Breastfeeding Initiation in Mothers with Repeat Cesarean Section: The Impact of Marital Status

Abstract

Background:

Approximately 90% of mothers with a primary C-section have a subsequent C-section. To date, research has demonstrated that primary C-sections are associated with breastfeeding noninitiation. However, it is unknown if this association persists after the primary C-section. Furthermore, literature has shown a differing relationship between breastfeeding initiations by marital status. Due to the high proportion of women who give birth while unmarried, investigating differences by marital status will add a significant contribution to breastfeeding literature. This study investigates the association between repeat C-section and breastfeeding initiation within marital status groups using a nationally representative cross-sectional survey.

Materials and Methods:

Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System were analyzed. The sample was restricted to women with a previous singleton live birth who had C-section and whose infant was alive at the time of interview (N = 34,854). Multiple logistic regression analyses were conducted to obtain crude and adjusted odds ratio (AOR) and 95% confidence intervals (CIs).

Results:

After adjusting for potential confounders, married women who had a repeat C-section were 2.2 times (AOR = 2.16, 95% CI = 1.69–2.77) more likely to never breastfeed compared to women with vaginal birth after caesarean section (VBAC). Similarly, the odds of breastfeeding noninitiation were 76% (AOR = 1.76, 95% CI = 1.47–2.12) higher among women with a repeat C-section compared to women with VBAC. No significant associations were exhibited among nonmarried women.

Conclusions:

Enhanced educational programs and counseling support may be needed to help families cope with delivery challenges and resulting stressors that may reduce their desire to initiate breastfeeding in the postpartum period.

Introduction

In recent years, efforts were made to encourage women to have vaginal birth after cesarean section (VBAC). In 2012, the United States (US) National Center for Health Statistics reported a VBAC rate of 10.2 percent in the United States, which is the highest percentage since 2005.¹ Despite this increase, ∼9 out of 10 women with a primary cesarean section (C-section) have a subsequent birth by C-section. This high proportion can be attributed to the lack of knowledge surrounding VBAC outcomes² and/or the poor implementation of VBAC initiatives.³ Nevertheless, VBAC has been associated with lower neonatal intensive care unit (NICU) rates, lower rates of oxygen for infants during delivery room resuscitation, and less oxygen requirement in the NICU compared to elective repeat C-sections.⁴

Research has also shown that women who have VBAC initiate breastfeeding more quickly compared to women who gave birth by C-section.⁵ Even for women who attempt VBAC (trial of labor), initiation of breastfeeding was higher than women with a scheduled C-section (61.3 percent and 58.9 percent, respectively).⁶ This suggests that C-sections are a potential barrier to breastfeeding initiation.⁷ This barrier could be caused by a delayed onset of milk production, which has been shown to be significantly associated with C-sections.⁸

In addition to C-section, marital status has been shown to impact breastfeeding practices.^9,10 For example, a United Kingdom cohort study reported that unmarried mothers had a higher risk for not breastfeeding their infant.⁹ Conversely, a nationally representative U.S. cross-sectional study found married women were at an increased risk for never breastfeeding and breastfeeding a shorter duration for overweight and obese women compared to nonmarried normal weight women.¹⁰ Although this relationship could be more related to obesity, marital status is an important factor to consider when examining breastfeeding practices due to recent trends and inconsistencies in previous literature.

According to the national KIDS Count Data Center, the prevalence of births to unmarried women have stayed constant at ∼41% from 2010 to 2014.¹¹ Because of the proven benefits of VBAC, the importance of breastfeeding initiation, and large proportion of births to unmarried women,¹² understanding how these health behaviors differ among groups of married and unmarried women would provide novel insights into maternal and child health. Even though research has clearly demonstrated a link between mode of delivery and success of breastfeeding initiation, literature is limited when considering differences between groups of married and unmarried women. Furthermore, additional research is needed to corroborate and expand Regan et al.'s findings—the only known study to investigate this relationship in the United States. Therefore, this study aims to investigate whether the association between repeat C-section and breastfeeding initiation differs by marital status groups.

Materials and Methods

Data from Phase 5 (2004–2008) and Phase 6 (2009–2011) of the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed. PRAMS is a population-based survey used to identify maternal experiences and behaviors before and during pregnancy, and during early months after birth. The sample includes women who recently had a live birth and are identified through state birth certificate records. Each participating state samples between 1,300 and 3,400 women per year with a minimum overall response rate of 65%. To ensure a representative sample population, higher risk groups are sampled at a higher rate. More information on PRAMS can be found elsewhere.¹³

The dataset used in this study included 319,689 women who had live births. Women who did not have a previous live birth, who had a multiparous birth whose infant was not alive at the time of interview, who did not have a prior C-section, or who had missing information for reported mode of delivery or breastfeeding initiation were excluded. This yielded a total of 34,854 women for analysis. This study was approved as exempt by the [anonymous for review] institutional review board.

Birthing method for the current delivery was defined using the survey item, “How was your new baby delivered, vaginally or by Cesarean delivery?” Based on this question, a dichotomous variable (VBAC; repeat C-section) was created. Breastfeeding initiation, the outcome variable, was based on the survey item, “Did you ever breastfeed or pump breast milk to feed your new baby after delivery?” and was dichotomized as yes or no.

To identify potential confounding variables, a variety of covariates were considered. These covariates were based on previous research and literature reviews^6,10,14,15 and included maternal race (Non-Hispanic Black, Non-Hispanic White, Hispanic, Non-Hispanic other), maternal age (<20; 20–24; 25–29; 30–34; 35+ years), maternal education (<12 years; 12 years/H.S. diploma; >12 years), maternal morbidity (yes; no), number of stressors (1; 2; 3; 4+), prepregnancy body mass index (BMI) (underweight [<18.5 kg/m²]; normal [18.5–24.9 kg/m²]; overweight [25–29.9 kg/m²]; obese [>30 kg/m²]), income (less than $20,000; $20,000–$34,999; $35,000–$49,999; $50,000+), marital status (married, other), WIC during pregnancy (yes; no), insurance (private; Medicaid; none; other; multiple), adequacy of prenatal care (inadequate; intermediate; adequate; adequate plus), and low birth weight of infant (normal weight; low birth weight; very low birth weight).

Maternal morbidity was defined by 12 different ailments, including diabetes before pregnancy, diabetes during pregnancy, vaginal bleeding, kidney/bladder infection, severe nausea, incompetent cervix, hypertension, placenta problems, preterm labor, premature rupture of membranes, blood transfusion, and injury from a car accident. Prepregnancy BMI was based on two survey items, weight before pregnancy and height without shoes. BMI groups were based on Centers for Disease Control and Prevention (CDCs) standard BMI categories. Due to the high number of missing values for smoking status during the last three months of pregnancy (36.9%), the variable was not considered for analysis.

Descriptive analysis was conducted to examine the distribution of the study population. Chi-square test was used to make bivariate group comparisons between women who initiated breastfeeding and those who did not. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated to examine the association between never breastfeeding and potential confounders. Race, prepregnancy BMI, age, marital status, and insurance were tested as effect modifier; however, marital status was the only significant effect modifier at p = 0.005. Due to the significant interaction, two separate models were considered. The first model did not stratify by marital status. Because marital status was a statistically significant effect modifier, it was not included in the first model. The second model utilizes a stratified analysis. Data were stratified by marital status to provide further insight into the association. Multiple logistic regression analyses were conducted to examine the associations after controlling for confounders. All potential confounders that resulted in at least a 10% change in the crude OR were included in the final models.¹⁶ If no potential confounders met this rule, a fully adjusted model was used. Data were analyzed using SAS version 9.4 statistical software and accounted for multistage complex sampling.

Results

Among the study population, the prevalence of breastfeeding initiation was 75.2%. One in ten (10.0%) women gave birth by VBAC. The majority of the women in this study sample were Non-Hispanic White (59.7%), married (70.3%), had at least some college education (56.6%), and had repeat C-section (90.0%). Breastfeeding initiation was highest among women aged 30–34 years (32.6%), who had private insurance (48.4%), and had an income of at least $50,000. In contrast, never breastfeeding was highest among women with Medicaid (47.8%), received WIC services (54.3%), and had an income less than $20,000. All potential confounders showed significant differences between women who never breastfed and initiated breastfeeding (Table 1).

Table 1.

Distribution of Maternal Characteristics by Breastfeeding Initiation

Potential confounders	Total n = 34,854	Never breastfed n = 8,302	Breastfed n = 26,552	Chi square p
Age (years)				<0.0001
≤19	2.0	3.6	1.4
20–24	16.1	23.8	13.6
25–29	27.1	27.4	27.0
30–34	31.3	27.3	32.6
≥35	23.5	17.9	25.4
Education (years)				<0.0001
Did not finish high school (<12 years)	16.5	22.1	14.7
High school diploma (12 years)	26.9	36.6	23.7
College or higher (>12 years)	56.6	41.3	61.6
Race/ethnicity				<0.0001
White, Non-Hispanic	59.7	63.6	58.4
Black, Non-Hispanic	14.9	22.4	12.5
Other, Non-Hispanic	6.6	3.4	7.6
Hispanic	18.8	10.6	21.5
Not married	29.7	44.8	24.8	<0.0001
Income				<0.0001
<$20,000	32.5	44.7	28.5
$20,000–$34,999	17.1	18.0	16.8
$35,000–$49,000	10.5	9.1	10.9
≥$50,000	39.9	28.1	43.8
Insurance				<0.0001
Private	45.3	35.8	48.4
Medicaid	34.1	47.8	29.6
None	3.3	1.5	3.9
Other	2.0	1.5	2.2
Multiple^a	15.4	13.4	16.0
Adequacy of prenatal care utilization				<0.0001
Inadequate	11.6	15.9	10.2
Intermediate	12.4	11.3	12.7
Adequate	45.3	40.3	46.9
Adequate plus	30.7	32.5	30.1
VBAC	10.0	6.3	11.2	<0.0001
WIC recipient	42.9	54.3	39.2	<0.0001
Prepregnancy BMI				<0.0001
Underweight	2.6	2.9	2.6
Normal	40.4	33.4	42.8
Overweight	27.0	27.8	26.7
Obese	29.9	35.9	27.9
Number of stressors				<0.0001
None	31.0	27.0	32.3
1	24.3	21.2	25.3
2	16.6	17.2	16.4
3 or more	28.1	34.7	26.0
Number of morbidities				<0.0001
None	36.6	31.8	38.1
1–2	48.7	50.8	48.0
3+	14.8	17.4	13.9

All analyses were performed on weighted data.

Multiple indicates two or more of the following insurances (private, Medicaid, or other).

BMI, body mass index; VBAC, vaginal birth after cesarean Section; WIC, women, infants, and children.

Bivariate analyses revealed that all variables among married women were significantly associated with never breastfeeding. Among women who were not married, statistically significant associations were found among age, education, race/ethnicity, income, insurance, adequacy of prenatal care utilization, and breastfeeding noninitiation (Table 2).

Table 2.

Factors Associated with Not Initiating Breastfeeding by Marital Status

Potential confounders	Odds ratio (95% CI) Married	Odds ratio (95% CI) Not married
Age (years)
≤19	2.69 (1.50–4.82)	1.69 (1.22–2.36)
20–24	1.51 (1.25–1.81)	1.44 (1.21–1.71)
25–29	Ref.	Ref.
30–34	0.92 (0.81–1.05)	0.99 (0.81–1.21)
≥35	0.84 (0.73–0.97)	0.72 (0.58–0.91)
Education (years)
Did not finish high school (<12 years)	1.76 (1.49–2.09)	1.57 (1.31–1.88)
High school diploma (12 years)	2.01 (1.79–2.26)	1.66 (1.40–1.97)
College or higher (>12 years)	Ref.	Ref.
Race/ethnicity
White, non-Hispanic	Ref.	Ref.
Black, non-Hispanic	0.90 (0.78–1.07)	1.15 (0.98–1.34)
Other, non-Hispanic	0.30 (0.24–0.38)	0.58 (0.43–0.78)
Hispanic	0.43 (0.35–0.52)	0.28 (0.22–0.35)
Income
<$20,000	1.68 (1.46–1.92)	1.79 (1.29–2.50)
$20,000–$34,999	1.35 (1.17–1.56)	1.55 (1.08–2.22)
$35,000–$49,000	1.19 (1.02–1.40)	1.31 (0.84–2.04)
≥$50,000	Ref.	Ref.
Insurance
Private	Ref.	Ref.
Medicaid	1.53 (1.35–1.73)	1.48 (1.22–1.80)
None	0.51 (0.35–0.74)	0.31 (0.18–0.52)
Other	0.65 (0.37–1.13)	0.72 (0.44–1.18)
Multiple^a	1.05 (0.92–1.20)	0.95 (0.72–1.24)
Adequacy of prenatal care utilization
Inadequate	0.95 (0.78–1.18)	1.38 (1.13–1.70)
Intermediate	0.69 (0.58–0.82)	0.98 (0.78–1.24)
Adequate	0.77 (0.69–0.86)	0.90 (0.76–1.07)
Adequate plus	Ref.	Ref.
WIC recipient	1.43 (1.29–1.60)	1.23 (1.04–1.44)
Prepregnancy BMI
Underweight	1.43 (1.02–1.99)	1.08 (0.71–1.62)
Normal	Ref.	Ref.
Overweight	1.40 (1.22–1.60)	1.10 (0.91–1.32)
Obese	1.79 (1.58–2.02)	1.19 (1.00–1.41)
Number of stressors
None	Ref.	Ref.
1	0.96 (0.84–1.10)	0.92 (0.73–1.18)
2	1.10 (0.95–1.27)	1.11 (0.88–1.40)
3 or more	1.34 (1.20–1.58)	1.05 (0.86–1.28)
Number of morbidities
None	Ref.	Ref.
1–2	1.28 (1.15–1.43)	1.06 (0.90–1.25)
3+	1.43 (1.22–1.67)	1.14 (0.94–1.37)

Bold estimates are significant.

Multiple indicates two or more of the following insurances (private, Medicaid, or other).

CI, confidence interval.

Table 3 shows the logistic regression analysis before stratification. Compared to women who gave birth by VBAC, the odds of never breastfeeding were 1.9 times (COR = 1.89, 95% CI = 1.61–2.21) higher among women who gave birth by repeat C-section. After fully adjusting for all covariates, the estimates were slightly attenuated but remained significant. The odds of never breastfeeding were nearly 1.8 times (adjusted odds ratio [AOR] = 1.76, 95% CI = 1.47–2.12) higher among women with a repeat C-section compared to women with VBAC.

Table 3.

Association Between Mode of Delivery and Breastfeeding Initiation

Mode of delivery	Never breastfed COR (95% CI)	Never breastfed AOR (95% CI) ^a
Repeat C-Section	1.89 (1.61–2.21)	1.76 (1.47–2.12)
VBAC	1.00	1.00

Adjusted for race, age, income, education, insurance, WIC participation during pregnancy, adequacy of prenatal care, maternal morbidity, prepregnancy BMI, and stress.

COR, crude odds ratio; AOR, adjusted odds ratio.

Table 4 shows the logistic regression analysis stratified by marital status. Although the unadjusted analysis showed higher odds of never breastfeeding among unmarried women who had a repeat C-section (COR = 1.38, 95% CI = 1.08–1.75), the estimate lost significance after adjusting for all covariates. Among married women who had a repeat C-section, the odds of never breastfeeding were 2.5 times (COR = 2.48, 95% CI = 1.99–3.09) higher compared to women with VBAC. The fully adjusted model demonstrated a significant yet attenuated estimate for married women. Women who had a repeat C-section were 2.2 times (AOR = 2.16, 95% CI = 1.69–2.77) more likely to never breastfeed compared to women with VBAC.

Table 4.

Association Between Repeat Cesarean Section and Breastfeeding Initiation Stratified by Marital Status

Mode of delivery	Never breastfed COR (95% CI)	Never breastfed^a AOR (95% CI)
Not married
Repeat C-section	1.38 (1.08–1.75)	1.35 (1.00–1.83)
VBAC	1.00	1.00
Married
Repeat C-section	2.48 (1.99–3.09)	2.16 (1.69–2.77)
VBAC	1.00	1.00

Bold estimates are significant.

Adjusted for maternal age, education, insurance, income, WIC participation, maternal morbidities, prenatal care adequacy, stress, race, and prepregnancy BMI.

Discussion

Breastfeeding initiation was prevalent among the majority of study participants (75%). Our results also demonstrate that repeat C-sections are associated with breastfeeding noninitiation. Furthermore, the current study revealed that this relationship differs by marital status. These results add to the growing evidence that C-sections negatively affect breastfeeding practices.

In the current study, women with a repeat C-section were more likely to never breastfeed compared to women with VBAC. This finding is consistent with previous research that demonstrated a negative association between having a C-section delivery and breastfeeding initiation.^5,6,17 This relationship could be explained by breastfeeding intention—a strong predictor of breastfeeding outcomes.¹⁸ Specifically, a prospective cohort study reported that women with a planned C-section are more likely to not intend to breastfeed.¹⁹

This finding could also be explained by the physiological differences effect resulting from a C-section. Lactogenesis has been shown to be significantly lower in the first 5 days postpartum in women with C-sections compared to women with a vaginal delivery.²⁰ Lactogenesis is defined as, “the onset of milk secretion and includes all of the changes in the mammary epithelium necessary to go from the undifferentiated mammary gland in early pregnancy to full lactation sometime after parturition.”²¹ In addition to the physiological effects, previous studies have hypothesized that pain after a C-section may make spending time with the newborn difficult or causes a lack of infant to breast contact, which is associated with never breastfeeding and a shorter duration of breastfeeding.^7,22

The current study also found that married women with a repeat C-section were more likely to never breastfeed, whereas unmarried women did not show an association. This finding is supported by Masho et al. (2016), a study that reported married women, who were overweight or obese, to be more at risk to never breastfeed or have a shorter breastfeeding duration. Despite previous evidence demonstrating that obesity results in delayed breastfeeding initiation, the current study controlled for prepregnancy BMI; as a result, influences from this factor are limited. Therefore, examining the association between VBAC and breastfeeding initiation among married women supports the need for practitioners to consider how interpersonal relationships may increase the risk of poor maternal health behaviors.

However, it is important to note that these findings conflict with other previous studies that demonstrated higher rates of breastfeeding initiation among married women than their nonmarried counterparts.^9,23,24 These inconsistencies may be the result of differences among each study's sample populations. For example, Chin et al. (2008) examined the association between race and education on breastfeeding among women in Louisiana and found that married Black women were more than twice as likely to breastfeed compared to nonmarried Black women. Another study that utilized data from parents with babies between 9 and 11 months old in the United Kingdom found that unmarried or cohabitating women were at a higher risk of not breastfeeding than married women.⁹ While these studies utilized state specific or international populations, the current study and Masho et al. (2016) both analyzed samples that were nationally representative of women in the United States, which may have contributed to the inconsistencies exhibited among these studies.

Furthermore, the difference between married and unmarried women may be explained by the lack of spousal support among the two groups. The 2011 U.S. Surgeon General's report on breastfeeding stated that some fathers may have concerns about being excluded from bonding and caring for their child if breastfeeding is practiced. In addition, some spouses may perceive breastfeeding as a barrier that may prevent mothers from maintaining other responsibilities, such as household chores.²⁵ Consequently, this negative influence may inherently decrease the mothers' willingness to breastfeed.

The current study not only contributes to the limited literature on repeat C-section and breastfeeding initiation but further also explored the importance of marital status on maternal health behaviors and outcomes. To the authors' knowledge, this is the first study to examine the association between repeat C-section and breastfeeding initiation by marital status. Furthermore, this study used a large, nationally- representative sample of women in the United States.

Despite its strengths, this study is not without limitations. Because of the cross-sectional nature of the study, causality cannot be inferred. The use of self-reported data may have resulted in recall bias among the survey respondents or the potential for under/overreporting of breastfeeding initiation; however, previous research has stated that maternal recall of breastfeeding initiation is reliable.²⁶ Furthermore, a variety of potential confounders such as breastfeeding intention, self-efficacy, and perceived milk supply were not available in the dataset and could not be assessed. Nonetheless, this study provides evidence that may help to improve public health practice and policy to increase breastfeeding initiation.

Conclusion

A woman's mode of delivery and marital status were both found to be significantly associated with breastfeeding initiation. Despite the potential for improved maternal and child health outcomes and the quality of nutrition provided from breastfeeding, maternal and familial perceptions compounded by potential adverse birth experiences may alter a mother's intention and willingness to breastfeed. Enhanced educational programs and counseling support may be needed to help families cope with delivery challenges and resulting stressors that may reduce their desire to initiate breastfeeding in the postpartum period. Using similar practices during the prenatal period may also prepare women and their families on how to successfully overcome any medical challenges that may hinder their potential to breastfeed. Moreover, providers should be aware of the effect of marital status when educating pregnant and postpartum women. Future research should examine alternative breastfeeding interventions for women with a repeat C-section delivery to promote the initiation and continuation of breastfeeding during the postnatal period. Mixed method analyses and qualitative studies that further explore the role of marital status on breastfeeding practices and the variation in factors identified to influence breastfeeding by marital status may also be beneficial. Findings from these additional research efforts may help develop enhanced interventions to increase breastfeeding initiation rates among women.

Footnotes

Disclosure Statement

No competing financial interests exist.

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