Abstract
Introduction
Many women seek lactation consultant support in the postpartum period. Lactation consultant support in community or clinical settings is often assumed to extend breastfeeding duration, improve breastfeeding experiences, and be well-received. Few studies have assessed women’s perceptions of the support they received, nor have perceptions been examined in relationship to breastfeeding outcomes and maternal well-being. Our objective was to characterize the lactation consultant support women received and examine how women’s perceptions about the support related to their breastfeeding outcomes, anxiety and depressive symptoms, and parenting stress.
Methods
This observational, cross-sectional study examined receipt of postpartum lactation consultant support among 210 US women. Perceptions of lactation consultant support were examined in relation to breastfeeding outcomes, anxiety and depressive symptoms, and parenting stress to explore outcomes of negative versus positive lactation consultant support experiences, using linear and proportional hazards regression.
Results
While overall perceptions of lactation consultant support were positive for most recipients (71%, n=98), 29% (n=40) reported negative perceptions of lactation consultant support. Negative perceptions were associated with lower breastfeeding self-efficacy (β=−11.7, 95% CI: −17.3, −6.0), a less successful breastfeeding experience (β=−19.5, CI: −27.8, −11.3), greater general anxiety (β=6.5, CI: 2.1, 10.9), and shorter total duration of milk production (HR=0.39, 95% CI: 0.18, 0.84). Perceptions were not associated with depressive symptoms or parenting stress.
Discussion
Findings highlight the importance of ensuring that postpartum breastfeeding support provided by lactation consultants is perceived positively by women.
Keywords: Breastfeeding support, Lactation consultant, Maternal psychology, Postpartum depression, Mental health
Introduction
Many U.S. women seek postpartum support from a lactation consultant (LC); for instance, of women in the Infant Feeding Practices Study II who received help with breastfeeding during their obstetric hospital stay, 61% reported receiving support from a LC (Infant Feeding Practices Study II, 2008). Numerous trials have evaluated the efficacy of individual-level breastfeeding support models including support from peers (Graffy, Taylor, Williams, & Eldridge, 2004), physicians (Labarere et al., 2005), nurses (Jones & West, 1986), or multiple supporters (K. Bonuck et al., 2014; Kools, Thijs, Kester, van den Brandt, & de Vries, 2005). Fewer have evaluated the efficacy of support from LCs specifically (K. A. Bonuck, Trombley, Freeman, & McKee, 2005). Ecologic studies have suggested that breastfeeding rates are higher in areas with International Board Certified Lactation Consultants (IBCLCs) (Wouk, Chetwynd, Vitaglione, & Sullivan, 2017). Unlike in carefully monitored trials, LCs in real-world settings vary in training and experience, and they adopt diverse approaches for support with varying degrees of evidence for effectiveness. The LC support most women receive outside of a research setting is often assumed to be effective and well-received by women. However, these assumptions are yet to be confirmed by research.
Among the trials testing individual-level breastfeeding support interventions (K. Bonuck et al., 2014; Graffy et al., 2004; Labarere et al., 2005), few have evaluated participant satisfaction or captured negative effects like feelings of inadequacy or mental health impacts. This gap was identified by the U.S. Preventive Services Task Force as important for future research to ensure interventions are not causing harms, particularly in psychosocial outcomes including feelings of anxiety and guilt (Patnode, Henninger, Senger, Perdue, & Whitlock, 2016). Only one trial measured participant satisfaction and potential negative outcomes upon receiving a support intervention from a professional (e.g., state anxiety). In that trial, nurse contact in the home was compared to nurse contact in the clinic within the first postpartum week, and no differences were reported in satisfaction or state anxiety (Gagnon, Dougherty, Jimenez, & Leduc, 2002). One peer support intervention study collected qualitative positive and negative comments about the intervention from women (Graffy & Taylor, 2005). In that study, effective advice for specific breastfeeding concerns, encouragement, and reassurance were reported as being helpful aspects, while misplaced advice, lack of time or help, not feeling listened to, and pressure to breastfeed were reported as unhelpful. An important limitation of assessing perceptions of LC support in the context of a trial is that participants may provide socially desirable responses, thereby under-reporting potential negative impacts. However, we are aware of no trials that collected data about perceptions and estimated this bias. Because of these knowledge gaps, it remains unknown what happens to women who have a negative LC support experience, in terms of their breastfeeding outcomes and psychosocial well-being.
As a next step toward building a stronger evidence base about the quality of LC support, the objective of this observational, cross-sectional study was to examine women’s receipt of postpartum LC support in a “real world context,” outside of an intervention study. Specifically, we assessed perceptions of the LC support women sought independently and received in relation to breastfeeding outcomes, anxiety and depressive symptoms, and parenting stress to examine associations with negative versus positive LC support experiences.
Methods
Design
The Life After Pregnancy Study (LAPS) was a cross-sectional study because participants could only be surveyed once. LAPS was approved by the Institutional Review Board at Nationwide Children’s Hospital and therefore, was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Setting
Between May and October 2016, women from the general population registered as research volunteers on the U.S. National Institutes of Health-sponsored Research Match website (http://www.researchmatch.org) were invited to participate. Research Match is a registry of research volunteers who may be recruited for a wide range of studies by authorized researchers upon appropriate human subjects protections review. Research Match sends email messages to invite volunteers to participate in studies for which they may qualify.
Sample
All registered women ages 18-47 years were sent an email to inform them about the study and invite their participation if they believed they were eligible. ResearchMatch did not permit targeting the study invitation to all of our specific eligibility criteria, and this limitation precluded assessment of what proportion of non-responders were ineligible, did not receive the email invitation, ignored the invitation, or decided not to participate. If women opened the email, they were presented with a study description about the many aspects of being a parent of an infant and postpartum health, not explicitly about infant feeding and lactation support. The invitation was also posted on several Facebook communities for women with children and on electronic message boards in a major children’s hospital. None of the advertising targeted participants with any particular health, infant feeding, or infant care issue. Eligible participants were women whose primary language was English, aged 18 years or older, with an infant 2-6 months old, who had tried breastfeeding their infant at least once. We also excluded women who provided no demographic data because they could not be characterized. Women who completed the survey were eligible to receive one of four gift cards as an incentive. For the present analysis, we included women who indicated whether they had or had not received lactation support since delivery.
Data collection and Measurement
The study invitation linked to an online REDCap survey, a secure research survey service with a local secure database.(Harris et al., 2009) The first questions confirmed eligibility. Informed consent was obtained from all individuals included in the study. The 45-minute survey assessed use of breastfeeding support services and personal evaluation of the breastfeeding experience; psychosocial well-being, mental health symptoms; lactation and infant feeding history up to the time of the study; and demographic and other personal characteristics. Among the questions about breastfeeding support, women were asked if they had received help with breastfeeding at any time since their baby was born from a “lactation consultant/specialist” (LC). Women who received LC support were asked using a novel question to rate how helpful they found the LC (4 categories, from “Not At all Helpful” to “Very Helpful”). Participants were presented with a list of 23 feelings selected by psychologist study team members and checked all that applied (“Which items best describe how you felt after receiving help with breastfeeding from the lactation consult/specialist?”).
Women also completed the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) to measure self-efficacy; the Maternal Breastfeeding Evaluation Scale (MBFES) to personally evaluate the overall breastfeeding experience (e.g., maternal enjoyment and role attainment, infant satisfaction and growth, lifestyle and body image); the state scale of the State-Trait Anxiety Inventory (STAI) to measure anxiety at the time of the study; the Edinburgh Postnatal Depression Scale (EPDS) to gauge current depressive symptoms; and the Parenting Stress Index, 4th edition short form (PSI-4-SF), to measure maternal distress around parenting (Abidin, 2002; Dennis, 2003; Dennis & Faux, 1999; Leff, Jefferis, & Gagne, 1994; Murray & Carothers, 1990; Spielberger, 1983).
Women were asked if they were currently breastfeeding, either at the breast or by pumping, and when they started and stopped (if they had stopped). The BSES-SF was designed to be completed by women who are still breastfeeding and the MBFES by women who have stopped. To evaluate these outcomes regardless of breastfeeding status at the time of the study, we altered the verb tense to create alternative versions.
Data analysis
Women who checked the box for “lactation consultant/specialist” about whom they had received support were considered to have received support from a LC, and women who did not check it were considered to have not received that support. An examination of patterns in the responses to the 23-item checklist about how women perceived the LC support revealed that most marked exclusively positive or exclusively negative feelings (see Results), so respondents were categorized as having an overall positive or overall negative perception of the LC support received.
Human milk feeding duration (feeding baby directly from the breast, expressed milk feeding, and those practices combined) was calculated as three continuous variables in units of days for women who had already stopped, by subtracting the age of the child when breastfeeding started from the age when breastfeeding stopped.
The instruments that assessed breastfeeding experiences and mental well-being were scored according to published methods. Specifically, the 14 BSES-SF items are rated on a Likert scale ranging from 1-4 (“not at all confident” to “always confident”). The sum formed a breastfeeding self-efficacy score, with higher scores indicating greater self-efficacy. The 30-item MBES is scored similarly with a 1-4 point scale (“strongly disagree” to “strongly agree”), and some items are reverse coded to form a score for the woman’s overall evaluation of the breastfeeding experience (higher scores indicated a more positive experience). EPDS depressive symptoms scores were calculated from the 10-items that assessed whether the woman felt each symptom over the previous 7 days with a scale of 0-3 for answer choices generally corresponding to “yes, most of the time” to “no, not at all.” Higher scores indicated more symptoms. State anxiety scores were calculated by summing 20 STAI items rated on a 1-4 scale ranging from “not at all” to “very much so” for each feeling indicative of anxiety, with higher scores indicating greater anxiety. For the PSI-SF, percentile scores (range: 1-99) were calculated for Parental Distress, Parent-Child Dysfunctional Interaction, Difficult Child and Total Stress, where higher scores indicated greater problems. Each of these scores formed continuous variables for analysis.
We used univariate and bivariate statistics to characterize the sample. We applied simple and multiple linear regression to examine associations between perceptions about LC support received (negative versus positive) and continuous scores for breastfeeding self-efficacy, personal evaluation of the breastfeeding experience, state anxiety, depressive symptoms, and parenting stress. We conducted survival analysis to examine associations between perception of LC support and the human milk feeding duration variables. Values for covariates were rarely missing, so we pursued complete case analyses. Variables listed in Table 1 that were associated with at least some outcomes and with perception of LC support per chi-square p<0.05 were considered confounders and included in regression models accordingly.
Table 1.
Participant Characteristics, Life After Pregnancy Study (2016)
| Maternal or infant characteristic | Total sample (n,%; N=210) |
Women who did not receive LCd support (n,%; n=72) |
Women who received LC support (n,%; n=138) | ||
|---|---|---|---|---|---|
| Total | Positive perceptione(n= 98) |
Negative perception (n=40) |
|||
| Maternal age – 18-26 | 39 (19) | 19 (26) | 20 (14) | 14 (14) | 6 (15) |
| 27-30 | 59 (28) | 18 (25) | 41 (30) | 32 (33) | 9 (23) |
| 31-34 | 58 (28) | 16 (22) | 42 (30) | 30 (31) | 12 (30) |
| ≥35 | 54 (26) | 19 (26) | 35 (25) | 22 (22) | 13 (33) |
| Maternal education – ≤High school/GED | 15 (7) | 12 (17) b | 3 (2) | 3 (3) | 0 |
| Some college/Associate’s degree | 45 (21) | 18 (25) | 27 (20) | 21 (21) | 6 (15) |
| College graduate | 63 (30) | 18 (25) | 45 (33) | 31 (32) | 14 (35) |
| Post graduate education | 87 (41) | 24 (33) | 63 (46) | 43 (44) | 20 (50) |
| Marital status – Married/living w/ partner | 190 (90) | 61 (85) a | 129 (93) | 93 (95) | 36 (90) |
| Single | 14 (7) | 9 (13) | 5 (4) | 4 (4) | 1 (3) |
| Separated, divorced, widowed or partner not living together | 6 (3) | 2 (3) | 4 (3) | 1 (1) | 3 (8) |
| Maternal race – Caucasian/White | 172 (82) | 54 (75)a | 118 (86) | 79 (81) c | 39 (98) |
| African-American/Black | 17 (8) | 11 (15) | 6 (4) | 5 (5) | 1 (3) |
| Other or multiple races | 18 (9) | 6 (8) | 12 (9) | 12 (12) | 0 |
| missing | 3 (1) | 1 (1) | 2 (1) | 2 (2) | 0 |
| Maternal ethnicity - Hispanic | 11 (5) | 5 (7) | 6 (4) | 5 (5) | 1 (3) |
| Non-Hispanic | 199 (95) | 67 (93) | 132 (96) | 93 (95) | 39 (98) |
| Currently have a mental health diagnosis | 47 (22) | 18 (25) | 29 (21) | 17 (17) | 12 (30) |
| Household income - <$35,000 | 30 (14) | 14 (19) | 16 (12) | 14 (14) | 2 (5) |
| $35,000-<$75,000 | 64 (30) | 23 (32) | 41 (30) | 31 (31) | 10 (25) |
| $75,000-<$95,000 | 30 (14) | 8 (11) | 22 (16) | 8 (8) | 14 (35) |
| ≥$95,000 | 85 (40) | 27 (36) | 58 (42) | 44 (45) | 14 (35) |
| missing | 1 (0) | 0 | 1 (1) | 1 (1) | 0 |
| Employment – Work in the home only | 59 (28) | 29 (40) a | 30 (22) | 27 (28) c | 3 (8) |
| Employed full-time or full-time student | 100 (48) | 30 (42) | 70 (51) | 41 (42) | 29 (73) |
| Employed part time | 30 (14) | 9 (13) | 21 (15) | 19 (19) | 2 (5) |
| Temporary maternity leave | 21 (10) | 4 (6) | 17 (12) | 11 (11) | 6 (15) |
| Child age when returned to work/school (among women who had returned) – 0 months | 7 (5) | 3 (8) | 4 (4) | 3 (5) | 1 (3) |
| 1 month | 32 (25) | 12 (31) | 20 (22) | 13 (22) | 7 (23) |
| 2 months | 41 (32) | 10 (26) | 31 (34) | 21 (35) | 10 (32) |
| 3 months | 32 (25) | 11 (28) | 21 (23) | 15 (25) | 6 (19) |
| 4-6 months | 8 (6) | 1 (3) | 7 (8) | 3 (5) | 4 (13) |
| missing | 10 (8) | 2 (5) | 8 (9) | 5 (8) | 3 (10) |
| Child attends daycare program (among women who were employed or in school) | 95 (45) | 28 (72) | 67 (74) | 43 (72) | 24 (77) |
| missing | 9 (7) | 2 (5) | 7 (8) | 5 (8) | 2 (6) |
| How household is able to make ends meet – With difficulty or great difficulty | 28 (13) | 12 (17) | 16 (12) | 10 (10) | 6 (15) |
| Just get by | 83 (40) | 28 (39) | 55 (40) | 36 (37) | 19 (48) |
| Easily or very easily | 98 (35) | 32 (44) | 66 (48) | 51 (52) | 15 (38) |
| missing | 1 (0) | 0 | 1 (1) | 1 (1) | 0 |
| Household size – 2-3 people | 103 (49) | 26 (36) a | 77 (56) | 51 (52) | 26 (65) |
| 4-5 people | 83 (40) | 34 (47) | 49 (36) | 36 (37) | 13 (33) |
| ≥6 people | 23 (11) | 12 (17) | 11 (8) | 10 (10) | 1 (3) |
| missing | 1 (0) | 0 | 1 (1) | 1 (1) | 0 |
| Number of children in household - 1 | 109 (52) | 28 (39) | 81 (59) | 54 (55) | 27 (68) |
| 2 | 63 (30) | 24 (33) | 39 (28) | 30 (31) | 9 (23) |
| 3 | 26 (12) | 13 (18) | 13 (9) | 9 (9) | 4 (10) |
| ≥4 | 11 (5) | 7 (10) | 4 (3) | 4 (4) | 0 (0) |
| missing | 1 (0) | 0 (0) | 1 (1) | 1 (1) | 0 (0) |
| Cesarean section | 52 (25) | 13 (18) | 39 (28) | 26 (27) | 13 (33) |
| missing | 1 (0) | 0 | 1 (1) | 1 (1) | 0 |
| Infant age at time of survey – 2 months | 45 (21) | 18 (25) | 27 (20) | 19 (19) | 8 (20) |
| 3-4 months | 89 (41) | 29 (40) | 60 (43) | 41 (42) | 19 (48) |
| 5-6 months | 76 (36) | 25 (35) | 51 (37) | 38 (39) | 13 (33) |
chi-square p<0.05
chi-square p<0.001, comparing women by whether they received LC support or not
chi-square p<0.05, comparing women by whether they perceived LC support positively or negative
LC – lactation consultant/specialist, GED – General Educational Development
Women were classified into the positive perception or negative perception group based on responses to the 23-item checklist about how women perceived the LC support. Most marked exclusively positive or exclusively negative feelings. The remaining women indicated feelings that were more positive or more negative and so were assigned to the positive or negative group, accordingly.
Results
The sample was mostly college-educated and married or living with a partner [Table1]. Some women identified as a race and ethnicity other than non-Hispanic White (17%). About half were engaged in full-time employment or education. Of 344 women who clicked the email invitation to the survey, agreed to participate, and met the eligibility criteria, 77 provided no demographic information (almost all of them provided no data at all), leaving 267 women. Of these 267 women, 210 indicated whether they had received LC support, and they formed the sample for this analysis. Of these 210 women, 138 (66%) had received LC support since delivery. Women who were single, African-American/Black, did not work outside the home, from larger households, who had less education, or who had more children were less likely to report receiving LC support (all chi-square p<0.05), but no differences in receipt of support were observed by other characteristics. Of those women who received LC support, 58 (42%) received it only during the delivery hospital stay, and 37 (27%) received it again during the first postpartum month but not afterwards.
How did women characterize the support they received from lactation consultants?
The most common positive feelings about LC support were “supported” and “informed.” The most common negative feelings were “pressured” and “disappointed” (Figure 1).
Figure 1.
Participants’ reported feelings after receiving help with breastfeeding from a lactation consultant/specialist (n=138). Participants could mark multiple feelings. Panel a. Proportion that endorsed each positive feeling. Panel b. Proportion that endorsed each negative feeling.
Most women (75% of those women who received support) indicated only positive or only negative feelings (Figure 2). The remaining women indicated feelings that were more positive or more negative and so were assigned to the positive or negative group, accordingly.
Figure 2.
Heat Map Displaying Participants by the Number of Negative and Positive Feelings They Reported (n=138).
Thus, 71% (98) of those women who received support had an overall positive perception and were classified as such, while 29% (40) had an overall negative perception. White women and women working full-time or on maternity leave were more likely to perceive the support negatively (chi-square p<0.05), but other characteristics were unassociated with positive versus negative perception [Table 1]. Between 65% and 73% of women had positive perceptions regardless of whether they received support during the delivery stay, post-discharge, or both.
Women’s ratings of how helpful they found the LC were related to whether they had an overall positive or negative perception of the support [Table 2]. However, 14% of the women who maintained a positive perception found the LC to be only a little helpful, and 30% of the women who maintained a negative perception still found the LC to be at least somewhat helpful.
Table 2.
Respondent Ratings of the Helpfulness of Lactation Consultant/Specialist who Provided Support by Perception about the Quality of the Support, Life After Pregnancy Study (2016)
| “Please rate how helpful you found the lactation consultant/specialist?” | Positive perception (n=98) |
Negative perception (n=40) |
Total (n=138) |
|---|---|---|---|
| Not at all helpful | 0 (0) | 9 (100) | 9 |
| A little helpful | 14 (42) | 19 (58) | 33 |
| Somewhat helpful | 32 (78) | 9 (22) | 41 |
| Very helpful | 52 (95) | 3 (5) | 55 |
How were their perceptions about the support related to breastfeeding outcomes, anxiety and depressive symptoms, and parenting stress?
Negative perception of support was associated with much lower breastfeeding self-efficacy (β=−11.7, 95% CI: −17.3, −6.0), a much less successful breastfeeding experience (β=−19.5, CI: −27.8, −11.3), and greater general anxiety (β=6.5, CI: 2.1, 10.9) [Table 3]. Perception was not associated with number of depressive symptoms (β=0.9, CI: −0.7, 2.5) or parenting stress. Among the 37 women who had stopped producing milk by the time of the study and had received LC support, negative perception of support was associated with much shorter duration of milk production (HR=0.39, 95% CI: 0.18, 0.84) [Table 4]. Results for the other human milk feeding duration variables were similar in magnitude, but confidence intervals were imprecise and included the null.
Table 3.
Associations between Perception about Lactation Consultant/Specialist Support Received and Maternal Mental Well-being Outcomes, Life After Pregnancy Study (2016)
| Women with Positive Perception (reference group) |
Women with Negative Perception |
Unadjusted β (95% CI) | Adjusted β (95% CI) a | |
|---|---|---|---|---|
| Median (inter-quartile range) | ||||
| Breastfeeding self-efficacy (BSES-SF) | 57 (16) | 43 (26) | −13.8 (−19.3, −8.3) | −11.7 (−17.3, −6.0) |
| Overall breastfeeding experience (MBES) | 122 (26) | 95 (33) | −22.5 (−30.4, −14.7) | −19.5 (−27.8, −11.3) |
| Depressive symptoms (EPDS) | 6 (6) | 7 (4) | 0.9 (−0.6, 2.5) | 0.9 (−0.7, 2.5) |
| State anxiety (STAI) | 33 (16) | 40 (12) | 6.1 (1.8, 10.3) | 6.5 (2.1, 10.9) |
| Mean (SD) | ||||
| Parental distress (PSI-SF) | 54 (25) | 59 (27) | 5.4 (−4.0, 14.7) | 9.4 (−0.1, 18.9) |
| Parent-child dysfunctional interaction (PSI-SF) | 38 (19) | 42 (20) | 4.4 (−2.6, 11.5) | 5.5 (−1.6, 12.7) |
| Difficult child (PSI-SF) | 45 (23) | 47 (24) | 2.0 (−6.7, 10.7) | 3.8 (−5.2, 12.7) |
| Total stress (PSI-SF) | 45 (21) | 50 (24) | 4.5 (−3.5, 12.5) | 7.3 (−1.0, 15.6) |
Missing data: BSES (16), MBES (16), PSI-SF (parental distress – 2, parent-child dysfunctional interaction −3 , difficult child – 4, total stress – 4)
Adjusted models included maternal race and employment status
Table 4.
Associations between Perception about Lactation Consultant/Specialist Support Received and Breastfeeding Outcomes, Life After Pregnancy Study (2016)
| Women with Positive Perception (reference group) |
Women with Negative Perception |
Unadjusted HRc (95% CI) |
Adjusted HR (95% CI) a |
|
|---|---|---|---|---|
| Median (inter-quartile range) | ||||
| Feeding at the breast durationb | 49 (70) | 13 (39) | 0.40 (0.19, 0.87) | 0.45 (0.20, 1.01) |
| Expressed milk feeding durationb | 89 (77) | 42 (54) | 0.52 (0.25, 1.08) | 0.54 (0.24, 1.23) |
| Total human milk feeding durationb | 86 (64) | 28 (51) | 0.41 (0.21, 0.81) | 0.39 (0.18, 0.84) |
Adjusted models included maternal race and employment status
Restricted to women who have stopped this practice
HR – hazard ratio
Discussion
The majority of women in this study received postpartum breastfeeding support from a LC, and their overall perceptions about the support varied. This study focused on the “real world” support most women receive in the U.S., not a model of support feasible only in research settings. A strength of this study was its focus specifically on LC support. LC support remains very popular in the U.S., perhaps even more so recently because of Affordable Care Act coverage (Hawkins, Dow-Fleisner, & Noble, 2015). While many women reported a positive experience, more than one-quarter reported a negative experience. Women with an overall negative perception had much lower breastfeeding self-efficacy, had human milk feeding duration less than half as long, and were more anxious. Women with a negative perception also rated their breastfeeding experience as much less satisfactory overall.
Women who had a negative perception were more likely to be White and to work full time or to currently be on maternity leave. The challenges of breastfeeding while working full time are well-recognized (Hawkins, Griffiths, Dezateux, & Law, 2007). These women may have felt significant pressure from LCs about breastfeeding or had ambitious personal breastfeeding goals that were hampered by breastfeeding difficulties and short maternity leave, and these factors inhibited breastfeeding practices that were personally satisfactory. One possibility is that LC support could not address all of these challenges, and so women felt disappointed and negative about the support. However, we could not explore these possibilities in this study with the available data.
Some women had a negative perception about the LC support and still felt helped by it, and others had a positive perception and did not feel helped. Like the women in the Graffy et al. study, women in this study likely had multiple criteria for what they would consider helpful support, and some of these criteria may have been met while others were unmet (Graffy & Taylor, 2005). Indeed, quality support is multi-faceted, addressing both physical, practical, and psychosocial needs. These findings are in line with prior studies that found societal or individual ideals about breastfeeding may not match reality (Fox, McMullen, & Newburn, 2015; Hoddinott, Craig, Britten, & McInnes, 2012; McInnes & Chambers, 2008).
The feelings expressed about LC support in this study are congruent with the feelings reported in prior studies about the overall breastfeeding experience within contemporary society. For example, Thomson et al. described how women today commonly experience shame when their intended experiences of infant feeding do not play out as hoped, leading to feelings of “incompetence, inadequacy and inferiority” – regardless of whether they breastfeed or formula feed – and these feelings can be exacerbated through encounters with professionals trying to help (Thomson, Ebisch-Burton, & Flacking, 2015).
By examining differences within the sub-sample of women who received LC support, we inherently controlled for factors associated with access to support and support-seeking behavior. This sample restriction permitted the study to focus more precisely on the perceptions about support. By measuring women’s perceptions, rather than on the curriculum, we took a woman-centered approach which appeared to have direct correlations with outcomes. That is, simply providing breastfeeding support seems inadequate to ensure positive outcomes, as perceptions of the quality are also important and were strongly associated with breastfeeding outcomes in this study.
Limitations and Strengths
One limitation of this work is that the sample was one of convenience, and the Research Match tool presented limitations in terms of tabulating participation refusals. Also, the sample was of higher socioeconomic status than the general population. However, the sample was national and was fairly typical in terms of post-partum maternal psychosocial well-being (Gray, Edwards, O'Callaghan, & Cuskelly, 2012; Vismara et al., 2016). (Fein, Labiner-Wolfe, Scanlon, & Grummer-Strawn, 2008)Second, we lacked data about the qualifications of the LCs (we were not confident women could report that accurately), amount and content of support received by each woman, setting where support was received, or objective indicators about quality. Third, this study focused on the first six months after delivery. As a result, we did not have data on breastfeeding duration for women who were still breastfeeding. However, we were able to make valuable comparisons among the women who had stopped. The cross-sectional design also precluded making clear inferences about temporality. For instance, elevated anxiety may have preceded LC support, which could in turn could color perceptions of LC support. Also, some women may have been on the way to poor breastfeeding outcomes before they received support, so all of the poor outcomes should not be attributed to poor quality support. Similarly, some women’s perceptions about support may have been colored by the outcomes they were experiencing at the time of the study. We were, however, able to note that the vast majority of the LC support was very early in the postpartum period before the survey, so some temporality can be deduced. Finally, the observational design prevented us from drawing conclusions about causality, and residual confounding by unmeasured factors is a possibility.
Despite its limitations, this study demonstrates that some women have a negative perception of LC support they receive, and this perception is associated with poorer breastfeeding and psychosocial outcomes. These findings highlight the importance of ensuring that women feel they are receiving high-quality breastfeeding support. Such positive support would help them set realistic goals and expectations given their life circumstances and help them meet their goals and needs. Furthermore, our results point to poorer outcomes for women with negative experiences that may have downstream effects on the psychosocial wellbeing of women with infants, their parenting, and parent-child relationships. Future studies should help determine ways to enhance LC support to ensure it is better aligned with women’s needs and expectations and determine the causal or mediating effects of LC support on maternal and child outcomes.
Significance: What is already known on this subject?
Of US women who receive breastfeeding help during the obstetric delivery stay, over half receive support from a lactation consultant. The US Preventive Services Task Force recently identified knowledge gaps about breastfeeding support interventions, including participant satisfaction and potential for negative mental health impacts.
What does this study add?
In this US study, 29% of women who received lactation consultant support had overall negative feelings about the support. Negative feelings were associated with lower breastfeeding self-efficacy, a poorer overall breastfeeding experience, shorter duration of feeding human milk, and greater anxiety, but not depressive symptoms or parenting stress.
Author Acknowledgements:
The project described was supported by Award Number Grant UL1TR001070 from the National Center For Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Advancing Translational Sciences or the National Institutes of Health. We thank Myra George of Nationwide Children’s Hospital Clinical Research Services; and Kelly Boone, Erin Shafer and Thalia Cronin of the Center for Biobehavioral Health. The authors declare they have no conflict of interest.
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