Hospital Care Practices Associated With Exclusive Breastfeeding 3 and 6 Months After Discharge: A Multisite Study

Abstract

Maternity care practices influence breastfeeding outcomes long after women leave the birth setting. We conducted this study to describe, from mothers' perspective, maternity care practices associated with breastfeeding at 3 and 6 months. Mothers who recalled having skin-to-skin care (SSC) and rooming-in for 23 or more hours/day were more likely to report exclusive breastfeeding when surveyed at 3 months. Perception of not enough milk and difficulty latching explained more than 85% of supplementing and weaning at 3 months. Women also reported that returning to work influenced their decision to supplement or wean. Our multisite study supports implementing low cost and evidence-based interventions such as immediate and uninterrupted SSC and rooming in to improve breastfeeding exclusivity. Findings highlight the ongoing need to bridge the gap between hospital discharge and community breastfeeding support, including workplace accommodations.

INTRODUCTION

The Centers for Disease Control and Prevention (CDC, 2019) describes breastfeeding as an investment in health; and UNICEF (2019), fundamental to child survival, growth, and development. Decades of evidence show that breastfeeding is critical to optimal child and maternal outcomes. Inadequate breastfeeding increases the risk of both short and long-term child conditions, such as asthma, overweight, and obesity, Type 2 diabetes, and ear, respiratory, and gastrointestinal infections. Inadequate breastfeeding increases the risk of maternal conditions such as high blood pressure, Type 2 diabetes, and ovarian and breast cancer (CDC, 2019). International and national public health experts(American Academy of Pediatrics [AAP] Section on Breastfeeding, 2012; World Health Organization [WHO] & UNICEF 2018) recommend that mothers and newborns receive skin-to-skin care (SSC) immediately after birth, and that breastfeeding begin during the first hour after birth and continue exclusively for 6 months. The WHO and UNICEF, (2018) recommend continued breastfeeding combined with appropriate complementary foods for at least 2 years; the AAP Section on Breastfeeding (2012) recommends continued breastfeeding for at least1 year.

Unfortunately, breastfeeding outcomes globally (WHO & UNICEF, 2018) and in the United States (CDC, 2018), fall short of international and national goals, particularly for 6 months exclusivity. Globally, only 42% of newborns are offered the breast within the first hour of birth and only 40% of infants are breastfed exclusively for 6 months (WHO & UNICEF, 2018). Of infants born in the United States during 2015, 83% breastfed, 47% breastfed exclusively for 3 months, and 36%, for 6 months (CDC, 2018).

Maternity care practices influence whether a woman chooses to breastfeed, whether a newborn whose mother chooses to exclusively breastfeed is supplemented with infant formula during the hospital stay, and whether a mother exclusively breastfeeds after discharge. The Baby-friendly Hospital Initiative (Baby-friendly), implemented in 1991, re-interpreted in 2006 and 2009, and “reinvigorated” in 2018, emphasized the dramatic impact of maternity care practices on breastfeeding outcomes, and subsequently, on maternal and child morbidity and child mortality. Adherence to the 10 evidence-based Baby-friendly maternity practices improve breastfeeding initiation, duration, and exclusivity and a dose response effect. Exposure to more of the Baby-friendly steps enhances outcomes (Pérez-Escamilla et al., 2016). Evidence-based practices such as immediate and uninterrupted SSC and rooming-in positively influence breastfeeding outcomes.

Many U.S. hospitals monitor their adherence to key maternity practices associated with exclusivity and their exclusive breastmilk feeding rate at hospital discharge, based on the documentation of health professionals. Reports based on mothers' perception of maternity experiences are lacking in the literature. We wanted to know, from mothers' perspective, their experience with key maternity practices associated with exclusivity, and their subsequent breastfeeding practices, so we conducted an infant feeding survey of mothers at about 3 and 6 months postpartum.

AIM

The aim of our study was to describe, from mothers' perspectives, the experience of maternity care practices associated with exclusive breastfeeding rates at 3 and 6 months after hospital discharge.

METHODS

Design

We conducted a cross sectional descriptive replication study using a modified, single-site, investigator-developed survey tool that was used in 2011 by DiFrisco, Goodman, Budin, Lilienghtal, Kleinman, and Holmes. Modifications of the original study design included adding six geographically diverse sites and updating the survey tool to reflect interpretation of the Ten Steps to Successful Breastfeeding by Baby-friendly United States at the time of the study. Researchers in the DiFrisco et al. study surveyed new mothers 2 to 4 weeks post discharge. We surveyed new mothers at 3 and 6 months post discharge, as these times were more closely aligned with the 2020 maternal, infant, and child health objectives and monitoring benchmarks for breastfeeding exclusivity in the United States (Office of Disease Prevention and Health Promotion, 2019).

Participants

Participants included women who gave birth during the data collection period at each study site. We included women 18 years of age or older who gave birth to one or more healthy newborns at the study sites and could read English or had someone available who could read English and assist with the survey. Exclusion criteria were women who did not meet inclusion criteria, and specifically, women who had a fetal demise or gave birth to an infant who was not expected to survive.

Human Subjects Protection

We received institutional review board (IRB) exempt approval for the multisite study and for each of the individual sites. Following IRB approval and prior to hospital discharge, mothers who met inclusion criteria were given an information sheet that described the study and were invited to participate in an anonymous electronic infant feeding survey at about 3 and 6 months after discharge. We defined agreement to receive the study e-mails as providing an e-mail address with the date the e-mail was provided. E-mail collection sheets were stored in a secured area accessible only to study personnel. By completing the online survey at about 3 and 6 months after discharge, participants consented to be in the study. To maintain anonymity, the survey did not collect Internet printing protocol (IPP) addresses and investigators did not know which participants did nor did not complete the survey.

Settings

Data collection sites included two large academic medical centers, one in the Northeast and two in the South-central region of the United States. The remaining two sites were smaller teaching hospitals and community hospitals in the Northeast and South-central region of the United States. The six study sites were either designated as Baby-Friendly by Baby-Friendly USA or were in the process of achieving this designation.

Survey

We sent a 43-item anonymous survey, accessible online only through Qualtrics, at about 3 and 6 months after birth. We designed the survey to be intuitive (questions to be answered were determined by previous answers). Therefore, all 43 items were not answered by each participant. The survey included questions about mothers' prenatal breastfeeding education, prenatal feeding intentions, birth experience, hospital stay, early infant feeding practices while in the hospital and after discharge, and type, timing, and reason(s) for supplements if a baby received a supplement. Demographic data included mothers' age in years, education, racial background, type of birth, newborn gestational age, number of pregnancies and live births, and time spent in the neonatal intensive care or special care nursery.

Specific question about hospital care practices, included “Did you hold your baby skin-to-skin?”; “How soon after birth did you begin holding your baby skin-to-skin?”; “Were routine newborn procedures performed while baby was being held skin-to-skin?”; and “How much time did your baby spend with you in your room while you were in the hospital?” Questions about infant feeding while in the hospital included, “Was baby fed breastmilk, infant formula or both?”; “How soon after birth did baby first latch-on to your breast?”; “If baby was fed infant formula, who guided this decision?”; “Was information provided on safe preparation, handling, storage and feeding of infant formula?”; and “What were the main reasons for feeding infant formula?”

At 3 months and 6 months after discharge, mothers were asked “How are you currently feeding your baby?”; “If supplementing what are the main reasons?”; “If you are no longer breastfeeding, when did you stop?”; “Main reasons for stopping breastfeeding?”; “Were you informed about any infant feeding resources available after discharge?”

Analysis and Statistical Methods

Data were analyzed using descriptive statistics and nonparametric tests. Chi square analyses were performed to test for an association between selected hospital care practices and exclusive breastfeeding at 3 months and 6 months post discharge

RESULTS

Survey Respondents

A total of 986 surveys were sent at 3 months and 672 surveys were sent at 6 months post discharge; 672 (68%) of those surveyed responded at 3 months post discharge, and 437 (65%), at 6 months. Sample characteristics were similar for both data-collection times indicating that the two samples were similar in terms of demographics and other characteristics (see Tables 1 and 2).

TABLE 1. Maternal Characteristics of Participants Responding to the Infant Feeding Survey 3 and 6 Months After Hospital Discharge.

Percentages and Frequencies, Study Variables	3 Months: n = 672		6 Months: n = 437
	Frequency	%	Frequency	%
Race
White	400	286	67.9
Asian	73	11.4	45	10.7
Hispanic	60	9.3	40	9.5
Black/African American	49	7.6	21	5.0
Multiracial	24	3.7	14	3.3
Other	36	5.7	12	2.9
Education
Bachelor's Degree or Higher	469	72.7	214	77.1
High School Diploma	147	22.8	84	20.0
Other	29	4.6	12	2.8
Number of births
Single birth (one baby)	643	96.0	416	96.1
Twins (two babies)	24	3.6	17	3.9
Other multiples	3	0.4	–	–
Marital status
Married or partnered	581	90.1	395	93.8
Single/divorced/separated/widowed	64	10.0	26	6.2
How many times gave birth
First time mothers	361	53.8	254	58.5
Type of birth
Vaginal	415	61.8	271	62.7
Vaginal birth assisted with forceps or vacuum	45	6.7	25	5.8
Planned/Scheduled Cesarean	102	15.2	60	13.9
Emergency Cesarean/Unscheduled	109	16.2	76	17.6

TABLE 2. Hospital Care Practices as Recalled at 3 Months and 6 Months After Discharge.

Hospital Care Practices	3-month data N = 672		6-month data N = 437
	n	%	n	%
Immediate skin-to-skin	571	85	376	86
Rooming in
More than 23 hours	403	60	284	65
16–23 hours	188	28	109	25
9–14 hours	34	5	18	4
8 or fewer hours	54	8	26	6

Three Month Survey Participants

The mean age for mothers at the 3-month data collection point was 32 years (SD = 5.3, range –18–48). Most participants had single births (96.0%, n = 643). In terms of racial background, 62.3% (n = 400) of the sample identified as White, 11.4% (n = 73) Asian, 9.3% (n = 60) Hispanic, 7.6% (n = 49) Black/African American, 3.7% (n = 24) multiracial, and 5.7% (n = 36) other. Overall the sample was highly educated with close to three quarters (72.7%, n = 469) having completed a bachelors or higher degree. A total of 90.1% (n = 581) were married or partnered, 53.8% (n = 361) were first time mothers and 68.5% (n = 460) had vaginal births. A total of 92 mothers (13.8%) reported that their babies spent time in the neonatal intensive care unit (NICU). The median length of stay in the NICU was 4 days (mean 11.74 days; SD = 20.5; range 1–90 days).

Six Month Survey Participants

The mean age of the 6-month was 32 years (SD = 5.0; range 18–48). Of the respondents at 6 months, 93.8% (n = 395) were married or partnered, 58.5% (n = 254) were first-time mothers, and 67.7% (n = 296) had vaginal births. Most participants had single births (96.1%, n = 416). The racial background of participants at 6-months was, 67.9% (n = 286) White, 10.7% (n = 45) Asian, 9.5% (n = 40) Hispanic, 5% (n = 21) Black/African American, 3.3% (n = 14) multiracial, and 2.9% (n = 12) other. Similar to 3 months, the 6-month sample was highly educated with (77%, n = 214) having completed a bachelors or higher degree. A total of 48 mothers (10.9%) reported that their babies spent time in the NICU. The median length of stay was 4 days spent time in the NICU.

Hospital Care Practices Associated With Breastfeeding Outcomes

Skin to Skin Care and Rooming in During the Hospital Stay

At the 3-month data collection point, 85% (n = 571) of mothers recalled that they experienced immediate SSC after birth; and at 6-months, 86% (n = 376). At the 3-month data collection point, 60% (n = 403) recalled rooming in more than 23 hours per day with their baby while in the hospital; 28% (n = 188), for 16-23 hours; 5% (n = 34), for 9 to 14 hours; and 8% (n = 54), 8 or fewer hours. At 6-months, 65% (n = 284) of mothers recalled rooming in with their babies more than 23 hours per day; 25% (n = 109), 16 to 23 hours, 4% (n = 18), 9 to 14 hours; and 6% (n = 26), 8 or fewer hours.

Breastfeeding in the Hospital

We asked mothers to recall how they fed their newborns while in the hospital. At 3-months post discharge, 95% (n = 638) of mothers recalled that they breastfed in the hospital and 65% (n = 437) recalled that they breastfed their newborn exclusively. At the 6-month data collection point, 97% (n = 424) recalled breastfeeding while in the hospital and 70% (n = 306) reported that they breastfed their newborn exclusively while in the hospital.

Breastfeeding After Discharge

When asked how they were currently feeding their baby (about 3 months after discharge), 79% (n = 531) reported that they were still breastfeeding; and, 62% (n = 417) reported that they were breastfeeding their baby exclusively. At the 6-month data collection point, 76% (n = 332) reported that they were still breastfeeding; and 58% (n = 253), reported that they were breastfeeding their baby exclusively (see Table 3).

TABLE 3. Breastfeeding Rates in the Hospital and After Discharge as Recalled at 3-Month and 6-Months After Discharge.

Breastfeeding Rates	3-Month Data, n = 672		6-Month Data, n = 437
	n	%	n	%
While in the hospital
Breastfed at all	638	95	424	97
Breastfed exclusively	437	65	306	70
Post discharge
Still breastfeeding?	531	79	332	76
Exclusively?	417	62	253	58

Hospital Practices and Breastfeeding Outcomes After Discharge

Results at the 3-Month Data Collection Point

Mothers who recalled having SSC immediately after birth (85.3%, n = 570) were significantly more likely to report exclusive breastfeeding for three months (88.8% vs. 80%). At the same time, mothers who recalled that they did not have SCC immediately after birth (14.7%, n = 98) were significantly less likely to report exclusive breastfeeding for 3 months (11.2% vs. 20.0%; chi square = 9.96, p = .002; see Table 4).

TABLE 4. Cross-Tabulation of Immediate Skin-to-Skin by Exclusive Breastfeeding 3-Months After Discharge With Chi-Square Analysis.

Did You Experience Skin-to-Skin Immediately After Birth?
			Exclusive Breastfeeding 3-Months After Discharge
			Yes	No	Total
Immediate Skin-to-Skin
	Yes
		n	358	212	570
		% within Exclusive BF—3 months	88.8%	80.0%	85.3%
		% of Total	53.6%	31.7%	85.3%
	No
		n	45	53	98
		% within Exclusive BF—3 months	11.2%	20.0%	14.7%
		% of Total	6.7%	7.9%	14.7%
	Total
		n	403	265	688
		% within Exclusive BF—3 months	100%	100%	100%
		% of Total	60%	39.7%	100%

Note. X² = 9.96, p = .002.

Mothers who recalled keeping their baby in the room with them 23 hours a day or more (58.2%, n = 391) were significantly more likely to report exclusive breastfeeding at 3 months (62.0% vs. 52.4%). Another way to say it was that mothers who reported that they did not have their baby in their room 23 or more hours per day or more (41.8%, n = 281) were significantly less likely to report exclusive breastfeeding for 3 months (38.0% vs. 47.6%; chi square = 6.1, p = 0.01; see Table 5).

TABLE 5. Cross-Tabulation of Rooming in 23 Hours or More by Exclusive Breastfeeding 3-Months After Discharge With Chi-Square Analysis.

Did You Keep Your Baby in Your Room 23 Hours or More per Day While in the Hospital?
			Exclusive Breastfeeding 3-Months After Discharge
			Yes	No	Total
Rooming—in 23-hours or more
	Yes
		n	250	141	391
		% within Exclusive BF—3 months	62.0%	52.4%	58.2%
		% of Total	37.2%	21.0%	58.2%
	No
		n	153	128	281
		% within Exclusive BF—3 months	38.0%	47.6%	41.8%
		% of Total	22.8%	19.0%	41.8%
	Total
		n	403	269	672
		% within Exclusive BF—3 months	100%	100%	100%
		% of Total	60%	40.0%	100%

Note. X² = 6.1, p = .01.

Results at the 6-Month Data Collection Point

Mothers who recalled having SSC immediately after birth (86.8%, n = 379) were not more likely to report exclusive breastfeeding for 6 months (chi square = 0.24, p = .876). Mothers who recalled keeping their babies in their room 23 hours a day or more (65.4%, n = 286) were not more likely to be exclusively breastfeeding 6 months after discharge (chi square = 3.4, p = .065).

Supplementing and Weaning

Results at the 3-Month Data Collection Point

The reasons mothers gave for supplementing with infant formula at 3-months were perceptions of not enough milk supply (53.7%, n = 361), returning to work (35.7%, n = 240), needing to go out without baby (15.2%, n = 37), and so that the partner/other could feed baby (13.9%, n = 93). The reasons mother gave for weaning were perception of not enough milk (64.8, n = 435), difficulty latching (32%, n = 215), returning to work (22.7%, n = 153), and feeling tired, (18%, n = 121).

Results at the 6-Month Data Collection Point

The reasons mothers gave for supplementing with infant formula at 6-months were returning to work (51%, n = 223), perception of not enough milk (49.7%, n = 217), needing to go out without baby (18%, n = 79), and so that the partner/other could feed baby (13.4%, n = 59). The reasons mother gave for weaning were perception of not enough milk (63.5%, n = 277), difficulty latching (20.2%, n = 88), returning to work (39.4%, n = 172), and feeling tired (18.3%, n = 80).

DISCUSSION

Our findings contribute to the growing body of knowledge about the influence of maternity practices on breastfeeding outcomes; and, are consistent with evidence on the improved breastfeeding outcomes associated with SSC (Moore, Berman, Anderson, & Medley, 2016; Safari, Saeed, Hasam, & Moghaddam-Banaem, 2018) and mother/newborn rooming-in (Bystrova et al., 2009; Colombo et al., 2018; Zenkner et al., 2013). These results support international (WHO & UNICEF, 2018) and national (AAP Section on Breastfeeding, 2012) rationale for recommending immediate and uninterrupted SSC for at least an hour and no separation of mothers and babies after birth (AAP Section on Breastfeeding, 2012).

SCC and Rooming In

We found that SSC and rooming-in had a stronger association with breastfeeding exclusivity at the 3-month data collection point when compared to the 6-month data collection point. This is surprising, based on outcomes associated with these evidence-based practices. A possible explanation may be that that we had slightly fewer responses at the 6-month data collection point compared to 3 months. Also, decisions to stop breastfeeding exclusively before 6 months may have been more strongly influenced by factors, such as such as the end of maternity leave, returning to work, lack of breastfeeding support in the workplace, early introduction of solids, and by factors that were not examined in the survey.

Supplementing and Weaning: 3 and 6 Months

For breastfeeding to continue, mothers required sustained breastfeeding support after discharge from a birth facility (WHO & UNICEF, 2018). Community-based support is pivotal to build and sustain an adequate milk supply and to breastfeed confidently. In our study, across six sites, insufficient milk (perceived or real), difficulty latching, and returning to work, were among the most frequently reported reasons for supplementing and weaning. More than half of the women at 3 months (54%, n = 361) and 6 months (50%, n = 217) reported supplementing because they did not have enough milk. More than half of the women at 3 months (65%, n = 435) and 6 months (64%, n = 277) reported weaning because they did not have enough milk. More than 1/3 of women at 3 months (32%, n = 215) and 1/5 at 6 months (20.2%, n = 88) reported difficulties with latching their baby to the breast as the reason for weaning. Staff at birth facilities have a responsibility to inform mothers before hospital discharge, where they can access skilled breastfeeding support in their community.

Returning to Work: 3 and 6 Months After Discharge

Our findings support the evidence calling for work-place support for breastfeeding women, which is particularly critical in countries, like the United States, where maternity leave is limited and unpaid. We found that the need to return to work was the second most frequently cited reason for supplementing and weaning. More than 1/3 of mothers at the 3-month data collection point (36%, n = 240) and more than half at 6 months (51%, n = 223), reported that return to work was the reason for supplementing with infant formula. Kim, Shin, and Donovan (2019), in their systematic review focused on the United States, found that workplace breastfeeding services such as prenatal education (which had a dose-response effect), return-to-work consultations, having a pump for a year, and telephone support were associated with longer durations of exclusive breastfeeding. Removing workplace barriers and increasing workplace services is essential to improving breastfeeding outcomes.

Limitations

Limitations of our study include the reliance on maternal recall, unknown factors influencing a woman's decision to complete the survey, and unknown differences between those who chose to respond and those who did not respond. Due to anonymity, we were not able to make comparisons between those who responded at 3 and 6 months. Another limitation of our study is that our data do not indicate when, after discharge, a mother chose to supplement or wean.

Conclusions

Mothers who recalled having SSC and rooming-in for 23 or more hours a day were more likely to report that they were exclusively breastfeeding when surveyed 3 months after discharge. Perception of not enough milk and difficulty latching explained more than 85% of supplementing and weaning that was reported at 3 and 6 months following discharge. In addition, returning to work was a barrier to continued and exclusive breastfeeding.

Our multisite study contributes to the evidence that supports implementing low cost and evidence-based interventions such as immediate and uninterrupted SSC and rooming in to improve breastfeeding exclusivity. Our findings also highlight the ongoing need to bridge the gap between hospital discharge and community breastfeeding support, including workplace accommodations.

Biographies

JEANNETTE T. CRENSHAW is a professor at Texas Tech University Health Sciences Center School of Nursing, in Lubbock, TX, USA. She is a nurse, educator, and researcher. Dr. Crenshaw is a past president of Lamaze International, a past chair of the United States Breastfeeding Committee, and a past chair of the American Academy of Nursing Expert Panel on Breastfeeding. She has consulted in China and the Middle East on implementing evidence-based maternity and breastfeeding practices.

WENDY BUDIN is a professor and associate dean at Rutgers University School of Nursing, in Newark, NJ, USA. Dr. Budin is a nurse, educator, and a research scientist, who has published extensively in peer reviewed journals and textbooks. She serves as Certification Council Chair for Lamaze.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.