Admitted when Breastfeeding: Impact and Experiences of Hospital Care

Abstract

Objective:

This study analyzes the impact and experiences of hospitalization for any reason on breastfeeding women.

Methods:

Cross-sectional online survey (November 2019–March 2020). Adults admitted to a Spanish hospital for at least one night, when actively breastfeeding, were included. The questionnaire aimed at assessing breastfeeding, breast complications, and support and perceived health care workers’ attitudes to breastfeeding.

Results:

Of the 266 included participants, 70 (26%) stopped breastfeeding during hospitalization, and 13 (5%) interrupted it permanently. A total of 24 (10%) participants reported that hospitalization meant problems for later breastfeeding, and 67 (25%) reported experiencing breast complications. The most common negative comment was that the child was too old to be breastfed (median age, 15 months [interquartile range (IQR) 11–25]). Problems for later breastfeeding due to the hospitalization were more likely if breastfeeding was interrupted (odds ratio [OR] 3.68, 95% confidence interval [CI] 1.32–10.5) or breast problems were experienced (OR 4.11, 95% CI 1.51–11.7). Problems were less likely when patients felt encouraged (OR 0.38, 95% CI 0.21–0.69) and hospitalized in a surgical inpatient area (OR 0.15, 95% CI 0.03–0.65).

Conclusions:

Hospitalizations can cause breastfeeding and breast problems. Hospital services must update protocols to integrate breastfeeding into usual care.

Introduction

Breastfeeding is beneficial for both breastfed and breastfeeding individuals. The World Health Organization (WHO) recommends breastfeeding exclusively for six months and for a minimum of two years.¹ Breastfeeding duration in Europe is shorter than WHO’s recommendations.² Breastfeeding can be interrupted^3,4 for various reasons, such as returning to work, psychological burden, and little support. Medical problems in mothers are among the causes of weaning. During breastfeeding, women may require specific health care and treatments, akin to women in the same age group, aside from complications of reproductive processes.

Hospitals are a significant environment for people and serve as benchmarks for health. In recent years, hospitals have committed themselves to integrate health promotion into daily activities⁵ and move toward patient-centered care and shared decisions.⁶ Furthermore, given the benefits of breastfeeding,⁷ health systems and hospitals should protect and empower breastfeeding mothers while considering their preferences regarding breastfeeding and their health, as well as in the event of hospitalization. The Baby-Friendly Hospital Initiative (BFHI) from the WHO^8,9 assists facilities providing maternity and newborn departments to initiate and support breastfeeding.^10,11 There is no such initiative for adult medical and surgical wards, and studies have detected the need for special training.¹² There are some comprehensive protocols to support breastfeeding during maternal hospitalization.^13–16 There are also some specialized guidelines for the use of anesthesia and analgesia¹⁷ online platforms for the use of medication during breastfeeding¹⁸ and recommendations for the use of radiological contrasts¹⁹ or surgical patients.²⁰ In Spain, the Lactation Commission of the Spanish Association of Pediatrics issued recommendations for healthcare workers (HCWs) regarding nursing mothers who require hospitalization, tests, or other special circumstances.²¹

To the best of our knowledge, no studies have yet explored the experiences of adult patients who are breastfeeding a child when mothers need hospitalization due to personal health problems or the birth of a new baby. We did not find studies that examined the effects of this hospitalization on breastfeeding or on the breasts of the person who is breastfeeding, either during the hospitalization of the mother or afterward. This study aimed to describe and analyze the impact and experiences of hospitalization for any reason on breastfeeding women.

Methods

Study design

The LactHos study is a cross-sectional online survey of breastfeeding mothers admitted to a hospital when breastfeeding.

Setting, participants, and study size

Participants residing in Spain, older than 18 years, who had been hospitalized for at least one night in the two years before the survey while actively breastfeeding at the time of admission were included. Participants were excluded if (1) they were still hospitalized at the time of completing the survey, (2) the hospitalization referred to the breastfed children and not the mother, or (3) the hospitalization was for the delivery of the first child. Participants were invited through the social networks of HCB and LactApp with posts explaining the aim of the study and the content of the online survey. Participants were asked to invite other participants who met the inclusion criteria and might be interested. The HCB is a university research hospital in Barcelona (Spain) with an important presence on social networks. LactApp is a reference app for breastfeeding with hundreds of thousands of users. It was decided that data collection would stop when 1,500 valid responses were reached or after the recruitment period finished (November 14, 2019–March 31, 2020).

Data source and variables

The online anonymous survey, available in Catalan and Spanish, contained structured and open questions with an approximate duration of 20 minutes and was hosted at the protected platform for data collection of the hospital which uses LimeSurvey. The survey was developed by the study team. A pilot study was conducted some weeks before the final survey and it was answered by 7 potential participants who gave useful feedback on its readability, detected technical problems with the web page visualization, and suggested splitting some questions into shorter ones and including some other topics.

The final version of the questionnaire of the LactHos study included demographic variables of the participant and the child (year of birth of the mother, country of birth of the mother, postal code, country of residence, years of residence in the country, level of education, occupation, and number of children). Some variables are grouped into wider categories. These include university studies (yes/no), currently employed (yes/no), inpatient area (medical, obstetrics & gynecology, surgical) and number of children per woman (1 or >1). Participants were also asked about the nights spent at the hospital, if the admission was urgent or planned (referred as type of admission), and the diagnosis that motivated hospitalization in an open question. This self-reported diagnosis was classified by two researchers using the International Classification of Diseases 10th Revision.

The survey recorded in structured questions mothers’ intention to continue breastfeeding (yes/no/not clear), breastfeeding interruption recommendation by HCWs (No/Yes, permanently/Yes, temporarily), breastfeeding interruption during hospitalization (yes/no), continuation of breastfeeding after discharge (yes/no), and reporting that hospitalization meant problems for later breastfeeding (yes/no). Participants were asked to select these problems for a list that admitted multiple responses (no more milk/pain/long relactation/child did not reattach). Participants reported if breast complications were experienced (yes/no) and selected them from a multiple response list (pain/breast engorgement/mastitis/breast abscess). Participants hospitalized due to mastitis were excluded in the calculation of the percentage of participants who later experienced breast complications.

Regarding the conversation with the HCWs, it was recorded who took the initiative in the conversation about breastfeeding (participants/HCWs/breastfeeding did not arise in the medical conversation), if medication contraindications were discussed (yes/no), if participants knew that medications compatible with breastfeeding were chosen (yes/no), and if participants were aware that HCWs looked for therapeutic alternatives because they knew they were breastfeeding (yes/no).

Participants were asked if they were hospitalized with breastfed children (yes/no). If answered yes, they were asked how it happened (requested by the participant/offered by HCWs). If answered no, participants selected the reason (participant did not request it/requested but it was denied/participants did not want it although it was offered by HCWs). The survey collected if participants were allowed to be visited by breastfed children (yes/no) and if a companion was allowed (yes/no). A participant was defined to have had access to breastfed children (yes) if the participant was hospitalized with the breastfed children or breastfed children were allowed to visit the mother.

Participants with planned admission who wanted to continue breastfeeding were asked if they had received any indication beforehand to help continue breastfeeding (yes/no) and, if affirmatively, if they had been advised to store breast milk (yes/no), if they had been advised to bring their breast pump (yes/no), if they had received instructions on hand expression techniques (yes/no), if the hospital had offered a breast pump during hospitalization in advance (yes/no), or if they had received explanations about techniques different from the bottle to feed with supplement of breast or artificial milk (yes/no).

Participants were asked about the breastfeeding support they had received during hospitalization as follows: if they had received advice on the use of breast pump or breast stimulation (yes/no), if they had been offered electric breast pumps (yes/no), instructed in hand expression techniques (yes/no), and instructed in manual breast pumps (yes/no). Participants were asked if they had received support from HCWs on the management of breastfeeding during hospitalization (yes/no) and if they had sought help or information outside the hospital to manage their breastfeeding (yes/no). Participants who were advised a permanent interruption of breastfeeding were asked if it had been carried out without any support or explanation or they had received medication.

Participants were asked to report if they had received positive comments (yes/no) and negative comments (yes/no) from HCWs. When negative comments were reported, participants were asked if the comment referred to the age of the children (yes/no). If they answered Yes, the age of the children was asked. We created a numerical score for the comments received from HCWs (adding +1 if a positive comment was received and −1 if it was negative, setting 0 if no response) and one for the encouragement received (+1 if encouraged by HCWs to continue breastfeeding and −1 if encouraged to quit breastfeeding, being 0 if no response). Scores were classified into positive (+1), neutral (0), or negative (−1). The participants were asked if they received encouragement to continue breastfeeding (yes/no), to quit breastfeeding (yes/no), and if they felt judged by their decision (yes/no).

Besides, the survey included open-ended questions to describe the participants’ experiences qualitatively, which will be described separately. In this article, we describe and analyze the structured questions of the LactHos Survey and the reported diagnosis.

Statistical methods

Answers were exported to a database for data analysis. Data management and statistical analyses were performed using R Statistical Software (v4.3.1; R Core Team 2023). Missing responses from variables were excluded from the analyses, and percentages were calculated based on the available responses. The age of participants and the number of nights of hospitalization were considered as a continuous variable, and the median and interquartile range (IQR, 25th–75th percentile) were used to summarize them. For categorical variables, frequencies and percentages were calculated to describe the distribution of data. Logistic regression analysis was performed to assess the likelihood that a participant reported that hospitalization meant (1) problems for breastfeeding and (2) breastfeeding interruption during hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. The selection of variables for inclusion in the multivariate models was based on their association with the outcome in univariate analyses.

Ethics

The study was carried out in compliance with the Declaration of Helsinki (version in force; currently Fortaleza, Brazil, October 2013) and in accordance with the protocol and relevant legal requirements of Law 14/2007, July 3. Informed consent was obtained from the participants before their inclusion in the study at the beginning of the online survey. The study was evaluated and approved by the Medical Research Ethics Committee of the Hospital Clínic de Barcelona.

Results

In total, 2,138 people accessed the survey platform, 1,038 agreed to participate, and 415 completed the survey. A total of 286 lived in Spain. Finally, 20 participants were excluded, 16 of them because they were hospitalized for the birth of their first child and the other 4 because it was the child who was hospitalized.

The demographic characteristics of the participants are summarized in Table 1. The median age of the participants was 36 (IQR 33–39 years). Participants were hospitalized for a median of 3 nights (IQR 1–4).

Table 1.

Demographic Characteristics of the Participants in the LactHos Survey

Variable	Answers	n (%)
Place of birth	264
Spain		241 (91%)
Latin America		17 (6.4%)
Rest of Europe		4 (1.5%)
Other		2 (0.8%)
University degree	266	202 (76%)
Currently employed	260	191 (73%)
Inpatient area	257
Medical		46 (18%)
Obstetrics & Gynecology		133 (52%)
Surgical		78 (30%)
Number of children per woman	263
1		169 (64%)
2		78 (30%)
3		12 (4.6%)
4		4 (1.5%)
Number of breastfed children during hospitalization	255
1		246 (96%)
2		9 (3.5%)
Type of admission	252
Planned		52 (21%)
Urgent		200 (79%)

A total of 257 participants described the reasons that motivated hospitalization (see Supplementary Table S1). The chapters Pregnancy, Childbirth and Puerperium, Diseases of the Genitourinary System, and Diseases of the Digestive System made up for two-thirds of the diagnoses.

Table 2 summarizes the main outcomes of the survey. Participants showed their intention to continue breastfeeding (98%). HCWs recommended interruption in 29% of the hospitalizations. Hospitalization meant 5% permanent interruptions and 26% temporary interruptions during hospitalization, 10% of the patients reported problems with breastfeeding after hospitalization, and 25% of the participants experienced breast complications. Regarding complications, 28 women (46% of those with complications) received support or treatment from HCWs. The survey detected 3 women who declared that no professional knew they were breastfeeding during hospitalization. A total of 222 women (83%) had access to their children during hospitalization, either participants were hospitalized with breastfed children or visits were allowed.

Table 2.

Intention, Interruption, Impact, Medical Conversations, and Access to the Facility of Breastfeeding Women from the LactHos Survey

Variable	Answers	n (%)
Intention, interruption, and impact
Mothers’ intention to continue with breastfeeding	266
Yes		260 (98%)
Not clear		6 (2.3%)
No		0 (0%)
Breastfeeding interruption was recommended by HCWs	241
No		172 (71%)
Yes, permanently		16 (7%)
Yes, temporarily		53 (22%)
Breastfeeding interruption during hospitalization	266	70 (26%)
Continued breastfeeding after discharge	266	253 (95%)
Hospitalization meant problems for later breastfeeding	241	24 (10%)
Problems reported (multiple responses allowed)	24
No more milk		8 (33%)
Pain		7 (29%)
Long relactation		7 (29%)
Child did not reattach		4 (17%)
Experienced breast complications	266	67 (25%)
Breast complications reported (multiple responses allowed)	75
Pain		48 (72%)
Breast engorgement		24 (36%)
Mastitis		23 (34%)
Breast abscess		9 (13%)
Medical conversations
How did breastfeeding arise in the medical conversation?	266
Participants informed their physician		192 (72%)
Was asked by the physician		58 (22%)
Breastfeeding did not arise in the medical conversation		11 (4%)
Other		5 (2%)
Medication contraindications were discussed	238	207 (87%)
Participants knew that medications compatible with breastfeeding were chosen	219	171 (78%)
Participants were aware that HCWs looked for therapeutic alternatives because they knew they were breastfeeding	194	123 (63%)
Access to the facility
Participants were hospitalized with breastfed children	266	148 (56%)
If answered yes, joint hospitalization was...	143
Requested by the participant		79 (55%)
Offered by HCWs		64 (45%)
If answered no, the reason was...	118
Participants did not request it		64 (56%)
Requested but it was denied		36 (32%)
Participants did not want it although offered by HCWs		14 (12%)
Were allowed to be visited by breastfed children	266	74 (28%)
A companion was allowed	266	218 (82%)

Preparation of hospitalization

In the group of 52 women whose admission was planned and who wanted to continue breastfeeding, 18 (35%) did not receive any indication beforehand to be able to continue breastfeeding and 17 (33%) patients were advised to store breast milk to supplement the child during breastfeeding interruption. None of the participants reported receiving instructions on hand expression techniques. In the same group of 52, 12 participants (23%) were advised to bring their breast pump to the hospital to maintain breastfeeding during hospitalization, and 4 women (8%) were informed that the hospital would provide a breast pump during hospitalization to maintain breastfeeding. Only 1 participant (2%) declared to have received explanations about techniques other than using the bottle to offer the baby breast milk or artificial infant formula.

Support during hospitalization

During hospitalization, over the total of 266 participants, 77 participants (29%) received advice on the use of breast pump or breast stimulation, 83 participants (31%) were offered electric breast pumps, 18 (7%) were instructed in hand expression techniques, and 8 (3%) in manual breast pumps. A total of 85 participants (32%) received support from a HCW regarding the management of breastfeeding during hospitalization, and 154 participants (58%) sought help or information outside the hospital to manage their breastfeeding. Permanent interruption of breastfeeding was carried out without any support or explanation to the participants in 10 cases, and 6 participants received medication.

Comments from HCWs

A total of 114 participants (43%) reported receiving positive comments from HCWs about breastfeeding and 43 (16%) received negative ones. When asked if the negative comments referred to the children being too old to be breastfed, 19 (45% of participants who received negative comments) answered yes. The children of these participants had a median age of 15 months (IQR 11–25), and 13 were under two years old. In terms of the comment score, 100 participants had a score of 1 (38%), 29 (11%) had a score of −1, and 137 (52%) had a score of 0. A total of 177 participants (67%) felt encouraged by HCWs to continue breastfeeding, 45 (17%) felt encouraged to quit, and 50 (19%) felt judged by their decision. In terms of the encouragement score, 170 participants (64%) had a score of 1, 38 (14%) had a score of −1, and 58 (22%) had a score of 0.

Variables associated to problems with later breastfeeding

After univariate analysis (see Supplementary Table S2), the adjusted model (see Table 3) shows that participants were more likely to report that hospitalization meant problems for later breastfeeding when breastfeeding was interrupted during hospitalization (OR 3.68, 95% CI 1.32–10.5) or if they experienced breast complications during their stay or after discharge, excluding participants whose diagnosis was mastitis (OR 4.11, 95% CI 1.51–11.7). A better score in encouragement (OR 0.38, 95% CI 0.21–0.69 for each encouragement score point) or entering a surgical inpatient area compared with a medical inpatient area (OR 0.15, 95% CI 0.03–0.65) was associated with fewer problems with later breastfeeding.

Table 3.

Multivariate Analysis of Hospitalization Meant Problems for Later Breastfeeding

Variable	Answers	OR	95% CI	p value
Inpatient area	234
Medical		—	—	—
Obstetrics & Gynecology		0.36	0.12–1.14	0.077
Surgical		0.15	0.03–0.65	0.016
Breastfeeding interruption during a hospitalization	241	3.68	1.32–10.5	0.013
Experienced breast complications excluding mastitis at admission	241	4.11	1.51–11.7	0.006
Encouragement from HCWs score	241	0.38	0.21–0.69	0.002

OR, odds ratio; 95% CI, 95% confidence interval.

Variables associated to breastfeeding interruption during hospitalization

In the multivariate model (Table 4, see univariate analysis in Supplementary Table S3), breastfeeding interruption was less likely when participants had access to the child (OR 0.1, 95% CI 0.05–0.21) or in urgent admission (OR 0.36, 95% CI 0.18–0.74).

Table 4.

Multivariate Analysis of Breastfeeding Interruption During Hospitalization

Variable	Answers	OR	95% CI	p value
Type of Admission	252
Planned		—	—	—
Urgent		0.36	0.18–0.74	0.005
Had access to breastfed children	266	0.10	0.05–0.21	<0.001

OR, odds ratio; 95% CI, 95% confidence interval.

Discussion

This is the first study to explore the outcomes and experiences of breastfeeding in relation to hospital admission of lactating mothers. Hospitalizations meant permanent and temporary breastfeeding interruptions, problems of breastfeeding after discharge, and breast complications. Most participants reported seeking help outside the hospital regarding breastfeeding. More participants received positive comments than negative ones. Reporting breastfeeding problems after discharge was associated with the perceived attitude of HCWs, inpatient area, experiencing breast problems during and after hospitalization, and breastfeeding interruption.

It has been found that lactating women frequently take medication,^22,23 and contraindications have been listed as a reason for cessation during the first year of breastfeeding in Spain.⁴ Hospitals and HCWs should be perceived as reliable environments for the maintenance of breastfeeding to encourage honest conversations and ensure patient safety for mothers and infants. In our study, participants reported taking the initiative in the medical conversation when it came to reporting their breastfeeding condition and asking about medication compatibilities. Very few participants reported that HCWs did not know about their breastfeeding status, which may have implications for patient safety (breast complications and medication compatibilities). In some situations, access to infants was ruled out. This access was more frequent in urgent admissions, which indicates that hospital care is flexible enough to adapt to diverse situations. Participants also showed proactivity in seeking help to maintain their breastfeeding. Finally, there is a high proportion of participants that experienced breast problems caused by hospitalization, but do not report that hospitalization meant problems for later breastfeeding. Further research is needed on these questions to prevent and address discomfort during breastfeeding.

Qualitative research¹² from other authors shows that HCWs consider breastfeeding beneficial, but lack the skills to support it, which is in line with what participants in the present study reported: a lack of access to technical means in hospitals, such as breast pumps, and insufficient support from HCWs regarding breast management and breastfeeding.

There are opportunities for improvement in the dimensions of anamnesis, treatment, structure, resources, knowledge, patient safety, and support to women and people who are breastfeeding during hospitalization. It would be appropriate to count with an international initiative, equivalent to BFHI, for adult medical and surgical hospital wards. Hospitals should have comprehensive protocols for the care of breastfeeding patients, including professional training for the detection, management, and support of patients who breastfeed, awareness-raising campaigns, and a caring structure for infants and caregivers. The structured recording of breastfeeding status in the medical records could facilitate the visibility and management of breastfeeding, as well as epidemiological studies on the subject. More research is needed on the prevalence of this situation and HCWs’ perceptions of breastfeeding in hospitals. This being the first study, it would be necessary to go deeper and explore this phenomenon and its impact in other geographic areas.

The recruitment process limits the generalization of the results to the total population that was breastfeeding and required hospitalization. A strength of this study, however, is that the questionnaire reached a very large population of breastfeeding patients. Even so, the small number in some responses limits the ability to explore some variables. In addition, as a limitation, no validated questionnaires existed to explore this topic. As a strength, the structured questionnaire was designed by professionals with experience in supporting breastfeeding women and was piloted in women who had been admitted when breastfeeding. In contrast, as a limitation, the collection of data through a self-reported survey cannot provide knowledge of whether the recommendation to interrupt breastfeeding is based on scientific evidence. Given that this is a cross-sectional survey, the direction of the association between participants’ experience and outcomes of breastfeeding should be interpreted with caution because bad results in breastfeeding could make participants remember more negative comments. In addition, because the survey is completed after discharge, there may be some recall bias. Despite the limitations, these results point to a relevant issue that will need to be studied in future research.

Conclusions

In this study, we analyzed the outcomes and experiences of patients who were breastfeeding an infant when they were hospitalized. Hospitalization can cause problems with breastfeeding after discharge, as well as problems with breasts, which may not be detected and treated within the hospital. The majority of participants felt well treated and were able to maintain their wishes to breastfeed after discharge. Encouragement of HCWs regarding breastfeeding is associated with breastfeeding outcomes. There is room for improvement during hospitalization regarding the prevention and treatment of breast complications, safety for the mother and breastfed child, and promotion and support of breastfeeding. Hospitals may need to update protocols to integrate breastfeeding in usual care.

Footnotes

Acknowledgment

The authors would like to especially thank the participants in this study for sharing their experiences and giving their time.

Authors’ Contributions

An.L. conceived the study, and Al.L. and An.L. designed it. An.L., Al.L., J.P., and L.A. collected the data. An.L., A.F., and J.P. carried out the analysis. All authors interpreted the findings. An.L. drafted the article, and all authors revised it and agreed in the conclusions. An.L. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All the authors read and approved the final article.

Data Availability Statement

Data supporting the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy restrictions.

Disclosure Statement

L.A. works at LactApp. The rest of the authors have no conflicts of interest relevant to this article to disclose.

Funding Information

No funding was secured for this study. The research of An.L. is supported by Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin, RD21/0012/0003, Instituto de Salut Carlos III, 28029 Madrid, Spain. The research of J.P. is supported by the grant PID-2021-122954NB-100 funded by MCIN/AEI/10.13039/501100011033 and by ERDF “A way of making Europe.”

Supplementary Material

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Supplementary Material

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