Reasons why women do not breastfeed: A southeastern state study

Background: Despite the increase in breastfeeding initiation and duration in the United States, only five states have met the three Healthy People 2010 breastfeeding objectives. The objectives of this study were to explore women's self-reported reasons for not initiating breastfeeding; and to assess the effects of race/ethnicity, other demographic characteristics, maternal behaviors, and hospital support characteristics. Methods: Data were from the 2000–2003 Arkansas Pregnancy Risk Assessment Monitoring System. Restricting the sample to women who did not breastfeed (Unweighted N = 2,917), we categorized reasons for not breastfeeding as individual (such as feeling embarrassed), household responsibilities, and circumstances (such as returning to work/school). Analyses included chi-square and multiple logistic regressions (SUDAAN). Results: 37.7% of women did not initiate breastfeeding. The prevalence of non-initiation was higher among non-Hispanic Blacks (66.3%) than among non-Hispanic Whites (33.7%). Among those who never breastfed, individual reasons were most frequently cited for non-initiation (59.3%). After adjusting for covariates, Blacks had 1.36 greater odds of citing individual reasons than Whites (95% confidence interval (CI)=0.99–1.85). Women who indicated that the hospital staff did not teach them how to breastfeed had twice the odds of citing individual reasons (odds ratio (OR) 2.01; 95% CI=1.14–3.54) or reasons related to household responsibilities (OR 2.27; 95% CI=1.16–4.43) than those who were taught. Conclusions: These findings suggest that women who do not initiate breastfeeding commonly cite individual reasons, especially Blacks. Public Health Implications: Identifying reasons for not breastfeeding may provide for better targeting of interventions.

Summary

Introduction

Research provides strong evidence that breastfeeding decreases the incidence and/or severity of a wide variety of infectious diseases in infants. Some studies have also shown that breastfeeding is protective against several childhood chronic diseases. Breastfeeding also offers important benefits for mothers. Economic, family, and environmental benefits of breastfeeding have also been described.

Recent estimates (2005) for initiating breastfeeding and continuing to six months of age in the United States are 72.9% and 39.1% respectively. In 2005, only five states – California, Hawaii, Oregon, Vermont, and Washington – achieved the three Healthy People 2010 breastfeeding objectives of 75% of mothers initiating breastfeeding, 50% continuing to six months, and 25% continuing to 12 months. Several states, especially Southern states Alabama, Arkansas, Mississippi, South Carolina, and West Virginia, have low breastfeeding initiation rates ranging from 48% to 59%. Racial and ethnic disparities also exist in breastfeeding rates. In 2005, the rate of ever breastfeeding was 79.0% among Hispanics, 74.1% among non-Hispanic Whites, and 55.4% among non-Hispanic Blacks.

Barriers to breastfeeding initiation and continuation include work-related issues, personal preferences, having an unsupportive partner, feeling embarrassed, concerns about pain, and physical/medical problems. Hospital support characteristics such as breastfeeding support from hospital delivery nurses, lactation specialist or peer counselor; and receipt of free formula packets in the hospital have also been described as important influences on women's breastfeeding decisions.

Although Blacks are markedly less likely to initiate breastfeeding, race-based differences in barriers to breastfeeding and reasons for not breastfeeding are seldom studied. In this study, we address two research questions: (1) What reasons do women give for not initiating breastfeeding? (2) Do these reasons differ significantly by race/ethnicity or other demographic/explanatory variables?

Methods

Study Design and Study Sample

We conducted a cross-sectional analysis for women in Arkansas for 2000 through 2003. Data were obtained from the Arkansas Pregnancy Risk Assessment Monitoring System (PRAMS). The PRAMS is a surveillance project instituted by the Centers for Disease Control and Prevention (CDC) and state health departments in 1987. The PRAMS collects data on the attitudes and experiences of mothers during the preconception, gestation, and postpartum periods. Each participating state conducts its own survey. Most states over sample low weight births. Mothers' responses are linked to extracted birth certificate data items for analysis. The data are statistically weighted to account for the sampling design, nonresponse, and noncoverage. Arkansas was selected because of the low rates of breastfeeding and the survey contained the complete set of breastfeeding-related questions in all four years. We used four years of data to achieve an adequate sample size (N = 7,127). We restricted our sample to mothers of live singletons who did not initiate breastfeeding (N = 2,917).

Variables

A modified version of Andersen's Classic Health Services Research model was used to guide the selection of variables.

Dependent variables

The dependent variables were mothers' reasons for not breastfeeding. Mothers were asked: “What were your reasons for not breastfeeding your new baby?” They could indicate up to nine options, including ‘other'. The ‘other' option allowed women to write written responses. These responses were analyzed descriptively using SAS software. Consistent with previous research, the remaining eight options/reasons were categorized into three groups: individual reasons, household responsibilities and circumstances.

Individual reasons included not liking breastfeeding, not wanting to be tied down, feeling embarrassed, and wanting body back to self. Household responsibilities included having other children to take care of and having too many household duties. The circumstances category included going back to work or school and having a partner who did not want the woman to breastfeed. Since mothers were allowed to choose more than one option, these categories were not mutually exclusive.

Independent variables

The main independent variable of interest was race/ethnicity. This was coded as White, non-Hispanic (hereafter, White); Black, non-Hispanic (hereafter, Black); other, non-Hispanic (hereafter, other), and Hispanic. Other independent variables which served as controls include predisposing factors (age, marital status, number of previous births); enabling factors (education, income, insurance, whether the mother was informed about breastfeeding during the prenatal period, and breastfeeding intent); maternal health behaviors (smoking, alcohol use); and hospital support characteristics (hospital policies regarding breastfeeding).

Analysis

Univariate analysis described the population of mothers who breastfed and those who did not. Chi-square tests were used to test for associations between breastfeeding status and the independent variables and also between each category of reason and each independent variable. Multiple logistic regressions were used to predict the odds of choosing a particular category of reason for each level of the independent variable while controlling for all other variables. SAS-callable SUDAAN version 9.0 was used to account for the complex survey design. This study was approved by the University of South Carolina Institutional Review Board and the Arkansas Department of Health and Human Services.

Results

Descriptive Statistics

About 38% of women did not initiate breastfeeding. A greater proportion of Black mothers (66.3%) did not initiate breastfeeding compared to Whites (33.7%).The proportion of women initiating breastfeeding increased with age: more than half of teenagers did not initiate breastfeeding (52.7%), compared with 28.9% of women age 35 and older. Breastfeeding status was significantly associated with all but two of the independent variables studied (using alcohol in the 3rd trimester of pregnancy, and whether the woman received information about breastfeeding during the prenatal period).

Bivariable Analysis

Among women who did not initiate breastfeeding, the most frequent reason given was: ‘I did not like breastfeeding' (48.2%). For the reason categories, the majority of women who did not initiate breastfeeding cited individual reasons (59.3%). Household responsibilities were cited by 34.0% of the women and circumstances were cited by 33.3% of them. There was some overlap across categories. Overall, 8.4% of the women cited reasons in all three categories.

Individual reasons: Black mothers who did not breastfeed were more likely to indicate individual reasons (64.6%) than were White (58.7%); other (51.1%); and Hispanic women (24.5%; p = 0.0002). A higher proportion of mothers who indicated that they were not taught how to breastfeed by the hospital staff identified individual reasons (60.9%) as compared to those who indicated that they were taught (43.0%; p = 0.0028).

Household responsibilities: The proportion of mothers from other racial/ethnic groups who indicated household responsibilities (41.9%) was higher than the proportion among White (36.8%); Black (29.0%) and Hispanic mothers (26.7%; p = 0.0253). Thirty-five percent of mothers who indicated that they were not taught how to breastfeed by the hospital staff cited household reasons as compared to 19.4% of mothers who indicated that they were taught (p = 0.0008).

Circumstances: A greater proportion of Hispanic mothers (44.3%) cited circumstances as compared to White (31.4%); Black (36.3%); and other mothers (17.3%; p = 0.0918). Teenage mothers (13 – 17) years were more likely to cite circumstances (53.3%) as compared to women aged 18 – 24 years (31.5%); 25 – 34 years (31.5%) and 35 years and older (35.1%; p = 0.0006).

Multivariable Analysis

Individual reasons: After controlling for all the other variables in the model, Blacks had a greater odds of indicating individual reasons than Whites (Odds Ratio (OR) = 1.36, 95% CI = 0.99 – 1.85). Mothers with high school education were more likely to cite individual reasons than those with greater than high school education (Odds Ratio, OR 1.41; 95% CI = 1.04 – 1.91). Women with low income were much less likely to indicate individual reasons than those with high incomes (OR 0.50; 95% CI = 0.30 – 0.85). Of the hospital variables, mother who indicated that the staff did not teach them how to breastfeed had twice the odds of citing individual reasons than mothers who indicated that the staff taught them how to breastfeed (95% CI = 1.14 – 3.54).

Household Responsibilities: Blacks had a lower odds (OR = 0.62, 95% CI = 0.44 – 0.87) of citing household responsibilities as compared to Whites. Mothers with no previous live birth were much less likely to cite household responsibilities compared to mothers with previous live births (OR 0.13; 95% CI =. 0.09 – 0.19). Mothers who indicated that staff did not teach them how to breastfeed had more than twice the odds of citing household responsibilities as compared to those who indicated that they were taught how to breastfeed by the staff (OR 2.27; 95% CI = 1.16 – 4.43).

Circumstances: Hispanics had almost three times greater odds of citing other circumstances (going to work/school or partner not wanting her to breastfeed) as compared to Whites (OR = 3.03, 95% CI = 1.30 – 7.07). Teenage mothers were much more likely to cite other circumstances than older mothers (OR 2.94, 95% CI = 1.33 – 6.47).

Conclusions

There are several policy implications of our findings. Our results indicate that going to work or school are reasons for not-initiating breastfeeding. Legislation that requires employers to provide flexible work schedules for new mothers and facilities that allow mothers to pump and store breast milk may promote breastfeeding among working mothers.

Hospital policies also play an important role in promoting breastfeeding, as indicated in our study. Our results suggest that it is useful for hospital staff to provide mothers with information about breastfeeding, show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants. The Baby Friendly Hospital Initiative (BFHI) which aims to ensure that every baby is given the best start in life by creating environments where breastfeeding is accepted as the norm, has to become a high priority activity in the United States health system.

As for practice implications, identifying reasons for not breastfeeding may help health care workers provide targeted interventions that address particular areas of concern for different groups of women. Our findings suggest that interventions for Hispanics and teenagers may yield better results if targeted to issues such as participating in school or work while breastfeeding.

This study is not without limitations. The data were from one state. Thus, our results may not be generalized to other regions. The data were cross-sectional, and so do not provide a basis for causal inferences.