Maternal Personality and Psychosocial Variables Associated with Initiation Compared to Maintenance of Breastfeeding: A Study in Low Obstetric Risk Women

Abstract

Introduction:

The benefits of breastfeeding are well known for mother and child. Research about the predictive factors related to the initiation and maintenance of breastfeeding is of great interest to public health.

Aim:

To analyze the factors associated with the timely initiation of breastfeeding at immediate postpartum and the variables that facilitate their maintenance 4 months after birth.

Materials and Methods:

A longitudinal prospective design was used, including four stages: first trimester of pregnancy (personality), third trimester (childbirth expectations, breastfeeding intention, pregnancy worries, and coping strategies), immediately after childbirth (initiation of breastfeeding and childbirth satisfaction), and 4 months after birth (continuation of breastfeeding).

Results:

A sample of 116 women took part in the study from the first trimester to 4 months after birth. Timely initiation of breastfeeding is associated with vaginal birth (p < 0.000) and with variables related to the absence of stress factors: fewer worries regarding childbirth (p = 0.009), higher satisfaction during birth in relation to holding the baby (p > 0.000), and the meeting of expectations (p = 0.017). These associations disappear when the type of birth is introduced. Maintenance of breastfeeding is associated with maternal personality and psychosocial variables: openness to experience (p = 0.007), increased worries about coping with the baby (p = 0.046), relationship with partner (p = 0.047), and overt emotional expression (p = 0.040).

Conclusion:

Different factors are associated with initiation and maintenance of breastfeeding. Specific prevention strategies are needed, aimed toward health care staff for improving breastfeeding initiation and to empower women during the entire pregnancy for breastfeeding maintenance.

Introduction

The World Health Organization (WHO) recommends breastfeeding for the first 6 months and supports maintaining it for 2 years or more with the inclusion of other complimentary and safe foods, which meet the nutritional requirements of the child.¹ Taking into account the health benefits of breastfeeding both for mother² and child,³ research regarding the predictive factors related to the initiation of lactation in the immediate postpartum, as well as its maintenance, would be of great importance in relation to public health, in particular in health promotion. Planned pregnancy, vaginal delivery, and having a male child have been shown to be associated with early breastfeeding.⁴ Health literacy, knowledge, intention, and self-efficacy have been positively and significantly associated with breastfeeding exclusivity in immediate postpartum.⁵ Regarding the maintenance of lactation, different studies have shown that certain factors such as having breastfed in the past, having received information regarding breastfeeding during the pregnancy, being older, having a small time window between birth and first breastfeed, not having given bottle feeds during the first days, and the type of birth all increase the likelihood of maintaining breastfeeding.⁶ The decision to interrupt breastfeeding is frequently associated with difficulties of breastfeeding (lack of milk and perceived hunger of baby) and with personal difficulties such as having low expectations regarding continuing breastfeeding.^7,8 It has been found that there is a positive association between labor satisfaction and maintenance of breastfeeding, in particular at 3 months postpartum.⁹

Psychological factors associated with breastfeeding initiation and maintenance include the role of stress.¹⁰ Stress issues such as severe life events,^10,11 pregnancy related worries,¹² and coping during pregnancy have been analyzed. In relation to the latter, continuing breastfeeding has been associated with variables such as degree of social support, increased knowledge of breastfeeding, establishing aims, and the use of problem solving strategies.¹³ Certain strategies such as keeping calm, “taking care of oneself”, practicing mindfulness, using positive self-instructions, and challenging of useless beliefs have all been associated with continuing breastfeeding.¹⁴

Few studies have focused on analyzing the extent to which the mother's personality per se influences breastfeeding. The few that have done so suggest that maternal personality along with context determines the decision and the way that the mother chooses to feed the child.¹⁵ Based on the Big Five personality model, it has been found that extroversion, agreeableness, and openness to experience increase both the likelihood to choose to breastfeed and the duration,^15,16 while neuroticism negatively influences the decision and the duration of breastfeeding.^16,17

The aim of this study has been to analyze the influence, on breastfeeding, of maternal personality and psychosocial variables (expectations, breastfeeding intention, pregnancy worries, coping, and childbirth satisfaction), along with sociodemographic and clinical variables, including childbirth satisfaction. Special attention has also been paid to the potential different influences of these variables on the initiation of breastfeeding within an hour of giving birth (immediate postpartum) and on the continuing of breastfeeding 4 months after birth.

Materials and Methods

Design type

A longitudinal prospective design was used. Four time points were included as follows: first trimester of pregnancy (personality factors), third trimester (childbirth expectations, pregnancy worries, coping strategies, and breastfeeding intention), immediately after birth (timely initiation of breastfeeding and childbirth satisfaction), and 4 months after birth (maintaining breastfeeding). The timely initiation of breastfeeding and the maintenance of breastfeeding are considered outcomes, while the rest of variables (psychosocial and personality) are considered exposures of the study.

Setting

The study is part of a larger research project carried out at the Fuenlabrada University Hospital, a public hospital in South Madrid (health area 9), Spain, which provides care to about 3,000 obstetric patients per year. The project has been financed by state funds (Health Research Fund, FIS, grant number PI07/0571). Pregnant women receiving obstetric care at this hospital were recruited between November 2014 and April 2015. Eligibility criteria were as follows: women >18 years of age, mentally and physically healthy, with a maximum gestational age of 14 weeks, and who had not been diagnosed with any maternal or fetal diseases.

Sample

The final sample consisted of 116 women (4 months after birth). During the first trimester 287 took part in the study and 122 continued during the third trimester and 120 at the moment of birth.

Data collection

Exposure variables (self-report questionnaires)

First trimester

Personality (“Big Five” traits)

The Spanish version of NEO Five-Factor Inventory was used. It contains 60 statements rated on a five-point Likert-type scale. It measures the five main factors of personality: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. This instrument has been widely used, translated, and validated into different languages, having shown good psychometric properties.¹⁸

Third trimester

Childbirth expectations

The Spanish version of the Childbirth Expectations Questionnaire was used.¹⁹ The subscales for childbirth expectations included the caregiving environment, offering support to the partner, control and participation, labor pain expectations, and medical support. It contains a total of 37 questions on a five-point Likert-type scale. Higher scores always indicate more positive expectations. This instrument has shown their factorial validity in different languages and cultures, and its internal consistency values range between 0.65 and 0.85.^19,20

Breastfeeding intention

An ad hoc self-report measure with two questions was used: “have you decided what type of feeding method you are going to use? (Yes/no)” “…if so, what type? (breastfeeding, formula feeding).”

Pregnancy worries

The Spanish version of the Cambridge Worry Scale (CWS) was used.²¹ The CWS includes 16 items, each having five Likert-type alternatives. The CWS has demonstrated good reliability and validity (convergent and discriminant).^21,22 For the current study we used each of the worries separately, as well as the global pregnancy worries measure.

Coping strategies

These were measured using the Coping Strategies Questionnaire (CSQ), which was constructed using rational–theoretical criteria based on the Folkman and Lazarus questionnaire. The CSQ is used to measure seven basic coping styles as follows: problem-solving coping, negative autofocused coping, positive reappraisal, overt emotional expression, avoidance coping, social support seeking, and religious coping. The scale contains 42 items, each rated on a five-point Likert-type scale. The CSQ has been used in different studies and has shown adequate reliability and validity.²³

After childbirth (<48 hours)

Childbirth satisfaction

The Spanish version of the Women's View of Birth Labor Satisfaction Questionnaire (WOMBLSQ) was used. Composed by 30 items, the WOMBLSQ is a widely used and validated tool used for a quick assessment of eight dimensions of the childbirth process (professional support, expectations, home assessment, holding baby, support from spouse/partner, pain in labor and after childbirth, continuity, and environment), as well as one dimension for overall satisfaction.²⁴

Outcome variables

After childbirth (1 hour)

Timely initiation of breastfeeding. This was assessed using observational measures by the midwife that was part of the research team.

Four months after childbirth

Women were asked, using a questionnaire sent in the post, if they maintained breastfeeding on demand.

Sociodemographic and gestational variables

Sociodemographic and gestational variables included age, educational level, working at the time of the study, previous miscarriages or abortions, previous deliveries, planning of the pregnancy, and type of delivery. An ad hoc self-report measure was used to assess them. These variables were also considered as possible confounding variables.

Procedure

The midwife of the research team established the first contact with the participants personally at the antenatal clinic at the first trimester ultrasound, assessing women that met the inclusion criteria (using the electronic clinical record). The women were informed about and invited to participate in the study. We approached 320 eligible women; 287 (89.68%) agreed to participate in the study and signed the informed consent form.

Once the women were enrolled, they were given a battery of questionnaires that included questions about demographic and pregnancy variables and the personality inventory. The relevant clinical variables were subsequently obtained from the hospital's medical records. The completed questionnaires were returned directly to the researcher. Two of the participants suffered miscarriages during this period and were therefore excluded from the analysis. Therefore, 285 expecting mothers made up the final sample at the initial data collection point (at first trimester).

In the third trimester (around week 30), instruments about childbirth expectations, breastfeeding intention, pregnancy worries, and coping strategies were mailed to the women with a prepaid envelope in which to return the completed questionnaire to the research team. Before the second questionnaire was sent, each participant's medical records were reviewed to confirm that none of the exclusion criteria had been met during this period. Five women had a miscarriage in the first half of their pregnancies, after completing the first questionnaire. The remaining enrolled women received a telephone call in which they were asked to return the second questionnaire upon completion. Thus, 280 questionnaires were mailed in the third trimester, and 122 of them were returned (43.6%).

In the third phase of the study, immediately postpartum (1 hour), the midwife of the research team registered if the mothers initiated timely lactation. Later, 24–48 hours after childbirth, during their hospital stay, the women completed the childbirth satisfaction questionnaire. In this phase, 120 women agreed to participate (42.1%). Finally, 4 months after birth, a questionnaire was sent in the post assessing the continuation of breastfeeding on demand; 116 (40.70%) women participated at this stage. There were no significant differences in sociodemographic or pregnancy variables among the first and third trimester, immediate postpartum, and 4 months after birth samples.

Ethics section

The research project was approved by the Human Research Ethics Committee at Fuenlabrada University Hospital in Madrid, Spain (PI07/0571). All participants signed a consent form to declare a voluntary agreement with all procedures implicated in this project. Furthermore, all participants were informed that their participation could be voluntarily terminated at any time without any consequence to the woman or to the quality of her health care.

Statistical analysis

Analyses were performed using the SPSS 21 Statistics Package (Armonk, NY). Descriptive analyses and internal consistency analyses (Cronbach's Alpha coefficient) were performed. T tests (quantitative variables) and chi-square tests (categorical variables) were used to analyze the associations between breastfeeding variables (timely initiation and maintenance) and the remaining exposure variables. Effect size differences were evaluated using Cohen d, with d = 0.2–0.49 being a small effect, d = 0.5–0.79 being a medium effect, and d ≥ 0.80 being a large effect size difference. Logistic regressions were used to control confounding effects (introducing confounding variables in the first step), using breastfeeding as the outcome variable, and statistically significant exposure variables (bivariate analyses) as predictors. The level of significance was established at p ≤ 0.05.

Results

Sociodemographic and clinical characteristics of the sample: descriptives of exposure and outcome variables

The women's mean age was 31.28 years (standard deviation 3.96; range 23–42), and 51.3% were primiparous. Most of the participants (48.3%) had secondary education (23.3% had primary education and 28.3% had attended university). Approximately, a quarter of the women (24.2%) had previously suffered at least one spontaneous miscarriage or voluntary interruption of pregnancy. For 85% of the sample the pregnancy had been planned. A total of 68.1% were working outside the home. In relation to the type of birth, 57.3% had vaginal births, 25.5% had cesarean sections, and 17.3% had instrumental births. Table 1 shows the descriptives of exposure and the outcome variables. Internal consistency is also shown (Cronbach's alpha) for the scales used, having found acceptable values in each case.

Table 1.

Descriptives for All Variables (Exposure and Outcome Variables)

	Mean (SD)	95% CI	Theoretical range	Sample range	Skew	Kurt	Alpha
Exposure variables
Personality (1T)
Neuroticism	18.19 (7.53)	16.62–19.76	0–48	1–38	0.37	0.40	0.80
Extraversion	31.25 (6.23)	29.95–32.55	0–48	9–46	−0.18	0.96	0.77
Openness	25.29 (6.52)	23.93–26.64	0–48	11–43	0.01	0.40	0.71
Agreeableness	30.67 (5.66)	29.49–31.85	0–48	15–43	−0.40	0.13	0.71
Conscientious	32.36 (6.10)	31.09–33.63	0–48	16–46	−0.12	0.07	0.74
Childbirth expectations (3T)
Caregiving environment	52.19 (6.65)	50.81–53.58	13–65	37–65	0.08	−0.46	0.90
Labor pain expectations	14.47 (3.52)	13.73–15.20	5–25	6–25	0.09	0.50	0.83
Support of the partner	26.74 (2.86)	26.15–27.34	5–30	19–30	−0.68	−0.30	0.68
Control and participation	33.17 (4.02)	32.33–34.01	9–45	25–43	0.47	−0.24	0.68
Medical support	16.13 (2.30)	15.65–16.61	4–20	12–20	0.13	−0.85	0.74
Pregnancy worries (3T)	1.23 (0.65)	1.08–1.36	0–5	0.19–3.69	0.94	1.40	0.70
Coping strategies (3T)
Problem-solving coping	14.69 (4.49)	13.76–15.63	0–24	2–24	−0.15	0.39	0.87
Negative autofocused coping	6.67 (2.87)	6.07–7.27	0–24	1–14	−0.01	0.05	0.62
Positive reappraisal	13.89 (3.31)	13.20–14.58	0–24	6–24	0.44	0.75	0.71
Overt emotional expression	6.44 (3.19)	5.78–7.10	0–24	0–15	0.47	−0.06	0.65
Avoidance coping	8.66 (3.65)	7.90–9.42	0–24	0–17	0.24	−0.24	0.71
Social support seeking	14.45 (6.12)	13.18–15.73	0–24	2–24	0.10	−0.45	0.81
Religious coping	2.46 (3.71)	1.69–3.24	0–24	0–16	1.58	1.83	0.88

	Yes n (%)	No n (%)
Breastfeeding intention (3T)	108 (90)	12 (10)
Outcome variables
Initiation to breastfeed	95 (79.8)	24 (20.2)
Maintaining breastfeeding	62 (51.7)	58 (48.3)

CI, confidence interval; SD, standard deviation; T, trimester.

Associations between breastfeeding variables and sociodemographic and clinical variables

The only statistically significant difference was found between the type of birth and the timely initiation of breastfeeding within the first hour postpartum. The participants who had vaginal births and instrumental births initiated breastfeeding within the hour in a greater proportion (93.5% and 94.7%, respectively) than women with cesarean sections (39.3%) (χ² = 38.435, gl = 2, p < 0.000).

Associations between breastfeeding variables and exposure variables

Timely initiation of breastfeeding within the first hour of postpartum

Table 2 shows the statistically significant results for the exposure variables considered during the first trimester (personality factors), the third trimester (childbirth expectations, pregnancy worries, coping strategies, and breastfeeding intention), and immediately after birth (childbirth satisfaction) in relation to the initiation of breastfeeding within the first hour of postpartum. As can be seen in the table, women who initiated breastfeeding within the first hour postpartum scored lower on worrying about giving birth and higher on childbirth satisfaction regarding expectations and holding the baby. Effect sizes could be considered medium–large.

Table 2.

Analysis of Variables Associated with Timely Initiation of Breastfeeding Within an Hour of Giving Birth (Only Significant Results Are Shown)

	Timely initiation of Breastfeeding
	No Mean (SD) [95% CI]	Yes Mean (SD) [95% CI]	t	p	Cohen d
Pregnancy worries (3T)
Worrying about giving birth	3.08 (1.55)[1.62–3.21]	2.26 (1.31)[1.71–2.31]	2.643	0.009	0.58
Childbirth satisfaction
Expectations	10.58 (9.51)[4.54–16.62]	17.02 (8.26)[15.02–19.02]	−2.437	0.017	0.72
Holding baby	11.75 (7.13)[7.21–16.28]	18.05 (4.92)[16.86–19.25]	−3.804	<0.000	1.02

CI, confidence interval; SD, standard deviation; T, trimester.

Three logistic regressions were used to control the confounding effects of the type of birth on the timely initiation of breastfeeding within the first hour of postpartum, inserting the type of birth (cesarean section/other type of birth) in the first step. Timely initiation of breastfeeding (yes/no) was considered the outcome variable; and worrying about giving birth, childbirth satisfaction regarding expectations, and childbirth satisfaction regarding holding baby were predictors independent for each of the regressions. The results show that, in every case, the statistically significant association found between the previous variables disappears when the type of birth is introduced into the equation.

Maintaining breastfeeding on demand 4 months postpartum

Table 3 shows the statistically significant results for the variables considered during the first trimester (personality factors), the third trimester (childbirth expectations, breastfeeding intention, pregnancy worries, and coping strategies), and immediately after birth (childbirth satisfaction) in relation to the maintaining of breastfeeding 4 months postpartum. As can be seen in the table, women who continued to breastfeed on demand 4 months postpartum scored higher on openness to experience, on pregnancy worries (in particular coping with the baby and the relationship with partner), on overt emotional expression, and on general childbirth satisfaction. Effect sizes could be considered medium. A statistically significant association was found between deciding to breastfeed before childbirth (third trimester) and the continuation of breastfeeding on demand 4 months postpartum.

Table 3.

Analysis of Variables Associated with Maintaining Breastfeeding 4 Months After Birth (Only Significant Results Are Shown)

	Breastfeeding on demand continues
	No	Yes
	Mean (SD) [95% CI]	Mean (SD) [95% CI]	t	p	Cohen d
Personality (1T)
Openness to experience	23.88 (6.49)[22.17–25.59]	26.87 (5.51)[25.47–28.27]	−2.727	0.007	0.56
Pregnancy worries (3T)
Coping with the new baby	1.17 (1.18)[0.82–1.52]	1.67 (1.14)[1.32–2.01]	−2.019	0.046	0.50
Relationship with spouse/partner	0.50 (0.81)[0.26–0.74]	0.96 (1.41)[0.53–1.38]	−2.032	0.047	0.46
Coping strategies (3T)
Overt emotional expression	5.76 (2.79)[4.93–6.59]	7.13 (3.44)[5.78–7.10]	−2.089	0.040	0.50
Childbirth satisfaction
General satisfaction	11.53 (3.47)[10.41–12.66]	12.90 (1.80)[12.34–13.46]	−2.242	0.028	0.56

	Breastfeeding on demand continues
	No n (%)	Yes n (%)	χ²	p
Deciding to breastfeed before childbirth (3T)
Yes	48 (87.3)	59 (98.3)	5.538	0.019
No	7 (12.7)	1 (1.7)

CI, confidence interval; SD, standard deviation; T, trimester.

Discussion

Our results show that there is a distinction between the factors that influence timely initiation of breastfeeding during the immediate postpartum and those that favor maintaining the behavior for 4 months postpartum. Immediate breastfeeding after childbirth associates with variables linked to “supportive contexts,” associated with feeling secure and calm (vaginal births, fewer worries about childbirth, high satisfaction in relation to holding the baby, and with meeting expectations), while maintaining breastfeeding (4 months later) associates with maternal personality and psychosocial variables.

Regarding the “supportive contexts,” type of birth has a fundamental role in predicting the timely initiation of lactation in the immediate postpartum, in accordance with other studies that have shown that vaginal births increase the probability of breastfeeding^4,25 or that Cesarean sections negatively affect starting breastfeeding.²⁶ In relation with the high proportion of women who breastfeed within the hour after an instrumental birth, it has been suggested that an unexpected delivery method (i.e., unplanned cesarean or instrument-assisted vaginal deliveries) is associated with an increased likelihood of initiating breastfeeding.²⁷ In this context, breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience and allows the individual to once again assume control.

The rest of variables associated with initiation of breastfeeding have shown to be related to the maternal perception of the birthing experience as stressful. Women with fewer previous worries about giving birth are more likely to commence breastfeeding within the hour; this could be due to the previously demonstrated association between childbirth worries during pregnancy and fear during birth.²⁸ In addition, this study has found that satisfaction with childbirth in relation to holding the baby or the meeting of expectations about labor can favor breastfeeding. This is in accordance with studies that suggest that emotional support during childbirth on behalf of the midwife, especially in relation to coping with caring for the baby, favors initiating postpartum breastfeeding.²⁹ Nevertheless, it should be highlighted that, in light of the results, the above variables associated to maternal perception are inherent to the type of birth, so much so that their effect reduces statistical significance to nothing when the type of birth is considered. In particular, vaginal births seem to benefit from more favorable psychosocial conditions, in relation to worries and satisfaction, and therefore increase the likelihood of initiating lactation immediately postpartum.

Maintaining breastfeeding for 4 months postpartum seems to associate with maternal personality and psychosocial variables, as this continuity seems to relate to personalities which are more open to experiences, more worried with coping with caring for the baby and the relationship with the partner, with previous intention to breastfeed, and with open and expressive emotional coping. The scarce literature on this matter seems to suggest that there is a positive influence of openness to experience and agreeableness on initiating breastfeeding.^15,16 The fact that openness to experience is associated with a tendency to look for new experiences, perceiving them as pleasant and valuable,³⁰ could support the hypothesis that women with high scores on this trait would perceive breastfeeding as an enriching experience for their lives and would therefore also choose to maintain it. These women would also be more sensitive to the needs of their babies, which would allow them to accept and supply breastfeeding for longer.¹⁶ Finally, childbirth satisfaction and the decision to breastfeed in advance are significantly associated with the maintaining of breastfeeding 4 months postpartum, in accordance with previous studies.^31,32

Limitations and strengths of the study

This study is not without limitations. The use of a convenience sample may limit its representativeness. Similarly, the fact that the sample involves only women receiving care in a public health center may also limit generalization, although public assistance is the main health service for the Spanish population. However, the sociodemographic, obstetric, and clinical data of the participants are very similar to those observed in other studies.^17,33 Finally, we had a high rate of dropouts by the third trimester, which may have resulted in retention bias, but the rate was similar to that of other studies in which the observation period spanned from pregnancy to postpartum.^34,35

The main strengths of this study reside in its prospective and longitudinal design and in the fact that it was carried out among women with low obstetric risk, unlike previous studies.

It should be pointed out that the core strength of this study is the finding of different initiation and maintenance factors for breastfeeding, as well as the inclusion of variables associated with maternal personality. Although recent studies have focused on the above distinction,^33,36 they have not found the differences here presented. This could be due, to the best of our knowledge, to the lack of studies that have included maternal personality variables in this distinction. The practical implications of the study are just as relevant. Because of the differences found between the psychosocial variables predicting the initiation of lactation within the first hour postpartum and its maintenance 4 months later, it would seem necessary to establish preventive measures and interventions specific to each case. Therefore, regarding the timely initiation of lactation it seems to be of utmost importance to continue to implement intervention programs specifically aimed toward health care staff for improving breastfeeding outcomes³⁷ paying special attention to those involved in nonvaginal births. Nevertheless, in relation to the maintenance of lactation 4 months later, it is also of great importance not only to maintain proper attention at the moment of birth but also to create effective programs aimed at empowering women during the entire pregnancy. Some strategies that could be efficient, in light of the results, would be as follows: change of focus (openness to experience), cognitive restructuring (pregnancy worries regarding coping with the new baby and relationship with partner), and emotional regulation techniques (overt emotional expression).

Conclusion

In low obstetric risk women, initiation of lactation in the immediate postpartum is associated to circumstances and worries regarding the birth itself, being less likely in cesarean section births. Nevertheless, the maintenance 4 months later is associated with certain personal variables of the mother (openness to experience, worries regarding coping with caring for the baby, previous intentions, and emotionally expressive coping). These results can have important clinical repercussions in implementing practical differential interventions for midwives to be able to cover the mother's needs.

Footnotes

Acknowledgments

This work was funded by the Health Research Fund (Fondo de Investigaciones Sanitarias, FIS), grant number PI07/0571 from the Instituto de Salud Carlos III (Spain).

Disclosure Statement

The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

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