Pregnant womens intention to breastfeed; their
estimated extent and duration of the
forthcoming breastfeeding in relation to the
actual breastfeeding in the first year
postpartum-A Swedish cohort study
Ing-Marie Claesson, Maria Myrgård, Malin Wallberg and Marie Blomberg
The self-archived postprint version of this journal article is available at Linköping University Institutional Repository (DiVA):
http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-158913
N.B.: When citing this work, cite the original publication.
Claesson, I., Myrgård, M., Wallberg, M., Blomberg, M., (2019), Pregnant womens intention to breastfeed; their estimated extent and duration of the forthcoming breastfeeding in relation to the actual breastfeeding in the first year postpartum-A Swedish cohort study, Midwifery, 76, 102-109. https://doi.org/10.1016/j.midw.2019.05.014
Original publication available at:
https://doi.org/10.1016/j.midw.2019.05.014
Copyright: Elsevier (12 months)
Pregnant women’s intention to breastfeed; their estimated extent and duration of the forthcoming breastfeeding in relation to the actual breastfeeding in the first year postpartum- a Swedish cohort study
Ing-Marie Claesson, RNM, PhD1, Maria Myrgård, MD2, Malin Wallberg, RN, MNSc2, Marie Blomberg, MD, PhD1
1Department of Obstetrics and Gynaecology, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
E-mail: Ing-Marie.claesson@liu.seMarie.Blomberg@regionostergotland.se
2Child Health Unit, and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
E-mail: Maria.Myrgard@regionostergotland.se Malin.Wallberg@regionostergotland.se
Conflicts of Interest: None of the authors have any conflicts of interest
Ethical Approval: The study was performed in accordance with the Declaration of Helsinki of 1975, as revised in 2013 and approved by the regional ethical review board in Linköping, Sweden (Dnr. 2015/45-31). All women were given written and oral information about the study. Written consent was obtained from all women. All data have been treated
confidentially.
Funding Sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Correspondence: Ing-Marie Claesson
Department of Clinical and Experimental Medicine Faculty of Medicine and Health Sciences
Linköping University
SE - 581 83 Linköping, Sweden Tel. +46101032923
Fax: +46 13 148156
Highlights
• Pregnant women have to a great extent the intention to exclusively breastfeed >4 months, irrespective of parity or Body Mass Index class
• Obese multiparous women plan partial breastfeeding to a greater extent than underweight and normal weight women
• Despite high-ranking breastfeeding targets, all women do not reach their goals
Abstract
Objectives: To investigate the prenatal intention to breastfeed and the estimated extent and duration of the forthcoming breastfeeding among nulliparous and multiparous women in different Body Mass Index (BMI) classes. Furthermore, in a sub-group we study the actual breastfeeding in relation to the prenatal intended extent and duration.
Design: A prospective cohort study
Methods: A total of 775 pregnant women answered a questionnaire concerning their intention to breastfeed and how they estimated the extent and duration of the forthcoming breastfeeding. In a sub-group of 174 women, data from the actual breastfeeding were obtained.
Findings: There was no difference concerning intention to breastfeed among underweight and normal weight women, overweight or obese nulliparous or multiparous women. Fewer multiparous women with BMI <25 judged that the forthcoming breastfeeding would be partial, compared to multiparous women with overweight and obesity (p=0.003). Furthermore, there was a significant difference within the group of nulliparous women concerning the prenatal intended extent and the actual breastfeeding at two weeks and five months postnatally (p=0.000 and p=0.041). There were more underweight and normal weight and overweight women who breastfed exclusively two weeks postnatally, compared with
obese women. Additional, at five months postnatally there were more obese women who had ceased to breastfeed, than underweight and normal weight women.
Conclusions: Among pregnant multiparous women there were more overweight and obese women who judged that the forthcoming breastfeeding would be partial, than pregnant underweight and normal weight women. The prenatal estimated extent of the forthcoming breastfeeding differed from the actually extent of breastfeeding among nulliparous women.
Implications for practice: The antenatal breastfeeding information and education should be tailored to prepare every woman/couple, irrespective of maternal body composition for the forthcoming task and furthermore, the continuum of care, from antenatal care to Child Health Service should offer a supportive atmosphere to protect and promote breastfeeding
Introduction
Breastfeeding is considered a natural part of motherhood among normal weight as well as overweight and obese women (Burns, Schmied, Sheehan, & Fenwick, 2010; Claesson,
Larsson, Steen, & Alehagen, 2018; A. M. Nelson, 2006) and its benefits for mother and child are well documented (WHO, 2013; Victora et al., 2016) . The World Health Organisation (WHO) recommends exclusive breastfeeding up to the age of six months, with continued breastfeeding along with appropriate complementary food during the two year of life, or as long as the parents and child want (WHO, 2003). Sweden and many other countries have adopted this recommendation. However, during the last decade in Sweden the percentage of children exclusively or partial breastfed up to four months of age has decreased and in the year 2016 a total of 74 % of children were breastfed at this age (The National Board of Health and Welfare, 2018). On the other hand, the percentage of breastfed children at six months of age has increased slightly and was reported to be 64 % in 2016 (The National Board of Health and Welfare, 2018).
Maternal obesity (Body Mass Index (BMI) >30 kg/m2) poses a risk for ante-, peri- and postnatal complications and an excessive gestational weight gain may further worsen the situation (Blomberg, 2011; Marchi, Berg, Dencker, Olander, & Begley, 2015). Additional, obesity is a major risk factor for reduced initiation and duration of breastfeeding (Bever Babendure, Reifsnider, Mendias, Moramarco, & Davila, 2015). International studies have shown that the prevalence of breastfeeding differs between women in different BMI classes (Baker, Michaelsen, Sorensen, & Rasmussen, 2007; Bjorset, Helle, Hillesund, & Overby, 2018; Guelinckx, Devlieger, Bogaerts, Pauwels, & Vansant, 2012). The duration of breastfeeding among underweight and overweight women and obese women has been reported to be shorter, compared with normal weight women. Breastfeeding support may increase the duration (McFadden et al., 2017).
In Sweden, the topic of breastfeeding arises during the antenatal visits and the expectant parents are offered information and education about breastfeeding, and further guidance is offered at the maternity ward in connection to the delivery, and at the Child Welfare Centre (CWC), which offers care and advice from one week of age. Antenatal education and information about breastfeeding has been the subject of various studies which have showed divergent results. Rosen et al. (Rosen, Krueger, Carney, & Graham, 2008) found that women who attended prenatal breastfeeding classes breastfed to a greater extent at six months, compared with a control group. On the other hand two Cochrane studies show no or low-quality evidence that antenatal education, support and interventions can improve the
prevalence of the forthcoming breastfeeding (Balogun et al., 2016; Lumbiganon et al., 2016). Intention to breastfeed has a large influence on the actual breastfeeding initiation and
duration (Donath, Amir, & Team, 2003). The topic has been investigated in systematic reviews (Amir & Donath, 2007; Turcksin, Bel, Galjaard, & Devlieger, 2014) and these have unanimously reported that obese women had a lower intention to breastfeed than non-obese women. The systematic review by Lyons et al. (Lyons, Currie, Peters, Lavender, & Smith, 2018) investigated the planned breastfeeding duration with respect to BMI </> 30 and the authors found no indications that intention to breastfeed and BMI had any impact on the planned breastfeeding duration.
It is possible that the prenatal breastfeeding intention and the planned extent and duration differ between parity and BMI, and few studies have so far focused on these potential differences and what these may mean in the long term. The aim of this paper is therefore to report findings concerning the prenatal intention to breastfeed and the estimated extent and duration of the forthcoming breastfeeding among nulliparous and multiparous women in different BMI classes. Furthermore, in a sub-group we explored the actual breastfeeding in relation to the prenatal intended extent and duration.
Materials and Methods
The Swedish antenatal healthcare system reaches almost 100 % of all pregnant women. The antenatal and delivery care is free of charge and pregnant women are advised to attend the regular antenatal programme visits to a midwife. When necessary, additional appointments with an obstetrician are included in the program.
All antenatal clinics (10) in south-east Sweden were included in the study and midwives at these clinics were asked to invite all Swedish-speaking pregnant women around gestational week 35 to participate in the study, which entailed answering a study-specific questionnaire. Written informed consent was obtained from all participants, who also gave permission to the researchers to obtain information from the antenatal record. The questionnaire contained socio-demographic information: age, parity, marital status, education level, occupation, tobacco habits and health status. Furthermore, it also contained pregnancy-related
information: possible pregnancy complications and previous breastfeeding experience. The women were also asked to state their intention to breastfeed (yes, no, uncertain), and if they stated an intention, they were asked to grade the extent and duration (exclusive breastfeeding >6 months, exclusive breastfeeding 4-6 months, exclusive breastfeeding for a maximum of four months or partial breastfeeding from the beginning) of the forthcoming breastfeeding. Thecompleted form was then dropped by the women themselves into a boxat the reception of the antenatal clinic.
All data related to pregnancy, delivery and the early period of the puerperium are registered in the standardised and identical Swedish antenatal, delivery and neonatal records.
Pregnancy-related data concerning health during pregnancy and weight and length in early pregnancy (gestational week 10-15) were obtained by the main author (IMC) from the pregnancy record. Based on weight and length data, BMI was calculated and the WHO classification of underweight, normal weight, overweight, and obesity were adopted (WHO).
A total of 1065 questionnaires were distributed between May 2015 and February 2016, and 775 pregnant women (72.8 %) were included in the study (Fig.1).
In a sub-group of 174 women with singleton pregnancies it was also possible to follow the extent and duration of the actual breastfeeding (Fig.1). These women were also recruited to participate in a study in the CWC aiming to investigate the prevalence of breastfeeding during the first year postnatally. Written informed consent to collect information from the antenatal, delivery and neonatal record and breastfeeding information from the child’s record at the CWC was obtained. Besides pregnancy-related information (see above) information concerning the delivery (incidence of complications) and the newborn child (gestational length, birth weight and possible care in a neonatal intensive care unit) were obtained by the main author (IMC) from medical records.
In Sweden all families are offered preventive health care for their children throughout childhood at the CWC. The preventive health care programme is free of charge and reaches almost 100% of all children. At the CWC, children are advised to attend the regular health programme (which assesses weight and length/height development, physical health, nutrition [breast milk/formula/normal diet] immunisations, cognitive and linguistic development). During the first year of life the regular programme consists of visits at 1-2 weeks of age, once a month from one to six months of age and further at eight, 10 and 12 month of age. The extent of breastfeeding (exclusive, partial or no breastfeeding) is documented in the record at the CWC at each visit and this information was collected by the main author (IMC).
The study was performed in accordance with the Declaration of Helsinki of 1975, as revised in 2013 and approved by the regional ethical review board in Linköping, Sweden (Dnr. 2015/45-31
Statistics
All analyses were performed using SPSS 23.0 (IBM, Armonk, NY). Statistical significance was defined as (two-sided) p < 0.05. The one-way ANOVA test and the Student’s t test were used as the methods of analysis of continuous variables. Significant p-values obtained were corrected for multiple testing using Bonferroni correction. Group differences were estimated by using the Pearson’s chi-square test and Fischer’s exact test on categorical variables. The answer alternatives “exclusive breastfeeding >6 months” and “exclusive breastfeeding 4-6 months” were combined in the analysis into “exclusive breastfeeding >4 months”.
Furthermore, in the analysis in the sub-cohort the answering alternative “exclusive breastfeeding for a maximum of four months” was included in the answer alternative “exclusive breastfeeding >4 months”, due to there being too few answers in this category.
Findings
The questionnaire was answered in pregnancy week 36.3 (SD 2.3). Background
characteristics among nulliparous and multiparous women are displayed in Table 1. There was a significant difference in age and education level among the nulliparous women
(p=0.028 respectively p=0.014). Underweight and normal weight women were younger than overweight women and also had a significantly higher education level, compared with obese women. Among the multiparous women there was a difference in marital status (p=0.012). More underweight and normal weight women were married or cohabiting with a partner, compared with obese women. Concerning educational status, there were differences between all three BMI classes (p=0.000) More underweight and normal weight women had a higher educational level than overweight and obese women and furthermore, overweight women had a higher education level compared with obese women. Additionally, there was a difference in occupational status (p=0.047). More overweight women were not gainfully employed than underweight and normal weight women. There were also more obese women who stated that they had no experience of breastfeeding compared to underweight and normal weight women (p=0.021). Nulliparous and multiparous women’s intention to breastfeed and the estimated extent and duration of the forthcoming breastfeeding are shown in Table 2. There were no differences in intention to breastfeed between the three BMI classes, irrespective of parity. Concerning the extent of the forthcoming breastfeeding there were fewer multiparous women with BMI <25 who judged that the forthcoming breastfeeding would be partial, compared to multiparous women with overweight and obesity (p=0.003).
The results for the prenatal stated intention to engage in exclusive breastfeeding >4 months in relation to the actual breastfeeding during the first year postnatally, among nulliparous and multiparous women in the three BMI classes in the sub-cohort, are displayed in Table 3. There was a significant difference between nulliparous women concerning actual
breastfeeding at two weeks and five months postnatally (p=0.000 and p=0.041). There were more underweight and normal weight and overweight women who breastfed exclusively two weeks postnatally, compared with obese women. Furthermore, at five months postpartum there were more obese women who had ceased to breastfeed, than underweight and normal weight women. The occurrence of adverse pregnancy, delivery, and neonatal outcomes in relation to actual breastfeeding during the first two months postpartum among the women in the sub-group who prenatally stated exclusively breastfeeding >4 months is shown in Table 4. The number of abnormal outcomes was too small for statistical analysis and therefore only frequencies are reported. The average gestational age and the average birth weight of the children were 39.8 (SD 1.3) full weeks and 3.6 (SD 0.43) kilos, and there were no differences between the three BMI classes (data not shown). An extended comparative analysis between the entire cohort and the sub-cohort concerning background characteristics and prenatal stated intention, extent and duration of breastfeeding, irrespective of parity or BMI class, indicated no differences between the cohorts (supplemental Table 1).
Discussion
In this prospective cohort study we investigated the prenatal intention and the estimated extent and duration of the forthcoming breastfeeding in relation to the actual breastfeeding during the first year postpartum among women with respect to their parity and BMI.
The percentage of women who prenatally stated that they had breastfeeding intentions was high (>90 %) both among nulliparous as well as multiparous women, irrespective of BMI class and we found no differences between the two groups. Our result is in agreement with the study by Newby & Davies (Newby & Davies, 2016) where the authors reported no differences between non-obese and obese nulliparous women. On the other hand, the studies by Guelinckx et al. (2012) , Visram et al. (Visram et al., 2013) and by Marshall et al.
(Marshall, Lau, Purnell, & Thornburg, 2018) showed a lower intention to breastfeed among overweight and obese women. Garner et al. (Garner, McKenzie, Devine, Thornburg, & Rasmussen, 2017) undertook a longitudinal qualitative study and found that obese women prenatally expressed less confidence about breastfeeding, compared with normal weight women. One can speculate about how a question about prenatal intention to breastfeed and the estimated extent and duration of the forthcoming breastfeeding is perceived by pregnant women. Do women answer what they think is expected and correct; “Yes I have
breastfeeding intentions and I will breastfeed for at least six months as recommended by WHO”? This is possible but on the other hand, breastfeeding is in general seen as a natural part of motherhood which encompasses an intention and wish for breastfeeding (Burns et al., 2010; Claesson et al., 2018).
Regarding the extent of the forthcoming breastfeeding a majority of the participants stated that they planned to breastfeed exclusively for at least four months. However, compared with women with BMI <25, there were more overweight and obese multiparous women who
judged that the forthcoming breastfeeding would be partial from the start. In this context, it may be worth noting that, compared to multiparous women with BMI <25, there were more obese multiparous women who stated that they had no previous breastfeeding experience. The reasons for this circumstance are unknown but it is possible that they had anxiety about the forthcoming breastfeeding and less confidence about their body, which in turn affected the motivation for breastfeeding. Several studies have pointed out psychological as well as technical concerns with breastfeeding (Han & Brewis, 2018; Keely, Lawton, Swanson, & Denison, 2015; McKenzie, Rasmussen, & Garner, 2018; Mok et al., 2008; Mulherin, Miller, Barlow, Diedrichs, & Thompson, 2013; Newby & Davies, 2016). It is also possible that multiparous women have a more realistic view on the forthcoming breastfeeding due to previous experience, compared with nulliparous women who have no breastfeeding experience. The study by Schafer (Schafer, Campo, Colaizy, Mulder, & Ashida, 2017) showed that women who experienced the breastfeeding troublesome and demanding with the first-born infant, were less likely to initiate breastfeeding with the second-born infant,
compared with women without experienced problems.
Our results are partly in line with the findings of the study by Hauff et al. (Hauff, Leonard, & Rasmussen, 2014). The authors found no difference between their intended breastfeeding duration and BMI class. Newby & Davies (2016) also found no difference between non-obese and non-obese nulliparous women concerning the prenatal intended breastfeeding duration. Donath et al. (2003) found in a large UK cohort that less than half of the participants planned to breastfeed exclusively for at least four months. Nelson and co-authors (J. M. Nelson, Li, Perrine, & Scanlon, 2018) investigated possible changes between the prenatal stated intended duration of breastfeeding during the third trimester and the neonatal stated intended duration of breastfeeding, approximately one month after birth. A total of 35 % of the women
intended duration. Concerning the women who shortened the intention, obese women had higher odds of shortening than normal weight women.
Concerning the prenatal stated intention to exclusively breastfeed >4 months in relation to the actual breastfeeding during the first year postnatally, there was a significant difference
between nulliparous women two weeks and five months postnatally. There were fewer obese women who breastfed exclusively for two weeks postnatally and more obese women who had ceased to breastfeed five months postnatally, compared with women in lower BMI classes. Our results are in agreement with the results in an American study (Marshall et al., 2018) which reports a lower rate of exclusive breastfeeding and a higher rate of lactation termination among obese women, compared to women of normal weight. A systematic review (McFadden et al., 2017) has shown when breastfeeding support is offered, the duration and exclusivity is increased. Effective support was characterised by care offered by trained staff, face-to-face, and at scheduled visits, so the woman knows when the support is available (McFadden et al., 2017). A recent study (Campbell & Shackleton, 2018) showed that among women who had begun to breastfeed, overweight and obese women were more likely to cease breastfeeding during the first week postnatally, compared with normal weight women. They were also less likely to continue breastfeeding in the following four months (Campbell & Shackleton, 2018). Furthermore, Newby and co-author (2016) found that there were differences between non-obese and obese nulliparous women. During the first year postnatally there were more overweight and obese women who had ceased to breastfeed, than non-obese women. The relation between any changes in the intended breastfeeding duration (pre- and postnatal) and the actual breastfeeding was investigated in the American study (J. M. Nelson et al., 2018). Women who shortened their intended breastfeeding duration also had shorter actual duration. A recent Norwegian study (Bjorset et al., 2018) reported an
and obese women had lower odds of performing exclusive breastfeeding, compared with normal weight women. The same study found also an association between parity and exclusive breastfeeding four months postnatally. Multiparous women had higher odds of breastfeeding exclusively than first-time mothers.
There are strengths as well as limitations to the present study. This is one of a few studies which report the outcome concerning breastfeeding intention and planned extent and duration among nulliparous and multiparous women, and furthermore, we followed the actual
breastfeeding in a sub-group of these women. Most of the data were obtained from
standardised medical records, i.e. there was little self-reported data. The comparison between the entire- and sub-cohort showed no differences, which suggests that the results can be generalised.
There was a discrepancy between the women’s prenatal estimated extent and duration of breastfeeding and the actual reported breastfeeding status at >4 months in the medical record at CWC. At around five months of age it is common in Sweden that the infant begins to get small tastes of other types of food, and breastfeeding is from this point in time not defined as exclusive. Our results are based on information in the medical records at CWC, whereas breastfeeding information obtained directly from the women themselves may have been different. It is possible that the women themselves had considered the extent of breastfeeding to be exclusive, despite giving their infants small tastes of other food. This can be seen as a limitation. Furthermore, we have no health information postnatally about the women and children. Therefore it is possible that in some cases there were medical circumstances which caused a breastfeeding termination. Additional, back-ground characteristics indicate
differences in age, educations level and occupation, within the group of nulliparous women as well as the group of multiparous women, and should be taken in account when
interpretation of the results. In comparison with women with BMI <25, obese women had a more unfavourable starting point.
It is also possible that during pregnancy you cannot imagine the hard work required for well-functioning breastfeeding. Breastfeeding has in some studies been described as a
time-consuming and demanding process and requires perseverance (Burns et al., 2010; Claesson et al., 2018; Garner et al., 2017). Hence, the antenatal breastfeeding information and education should be careful, thorough and realistic to prepare the woman/couple for the forthcoming task, and furthermore, the maternity ward and CWC should offer a supportive atmosphere to protect and promote breastfeeding (WHO, 2018). In future studies, as a suggestion for a study with qualitative design, it is important to continue to investigate the reasons, apart from the medical ones, for the possible discrepancy between the prenatal intention and the actual breastfeeding outcome in order to offer optimal guidance, support and education antenatally as well as postnatally.
Conclusions
A majority of pregnant women, irrespective of BMI or parity, expressed an intention to breastfeed. Pregnant multiparous obese women judged that the forthcoming breastfeeding would be partial. The prenatal estimated extent of the forthcoming breastfeeding did not corresponded to the actually extent of breastfeeding among nulliparous women. Antenatal tailored preparation as well as a careful support during the breastfeeding period is extremely important. Future studies should have focus on the need of optimal guidance, support and education.
References
Amir, L. H., & Donath, S. (2007). A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth, 7, 9. doi: 1471-2393-7-9 [pii] 10.1186/1471-2393-7-9
Baker, J. L., Michaelsen, K. F., Sorensen, T. I., & Rasmussen, K. M. (2007). High prepregnant body mass index is associated with early termination of full and any breastfeeding in Danish women. Am J Clin Nutr, 86(2), 404-411. doi: 10.1093/ajcn/86.2.404
Balogun, O. O., O'Sullivan, E. J., McFadden, A., Ota, E., Gavine, A., Garner, C. D., . . . MacGillivray, S. (2016). Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst
Rev, 11, CD001688. doi: 10.1002/14651858.CD001688.pub3
Bever Babendure, J., Reifsnider, E., Mendias, E., Moramarco, M. W., & Davila, Y. R. (2015). Reduced breastfeeding rates among obese mothers: a review of contributing factors, clinical
considerations and future directions. Int Breastfeed J, 10, 21. doi: 10.1186/s13006-015-0046-5
Bjorset, V. K., Helle, C., Hillesund, E. R., & Overby, N. C. (2018). Socio-economic status and maternal BMI are associated with duration of breast-feeding of Norwegian infants. Public Health Nutr,
21(8), 1465-1473. doi: 10.1017/S1368980017003925
Blomberg, M. (2011). Maternal and neonatal outcomes among obese women with weight gain below the new institute of medicine recommendations. Obstet Gynecol, 117(5), 1065-1070. doi: 10.1097/AOG.0b013e318214f1d1 00006250-201105000-00007 [pii]
Burns, E., Schmied, V., Sheehan, A., & Fenwick, J. (2010). A meta-ethnographic synthesis of women's experience of breastfeeding. Matern Child Nutr, 6(3), 201-219. doi:
10.1111/j.1740-8709.2009.00209.x
Campbell, T., & Shackleton, N. (2018). Pre-pregnancy body mass index and breastfeeding initiation, early cessation and longevity: evidence from the first wave of the UK Millennium Cohort Study. J Epidemiol Community Health. doi: 10.1136/jech-2017-209074
Claesson, I. M., Larsson, L., Steen, L., & Alehagen, S. (2018). "You just need to leave the room when you breastfeed" Breastfeeding experiences among obese women in Sweden - A qualitative study. BMC Pregnancy Childbirth, 18(1), 39. doi: 10.1186/s12884-017-1656-2
Donath, S. M., Amir, L. H., & Team, A. S. (2003). Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study. Acta Paediatr, 92(3), 352-356.
Garner, C. D., McKenzie, S. A., Devine, C. M., Thornburg, L. L., & Rasmussen, K. M. (2017). Obese women experience multiple challenges with breastfeeding that are either unique or
exacerbated by their obesity: discoveries from a longitudinal, qualitative study. Matern Child
Nutr, 13(3). doi: 10.1111/mcn.12344
Guelinckx, I., Devlieger, R., Bogaerts, A., Pauwels, S., & Vansant, G. (2012). The effect of pre-pregnancy BMI on intention, initiation and duration of breast-feeding. Public Health Nutr,
15(5), 840-848. doi: 10.1017/S1368980011002667
Han, S. Y., & Brewis, A. A. (2018). Influence of weight concerns on breastfeeding: Evidence from the Norwegian mother and child cohort study. Am J Hum Biol, 30(2). doi: 10.1002/ajhb.23086 Hauff, L. E., Leonard, S. A., & Rasmussen, K. M. (2014). Associations of maternal obesity and
psychosocial factors with breastfeeding intention, initiation, and duration. Am J Clin Nutr,
99(3), 524-534. doi: 10.3945/ajcn.113.071191
Keely, A., Lawton, J., Swanson, V., & Denison, F. C. (2015). Barriers to breast-feeding in obese women: A qualitative exploration. Midwifery, 31(5), 532-539. doi:
10.1016/j.midw.2015.02.001
Lumbiganon, P., Martis, R., Laopaiboon, M., Festin, M. R., Ho, J. J., & Hakimi, M. (2016). Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev,
Lyons, S., Currie, S., Peters, S., Lavender, T., & Smith, D. M. (2018). The association between psychological factors and breastfeeding behaviour in women with a body mass index (BMI) >/=30 kg m(-2) : a systematic review. Obes Rev, 19(7), 947-959. doi: 10.1111/obr.12681 Marchi, J., Berg, M., Dencker, A., Olander, E. K., & Begley, C. (2015). Risks associated with obesity in
pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev, 16(8), 621-638. doi: 10.1111/obr.12288
Marshall, N. E., Lau, B., Purnell, J. Q., & Thornburg, K. L. (2018). Impact of maternal obesity and breastfeeding intention on lactation intensity and duration. Matern Child Nutr, e12732. doi: 10.1111/mcn.12732
McFadden, A., Gavine, A., Renfrew, M. J., Wade, A., Buchanan, P., Taylor, J. L., . . . MacGillivray, S. (2017). Support for healthy breastfeeding mothers with healthy term babies. Cochrane
Database Syst Rev, 2, CD001141. doi: 10.1002/14651858.CD001141.pub5
McKenzie, S. A., Rasmussen, K. M., & Garner, C. D. (2018). Experiences and Perspectives About Breastfeeding in "Public": A Qualitative Exploration Among Normal-Weight and Obese Mothers. J Hum Lact, 34(4), 760-767. doi: 10.1177/0890334417751881
Mok, E., Multon, C., Piguel, L., Barroso, E., Goua, V., Christin, P., . . . Hankard, R. (2008). Decreased full breastfeeding, altered practices, perceptions, and infant weight change of prepregnant obese women: a need for extra support. Pediatrics, 121(5), e1319-1324. doi:
10.1542/peds.2007-2747
Mulherin, K., Miller, Y. D., Barlow, F. K., Diedrichs, P. C., & Thompson, R. (2013). Weight stigma in maternity care: women's experiences and care providers' attitudes. BMC Pregnancy
Childbirth, 13, 19. doi: 10.1186/1471-2393-13-19
Nelson, A. M. (2006). A metasynthesis of qualitative breastfeeding studies. J Midwifery Womens
Health, 51(2), e13-20. doi: 10.1016/j.jmwh.2005.09.011
Nelson, J. M., Li, R., Perrine, C. G., & Scanlon, K. S. (2018). Changes in mothers' intended duration of breastfeeding from the prenatal to neonatal periods. Birth, 45(2), 178-183. doi:
10.1111/birt.12323
Newby, R. M., & Davies, P. S. (2016). Antenatal breastfeeding intention, confidence and comfort in obese and non-obese primiparous Australian women: associations with breastfeeding duration. Eur J Clin Nutr, 70(8), 935-940. doi: 10.1038/ejcn.2016.29
Rosen, I. M., Krueger, M. V., Carney, L. M., & Graham, J. A. (2008). Prenatal breastfeeding education and breastfeeding outcomes. MCN Am J Matern Child Nurs, 33(5), 315-319. doi:
10.1097/01.NMC.0000334900.22215.ec
Schafer, E. J., Campo, S., Colaizy, T. T., Mulder, P. J., & Ashida, S. (2017). Influence of Experiences and Perceptions Related to Breastfeeding One's First Child on Breastfeeding Initiation of Second Child. Matern Child Health J. doi: 10.1007/s10995-016-2228-1
The National Board of Health and Welfare, S. (2018). Statistics on breastfeeding 2016. from Available at: http://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/21057/2018-9-3.pdf Retrieved February 2019
Turcksin, R., Bel, S., Galjaard, S., & Devlieger, R. (2014). Maternal obesity and breastfeeding intention, initiation, intensity and duration: a systematic review. Matern Child Nutr, 10(2), 166-183. doi: 10.1111/j.1740-8709.2012.00439.x
WHO. Body mass index - BMI. from Available at http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi Retrieved February 2019 WHO. (2003). Global strategy for infant and young child feeding. from Available at
http://www.who.int/nutrition/topics/global_strategy_iycf/en/ Retrieved October 2018. WHO. (2013). Long-term effects of breastfeeding: a systematic review from Available at:
http://apps.who.int/iris/bitstream/handle/10665/79198/9789241505307_eng.pdf?sequenc e=1&isAllowed=y Retrieved November 2018
WHO. (2018). Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Baby-friendly Hospital Initiative 2018. from Available at
http://www.who.int/nutrition/bfhi/en/ Retrieved April 2019
Victora, C. G., Bahl, R., Barros, A. J., Franca, G. V., Horton, S., Krasevec, J., . . . Lancet Breastfeeding Series, G. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet, 387(10017), 475-490. doi: 10.1016/S0140-6736(15)01024-7
Visram, H., Finkelstein, S. A., Feig, D., Walker, M., Yasseen, A., Tu, X., & Keely, E. (2013). Breastfeeding intention and early post-partum practices among overweight and obese women in Ontario: a selective population-based cohort study. J Matern Fetal Neonatal Med,
Table 1.Back-ground characteristics among nulliparous and multiparous womena
Nulliparous women Multiparous women BMIb <25 BMIb 25.0 – 29.9 BMI b >30 BMIb <25 BMI b 25.0 – 29.9 BMI b >30 n % n % n % pc n % n % n % pc Age (mean, SD) 234 27.5 (4.0) 80 (4.6) 29.0 56 (4.6) 28.0 0.028 d 241 31.4 (4.5) 103 (5.1) 31.0 61 (5.0) 30.6 0.501 d Marital status 0.516e 0.012e
Married / cohabiting with a partner 230 98.3 77 96.3 55 98.2 238 98.8 100 97.1 56 91.8
Other family situation 4 1.7 3 3.8 1 1.8 3 1.2 3 2.9 5 8.2
Education level, year 0.014f 0.000f
<12 95 40.6 41 51.2 34 60.7 85 35.3 55 53.4 44 72.1 >12 139 59.4 39 48.8 22 39.3 156 64.7 48 46.6 17 27.9
Occupation 0.458f 0.047e
Gainfully employed / parental leave /
student 213 91.0 73 91.3 48 85.7 231 95.9 92 89.3 58 95.1 Not gainfully employed 21 22.8 7 8.8 8 14.3 8 3.3 10 4.1 2 3.3
No information — — — — — — — 2 0.8 1 0.4 1 1.6
Tobacco user 0.325e 0.523e
No 229 97.9 79 98.8 53 94.6 231 95.9 101 98.1 58 95.1
Yes 5 2.1 1 1.3 3 5.4 10 4.1 2 1.9 3 4.9
Health status (self-reported) 1.000e 0.149e
“I am healthy” 230 98.3 79 98.8 56 100.0 241 100.0 103 100.0 59 96.7
“I am not healthy” 3 1.3 1 1.3 0 0.0 0 0.0 0 0.0 1 1.6
No information 1 0.4 0 0.0 0 0.0 0 0.0 0 0.0 1 1.6
Complications during pregnancy 0.074e 0.070e
No 225 96.2 73 91.3 51 91.1 227 94.2 91 88.3 53 86.9
Yes 8 3.4 7 8.8 5 8.9 13 5.4 10 9.7 8 13.1
Previous experiences of breastfeeding
(multiparous women) — 0.021e
Yes — — — — — — 232 96.3 95 92.2 52 85.2
No — — — — — — 9 3.7 6 5.8 8 13.1
No information — — — — — — 0 0.0 2 1.9 1 1.6
a All values are given as frequencies unless otherwise stated b Body Mass Index
c Missing data are not included in the analyses d One-way ANOVA
e Fischer’s Exact test fPearson Chi-Square Test
Table 2. Women´s prenatal intention to breastfeed and the estimated extent and duration of the forthcoming breastfeeding according to Body Mass Index in nulliparous and multiparous womena
Nulliparous women Multiparous women
BMIb <25 BMIb 25.0 – 29.9 BMI b >30 BMIb <25 BMI b 25.0 – 29.9 BMI b >30 n % n % n % pc n % n % n % pc
Prenatal stated intention to breastfeeding 0.051d 0.331d
Yes 232 99.1 76 95.0 55 98.2 232 96.3 98 95.1 56 91.8
No/uncertain 2 0.9 4 5.0 1 1.8 9 3.7 5 4.9 5 8.2
Extent and duration of the forthcoming
breastfeeding among the women who answered
yes in the intention question 0.261
d 0.003d
Exclusive breastfeeding >4 months 211 90.6 69 90.8 52 94.5 212 91.8 82 83.7 42 75.0 Exclusive breastfeeding for maximum 4 months 7 3.0 5 6.6 0 0.0 4 1.7 5 5.1 5 8.9
Partial breastfeeding from the beginning 9 3.9 1 1.3 2 3.6 12 5.2 11 11.2 8 14.3
No information 6 2.6 1 1.3 1 1.8 3 1.3 0 0.0 1 1.8
Table 3. Prenatal stated intention to exclusive breastfeeding >4 months in relation to actual breastfeeding among nulliparous and multiparous women during the first postnatal year a
Nulliparous women
Multiparous women
Prenatal intention for exclusive breastfeeding >4 months Prenatal intention for exclusive breastfeeding >4 months BMIb <25.0 BMIb
25.0 – 29.9 BMIb >30 BMIb <25.0 BMI b 25.0 – 29.9 BMIb >30 n=46 % n=22 % n=16 % pc n=44 % n=19 % n=12 % pc Actual breastfeeding at 2 weeks postpartum 0.000d 0.484 d Exclusive breastfeeding 42 91.3 21 95.5 8 50.0 38 86.4 16 84.2 10 83.3 Partial breastfeeding 4 8.7 1 4.5 8 50.0 3 6.8 3 15.8 2 16.7 No breastfeeding — — — 3 6.8 0 0.0 0 0.0 Actual breastfeeding at 1 month postpartum 0.170 d 0.831 d Exclusive breastfeeding 37 80.4 19 86.4 9 56.3 34 77.3 15 78.9 9 75.0 Partial breastfeeding 8 17.4 3 13.6 6 37.5 6 13.6 3 15.8 3 25.0 No breastfeeding 1 2.2 0 0.0 1 6.3 4 9.1 1 5.3 0 0.0 Actual breastfeeding at 2 months postpartum 0.096 d 0.776 d Exclusive breastfeeding 36 78.3 15 68.2 8 50.0 35 79.5 15 78.9 8 66.7 Partial breastfeeding 7 15.2 7 31.8 6 37.5 5 11.4 3 15.8 2 16.7 No breastfeeding 3 6.5 0 0.0 2 12.5 4 9.1 1 5.3 2 16.7 Actual breastfeeding at 3 months postpartum 0.069 d 0.931 d Exclusive breastfeeding 31 67.4 13 59.1 6 37.5 33 75.0 14 73.7 8 66.7
Partial breastfeeding 11 23.9 8 36.4 5 31.3 7 15.9 3 15.8 2 16.7 No breastfeeding 4 8.7 0 0.0 4 25.0 4 9.1 2 10.5 2 16.7 No information — 1 4.5 1 6.3 — — — Actual breastfeeding at 4 months postpartum 0.141 d 0.680 d Exclusive breastfeeding 29 63.0 14 63.6 6 37.5 30 68.2 10 52.6 9 75.0 Partial breastfeeding 12 26.1 5 22.7 3 18.8 9 20.5 5 26.3 1 8.3 No breastfeeding 5 10.9 2 9.1 6 37.5 5 11.4 3 15.8 2 16.7 No information — 1 4.5 1 6.3 — 1 5.3 — Actual breastfeeding at 5 months postpartum 0.041 d 0.376 d Exclusive breastfeeding 13 28.3 6 27.3 2 12.5 17 38.6 5 26.3 2 16.7 Partial breastfeeding 27 58.7 11 50.0 5 31.3 20 45.5 7 36.8 6 50.0 No breastfeeding 6 13.0 3 13.6 8 50.0 7 15.9 6 31.6 4 33.3 No information — 2 9.1 1 6.3 — 1 5.3 — Actual breastfeeding at 6 months postpartum 0.057 d 0.807 d Exclusive breastfeeding 5 10.9 3 13.6 0 0.0 3 6.8 2 10.5 0 Partial breastfeeding 31 67.4 12 54.5 7 43.8 30 68.2 10 52.6 8 No breastfeeding 7 15.2 7 31.8 8 50.0 9 20.5 5 26.3 3 No information 3 6.5 — 1 6.3 2 4.5 2 10.5 1 Actual breastfeeding at 8 months postpartum 0.058 d 0.945 d Partial breastfeeding 27 58.7 14 63.6 4 25.0 23 52.3 11 57.9 7 58.3 No breastfeeding 15 32.6 8 36.4 10 62.5 19 43.2 7 36.8 5 41.7 No information 4 8.7 — 2 12.5 2 4.5 1 5.3 —
Actual breastfeeding at 10 months postpartum 0.127 d 0.447 d Partial breastfeeding 15 32.6 10 45.5 2 12.5 16 36.4 5 26.3 6 No breastfeeding 28 60.9 11 50.0 12 75.0 25 56.8 12 63.2 5 No information 3 6.5 1 4.5 2 12.5 3 6.8 2 10.5 1 Actual breastfeeding at 12 months postpartum 0.110 d 0.545 d Partial breastfeeding 3 6.5 5 22.7 1 6.3 8 18.2 2 10.5 3 No breastfeeding 34 73.9 12 54.5 13 81.3 28 63.6 12 63.2 6 No information 9 19.6 5 22.7 2 12.5 8 18.2 5 26.3 3
a All values are given as frequencies unless otherwise stated b Body Mass Index
c Missing data are not included in the analyses d Fischer’s Exact test
Table 4. Occurrence of adverse pregnancy-, delivery- and neonatal outcomes in relation to actual breastfeeding from two weeks until two months postpartum among women in different Body Mass Index classes and who prenatal stated to breastfeed exclusively >4 monthsa
Prenatal stated intention to breastfeed exclusively >4 months
BMIb <25 BMIb 25.0 –
29.9 BMI
b >30
n % n % n %
Incidence of pregnancy complications
Actual breastfeeding at: 2 weeks ppc
Exclusive breastfeeding 3 100.0 3 100.0 3 75.0 Partial breastfeeding 0 0.0 0 0.0 1 25.0 1 month ppc Exclusive breastfeeding 3 100.0 3 100.0 2 50.0 Partial breastfeeding 0 100.0 3 100.0 2 50.0 2 months ppc Exclusive breastfeeding 3 100.0 2 66.7 1 25.0 Partial breastfeeding 0 0.0 1 33.3 2 50.0 No breastfeeding 0 0.0 0 0.0 1 25.0
Incidence of delivery complications
Actual breastfeeding at: 2 weeks ppc
Exclusive breastfeeding 14 100.0 8 88.9 2 28.6 Partial breastfeeding 0 0.0 1 11.1 5 71.4 1 month ppc Exclusive breastfeeding 13 92.9 7 77.8 3 42.9 Partial breastfeeding 1 7.1 2 22.2 4 57.1 2 months ppc Exclusive breastfeeding 13 92.9 5 55.6 3 42.9 Partial breastfeeding 1 7.1 4 44.4 3 42.9 No breastfeeding 0 0.0 0 0.0 1 14.3
Not healthy newborn child
Actual breastfeeding at: 2 weeks ppc
Exclusive breastfeeding 2 66.7 3 100.0 1 50.0 Partial breastfeeding 1 33.3 0 0.0 1 50.0 1 month ppc Exclusive breastfeeding 2 66.7 3 100.0 1 50.0 Partial breastfeeding 1 33.7 0 0.0 1 50.0 2 months ppc Exclusive breastfeeding 3 100.0 2 66.7 1 50.0 Partial breastfeeding 0 0.0 1 33.3 1 50.0
Care at “Neonatal intensive care unit”
Actual breastfeeding at: 2 weeks ppc
Exclusive breastfeeding 6 100.0 4 100.0 1 100.0 1 month ppc Exclusive breastfeeding 6 100.0 4 100.0 1 100.0 2 months ppc Exclusive breastfeeding 5 83.3 3 75.0 1 100.0 Partial breastfeeding 1 16.7 1 25.0 0 0.0 a All values are given as frequencies b Body Mass Index c postpartum
Supplemental Table 1. Background characteristics and stated breastfeeding intention. The entire cohort compared with the sub-cohorta
The entire cohort The sub-cohort
BMIb <25 BMIb 25.0 – 29.9 BMI b >30 BMIb <25 BMI b 25.0 – 29.9 BMI b >30 n % n % n % n % n % n % pc Age (mean, SD) 475 29.5 (4.6) 183 30.1 (5.0) 117 29.3 (5.0) 96 29.4 (4.5) 48 29.9 (4.8) 30 30.8 (5.3) 0.553 d Marital status 1.000e
Married / cohabiting with a partner 468 98.5 177 96.7 111 94.9 96 100.0 47 97.9 27 90.0 Other family situation 7 1.5 6 3.3 6 5.1 0 0.0 1 2.1 3 10.0
Parity 0.172f
Nulliparous 234 49.3 80 43.7 56 47.9 50 52.1 24 50.0 17 56.7 Multiparous 241 50.7 103 56.3 61 52.1 46 47.9 24 50.0 13 43.3
Education level, year 0.663f
<12 180 37.9 96 52.5 78 66.7 37 38.5 27 56.3 18 60.0 >12 295 62.1 87 47.5 39 33.3 59 61.5 21 43.8 12 40.0
Occupation 0.832f
Gainfully employed / parental leave / student 444 93.5 165 90.2 106 90.6 91 94.8 44 91.7 27 90.0 Not gainfully employed 29 6.1 17 9.3 10 8.5 5 5.2 4 8.3 3 10.0
No information 2 0.4 1 0.5 1 0.9 — — — — — —
Tobacco user 0.847f
No 460 96.8 180 98.4 111 94.9 93 96.9 47 97.9 29 96.7
Yes 15 3.2 3 1.6 6 5.1 3 3.1 1 2.1 1 3.3
Health status (self-reported) 0.078e
“I am healthy” 471 99.2 182 99.5 115 98.3 94 97.9 47 97.9 30 100.0 “I am not healthy” 3 0.6 1 0.5 1 0.9 2 2.1 1 2.1 0 0.0
No information 1 0.2 0 0.0 1 0.9 — — — — — —
Complications during pregnancy 0.616f
No 452 95.2 164 89.6 104 88.9 93 96.9 44 91.7 26 86.7 Yes 21 4.4 17 9.3 13 11.1 3 3.1 3 6.3 4 13.3 No information 2 0.4 2 1.1 0 0.0 0 0.0 1 2.1 0 0.0
Previous experiences of breastfeeding (multiparous
women) 0.059
e
Yes 232 96.3 95 92.2 52 85.2 46 100.0 23 95.8 12 92.3
No 9 3.7 6 5.8 8 13.1 0 0.0 0 0.0 1 7.7
No information 0 0.0 2 1.9 1 1.6 0 0.0 1 4.2 0 0.0
Prenatal intention to breastfeed 0.938f
Yes 464 97.7 174 95.1 111 94.9 96 100.0 43 89.6 29 96.7 No/uncertain 11 2.3 9 4.9 6 5.1 0 0.0 5 10.4 1 3.3
Prenatal stated extent and duration of the forthcoming breastfeeding among the women who answered ‘yes’ in the intention question
0.513f
Exclusive breastfeeding >4 months 434 93.5 161 92.5 99 89.2 90 93.8 41 95.3 29 96.6 Partial breastfeeding from the beginning 21 4.5 12 6.9 10 9.0 5 5.2 2 4.7 1 3.4
No information 9 1.9 1 0.6 2 1.8 1 1.0 0 0.0 0 0.0
a All values are given as frequencies unless otherwise stated b Body Mass Index
c Comparison between the entire- and sub-cohort. Missing data are not included in the analyses d Student’s t test e Fischer’s Exact test
Figure 1. Description of the population in the study
782 pregnant women gave written informed consent to participate in the study and completed the
questionnaire
4 questionnaires were excluded due to incomplete information
775 pregnant women were included in the study
Asub-group of 174 women also
gave their written informed consent to collect information from medical records (ante-, peri- and postnatal and breastfeeding information)
3 questionnaires were excluded when breastfeeding was impossible
due to medication Midwives at 10 antenatal care clinics distributed a
total of 1065 questionnaires among pregnant women in gestational week ≈ 35
