Barriers and Contributors to Breastfeeding in WIC Mothers: A Social Ecological Perspective

Abstract

Background:

In response to the Surgeon General's Call to Action to Support Breastfeeding, the goal of this research was to assess the barriers and positive contributors to breastfeeding initiation and duration in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants using the social ecological model (SEM).

Materials and Methods:

A cross-sectional design was used to survey WIC mothers (n = 283) in southern New Hampshire. Analysis of breastfeeding initiation and duration revealed statistically significant results primarily at the individual level of the SEM. Findings also showed influences at the interpersonal, community, and organizational levels. There were significant differences in beliefs toward breastfeeding between women who ever breastfed and women who never breastfed. Women who ever breastfed were more likely to agree that breastfeeding assists with losing baby weight (89% versus 77%; p = 0.03), babies fed breastmilk are less likely to get sick (86% versus 74%; p = 0.04), and breastfeeding helps mothers bond with their babies more quickly than formula feeding (88% versus 72%; p < 0.01). Breastfeeding duration was significantly related to employment status; among women who breastfed for 6 months or longer, 15% were employed full-time, 30% worked part-time, and 55% indicated “other” such as unemployed or stay-at-home mother (p = 0.01). Logistic regression revealed that maternal age was the most significant predictor of breastfeeding duration (odds ratio = 1.11; 95% confidence interval, 1.03, 1.19; p < 0.004).

Conclusions:

Results indicate opportunities to inform and support women in the prenatal and postpartum period, improve the social and built environment, and develop and advocate for policies in an effort to support breastfeeding.

Introduction

The Surgeon General's Call to Action to Support Breastfeeding recommends building capacity for lactation-based research to investigate populations with a lower prevalence of breastfeeding, particularly among economically disadvantaged women.¹ Breastfeeding prevalence among low-income women, specifically women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), continues to be below national targets set forth by Healthy People 2020.^2,3 Nationally, WIC participants have lower rates of breastfeeding initiation and duration than the general public and women who are WIC eligible, but not enrolled.² These lower rates persist despite WIC's efforts to encourage breastfeeding through their “Loving Support Makes Breastfeeding Work” campaign⁴ and changes to the food package that incentivize breastfeeding.^4,5 According to data from the 2012 and 2013 National Immunization Survey, women enrolled in WIC reported a 71.8% breastfeeding initiation rate compared with 89.8% among ineligible women.² Furthermore, women who were WIC eligible, but not enrolled, had a breastfeeding initiation rate of 83.4%²; it has been suggested that the extra expense associated with infant formula is an encouraging factor for non-WIC women to breastfeed.^6–8

Despite the widely recognized benefits of breastfeeding and the endorsement of human milk as the optimal nutrition for infants from professional health organizations,^1,9 it is well documented that breastfeeding disparities persist in low-income women due to individual and environmental barriers. Numerous barriers have been documented in the literature such as embarrassment to breastfeed in public, the mother's return to work or school, infant behavior (e.g., crying, waking, perceived hunger), lactation difficulties, sociocultural influences, lack of self-efficacy, lower income, limited social and professional support, less education, hospital practices that do not support breastfeeding, and inadequate health insurance and child care,^8,10–22 as well as WIC policies around the provision of supplemental formula.^{6–8,13,22–25} Because of the multiple and complex factors that affect a low-income woman's decision to breastfeed, it is necessary to use a comprehensive approach that will provide a holistic understanding of determinants that influence health choices.

The social ecological model (SEM) is a comprehensive conceptual framework that has the ability to capture the relationship between people and their environment as it focuses on individual, interpersonal, community, organizational, and public policy influences on health-related choices.^26–28 The individual level of the SEM explores intrapersonal characteristics such as one's knowledge, intentions, and skills that influence decision-making.^27,28 The interpersonal level involves formal and informal social support systems including family, friends, neighbors, and colleagues who can be important sources of influence.^27,28 Relationships among various formal and informal social networks are examined at the community level.^27,28 The organizational level explores influences by established institutions and their structure and processes for operation.^27,28 Lastly, regulatory policies, procedures, and laws that are set at the local, state, and national level that influence decision-making are examined at the policy level.^27,28

Even though use of the SEM in breastfeeding research is limited,^10,29–32 its application to public health issues has been extensive and therefore serves as an appropriate lens through which to view the many determinants that influence a woman's decision to initiate and sustain breastfeeding. In recognition of the Surgeon General's Call to Action to Support Breastfeeding,¹ specifically focusing on economically disadvantaged women, the goal of this research was to assess the barriers and positive contributors to breastfeeding initiation and duration in WIC participants at all levels of the SEM.

Materials and Methods

Setting and approach

This research study used a cross-sectional design that surveyed WIC mothers from three counties in southern New Hampshire. Cheshire and Sullivan Counties were selected because of their proximal location to the research team, whereas Hillsborough County was selected for its racial and geographic diversity. These three counties represent 40% of the state's population with a combined population of 521,580 people having 8.6% of the region living below the federal poverty level, which is similar to the state's level of 8.4%.³³

The initial step of the research process was to form the Community Coalition for the Promotion of Breastfeeding, composed of field-based breastfeeding professionals and advocates who informed various aspects of the research and served as key informants in a qualitative assessment (focus groups)³² that ultimately informed the creation of a comprehensive survey. Using information gathered from the focus groups and supporting literature, including a review of other breastfeeding-related surveys, a 14-page, scripted survey was created to identify and quantify the individual and environmental contributors and barriers to breastfeeding initiation and continuation. The final survey (see Supplementary Data [available online at www.liebertpub.com/bfm]) consisted of 65 questions that explored concepts identified from the focus groups and contained five sections (maternal demographic characteristics, breastfeeding beliefs, social support, infant feeding practices, and information/support received around breastfeeding) that were categorized into one of the five levels of the SEM: (1) individual, (2) interpersonal, (3) community, (4) organizational, and (5) policy. Even though the final survey questions represented all five levels of the SEM, 60% of the questions were at the individual level. This also parallels most of the responses from focus group participants and reflects their perceptions on the level at which the majority of barriers and contributors influence breastfeeding initiation and continuation in southern New Hampshire.

Prior to implementation, the survey was reviewed by professionals separate from the Coalition, including a subcommittee of the New Hampshire Breastfeeding Task Force, the Director of Community Based Education and Research from Dartmouth Hitchcock Medical Center, and, additionally, a small group of WIC mothers. These external reviewers provided valuable feedback that resulted in refinement of various aspects of the survey.

The initial length of the survey was of particular concern; therefore, some questions were collapsed, and others were further examined for their applicability to the research objectives. A pro-breastfeeding bias was initially noted in the breastfeeding beliefs section, so questions were reworded to achieve balance. Confidentiality was also a concern as it was suggested that some recipients may fear losing their WIC benefits if they were to take part in the survey. This concern was addressed in the written informed consent by stating individual responses would not be shared. Suggestions were also provided to refine questions to accommodate a lower literacy level. The final survey was at a Flesch–Kincaid grade level of 7.6; however, because questions were asked in face-to-face interviews, clarification was provided to participants as necessary. Reviewers also recommended clarification around some areas of the survey where questions could have multiple meanings.

After final revisions were made to the survey, the Keene State College Institutional Review Board granted approval for data collection, and participants provided written, informed consent. To acknowledge WIC participants' time commitment to complete the survey, a $10 grocery gift card was provided.

To be eligible for the study, women had to be the birth mother of their child and be enrolled in the New Hampshire WIC program. WIC participants were recruited on routine clinic days from February to May 2012 through flyers, by referrals from WIC staff, and by verbal recruitment from members of the research team/student volunteers. In recognition of varying educational backgrounds of WIC recipients, participants were individually surveyed by members of the research team and/or student volunteers, all of whom completed structured educational sessions prior to survey implementation, which included in-depth survey reviews with mock interviews and human subjects training. All questionnaires were administered in English and took approximately 20 minutes to complete.

Statistical analysis

In total, 295 women completed the survey; however, this analysis includes only women whose children were less than 6 years of age (reflecting WIC guidelines for eligibility); 12 women were excluded because their children were older than 6 years of age (n = 283). In the analysis of breastfeeding initiation, women who answered “yes” to the question “Have you ever fed breastmilk to your child?” were compared with women who answered “no” to the question. Thirty women were excluded from the analysis of breastfeeding duration as they were currently breastfeeding and their infants were less than 6 months of age so they could not be assigned to a breastfeeding duration subgroup.

Mean values between the groups for continuous variables were compared using independent-samples t tests; chi-squared analyses were used to compare proportions of categorical variables between the groups. Logistic regression was used to predict the odds of initiating and sustaining breastfeeding from a set of predictors. Analyses were conducted using IBM (Armonk, NY) SPSS Statistics 20 and SAS version 9.2 (SAS Institute, Cary, NC) software. Results were considered statistically significant when p < 0.05.

Results

Of the 283 eligible women who completed the survey, the average age was 27 years (range, 15–45 years). Descriptive analysis revealed that 78% (n = 220) of WIC participants initiated breastfeeding. Of those who ever breastfed, 72% supplemented with formula. Thirty-two percent of women who ever breastfed discontinued breastfeeding at 1 month or sooner; an additional 26% stopped breastfeeding at 3 months, and 8.5% breastfed for 1 year or longer. Of the 67 women who breastfed for at least 6 months, 13% (n = 25) exclusively breastfed for the first 6 months.

Participants' residential locations represented 38 different towns from southern New Hampshire and eight WIC clinics. The highest percentage (44%) of participants attended the Manchester, NH WIC clinic, which serves approximately 3,000 women, infants, and children annually (16% of the New Hampshire WIC population).³⁴ There was limited racial diversity among participants as 218 of 283 participants (77%) were white (Table 1). The selected regions' population is 93% white, with the most common minority populations identified as Hispanic, Asian, and African American, in descending order of frequency.³³

Table 1.

Maternal Demographic Characteristics by Breastfeeding Initiation (Never Versus Ever)

	Overall (n = 283)	Never breastfed (n = 63)	Ever breastfed (n = 220)	p value
Age (years) of mother [mean (SD)]	27.2 (5.7)	27.3 (6.1)	27.2 (5.5)	0.96
Relationship status				0.69
Single/separated/divorced/widowed	25% (n = 71)	27% (n = 17)	25% (n = 54)
In a relationship/married/civil union	75% (n = 212)	73% (n = 46)	75% (n = 166)
Employment status				0.27
Full-time	18% (n = 50)	14.5% (n = 9)	18.8% (n = 41)
Part-time	16% (n = 46)	11.3% (n = 7)	17.9% (n = 39)
Other	66% (n = 184)	74.2% (n = 46)	63.3% (n = 138)
Type of delivery				0.91
Vaginally	72% (n = 203)	71% (n = 45)	72% (n = 158)
Cesarean section	28% (n = 79)	29% (n = 18)	28% (n = 61)
Race/ethnicity^a				<0.001
White	77% (n = 218)	97% (n = 61)	72% (n = 157)
Nonwhite	23% (n = 64)	3% (n = 2)	28% (n = 62)
Education				0.02
Less than high school	21% (n = 58)	30% (n = 19)	18% (n = 39)
High school/some college or tech school	60% (n = 171)	60% (n = 38)	60% (n = 133)
Associates/bachelors/graduate	19% (n = 54)	10% (n = 6)	22% (n = 48)
Prior to the birth of your baby, did you plan to breastfeed?				<0.001
Yes	71% (n = 199)	14% (n = 9)	86% (n = 190)
No	18% (n = 52)	70% (n = 44)	4% (n = 8)
Was undecided	11% (n = 31)	16% (n = 10)	10% (n = 21)
Were you breastfed as a child?^b				0.003
No	52% (n = 125)	70% (n = 37)	47% (n = 88)
Yes	48% (n = 116)	30% (n = 16)	53% (n = 100)
Were (or are) you afraid breastfeeding would be painful?				0.01
No	68% (n = 191)	56% (n = 35)	72% (n = 156)
Yes	32% (n = 89)	44% (n = 28)	28% (n = 61)
Were you given free formula prior to or at the birth of your baby?				0.53
No	40% (n = 111)	37% (n = 23)	41% (n = 88)
Yes	60% (n = 167)	64% (n = 40)	59% (n = 127)
I have a strong social support system.				0.27
Agree	92% (n = 256)	89% (n = 55)	94% (n = 201)
Disagree	8% (n = 21)	11% (n = 7)	7% (n = 14)

Column percentage tabulated; row percentage reported in text of results.

Excludes 39 participants who were unsure if they were breastfed as a child.

SD, standard deviation.

Breastfeeding initiation

Analysis of breastfeeding initiation revealed that statistically significant results were primarily at the individual level of the SEM. The distribution of maternal demographic characteristics was compared between women who reported ever giving their child breastmilk and women whose child was never breastfed (Table 1). There was no significant difference in average maternal age between the two groups (27.3 years versus 27.2 years; p = 0.96). Nonwhite women were more likely to report ever breastfeeding compared with white women (97% versus 72%; p < 0.001). Educational level was significantly related to breastfeeding initiation (p = 0.02); a greater proportion of women who ever breastfed reported having an associates/bachelors/graduate degree compared with women who never breastfed (22% versus 10%). Among women who had ever breastfed, 86% intended to breastfeed prior to the birth of their baby, compared with only 14% of those who never breastfed (p < 0.001). In addition, 53% of women who ever breastfed reported that they were breastfed as a child, compared with 30% of women who never breastfed (p = 0.003). A greater proportion of women who never breastfed reported that they were (or are) afraid that breastfeeding would be painful (44% versus 28%; p = 0.01). There were no significant differences between the groups in relationship status, employment status, type of delivery (vaginal/cesarean section), whether or not a mother received formula prior to the birth of her baby, or the presence of a strong social support system (p > 0.05).

There were significant differences in beliefs toward breastfeeding between women who ever breastfed and women who never breastfed (Table 2). Women who ever breastfed were more likely to agree that breastfeeding assists with losing baby weight (89% versus 77%; p = 0.03), babies fed breastmilk are less likely to get sick (86% versus 74%; p = 0.04), and breastfeeding helps mothers bond with their babies more quickly than formula feeding (88% versus 72%; p < 0.01). Mothers who had ever breastfed were also more likely to agree that breastfeeding helps prevent obesity in children (81% versus 31%; p < 0.001), reduces the risk of certain types of cancers (91% versus 48%; p < 0.001), and is convenient (87% versus 51%, p < 0.001) compared with mothers who had never breastfed. Women who reported ever breastfeeding were less likely to agree that formula is as healthy as breastmilk (25% versus 47%; p = 0.002), breasts are not meant for feeding (3% versus 17%; p < 0.001), breastfeeding makes leaving the home difficult (28% versus 50%; p = 0.002), and WIC benefits are better for women who are not breastfeeding (29% versus 56%; p < 0.001). Nonwhite race and having planned to breastfeed prior to the birth of the baby were the most significant predictors of breastfeeding initiation; when these variables were included in a logistic regression model adjusted for age, education, and having been breastfed as a child, the odds ratios were comparable to the crude odds ratios.

Table 2.

Beliefs About Breastfeeding by Initiation Status

	Percentage
	Never	Ever	p value
Breastfeeding assists with losing the “baby weight.”			0.03
Agree	77	89
Disagree	23	11
Babies who are fed breastmilk are less likely to get sick than formula-fed babies.			0.04
Agree	74	86
Disagree	26	14
Babies fed formula sleep longer than babies fed breastmilk.			0.23
Agree	35	47
Disagree	65	53
Breastfeeding helps mothers bond with their babies more quickly than formula feeding.			<0.01
Agree	72	88
Disagree	28	12
Breastfeeding helps to prevent obesity in children.			<0.001
Agree	31	81
Disagree	69	19
Formula is as healthy as breastmilk.			0.002
Agree	47	25
Disagree	53	75
Breastfeeding reduces the risk of certain types of cancers in women.			<0.001
Agree	48	91
Disagree	52	9
Breastfeeding is difficult to learn.			0.36
Agree	35	29
Disagree	65	71
Pumping breastmilk is too much effort.			0.15
Agree	39	29
Disagree	61	71
Breastfeeding is convenient.			<0.001
Agree	51	87
Disagree	49	13
Breasts are not meant for feeding.			<0.001
Agree	17	3
Disagree	83	97
Breastfeeding makes leaving the home difficult.			0.002
Agree	50	28
Disagree	50	72
WIC benefits are better for women who are not breastfeeding.			<0.001
Agree	56	29
Disagree	44	71

WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Breastfeeding duration

Similar to the analysis of breastfeeding initiation, statistically significant results regarding breastfeeding continuation were primarily at the individual level of the SEM. However, findings also suggested influences at the interpersonal, community, and organizational levels. The distribution of maternal demographic characteristics were compared between women who reported breastfeeding for less than 6 months (n = 123) and women who reported breastfeeding for 6 or more months (n = 67) (Table 3).

Table 3.

Maternal Demographic Characteristics by Breastfeeding Duration (<6 Months Versus >6 Months)

	<6 months (n = 123)	>6 months (n = 67)	p value
Age (years) of mother [mean (SD)]	26.4 (5.3)	29.6 (5.1)	<0.001
Relationship status			0.11
Single/separated/divorced/widowed	30% (n = 37)	19% (n = 13)
In a relationship/married/civil union	70% (n = 86)	81% (n = 54)
Employment status			0.01
Full-time	23% (n = 28)	15% (n = 10)
Part-time	13% (n = 16)	30% (n = 20)
Other	64% (n = 78)	55% (n = 36)
Type of delivery			0.79
Vaginally	71% (n = 87)	73% (n = 49)
Cesarean section	29% (n = 35)	27% (n = 18)
Race/ethnicity			0.45
White	75% (n = 92)	70% (n = 46)
Nonwhite	25% (n = 31)	30% (n = 20)
Education			0.04
Less than high school	20% (n = 25)	13% (n = 9)
High school/some college or tech school	63% (n = 77)	54% (n = 36)
Associates/bachelors/graduate	17% (n = 21)	33% (n = 22)
Intention to breastfeed			0.14
Yes	84% (n = 104)	89% (n = 59)
No	6% (n = 7)	0
Was undecided	10% (n = 12)	11% (n = 7)
Were you breastfed as a child?^a			0.03
No	54% (n = 53)	35% (n = 22)
Yes	46% (n = 46)	65% (n = 40)
Were (or are) you afraid breastfeeding would be painful?			0.07
No	67% (n = 80)	79% (n = 53)
Yes	33% (n = 40)	21% (n = 14)
Did (or do) you have access to a breast pump?			0.70
No	9% (n = 11)	8% (n = 5)
Yes	91% (n = 110)	92% (n = 62)
Were you given free formula prior to or at the birth of your baby?			0.24
No	45% (n = 54)	36% (n = 24)
Yes	55% (n = 67)	64% (n = 43)
Upon returning home after the birth of your baby, did you receive breastfeeding support?			0.67
No	21% (n = 25)	18% (n = 12)
Yes	79% (n = 95)	82% (n = 54)
Have you ever breastfed in public?			<0.001
No	65% (n = 77)	26% (n = 17)
Yes	35% (n = 42)	74% (n = 49)
I have a strong social support system.			1.0
Agree	93% (n = 112)	94% (n = 61)
Disagree	7% (n = 8)	6% (n = 4)
For the first 6 weeks after the birth of your baby, did you have assistance with
Meal preparation			0.75
No	34% (n = 41)	31% (n = 21)
Yes	66% (n = 81)	67% (n = 46)
Household chores			0.16
No	22% (n = 27)	31% (n = 21)
Yes	78% (n = 95)	69% (n = 46)
Errands			0.60
No	24% (n = 29)	28% (n = 18)
Yes	76% (n = 91)	72% (n = 47)
Childcare for other children			0.41
No	37% (n = 30)	30% (n = 16)
Yes	63% (n = 51)	70% (n = 37)
Doctor's appointments			0.01
No	21% (n = 25)	38% (n = 24)
Yes	79% (n = 96)	62% (n = 40)
Total number of “encouraging” people [mean (SD)]	3.6 (2.7)	4.5 (2.9)	0.05

Excludes 39 participants who were unsure if they were breastfed as a child.

SD, standard deviation.

Breastfeeding duration was significantly related to employment status (p = 0.01); among women who breastfed for 6 months or longer, 15% were employed full-time, 30% worked part-time, and 55% indicated “other” such as unemployed or stay-at-home mother. Further analysis revealed a significant association between the breastfeeding duration category and employment status (p = 0.01); looking at the number of women who breastfed for 6 months or longer within each employment category, 26% of women employed full-time reported breastfeeding for 6 months or longer, compared with 56% of women employed part-time, and 32% of women in the “other” category.

A greater proportion of women who breastfed for at least 6 months had an associates/bachelors/graduate degree compared with women who breastfed less than 6 months (33% versus 17%; p = 0.04).

In addition, 65% of women who breastfed for at least 6 months reported that they were breastfed as a child, compared with 46% of women who breastfed less than 6 months (p = 0.03).

As might be expected, a greater proportion of women who breastfed for at least 6 months reported that they had breastfed in public (74% versus 36%; p < 0.001).

There were no significant differences between the groups in relationship status, type of delivery (vaginal/cesarean section), race/ethnicity, intention to breastfeed, fear of pain, access to a breast pump, whether or not a mother received formula prior to the birth of her baby, or the presence of breastfeeding or social support systems (p > 0.05). However, 79% of women who reported breastfeeding for less than 6 months had acknowledged support with doctor's appointments for the first 6 weeks after the birth of their baby compared with 62% of women who breastfed for more than 6 months (p = 0.01).

There were significant differences in beliefs toward breastfeeding between women who breastfed for at least 6 months and women who breastfed for less than 6 months (Table 4). Women who breastfed for at least 6 months were more likely to agree that babies fed breastmilk are less likely to get sick (94% versus 80%; p = 0.01), breastfeeding helps prevent obesity in children (89% versus 74%; p = 0.04), breastfeeding helps reduce the risk of certain types of cancers (100% versus 81%; p = 0.003), and breastfeeding is convenient (97% versus 80%; p = 0.002) compared with mothers who breastfed for less than 6 months. Women who reported breastfeeding for at least 6 months were less likely to agree that formula is as healthy as breastmilk (12% versus 33%; p = 0.002), breastfeeding is difficult to learn (19% versus 34%; p = 0.03), breastfeeding makes leaving the home difficult (16% versus 32%; p = 0.02), and WIC benefits are better for women who are not breastfeeding (19% versus 36%; p = 0.02) compared with women who breastfed for less than 6 months.

Table 4.

Beliefs About Breastfeeding by Duration Status

	Percentage
	<6 months	>6 months	p value
Breastfeeding assists with losing the “baby weight.”			0.90
Agree	88	87
Disagree	12	13
Babies who are fed breastmilk are less likely to get sick than formula-fed babies.			0.01
Agree	80	94
Disagree	20	6
Babies fed formula sleep longer than babies fed breastmilk.			0.50
Agree	44	50
Disagree	56	50
Breastfeeding helps mothers bond with their babies more quickly than formula feeding.			0.39
Agree	85	89
Disagree	15	11
Breastfeeding helps to prevent obesity in children.			0.04
Agree	74	89
Disagree	26	11
Formula is as healthy as breastmilk.			0.002
Agree	33	12
Disagree	67	88
Breastfeeding reduces the risk of certain types of cancers in women.			0.003
Agree	81	100
Disagree	19	0
Breastfeeding is difficult to learn.			0.03
Agree	34	19
Disagree	66	82
Pumping breastmilk is too much effort.			0.07
Agree	36	23
Disagree	64	77
Breastfeeding is convenient.			0.002
Agree	80	97
Disagree	20	3
Breasts are not meant for feeding.			0.22
Agree	5	2
Disagree	95	98
Breastfeeding makes leaving the home difficult.			0.02
Agree	32	16
Disagree	68	84
WIC benefits are better for women who are not breastfeeding.			0.02
Agree	36	19
Disagree	64	81

WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Logistic regression revealed that maternal age was the most significant predictor of breastfeeding duration (Table 5). For each additional year of age, an 11% increase in the odds of breastfeeding for at least 6 months was expected (odds ratio = 1.11; 95% confidence interval, 1.03, 1.19; p < 0.004). When asked about reasons for discontinuing breastfeeding, women who breastfed for less than 6 months were more likely to report that they made too little breastmilk compared with women who breastfed for at least 6 months (62% versus 42%; p = 0.01) and that pain was a reason for stopping (24% versus 2%; p < 0.01). Women who breastfed for at least 6 months were more likely to report that the age of the child was the reason for discontinuing breastfeeding compared with women who breastfed for less than 6 months (57% versus 14%; p < 0.001).

Table 5.

Logistic Regression Predicting Breastfeeding Duration (>6 Months Versus <6 Months)

Duration	β	OR	95% CI	p value
Maternal age	0.103	1.11	1.03, 1.19	0.004
White race (nonwhite versus white)^a	−0.073	0.93	0.42, 2.1	0.86
Education level^b				0.55
HS/some college versus < HS	0.007	1.0	0.37, 2.74	0.99
College versus < HS	0.46	1.59	0.50, 5.1	0.44
Relationship status^c
In a relationship/married versus others	−0.76	0.47	0.20, 1.1	0.08
Employment status^d				0.09
Full-time versus other	−0.17	0.84	0.32, 2.2	0.73
Part-time versus other	0.89	2.5	1.0, 6.0	0.05
Was breastfed (no versus yes)^e	0.73	2.08	0.99, 4.3	0.05

White is reference category.

< high school (HS) is reference category.

In a relationship/married is reference category.

Other is reference category.

Not breastfed is reference category.

CI, confidence interval; OR, odds ratio.

Discussion

Using the SEM, this research responded to the Surgeon General's Call to Action to Support Breastfeeding¹ by quantifying factors that influence a woman's decision to initiate and sustain breastfeeding, specifically women enrolled in WIC. Our results revealed that breastfeeding initiation and continuation were primarily influenced at the individual level of the SEM but also suggested influences at the interpersonal, community, and organizational levels. Many of our findings verify those that have been previously reported in both qualitative and quantitative lactation-based research studies. For example, our results were consistent with others^6,14,18 in showing that maternal age was a significant predictor of breastfeeding duration. However, our research revealed that nonwhite women were more likely to report ever breastfeeding when compared with white women, suggesting an opportunity to explore and ultimately address unique cultural and racial differences.

The individual level of the SEM explores one's knowledge, intentions, and skills,^27,28 and our results revealed that a mother's educational level, beliefs, and intentions were related to breastfeeding initiation and duration. The results showed that mothers with a higher educational level (i.e., associates, bachelors, or graduate degree) were more likely to initiate and continue breastfeeding for 6 months or more, which is a similar finding in other studies.^6,18,24 Additionally, a mother's beliefs were related to breastfeeding initiation and duration. For example, women who initiated and continued breastfeeding for 6 months or more were more likely to agree that babies fed breastmilk are less likely to get sick, that breastfeeding helps prevent obesity in children and reduces the risk of certain types of cancers, and is convenient; other studies have identified these beliefs as being positive influential factors in a woman's decision to initiate and sustain breastfeeding.^{8,11–13,15,19} Our research also confirmed the finding that if women perceive breastfeeding as painful this could be a discouraging factor for initiation.^{10–12,18,19}

It is noted that 71% of participants in our study intended to breastfeed, but 78% actually did, which is higher than statewide and national WIC data for “ever breastfeeding” (72.8% and 71.8%, respectively),^2,33 potentially signifying WIC's positive influence on promoting breastfeeding. Metallinos-Katsaras et al.³⁵ found that a greater duration of exposure to WIC services resulted in a positive association in the initiation and duration of breastfeeding. Additionally, Murimi et al.³⁶ reported that 96% of their participants indicated that the information and advice provided to them from WIC about the benefits of breastfeeding guided their breastfeeding decisions.

Even though women in our study had a higher breastfeeding initiation rate compared with national WIC data, exclusive breastfeeding at 6 months was lower (13% versus 13.9%).² The top reasons cited for breastfeeding cessation in our study were mainly at the individual level (e.g., milk supply and pain); however, it is important to not ignore factors occurring at other levels of the SEM as these may have influenced the responses.

The interpersonal level of the SEM focuses on formal and informal social support systems such as family and friends who can influence decision-making.^27,28 Our data showed that mothers who were breastfed as a child were more likely to initiate and continue breastfeeding for 6 months and beyond, suggesting that social support systems may influence decision-making, which has been documented in the literature.^14,22 Even though the difference was not statistically significant (p = 0.05), women who breastfed for 6 months or more had a greater number of people supporting their decision to breastfeed.

Additionally, our results revealed that there were influences at the community (social networks) and organizational (institutional structure) levels of the SEM when examining breastfeeding duration. At the community level, women who breastfed for 6 months or more had breastfed in public, which could indicate their own comfort level with breastfeeding (individual level of the SEM) but could also be the result of the social and built environment in which public breastfeeding is viewed as socially acceptable. Those women who discontinued breastfeeding prior to 6 months may have experienced personal or interpersonal discomfort or found themselves in environments in which breastfeeding was not the social norm. At the organizational level, women who were employed full-time were less likely to continue breastfeeding beyond 6 months, presenting an opportunity to partner with workplaces to develop breastfeeding-friendly policies.

Strengths and limitations of the study

Few lactation-based research studies have used the SEM as a conceptual framework to determine barriers and positive contributors to initiating and sustaining breastfeeding. A woman's decision to initiate and continue breastfeeding is influenced by multiple, complex factors. Therefore, using the SEM encouraged a holistic understanding of the many determinants that influence breastfeeding. However, because the subject of our study was the individual mother, it was not surprising that our survey emphasized questions at the individual level of the SEM. Despite the use of convenience sampling for two of the three counties that were surveyed, a third county (Hillsborough) was included to provide greater racial diversity, and because of this we were mindful to include questions that addressed acculturation, such as length of time in the United States and the primary language spoken in the home. Because of a low percentage of participants being nonwhite, our results may not accurately reflect the varying rates of breastfeeding initiation in nonwhite women compared with white women. It is important to note that the results of our research may not be applicable to other regions within New Hampshire and may not be representative of the WIC population. However, the results of our study are consistent with other qualitative and quantitative research, thus confirming reliability and applicability of the findings.

Even though members of the research team and student volunteers received instructional training for administering the survey, we cannot rule out the possibility of interviewer bias. In addition, recall bias could have also influenced the results as some of the data were a retrospective account of breastfeeding experiences for a portion of our participants. It is noted that the final survey did not directly ask participants the question “Did the availability of free supplemental formula from WIC influence your decision to stop breastfeeding?”; instead a question that more broadly captured the receipt of formula was included in the survey. Even though WIC promotes and supports breastfeeding, its formula procurement practices resulting in substantial rebates for state programs for each can of formula distributed have been identified as having a negative impact on breastfeeding rates.^{6–8,23–25} Although WIC participants report having breastfeeding support from WIC staff, they have viewed the agency as also supporting the supplementation of formula, thus undermining the importance of exclusive breastfeeding.⁸ Therefore, including a specific question in our survey that inquired about the availability of free supplemental formula from WIC would have provided insight on organizational and policy influences on decisions around breastfeeding initiation and continuation.

In addition, we acknowledge the oversight of not investigating the impact of breastfeeding-friendly hospital settings such as Baby Friendly Hospital designations, which would have provided further insight on organizational influences around breastfeeding. However, we did inquire about support of WIC staff but were not specific in distinguishing peer counselors from nutrition/breastfeeding counselors.

Conclusions

This study provides a SEM perspective that presents opportunities for targeted evidence-supported initiatives to promote and support breastfeeding during the prenatal and postpartum stages. Our results indicate that interventions should focus on informing and supporting women in the prenatal period as well as breastfeeding mothers and families, improving the social and built environment for breastfeeding mothers, and developing and advocating for policies that support breastfeeding. The results from this study call to action healthcare providers, community networks, and organizational structures to actively promote and support breastfeeding women. Healthcare providers can personalize their messaging to the individual/family unit based on age, educational background, infant feeding beliefs, and available support. For example, healthcare providers can appropriately refer women and families to available home-based supports and other breastfeeding resources. Community networks can take action by supporting breastfeeding mothers through offering welcoming environments. Additionally, implications for organizational structures signify the need of workplace policies that support breastfeeding women. A comprehensive understanding of the barriers and contributors across the dimensions of the SEM empower practitioners and institutions to meet the unique needs and beliefs of specific population groups such as low-income women.

Footnotes

Acknowledgments

We thank Dr. Meg Henning, Liza Drew, Kara Squillante, Keene State Dietetic Interns and Nutrition Option students, members of the Coalition, Southwestern Community Services and Southern New Hampshire WIC, Monadnock Birthing Center, Cheshire Medical Center/Dartmouth-Hitchcock Keene, Home Healthcare Hospice and Community Services, Monadnock Regional Hospital, the New Hampshire Breastfeeding Task Force, Karen Schifferdecker, and Maryanne Keating for their assistance. Support for the research was funded through a Keene State College Faculty Development Grant and the Cheshire County Healthy Eating Active Living.

Disclosure Statement

No competing financial interests exist.

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