Associations Between Postpartum Physical Symptoms and Breastfeeding Outcomes Among a Sample of U.S. Women 2–6 Months' Postpartum: A Cross-Sectional Study

Abstract

Objective:

Postpartum urogynecologic and other physical symptoms are common and burdensome. Whether they interfere with breastfeeding has not been thoroughly examined, and this study aims to fill this gap.

Methods:

Mothers with an infant (2 to 6 months) were recruited from the U.S. ResearchMatch volunteer registry and completed the Life After Pregnancy Study, which assessed postpartum physical symptoms and breastfeeding self-efficacy, experiences, and problems. Modified Poisson regression and linear regression with fully conditional specification multiple imputation to handle missing data were used to examine the associations between physical symptoms and breastfeeding-related outcomes.

Results:

Among 222 participants, postpartum physical symptoms were common [e.g., painful sex (42%), urinary incontinence (32%)]. Breastfeeding problems were experienced by most participants [e.g., engorged breasts (72%), sore or cracked nipples (70%), breastfeeding or pumping was painful (67%)]. Although postpartum physical symptoms were not associated with breastfeeding for less than 2 months versus greater than/equal to 2 months (β = 0.94, 95% confidence interval [CI]: 0.78, 1.13), women with excess weight retention and those reporting painful sex or hemorrhoids were more likely to report breastfeeding problems such as sore or cracked nipples or perceived low milk supply. Overall, more physical symptoms were associated with more breastfeeding problems (adj β = 0.39, 95% CI: 0.17, 0.62) and lower breastfeeding self-efficacy (adj β = −2.24, 95% CI: −4.36, −0.13).

Conclusions:

Postpartum physical symptoms were associated with breastfeeding problems and overall poorer breastfeeding self-efficacy, but not with short-term breastfeeding duration. Future studies should explore how addressing physical symptoms among postpartum mothers might improve breastfeeding outcomes.

Introduction

According to the U.S. Centers for Disease Control and Prevention's (CDC) most recent Breastfeeding Report Card, 46.9% of children born in 2017 were exclusively breastfed through the first 3 months, significantly dropping to 25.6% by 6 months.¹ Despite the known benefits, many women and infants are not meeting medical and public health recommendations for breastfeeding duration and exclusivity.² Reasons for why women and infants stop breastfeeding are often tied to emergent physical challenges. For instance, perceived low milk supply is a common reason why women stop breastfeeding.³ Especially early in lactation, pain with breastfeeding and sore and crackled nipples are common reasons for breastfeeding cessation.³ Understanding the complex factors underlying these breastfeeding problems would help inform additional prevention efforts.

Postpartum physical symptoms such as urinary incontinence,^4,5 sexual problems,⁶ and perineal pain⁵ are common and burdensome challenges women face during the postpartum period, simultaneous with establishing breastfeeding. Albers⁷ refers to these physical symptoms as “hidden morbidities” due to the stigma associated with discussing such issues and the focus on the baby's health in place of the new mother's health; thus, such symptoms often escape clinical attention. The Listening to Mother's III (LTMIII) national survey conducted by Childbirth Connection polled 2,400 women who gave birth in United States hospitals in 2011–2012 on their maternity experiences.⁸

Findings showed that women commonly reported the following symptoms as a major or minor new problem: sore nipples/breast tenderness (48%), weight control (45%), painful perineum (among vaginal births, 41%), urinary problems (31%), bowel problems (30%), painful intercourse (27%), and hemorrhoids (23%). These women reported that symptoms persisted 6 months or more at the following rates: hemorrhoids (9%), painful intercourse (10%), sore nipples/breast tenderness (9%), weight control (29%), urinary problems (11%), bowel problems (9%), and painful perineum (vaginal births only, n = 1,656, 7%).⁸ In addition, pelvic organ prolapse affects 3% of U.S. nonpregnant women, and the associated symptoms have significant effects on a new mother's functional and physical wellbeing.⁹

Physical postpartum symptoms could be associated with poorer breastfeeding outcomes. Multiple possible mechanisms may connect these phenomena, including mental and emotional factors and changes in hormonal states during the postpartum period.^10–15 However, scant research has investigated the relationship between a full range of common postpartum physical symptoms and breastfeeding outcomes. While there are a handful of existing studies that previously explored the relationship between postpartum physical symptoms and emotional well-being, these studies did not focus on breastfeeding outcomes, as our study has done.^10,11,16

Understanding relationships of common postpartum physical symptoms and breastfeeding outcomes can help clinicians deliver better postpartum care and potentially help new mothers increase breastfeeding duration, breastfeeding efficacy, and positive breastfeeding experiences. To address these gaps in knowledge, this study evaluated the relationship between physical symptoms and breastfeeding duration and self-efficacy. We hypothesized that the presence of postpartum urogynecologic and other physical symptoms would be associated with poorer breastfeeding outcomes.

Methods

Participants, eligibility, and procedures

In 2016, the U.S. National Institutes of Health-sponsored ResearchMatch website (http://www.researchmatch.org) was used to recruit women aged 18 years and older, whose primary language was English, who had a 2 to 6-month old infant they had tried breastfeeding at least once, and who were registered as research volunteers anywhere in the United States. The email invitation contained a description of the Life After Pregnancy Study, which mentioned many aspects of being a parent of an infant and postpartum health, but did not explicitly discuss breastfeeding or postpartum symptoms. Study staff also posted the invitation on several Facebook communities for women with children and on electronic message boards in a major children's hospital. None of the advertising targeted participants with any specific health, breastfeeding, or postpartum issues.

Women who agreed to participate were sent a link to a secure online survey. Research Electronic Data Capture (REDCap), a secure research survey service with a local secure database, was utilized to administer the survey.¹⁷ Informed consent was obtained electronically on the first page of the survey for all individuals who chose to participate. The second page of the survey confirmed eligibility requirements.

The 45-minute survey assessed postpartum physical symptoms (i.e., weight retention, urinary incontinence, uterine prolapse, pain with sex, and hemorrhoids) breastfeeding problems, duration, self-efficacy, and support; demographics; and other personal characteristics. Upon survey completion, participants were entered into a drawing for the chance to win one of four gift cards as an incentive. This secondary analysis included women who had data for at least one postpartum physical symptom and at least one breastfeeding outcome question. This study was reviewed and approved by the Institutional Review Board at Nationwide Children's Hospital (Columbus, OH).

Study variables and scoring

Demographic variables

All demographic variables were self-reported and included age, race, ethnicity, maternal education, marital status, infant age, employment status, number of children in their household, and annual household income. Participants also answered a question about perceived wealth (“How would you say that your household is able to make ends meet”). The response categories were “with great difficulty,” “with difficulty,” “just get by,” “easily,” and “very easily.” Women also reported the mode of delivery for their most recent pregnancy (vaginal birth or Cesarean section).

Postpartum physical symptoms

Weight retention

To measure weight retention, respondents self-reported their prepregnancy and current postpartum weight. High weight retention was endorsed if retention was greater than 11 lbs (5 kg), a common cutoff for excess weight retention used in past studies.¹⁸

Painful sex

Questions about pain during sexual intercourse were derived from the Female Sexual Function Index and asked about the frequency of pain during vaginal penetration and pain severity.¹⁹ Women were classified as having pain with sex if they reported regular pain with sex, a high severity of pain with sex, or both.

Hemorrhoids

Questions regarding hemorrhoids were modeled after the pain with sex questions; first asking about the presence of hemorrhoid symptoms (e.g., bleeding, pain, swelling, itching, and discomfort in the part of body where bowel movements occur) and then inquiring if the participant had experienced hemorrhoids during the past 4 weeks. Hemorrhoids were endorsed if the participant reported having hemorrhoids in the past 4 weeks, experienced hemorrhoid symptoms in the past 4 weeks, or both.

Uterine prolapse and urinary incontinence

Both the uterine prolapse and urinary incontinence questions came from a validated short-form questionnaire used to identify genital organ prolapse.²⁰ Presence of uterine prolapse was endorsed if the participant reported experiencing a sensation of vaginal pressure or heaviness, a sensation of tissue protrusion, or both.²⁰ For the purposes of our study, women endorsed urinary incontinence if they reported leaking during coughing, sneezing, or heavy lifting.

Breastfeeding

Breastfeeding self-efficacy and experience

Participants completed the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF)²¹ to measure breastfeeding self-efficacy and the Maternal Breastfeeding Evaluation Scale (MBFES)²² to evaluate their overall breastfeeding experience (i.e., maternal enjoyment and role attainment, infant satisfaction and growth, and lifestyle and body image). Women were asked whether they were currently breastfeeding, either at the breast or by pumping, and if so, when they started and stopped. All women completed the BSES-SF and the MBFES; however, the wording was altered to reflect past or present tense depending on whether or not the participant reported currently breastfeeding.

The MBFES and BSES-SF were scored according to published methods. Specifically, the 14 BSES-SF items are presented on a Likert scale ranging one to four (“not at all confident” to “always confident”). Items were summed to form a breastfeeding self-efficacy score with higher scores indicating greater self-efficacy and lower scores indicating reduced self-efficacy. The 30-item MBFES was scored with a four-point scale ranging from “strongly disagree” to “strongly agree.” Higher scores indicated a more positive breastfeeding experience.

Breastfeeding problems

To assess breastfeeding problems, women endorsed an abridged list of breastfeeding problems taken from Binns and Scott.²³ Breastfeeding problems included sore or cracked nipples, painful breastfeeding or pumping, mastitis, engorged breasts, inverted nipples, baby got too much milk or milk came out too fast, milk did not “let down” well, baby had trouble sucking, and mother did not produce enough milk.²³ We included breastfeeding problems specific to lactation and feeding at the breast because they were more relevant to the focus of this study and excluded those less proximally related (e.g., baby refused to breastfeed or was unsettled) that were in Binns and Scott's original instrument.

All breastfeeding problems were scored as either (1) yes or (0) no. A total count of breastfeeding problems were tallied and categorized for analysis as one, two, greater than/equal to three problems. Overall breastfeeding duration, direct breastfeeding duration, and pump breastfeeding duration were categorized as either greater than/equal to 2 months or less than 2 months.

Missing data and statistical analysis

To address missing data (≤7% of respondents were missing responses to one or more demographic questions, 12% were missing MBFES scores, 13% were missing BSES scores, and 32% were missing pain with sex data), multiple imputation by fully conditional specification (FCS) was performed by SAS PROC MI to impute missing values for both continuous and categorical variables with arbitrary missing patterns. This approach allowed convergence on a prediction even when its exact distribution was unknown.²⁴ The FCS regression, logistic regression, and discriminant function were used to impute continuous, binary, and nominal variables separately. Twenty-five imputations (SAS default) were used to achieve nominal coverage for MI confidence intervals (CIs) in the substitution of missing data with imputed estimates.²⁵

Descriptive statistics and frequencies were calculated for all postpartum physical symptoms and breastfeeding outcomes. For binary outcomes, modified Poisson regression with robust error variance was used to estimate the relative risk (RR) for each physical symptom and each binary breastfeeding outcome. If a demographic variable was associated (p < 0.05) with any binary breastfeeding problem and at least one physical symptom, then all the regression models were adjusted accordingly. Linear regression was used to estimate the associations between physical symptoms and continuous breastfeeding outcomes. All data cleaning, imputation, and analysis were performed in SAS version 9.4 (SAS Institute, Inc., Cary, NC).

Results

Sociodemographic and other relevant characteristics for the 222 eligible survey respondents are presented in Table 1. More than half of the sample was older than 30 years. The majority of respondents were white/Caucasian (78%), non-Hispanic (90%), had a bachelor's or postgraduate degree (70%), and were married or living with their partner (91%). Half of the sample reported that they make ends meet “with great difficulty,” “with difficulty” or “just get by” (50%) and were employed full/part-time or were students (61%). Participants had one or two children in total (49% and 28%, respectively). Most women had a vaginal delivery for their youngest child (75%). The majority had household incomes ≥$55,000 (58%).

Table 1.

Maternal Characteristics, Life After Pregnancy Study (2016) (n = 222)

Demographics	No. of respondents	%
Age category
18–26	41	18
27–30	61	28
31–35	61	28
35+	59	26
Race
White/Caucasian	172	78
Black/African American	17	8
Other	18	8
Missing	15	56
Ethnicity
Hispanic	11	5
Non-Hispanic	199	90
Missing	12	5
Education
Less than high school	6	3
High school diploma/GED	11	5
Associate degree or some college	49	22
Bachelor's degree	67	30
Postgraduate degree	89	40
Marital status
Married or living with partner	201	91
Single	14	6
Separated or not living with partner	7	3
Infant age (from most recent pregnancy) (months)
2	49	22
3	52	23
4	43	20
5	36	16
6	42	19
Perceived wealth
With great difficulty	10	5
With difficulty	18	8
Just get by	83	38
Easily	70	32
Very easily	28	13
Missing	13	6
Employment status
Employed full- or part-time/Student	135	61
Stay at home/Disabled/Temporary maternity leave	87	39
Number of children
1	109	49
2	63	28
3	26	12
4	8	4
5	2	1
8	1	0
Missing	13	6
Type of delivery
Vaginal delivery	166	75
C-section	55	25
Missing	1	0
Annual household income
Less than $15,000	8	4
$15,000–$35,000	22	10
$35,000–$55,000	26	12
$55,000–$75,000	38	17
$75,000–$95,000	30	13
$95,000+	85	38
Missing	13	6

GED, General Equivalency Diploma.

Postpartum physical symptoms were common among the respondents, including pain with sex (42% overall, 50% among those at 2 months postpartum, 16% at 6 months postpartum, χ² = 15.7, p = 0.0035), weight retention >5 kg (39%), urinary incontinence (32%), hemorrhoids (29%), and uterine prolapse (10%). Breastfeeding problems were also common, including: engorged breasts (72%), sore or cracked nipples (70%), breastfeeding or pumping was painful (67%), baby got too much milk or milk came out too fast (44%), baby had trouble sucking (33%), mother did not produce enough milk (32%), milk did not “let down” well (23%), mastitis (14%), and inverted nipples (11%).

Associations between postpartum physical symptoms and breastfeeding duration and breastfeeding problems are depicted in Table 2. Overall, uterine prolapse was not associated with any breastfeeding problems, and none of the physical symptoms was associated with breastfeeding duration. However, other physical symptoms were found to be associated with multiple breastfeeding problems. Participants who reported excess weight retention were less likely to report that their baby received too much milk (adj RR = 0.70, 95% CI: 0.51, 0.98). Women who reported experiencing hemorrhoids were more than 1.5 times more likely to not produce enough milk (adj RR = 1.67, 95% CI: 1.18, 2.36).

Table 2.

Associations Between Postpartum Physical Symptoms and Breastfeeding Duration and Problems

	Breastfeeding duration	Direct breastfeeding duration	Pump breastfeeding duration	Sore or cracked nipples	Breastfeeding pain	Mastitis	Engorged breasts	Inverted nipples	Baby got too much milk	Milk did not “let down”	Baby had trouble sucking	Did not produce enough milk
Weight retention RR (95% CI)
Unadjusted	0.90 (0.78, 1.02)	0.92 (0.79, 1.07)	0.79 (0.65, 0.96)^a	1.04 (0.88, 1.23)	1.03 (0.86, 1.23)	1.16 (0.61, 2.20)	1.00 (0.85, 1.18)	1.20 (0.57, 2.54)	0.68 (0.49, 0.96)^a	1.05 (0.64, 1.71)	1.44 (1.00, 2.07)^a	1.69 (1.18, 2.43)^a
Adjusted	0.94 (0.82, 1.07)	0.96 (0.82, 1.13)	0.84 (0.69, 1.01)	1.06 (0.90, 1.26)	1.00 (0.84, 1.20)	1.06 (0.56, 2.00)	1.01 (0.86, 1.19)	1.08 (0.52, 2.33)	0.70 (0.51, 0.98)^a	1.04 (0.64, 1.70)	1.48 (1.02, 2.15)^a	1.62 (1.14, 2.31)
Painful sexRR (95% CI)
Unadjusted	1.09 (0.95, 1.25)	1.07 (0.90, 1.26)	1.03 (0.85, 1.25)	1.34 (1.13, 1.59)^a	1.24 (1.03, 1.49)^a	1.36 (0.68, 2.72)	1.20 (1.01, 1.41)^a	2.28 (0.97, 5.34)	1.59 (1.16, 2.18)^a	1.19 (0.70, 2.01)	1.26 (0.86, 1.84)	1.06 (0.71, 1.57)
Adjusted	1.07 (0.94, 1.22)	1.04 (0.88, 1.22)	1.05 (0.87, 1.26)	1.36 (1.14, 1.63)^a	1.22 (1.01, 1.47)^a	1.50 (0.76, 2.98)	1.16 (0.97, 1.38)	2.25 (0.89, 5.69)	1.51 (1.08, 2.10)^a	1.23 (0.73, 2.05)	1.26 (0.85, 1.87)	1.12 (0.75, 1.66)
HemorrhoidsRR (95% CI)
Unadjusted	0.93 (0.80, 1.08)	0.93 (0.79, 1.11)	0.93 (0.75, 1.15)	1.01 (0.84, 1.20)	0.90 (0.73, 1.11)	1.34 (0.70, 2.59)	1.13 (0.97, 1.32)	0.98 (0.44, 2.19)	1.32 (0.98, 1.77)	0.90 (0.52, 1.55)	0.95 (0.63, 1.44)	1.60 (1.12, 2.30)^a
Adjusted	0.93 (0.81, 1.07)	0.93 (0.79, 1.09)	0.93 (0.77, 1.13)	1.36 (1.14, 1.63)^a	0.90 (0.73, 1.11)	1.46 (0.76, 2.80)	1.11 (0.95, 1.29)	1.05 (0.47, 2.33)	1.29 (0.97, 1.72)	0.98 (0.57, 1.70)	0.96 (0.64, 1.45)	1.67 (1.18, 2.36)^a
Uterine prolapseRR (95% CI)
Unadjusted	0.95 (0.76, 1.19)	0.95 (0.73, 1.23)	0.77 (0.53, 1.12)	0.91 (0.67, 1.23)	1.20 (0.97, 1.49)	1.74 (0.79, 3.84)	0.97 (0.75, 1.26)	1.20 (0.38, 3.82)	1.28 (0.86, 1.91)	1.44 (0.75, 2.78)	1.30 (0.78, 2.17)	1.12 (0.63, 1.98)
Adjusted	0.95 (0.78, 1.17)	0.94 (0.73, 1.20)	0.88 (0.63, 1.22)	0.90 (0.66, 1.23)	1.15 (0.90, 1.46)	1.55 (0.65, 3.69)	0.94 (0.72, 1.24)	0.89 (0.30, 2.66)	1.25 (0.81, 1.90)	1.59 (0.79, 3.18)	1.37 (0.80, 2.34)	1.31 (0.71, 2.42)
Urinary incontinenceRR (95% CI)
Unadjusted	0.90 (0.77, 1.05)	0.90 (0.76, 1.08)	0.87 (0.70, 1.07)	1.01 (0.85, 1.20)	1.09 (0.91, 1.30)	0.73 (0.35, 1.50)	1.04 (0.89, 1.22)	1.15 (0.53, 2.52)	0.76 (0.54, 1.07)	1.58 (0.98, 2.55)	1.06 (0.72, 1.55)	1.28 (0.88, 1.85)
Adjusted	0.90 (0.78, 1.04)	0.90 (0.77, 1.06)	0.92 (0.75, 1.12)	1.02 (0.86, 1.20)	1.07 (0.90, 1.28)	0.72 (0.36, 1.46)	1.03 (0.88, 1.21)	1.16 (0.55, 2.43)	0.76 (0.55, 1.06)	1.65 (1.05, 2.62)^a	1.07 (0.73, 1.57)	1.28 (0.89, 1.85)
Total symptomsRR (95% CI)
Unadjusted	0.91 (0.75, 1.10)	0.92 (0.74, 1.14)	0.78 (0.57, 1.05)	1.15 (0.90, 1.46)	1.11 (0.82, 1.49)	1.49 (0.53, 4.17)	1.17 (0.90, 1.51)	1.52 (0.47, 4.90)	1.22 (0.73, 2.05)	1.44 (0.69, 3.00)	1.36 (0.78, 2.36)	2.07 (1.11, 3.87)^a
Adjusted	0.94 (0.78, 1.13)	0.93 (0.75, 1.16)	0.87 (0.65, 1.18)	1.17 (0.91, 1.50)	1.05 (0.77, 1.42)	1.49 (0.53, 4.21)	1.13 (0.86, 1.48)	1.25 (0.34, 4.57)	1.19 (0.72, 1.99)	1.62 (0.79, 3.32)	1.41 (0.80, 2.49)	2.25 (1.22, 4.15)^a

Adjusted models for breastfeeding duration included terms for perceived wealth, employment status, education, and number of children.

Adjusted models for breastfeeding problems included terms for perceived wealth, race, employment status, infant age, and type of delivery.

CIs that exclude the null indicate statistical significance based on p < 0.05.

CI, confidence interval; RR, relative risk.

Women who reported experiencing moderate/frequent pain with sex were 1.51 times more likely to report that the baby got too much milk or the milk came out too fast (adj RR = 1.51, 95% CI: 1.08, 2.10), 1.36 times more likely to report sore or cracked nipples (adj RR = 1.36, 95% CI: 1.14, 1.63), and 1.22 times more likely to report painful breastfeeding or pumping (adj RR = 1.22, 95% CI: 1.01, 1.47) compared to women who reported low/infrequent/no pain during sex. Women who experienced urinary incontinence were much more likely to experience milk not “letting down” well (adj RR = 1.65, 95% CI: 1.05, 2.62). Total symptoms were associated with not producing enough milk after adjusting for perceived wealth, race, employment status, infant age, and type of delivery (adj RR = 2.25, 95% CI: 1.22, 4.15).

Table 3 shows the associations between postpartum physical symptoms and the sum of breastfeeding problems, the overall breastfeeding experience, and breastfeeding self-efficacy. Women who reported experiencing moderate/frequent pain with sex reported on average one or more breastfeeding problems (adj β = 1.00, 95% CI: 0.50, 1.51) when compared to women who reported not experiencing pain with sex. Although all effect estimates were less than zero, no statistically significant associations between physical symptoms and the reported overall breastfeeding experience were observed.

Table 3.

Associations Between Postpartum Physical Symptoms and Breastfeeding Problems, Experiences, and Self-Efficacy

	Total breastfeeding problems	MBFES	BSES
Weight retentionβ (95% CI)
Unadjusted	0.27 (−0.20, 0.75)	−1.76 (−8.43, 4.92)	−1.98 (−6.53, 2.58)
Adjusted	0.28 (−0.20, 0.76)	−1.17 (−7.75, 5.40)	−1.45 (−5.87, 2.97)
Painful sexβ (95% CI)
Unadjusted	1.02 (0.53, 1.51)^a	−2.40 (−9.59, 4.78)	−2.68 (−7.54, 2.18)
Adjusted	1.00 (0.50, 1.51)^a	−2.83 (−9.59, 4.54)	−2.79 (−7.54, 1.96)
Hemorrhoidsβ (95% CI)
Unadjusted	0.35 (−0.15, 0.85)	−3.17 (−10.27, 3.93)	−2.87 (−7.65, 1.91)
Adjusted	0.35 (−0.15, 0.85)	−3.06 (−10.01, 3.89)	−2.77 (−7.38, 1.84)
Uterine prolapseβ (95% CI)
Unadjusted	0.57 (−0.21, 1.34)	−3.15 (−14.13, 7.83)	−1.97 (−9.54, 5.61)
Adjusted	0.57 (−0.21, 1.34)	−2.80 (−13.58, 7.99)	−1.65 (−8.99, 5.70)
Urinary incontinenceβ (95% CI)
Unadjusted	0.17 (−0.32, 0.66)	−7.03 (−13.88, −0.0.19)^a	−4.99 (−9.70, −0.27)^a
Adjusted	0.18 (−0.31, 0.66)	−6.70 (−13.40, 0.01)	−4.68 (−9.24, −0.13)^a
Total symptomsβ (95% CI)
Unadjusted	0.39 (0.17, 0.61)^a	−2.95 (−6.17, 0.27)	−2.51 (−4.69, −0.33)^a
Adjusted	0.39 (0.17, 0.62)^a	−2.66 (−5.81, 0.49)	−2.24 (−4.36, −0.13)^a

β = Effect estimate from linear regression model.

Adjusted models for breastfeeding problems included terms for perceived wealth, race, ethnicity, employment status, infant age, and type of delivery.

Adjusted models for breastfeeding duration included terms for perceived wealth, education, and the number of children.

CIs that exclude the null indicate statistical significance based on p < 0.05.

BSES-SF, Breastfeeding Self-Efficacy Scale-Short Form; CI, confidence interval; MBFES, Maternal Breastfeeding Evaluation Scale.

Urinary incontinence was associated with lower breastfeeding self-efficacy (adj β = −4.68, 95% CI: −9.24, −0.13). Exposure to more postpartum physical symptoms was associated with slightly more breastfeeding problems (adj β = 0.39, 95% CI: 0.17, 0.62) and slightly lower breastfeeding self-efficacy (BFSES-SF adj β = −2.24, 95% CI: −4.36, −0.13).

Discussion

Although breastfeeding has significant health benefits for mothers and infants,² postpartum physical symptoms may pose common and burdensome barriers to breastfeeding if they compound physical discomfort or increase the challenges and stress of caring for oneself and one's infant. Current literature has not thoroughly examined how physical symptoms affect breastfeeding outcomes, such as breastfeeding efficacy and overall breastfeeding experience. This cross-sectional study examined the association between five postpartum physical symptoms (including a composite score), breastfeeding duration and experiences, and 12 breastfeeding problems among a sample of U.S. mothers.

Results offer insight into physical symptoms experienced by women during the first 6 months postpartum. Women reported experiencing postpartum physical symptoms frequently, which is consistent with previous literature.^8,26 Over 90% of women in a prior cross-sectional study reported at least one health problem during the 2 months after birth, and the majority (62.5%) reported two to five symptoms.²⁶ However, the rates of experiencing these symptoms vary across studies.

A prospective cohort study measuring relationships between maternal physical health, breastfeeding problems, and maternal mood in the early postpartum period (weeks 1 through 8) of first-time mothers found similar rates of physical postpartum symptoms as our study.¹⁶ Nipple pain for week 1 was reported at a comparable rate to our measure of sore or cracked nipples (77% vs. 70%), although our sample was surveyed later in the postpartum period.

Concerns about milk supply were greater among our study participants (32%) relative to Cooklin et al.'s study (at week 1, 21%). Our study reported a greater percentage of women with mastitis (14%) when compared to the other study's highest percentage at week 8 (8%). Differences in these rates may be attributed to the timing of each study's assessments; our study asked participants to recall physical symptoms at the time of the survey (which occurred between 2 and 6 months postpartum), whereas Cooklin et al.'s study followed the participants prospectively from the first week until 2 months. While our study is potentially subject to greater recall bias due to its design, it is possible that our study was able to capture physical symptoms that may emerge past the 2-month postpartum period.

Pain with sex was associated with multiple breastfeeding problems (i.e., sore or cracked nipples and painful breastfeeding or pumping) in unadjusted and adjusted models and was associated with having had more breastfeeding problems (one more problem, on average) when compared to women reporting no pain with sex. These relationships may be further clarified through a biological lens, as lactation is known to decrease vaginal lubrication during sexual arousal.²⁷ Further, during intercourse, touching or stimulating breasts or nipples may not induce typical sexual desire, despite heightened nipple sensitivity during breastfeeding.²⁷

Coinciding with this study's findings, past research has found that obese women have a less adequate milk supply when compared with normal weight women.²⁸ In our study, weight retention was associated with being more likely to report producing too little milk. Mok et al.²⁹ reported that fewer obese women (prepregnancy body mass index [BMI] >30 kg/m²) described their milk supply as adequate when compared to reference weight women (18.5≤ prepregnancy BMI <25 kg/m²) at two separate time points, 1 month (60% vs. 94%) and 3 months (55% vs. 92%) postpartum. Another study found that women with a prepregnancy BMI >30 kg/m² more frequently provide insufficient milk supply as a reason to stop breastfeeding than women without obesity (24% vs. 13%, p = 0.041).³⁰

The results of this study address the gap between breastfeeding and postpartum physical symptoms, which has not been extensively investigated in the literature. This study utilized a nationwide sample which was not selected by potential physical symptoms or breastfeeding problems. Another strength of the Life After Pregnancy Study is that the questionnaire utilized several previously validated measures and items (i.e., measures for vaginal heaviness, pain with sex, breastfeeding). As to be expected with lengthy surveys, we encountered missing values. However, to maximize available data, imputation was used for participants with arbitrary missing patterns for continuous and categorical variables.

Limitations of the current study include the cross-sectional design. Future longitudinal research could assess how new mothers experience postpartum physical symptoms and correlate those with breastfeeding outcomes across time to establish temporality. Also, the sample had higher socioeconomic status than average, so the results may not be generalizable to all U.S. postpartum women. While the results might not be generalizable to all postpartum women, participants from all over the United States responded to the study. Women who breastfeed tend to be white, leaner, married, and of higher socioeconomic status than those who do not; however, we controlled for sociodemographic factors to reduce confounding.³¹

ResearchMatch did not allow the study invitation to be exclusively sent to those fitting all of the study's eligibility criteria (e.g., could not limit the invitation to women with infants); thereby, an assessment of the proportion of nonresponders who were ineligible, did not receive the email invitation, ignored the invitation, or decided not to participate was not possible. Finally, while validated scales were used whenever possible, all physical symptoms were self-reported and not based on clinical diagnoses.^20,32 Past research demonstrates that self-reported physical symptoms among adult women are shown to be reliable.^33–35

Understanding the relationship between postpartum physical symptoms and poorer breastfeeding outcomes has direct implications for postpartum clinical care. In particular, questions regarding postpartum physical symptoms should be asked in the early postpartum period so that women who are at risk for early termination of breastfeeding can be treated for these issues in the hopes of promoting breastfeeding. Future studies should explore how addressing physical symptoms in a clinical setting among postpartum women can improve breastfeeding outcomes.

Footnotes

Acknowledgment

The authors thank Jennifer Litteral and Kyle Schofield.

Authors' Contributions

All authors contributed to the drafting or critical review and revision of the article.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was supported by the NIH/National Center for Advancing Translational Sciences (UL1TR001070) and internal funds of the Research Institute at Nationwide Children's Hospital.

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