What Factors May be Driving U.S. Women’s Breastfeeding Choices and Experiences?: A Listening to Mothers III Data Brief
Exclusive breastfeeding is optimal nutrition for the first six months of a baby’s life, and protects maternal health as well. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for about six months and continued breastfeeding for at least one year. National Listening to MothersSM III surveys asked in-depth questions about women’s breastfeeding knowledge, experiences, and choices. These nationally representative data are from an initial survey of 2400 women, 18-45, who had given birth to a single baby in U.S. hospitals from July 2011 through June 2012 and could participate in English, as well as a follow-up survey of 1072 of the initial participants carried out several months later. Childbirth Connection’s Listening to MothersSM III surveys were conducted by Harris Interactive and funded by the W.K. Kellogg Foundation.
SUMMARY OF KEY FINDINGS
Women appear to be aware of national breastfeeding recommendations. On average, women believed the American Academy of Pediatrics recommended exclusive breastfeeding for seven months and any breastfeeding for at least eleven months, close to the Academy’s actual six- and twelve- month recommendations. However, only 54% hoped to breastfeed exclusively for any duration as they neared the end of pregnancy.
A gap exists between national standards for hospital breastfeeding support and the hospital practices women experienced after birth. The American Academy of Pediatrics Policy Statement, “Breastfeeding and the Use of Human Milk” (2012) and its companion “Sample Hospital Breastfeeding Policy for Newborns” (2010) provide guidance to hospitals to implement practices that support breastfeeding and avoid disruptive ones. Contrary to these guidelines, survey participants who intended to exclusively breastfeed experienced the following:
- 49% were given free formula samples or offers
- 47% were not told about breastfeeding resources in their communities
- 37% of their babies were given pacifiers by staff
- 36% were not shown how to position the baby to limit nipple soreness
- 35% of babies did not “room in” with their mothers while in the hospital
- 31% were not encouraged to breastfeed on demand
- 29% were given formula or water to supplement their mother’s breast milk
- 19% did not receive help to start breastfeeding when they were ready.
Mothers fell far short of American Academy of Pediatrics recommendations for exclusive and mixed breastfeeding duration. One week after giving birth, 50% of the mothers reported feeding their babies breast milk only, and this proportion dropped rapidly over the coming months (see figure below). Just 17% of respondents met the AAP standard of exclusive breastfeeding for at least six months, and 31% met the standard of some breastfeeding to at least 12 months.
The mothers identified barriers to fulfilling their intention to exclusively breastfeed. The most common reasons cited for not establishing exclusive breastfeeding were (women could choose more than one):
- “My baby had difficulty nursing” – 31%
- “It was too hard to get breastfeeding going” – 23%
- “Formula was more convenient” – 23%
- “I didn’t get enough support to get breastfeeding going” – 17%
- “I didn’t plan to breastfeed much anyway, as I planned to go back to my paying job soon” – 13%
- “I had to take medicine and didn’t want my baby to get it through breast milk” – 12%)
- “I tried breastfeeding and didn’t like it” – 12%
- “It was too hard with my own health challenges” – 12%
- “After the birth, I changed my mind about wanting to breastfeed” – 9%
Many women experienced breast-related discomfort, infections, or other problems in the weeks and months after giving birth. In particular, discomfort affected almost half of women.
- Nipple soreness/breast tenderness was reported as a problem in the first two months by 48% of the mothers (35% “major” problem; 12% “minor” problem), with 9% still experiencing this discomfort at or beyond 6 months.
- Breast infections were a problem for 15% of women in the first two months (9% “major”; 6% “minor”), with 3% still experiencing breast infections at or beyond 6 months.
- Other breastfeeding problems affected 33% of women in the first two months (16% “major”; 17% “minor”), with 5% still experiencing other problems at or beyond 6 months.
Only about half (49%) of women breastfed as long as they had wanted. Various support services – participating in the WIC program for supplemental food in pregnancy or after birth, having a home visit, and having a telephone number to call for help – were not associated with breastfeeding as long as a mother wanted. The likelihood that a mother breastfed as long as she wanted was strongly related to her reported family income, with mothers reporting an income of more than $98,000 more likely (62%) to report they breastfed as long as they wanted to compared with mothers with an income less than $37,000 (44%) (p < .01). Mothers who reported that they and their spouse shared responsibilities for care of the baby equally were more likely to feel they had breastfed as long as they wanted (57%) compared with mothers who reported they or their spouse were the primary carer for their child (46%) (p < .01). Other, often important characteristics shown in the figure did not reach significance.
Employment posed breastfeeding challenges for many mothers. Nearly half (49%) of women who were employed at the time of the follow-up survey said that their plans for employment after giving birth had impacted feeding decisions. In the open-ended responses to probe specific details, most who responded affirmatively described ways that employment had impinged on breastfeeding, implying that the volume and/or duration of breastfeeding would otherwise have been greater. In rating possible challenges involved with the transition to employment, 28% felt that breastfeeding had been a “major” challenge, and 30% a “minor” challenge.
The follow-up survey asked women who were employed and working at their employers’ workplace about two provisions of the Patient Protection and Affordable Care Act. Most (61%) stated that their employer offered reasonable breaks to allow nursing mothers to express milk, and half (50%) said that a private place that was not a bathroom was available for nursing mothers to express milk.
Trouble getting breastfeeding going was the most common reason for stopping. Women who were breastfeeding at one week, either exclusively or in combination with formula feeding, and were not breastfeeding at the time of the follow-up survey gave the following leading reasons for discontinuing (women could choose more than one):
- “I had trouble getting breastfeeding going well” – 39%
- “Formula or solid food was more convenient” – 22%
- “I fed my baby breast milk as long as I had planned” – 22%
- “My baby stopped nursing; it was the baby’s decision” – 18%
- “I was working at a paying job or school, and other people were feeding the baby” – 9%
- “I did not have enough help to work through the challenges” – 8%
- “I had to take medicine and didn’t want my baby to get it through breast milk” – 8%
Exclusive breastfeeding intent and practice appear to be inversely related to the number of children a woman has had. The follow-up survey explored breastfeeding history of respondents who had had one or more children prior to the baby born in 2011-12. As shown in the table below, both their intention to exclusively breastfeed and actually doing so a week after the birth appears to drop off substantially as the number of prior children increases.
Some aspects of breastfeeding vary by race/ethnicity. We had enough participants to explore some possible differences among white non-Hispanic (“white”), black non-Hispanic (“black”), and Hispanic mothers. White mothers (61%) were more likely to intend to exclusively breastfeed than black (43%) or Hispanic (51%) mothers, and were less likely (21%) to plan mixed feeding (34%) than Hispanic (34%) or black (35%) mothers. We found no significant differences among these groups in experience of “Baby-Friendly” hospital practices. A week after the birth, Hispanic mothers (33%) were more likely than black (28%) or white (23%) mothers to be feeding both breast milk and formula. Many questions directed to subsets of mothers had samples that were too small to detect differences that may exist.