Interruption of Breastfeeding,Relactation,Relactation Awareness,and Related Factors: A Cross-Sectional Study

Abstract

Objective:

In this study, it was aimed to investigate interruptions in breastfeeding, relactation, and relactation awareness-related factors.

Methods and Study Design:

This cross-sectional online survey was conducted in 2020 with women who had children between 6 and 36 months of age. Women >18 years of age and willing to consent to study participation (n = 392) were recruited throughout Turkey. Data were collected online through Google forms using the Personal Information Form, and Relactation Awareness Index (RAI). The dependent variables of the study were continuing breastfeeding, relactation, and breastfeeding awareness. Logistic and linear regression analyses were performed.

Results:

Of the participants, 53.1% exclusively breastfed their infants in the first 6 months of life, and 34.9% interrupted breastfeeding. Of those who interrupted breastfeeding, 39.4% achieved success in relactation. The rate of failed relactation was 9.16 times higher in primary school graduates and 2.37 times higher in those who perceived their milk supply as insufficient. The rate was also high in those whose RAI score was low (p < 0.05). Factors such as perception that milk supply is inadequate, lack of education and interruption of breastfeeding are associated with awareness of relactation. According to the linear regression analysis, breastfeeding within the first hour of delivery, length of time planned for breastfeeding, exclusive breastfeeding for the first 6 months of life affected relactation awareness positively, whereas the perceived milk supply affected it negatively (p < 0.05).

Conclusion:

Awareness of relactation should be raised and trainings should be organized to increase the success of relactation. Especially mothers who have interrupted breastfeeding need supportive and professional interventions to continue breastfeeding.

Introduction

The most suitable, healthiest, and safest food for the healthy growth and development of the newborn is breast milk.¹ The World Health Organization recommends that newborns should be exclusively breastfed for the first 6 months of their life, and that after the first 6 months, breastfeeding should be continued until 2 years of age or beyond together with complementary foods.² As reported worldwide, the prevalence of exclusive breastfeeding in the first 6 months ranges between 14.4% and 46%.^3–5 According to Turkey Demographic and Health Survey (TDHS), the prevalence of exclusive breastfeeding during the first 6 months of life was 41%, and the prevalence of continuing breastfeeding within the first 2 years of life was 34%.⁴ Although breast milk is the healthiest and safest nutrient for the health of the newborn, breastfeeding may be interrupted due to separation of the infant from the mother, mothers having to take medication incompatible with breastfeeding, perceived insufficient milk supply, breast problems, untimely weaning, and intense stress and depression experienced after birth.^6–8

According to the data in the literature, the success rate of relactation varies between 6% and 83.4%.^6,7,9,10 Synthesis and secretion of breast milk depend on the release of progesterone and oxytocin hormones, and autocrine control. Oxytocin and prolactin secretions occur through nipple stimulation and breast manipulation (such as infant's sucking on the breast, nipple massage). The most effective way to stimulate the secretion of these hormones is the infant's sucking. Autocrine control of the breast is the state of preventing milk production by the “feedback inhibitor of lactation” protein secreted when milk is not emptied from the breast. With the regular emptying of the breasts by the infant, or manual milking or pumping, the amount of milk inhibiting hormone decreases and milk secretion increases and the milk supply is established. Initiating and maintaining milk production and secretion by increasing the secretion of prolactin and oxytocin hormones through stimulating the breasts with some methods are the basic processes for relactation.¹¹

Among the main methods used in relactation are the stimulation of the nipple during the relactation process, breastfeeding supplement drop and drip technique, skin-to-skin contact, and use of galactagogues.^11–14 The number of studies conducted on relactation is limited in the literature. In the existing studies, focus is on the techniques used and success factors, and the prevalence, awareness, and determinants of the relactation have been addressed to a limited extent.^1,11,14

In a study conducted in Colombia, the main reason for discontinuing breastfeeding was the hospitalization of children, followed by low birth weight, no previous breastfeeding experience, and incorrect breastfeeding position of the mother. In the same study, it was found that among the success of relaxation were the support provided by health professionals, the high motivation of the mother, the short duration of breastfeeding, and the infant being younger than 1 month old.⁶ In a study conducted in India, it was determined that the young age of the baby and the mother affected relactation positively, and bottle feeding reduced the success of relactation.⁷ In a study conducted in Spain, women who had adopted children thought that professional support was not provided adequately during the relactation process, and they received emotional support from their partners. However, the support they received from their friends was much less than what was received by women who breastfed their own baby.¹

In this study, it was aimed to investigate factors associated with interruptions in breastfeeding (total absence of milk flow or secretion of only a few drops of milk following regular suckling for a period of at least 7 days), relactation awareness/knowledge level about relactation (relactation is the process by which a woman who gave birth but did not initially breastfeed or stopped after breastfeeding for a few days to a few weeks, is stimulated to lactate), factors associated with relactation awareness, attempts, and success.

Materials and Methods

Research design

We used a descriptive cross-sectional survey by electronically distributing a questionnaire on social media platforms.

Setting and relevant context

Breastfeeding is encouraged and supported in both the public and private systems. In both systems, pregnant women receive breastfeeding training and support during pregnancy, immediately after childbirth, and during postpartum visits.¹⁵ Outside the health system, women can also receive breastfeeding support privately from lactation support providers.

Sample

The study population consisted of women who had 6- to 36-month-old children, volunteering to participate in the research, and who followed mother and breastfeeding groups on social media platforms (WhatsApp, Instagram, Facebook, and Twitter). The sample size of the study was calculated in the Epi Info 7.0 program. A sample of n = 384 is needed to estimate the prevalence of relactation with a 95% confidence interval and 5% margin of error, assuming that the proportion of relactation is 50%. The study data were collected online from the mothers who agreed to participate in the study and who took part in breastfeeding groups on the social media. A total of 392 participants were recruited using a convenience random sampling method.

Measurement

The dependent variables of the study were interruption of breastfeeding, relactation, and relactation awareness. The independent variables of the study were sociodemographic characteristics such as the mother's age, educational status, employment status, the number of children, and the age of the infant. The other independent variables were related to breastfeeding such as the time of the first breastfeeding, feeding style of the infant, breastfeeding frequency, length of time planned for breastfeeding, perception of milk supply sufficiency, the method frequently used to increase milk production, and exclusive breastfeeding in the first 6 months. Dependent variables were captured by asking questions on the interruption of breastfeeding, and relactation if breastfeeding is interrupted, using the relactation awareness form. Independent variables were evaluated using the Personal Information Form.

The Personal Information Form developed based on the pertinent literature consists of 22 items questioning the participants' sociodemographic characteristics, such as age, educational status, employment status, types of work schedules, number of pregnancies, number of children, age of the infant, and breastfeeding characteristics such as the time of the first breastfeeding, length of time planned for breastfeeding (months), perceived milk supply using a method to increase milk production, and the method used to increase milk production.^1,7

In addition, besides these variables, the mothers were asked categorical questions, such as what the first breastfeeding time was, how the baby was breastfed, how often the baby was breastfed, how long it was planned to breastfeed the baby, whether the mother perceived her milk supply was sufficient or not, what she usually did to increase milk production, and whether the mother exclusively breastfed the baby for the first 6 months.

In the literature, there is no scale on Relactation Awareness whose validity and reliability study were performed for the Turkish society. Therefore, we, the researchers, developed the 20-item “Relactation Awareness Index (RAI)” based on the relevant literature.^1,6,16,17 The 20 items in the RAI question the following: the meaning of relactation, relactation techniques, the effect of the interruption to breastfeeding during the relactation process, interruption of breastfeeding and relactation, effects of the age of the mother, the age of the adopted or own infant, the mother's diet, the mother's motivation, skin-to-skin contact and stress on the relactation process, breastfeeding of the adopted infants, and the institution where relactation is performed (Table 1). A pilot study was then carried out with 20 people who were not included in the sample. Based on their feedback, necessary revisions were made on the questionnaire, and then, the data were collected.

Table 1.

Relactation Awareness Index

	Statements	Correct (1)	Wrong (0)
1	Have you heard of the word “Relactation”?	Yes	No
2	Do you think it is possible to interrupt breastfeeding (for 1–2 weeks) and continue it again?	Yes	No
3	Do you think that mothers who have been separated from their infants for a long time and whose milk is weaned can provide sufficient milk production again?	Yes	No
4	Can a woman produce enough milk to breastfeed her adopted infant?	Yes	No
5	Does the age of the woman who wants to breastfeed her adopted infant affect the milk production?	Yes	No
6	Does increasing skin-to-skin contact (kangaroo care) affect relaxation?	Yes	No
7	For the mother to produce breast milk, do you think the mother's having balanced diet and adequate fluid intake would be sufficient?	Yes	No
8	Does the stress experienced by the mother affect the production of breast milk?	No	Yes
9	Is the use of galactagogue the most successful relactation technique?	Yes	No
10	Does the age of the adopted infant affect its lactation and milk production?	Yes	No
11	Should a health institution be consulted when there is a problem with breastfeeding (low or no milk supply, etc.)?	Yes	No
12	Have you ever stopped breastfeeding and tried to breastfeed again?	Yes	No
13	Does the mother's motivation and willingness affect relactation?	Yes	No
14	Are you familiar with techniques such as the breastfeeding support system?	Yes	No
15	Does the use of galactagogue affect relactation?	Yes	No
16	Should the breast be stimulated, and the infant be frequently breastfed for relactation to be successful?	Yes	No
17	If lactation is tried again after giving up breastfeeding completely, is milk produced in the desired amount immediately?	Yes	No
18	It is easier to breastfeed an infant who has just stopped breastfeeding than an infant who has stopped breastfeeding a long time ago.	Yes	No
19	Does pacifier use affect the relactation process?	Yes	No
20	Does bottle use affect the relactation process?	Yes	No

The items are scored by giving 1 point to correct responses and 0 points to wrong responses. The minimum and maximum possible scores that can be obtained from the index are 0 and 20, respectively.^1,7,12,13,18 The reliability test showed that the Cronbach's α value for the “Relactation Awareness Index” was 0.84, which was greater than 0.70 and indicated that the survey results were highly reliable.¹⁹

In the study, breastfeeding interruption, relactation, and relactation failure were evaluated as stated below:

Interruptions in breastfeeding/lactation failure; “Total absence of milk flow or secretion of only a few drops of milk following regular suckling for a period of at least 7 days.”²⁰ Relactation is the process by which a woman who gave birth but did not initially breastfeed or experienced absence of regular suckling, is stimulated to lactate.²¹ On the other hand, absence of milk secretion even after 2 weeks of continuous effort, was regarded as relactation failure.⁷

Interrupted breastfeeding

To stop breastfeeding for a period of time and then to start it again (1 = I stopped breastfeeding, 0 = I continued breastfeeding).

Stopped breastfeeding

In the questionnaire, the mothers who stopped breastfeeding at any time of the baby's life were asked whether they stopped breastfeeding permanently (1 = I stopped breastfeeding permanently, 0 = I tried to start breastfeeding again).

Relactation

Relactation is the process of rebuilding a milk supply and resuming breastfeeding at some time after breastfeeding has been stopped. The mothers who tried to start breastfeeding again were asked whether they could start breastfeeding again within 2 weeks after they stopped breastfeeding at any time in the child's life (1 = I started breastfeeding again, 2 = I could not start breastfeeding again).

Data collection

The participants were enrolled between August 2020 and November 2020. The data were collected from mothers 18 years of age and over who had 6- to 36-month-old children and volunteered to participate in the study by using the online questionnaire prepared on Google form. The link included an introductory letter describing the purpose of the survey, inclusion criteria for the participants, instructions for filling in the questionnaire, and information on how to contact the researchers. All the participants completed the questionnaire after providing their consent. No names, Internet Protocol addresses, or other identifying information was collected; thus, the participants' responses were anonymous, and no personal information was attached to the data. All the participants gave their informed consent by giving the “Yes” answer to the question “Are you willing to participate in the study?.” All the data were handled and stored anonymously.

Data analysis

Data were analyzed using the SPSS 25.0 for Windows.²² Continuous variables were reported as arithmetic mean (M) and standard deviation (SD) and categorical variables as counts and percentages. In the analysis, whether the continuous data met the normality assumption was assessed according to the Shapiro–Wilk test and based on the Kurtosis and Skewness coefficients ranging between +1.5 and 1.5. Since the assumption of normality was provided, the Student's t test was used to compare the relationship between independent variables and RAI if there were two groups, and the one-way analysis of variance (posthoc Tukey Honestly Significant Difference) test was used to compare if there were more than two groups.

Enter multiple linear regression was used to identify the influencing factors, and the significant variables on univariate analysis were included in the multiple linear regression. The p-Values <0.05 were considered statistically significant. A univariate analysis using independent samples chi-square test was conducted to determine the associations between the demographic data, and relactation and interruption of breastfeeding. Backward multiple logistic regression was used to identify the influencing factors, and the significant variables on univariate analysis were included in the multiple linear regression. The p-Values <0.05 were considered statistically significant. Multicollinearity among independently associated variables was checked by the multicollinearity diagnostic test VIF in linear regression and none was collinear.

Ethics approval

Before the study was conducted, ethics approval was obtained from the Balikesir University Clinical Research Ethics Committee (Decision Date: August 10, 2020, decision number: 2020/139).

Results

Sample characteristics

The mean age of the participants was 30.92 (4.66) years. The mean age of the infants of the mothers who stopped breastfeeding was 17.11 (4.10) months. Of the mothers, 66.1% were in the 27–35 age group, 63.8% were university graduates, 56.6% were unemployed, 54.8% had one child, 55.6% had children ≥12 months of age, 80.4% breastfed their child within the first hour after birth, 78.1% planned to breastfeed their child for 12–23 months, 70.7% perceived their milk supply as sufficient, 53.1% exclusively breastfed their children in the first 6 months of life, 20.2% did not exclusively breastfeed in the first 6 months because they thought that their milk supply was not enough, 34.9% interrupted breastfeeding, and 39.4% resumed breastfeeding. Of the mothers, 90.3% took a galactagogue. The most common galactagogue taken by 67.2% of women was herbal tea. The mean duration of interrupting breastfeeding was 9.35 (7.85) days (Table 2).

Table 2.

Sociodemographic and Breastfeeding Characteristics of the Participants (N = 392)

Variable	n (%)
Age (year)
18–26 years	68 (17.3)
27–35 years	259 (66.1)
≥36 years	65 (16.6)
Educational status
Primary school	47 (12.0)
High school	95 (24.2)
University	250 (63.8)
Employment status
Unemployed	222 (56.6)
Employed	170 (43.4
The number of children
1	215 (54.8)
2	143 (36.5)
≥3	34 (8.7)
The age of the infant (months)
0–11	174 (44.4)
≥12	218 (55.6)
Time of the first breastfeeding
Within the first hour of delivery	315 (80.4)
After the first hour of delivery	77 (19.6)
Length of time planned for breastfeeding (months)
0–11	34 (8.7)
12–23	306 (78.1)
≥24	52 (13.3)
Perceived milk supply
Sufficient	277 (70.7)
Insufficient	115 (29.3)
Using a method to increase milk production (took a galactagogue)
Yes	354 (90.3)
No	38 (9.7)
The method used to increase milk production (took a galactagogue)
Herbal tea	238 (67.2)
Malt drinks	50 (14.1)
Drinking plenty of water	31 (7.9)
Other (Tahini, nuts, starchy food)	35 (8.9)
Exclusive breastfeeding in the first 6 months
Yes	208 (53.1)
No	184 (46.9)
Reason for not breastfeeding exclusively in the first 6 months
Thinking that milk supply is not enough	79 (20.2)
Working or starting to work	14 (3.6)
Infant-related problems (allergies, sleep problems, restlessness)	48 (12.2)
Thinking that the infant will gain less weight	43 (11.0)
Interrupting breastfeeding
Yes	137 (34.9)
No	255 (65.1)
The method often used for relactation
Took a galactagogue	39 (28.5)
Nipple stimulation	28 (20.4)
Increasing skin-to-skin contact	28 (20.4)
Using a breastfeeding support system	26 (19.0)
Trying to increase milk production by pumping	19 (11.7)
Relactation
Yes	54 (39.4)
No	83 (60.6)
Using a pacifier or bottle
Yes	208 (53.1)
No	184 (46.9)

Of the participating mothers, while 65.1% continued breastfeeding, 34.9% stopped breastfeeding. Of those who stopped breastfeeding, 94.2% (n = 129) tried to start breastfeeding. Of those who tried to start breastfeeding, 41.9% started breastfeeding. The mean age of the babies in the study was 15.32 (12.92) months. The mean RAI score was 10.98 (1.75). The mean duration that mothers planned to breastfeed their babies was 23.22 (5.29) months. The duration of stopping breastfeeding for those who tried to stop breastfeeding and started again and were successful was 9.35 (7.85) days. The duration of stopping breastfeeding for those who tried to stop breastfeeding and started again but were not successful was 19.26 (9.54) days (Table 3).

Table 3.

Breastfeeding-Related Characteristics of the Participants (N = 392)

Variables	n (%)
Those who continue breastfeeding	255 (65.1)
Those who stopped breastfeeding	137 (34.9)
Those who did not try to restart breastfeeding	8 (5.8)
Those who tried to restart breastfeeding	129 (94.2)
Those who restarted after stopping breastfeeding	54 (41.9)
Those who did not restart after stopping breastfeeding	75 (58.1)
	M (SD)
Mean age of the babies (months)	15.32 (12.92)
RAI score	10.98 (1.75)
Duration of planned breastfeeding	23.22 (5.29)
Duration of not breastfeeding for those who stopped breastfeeding, tried to start again, and were able to restart (days)	9.35 (7.85)
Duration of not breastfeeding for those who stopped breastfeeding, tried to start again, but were not able to restart (days)	27.26 (9.54)

RAI, Relactation Awareness Index.

Study aim 1: Interruption of breastfeeding and related factors

The prevalence of interrupting breastfeeding was significantly higher among the participants who did not breastfeed their infants within the first hour of delivery, who did not plan to breastfeed their child for ≥12 months, who perceived their milk supply as insufficient, who did not use a method to increase milk production, and who did not exclusively breastfeed their children for the first 6 months of life (p < 0.05). However, it was significantly lower among the participants who were in the 27–35 age group (p < 0.05). There was no significant difference between the prevalence of interrupting breastfeeding and the variables, such as education, employment status, the number of children, infant age, and the method used to increase milk production (p > 0.05) (Table 4).

Table 4.

Characteristics of the Study Sample by Interrupting Breastfeeding (N = 392)

Variable	Interrupting breastfeeding		χ²	p
	Yes	No
	n (%)	n (%)
Age (year)
18–26	32 (47.1)	36 (52.9)	3.663	<0.001
27–35	74 (28.6)	185 (71.4)
≥36	31 (47.7)	34 (52.3)
Educational status
Primary school/high school	55 (38.7)	87 (34.1)	1.402	0.236
University	82 (32.8)	168 (67.2)
Employment status
Unemployed	74 (33.3)	148 (66.7)	0.558	0.443
Employed	63 (37.1)	107 (62.9)
The number of children
1	77 (35.8)	138 (64.2)	3.363	0.186
2	44 (30.8)	99 (69.2)
≥3	63 (37.1)	107 (62.9)
Age of the infant (months)
0–11	56 (32.2)	118 (67.8)	1.052	0.305
≥12	81 (37.2)	137 (62.8)
Time of the first breastfeeding
Within the first hour of delivery	91 (28.9)	224 (71.1)	25.905	<0.001
After the first hour of delivery	46 (59.7)	31 (40.3)
Length of time planned for breastfeeding (months)
0–11	19 (55.9)	15 (44.1)	8.872	0.012
12–23	105 (34.3)	201 (65.7)
≥24	13 (25.0)	39 (75.0)
Perceived milk supply
Sufficient	66 (23.8)	211 (76.2)	51.377	<0.001
Insufficient	71 (61.7)	44 (38.3)
Using a method to increase milk production (took a galactagogue)
Yes	133 (37.6)	221 (62.4)	11.040	<0.001
No	4 (10.5)	34 (89.5)
The method used to increase milk production (took a galactagogue)
Herbal tea	91 (38.2)	147 (61.8)	7.529	0.057
Malt drinks	21 (42.0)	29 (58.0)
Drinking plenty of water	5 (16.2)	26 (83.9)
Others^a	16 (45.7)	19 (54.3)
Exclusive breastfeeding in the first 6 months
Yes	38 (18.3)	170 (81.7)	54.228	<0.001
No	85 (46.2)	99 (53.8)

Tahini, nuts, starchy food.

Study aim 2: Relactation and related factors

The rate of relactation was significantly higher among the participants who were not in the 27–35 age group, who had 0- to 11-month-old infants and who perceived their milk supply as sufficient (p < 0.05). There was no significant relationship between the relactation behavior and the other variables (p > 0.05) (Table 5).

Table 5.

Association Between Relactation and Sociodemographic Characteristics (N = 137)

Variable	Relactation		χ²	P
	Yes	No
	n (%)	n (%)
Age of the mother (year)
18–26	32 (47.1)	36 (52.9)	3.663	<0.001
27–35	74 (28.6)	185 (71.4)
≥36	31 (47.7)	34 (52.3)
Educational status
Primary school/high school	18 (32.7)	37 (67.3)	1.722	0.189
University	36 (43.9)	46 (56.1)
Employment status
Unemployed	25 (33.8)	49 (66.2)	2.138	0.144
Employed	29 (46.0)	34 (54.0)
The number of children
1	30 (39.0)	47 (61.0)	2.071	0.355
2	20 (45.5)	24 (54.0)
≥3	4 (25.0)	12 (75.0)
Age of the infant (months)
0–11	29 (51.8)	27 (48.2)	6.069	0.014
≥12	25 (30.9)	56 (61.9)
Time of the first breastfeeding
Within the first hour of delivery	37 (40.7)	54 (59.3)	0.175	0.675
After the first hour of delivery	17 (37.0)	29 (63.0)
Length of time planned for breastfeeding (months)
0–11	9 (47.4)	10 (52.6)	3.935	0.140
12–23	37 (35.2)	68 (64.8)
≥24	8 (61.1)	5 (38.5)
Perceived milk supply
Sufficient	41 (62.1)	25 (37.9)	27.493	<0.001
Insufficient	13 (18.3)	58 (81.7)
Using a method to increase milk production (took a galactagogue)
Yes	52 (39.1)	81 (60.9)	0.193	0.660
No	2 (50.0)	2 (50.0)
The method used to increase milk production (took a galactagogue)
Herbal tea	34 (37.1)	57 (62.6)	1.187	0.756
Malt drinks	8 (38.1)	13 (61.9)
Drinking plenty of water	3 (60.0)	2 (40.0)
Others^a	7 (43.8)	9 (56.3)
Exclusive breastfeeding in the first 6 months
Yes	16 (42.1)	22 (57.9)	0.159	0.690
No	38 (38.4)	61 (61.6)

Tahini, nuts, starchy food.

Study aim 3: RAI and related factors

The mean score of the participants obtained from the RAI was 10.98 (1.75) (Min: 0, Max: 20). The participants were, those who were ≤35 years old, those who were not primary school graduates, those who were employed, those who had 1–2 children, those whose children were over the age of 1 year, those who breastfed their infants within the first hour of delivery, those who breastfed their children, those who planned to breastfeed their children up to the age of two, those who perceived their milk supply as sufficient, those who exclusively breastfed their infants for 6 months after delivery, those who did not interrupt breastfeeding, and those who obtained significantly higher scores from the index (p < 0.05). There was no significant correlation between the RAI scores and the other variables (p > 0.05) (Table 6).

Table 6.

Association Between the Relactation Awareness Index Scores and Sociodemographic Characteristics (N = 392)

Variable	N	Relactation awareness	t/F ^**	p
Variable	N	M (SD)	t/F ^**	p
Age (years)
18–26^a	68	10.95 (1.76)	F = 4.288	0.014
27–35^b	259	11.13 (1.65)		a = c<b
≥36^c	65	10.43 (2.00)
Educational status
Primary school/high school	142	10.59 (1.82)	t = −3.418	<0.001
University	250	11.21 (1.67)
Employment status
Unemployed	222	10.77 (1.80)	t = −2.769	0.006
Employed	170	11.26 (1.64)
The number of children
1^a	215	11.04 (1.70)		0.004
2^b	143	11.14 (1.66)	F = 6.992	a = b>c
≥3^c	34	9.94 (2.10)
Age of the infant (months)
0–11	174	10.75 (1.76)	t = −2.322	0.021
≥12	218	11.16 (1.71)
Infant's diet
Exclusive breastfeeding^a	131	11.59 (1.72)	F = 4.127	<0.001
Only formula^b	28	10.50 (1.73)		a>b,c,d,e,f,g
Formula+complementary food^c	94	10.65 (1.80)
Cow milk^d	47	10.97 (1.79)
Breast milk+cow milk^e	31	10.06 (1.50)
Breast milk+complementary food^f	34	10.30 (1.92)
Breast milk+formula+complementary food^g	27	10.62 (1.75)
Prevalence of breastfeeding
Whenever the infant cries	160	11.20 (1.72)
Every 1–2 hours	116	10.89 (1.71)	F = 1.490	0.227
Every ≥3 hours	30	11.05 (1.70)
Length of time planned for breastfeeding (months)
0–11^a	34	10.35 (2.05)		< 0.002
12–23^b	306	11.30 (1.69)	F = 6.503	a<b<c
≥24^c	52	11.97 (1.65)
Perception of milk supply sufficiency
Sufficient	280	11.12 (1.71)
Not sufficient	112	10.64 (1.79)	t = 2.479	<0.014
Using a method to increase milk production (took a galactagogue)
Yes	354	10.96 (1.78)
No	38	11.18 (1.39)	t = −0.890	0.377
Method frequently used to increase milk production (took a galactagogue)
Herbal tea	238	10.89 (1.78)
Malt drinks	50	11.04 (1.60)	F = 1.053	0.369
Drinking plenty of water	31	11.48 (1.87)
^*Others	35	10.85 (1.97)
Exclusive breastfeeding in the first 6 months
Yes	208	11.34 (1.66)
No	184	10.66 (1.68)	t = 3.478	< 0.001
Interrupting breastfeeding
Yes	94	10.35 (1.70)	t = 5.470	< 0.001
No	255	11.32 (1.67)
Relactation
Yes	54	10.96 (1.51)
No	83	9.95 (1.71)	t = 3.523	< 0.001

Tahini, nuts, starchy food.

Posthoc (Tukey HSD).

a–g

Significant differences detected by post hoc test (Tukey HSD) at the 0.05 level.

HSD, Honestly Significant Difference.

Multivariate analysis

Interruption of breastfeeding was analyzed by logistic regression analysis, and the variables such as age, the time of first breastfeeding, length of time planned for breastfeeding included in the model accounted for 30% of the continuation of breastfeeding (Nagelkerke R² = 0.30, χ² = 97.109, p < 0.001). The rate of breastfeeding interruption was 2.84 times higher among those who started breastfeeding after the first 1 hour of delivery, 2.82 times higher in those who perceived their milk supply as insufficient, and 3.13 times higher in those who did not exclusively breastfeed in the first 6 months of life. A one-unit increase in the RAI score decreased the odds of interruption of breastfeeding by 29% (p < 0.05) (Table 7).

Table 7.

Logistic Regression Analysis of Interrupting Breastfeeding (N = 392)

Variable	Crude OR	95.0% CI	B	OR	95.0% CI
Time of the first breastfeeding
Within the first hour of delivery (ref.)
After the first hour of delivery	3.65	2.17–6.12	1.044	2.84	1.59–5.07
Exclusive breastfeeding in the first 6 months
Yes (ref.)
No	4.30	2.64–7.00	1.039	2.82	1.66–4.80
Perceived milk supply
Sufficient (ref.)
Not sufficient	4.72	2.96–7.53	1.143	3.13	1.87–5.25
Relactation awareness	0.71	0.62–0.81	−0.298	0.74	0.64–0.85

Nagelkerke R² = 0.30, χ² = 97.109, p < 0.001, Ref.: refers to the reference groups.

CI, confidence interval.

Variables included in the model were: age, the time of first breastfeeding, length of time planned for breastfeeding, exclusive breastfeeding in the first 6 months of life, infant's diet, and relactation awareness. Relactation failure, in other words, no milk secretion even after 2 weeks of continuous effort, was analyzed through the logistic regression analysis, and the variables such as the infant's age and perceived milk supply included in the model accounted for 56% of the continuation of breastfeeding. The rate of failed relactation was 9.16 times higher in primary school graduates and 2.37 times higher in those who perceived their milk supply as insufficient. A one-unit increase in the RAI score decreased the odds of relactation by 29% (p < 0.05) (Table 8).

Table 8.

Logistic Regression Analysis of the Relactation Failure (N = 392)

Variable	Crude OR	95.0% CI	B	OR	95.0% CI
Perceived milk supply
Sufficient (ref.)
Not sufficient	1.80	1.90–3.62	0.864	1.37	1.10–5.11
Relactation awareness	0.68	0.54–0.85	−0.293	0.74	0.61–0.90

Nagelkerke R² = 0.56, χ² = 160.992, p < 0.001, Ref.: refers to the reference groups.

In Table 9, the linear regression analysis of RAI is given. Variables such as the mother's age, educational status and employment status, the number of children, age of the infant, time of the first breastfeeding, infant's diet, length of time planned for breastfeeding, perceived milk supply, exclusive breastfeeding in the first 6 months of life, and interruption of breastfeeding included in the model accounted for 33% of relactation awareness (Adjusted R² = 0.33, F = 5.693, p < 0.001, Durbin Watson = 1.690). According to the linear regression analysis, breastfeeding within the first hour of delivery, length of time planned for breastfeeding, exclusive breastfeeding for the first 6 months of life affected relactation awareness positively, whereas the perceived milk supply affected it negatively (p < 0.05).

Table 9.

Linear Regression Analysis of Relactation Awareness (N = 392)

Variable	B	t	95.0% CI	Collinearity statistics
Variable	B	t	95.0% CI	Tolerance	VIF
Breastfeeding within the first hour of delivery	1.346	3.680	1.24–2.16	0.834	1.200
Length of time planned for breastfeeding	1.213	3.190	1.12–1.78	0.967	1.034
Perceived milk supply	0.723	3.68	1.16–1.36	0.952	1.051
Exclusive breastfeeding for the first 6 months of delivery	1.113	2.416	1.09–1.23	0.825	1.213

Adjusted R² = 0.33, F = 5.693, p < 0.001, Durbin Watson = 1.690.

Discussion

The present study is one of the first studies in which interruption of breastfeeding, prevalence of relactation, and awareness of relactation, which are important issues in terms of maternal and child health, are addressed in Turkey.

Data regarding the interruption of breastfeeding in this study are presented in Table 3. However, we did not have any data on how much milk supply women had when they stopped breastfeeding or when they started breastfeeding again. In short, those who started breastfeeding consisted of those with milk supply and those with no milk supply at all. In the present study, 34.9% of the participants interrupted breastfeeding. The mean duration of interrupting breastfeeding was 9.35 (7.85) days (Min = 1, Max = 32), approximately one-third of those who interrupted breastfeeding relactated, and the mean score they obtained from the RAI was high. Similarly, in the literature, the longer the breastfeeding interruption is, the higher the incidence of lactation failure is.^7,10

In studies in the literature, the success of relactation varies between 6% and 83.4%.^6,7,9,10 This variation may be due to the differences between the inclusion criteria and methods of the studies. Relactation success is reported to be 95% for those who interrupted breastfeeding for 15 to 30 days.⁶ In our study, as in the literature, the success rate of relactation was high in patients whose breastfeeding cessation period was short from breastfeeding.

On the other hand, it is thought that mothers' perception that their milk supply is insufficient and their low level of relactation awareness, associated with the interruption of breastfeeding, decrease the prevalence of relactation. For instance, similarly, in Yuzugullu et al's study, a relationship was found between the perception of insufficient milk supply and interruption of breastfeeding.²³ According to TDHS 2018, among the reasons for not breastfeeding exclusively in the first 6 months of life are perception that the human milk is not enough (39%), resuming work (11%), infant-related problems (23.5%), and perception that the infant will gain less weight (26.5%).⁴ According to the review of the results of the present study and other studies in the literature, among the reasons for stopping breastfeeding early or not breastfeeding exclusively in the first 6 months of life, the leading one is not the problems related to the health of the mother or the infant, but mothers' perception that their milk supply is insufficient.⁶

The rate of breastfeeding interruption was 3.01 times higher among those who started breastfeeding after the first 1 hour of delivery, 3.50 times higher in those who perceived their milk supply as insufficient, and 3.25 times higher in those who did not breastfeed their infants in the first 6 months of life. Our review of studies in the literature demonstrated that the main factor leading to the interruption of breastfeeding was the perception that milk supply was insufficient.^6,24 According to Majra and Silan's study, not starting breastfeeding within the first hour of delivery affected the continuation and motivation of breastfeeding.²⁵ Similarly, in their study, Gribble et al stated the perception that milk supply was adequate and feeding newborn babies within an hour after birth and every 2–3 hours increased the success of breastfeeding.²⁶

In the present study, the rate of not relactating was 23.62 times higher in the primary school graduates, 7.89 times higher in those who perceived their milk supply as insufficient. The rate was low in those whose relactation awareness level was high. Educational status is a social determinant that is highly correlated with health behaviors and healthy lifestyle.²⁷ In the present study, the fact that relactation failure occurred in primary school graduates may have stemmed from the negative effects of extended family structure and traditional practices. For instance, in Montoya et al's study, the family played an important role in relactation.⁶ In the present study, as in the literature, perception that milk supply is insufficient and low level of knowledge/awareness negatively affected the success of relactation.^6,7,23 In the literature, it was observed that the training given to mothers by health care professionals reduced mothers' anxiety levels and thus improved their awareness and success of relactation.^11,27

While factors such as starting breastfeeding within the first hour of delivery, planning to breastfeed the infant for 2 years, exclusive breastfeeding within the first 6 months of life positively affects the awareness of relactation, the perception that milk supply is insufficient affects the awareness of relactation negatively.¹⁷ The mother's breastfeeding the newborn in the first hour of delivery may be related to the effectiveness of prenatal and postnatal care and raising the mother's awareness of relactation. For instance, in Rahim et al's and Saglık's studies, it was found that supporting mothers mentally through the breastfeeding support systems, and enhancing their knowledge improved their awareness of lactation.^28,29 In addition, exclusive breastfeeding for the first 6 months of life and planning to breastfeed the infant for 2 years indicates that mothers are conscious about this issue. Thinking that milk supply is not sufficient not only leads to the interruption of breastfeeding but also affects awareness negatively, which suggests that mothers need professional support in this regard.⁸

The high rate of interruption of breastfeeding and the low level of awareness in the study may be due to the coronavirus disease 2019 (COVID-19) pandemic. Therefore, it is obvious that prevention of disruption of access to health services and provision of support to mothers during the COVID-19 pandemic are of great importance if mother–infant health is to be protected and if the breastfeeding of the infant is to be maintained. On the other hand, the pandemic also had positive effects. For instance, in their study, Hull et al found that mothers were motivated to breastfeed again in the pandemic, and that the pandemic helped mothers to notice how they could protect their babies by breastfeeding.³⁰

Limitations

The fact that the study included only the mothers who were the members of breastfeeding groups on social media and that mothers who were not members were not contacted due to the COVID-19 pandemic is a limitation in terms of generalizability. Beyond carrying out the study during the pandemic, health care professionals not being able to help mothers comprehensively due to the pandemic affected generalizability. Because the study was conducted during the pandemic, failure to continue to work and the limited number of interventions performed by health care professionals, such as midwives and nurses, were also limiting factors regarding the evaluation of the data. Another limitation of the study was that the number of studies conducted on relaxation in the literature was inadequate, which caused us to make discussions horizontally.

Conclusion

In our study, the aims mentioned in the introduction part were achieved to a great extent. The goals regarding the interruption of breastfeeding or relactation and their determinants were achieved. One-third of all the participants stopped breastfeeding and one-third of them were able to relactate. The participants' awareness of relactation levels were also at a moderate level, which suggests that although the level of breastfeeding interruption was high, the mothers who were aware of relactation were able to cope with the interruption. Therefore, training programs should be designed to raise mothers' awareness. To help women during breastfeeding and relactation process, galactagogue use should be comprehensively researched and compared in terms of participants' socioeconomic development status. In our study, galactagogue use was not associated with relactation; however, the participants used it, which suggests that they believed in the benefit of using galactagogue. Within this context, health care professionals can play a role in enlightening women about galactagogue use.

Perception that milk supply is inadequate, lack of education and interruption of breastfeeding affect awareness of relactation. Therefore, professional support programs should be performed to help mothers achieve successful results in the relactation process. The mother's motivation and willingness are the factors affecting the relactation process most. If health care professionals are to increase mothers' self-confidence, they should listen to mothers' concerns related to breastfeeding. In addition, health care professionals should evaluate both the mother's and the newborn's/infant's condition and ensure that mothers continue breastfeeding by teaching them relactation techniques and having them implement such techniques. Breastfeeding support received within Facebook/WhatsApp groups may compensate for inadequate support received within mothers' networks.

Footnotes

Acknowledgments

All authors read and approved the final version of the article. The authors would like to sincerely thank all the mothers who participated in this study.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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