Health and Science News for Parents

Nearly “universal” breastfeeding concerns call for universal breastfeeding support

written by Tara Haelle

When nearly all first-time moms are reporting breastfeeding concerns just a few days after giving birth, it’s pretty safe to say that breastfeeding support resources need a boost. The former was the finding of a study published today in Pediatrics. The latter, mentioned in the study, is my big takeaway from the findings.

About three quarters of all mothers begin to breastfeed their newborns after birth. But six months later — the recommended length of time for exclusive breastfeeding by the American Academy of Pediatrics — only 16 percent are still exclusively breastfeeding. Three months after giving birth, just over a third of women are still exclusively breastfeeding. Reliable, updated comparative data on other countries is difficult to find (here are some resources), but many other developed countries, especially in Scandinavia, far exceed these numbers.

Photo courtesy of Microsoft stock images.

Of course, not all women want or plan to breastfeed exclusively for three or six months, and that’s a reasonable choice for many women, depending on their personal circumstances, their values and their children. While I believe breastfeeding should be encouraged and supported because of its benefits, I do not believe any woman should feel obligated to breastfeed or should feel bad if she cannot or chooses not to do so.

Yet what about the women who want to breastfeed but give up earlier than they planned to? In fact, one study last year found that only a third of mothers achieved their exclusive breastfeeding goals. While some are likely content with their decision to stop breastfeeding earlier than planned, others feel frustrated or despondent about their “failure” to breastfeed for as long as they planned to. Some of the most commonly cited reasons for quitting breastfeeding sooner than planned are concerns about babies’ nutritional needs, feeling uncomfortable nursing in public, needing to return to school or work or having a hard time breastfeeding at the start.

And unsurprisingly, two of these dominate today’s Pediatrics study  about women’s breastfeeding concerns. The study looked at the relationship between women’s breastfeeding concerns and how long they breastfed (up to two months) or whether they fed their child any formula. To me, the findings of the study were about as unsurprising as the obvious implications of them: women in the US desperately need better support and resources for breastfeeding. For all the lip service given to breastfeeding benefits by the AAP and other public health and medical organizations, the infrastructure to really support women from before birth until months later in meeting their goals is severely lacking.

The study was pretty comprehensive. The researchers started by interviewing 532 expecting first-time moms when they were between 32 and 40 weeks of pregnancy. Then the researchers followed up with 447 women after they gave birth (some were lost to follow-up, some went to NICI and some decided not to breastfeed). The women reported breastfeeding concerns in interviews within 24 hours of giving birth and then 3, 7, 14, 30 and 60 days postpartum.

By the end of the two months, the researchers had complete data through two months on 418 mothers, and the complete data set included 2,946 interviews. Because the researchers had asked open-ended questions about breastfeeding concerns, they categorized the 4,179 open-ended responses into nine main categories (49 subcategories) of concerns. They include the usual suspects:

  • infant feeding difficulties
  • milk quantity concerns
  • uncertainty with own breastfeeding ability
  • pain while breastfeeding
  • signs of inadequate uptake in the infant
  • mother/infant separation (work/school)
  • maternal health/medication
  • too much milk production in mother
  • other

Infant feeding difficulties included latch problems, sleepy babies, nipple confusion, infant refusal of the breast, fussy or frustrated babies, problems with how long each feeding session lasts, or other difficulties with feeding.

What’s concerning about this study is how many women reported concerns and how highly ranked several concerns were. At three days after giving birth, 92 percent of the women reported at least one breastfeeding concern. That’s huge! Nearly every woman had some concern about breastfeeding — and concerns during that first week postpartum played the biggest part in whether women breastfed at least two months or not.

Here is a sampling of the most significant findings:

  • Mothers reporting any breastfeeding concern three days postpartum were NINE times more likely to stop breastfeeding within two months.
  • Mothers reporting any breastfeeding concern three days postpartum were about three times more likely to feed their child any formula between the child’s first and second month.
  • Of the 354 mothers who intended to exclusively breastfeed their child for at least two months, 47 percent fed their child formula between one and two months postpartum.
  • Of the 406 mothers who planned to breastfeed for at least two months, 21 percent stopped breastfeeding by the end of the second month.
  • The most commonly reported concern was difficulty with infant feeding, which 44 percent of women reported the day they gave birth and 54 percent reported three days postpartum.
  • On the third day postpartum, 44 percent of moms reported breastfeeding pain, and 40 percent reported concerns about milk quantity/production.
  • An estimated 32 percent of the women who stopped breastfeeding could be attributed to “infant feeding difficulties” reported by women a week after giving birth.
  • An estimated 23 percent of women who stopped breastfeeding could be attributed to “milk quantity” concerns reported two weeks after giving birth.

I could go on, but those numbers provide enough of the big picture to zero in on two other points. First, even though 79 percent of the moms had at least some concern about breastfeeding before having their babies, the researchers found no link between prenatal concerns and either stopping breastfeeding early or feeding their child formula early, meaning “these results do not appear to be simply the ‘self-fulfillment’ of anticipated problems.”

Second, concerns reported within the first week after giving birth had the biggest influence on whether women stopped breastfeeding earlier than planned or fed their baby formula earlier than planned. The researchers reasonably suggested those findings “may be because our day 3 and day 7 interviews captured a time when there is often a gap between hospital and community lactation support resources.”

I know for me personally, that first week was definitely the most hellish for breastfeeding. I’ve shared a bit of my person story on this blog before, and this study quantitatively reveals that my own anecdote is pretty representative of the broader experience.

The most common subcategories of “infant feeding difficulties” reported one week postpartum included “fussy or frustrated at the breast,” “infant refusing to breastfeed/nipple confusion” and “problems with latch.” These are precisely the sorts of problems that lactation consultants can help women address — IF women have access to a lactation consultant. Many women may not: the hospital may not have provided one, the woman may not know they exist, the woman may not be able to afford one… There are so many (inexcusable) reasons why women may not receive the support and resources they need to meet their own personal breastfeeding goals.

Unsurprisingly, the 34 outliers identified in the study — moms who reported no breastfeeding concerns at any point and all but one of whom were still breastfeeding at two months postpartum — were more likely to report confidence in their breastfeeding abilities during prenatal interviews and to report having strong breastfeeding support. (They were also more likely to be younger (under 30) and Hispanic and to have had an unmedicated vaginal birth.)

The authors concluded that “breastfeeding problems were a nearly universal experience in this cohort of first-time mothers.” While the study cannot necessarily be generalized to every community in the US, there is little reason to suspect that similar findings would not be found in many other US communities. It’s unrealistic to expect women not to have any breastfeeding concerns, but it is reasonable to demand universal access to breastfeeding support and resources for mothers.

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8 Responses to “Nearly “universal” breastfeeding concerns call for universal breastfeeding support”

  1. I’m currently at almost 5 weeks of exclusively breast-feeding my first child, and we’re off to the doctor tomorrow because we’ve managed to develop thrush. Most of my breastfeeding experience so far has been fine, if a bit uncomfortable, but I think sometimes the classes and books on breastfeeding don’t do so well with conveying that it’s a lot of work, and that it won’t necessarily cease to feel a bit weird once it stops hurting. Once I’d gotten past the first couple of weeks, but before I developed thrush, breastfeeding was still a little uncomfortable, despite a good latch. And I don’t enjoy it that much. I’m doing it because it’s good for my child and because formula’s so horribly expensive, but it’s not easy, and I’m already counting down to when we can introduce solid foods.

    • Tara Haelle

      I’m sorry to hear about the thrush – that’s no fun. I had blocked ducts several times and milk blisters, and both were very difficult. I had a hard time finding information and people who could really help me. I had excruciating pain in the beginning and didn’t really ease into breastfeeding until my son was probably 2 months old. It did become easier for me over time, and I breastfed for much longer than I had expected/planned, but the fact remains that support for breastfeeding moms is severely lacking. I remember that neither my OB nor my son’s pediatrician could offer any help at all. Hang in there, and good luck!

  2. AES

    I agree with Anna. Breastfeeding support classes do a very bad job of preparing women for the all of the difficulty and uncertainty of breastfeeding during the first month or so. They make it sound like breastfeeding is just a simple technical process, and they dont tell you things like how much time a newborn can spend nursing.

    • Tara Haelle

      I agree. I think back to the classes I had, both through the hospital and an independent Bradley class I took, and the information was not nearly thorough enough. I don’t think anyone mentioned growth spurts — good lord!

  3. kaitch

    I imagine, though, that definition is probably an issue. Six months’ exclusive BF is no longer the hard&fast gold standard, due to research and now guidelines supporting introduction of solids between 4&6 months. Neither of my kids have had any formula, but they probably don’t make the cut here because they both showed signs of readiness for solids prior to six months, so I introduced solids. I definitely had a lot of early BF troubles, especially with my first, which is another story!

    • Tara Haelle

      Thanks for this point, kaitch. I actually thought about that while writing this. I agree the guidelines are out of date. My son had formula on the first night home from the hospital (I describe the story in the linked piece above) but otherwise had none and was exclusively breatsfed until solids, but we started those at right about 5 months because he seemed ready. We could have started sooner probably (and I likely would have if we’d used baby-led weaning, which I didn’t know about at the time).

      However, at least the authors of this study did two things to try to get a better sense of actual rates: they only went to two months (I haven’t heard of any infants who have shown readiness for other foods that early), and they measured breastfeeding at all as well as “giving any formula between 30 and 60 days.” I thought the latter was interesting. If they had said “given any formula at all before 60 days,” I wouldn’t have qualified, despite pretty much doing so barring that one night, but with the definition they used, I would qualify. I wonder if that was part of their rationale.

  4. There is a fine line between ‘support’ for breastfeeding and ‘pressure’ to breastfeed.

    I do not think hospitals (in Canada) have detected that difference yet. It’s very subtle but so important.

    I also wonder if over-teaching breastfeeding might lead to some of the problems uncovered by this study.

    Thank you for reporting on this.

  5. Tara Haelle

    I agree that it’s a challenging balance to strike. I strongly support breastfeeding, but I do not feel it is helpful to criticize women who cannot or choose not to breastfeed for any number of reasons. And for those who do want to breastfeed, they should feel SUPPORT, not pressure.

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