TABLE 3
Percentage of women citing given reason for termination of breastfeeding
| Week 3 | Week 6 | Week 9 | Week 12 | |
|---|---|---|---|---|
| Reason | (n = 67) | (n = 60) | (n = 32) | (n = 36) |
| Insufficient milk supply | 37.3 | 35.0 | 25.0 | 13.9 |
| Inconvenient | 17.9 | 25.0 | 21.9 | 33.3 |
| Returned to work | 4.5 | 31.7 | 53.1 | 58.3 |
| Breast pain or infection | 32.9 | 23.3 | 0 | 5.6 |
| Baby stopped nursing | 7.5 | 5.0 | 3.1 | 11.1 |
| Other | 22.4 | 18.3 | 3.1 | 5.6 |
| NOTE: Percentages total more than 100% because respondents could cite multiple reasons. | ||||
Discussion
Mastitis, pain, and days with pain in the first 3 weeks were important clinical factors associated with breastfeeding cessation in this cohort of women who prenatally self-identified as intending to breastfeed. Women who intend to breastfeed should be counseled regarding these possible complications, their temporary nature, prevention, and treatment. Mastitis is not an indication for breastfeeding termination; in fact, increased feedings and milk expression are considered treatment.26,27 Women who reported pain the first 3 weeks were more likely to stop breastfeeding than women who reported pain after the first 3 weeks. It is difficult to explain this finding; perhaps there are women who have pain during their entire breastfeeding career and yet continue to breastfeed because they are more pain-tolerant, have less severe or frequent pain than those who wean, or are more committed to breastfeeding.
Other clinical factors investigated were depression and daily sleep hours. Weaning was not associated with subjective depression. However, subjects did not undergo formal psychological testing as in the study that reported an association.24 The relationship between daily sleep hours and termination was not consistent, and likely not clinically significant.
The demographic risk factors related to breast-feeding termination in our study are similar to those previously reported,14,15,20,21,23,24 namely, younger maternal age and lower educational level. Investigations of parity have been inconsistent.16,28 We found no association of weaning with parity. Prior breastfeeding experience has been reported as improving breastfeeding rates15,28; our results are consistent with those findings, but not significantly so. All subjects had access to prenatal breastfeeding education and postnatal breastfeeding support, which may have diminished the differences between women with breastfeeding experience and those without experience.20
Michigan and Nebraska women who pumped or bottle-fed during weeks 4 through 12 were significantly less likely to terminate breastfeeding. In contrast, Michigan women who pumped or bottle-fed during the first 3 weeks postpartum were more likely to terminate even after controlling for pain and mastitis. A commitment to exclusive breastfeeding may be necessary in the early postpartum period for long-term success.15,19 To our knowledge, the seemingly protective effect associated with pumping and bottle-feeding after the first 3 weeks has not been previously reported.
Breastfeeding 6 or fewer times per day and feedings of 10 minutes or less were associated with termination during the first 3 weeks. Other studies also indicate that the ratio of breast to bottle feedings is important for long-term success. Feinstein and colleagues15 found that more than one daily bottle of formula supplementation was associated with shorter breastfeeding duration, which was minimized if there were 7 or more breastfeedings per day. Another study found no weaning difference between women who offered their infant only one bottle daily during weeks 2 through 6 and a bottle-avoiding group.17
The most frequent reasons given for termination were similar to those reported by others, namely, insufficient milk supply and return to work.11-15,21,22 Insufficient milk supply was a more common reason in the first few weeks after birth; return to work became an increasingly common reason after week 6.
We were unable to examine the role of pacifiers or smoking in breastfeedng termination because pacifier information was not collected and there were too few smokers for meaningful analysis. Smoking has been consistently reported as associated with early cessation.15,20,29,30 Although pacifier use does not appear to be directly related,31,32 it has been proposed as a marker for breastfeeding problems. The homogeneity of the sample limits our ability to make generalizations regarding other populations, such as women of color. However, the large sample size and the similarity of termination risk factors between 2 different populations of women lend confidence to our conclusions. As we did not assess mothers’ intentions, some of the variables found associated with termination might be intentional activities of weaning rather than risk factors for termination. The significant difference in termination risk between the sites also may be related to mothers’ intentions or level of commitment. The Michigan women may have intended to breastfeed longer from the outset. The Michigan recruitment site was an alternative birthing center. Women being delivered there may be more persistent in their breast-feeding efforts. Both sites provided access to breast-feeding support personnel, but the Michigan women, as a group, may have been more motivated to continue.
Our results provide clinically useful information. Additional support may be needed for younger and less educated women. Special efforts should be made for early diagnosis and treatment of mastitis and breast pain, particularly during the first 3 weeks. Exclusive breastfeeding without bottle supplementation should be recommended for the first 3 weeks, with at least 7 feedings per day. Each feeding should preferably last more than 10 minutes.