the
initiation of breastfeeding (review). Cochrane Database of Syst
Rev 2:

CD001688.
38. Demirci JR, Bogen DL, Holland C, Tarr JA, Rubio D, et al.
(2013)
Characteristics of breastfeeding discussions at the initial
prenatal visit. Obstet
Gynecol 122: 1263–1270.
39. Declercq E, Sakala C, Corry M, Applebaum S, Herrlich A
(2013) Listening to
Mothers III: Pregnancy and Childbirth. New York: Childbirth
Connection.
40. Gray JE, Davis D, Pursley DM, Smallcomb JE, Geva A, et
al. (2010) Network
analysis of team structure in the neonatal intensive care unit.
Pediatrics 125:
e1460–e1467.
41. AAP Committee on Fetus and Newborn, ACOG Committee
on Obstetric
Practice (2012) Guidelines for perinatal care (AAP/ACOG). 7th
ed. Riley LE,
Stark AR, eds. Washington, DC: American Academy of
Pediatrics.
42. Association of Women’s Health, Obstetric and Neonatal
Nurses (AWHONN)
(2009) Standards for professional nursing practice in the care of
women and

newborns. Washington, DC: AWHONN.
43. Flaherman VJ, Lee HC (2013) Breastfeeding’’ by feeding
expressed mother’s
milk. Pediatr Clin North Am 60: 227–46.
44. Barbero P, Madamangalam AS, Shields A (2013) Skin to
skin after cesarean
birth. J Hum Lact 29: 446–8.
45. Velandia M, Uvnäs-Moberg K, Nissen E (2012) Sex
differences in newborn
interaction with mother or father during skin-to-skin contact
after Caesarean
section. Acta Paediatr 101: 360–7.
46. Flaherman VJ, Newman TB (2011) Regulatory monitoring
of feeding during the
birth hospitalization. Pediatrics 127: 1177–9.
47. Ekström A, Widström A, Nissen E (2003) Duration of
breastfeeding in Swedish
primiparous and multiparous women. J Hum Lact 19: 172–8.
48. Dumas L, Lepage M, Bystrova K, Matthieson A, Welles-
Nyström B, et al. (2013)
Influence of skin-to-skin contact and rooming-in on early
mother-infant
interaction: A randomized controlled trial. Clin Nurs Res 22:
310–36.

49. Weimers L, Svensson K, Dumas L, Navér L, Wahlberg V
(2006) Hands-on
approach during breastfeeding support in a neonatal intensive
care unit: A
qualitative study of Swedish mothers’ experiences. In
Breastfeed J 1: 20–31.
8 | e104820
http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportc
ard.pdf
http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportc
ard.pdf
http://www.babyfriendlyusa.org/
http://www.babyfriendlyusa.org/
www.babyfriendlyusa.org/find-facilities
www.babyfriendlyusa.org/find-facilities
University of Phoenix Material
Time to Practice – Week Four
Complete Parts A, B, and C below.
Part A
Some questions in Part A require that you access data
from Statistics for People Who (Think They) Hate
Statistics.This data is available on the student website under the
Student Text Resources link.

1. Using the data in the file named Ch. 11 Data Set 2, test the
research hypothesis at the .05 level of significance that boys
raise their hands in class more often than girls. Do this practice
problem by hand using a calculator. What is your conclusion
regarding the research hypothesis? Remember to first decide
whether this is a one- or two-tailed test.
2. Using the same data set (Ch. 11 Data Set 2), test the
research hypothesis at the .01 level of significance that there is
a difference between boys and girls in the number of times they
raise their hands in class. Do this practice problem by hand
using a calculator. What is your conclusion regarding the
research hypothesis? You used the same data for this problem as
for Question 1, but you have a differenthypothesis (one is
directional and the other is nondirectional). How do the
resultsdiffer and why?
3. Practice the following problems byhand just to see if you
can get the numbersright. Using the following information,
calculate the ttest statistic.
a.
b.
c.
4. Using the results you got from Question 3 and a level of
significance at .05,what are the two-tailed critical values
associated with each? Would the nullhypothesis be rejected?
5. Using the data in the file named Ch. 11 Data Set 3, test the
null hypothesis that urban and rural residents both have the
same attitude toward gun control. UseIBM®SPSS®software to
complete the analysis for this problem.
6. A public health researcher tested the hypothesis that

providing new car buyers with child safety seats will also act as
an incentive for parents to take other measures to protect their
children (such as driving more safely, child-proofing the home,
and so on). Dr. L counted all the occurrences of safe behaviors
in the cars and homes of the parents who accepted the seats
versus those who did not. The findings:a significant difference
at the.013 level. Another researcher did exactly the same study;
everything was the same—same type of sample, same
outcomemeasures, same car seats, and so on. Dr. R’s results
were marginally significant(recallCh. 9) at the .051 level.
Whichresult do you trustmore and why?
7. In the following examples, indicate whether you would
perform a t test ofindependent means or dependent means.
a. Two groups were exposed to different treatment levels for
ankle sprains.Which treatment was most effective?
b. A researcher in nursing wanted to know if the recovery of
patients was quickerwhen some received additional in-home
care whereas when others received thestandard amount.
c. A group of adolescent boys was offered interpersonal
skills counseling andthen tested in September and May to see if
there was any impact on familyharmony.
d. One group of adult men was given instructions in reducing
their high bloodpressure whereas another was not given any
instructions.
e. One group of men was provided access to an exercise
program and tested twotimes over a 6-month period for heart
health.
8. For Ch. 12 Data Set 3, compute the t value and write a
conclusion on whether there is a difference in satisfaction level
in a group of families’ use of service centers following a social
service intervention on a scale from 1 to 15. Do this exercise
using IBM®SPSS®software, and report the exact probability of
the outcome.

9. Do this exercise by hand. A famous brand-name
manufacturer wants to know whether people prefer Nibbles or
Wribbles. They sample each type of cracker and indicate their
like or dislike on a scale from 1 to 10. Which do they like the
most?
Nibbles rating
Wribbles rating
9
4
3
7
1
6
6
8
5
7
7
7
8
8
3
6
10
7
3
8
5
9
2
8
9
7
6

3
2
6
5
7
8
6
1
5
6
5
3
6
10. Using the following table, provide three examples of a
simple one-way ANOVA, two examples of a two-factor
ANOVA, and one example of a three-factor ANOVA. Complete
the table for the missing examples.Identify the groupingand the
test variable.
Design
Grouping variable(s)
Test variable
Simple ANOVA
Four levels of hours of training—2,4,6,and8hours
Typing accuracy
Enter Your Example Here
Two-factor ANOVA

Two levels of training and gender(two-way design)
Typing accuracy
Three-factor ANOVA
Two levels of training, two of gender, and three of income
Voting attitudes
11. Using the data in Ch. 13 Data Set 2 and the
IBM®SPSS®software, compute the F ratio for a
comparisonbetween the three levels representing the average
amount of time thatswimmers practice weekly (<15, 15–25, and
>25 hours) with the outcome variablebeing their time for the
100-yard freestyle. Does practicetime make a difference?Use
the Options feature to obtainthe meansfor the groups.
12. When would you use a factorial ANOVA rather than a
simple ANOVA to test thesignificance of the difference between
the averages of two or more groups?
13. Create a drawing or plan for a 2 × 3 experimental design
that would lend itself toa factorial ANOVA. Identify the
independent and dependent variables.
From Salkind (2011). Copyright © 2012 SAGE. All Rights
Reserved. Adapted with permission.
Part B

Some questions in Part B require that you access data
from Using SPSS for Windows and Macintosh. This data is
available on the student website under the Student Text
Resources link.
The data for Exercise 14 is in thedata file named Lesson 22
Exercise File 1.
14. John is interested in determining if a new teaching method,
the involvement technique, iseffective in teaching algebra to
first graders. John randomly samples six first graders from
allfirst graders within the Lawrence City School System and
individually teaches them algebra withthe new method. Next,
the pupils complete an eight-item algebra test. Each item
describes aproblem and presents four possible answers to the
problem. The scores on each item are 1 or 0,where 1 indicates a
correct response and 0 indicates a wrong response. The
IBM®SPSS® data file containssix cases, each with eight item
scores for the algebra test.
Conduct a one-sample t test on the total scores. On the output,
identify the following:
a. Mean algebra score
b. T test value
c. Pvalue
The data for Exercise 15 isin thedata file named Lesson 25
Exercise File 1.
15. Marvin is interested in whether blonds, brunets, and
redheads differ with respect to their extrovertedness. He
randomly samples 18 men from his local college campus: six
blonds, six brunets, and six redheads. He then administers a
measure of social extroversion to each individual.

Conduct a one-way ANOVA to investigate the relationship
between hair color and social extroversion. Conduct appropriate
post hoc tests. On the output, identify the following:
a. F ratio for the group effect
b. Sums of squares for the hair color effect
c. Mean for redheads
d. Pvalue for the hair color effect
From Green &Salkind (2011).Copyright © 2012 Pearson
Education. All Rights Reserved.Adapted with permission.
Part C
Complete the questions below. Be specific and provide
examples when relevant.
Citeany sources consistent withAPA guidelines.
Question
Answer
What is meant by independent samples? Provide a research
example of two independent samples.
When is it appropriate to use a t test for dependent samples?
What is the key piece of information you must know in order to
decide?
When is it appropriate to use an ANOVA? What is the key piece
of information you must know in order to decide?
Why would you want to do an ANOVA when you have more
than two groups, rather than just comparing each pair of means
with a ttest?

Awareness, Intention, and Needs Regarding Breastfeeding:
Findings from First-Time Mothers in Shanghai, China
Hong Jiang,1,2 Mu Li,3 Dongling Yang,1,2 Li Ming Wen,3,4
Cynthia Hunter,3
Gengsheng He,1,2 and Xu Qian1,2
Abstract
Background and Objectives: Despite efforts, a decline in
breastfeeding rates has been documented in China
recently. This study explored the awareness of the World Health
Organization (WHO) guidelines for breast-
feeding and intention to breastfeed among first-time mothers
and identified the gap between mothers’ needs and
perinatal care provision regarding breastfeeding promotion.
Subjects and Methods: In total, 653 women at 5–22 gestational
weeks were recruited from four community
health centers in Shanghai, China. They completed a self-
administered questionnaire at recruitment. Two focus
group discussions were held among third-trimester pregnant
women who had received prenatal education.
Twenty-four in-depth interviews were conducted among
postpartum mothers.
Results: During early pregnancy, a substantial proportion of
mothers were not aware of the nutritional value of
breastmilk (40%) or the value of exclusive breastfeeding for 6
months (80%) or any breastfeeding for 24 months
(98%). The awareness of the WHO guidelines for breastfeeding
was associated with intention to breastfeed
(adjusted odds ratio [OR] 2.67, 95% confidence interval [CI]
1.88, 3.78) or intention to breastfeed exclusively

(adjusted OR 3.31, 95% CI 1.81, 6.06). In late pregnancy and
postpartum, most mothers were still not fully aware
of the breastfeeding recommendations and nutritional value of
breastmilk. Limited communications with
healthcare providers and lack of support for dealing with
breastfeeding difficulties were reported.
Conclusions: Low awareness of the WHO breastfeeding
guidelines was found among first-time mothers in
Shanghai. Awareness of breastfeeding guidelines was
independently associated with mothers’ intention to
breastfeed and intention to breastfeed exclusively. The health
benefits of breastfeeding and the recommended
duration of breastfeeding should be emphasized in prenatal
education programs.
Background
Breastfeeding is recommended by the World HealthOrganization
(WHO) as a key measure to ensure the
health of mothers and children. In 2002, WHO updated the
breastfeeding guidelines and recommended ‘‘all infants
should be exclusively breastfed for the first six months of life,
and receive nutritionally adequate and safe complementary
foods while breastfeeding continues for up to two years of age
or beyond’’ (WHA55 A55/15, paragraph 10, p. 5).1
Efforts have been made to promote breastfeeding in China,
where there are more than 10 million live births every year.
The Baby Friendly Hospital Initiative has been scaled up in all
regions of China since the 1990s.2 The target for breastfeeding
promotion was set in the National Program of Action for
Child Development of China in the 1990s and 2000s. Its aim
was to promote the ‘‘exclusive breastfeeding’’ rate (defined as
‘‘breastfeeding while giving no other food or liquid, not even
water, with the exception of drops or syrups consisting of

vitamins, mineral supplements or medicine’’)3 for 4 or 6
months and achieve an ‘‘any breastfeeding’’ (defined as ‘‘the
child has received breast milk with or without other drinks,
formula or other infant food’’)3 rate of 80% by 2000 and of
85%
by 2010 (province-based) at 4 months.4,5 Following the
WHO’s lead, the China Nutrition Society also updated the
national breastfeeding guidelines in 2007. 6
Despite these efforts, a decline in breastfeeding has been
documented in China recently. The rate of full breastfeeding
(defined as ‘‘while breastfed an infant may also receive small
amounts of culturally valued supplements—such as water,
1School of Public Health, Fudan University, Shanghai, China.
2Key Laboratory of Public Health Safety, Ministry of
Education, Shanghai, China.
3Sydney School of Public Health, The University of Sydney,
Sydney, New South Wales, Australia.
4Health Promotion Service, Sydney South West Area, Health
Service, Sydney, New South Wales, Australia.
BREASTFEEDING MEDICINE
Volume 7, Number 6, 2012
ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2011.0124
526
water-based drinks, fruit juice’’)3 for infants 0–5 months was
49% in 2006 and only 28% in 2008.7,8 Data from the 4th Na-
tional Health Services Survey (in 2008)9 revealed that the ex-
clusive breastfeeding rate in urban areas was only 15.8% for
infants £ 6 months. Furthermore, a survey (n = 3,414) con-

ducted in 2002 covering five large cities from different regions
of China (Guangzhou, Shanghai, Chongqing, Xi’an, and
Changchun) showed that the ‘‘any breastfeeding’’ rates at 4, 6,
12, and 24 months were only 61%, 50%, 5%, and 0.4%, re-
spectively. These were much lower than in other countries like
Australia and the United States.3,10
Breastfeeding decisions and practices are influenced by a
wide range of factors, including knowledge, attitudes, beliefs,
and sociocultural environments.11–14 A recent study showed
that awareness of the WHO breastfeeding recommendations
was strongly associated with intention to breastfeed among
mothers in southwest Sydney, Australia.15 Other studies have
repeatedly found that women’s pre-birth breastfeeding inten-
tions are a good predictor of the actual duration of breast-
feeding.16,17 However, no studies in China have explored
mothers’ awareness of the WHO breastfeeding guidelines and
the relationship between this awareness and intention to
breastfeed, and none has examined mothers’ perceptions of
breastfeeding and whether there is any gap between perinatal
health care and mothers’ needs for breastfeeding.
The aims of this study were to explore mothers’ awareness
of the WHO guidelines for breastfeeding and their intention to
breastfeed. The study also aimed to identify the gap between
mothers’ needs and perinatal care provision for breastfeeding.
Subjects and Methods
Study design
This was part of an intervention study (quasi-experimental
design) that aimed to investigate the effectiveness of short
mobile message health promotion on infant feeding practices.
To explore the breastfeeding issues, we analyzed the baseline
data collected by mixed quantitative and qualitative methods.

The study was approved by the Institutional Review Board of
the School of Public Health, Fudan University, Shanghai,
China and the Human Research Ethics Committee of the
University of Sydney, Sydney, Australia. Written informed
consent was obtained from each participant.
Four community health centers (CHCs) were purposively
selected as the project sites in two districts of Shanghai, China.
In Shanghai, maternal and child health (MCH) care is pro-
vided by CHCs and maternity hospitals. Usually, a pregnant
woman needs to register and receives the ‘‘Pregnant Women
Healthcare Card’’ at around 12 gestational weeks at the health
center of the community where her household registration is
held. She receives early antenatal care, including the first
prenatal education on breastfeeding there. From about 20
weeks of gestation the pregnant woman receives antenatal
care and delivery service at the maternity hospital of her
choice, where free prenatal education is provided on about
four occasions in groups. There is one session delivered by
nurses focusing on breastfeeding knowledge, and the educa-
tion usually lasts for around 1 hour. After childbirth, most
new mothers are encouraged to initiate breastfeeding as soon
as possible in the delivery room or operating room by mid-
wives or nurses. In maternity ward, a new mother will get
detailed guidance for breastfeeding practice from nurses such
as postures for breastfeeding, more sucking by the baby,
nipple treatment, etc. The content and quality of breastfeeding
guidance vary from delivery hospital to delivery hospital.
After discharge from the hospital, the new mother is referred
back to the CHC in her household registration area. The
mother and baby are followed up by the CHC staff, who
understands their overall health status with usually one to
three home visits within the first month after delivery. CHCs
are also responsible for child healthcare services from age 0 to
6 years.18

Quantitative study
Participants. When mothers attended the CHC for the
first time around 12 weeks of their pregnancy, they were
approached by MCH staff with a letter of invitation and in-
formation about the main study. Mothers were eligible to
participate if they were first-time mothers, were older than 20
years, had at least completed junior high school education (9
years), had conceived a singleton fetus, and had no illness that
limits breastfeeding after childbirth. From around 1,200 wo-
men approached between October 2010 and January 2011, in
total, 653 mothers at 5–22 weeks of gestation were recruited.
Data collection. Participating mothers were invited to
complete the self-administered questionnaire prior to the first
time of prenatal education using the questions adapted from
the Healthy Beginning Trial.15 Questions included demograph-
ics and health information, access to social support, awareness
of the WHO breastfeeding guidelines, intention to breastfeed,
knowledge of infant feeding, and awareness of childhood
obesity. There were six questions related to the WHO breast-
feeding guidelines, including the nutritional value of
breastmilk,
the health benefits of breastfeeding, the recommended duration
for exclusive breastfeeding, and any breastfeeding. Mothers
were also asked to provide main reasons for intending or not
intending to breastfeed using an open-ended question.
Data analysis. Each of the six questions about the WHO
breastfeeding guidelines was graded with one score, with
pregnant women receiving 0 for none correct to 6 for all correct
answers. Based on the women’s scores they were categorized
into the ‘‘high’’ or the ‘‘low’’ awareness groups, depending on
their score equal/above or below the medium score.

Statistical analyses were carried out using the Statistical
Package for Social Sciences (SPSS) for Windows version 17.0.
One-way analysis of variance/t test was used to determine
differences for continuous outcomes, whereas the Pearson v2
test was used for categorical outcomes, and Mantel–Haenszel
v2 tests were used for trend in proportions. Multiple logistic
regression was performed for determining the factors asso-
ciated with awareness of breastfeeding guidelines and inten-
tion to breastfeed. Unadjusted odds ratios (ORs) and adjusted
ORs were calculated for assessing the likelihood of intention
to breastfeed.
Qualitative study
Participants. Purposive sampling was applied in recruit-
ing participants. Twenty-four new mothers (1–11 months
after childbirth) were interviewed using semistructured in-
depth interviews and focused group discussions. Among
them, nine practiced exclusive breastfeeding or had experi-
enced 4–6 months of exclusive breastfeeding, nine used mixed
AWARENESS, INTENTION, AND NEEDS OF
BREASTFEEDING 527
infant feeding, and six had stopped breastfeeding before the
baby turned 4 months.
Two focused group discussions were conducted with
pregnant women in the third trimester who had completed
the prenatal education programs provided by delivery hos-
pitals. Fourteen pregnant women were recruited from two
large communities, seven from each, respectively.

Data collection. For the in-depth interviews, postpartum
mothers were approached by CHC staff in the child health
clinics of each CHC when they brought babies for health
check-ups. If they agreed to be interviewed, appointments
were set up. The interview guide was piloted before inter-
views. All mothers were asked about their experience of
breastfeeding, awareness of the WHO breastfeeding guide-
lines, problems encountered during breastfeeding, reasons for
breastfeeding or not breastfeeding, reflections on breastfeed-
ing service during perinatal care, and planned duration of
breastfeeding if mothers were breastfeeding.
For the focused discussion groups, the CHC staff contacted
potential participants by telephone, verified their eligibility,
and arranged a focused discussion group time. The focused
discussion group examined mothers’ experiences of prenatal
education and reasons behind their intentions of breastfeed-
ing or not.
All interviews were carried out in a private room. Two
researchers from the MCH Department of the School of Public
Health, Fudan University, who have been trained for quali-
tative research conducted all the interviews, one as the facil-
itator and the other as the recorder. All qualitative interviews
were digitally recorded. Each interview lasted between 30 to
60 minutes.
Data analysis. All recorded materials were transcribed
verbatim by the interviewer and the recorder and other re-
search assistants. Transcripts were kept as Microsoft Word
documents. A de-identification process was applied during
data analysis. A content analysis approach was used to cate-
gorize the transcript contents.19 Two interviewers carefully
reviewed the transcripts to identify emerging themes and
coded for themes using Nvivo version 7.0 computer software.

Results
The main characteristics of the participants are shown
in Table 1. The mean age of the mothers was 28 years (range,
Table 1. Characteristics of Participants and Factors Associated
with Intention
to Breastfeed and Exclusively Breastfeed on Bivariate Analysis
Intention to breastfeed Intention to exclusively breastfeed
Characteristic Of total n = 653, n (%) Yes n (row %) p Yes n
(row %) p
Age (years)
< 25 77 (11.8) 67 (87.0) 0.330a 30 (39.0) 0.755a
25–29 384 (58.8) 350 (91.4) 114 (29.7)
‡ 30 192 (29.4) 176 (91.7) 70 (36.5)
Household registration
Non-Shanghai 498 (76.3) 454 (91.3) 0.527 336 (67.5) 0.814
Shanghai 155 (23.7) 139 (89.7) 103 (66.5)
Pregnant women’s education level
Junior middle school 21 (3.2) 20 (95.2) 0.522a 16 (76.2) 0.897a
Senior middle school 70 (10.7) 64 (91.4) 44 (62.9)
College and above 562 (86.1) 509 (90.7) 379 (67.4)
Partner’s education level
Junior middle school 14 (2.1) 13 (92.9) 0.788a 9 (64.3) 0.969a
Senior middle school 58 (8.9) 53 (91.4) 40 (69.0)
College and above 581 (89.0) 527 (90.9) 390 (67.1)

Family income per month
< 4,000 RMB 47 (7.2) 6 (12.8) 0.337 19 (40.4) 0.233
‡ 4,000 RMB 604 (92.5) 52 (8.6) 193 (32.0)
Women’s employment status
Unemployed 106 (16.2) 93 (87.7) 207 64 (60.4) 0.101
Employed 547 (83.8) 500 (91.6) 375 (68.6)
Intended time back to work
< 6 months 496 (76.0) 450 (90.9) 0.049 329 (66.3) 0.094
‡ 6 months or don’t plan to go back 83 (12.7) 80 (96.4) 64
(77.1)
Don’t know 74 (11.3) 63 (85.1) 46 (62.2)
Rented accommodation
No 152 (23.3) 49 (9.8) 0.138 328 (65.7) 0.127
Yes 499 (76.4) 9 (5.9) 110 (72.4)
Awareness of breastfeeding guidelinesb
Lower 289 (44.3) 248 (85.8) < 0.001 162 (56.1) < 0.001
Higher 364 (55.7) 345 (95.0) 127 (43.9)
aBy Mantel–Haenszel v2 test.
bMean score, 3.6; median score, 4.0.
528 JIANG ET AL.
20–41 years). Nearly 90% of mothers were employed and re-
ported their monthly family income as 4,000 RMB (*USD
$615, middle–low living condition) or more. About 76% of
women planned to return to work within 6 months after
childbirth. The average gestational age of mothers was 11
weeks (range, 5–22 weeks) at the time of the baseline study.

Mother’s awareness of the breastfeeding guidelines
prior to receiving prenatal education
The median score of awareness of the WHO breastfeeding
guidelines was 4.0 (range, 1.0–6.0). Although almost all
mothers (99%) knew breastfeeding was good for the baby’s
health, 22% of mothers did not think breastfeeding was ben-
eficial to the mother’s health. Close to 80% and nearly all
mothers (98%), respectively, were not aware of the WHO-
recommended duration for exclusive breastfeeding or any
breastfeeding. In addition, approximately 40% of mothers did
not think breastmilk could meet all the nutritional needs for
babies less than 6 months old.
Mother’s intention to breastfeed in early pregnancy
prior to receiving prenatal education
Prior to receiving any prenatal education, 91% of expectant
mothers planned to breastfeed their babies, and the remaining
9% had yet to decide. Only two women claimed that they
would not breastfeed. Sixty-seven percent of mothers planned
to exclusively breastfeed their babies, only 9% planned not to
exclusively breastfeed, and 24% had not decided. Table 1
shows the factors associated with intention to breastfeed on
bivariate analysis.
After multivariate analyses, the only factor associated with
the mother’s intention to exclusive breastfeeding was the
mother’s awareness of the breastfeeding guidelines (Table 2).
Mothers who had a higher awareness score intended to
breastfeed (OR 2.67, 95% confidence interval [CI] 1.88, 3.78,
p < 0.001) and intention to breastfeed exclusively (OR 3.31,
95% CI 1.81, 6.06, p < 0.001). In addition, compared with
mothers intending to go back to work within 6 months after

childbirth, mothers who intended to stay at home for ‡ 6
months were more likely to breastfeed (OR 1.89, 95% CI 1.03,
3.47, p = 0.039).
Reasons of breastfeeding intention among mothers
in early pregnancy
The main reasons given by the 537 mothers to the open-
ended question on the intention to breastfeed in the survey
were for the health benefits of the child and mother, for ex-
ample: ‘‘.to ensure baby’s health. Baby will have better im-
munity’’ and ‘‘Safe, natural, nutritional, good for both baby
and mother.’’
Among the 43 mothers who had not decided whether to
breastfeed or not, the main issues are revealed in Table 3. The
Table 2. Factors Associated with Intention to Breastfeed and
Exclusively
Breastfeed in Multiple Logistic Analysis (n = 653)
Intention to breastfeed Intention to exclusively breastfeed
Variable OR 95% CI p OR 95% CI p
Age (years)
< 25 1 1
25–29 1.774 0.9783.220 0.059 2.095 0.884–4.966 0.093
‡ 30 1.234 0.652–2.336 0.519 2.077 0.795–5.424 0.136
Household registration
Non-Shanghai 1 1
Shanghai 1.006 0.659–1.563 0.979 0.885 0.456–1.721 0.720
Pregnant women’s education level
Junior middle school 1 1

Senior middle school 0.362 0.109–1.203 0.097 0.348 0.036–
3.408 0.365
College and above 0.321 0.097–1.065 0.063 0.187 0.019–1.824
0.149
Family income per month
< 4,000 RMB 1 1
‡ 4,000 RMB 1.484 0.744–2.959 0.263 1.499 0.510–4.408 0.462
Women’s employment status
Unemployed 1 1
Employed 1.612 0.942–2.758 0.081 1.657 0.706–3.888 0.246
Intended time back to work
< 6 months 1 1
‡ 6 months or don’t plan to go back 1.894 1.033–3.471 0.039a
2.707 0.756–9.697 0.126
Don’t know 1.071 0.578–1.986 0.828 0.683 0.275–1.695 0.411
Rented accommodation
No 1 1
Yes 1.438 0.910-2.271 0.119 1.887 0.824-4.321 0.133
Awareness of breastfeeding guidelines
Lower 1 1
Higher 2.666 1.878–3.784 < 0.001a 3.307 1.805–6.059 < 0.001a
aSignificant difference.
CI, confidence interval; OR, odds ratio.
BREASTFEEDING 529
main reasons for not having decided to breastfeed included

the reasons ‘‘concerns about insufficient milk supply,’’ ‘‘ had
not yet thought about it,’’ ‘‘concerns about HBV [hepatitis B
virus] transmission to the baby,’’ ‘‘concerns about their own
figure,’’ ‘‘felt lack of sufficient knowledge,’’ etc.
There were two mothers who did not plan to breastfeed:
One responded, ‘‘Just do not want breastfeeding,’’ and the
other one did not give any reason.
Perceptions on breastfeeding among mothers
in late pregnancy and postpartum
The qualitative study revealed that mothers in their late
pregnancy or postpartum period had some knowledge about
the health benefits of breastfeeding and the recommended
duration of exclusive breastfeeding. However, they still did
not know the key components of the WHO breastfeeding
guidelines. Some mothers considered that mixed feeding
could provide more nutrition to their babies and that it was
convenient for weaning. No mothers knew the recommended
duration for any breastfeeding. Many were misinformed by
traditional perceptions, for example, that breastmilk would
not have any nutritional value after the mother resumed
menstruation and therefore breastfeeding should be stopped.
As shown in Table 4, although mothers would trust the
information provided by health professionals, they reported
that MCH doctors were often too busy to deliver sufficient
information on breastfeeding during perinatal care visits.
Consequently, the Internet, books, families, and friends be-
came the major sources of information on breastfeeding.
Furthermore, the prenatal education programs were only of-
fered during business hours, which prevented most mothers
from attending.

Discussion
This study found that prior to receiving prenatal educa-
tion, a substantial proportion of mothers were not aware
of the nutritional value of breastmilk (40%) or the WHO-
recommended duration of exclusive breastfeeding (80%) or
any breastfeeding (98%). Mothers’ intention to breastfeed or
intention to breastfeed exclusively was significantly associ-
ated with their awareness of the WHO breastfeeding guide-
lines in early pregnancy. In late pregnancy and postpartum,
the majority of mothers still did not fully understand the
nutritional values of breastmilk or the recommended duration
of breastfeeding. Lack of communication and support from
the healthcare providers has been identified. These results
highlight the importance of promotion and support of breast-
feeding in perinatal care services to address the unmet needs.
The strength of this study was that we used a concurrent
design with quantitative and qualitative mixed methods to
explore breastfeeding issues among first-time mothers in
Shanghai, China, in order to tackle the recent decline of
breastfeeding in China, particularly in large cities. The
quantitative component of our study provided the empirical
evidence of the link between mothers’ awareness and their
intention of breastfeeding. The qualitative component al-
lowed participants to play an active role in identifying prob-
lems through voicing their opinions and perceptions in
relation to breastfeeding. In addition, the participants of the
study were at the different stages of receiving MCH services
in the health system (i.e., early and late pregnancy and post-
partum), which allowed us to gather information on services
provided particularly in relation to breastfeeding promotion
across different services. Thus, the qualitative component al-
lowed for the emergence of contextual meaning, as a com-
plement to the quantitative data. Our findings about mothers’
awareness, intention, and needs regarding breastfeeding will

significantly contribute to the body of evidence that supports
the promotion of the WHO breastfeeding guidelines and ad-
dresses mothers’ needs in relation to breastfeeding.
The positive association between the awareness of the
WHO breastfeeding guidelines and the intention to breastfeed
or intention to breastfeed exclusively suggests that breast-
feeding promotion and education should be initiated early,
when mothers have their first visit to the CHC (around 12
gestational weeks). This association was consistent with the
study by Wen et al.15 in which participants were recruited
from Week 24 to 34 of gestation. Our study showed that the
positive relationship between awareness and intention ex-
isted even among women in relatively early pregnancy,
Table 3. The Main Reasons Given by the Women
Without Intention to Breastfeed
at Early Pregnancy
Reasons for
not having
decided to breastfeed
Number (%)
of total n = 43
Examples of what
women said
Concerns about
insufficient
milk supply
16 (37) ‘‘Not sure whether
I will have enough

breastmilk because
my breasts looked
small’’
Had not yet
thought about it
10 (23) ‘‘Have not yet
thought about it’’
Concerns about
HBV transmission
to the baby
6 (14) ‘‘I have hepatitis
B and don’t know
whether baby
would have it
through
breastfeeding’’
Concerns about
their own figure
4 (9) ‘‘Breastfeeding
will influence
my breast figure’’
Felt lack of sufficient
knowledge
3 (7) ‘‘Not know too
much about
breastfeeding,
will decide after
know more

about it’’
Other reasons
included lack
of freedom,
time conflict
with work,
and cracked
nipples
4 (9) ‘‘I will be occupied
by the baby all
the time if
breastfeed’’
Not planning
to breastfeed
Number (%)
of total n = 2
Do not want
breastfeeding
1 (50) ‘‘Just do not want
breastfeeding’’
HBV, hepatitis B virus.
530 JIANG ET AL.
Table 4. Themes and Supporting Quotes About the
Understanding of Breastfeeding
Among Pregnant Women at the Third Trimester and Postpartum

Mothers
Selected quotes
Themes
Pregnant women
(focused group discussion)
Postpartum mothers
(in-depth interview)
Awareness of some components of breastfeeding guidelines
1. Know the general health benefit
of breastfeeding
‘‘[Breastfeeding is] good for baby’s,
especially the foremilk very good
for baby’s immune system.
In addition, breastfeeding could
improve the mother–baby relationship’’
(28 years old, 34th gestational week,
teacher)
‘‘Breastfeeding is the best.
It is safe. You know the
‘melamine infant formula
contamination incidentsa
in 2008,’ I worry about the
quality of formula’’
(28 years old, 6 months
postpartum, mixed
breastfeeding, company
employee)

2. Know the recommended
duration for exclusive
breastfeeding
‘‘In the prenatal education, I knew
exclusive breastfeeding should last
for 6 months’’ (30 years old,
37th gestational week, dentist)
Misunderstanding of breastfeeding
3. Don’t actually know the difference
between breastmilk and formula;
regard mixed feeding as the ideal
way to ensure nutrition
and convenience of weaning
‘‘If baby is fed by a mixed way,
the nutrition would be better.
I know foremilk would help
baby’s immune system,
but how about other nutrients?
Formula has many nutritional
elements.Furthermore,
it would be easy for weaning.’’
(34 years old, 35th week gestational,
teacher /dancer)
‘‘Although I know
breastfeeding is good,
but what’s the difference
between breastmilk
and infant formula?
Formula includes many
nutrients. Does breastmilk
have enough [nutrients]

too? I don’t know’’
postpartum, mixed feeding,
company employee)
4. Unawareness of the recommended
duration for breastfeeding and
traditional idea about
discontinuing breastfeeding
‘‘Usually breastfeeding would
last for 9–10 months, at most
1 year’’ (31 years, 36th week, teacher)
‘‘I know from my doctor
that breastfeeding should
last for 10–12 months’’
postpartum, mixed
breastfeeding, physician)
‘‘After menstruation resumed,
breastmilk would have no any
nutrition value, just like water’’
teacher/dancer)
‘‘Many people told me that
after the menstruation
resumed, breastmilk
would have no any
nutritional value’’ (31 years
old, 4 months postpartum,
exclusively breastfeeding,
company employee)

Feedback on breastfeeding service through perinatal care
5. Don’t have time to join in the
prenatal education
‘‘[I did not join in the prenatal
education] since I have to work’’
company employee)
‘‘There were prenatal classes
in hospitals, but I just
didn’t have time
to attend.I needed
to work’’ (28 years old,
2 months postpartum,
exclusively breastfeeding,
physician)
6. Don’t have enough communication
with MCH care providers
During prenatal care: ‘‘It was very fast
for each antenatal check-up, less than
10 minutes. But I had to wait for
[the doctor] more than 3 hours’’
company employee)
During childbirth in hospitals:
‘‘No specific guidance
on breastfeeding when
I lived in hospital after
childbirth. They (health
staff) just told us not to
bring bottle milk to the

(continued)
BREASTFEEDING 531
before 22 gestational weeks, prior to receiving prenatal edu-
cation. A recent review concluded that breastfeeding inten-
tion was a strong indicator for breastfeeding initiation and
duration.20 Therefore, improving mothers’ awareness and
addressing mothers’ intention to breastfeed will help to im-
prove breastfeeding practice.
In this study, planned longer maternal leave was shown to
be associated with stronger intention to breastfeed. However,
more than 75% of mothers revealed that they would need to
return to work within 6 months after childbirth. Thus, the
appropriate public policies are required to remove barriers
and to create enabling environments at the workplace for
women to continue breastfeeding and facilitate mothers to
meet the WHO recommendations.
Consistent with other studies,21 we found that the health
benefits of breastfeeding served as a strong incentive for
Table 4. (Continued)
Selected quotes
Themes
Pregnant women
(focused group discussion)

Postpartum mothers
(in-depth interview)
hospital. Every day, nurses
asked me whether I had
breastmilk. If I had not,
she then gave us a cup
with a fixed quantity of
formula to feed the baby
every 4 hours. They didn’t
require me to breastfeed
my baby and didn’t teach
me how to breastfeed the
baby’’ (35 years old,
formula feeding,
company employee)
‘‘There are always a lot of patients.
Doctors must be bored since every
woman has a lot of questions’’
company employee)
During child health care:
‘‘At the kid health check-up,
doctors just asked me
whether my baby was
having breastmilk or
formula. They didn’t
say any others’’ (30 years
old, 8 months postpartum,
mixed feeding, unemployed)
7. Get the knowledge and information
of breastfeeding mainly from Internet,

books, friends, and families
‘‘Some prenatal education will have
charge. Internet is very convenient
to get all information. No need to
take the class’’ (29 years old,
35th gestational week, company
employee)
‘‘Usually I know [breastfeeding]
from the Internet and one
book. I was encouraged
and decided to breastfeed
by one book’’ (27 years old,
mixed feeding, company
employee)
8. Need support to deal with the difficult
during breastfeeding
‘‘No any health staff member
told me how to deal with
the insufficient breastmilk
production. How can I
produce enough breastmilk?’’
postpartum, mixed feeding,
company manager)
‘‘The baby had a disease
1 month ago and he
stopped breastfeeding
himself’’ (29 years old,
having ceased breastfeeding,

accountant)
aInfant formula contamination incidents. A food safety incident
in China revealed in September 2008 that powdered formula,
fresh milk,
and other products in China were found to be adulterated with
melamine, a synthetic nitrogenous product, to confound a test
for
determining crude protein content.
MCH, maternal and child health.
532 JIANG ET AL.
mothers’ intention to breastfeed. We also found that mothers’
hesitation in breastfeeding their babies was due to the concern
about insufficient breastmilk supply, which has been reported
by other studies.12,15,22 Furthermore, concerns about mother-
to-child hepatitis B transmission were also expressed by those
mothers who were hepatitis B positive.23 Targeted health
promotion efforts should be directed to address the concerns
of these mothers.
This study also revealed that the infant formula contami-
nation incidents that occurred in China in 2008 greatly weak-
ened mothers’ trust in the quality of infant formula. The event
had motivated mothers to breastfeed their babies, which is a
window of opportunity to accelerate the promotion of breast-
feeding in China. As a study had shown the incidents had a
significant positive impact on breastfeeding among Chinese
mothers,24 it is promising to translate mothers’ intention to
successful breastfeeding practice through appropriate support.
As indicated in this study, however, the current perinatal care
model does not provide sufficient support for breastfeeding.

The perception of the superior nutritional value of formula
could be the result of inadequate information provision about
breastmilk during perinatal care and the successful marketing
of infant formula. The misunderstanding of mixed infant
feeding among mothers in this study was similar to the find-
ings of Holmes et al.,25 who showed the inadequate advocacy
on exclusive breastfeeding by health professionals and lack of
supportive social environment for breastfeeding. The extensive
impact of traditional perceptions on breastfeeding duration
among mothers, newly reported by this study, further high-
lights the inadequate provision of health promotion in the
current MCH service. Young mothers obtained breastfeeding
information mainly from their own mothers or mothers-in-law,
colleagues or friends, the Internet, and books, rather than from
health professionals. This indicates that health professionals
had
not played an active role in providing correct information. The
difficulties and concerns raised by mothers in this study, such
as
‘‘insufficient breastmilk,’’ what to do in situations with
‘‘mother
or child being sick,’’ and ‘‘cracked nipples,’’ have been
reported
by many other studies.6,26–29 This further suggests inadequate
guidance on breastfeeding practice. One study has shown that
professional support had the most important influence on
breastfeeding intentions and behaviors.30 Health professionals’
support could either increase exclusive breastfeeding31 or pro-
long any breastfeeding.32 Thus, approaches to enhance profes-
sional supports should be explored as an important component
for breastfeeding promotion in the next step.
This study has several limitations. First, because of its cross-
sectional design, no causal relationships can be concluded in
relation to the study findings. Second, the study sample had a
large proportion of well-educated women, which could lead

to selection bias and limit its generalizability, although it may
be a true reflection of Chinese urban areas where young
people have more opportunities to study in colleges and
universities since the expansion of high education in the
1990s. In addition, further studies are needed to explore
whether awareness and intention of breastfeeding can be
translated to future breastfeeding practice.
Conclusions
Low awareness of the WHO breastfeeding guidelines was
found among first-time mothers in Shanghai. Awareness of
the breastfeeding guidelines was independently associated
with their intention to breastfeed and intention to breastfeed
exclusively. The health benefits of breastfeeding and re-
commended breastfeeding duration should be emphasized in
prenatal education programs when encouraging mothers to
comply with the WHO breastfeeding guidelines. Specific
concerns about breastfeeding and breastfeeding difficulties
encountered by mothers should be addressed by health pro-
viders in a more supportive manner. It is important to ad-
vocate for appropriate public policy on maternal leave and for
a workplace breastfeeding-friendly environment to support
mothers returning to work.
Acknowledgments
The authors are grateful to the staff at Longhua, Caohejing,
Meilong, and Xinzhuang Community Health Centers of
Shanghai, China for their support during data collection. We
thank all the participants for their collaboration. This study
was funded by the Nestle Foundation.
Disclosure Statement

No competing financial interests exist.
References
1. World Health Organization. Global Strategy for Infant and
Young Child Feeding. Report by the Secretariat. World Health
Organization, Geneva, 2002.
2. Song L. Implement of Chinese Children’s Development Plan
in 1990’s [in Chinese]. Chin J Pediatr 2000;38:271–273.
3. Xu FL, Qiu LQ, Binns CW, et al. Breastfeeding in China: A
review. Int Breastfeed J 2009;4:6.
4. National Program of Action for Child Development in
China (1990’s) [in Chinese]. www.nwccw.gov.cn/?action-
viewnews-itemid-121195 (accessed December 17, 2011).
5. National Program of Action for Child Development in China
(2001–2010) [in English]. www.womenofchina.cn/html/
report/514-1.htm (accessed December 17, 2011).
6. Maternal and Child Health Branch of Chinese Nutrition
Society. Nutrition and Food Guidelines for Women in
Pregnancy and Lactation, and Children from 0 to 6 Years of
China [in Chinese]. 2007. www.cnsoc.org/cn/nutrition
.asp?nid = 10 (accessed August 14, 2011).
7. Yin SA. The status of growth and complimentary introduc-
tion among Chinese infants and young children [in Chinese].
Chin J Child Health Care 2004;12:509–511.
8. Liu AD, Zhao LY, Yu DM, et al. Study of feeding status on
infants and young children under 2 years old in China. J Hyg
Res 2009;38:555–557.

9. Center for Health Statistics and Information, Ministry of
Health. An Analysis Report of National Health Services Survey
in China, 2008 [in Chinese]. China Xiehe Medical University
Publishing House, Beijing, 2009.
10. Amir LH. Donath SM. Socioeconomic status and rates of
breastfeeding in Australia: Evidence from three recent na-
tional health surveys. Med J Aust 2008;189:254–256.
11. Chambers JA, McInnes RJ, Hoddinott P, et al. A systematic
review of measures assessing mothers’ knowledge, atti-
tudes, confidence and satisfaction towards breastfeeding.
Breastfeed Rev 2007;15:17–25.
12. Li R, Fein SB, Chen J, et al. Why mothers stop
breastfeeding:
Mothers’ self-reported reasons for stopping during the first
year. Pediatrics 2008;122(Suppl 2):S69–S76.
BREASTFEEDING 533
13. Hotnett ED, Gate S, Hofmeyr GJ, et al. Continuous support
for women during childbirth. Cochrane Database Syst Rev
2011;(2):CD003766.
14. Forster D, McLachlan H, Lumley J. Factors associated with
breastfeeding at six months postpartum in a group of Aus-
tralian women. Int Breastfeed J 2006;1:1–18.
15. Wen LM, Baur LA, Rissel C, et al. Intention to breastfeed
and
awareness of health recommendations: Findings from first-
time mothers in southwest Sydney, Australia. Int Breastfeed J

2009;4:9.
16. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding
and the use of human milk. Pediatrics 2005;115:496–506.
17. Donath S, Amir LH, ALSPAC Study Team. Relationship
between prenatal infant feeding intention and initiation and
duration of breastfeeding: A cohort study. Acta Paediatr
2003;92:352–356.
18. Li N, Sheng Y, Sun Y, et al. Administration model of ma-
ternal and children’s health care in Shanghai [in Chinese].
Chin J Matern Child Health Care 2008;23:2051–2053.
19. Green J, Thorogood N. Qualitative Methods for Health Re-
search. Sage Publication Ltd., London, 2009.
20. Meedya S. Fahy K, Kable A. Factors that positively
influence
breastfeeding duration to 6 months: A literature review.
Women Birth 2010;23:135–145.
21. Alexander A, Dowling D, Furman L. What do pregnant low-
income women say about breastfeeding? Breastfeed Med
2010;5:17–23.
22. Bunik M, Shobe P, O’Connor ME, et al. Are 2 weeks of
daily
breastfeeding support insufficient to overcome the influ-
ences of formula? Acad Pediatr 2010;10:21–28.
23. Qiu L, Binns CW, Zhao Y, et al. Hepatitis B and breast-
feeding in Hangzhou, Zhejiang Province, People’s Republic
of China. Breastfeed Med 2010;5:109–112.
24. Seror J, Amar A, Braz L, et al. The Google News effect: Did

the tainted milk scandal in China temporarily impact new-
born feeding patterns in a maternity hospital? Acta Obstet
Gynecol Scand 2010;89:823–827.
25. Holmes AV, Chin NP, Kaczorowski J, et al. A barrier to
excusive breastfeeding for WIC enrollees: Limited use of
exclusive breastfeeding food package for mothers. Breastfeed
Med 2009;4:25–30.
26. Gui F. Reasons for stopping breastfeeding [in Chinese]. J
North Sichuan Med Coll 2002;17:52–53.
27. Chen SN, Liu NN. The investigation of breastfeeding
knowledge and practice among primiparas. Today Nurse
(Academic) 2010;1:68–70.
28. Li XY, Xu YQ, Xie HH, et al. The reasons of breastfeeding
cessation in the past 5 years of Nanjing city [in Chinese].
Acta Univ Med Nanjing (Nat Sci) 2005;25:359–360.
29. Tian G, Xie H. Breastfeeding and associated factors in
Nanjing city [in Chinese]. Jiangsu Med J 2003;29:612–613.
30. Kervin BE, Kemp L, Pulver LJ. Types and timing of breast-
feeding support and its impact on mothers’ behaviours. J
Paediatr Child Health 2010;46:85–91.
31. Garg R, Deepti S, Padda A, et al. Breastfeeding knowledge
and practices among rural women of Punjab, India: A
community-based study. Breastfeed Med 2010;5:303–307.
32. Britton C, McCormick FM, Renfrew MJ, et al. Support for
breastfeeding mothers. Cochrane Database Syst Rev 2007;
(1):CD001141.

Address correspondence to:
Xu Qian, M.D., Ph.D.
School of Public Health
Fudan University
Mailbox 175, 138 Yixueyuan Road
Shanghai 200032, China
E-mail: [email protected]
534 JIANG ET AL.
Hindawi Publishing Corporation
Journal of Nutrition and Metabolism
Volume 2013, Article ID 243852, 8 pages
http://dx.doi.org/10.1155/2013/243852
Research Article
An Assessment of the Breastfeeding Practices and
Infant Feeding Pattern among Mothers in Mauritius
Ashmika Motee,1 Deerajen Ramasawmy,2 Prity Pugo-Gunsam,3
and Rajesh Jeewon1
1 Department of Health Science, Faculty of Science, University
of Mauritius, Reduit, Mauritius
2 Faculty of Law and Management, University of Mauritius,
Reduit, Mauritius
3 Department of Bioscience, Faculty of Science, University of
Mauritius, Reduit, Mauritius
Correspondence should be addressed to Rajesh Jeewon;
[email protected]

Received 30 March 2013; Revised 8 June 2013; Accepted 9 June
2013
Academic Editor: Johannes B. van Goudoever
Copyright © 2013 Ashmika Motee et al.This is an open access
article distributed under the Creative CommonsAttribution
License,
which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Proper breastfeeding practices are effective ways for reducing
childhoodmorbidity andmortality.While manymothers
understand
the importance of breastfeeding, others are less knowledgeable
on the benefits of breastfeeding and weaning. The aim in here is
to
assess breastfeeding pattern, infant formula feeding pattern, and
weaning introduction in Mauritius and to investigate the factors
that influence infant nutrition. 500 mothers were interviewed
using a questionnaire which was designed to elicit information
on
infant feeding practices. Statistical analyses were done using
SPSS (version 13.0), whereby chi-square tests were used to
evaluate
relationships between different selected variables. The
prevalence of breastfeeding practice in Mauritius has risen from
72% in 1991
to 93.4% as found in this study, while only 17.9% breastfed
their children exclusively for the first 6 months, and themean
duration of
EBF (exclusive breastfeeding) is 2.10 months. Complementary
feeding was more commonly initiated around 4–6 months
(75.2%).
Despite the fact that 60.6% of mothers initiate breastfeeding
and 26.1% of mothers are found to breastfeed up to 2 years, the

practice
of EBF for the first 6 months is low (17.9%). Factors found to
influence infant feeding practices are type of delivery, parity,
alcohol
consumption, occupation, education, and breast problems.
1. Introduction
Adequate nutrition during infancy and early childhood is
essential to ensure the growth, health, and development of
children to their full potential [1]. It has been recognized
worldwide that breastfeeding is beneficial for both themother
and child, as breast milk is considered the best source of
nutrition for an infant [2].
The World Health Organization (WHO) recommends
that infants be exclusively breastfed for the first six months,
followed by breastfeeding along with complementary foods
for up to two years of age or beyond [3]. Exclusive breastfeed-
ing can be defined as a practice whereby the infants receive
only breast milk and not even water, other liquids, tea, herbal
preparations, or food during the first six months of life, with
the exception of vitamins,mineral supplements, ormedicines
[4].Themajor advantage of exclusive breastfeeding from 4 to
6 months includes reduced morbidity due to gastrointestinal
infection [5]. However, many researchers are questioning
if there is sufficient evidence to confidently recommend
exclusive breastfeeding for 6 months for infants in developed
countries due to the fact that breast milk may not meet the
full energy requirements of the average infant at 6 months of
age [6]. Nevertheless, there is scanty data that give estimation
about the proportion of exclusively breastfed infants at risk of
specific nutritional deficiencies.
Several studies have shown that mothers find it difficult

to meet personal goals and to adhere to the expert recom-
mendations for continued and exclusive breastfeeding despite
increased rate of initiation [7]. Some of the major factors
that affect exclusivity and duration of breastfeeding include
breast problems such as sore nipples or mother’s perceptions
that she is producing inadequate milk [4, 8, 9]; societal
barriers such as employment and length of maternity leave
[9]; inadequate breastfeeding knowledge [8]; lack of familial
and societal support; lack of guidance and encouragement
from health care professionals [2, 9]. These factors in turn
promote the early use of breast milk substitute.
2 Journal of Nutrition and Metabolism
When breast milk or infant formula no longer supplies
infants with required energy and nutrients to sustain normal
growth and optimal health and development, complementary
feeding should be introduced [10]. According to the WHO
recommendations, the appropriate age at which solids should
be introduced is around 6 months [11] owing to the immatu-
rity of the gastrointestinal tract and the renal system as well
as on the neurophysiological status of the infant [12]. Factors
that influence the weaning process include infant feeding
problems such as refusal to eat, colic, and vomiting among
others [13]. These factors represent challenges for mothers
and in turn may either directly or indirectly influence the
feeding pattern. Hence, understanding the factors affecting
infant nutrition inMauritius can help in developing strategies
to promote breastfeeding and overcoming problems faced by
mothers and children.
Predictors of breastfeeding and weaning practices vary
between and within countries. Urban or rural difference, age,
breast problems, societal barriers, insufficient support from

family, knowledge about good breastfeeding practices, mode
of delivery, health system practices, and community beliefs
have all been found to influence breastfeeding in different
areas of developing countries [4, 8, 9]. Information on the
prevalence and factors influencing infant feeding practices
is limited in Mauritius and dates back to 1996 [14]. This
present study aims to determine infant feeding pattern and
its predictors among Mauritian mothers with the following
objectives: (1) to elucidate breastfeeding practices, in terms
of initiation, exclusivity, and termination, and the factors
influencing them; (2) to determine the time when weaning
starts, the challengesmet bymothers, and the type of weaning
adopted.
2. Methods
2.1. Study Design and Data Collection. A survey-based study
was conducted on a group of 500 mothers in 2011 (from
August 2011 to January 2012) to elicit information about
infant feeding practices by the use of a properly designed
questionnaire given to mothers in Area Health Centres
(AHCs) and Community Health Centres (CHCs) both in
rural and urban areas of the island. Research has been granted
approval by the University Research Ethics Committee, and
prior consents were obtained from all participants.
2.1.1. Questionnaire Design. The questionnaire consisted pri-
marily of a closed format including dichotomous questions
(e.g., yes/no) and multiple response for ease of completion
and analysis. The resulting questionnaire consisted of 46
close-ended questions, all categorized in 4 sections as follows.
(i) Section A: the first section elicited information on
the participants in terms of age, place of residence,
marital status, type of family, parity, lifestyle fac-
tors (smoking and alcohol consumption), education,

occupation, income, religion, and age of baby.
(ii) Section B: this section was sought to understand the
main factors encouragingmothers to breastfeed, their
awareness on colostrum, the practice of exclusive
breastfeeding, the termination of breastfeeding, as
well as themain problems encountered during breast-
feeding.
(iii) Section C: multiple response questions were mainly
used in this section to determine more information
on the uptake of infant formula.
(iv) Section D: it consists of dichotomous and multiple
response questions to find out more details on the
weaning process.
2.1.2. Subjects. A sample of the female population consisting
of mothers aged 18–45 years was considered since they are
adults and are mature enough to participate in the study. In
addition, the sampling was based on the following inclusion
and exclusion criteria.
(i) Inclusion Criteria. Mothers who already delivered their
baby and those with a child who is below 5 years old were
considered in this survey.
(ii) Exclusion Criteria. Pregnant women or mothers having a
child with any kind of malformations. Mothers with children
who are above 5 years old.
2.2. Statistical Analysis. Questionnaire responses were col-
lected and analysed using SPSS (version 13.0). Chi-square
tests were used to evaluate relationships between different
selected variables (e.g., to find association between breast-

feeding initiation and mode of delivery; association between
breastfeeding duration and parity, alcohol consumption,
education, and occupation of respondents).The critical value
for significance was set at � < 0.05 for all analyses.
3. Results
3.1. Breastfeeding Practices. A total of 500 respondents com-
pleted the questionnaire of which 216 were from urban
areas and 284 were from rural areas, with 53% mothers
having completed at least secondary level education. Equal
representation of mothers from rural and urban areas was
achieved through a quota sampling technique based on place
of residence [15].The age of the participants ranged from 18 to
45 years old whereby the majority of the participants (38.4%)
belonged to the age group 25–31 years andmost of themwere
married (92.6%) living in a nuclear family (58.6%). A total of
93.4% of the mothers acknowledged that they breastfed their
infants of which 64.7% stated that they were self-motivated to
opt for the natural way of feeding their infant since they were
aware of the health benefits of breast milk and claimed that
“breast milk is best.”
3.2. Initiation of Breastfeeding. Additionally, 60.6% of the
participants initiated breastfeeding the same day after deliv-
ery, while 39.4% started to nurse their baby 24 hours after
delivery. Chi-square (�2) test confirmed that the timing of
breastfeeding initiationwas significantly associated withmode
of delivery (�2 = 212,� < 0.001). It should be noted that there
were a greater number of mothers, that is, 294 participants
Journal of Nutrition and Metabolism 3
Table 1: Reasons for not adhering to the WHO recommendations

Medically Complex Pregnancies and Early BreastfeedingBehavio.docx

Medically Complex Pregnancies and Early BreastfeedingBehavio.docx

Recommended

Recommended

More Related Content

Similar to Medically Complex Pregnancies and Early BreastfeedingBehavio.docx

Similar to Medically Complex Pregnancies and Early BreastfeedingBehavio.docx (20)

More from ARIV4

More from ARIV4 (20)

Recently uploaded

Recently uploaded (20)

Medically Complex Pregnancies and Early BreastfeedingBehavio.docx