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Provider Encouragement of Breast-feeding: Evidence From a National Survey

From the Departments of Obstetrics and Gynecology and Pediatrics, University of California, Los Angeles, CA (UCLA) School of Medicine; the Department of Community Health Sciences and the UCLA Breast-feeding Resource Program of the Center for Healthier Children, Families, and Communities, UCLA School of Public Health, Los Angeles, CA; and the Department of Economics, Occidental College, Los Angeles, CA.USA

Address reprint requests to: Michael C. Lu, MD, MS, MPH Department of Community Health Sciences University of California, Los Angeles School of Public Health Box 951772 Los Angeles, CA 90095-1772 E-mail: mclu{at}ucla.edu

	Abstract

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Objective: To examine the influence of provider encouragement on breast-feeding among women of different social and ethnic backgrounds in the United States.

Methods: A nationally representative sample of 2017 parents with children younger than 3 years was surveyed by telephone. The responses of the 1229 women interviewed were included in the analysis. Respondents were asked to recall whether their physicians or nurses had encouraged or discouraged them from breast-feeding. The effects of provider encouragement on breast-feeding initiation and duration were evaluated by multivariate logistic regression. The sample was then stratified to allow subset analyses by race and ethnicity, education, income class, age group, and marital status.

Results: More than one-third (34.4%) of respondents did not initiate breast-feeding. Three-fourths (73.2%) of women reported having been encouraged by their physicians or nurses to breast-feed; 74.6% of women who were encouraged initiated breast-feeding, compared with only 43.2% of those who were not encouraged (P < 0.001). Women who were encouraged to breast-feed were more than four times (relative risk 4.39; 95% confidence interval 2.96, 6.49) as likely to initiate breast-feeding as women who did not receive encouragement. The influence of provider encouragement was significant across all strata of the sample. In populations traditionally less likely to breast-feed, provider encouragement significantly increased breast-feeding initiation, by more than threefold among low-income, young, and less-educated women; by nearly fivefold among black women; and by nearly 11-fold among single women.

Conclusion: Provider encouragement significantly increases breast-feeding initiation among American women of all social and ethnic backgrounds.

Despite the well-known benefits of breast-feeding,¹ 40% of women in the United States never initiate nursing, and only 22% breast-feed for longer than 6 months.² The initiation and duration of breast-feeding are significantly lower among certain subgroups. In 1995, only 37% of black women initiated breast-feeding, and only 11% breast-fed for longer than 6 months. Less than half of women with a high school education or an annual family income of less than $15,000 initiated breast-feeding, and less than one in six continued to breast-feed at 6 months.² These disparities are of special concern because these subgroups could be expected to benefit the most from breast-feeding, given their increased risk for infancy and childhood morbidity.

It is important to identify factors that may influence a woman’s decision whether to breast-feed, particularly among subgroups traditionally less likely to breast-feed. Several studies have linked breast-feeding to encouragement by health care professionals.^3–7 However, most of these studies were based on small convenience samples, and none of them examined the impact of provider encouragement on breast-feeding in different at-risk populations.

Using data from a national survey of American families,⁸ we were able to determine what influence provider encouragement has on a woman’s decision of whether to breast-feed among women of different races and ethnicities, education, income classes, age groups, and marital status.

	Materials and Methods

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The primary study was funded by the Commonwealth Fund (New York, NY) to assess parenting needs and behaviors of a nationally representative sample of parents with children younger than 3 years, as described previously.⁸ A series of 26-minute, in-depth, structured telephone interviews were conducted by trained staff at DataStat Inc. (Ann Arbor, MI) using a stratified random-digit-dial sample design. At least six attempts were made at different times to establish contact. Using census-tract data on race-ethnicity for stratification, the survey oversampled black and Hispanic parents so their experiences could be analyzed in detail. Male respondents were excluded from our analysis because they may not know with certainty whether their spouses had actually received provider encouragement. Asian Americans, Native Americans, and women of other or mixed races and ethnicities were excluded from our analysis because of small sample sizes.

The primary independent variable for our secondary analysis was provider encouragement. All respondents were asked, "In general, did the doctors/nurses encourage or discourage (you/child’s mother) from breast-feeding?" The survey question did not specify the timing or the content of provider encouragement. Because the question followed several questions on newborn care in the hospital or birthing center, it was probably interpreted by most respondents to mean in-hospital, peripartum encouragement.

The primary outcome variable was the initiation of breast-feeding. This was assessed with the question, "Was [your child] breast-fed for more than a month, less than a month, or not at all?" The secondary outcome variable was the duration of breast-feeding among women who breast-fed, dichotomized as greater or less than 1 month. Data were also collected on demographic characteristics and obstetric history.

We analyzed the data with SAS (SAS Institute Inc., Cary, NC) and Stata (Stata Corp., College Station, TX) statistical analysis software packages. We performed bivariate comparisons using the Pearson ² statistic. Multivariable analysis was performed to examine the independent effect of provider encouragement on breast-feeding initiation and duration. In our regression model, we adjusted for variables known to be associated with breast-feeding from our review of the literature. Household income was omitted from the model to avoid problems associated with missing data and multicollinearity with several other demographic variables. Separate subset analyses using the same multivariable logistic regression model were conducted after the sample had been stratified by race-ethnicity, education, household income, marital status, and age.

	Results

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Sixty-eight percent of those contacted completed the survey, providing a sample of 2017 parents with children younger than 3 years. The primary study did not obtain information on nonrespondents. After the exclusion of 697 male respondents and 91 female respondents because of race-ethnicity or missing data, the responses of 1229 women were included in the analysis. The sample consisted of 73% white women, 13% black women, and 14% Hispanic women. Eighty-one percent of the women were married; 6% were divorced and 14% were single. Fifty-six percent of the respondents were between ages 25–34 years; 12% were older than 35 years and 4% were 17 years or younger. Thirty-two percent of the respondents had completed only a high school education and 15.5% had not attended high school; 52% had received some college or graduate education. Twenty-eight percent of the women reported an annual household income of less than $20,000; 43% reported an income of greater than $40,000. The proportions of respondents who resided in the northeast, north central, south, and west US regions were 20%, 25%, 34%, and 22%, respectively.

Of the 1229 women included in the study, 34.4% never initiated breast-feeding, 12.4% breast-fed for less than 1 month, and 53.2% breast-fed for more than 1 month. Table 1 presents the characteristics of women who initiated breast-feeding. Whereas approximately 70% of white and Hispanic women initiated breast-feeding, only 41% of black women did so. Women were significantly less likely to breast-feed if they were younger than 25 years, single or divorced, had a household income of less than $20,000, resided in the South, received government assistance, or did not attend college or childbirth classes (Table 1).

Three-fourths (74.6%) of the women who were encouraged initiated breast-feeding, but less than half (43.2%) of those who were not encouraged breast-fed (P < .001). The adjusted relative risk (RR) for initiating breast-feeding among women who were encouraged to breast-feed was 4.39 in our logistic regression model (95% confidence interval [CI] 2.96, 6.49) (Table 2). Maternal age (between 25 and 34 years), parity (multiparous), marital status (married or divorced), education (at least a high school education), race-ethnicity (being white or Hispanic), region of residency (west), and attendance at childbirth classes were associated with a significantly increased likelihood of breast-feeding (Table 2).

In our subset analyses using the same logistic regression model applied to each stratum, provider encouragement exerted an independent positive influence on breast-feeding initiation in every stratum. The influence was clinically important and statistically significant except for women who were divorced. The risk ratios ranged from 3.24 among women with less than a high school education to 10.95 for women who were single The imprecision of the risk ratio in some strata with small sample sizes is indicated by the wide CIs.

In separate logistic regression and stratified analyses, provider encouragement was not found to be a significant predictor of the duration of breast-feeding (data not shown).

	Discussion

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Our findings suggest that provider encouragement significantly increases the likelihood that a woman will initiate breast-feeding. Specifically, women who were encouraged by their physicians or nurses to breast-feed were more than four times as likely to initiate breast-feeding than women who did not receive encouragement, everything else being equal.

Our study confirms the findings of previous studies based on smaller, more localized samples. Halpern et al³ found that significantly more infants were breast-fed if their pediatricians had encouraged their mothers to breast-feed, compared with those whose pediatricians were indifferent about breast-feeding. Newton⁴ reported a doubling in the rate of hospital breast-feeding after a prenatal lactation discussion group was started. The group was led by an obstetrician. Haider⁵ found that 80% of women breast-fed after attending a group discussion on breast-feeding conducted by a physician, compared with only 20% among women who did not attend. Cole⁶ found that 79% of postpartum women given helpful information on breast-feeding were still breast-feeding at 3 months postpartum, a significantly higher proportion than among women who were not given information. None of these studies adequately controlled for potential selection bias and other confounding factors.

Kistin et al⁷ demonstrated in the first randomized controlled trial that among 159 predominantly low-income, black expectant mothers, women who received prenatal encouragement by a physician or a nurse practitioner were significantly more likely to breast-feed than control subjects. More than one-third (38%) of women who received prenatal counseling changed their feeding plan from bottle-feeding to breast-feeding, as compared with 8% of women who received no prenatal counseling. In our study, three-fourths of women who were encouraged to breast-feed initiated breast-feeding; less than half did so without encouragement.

The large sample size and the oversampling of black and Hispanic women in our national survey enabled us to examine the influence of provider encouragement among women of different races and ethnicities, education, income class, age group, and marital status. Previous smaller, more localized studies yielded inconsistent results on the influence of provider encouragement in certain subgroups.^9,10 In contrast to these studies, we found that provider encouragement exerted a consistent and powerful influence across the board. This is particularly noteworthy among subgroups that traditionally have had low breast-feeding rates. Provider encouragement, by itself, increased the likelihood of breast-feeding more than threefold among young, low-income, and less educated women; nearly fivefold among black women, and nearly 11-fold among single women.

Our data do not allow us to suggest the mechanism by which provider encouragement exerts its influence on breast-feeding initiation. Studies have shown that a woman’s decision to breast-feed is influenced by her own cognitive processes (knowledge, attitudes, beliefs, and previous experiences).¹¹ For example, knowledge of the benefits and negative attitudes toward personal inconvenience have been identified as the two most important predictors of breast-feeding among black women.¹² Provider encouragement may influence these cognitive processes. Other studies have found that women who are more confident about their ability to breast-feed are more likely to do so.^13,14 Provider encouragement may enhance self-efficacy. Social support has also been shown to influence breast-feeding.^15,16 Provider encouragement may reinforce such support. Several studies^12,17–19 have found support from a male partner in particular to exert a significant influence on breast-feeding. When such partner support is missing, as is the case with many single mothers, provider support gains an even greater influence over a woman’s decision to breast-feed.

There are several important limitations to our study. First, the survey asked mothers to recall an event (whether they were encouraged to breast-feed) that took place up to 3 years before the survey. Recall error may occur, although studies have shown that long-term maternal recall of perinatal events, including breast-feeding, is fairly accurate and reproducible.^20,21 If women who breast-fed are more likely to recall having been encouraged than women who never breast-fed, this recall bias may inflate the effect of provider encouragement.

Second, the survey question did not clearly define breast-feeding initiation. Getting the infant to the nipple is different from one or more successful breast-feedings per day. The survey question also did not examine the duration of breast-feeding beyond 1 month, although some researchers²² have found that breast-feeding behavior at 1 month is highly predictive of that at 6 months.

Finally, the survey question did not specify where, when, and by whom the encouragement was provided. The question also did not assess the content or the intensity of the encouragement. It is remarkable that provider encouragement was shown to have such a strong influence on breast-feeding initiation despite such imprecise wording, which would typically bias the result toward the null. The optimal timing and content for effective provider encouragement remain to be determined in future studies.

Our finding has several important implications. It points to the importance of training physicians and nurses to support breast-feeding. Most obstetricians and pediatricians in training lack the knowledge, skills, and experience to adequately support breast-feeding.²³ The finding also suggests that programs of breast-feeding education and support could have a particularly strong influence if they target those populations who are least likely to initiate breast-feeding. It further suggests that provider encouragement of breast-feeding should be considered for inclusion as a performance measure in the Health Plan Employer Data and Information Set to monitor the quality of perinatal care.

Obstetricians, midwives, and obstetric nurses have a special responsibility and capacity to promote breast-feeding, given their unique relationship with the pregnant woman.²³ That one in four women reported that their physicians or nurses did not encourage them to breast-feed points to important missed opportunities in promoting breast-feeding among American women.

	Footnotes

 
PII S0029-7844(00)01116-9

Received May 17, 2000. Received in revised form August 8, 2000. Accepted October 5, 2000.

	References

Top Abstract Materials and Methods Results Discussion References

 
1. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997;100: 1035–7.[Abstract/Free Full Text]

2. Ryan AS. The resurgence of breastfeeding in the United States. Pediatrics 1997;99:E12.

3. Halpern SR, Sellars WA, Johnson RB. Factors influencing breast-feeding: Notes on observations in Dallas, Texas. South Med J 1972;65:100–2.[Medline]

4. Newton N. Key psychological issues in human lactation. In Waletzky L, ed. Proceedings of symposium on human lactation. Washington, DC: US Government Printing Office, 1979.

5. Haider SA. Encouragement of breast-feeding. BMJ 1976;1:650.

6. Cole JP. Breast-feeding in the Boston suburbs in relation to personal social factors. Clin Pediatr 1977;16:352–6.

7. Kistin N, Benton D, Rao S, Sullivan M. Breast-feeding rates among black urban low-income women: Effect of prenatal education. Pediatrics 1990;86:741–6.[Abstract/Free Full Text]

8. Young KT, Davis K, Schoen C, Parker S. Listening to parents: A national survey of parents with young children. Arch Pediatr Adolesc Med 1998;152:255–62.[Abstract/Free Full Text]

9. Wiemann CM, DuBois JC, Berenson AB. Racial/ethnic differences in the decision to breastfeed among adolescent mothers. Pediatrics 1998;101:1068.

10. Humphreys AS, Thompson NJ, Miner KR. Intention to breastfeed in low-income pregnant women: The role of social support and previous experience. Birth 1998;25:169–74.[Medline]

11. Black R, Blair JP, Jones VN, DuRant RH. Infant feeding decisions among pregnant women from a WIC population in Georgia. J Am Diet Assoc 1990;90:255–9.[Medline]

12. Baranowski T, Bee DE, Rassin DK, Richardson CJ, Brown JP, Guenther N, et al. Social support, social influence, ethnicity and the breastfeeding decision. Soc Sci Med 1983;17:1599–611.

13. Buxton KE, Gielen AC, Faden RR, Brown CH, Paige DM, Chwalow AJ. Women intending to breastfeed: Predictors of early infant feeding experiences. Am J Prev Med 1991;7:101–6.[Medline]

14. Ferris AM, McCabe LT, Allen LH, Pelto GH. Biological and sociocultural determinants of successful lactation among women in eastern Connecticut. J Am Diet Assoc 1987;87:316–21.[Medline]

15. Krishna V, Plichta SB. The role of social support in breastfeeding promotion: A literature review. J Hum Lact 1998;14:41–5.[Abstract/Free Full Text]

16. Kessler LA, Gielen AC, Diener-West M, Paige DM. The effect of a woman’s significant other on her breastfeeding decision. J Hum Lact 1995;11:103–9.[Abstract/Free Full Text]

17. Bar-Yam NB, Darby L. Fathers and breastfeeding: A review of the literature. J Hum Lact 1997;13:45–50.[Abstract/Free Full Text]

18. Grossman LK, Fitzsimmons SN, Larsen-Alexander JB, Sachs L, Harter C. The infant feeding decision in low and upper income women. Clin Pediatr 1990;29:30–7.

19. Giugliani ER, Caiaffa WT, Vogelhut J, Witter FR, Perman JA. Effect of breastfeeding support from different sources on mother’s decisions to breastfeed. J Hum Lact 1994;10:157–61.[Abstract/Free Full Text]

20. Tomeo CA, Rich-Edwards JW, Michels KB, Berkey CS, Hunter DJ, Frazier AL, et al. Reproducibility and validity of maternal recall of pregnancy-related events. Epidemiology 1999;10:774–7.[Medline]

21. McCormick MC, Brooks-Gunn J. Concurrent child health status and maternal recall of events in infancy. Pediatrics 1999;104:1176–81.[Abstract/Free Full Text]

22. Piper S, Parks PL. Predicting the duration of lactation: Evidence from a national survey. Birth 1996;23:7–12.[Medline]

23. Winikoff B, Baer EC. The obstetrician’s opportunity: Translating "breast is best" from theory to practice. Am J Obstet Gynecol 1980;138:105–17.[Medline]

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