This document proposes a mixed methods study to examine breastfeeding position related musculoskeletal pain (BPRMSP) in postpartum women. The study will have two phases: 1) A survey will be distributed to 500 postpartum women to quantify the prevalence of BPRMSP and identify risk factors. 2) Interviews with 50 women will explore the impact of BPRMSP on quality of life and breastfeeding attitudes. Results may inform interventions to reduce musculoskeletal pain and support breastfeeding.

1. PREVALENCE, CONTRIBUTING RISK
FACTORS AND IMPACT ON QUALITY
OF LIFE OF BREASTFEEDING
POSITION RELATED
MUSCULOSKELETAL PAIN (BPRMSP)
IN POSTPARTUM WOMEN
Amy
Wagner, PT, D
PT, GCS

2. THEORY
Breastfeeding is an
occupational
activity/ADL that
requires physical
endurance:
 Sustained posture
 Ergonomics is
important to maintain
position
 8 to 10 episodes a day
 10 to 45 minutes

3. THEORY
Ergonomic and posture
principles can be applied to task
of breastfeeding mother s
Many women bend their
neck down, sit
unsupported

4. BPRMSP: DEFINITION
Musculoskeletal
pain associated
with certain
breastfeeding
positions
(Mbada, 2013)

5. BACKGROUND
 Breastfeeding recommended by
AAP and WHO for 6 months or
more: 4.5 million bir ths, 80%
mothers attempt breastfeeding
in US.
 Many barrier s exist to reaching
these goals.
 Musculoskeletal pain may be
associated with reduced ability
to achieve the duration of this
activity, but little is known
 Other occupations have been
examined for ergonomic barrier s
to par ticipation
 Gaps in the literature to examine
demographic risk factors, and
positions of mother and baby
that are associated with
increased incidence of BPRMSP.

6. PURPOSE
 This proposed work will
use mixed methods, and
have two distinct phases:
survey (quantitative) and
interviews (qualitative).
 Nonexperimental/primarily
observational to gain
awareness and
understanding of the
problem of BPRMSP
 This work will fill a gap in
the literature in order to
examine the problem of
musculoskeletal pain
associated with the
occupation of
breastfeeding.

7. HYPOTHESES
 The survey instrument
to assess BPRMSP will
have good reliability
and validity:
 face validity and content
validity
 good (> 0.95) test-retest
reliability.
 Less strenuous
positions such as
sidelying and “laid
back” will be associated
with statistically
significant lower pain
ratings

8. RESEARCH QUESTIONS
 What is the point prevalence of Breastfeeding Position Related
Musculoskeletal Pain (BPRMSP) in Postpartum Mothers?
 What are the risk factors for BPRMSP? What role does prior
history of musculoskeletal pain, lifting of the child or wearing
them in a sling play in the pain? How has this BRMSP played
role in attitudes towards breastfeeding and willingness to
continue? What role does the lactation consultant or ergonomic
aids play in mitigating the ef fects of BRMSP?
 What is the impact on quality of life of BPRMSP on
breastfeeding mothers and is it a perceived barrier to continued
breastfeeding in the early postpartum period? How has this
BRMSP played role in attitudes towards breastfeeding and
willingness to continue?

9. INCIDENCE/PREVALENCE IN THE
LITERATURE
 Mbada, et. Al (2013) 1 : n=
397
 Lifetime prevalence of 39.4%
 Point prevalence: 15.9%
 Unsupported sitting: 20.5-39%
 Area of body:
 Neck (20.5%)
 Neck and shoulder (16.6%)
 Back and neck (12.6%)

1 Mbada,
C. E., Oyinlola, F.
C., Olatunbosun , T. O., Awotidebe , T.
O., Arije, O. O., Johnson, O. E., &
Fashote, E. O. (2013). Is Baby -Friendly
Breastfeeding Mother -Friendly?.
Journal of Women’s Health Physical
Therapy, 37(1), 19-28.

10. MORE LITERATURE

General post-partum pain is common: 41% of
post-partum women had pelvic girdle pain 3

Suzanne Colson: Laid back breastfeeding has
lower incidence of body pain. 4 (2010, n=12)
OT: improved infant motor milestones-ventral
feeder

Women with fibromyalgia are more likely to be
unsuccessful at breastfeeding due to
musculoskeletal pain. 5

M u k k a n n a v a r, P. , D e s a i , B . R . , M o h a n t y, U . , K u l k a r n i , S . , P a r v a t i k a r, V. , & D a i w a j n a , S .
( 2 0 1 3 ) . P e l v i c g i r d l e p a i n i n I n d i a n p o s t p a r t u m w o m e n : a c r o s s - s e c t i o n a l s t u d y. P h y s i o t h e r a p y
theor y and practice, (0), 1-8.
 4 Colson S. An introduction to biological nur turing: New angles on breastfeeding. Hale Pub;
2010.
 5Schaefer KM. Breastfeeding in chronic illness: The voices of women with fibromyalgia.
MCN: The American Journal of Maternal/Child Nursing . 2004;29(4):248-253.

3

11. THAI STUDY OF BACK PAIN WITH BREASTFEEDING 2
(2010); N= 12
2Klinpikul
N, Srichandr P, Poolthong N, Thavarangkul N.
Factors affecting low back pain during breastfeeding of
thai woman. . 2010.

12. STUDY DESCRIPTION: SUBJECTS
 INCLUSION CRITERIA: 18 to 49 year old women who gave birth
past 6 months, and are breastfeeding
 EXCLUSION CRITERIA: Women who have had musculoskeletal
surgery or injury in the past 6 months, or have stopped
breastfeeding
 RECRUITMENT: physician and midwife offices at postpartum visit.
 San Antonio, Austin, and Los Angeles to gain a wide diversity of
socioeconomic and educational backgrounds.
 Interview recruitment: La Leche league, Lactation consultants, BF task
forces, hospital outpatient lactation centers
 Preliminary analysis states that 247 surveys will be needed for an
epidemiological survey. 500 surveys will be distributed with the goal of
at least 50% return rate.

13. INSTRUMENTS/METHODS
 Questionnaire (500) to have women rate pain associated with
certain positions.
 To be tested for reliability and validity (test -retest reliability and
face/content validity-review by experts) in pilot studies
 Previous study (Mbada) showed agreement percentage of k = . 94 to
1.0 for questionnaire.
 To be translated into Spanish.
 Survey will be anonymous and single blinded; interview not blinded.
 Interviews with 50 women post-partum to determine what
impact on quality of life is of BPRMSP.
 This survey modified from version used by Mbada which was
tested for reliability (test -retest) and validity
 Study location: 3 metro areas, and interviews in SA , Austin private of fice

14. WHAT IS DIFFERENT?
Demographic variables and questions added
 open ended component-qualitative
 ergonomic aids
 socioeconomic variables
 position used by mother
 baby’s position
 Pain with other activities
 Different geographic regions
 Ethnicity/language variables

15. ERGONOMIC AIDS FOR BREASTFEEDING

16. DEMOGRAPHIC VARIABLES
Personal Information:
Your DOB:
Your present baby’s DOB:
Occupation:
How many births have you had?
How many children do you have?
Was your present birth:
a.
Vaginal
a.
Cesarean section
Do you exclusively breastfeed?
Height and Weight
Ethnicity
Education level

17. SURVEY COMPONENTS
_____ Lying down on
my side
_____ Lying down (“laid
back”)
_____ Sitting- Football hold
_____ Child in sling
_____ Sitting –cradle
hold
_____Sitting: cross –cradle
hold
_____Sitting-koala hold (baby
upright)
_____ Other: (please
describe)

18. QUANTITATIVE RATING OF PAIN (0-10)
PAIN SCALE
Body Area
Head
Neck
Shoulder
Elbow
Wrist
Upper Back
Lower Back
pelvis
General
Body
0= no
pain
1
2
3
4
5=
modera
te pain
6
7
8
9
10 = worst pain possible

19. SAMPLE OF MORE SURVEY QUESTIONS

9.
Which of the following has eased
your aches or pains in your body while
breastfeeding? Mark all that apply.

a.
_____
as
friend
b.
_____
c.
_____
d.
_____
e.
_____
counter or
f.
_____
g.
_____
h.
_____
i.
_____















11.
Have you experienced
musculoskeletal pain with any of the
following activities currently (in the
past week)?

a.
_____ Lifting or carrying child or
other children?
b.
_____ Lifting car seat, stroller, or
other equipment?
c.
_____ Using a baby wearing
device or sling to carry child in?
d.
_____ Other daily activities such
as household chores or driving?
e.
_____ Computer use
f.
_____ Other:
Use of ergonomic aid such
Boppy or my breast
Use of regular pillows
Use of footstool
Alternating positions
Medication-over the
prescription
Massage
Stretching/exercise
Abdominal corset or brace
Other: ___________________
10.
Have you utilized any of the
following services in regards to
positioning with breastfeeding (circle
all that apply)?
a.
b.
c.
group
d.
center
e.
f.

_____ Lactation Consultant
_____La Leche League
_____ Breastfeeding support
_____ hospital based lactation
_____Postpartum doula
_____ Other: ______________________






12.
During your pregnancy, did you
experience any symptoms of pain, ache
or discomfort


a.
b.

14.
Is there anything else you would
like to share about any muscle or body
pain you may have experienced while
breastfeeding?
_____ Yes
_____ No

20. METHODS:
 The paper survey will be distributed in person to physician
(OB/GYN and pediatrician) of fices and nurse -midwife of fices in
each of 3 large metropolitan cities (San Antonio, Austin, and
Los Angeles).
 Self-addressed stamped envelopes will be given for return .
 Personal interviews will be conducted through recruitment via
local La Leche League Groups, breastfeeding task force
organizations, and hospital outpatient lactation centers.
Interviews will be conducted in person in a private of fice
setting in both San Antonio and Austin.

21. DATA ANALYSIS: SPSS AND NVIVO
SOFTWARE
Correlation coefficients will be determined for
test-retest reliability, agreement between
translated versions
Descriptive statistics will be used to summarize
data regarding prevalence of BPRMSP.
Non-parametric tests such as chi-squared will
be used to determine associations between
BRMSP and sociodemographic variables of the
participant (age, parity, type of
birth, socioeconomic strata, education, BMI)
NVIVO will be used to code, translate, verify
and analyze qualitative data.

22. SUMMARY
 This proposed work will use
mixed methods, and have two
distinct phases: sur vey
(quantitative) and inter views
(qualitative).
 This work will fill a gap in the
literature in order to examine
the problem of
musculoskeletal pain
associated with the
occupation of breastfeeding.
 This project may lead to
increased knowledge of
potential risk factor s and
mitigating factor s for
BPRMSP, as well as increase
knowledge to be used for
planning inter vention studies
to decrease musculoskeletal
pain in the postpar tum period.