Maternal and Child Health Journal

, Volume 16, Supplement 2, pp 231–237

Breastfeeding Practices: Does Method of Delivery Matter?

Authors

    • Division of Reproductive Health, National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and Prevention
  • Ruowei Li
    • Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and Prevention
  • Brian Morrow
    • Division of Reproductive Health, National Center for Chronic Disease Prevention and Health PromotionCenters for Disease Control and Prevention
Article

DOI: 10.1007/s10995-012-1093-9

Cite this article as:
Ahluwalia, I.B., Li, R. & Morrow, B. Matern Child Health J (2012) 16: 231. doi:10.1007/s10995-012-1093-9

Abstract

Objective of this study was to assess the relationship between method of delivery and breastfeeding. Using data (2005–2006) from the longitudinal Infant Feeding Practices Study II (n = 3,026) we assessed the relationship between delivery method (spontaneous vaginal, induced vaginal, emergency cesarean, and planned cesarean) and breastfeeding: initiation, any breastfeeding at 4 weeks, any breastfeeding at 6 months, and overall duration. We used SAS software to analyze data using multivariable analyses adjusting for several confounders, including selected demographic characteristics, participants’ pre-delivery breastfeeding intentions and attitude, and used event-history analysis to estimate breastfeeding duration by delivery method. We found no significant association between delivery method and breastfeeding initiation. In the fully adjusted models examining breastfeeding duration to 4 weeks with spontaneous vaginal delivery group as the reference, those with induced vaginal deliveries were significantly less likely to breastfeed [adjusted odds ratio (AOR) = 0.53; 95 % CI = 0.38–0.71]; and no significant relationship was observed for those who had planned or emergency cesarean deliveries. Again, compared with spontaneous vaginal delivery group, those with induced vaginal [AOR = 0.60; 96 % CI = 0.47–0.78] and emergency cesarean [AOR = 0.68; 96 % CI = 0.48–0.95] deliveries were significantly less likely to breastfeed at 6 months. Median breastfeeding duration was 45.2 weeks among women with spontaneous vaginal, 38.7 weeks among planned cesarean, 25.8 weeks among induced vaginal and 21.5 weeks among emergency cesarean deliveries. While no significant association was observed between delivery method and breastfeeding initiation; breastfeeding duration varied substantially with method of delivery, perhaps indicating a need for additional support for women with assisted deliveries.

Keywords

BreastfeedingInitiationDurationDelivery method

Background

The health benefits of breastfeeding have been documented extensively, and breastfeeding is widely accepted as an important health-promotion strategy for mothers and their infants [18]. Some studies have shown that breastfed infants are less likely to experience atopic disorders [4] and likely to experience fewer episodes of otitis media [5] and gastrointestinal illnesses [2, 3, 5, 6]. Breastfeeding has also been associated with a reduced risk for childhood obesity [9, 10] and with better long-term neuro-developmental outcomes [1114]. In addition, some study results suggest that breastfeeding decreases mothers’ risk for cardiovascular disease [15, 16] and for breast and ovarian cancer [15], and that it may benefit both infants and mothers [2]. Furthermore, breastfeeding is financially advantageous in that it reduces or eliminates costs associated with purchasing formula and reduces costs associated with treating illness among infants [1, 2, 79, 15, 16]. Despite these benefits, breastfeeding rates and average breastfeeding duration among US women remain low (e.g., breastfeeding at 6 months was 43.4 %) according to the 2010 Breastfeeding Report Card published by the Centers for Disease Control and Prevention [17]. As noted in the recent Surgeon General’s Call to Action to Support Breastfeeding [18], there are numerous barriers to breastfeeding, and one of the important factors thought to be associated with breastfeeding is method of delivery [1926].

Study results have shown that women who have induced labor or cesarean deliveries are less likely to initiate breastfeeding and, on average, breastfeed for a shorter duration than women who have spontaneous vaginal deliveries [1924]. One recent study showed that women who had complex second-stage vaginal instrumental deliveries were just as likely to initiate breastfeeding as those who had cesarean deliveries, but the authors of that study did not distinguish between planned and emergency cesarean deliveries [23]. In the United States, 32 % of babies were delivered by cesarean section in 2007, and the percentage has increased over the past several years [24]. Interventions during delivery [e.g., the use of instruments or surgical procedures and medications] have shown to affect the mother and mother-infant pair postpartum [21, 25, 26]. One of the recommendations that emanated from the Baby Friendly Hospital Initiative in the United States is that breastfeeding should be initiated within the first hour after birth (http://babyfriendlyusa.org/). Given the importance of early breastfeeding initiation, anything (including assisted delivery methods) that interferes with contact between a mother and her newborn may affect breastfeeding behaviors. Certain delivery methods have been associated with delays in lactation [25, 26], delays in mother-infant bonding due to mother infant separation after operative/assisted deliveries and use of medications [19, 21], and maternal delivery-related discomfort during the postpartum period [27]. In this study, we sought to determine the relationships between delivery method and four measures of breastfeeding: prevalence of breastfeeding initiation, prevalence of breastfeeding 4 weeks after delivery, prevalence of breastfeeding 6 months after delivery, and overall breastfeeding duration.

Methods

Study Population

We analyzed data from the Infant Feeding Practices Study II (IFPS II), a longitudinal follow-up study of pregnant women and new mothers conducted by the US Food and Drug Administration during 2005 and 2006. The study sample was obtained from a consumer panel of 500,000 households. Survey questionnaires were sent to pregnant women before their delivery and 10 times at regular intervals during the year after they gave birth. To be eligible to participate in the IFPS II, women had to be ≥18 years of age and to have delivered a healthy singleton infant who weighed ≥5 pounds at birth, had a gestational age at birth of ≥35 weeks, and spent <3 days in intensive care. Of the initial panel of 15,147 women identified, 14,618 were mailed a prenatal questionnaire, of these 4,902 qualified and completed the prenatal questionnaire; all of these women were sent the birth screener and subsequent neonatal survey [28]. Of the total neonatal surveys mailed (n = 4,013), 76.9 % (n = 3,033) completed and qualified to participate in the study; additional information about IFPS II methods and response rates for the entire study is available [28]. The study sample was limited to women who reported on their method of delivering the index child on their neonatal survey (n = 3,026), which was completed approximately 4 weeks postpartum. Of these women, breastfeeding initiation data were available for more than 99 % of the women (n = 3,002); 98 % (n = 2,995) were available for 4 weeks and 70 % (n = 2,088) for 6 months breastfeeding analyses.

Variable Definitions

Our outcome variables were breastfeeding initiation, any breastfeeding at 4 weeks postpartum, and any breastfeeding at 6 months postpartum, and breastfeeding duration in weeks. We defined breastfeeding duration as the total number of weeks an infant was fed any breast milk. The main independent variable, method of delivery, was ascertained from responses to the neonatal survey sent to survey participants approximately 4 weeks post-delivery. The method of delivery categories were spontaneous vaginal, induced vaginal, planned cesarean, and emergency cesarean.

Control variables were maternal age, race/ethnicity, education, parity, and percent of federal poverty level constructed using household income and household size variables. Women’s pre-pregnancy body mass index (BMI) was calculated from their reported weight and height, and women with a BMI ≥ 25 were classified as overweight. We controlled for BMI-based weight classification in our analysis because it had previously been shown to be associated with breastfeeding [29]; we also examined the interaction between maternal race/ethnicity and BMI [30]. We assessed maternal prenatal infant feeding intentions and attitude about breastfeeding because of their association with breastfeeding behaviors [31]. Women’s attitude about breastfeeding was based on the strength of their agreement with the following statement: “Infant formula is as good as breast milk.” Those who disagreed were categorized as having a favorable attitude and others as having an unfavorable attitude. The assessment of women’s breastfeeding intention was based on their response to a question about how their planned to feed their baby “in the first few weeks” after birth with the following response options: “breastfeed only,” “formula feed only” “both breast and formula [feed],” and “don’t know yet.” In the multivariable analysis, we collapsed the final three breastfeeding intention categories into “other feeding method.” We also examined the correlation between maternal intention to breastfeed and attitude toward breastfeeding to determine whether they represented independent constructs. Because we found the correlation to be <0.40, we used both variables in our analyses. We used SAS 9.2 (SAS Institute, Inc., Cary, NC) for all data analyses. Procedures used included means, frequencies, Chi-square tests, logistic regression, and survival analysis. We considered differences to be significant at P values <0.05. We conducted Kaplan–Meier survival analysis of breastfeeding duration among those who initiated (n = 2,579), with those who were still breastfeeding at the last completed survey being censored. The survival analysis allowed us to examine breastfeeding duration using all available data and to obtain a visual representation of the data by delivery group. We also calculated hazard ratios indicating the relative likelihood that women who delivered by various methods discontinued breastfeeding within 12 months postpartum.

Results

Of the 3,026 women in our analysis, 1,157 [38.2 %] had spontaneous vaginal deliveries, 1,017 [33.6 %] had induced vaginal deliveries, 489 [16.2 %] had planned cesarean deliveries, and 363 [12 %] had emergency cesarean deliveries. Women who had planned cesarean deliveries were, on average, approximately 2 years older than those in the other groups; multipara women were more likely than primipara women to have had a spontaneous vaginal delivery or a planned cesarean delivery; and marital status, BMI-based weight classification, and poverty status were also significantly associated with delivery method (Table 1).
Table 1

Distribution of selected characteristics among study participants by method of delivery

Characteristic

Number of study participants

Spontaneous vaginal (n = 1,157) %

Induced vaginal (n = 1,017) %

Planned cesarean (n = 489) %

Emergency cesarean (n = 363) %

P value for t test or Chi-square

All participants

3,026

38.2

33.6

16.2

12.0

Race/ethnicity

 White

2,481

38.0

34.2

16.6

11.2

 

 Black

143

35.7

30.8

8.4

25.2

 

 Hispanic

182

45.6

29.7

14.8

9.9

 

 Other

135

35.2

31.6

18.9

14.2

NS

Marital status

 Married

2,209

37.7

33.7

17.9

10.6

 

 Singlea

586

41.0

32.3

11.5

15.2

<0.0001

Parity

 Primiparous

858

36.1

31.8

6.3

25.8

 

 Multiparous

1,207

39.1

31.2

23.0

6.8

<0.0001

Education

 ≤High school

582

37.5

37.5

14.8

10.3

 

 Some college

1,118

37.4

34.1

17.1

11.4

 

 College grad

1,076

39.8

31.0

16.8

12.4

NS

Annual income as % of federal poverty level

 <185

1,267

38.4

36.2

14.2

11.2

 

 185–349

1,086

39.4

32.0

19.1

9.6

 

 ≥350

673

36.1

31.4

15.2

17.4

<0.0001

Overweight/obeseb

 Yes

1,490

31.7

32.8

19.9

15.5

 

 No

1,494

45.1

34.4

12.2

8.4

<0.001

Maternal age years (mean; SD)

 

28.4 (5.4)

28.4 (5.2)

30.4 (4.9)

28.8 (6.3)

0.02

aIncludes women who were widowed or divorced

bBased on body mass index [BMI; weight in kg/height in m2] ≥25. BMI values were calculated from participants’ self-reported pre-pregnancy weight and height

Women who had planned cesarean deliveries were less likely to report that they intended to breastfeed their babies and reported a less favorable attitude towards feeding breastfeeding than were those who delivered by other methods (Table 2). Breastfeeding practices also varied by delivery method: proportions of women who initiated breastfeeding was higher among those who had vaginal and unplanned deliveries as compared to those with a planned cesarean. Those who had spontaneous vaginal deliveries were more likely to have breastfed at 4 weeks and at 6 months postpartum as compared to the other three delivery methods (Table 2). Reporting of the multivariable results is for the main effects only as the interaction between maternal pre-pregnancy BMI and race/ethnicity was not significant. Results of multivariable analyses that accounted for women’s pre-delivery breastfeeding intentions and attitude toward breastfeeding showed that compared with women who had spontaneous vaginal deliveries, those who had induced vaginal deliveries and those who had emergency cesarean deliveries were less likely to have breastfed their infants at 4 weeks or at 6 months postpartum. For some women, this relationship persisted even after taking into account demographics (Table 3).
Table 2

Prevalence of prenatal breastfeeding intentions, a favorable prenatal attitude toward breastfeeding, and actual breastfeeding behaviors among IFPS II participants, by delivery method, 2005–2006

Breastfeeding intentions/attitude/behaviors

Spontaneous vaginal (n = 1,157) %

Induced vaginal (n = 1,017) %

Planned cesarean (n = 489) %

Emergency cesarean (n = 363) %

P value

Prenatal breastfeeding intention

 Breastfeed only

62.7

60.0

52.2

60.5

0.003

 Formula feed only

12.2

12.2

18.8

12.7

 Both (breast/formula)

21.8

24.9

24.5

22.7

 Don’t know

3.3

2.9

4.5

4.1

Attitude toward breastfeedinga

 Favorable

62.3

61.2

54.0

59.9

0.04

Breastfeeding behaviors

 Breastfeeding initiated

87.0

85.5

79.9

85.9

0.001

 Breastfeeding at 4 weeks

78.6

70.3

70.4

73.0

0.001

 Breastfeeding at 6 months

57.1

46.0

48.6

39.2

0.001

aBased on responses to the statement: “Infant formula is as good as breast milk.” Respondents who disagreed were categorized as having a favorable attitude and those who agreed or were unsure were categorized as having an unfavorable attitude

Table 3

Associations between breastfeeding behaviors and method of delivery among participants in IFPS II according to three models

Breastfeeding behaviors

Model

Spontaneous vaginal

Induced vaginal OR

(95 % CI)

Planned cesarean OR

(95 % CI)

Emergency cesarean OR

(95 % CI)

Initiated breastfeeding

Unadjusted

Reference

0.67 (0.47–0.95)

0.51 (0.34–0.76)

0.69 (0.44–1.01)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed

Reference

0.73 (0.48–1.09)

0.81 (0.52–1.27)

0.76 (0.46–1.28)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed and selected demographic factorsa

Reference

0.75 (0.49–1.14)

0.82 (0.51–1.31)

0.68 (0.38–1.19)

Breastfeeding at 4 weeks

Unadjusted

Reference

0.58 (0.44–0.75)

0.63 (0.46–0.86)

0.64 (0.46–0.89)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed

Reference

0.53 (0.39–0.71)

0.86 (0.59–1.22)

0.59 (0.48–0.88)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed and selected demographic factorsa

Reference

0.53 (0.38–0.72)

0.70 (0.47–1.02)

0.71 (0.46–1.07)

Breastfeeding at 6 months

Unadjusted

Reference

0.61 (0.49–0.76)

0.77 (0.59–1.02)

0.58 (0.44–0.76)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed

Reference

0.59 (0.46–0.75)

1.04 (0.76–1.51)

0.45 (0.39–0.75)

Adjusted for pre-delivery attitude toward breastfeeding and intention to breastfeed and selected demographic factorsa

Reference

0.60 (0.47–0.78)

0.88 (0.64–1.21)

0.68 (0.48–0.95)

aMaternal age, race/ethnicity, education, income/poverty level ratio, marital status, parity, and pre-pregnancy weight classification

Survival analysis showed that median breastfeeding duration was 45.2 weeks among women who had spontaneous vaginal deliveries, 25.8 weeks among those who had induced vaginal deliveries, 38.7 weeks among those who had planned cesarean deliveries, and 20.6 weeks among those who had emergency cesarean deliveries. As one would expect given these median durations, the Kaplan–Meier curves for breastfeeding duration among women who initiated breastfeeding show that the prevalence of breastfeeding at any time through 60 weeks after delivery was lowest for those who had induced vaginal or emergency cesarean deliveries than among those in the other two groups (Fig. 1). The adjusted hazard ratios (HRs) indicating time to breastfeeding cessation showed that compared with women who had spontaneous vaginal deliveries, the likelihood of breastfeeding cessation was significantly higher among those who had induced vaginal deliveries [HR = 1.39; 95 % CI 1.19–1.62] and those who had emergency cesarean deliveries [HR = 1.31; 95 % CI 1.07–1.60], and the results for those with planned cesarean were not statistically significant [HR = 1.16; 95 % CI 0.96–1.41].
https://static-content.springer.com/image/art%3A10.1007%2Fs10995-012-1093-9/MediaObjects/10995_2012_1093_Fig1_HTML.gif
Fig. 1

Estimated probabilities of breastfeeding continuation by delivery method, IFPS II

Discussion

Our results showed that several measures of breastfeeding were associated with method of delivery. They also suggest that women who had induced vaginal or emergency cesarean deliveries may need extra breastfeeding assistance and support to help them continue breastfeeding beyond the immediate postpartum period. Despite the difficulties women may have experienced during delivery, they might still succeed in initiating and perhaps continuing breastfeeding through a combination of their own persistence and support from clinicians/lactation service providers.

Our finding that method of delivery is associated with breastfeeding, and particularly that breastfeeding is less likely among women who have cesarean deliveries, is in agreement with results from previous studies [1923]. In addition, our results suggest that having an induced vaginal delivery and having an emergency cesarean delivery have similar negative associations with breastfeeding duration. Interventions during delivery are thought to interfere with the mother-infant bonding experience [19], and cesarean delivery in particular is thought to delay breastfeeding [2123]. Mothers whose labor is induced or who have emergency cesarean deliveries often experience long, difficult labor characterized by the administration of analgesia or anesthesia and labor-inducing hormones; stress associated with their difficult delivery; and delays in mother-infant interactions, each of which may reduce the likelihood or duration of breastfeeding [21, 2326]. Our findings on women’s pre-delivery breastfeeding intentions and attitudes toward breastfeeding initiation are similar to findings from previous studies suggesting that women’s pre-delivery infant feeding intentions and attitude toward breastfeeding are associated with their decisions both to start and to continue breastfeeding [30, 31]. When we adjusted for these factors and for maternal demographic characteristics, the association between method of delivery and breastfeeding initiation was no longer significant. In contrast, breastfeeding rates at 4 weeks and 6 months after delivery were significantly lower among women who had emergency cesarean deliveries even after we adjusted for women’s pre-delivery infant feeding intentions and attitude toward breastfeeding. These findings suggest that although women who have an emergency cesarean delivery or an induced vaginal delivery may initiate breastfeeding, they have more difficulty continuing, possibly because of delays in lactation and in initial mother-infant contact attributable to the longer recovery time associated with these types of deliveries [2527]. It is interesting to note that 89.9 % of women who had planned cesarean deliveries had a previous cesarean delivery. Part of the reason that they breastfed their infants longer than those with emergency cesarean or induced vaginal deliveries may be because they knew what to expect postpartum, whereas women in the other two groups may not have had much time to plan for breastfeeding difficulties or to request additional breastfeeding support. These issues need to be explored fully in future research.

Our results are subject to several limitations. An important limitation to keep in mind is that as time increased the number of women available for analysis decreased potentially introducing a response bias in that women who do not return the surveys may have stopped breastfeeding as the published information about the methods shows that number of people who do not return surveys increased over time [28]. We did not account for variations in the complexity or duration of delivery interventions and did not distinguish between women who were overweight and those who were obese because of the small sample size. We did not examine possible effects of postpartum fatigue, pain, or delivery-related complications on women’s breastfeeding behaviors even though each may predispose women to stop breastfeeding [28]. Another limitation to consider is that the IFPS II data originate from a consumer panel survey and therefore have limited generalizability because the participants are more likely to be of higher socio-economic status in general [28]. It is possible that women who initiate breastfeeding while in the hospital may need additional assistance/support in order to continue doing so after they are discharged, especially if they had a difficult delivery. Strengths of our study included the IFPS II’s longitudinal follow-up of mother-infant pairs from the last trimester of pregnancy until 12 months following birth, our ability to account for women’s pre-delivery breastfeeding intentions and attitude toward breastfeeding, and our assessment of breastfeeding behaviors among women in four delivery categories rather than only two [vaginal and cesarean]; thereby extending our understanding of breastfeeding and delivery method further.

Conclusions

Our findings showed a significantly lower prevalence of breastfeeding at 4 weeks and 6 months among women who had induced vaginal or emergency cesarean deliveries than among those who had spontaneous vaginal deliveries. However, breastfeeding prevalence rates were not significantly lower among women who had planned cesarean deliveries, possibly because they were more prepared for the breastfeeding difficulties they were likely to experience than those who had induced vaginal or emergency cesarean deliveries. Our results suggest that mothers who have induced vaginal deliveries or emergency cesarean deliveries may need additional breastfeeding support immediately postpartum as well as continued breastfeeding assistance after they leave the hospital.

Conflict on interest

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Copyright information

© Springer Science+Business Media, LLC (outside the USA)  2012