Reasons for Early Cessation of Breastfeeding Among Women with Low Income

Abstract

Background:

Most women in the United States do not meet their breastfeeding goals, and low-income women breastfeed at lower rates than the general population. While risk factors for early cessation have been documented, specific reasons for discontinuing among this population are less understood. We examined reasons for cessation among low-income mothers to inform the development of targeted strategies to address breastfeeding disparities.

Materials and Methods:

We performed a secondary data analysis using prospective data collected during a randomized intervention trial of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible women interviewed in the third trimester and at 1, 3, and 6 months postpartum. We included the 221 women who initiated breastfeeding and stopped by 6 months. Women's reasons for discontinuing breastfeeding were grouped by thematic category and compared by time of breastfeeding cessation.

Results:

The most common reasons reported overall for breastfeeding cessation were concerns about breast milk supply and latch difficulty. Some reasons differed significantly by time of cessation. Latch difficulty was reported most often by women who breastfed for 1 month or less; supply concerns increased with increasing breastfeeding duration. Returning to work/school was uncommonly reported for those who stopped by 1 month, but more frequently reported in those with later cessation.

Conclusions:

We found that low-income women reported similar reasons for early breastfeeding cessation as have been reported for other populations of women. These results underscore the need for appropriately timed, culturally sensitive interventions to reduce disparities in duration of breastfeeding, specifically to address latch difficulty in the first few weeks and supply concerns as infants grow.

Introduction

Breastfeeding rates vary markedly between demographic groups in the United States, with low rates occurring among women with low income and those who participate in the U.S. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).^1–4 Moreover, infants residing in low-income households are less likely to live in smoke-free housing, have a safe-sleep environment, and have access to high-quality health care.^5–7 Combining these disparities with lower rates of breastfeeding may put low-income infants' health at additional risk and lead to lifelong health deficits.

While past research has addressed factors associated with the likelihood of breastfeeding and barriers to breastfeeding in this population,^8,9 research on reasons for early breastfeeding cessation is limited. Most of the previous research has focused on more advantaged groups.^10–14 One study among WIC participants relied on retrospective data.¹⁵ Without a clear understanding of the reasons women terminate breastfeeding early, interventions to prolong breastfeeding among this at-risk group cannot be effectively designed.

Thus, the purpose of this analysis was to assess reasons for breastfeeding cessation among a group of WIC-eligible women and to determine if these reasons differed based on when the mother stopped breastfeeding.

Materials and Methods

The Prenatal Education Video Study (PEVS) was conducted at the University of Virginia and Virginia Commonwealth University to test the efficacy of an educational video on breastfeeding initiation and duration. The Institutional Review Boards of the University of Virginia, Virginia Commonwealth University, and the Virginia Department of Health approved this study. Details about the study design have been published previously.^16–18 Briefly, WIC-eligible women in their third trimester (24–41 weeks' gestation) seeking care in prenatal clinics at both sites were eligible to participate. Women were recruited in clinic and interviewed after giving informed consent. Following the enrollment interview, each participant was randomly assigned to the intervention (breastfeeding education video) or sham (prenatal nutrition and exercise video) group. Following delivery, research assistants blinded to group assignment abstracted maternal and infant medical records and conducted follow-up telephone interviews with participants at 1, 3, and 6 months postpartum.

Data on demographic characteristics, past breastfeeding experience, and infant feeding plan were collected from participants at baseline. Data on breastfeeding initiation, visit by a lactation consultant, and labor and delivery were abstracted from the maternal and infant medical records from the newborn hospital stay; duration of breastfeeding and whether the woman returned to work were determined based on data collected during the telephone interviews at 1, 3, and 6 months. For the purposes of the current analysis, we defined breastfeeding as full or partial breastfeeding.¹⁹

Participants were asked at each follow-up interview whether they had discontinued breastfeeding and, if so, for what reason. The question asking for reasons for cessation was open ended; however, the interview data collection form included a predetermined list of possible reasons, as well as a place to record reasons not anticipated in the list, to aid in coding participant responses. Participants could provide more than one reason. By consensus of the research team, we grouped the reasons reported by the mothers into the following thematic categories: supply concerns, latch difficulty, “medical condition” of mother or infant, inconvenience/fatigue, work/school, and personal decision. The “medical condition” category included any condition reported and perceived by the mother to be a contraindication to continued breastfeeding. However, we did not have enough information to determine if these were true contraindications as per the American Academy of Pediatrics guidelines.²⁰

This secondary analysis was carried out on the entire cohort of eligible participants regardless of their intervention status, as our previous analyses indicated that the video intervention was not statistically significantly related to breastfeeding duration.¹⁸ While the original study was designed to have statistical power to detect an effect of the educational video intervention on full or partial breastfeeding up to 6 months,¹⁸ the analyses for this current article were descriptive. Kaplan–Meier curves were used to calculate the time of breastfeeding cessation, up to 6 months. The reasons for cessation were tabulated and compared by thematic category, using the Chi-square test, according to the time at which breastfeeding was discontinued (≤1, ≤3, and ≤6 months).

Results

Of the 522 mothers enrolled in PEVS, 359 initiated any breastfeeding in the hospital. Complete data on duration of breastfeeding were missing for 64 participants. Among the 295 women with duration of breastfeeding data, 74 (25%) were still breastfeeding at 6 months, and the remaining 221 (75%) discontinued all breastfeeding before 6 months. Those who continued breastfeeding differed in ways that have been previously reported: they were more likely to be older, be married or living with a partner, have a higher level of education, be a nonsmoker, and have breastfed a prior infant for more than 6 months (data not shown).

For the purposes of this secondary analysis of reasons for breastfeeding cessation, our study population consisted of the 221 women who had discontinued full or partial breastfeeding before 6 months. Overall, they were predominantly non-Hispanic black or white and educated at the high school level or less; the majority lived with a partner or other adult (Table 1). The median duration of breastfeeding was 0.69 months (95% confidence interval [CI]: 0.56–0.99). The proportions of women who had stopped breastfeeding by 1 and 3 months were 63% (95% CI: 57–69) and 91% (95% CI: 87–94), respectively (Fig. 1). We did not categorize women according to their amount of breastfeeding (full or partial) for our analysis of reasons for stopping. Most women only breastfed fully for a short duration or had switched to partial breastfeeding at the time that they stopped, which limited our ability to meaningfully attribute reasons for stopping to differences in amount of breastfeeding.

FIG. 1.

Breastfeeding cessation among study participants, N = 221.

Table 1.

Sociodemographic and Other Characteristics of Study Participants, N = 221

	N (%)^a,b
Maternal age, mean years ± SD	24.5 ± 5.6
Race/ethnicity
Non-Hispanic, white	96 (44)
Non-Hispanic, Black	98 (45)
Non-Hispanic, other	11 (5)
Hispanic	15 (7)
Education
Less than high school diploma	38 (17)
HS diploma, GED, tech training	115 (52)
Some college	55 (25)
College graduate	12 (5)
Marital status
Married/living with partner	113 (51)
Never married	8 (4)
Separated, divorced, or widowed	99 (45)
Other adult living in the home^c
Partner	106 (48)
Parent or grandparent	99 (45)
Other	46 (21)
No others living in the home	23 (10)
Ever smoked	84 (38)
BMI category
BMI < 25.0	35 (16)
25.0 ≤ BMI < 30.0	62 (28)
30.0 ≤ BMI	124 (56)
C-section delivery	81 (37)
Any maternal complication^d	132 (60)
Any infant complication^e	135 (62)
Gestational age
<34 Weeks	6 (3)
34 to <37 weeks	22 (10)
≥37 Weeks	192 (87)
Birth weight (≥2,500 g)	197 (90)
Service, ever NICU and/or ICN	38 (17)
Breastfeeding experience
Primiparous	115 (53)
Never previously initiated	38 (18)
Maximum duration 1–180 days	49 (23)
Maximum duration 181+ days	14 (6)
Intention
Breast milk	121 (55)
Artificial breast milk substitute	27 (12)
Both	59 (27)
Don't know	12 (5)
Planned duration of breastfeeding
1–30 Days	25 (15)
31–90 Days	52 (32)
90+ Days	87 (53)
Visit by a lactation consultant	191 (87)
Return to work
Unemployed before giving birth	91 (41)
Did not return to work	29 (13)
Returned 3–6 months postpartum	15 (7)
Returned 1–3 months postpartum	58 (26)
Returned before 1 month	28 (13)
Family support of infant feeding method
Poor	2 (1)
Fair	6 (3)
Good	32 (15)
Very good	31 (14)
Excellent	148 (68)

For columns that do not sum to 221, data were missing for some participants.

Data presented as N (%) except where indicated.

Categories are not mutually exclusive.

Maternal complications included placental abruption, uterine atony, preeclampsia, chorioamnionitis, methadone use, and others.

Infant complications included hypoglycemia, transient tachypnea of the newborn, other breathing problems, cardiac problem, hyperbilirubinemia, and others.

BMI, body mass index; ICN, intensive care nursery; NICU, neonatal intensive care unit; SD, standard deviation.

The most common reasons cited for breastfeeding cessation were breast milk supply concerns, reported by 41% of women (Table 2). The next most common category of concern was difficulties with latch, reported by nearly one-third of women. Approximately one-fifth of women gave a reason related to a “medical condition” of herself or her infant, and about the same proportion cited a reason related to inconvenience or fatigue. Returning to work or school was reported by 14% of women. It is noteworthy that only five women said that they discontinued because they breastfed for as long as they had intended. Ten women (5%) did not report a reason for discontinuing breastfeeding.

Table 2.

Categories of and Specific Reasons for Early Breastfeeding Cessation, N = 221

	N^a	%
Supply concerns	91	41
Insufficient milk supply	88	40
Breast pump not working	4	2
Latch difficulty	60	27
Latch problems	35	16
Pain and discomfort	31	14
“Medical condition” (mother or infant)^b	40	18
Medical problem or procedure for mother	11	5
Prescription drug use	10	5
Baby losing weight/needs to gain weight	8	4
Maternal smoking	8	4
Medical complications or procedure for baby	6	3
Maternal alcohol use	1	0.5
Inconvenience/fatigue	39	18
Formula easier	30	14
Lack of support	8	4
Low self-efficacy	2	1
Embarrassment	1	0.5
Maternal fatigue	1	0.5
Work/school	31	14
Other/personal decision	18	8
Infant reportedly self-weaned	8	4
Infant reportedly lactose intolerant	6	3
Breastfed as long as intended	5	2
Clogged duct/mastitis	1	0.5
No reason reported	10	5

Women could report more than one reason; numbers in bold represent women who reported at least one reason in the category.

As reported by the woman; includes reasons that are not contraindications for breastfeeding.

The reasons for cessation differed by when the mother discontinued breastfeeding (Fig. 2). The majority of mothers who reported latch problems discontinued breastfeeding by 1 month (p < 0.01). Supply concerns were increasingly reported as duration of breastfeeding increased (p < 0.01), with 71% of women who stopped between 3 and 6 months citing this reason. Those reporting cessation for work and/or school were significantly more likely to have discontinued breastfeeding later (by either 3 or 6 months, p < 0.05). Medical reasons were reported only by women who stopped by 1 or 3 months. Discontinuing breastfeeding for reasons related to inconvenience or personal decision did not differ significantly by time of breastfeeding cessation.

FIG. 2.

Reasons for early cessation by duration of breastfeeding, N = 221. *p < 0.05, **p < 0.01.

Discussion

In this WIC-eligible, low-income population, the most common reasons reported for early breastfeeding cessation were concerns about breast milk supply and latch difficulty, followed by self-perceived “medical conditions,” inconvenience or fatigue, and returning to work or school. Some of these reasons differed significantly by timing of breastfeeding cessation. Our findings are consistent with past research among more-advantaged populations; however, given the ongoing disparities in breastfeeding practices, our study further supports the need for appropriately-timed, culturally-sensitive interventions for this at-risk population.

In our study, concern about insufficient breast milk supply (real or perceived) was cited by 41% of women overall and was reported more frequently by women who stopped breastfeeding later. In our study population, only a small minority of women were still fully breastfeeding at 3 months (5 of 32 women); thus we could not determine if this reason was related to the amount of breastfeeding the woman was doing when she stopped. Our finding is consistent with past research among more advantaged populations, which has estimated anywhere from a fifth to over half of women reporting breast milk supply as a reason for breastfeeding cessation, although not every study documented a change in this factor by time of cessation.^7,8,10,11,18 One previous study conducted among WIC recipients in Connecticut found a much smaller proportion of women citing concerns about breast milk supply as a reason for early cessation. However, unlike in our study, data were collected retrospectively, and participants were asked to recall their reason for cessation up to 5 years later.¹⁵ While physicians need to be skilled at recognizing signs of true low milk supply, effective interventions for mothers with Perceived Insufficient Milk supply (PIM) are needed. Evidence-based approaches, however, are lacking.²¹

Other studies have found that PIM and latch difficulty were top reasons for breastfeeding cessation.^11,22 Latch difficulty was the second most common reason reported in our study and was reported most frequently by women who stopped by 1 month. Previous studies have also found this to be an important reason, with similar patterns by timing of cessation. In the study of WIC-eligible women, sore nipples and pain were more often cited by women who discontinued breastfeeding before 6 months than by those who breastfed longer.¹⁵ Two other studies found that approximately half of women who discontinued breastfeeding before 1 week cited baby's difficulty with sucking or latching on, with the proportion of women reporting this reason decreasing as breastfeeding duration increased.^10,13 To address latch difficulty, lactation support should be delivered as part of routine care during the first feeding, throughout the hospital stay, and during newborn outpatient visits or at the dyad's home, with feeding observations and instruction provided until a reproducible, comfortable, and effective latch is achieved. These services could be provided by lactation consultants, trained postpartum staff members, home-visiting nurses, or doulas. For example, services provided in the home and by phone by lactation consultants have been shown to improve breastfeeding rates among low-income minority women.²³ Our findings add to the body of evidence indicating the need for evidence-based educational and other interventions to address PIM and latch issues for all women as they are initiating and continuing breastfeeding.

Self-perceived medical conditions were reported by nearly one-fifth of participants. The proportion of women citing these reasons in other studies has varied from 4% to 28%, depending on what was classified as a medical condition.^{10,11,13,15,24} Early breastfeeding education and support should clarify true contraindications and address misconceptions that women might have regarding other factors, such as use of alcohol and tobacco (which were included in this category).

We also found that nearly one-fifth of participants reported a reason in the category of inconvenience/fatigue. Past studies among more advantaged groups have found this reason for cessation cited by a similar proportion of women.^10,13,24 This issue could be addressed through breastfeeding support that enables women to develop realistic expectations of breastfeeding; hospital policies specified in the Baby Friendly Hospital Initiative (BFHI) that promote skin-to-skin bonding time, rooming-in to learn baby's feeding cues, and opportunities to rest; and increased support throughout the infant's first year, including help from peers, family, and home visits.^25,26 Research shows the effectiveness of support, both lay and professional, across different maternal populations.^9,27 Support provided specifically by health care professionals may be particularly effective for some African American women.²⁸

“Too difficult due to work or school” was not cited by many women in our study; however, this reason was reported most by women who returned to work early. This was the most common reason in the previous study of a WIC-eligible population, but nearly two-thirds of those women were employed compared to less than half of our study population.¹⁵ Still, past research has identified specific barriers to continuing to breastfeed when returning to work for minority and low-income women.²⁹ Consistent with others' recommendations, workplace policies and facilities in support of breastfeeding are needed, especially for women in lower paying jobs where such benefits are often lacking.^30–32 For example, employers and breastfeeding mothers desiring to return to work could be made aware of the Business Case for Breastfeeding resources, specifically the Easy Steps to Supporting Breastfeeding Employees and The Employee's Guide to Breastfeeding and Working.³⁰

Very few women in our study indicated that they breastfed for as long as they had intended. Although the majority of women in the United States do not achieve their intentions for breastfeeding duration, BFHI practices can help, most notably not introducing artificial breast milk substitutes during the hospital stay.³³ Research has documented racial disparities in access to best practices for breastfeeding support, however.³⁴ Our findings point to the persistent need to ensure that low-income women benefit from these practices.

Persistent disparities indicate that national campaigns to increase breastfeeding duration have not been effective to date for all groups of women.³⁵ Although reasons for stopping within at-risk populations may be similar to those for more advantaged groups, interventions to address and overcome these reasons may need to differ. Culturally-sensitive tailored messaging has been shown to be effective for postpartum depression and maternal and child health programs.^36,37 Ensuring that low-income women receive existing services that are proven to be effective should also be a priority; for example, the effectiveness of lactation consultants on breastfeeding rates up to 1 month has been clearly demonstrated.³⁸

This study's strengths include a focus on an understudied at-risk population and the use of prospectively collected longitudinal data. However, our study had some limitations. This is a secondary data analysis that contributes purely descriptive information. The data are self-reported, and both the duration of breastfeeding and the reasons for cessation might be inaccurate due to the perceived social desirability of certain responses. The question about reasons for cessation was open ended, and research assistants were instructed to record the reasons provided by the participant. However, since numerous predetermined answers were included for ease of response coding, they may have read from this list to prompt a woman to provide a reason. This could have influenced respondents to cite certain suggested reasons, rather than provide their own. We did not have data on reasons for supplementation or the introduction of complementary foods while breastfeeding continued. We also did not have data on reasons for stopping for women who breastfed for more than 6 months. Finally, data from those for whom duration of breastfeeding was missing could not be included in our analyses and may have impacted the validity of our findings.

Conclusion

We found that low-income women reported similar reasons for early breastfeeding cessation as have been reported for other populations of women and that these reasons varied by time of breastfeeding cessation. Appropriately-timed effective interventions are needed. Specifically, to prolong breastfeeding among WIC-eligible women, the following targeted interventions could be explored: comprehensive, individually-tailored lactation consultation in-hospital and during the first weeks of breastfeeding to address latch difficulty, and evidence-based educational and other programs to address supply concerns as infants grow. Further research is needed to inform the development of these interventions.

Footnotes

Acknowledgment

This study was supported by a contract with the Virginia Department of Health.

Disclosure Statement

No competing financial interests exist.

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