Birth Complications and Breastfeeding Duration

This is a preprint copy of the text prior to print review. For the full published work please see:

Brown, A., & Jordan, S. (2013). Impact of birth complications on breastfeeding duration: an internet survey. Journal of advanced nursing, 69(4), 828-839.

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2012.06067.x/full

Corresponding Author Dr. Amy Brown College of Human and Health Sciences Swansea University, UK SA2 8PP Email: [email protected]

1 Impact of Birth Complications on breastfeeding duration: an internet survey

Abstract

Aim: To explore reasons underlying cessation of breastfeeding in mothers with uncomplicated vaginal deliveries and those experiencing complications during childbirth.

Background: Interventions during labour and delivery can impact negatively upon breastfeeding. Explanations include adverse reactions to medication, delayed breastfeeding initiation and disruption of the normal endocrinology of childbirth. However reasons for breastfeeding cessation linked to birth experience have not been fully examined. Increasing breastfeeding duration and, consequently, improving infant and maternal health in the UK, depends on understanding why women stop breastfeeding.

Method: 284 mothers who initiated breastfeeding but discontinued before six months postpartum reported their reasons for breastfeeding cessation in a questionnaire. These were examined in relation to birth type and complications.

Results: Mothers who experienced birth complications breastfed for a significantly shorter duration than those who did not. Specifically, caesarean deliveries, foetal distress, failure to progress and post partum haemorrhage were each associated with a shorter breastfeeding duration. Mothers who experienced complications were more likely to discontinue breastfeeding for reasons of pain and difficulty than mothers who did not experience complications, yet no difference was seen between groups for social reasons such as embarrassment or a lack of support.

Conclusion: Certain interventions and complications during labour may increase risk of specific physical difficulties with breastfeeding, potentially due to their association with medications received. Health professionals should be alert to this possibility to

2 offer enhanced attention and care to overcome these issues and prolong breastfeeding duration.

237 words

Key words: breastfeeding; medication; midwifery; pain; childbirth

3 Summary statement What is already known about this topic o Low breastfeeding rates are a major public health issue o We do not know why many women intending to breastfeed find themselves unable to do so. What this paper adds o Women who experience complications during childbirth discontinue breastfeeding sooner than those who do not. o This increase in discontinuation is entirely attributable to a higher incidence of physical difficulties and pain in breastfeeding. Implications for practice and policy o Extra breastfeeding support should be targeted at women whose labours are complicated and medicated. o Research is needed to identify the reasons behind the associations of breastfeeding difficulties and pain with childbirth complications and drugs administered.

4 Introduction

Breastfeeding benefits both infant and maternal health, reducing the incidence of childhood infections, obesity, allergic conditions, diabetes and maternal cancers (Kramer & Kakuma, 2004; Ip et al 2009). However breastfeeding rates in the UK are low: 76% of mothers initiate breastfeeding at birth (NHS, 2011), but by six weeks only 48% are breastfeeding at all, and this falls to 25% at six months (Bolling et al 2007). An important subgroup of mothers intend to initiate breastfeeding, but do not do so at birth or discontinue fully or partially within the first few days (Jordan et al 2005).

Understanding why women do not initiate breastfeeding or discontinue within a very short period of time is crucial to developing interventions to promote increased and sustained levels of breastfeeding. Birth experience can impact upon initiation of breastfeeding (Chapman & Perez-Escamilla 1999; Dewey et al , 2003; Scott, Binns, Oddy, 2007) but little is understood about the influence of birth complications upon breastfeeding duration or specific reasons for cessation.

5 Background

Reasons for short duration of breastfeeding are complex but can be split into two main categories; psychological and physical (Thulier & Mercer, 2009). Negative attitudes about the impact of breastfeeding upon lifestyle (Wright & Weaver, 2007), poor support from family or peers (Gill, Reifsnider & Lucke, 2007) and lack of knowledge or confidence (Mitra, Khourty, Hinton & Carothers, 2004) all affect decisions to initiate breastfeeding and breastfeeding duration. Amongst mothers who wish to breastfeed, physical difficulties establishing feeding due to pain or nipple trauma (Gatrell, 2007), an infant that will not latch or suck sufficiently

(Wright & Weaver, 2007) and actual or perceived insufficiency of milk (Brown,

Raynor & Lee, 2011) are common reasons for breastfeeding cessation.

Intention to initiate breastfeeding amongst pregnant women predicts breastfeeding initiation (Forster, McLachlan & Lumley, 2006) and breastfeeding at discharge

(Jordan et al 2005). However some 17%, (31/1830) women who plan to breastfeed fail to initiate breastfeeding at birth (Jordan et al 2005). One possible explanation for this change is the experience of labour and delivery. The best breastfeeding outcomes are associated with uncomplicated unassisted vaginal birth where mother and infant remain together and breastfeeding is started as soon as possible after the birth, preferably within one hour after delivery (DiGirolamo, Grummer-Strawn &

Fein, 2008) and following skin to skin contact (Anderson, Moore, Hepworth &

Bergman, 2003). However, complications or interventions during labour and delivery can impact upon both breastfeeding initiation and duration. Mothers who require a

6 caesarean delivery, particularly as an emergency, measure in labour, are less likely to initiate breastfeeding (Chapman & Perez-Escamilla; Dewey, Nommsen-Rivers, Heinig

& Cohen, 2003; Scott, Binns, Oddy, 2007), although not all studies support this association (Patel et al 2003, Bick et al 1998), and others have found that only elective caesareans impact on breastfeeding rates (Jordan et al 2009). Assisted delivery using forceps or ventouse (Leung, Lam & Ho, 2002), a prolonged second stage of labour (Wiklund, Norman, Uvnas-Mober, Ransjo-Arvidson & Andolf, 2009) and foetal distress during labour (Chapman et al, 2003) are all associated with a shorter breastfeeding duration, possibly due to delayed breast fullness and lower subsequent milk volume (Chen, Nommsen-Rivers, Dewey & Lonnderdal, 1998) or through increased postnatal pain from perineal trauma (Rajan, 1994). Separation of mother and infant in the moments after birth can also interfere with breastfeeding, especially if the birth was medicated. Even if the separation is short (less than 20 minutes), there is increased risk of suckling problems (Righard & Alade, 1990) and mothers who are separated from their infants after birth breastfeed for a shorter duration (Rojas et al. 2003).

Women experiencing a difficult birth or requiring interventions are likely to need high doses of analgesia. However, as reviewed elsewhere (Jordan 2006), epidural analgesia in labour reduces breastfeeding rates (Beilin et al 2005, Henderson et al

2003), is associated with a delayed onset of breastfeeding (Wiklund, Norman, Uvnas-

Mober, Ransjo-Arvidson & Andolf, 2009) and a perception of poorer milk supply

(Volmanen, Valanne & Alahuhta, 2004). Opioids given during labour are associated with a delayed initiation of breastfeeding and poorer breastfeeding duration

7 (Matthews, 1989; Rajan 1994, Jordan et al, 2005). This is often attributed to the infant’s poor suckling (Dewey, Nommsen-Rivers, Heinig & Cohen, 2003; Riordan,

Gross, Angernon, Krumwiede & Melin, 2000), with one study suggesting that up to

63% of infants whose mothers received opioids in labour are too sedated to latch on

(Righard & Alade, 1990).

Maternal experience of labour and birth can therefore affect breastfeeding duration.

Although delayed breast fullness and adverse reactions to intrapartum medication may help to explain reduced breastfeeding duration, previous research has not fully explored the reasons mothers give for stopping breastfeeding in relation to their birth experience. Helping mothers breastfeed is a central aspect of health professionals’ roles. Identifying women willing to breastfeed but at risk of failure is key to targeting breastfeeding support, but more information is needed. This paper aims to identify women at risk of ‘failure to breastfeed’ by exploring the differences in determinants of short breastfeeding duration between mothers with uncomplicated vaginal deliveries and mothers who experienced complications during childbirth.

THE STUDY

The aim of the current study was to explore differences in determinants of short breastfeeding duration between mothers with uncomplicated vaginal deliveries and mothers who experienced complications during childbirth.

8 Design

An exploratory cross sectional survey.

Participants

Participants were recruited to the study through posters asking for mothers with a baby aged six to twelve months to talk about their experiences of infant feeding.

Posters were placed in day care centres, postnatal groups and mother and baby groups in the City and County of Swansea, Wales, UK. The community groups were located in areas with varying degrees of social deprivation as measured by the Welsh

Indices of Multiple Deprivation (WIMD, 2008). Data presented here are from a sub- sample of mothers who initiated breastfeeding but stopped before six months.

Between January and May 2009, 602 mothers with infants aged six to twelve months completed a self – report questionnaire examining their experiences of breast or formula feeding. Within the sample, mothers who initiated breastfeeding at birth but stopped before six months postpartum completed a self-reported questionnaire

(n = 284). Multiparous mothers completed the questionnaire in relation to their youngest child. Dyads were excluded from the analysis if infants were of low birth weight (< 2500g) or were born prematurely (< 37 weeks) (World Health

Organisation, 1992).

Data Collection

Participants reported breastfeeding duration (for how long they breastfed the infant even partially) and completed a 44 item self-administered questionnaire indicating

9 their reasons for discontinuing breastfeeding (Table 1). Responses were based on five point likert scales (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree). In addition participants provided information regarding birth experience by indicating whether the birth was vaginal or caesarean and responding to the open ended item ‘Did you have any complications during your labour or birth? If so please list’.

Ethical considerations

Approval for this study was granted by a University Department of Psychology

Research Ethics Committee. All applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research.

All participants gave informed consent and were debriefed post questionnaire.

Data analysis

Data were tested for normal distribution and found adequate. An exploratory factor analysis was conducted on all items examining reasons for discontinuing breastfeeding. Factor analysis is a statistical technique that searches for patterns in relationships between variables. It combines large numbers of variables together into a smaller number of factors based on similarities in the variables. For example, items that measure beliefs about the difficulty of breastfeeding in different ways may be grouped together based on statistical associations. A regression score for each factor based on these grouped items is then computed and can be used for comparison (Field, 2009). This method is commonly used to increase validity of questionnaire measures in the health sciences (Buck, Vrielong, Flesch-Janys & Chang-

10 Claude, 2011; Grieger, Scott & Cobiac, 2011; Nommsen-Rivers, Cohen, Chantry &

Dewey, 2010).

To undertake this, a principal components factor analysis using varimax rotation carried out using the statistical package for the social sciences version 16 for windows (SPSS Inc., Chicago, Illinois, USA) Factors with eigenvalues over 1 were retained. A threshold of 0.5 was used to determine which variables should be retained. Confirmatory analyses performed on split samples of the date (infant gender, maternal age and education (median splits]) found similar structures. The factor scores computed were saved as regression scores and used for the data analysis as recommended by Tabachnik and Fidell (2006). Cronbach’s alpha was computed for each factor to examine internal consistency of the factors produced.

Responses to the item targeting complications were coded. The sample was divided into those who experienced at least one complication and those with no complications. Further binary variables were created for reports of frequently occurring complications such as, perineal tears, post partum haemorrhage. Births were coded into vaginal or caesarean.

Student’s t tests were used to examine differences in breastfeeding duration for those experiencing complications [yes / no] and different birth types [vaginal versus

Caesarean ]. (MANCOVA) compared reasons for stopping breastfeeding for experience of any complications [yes / no], specific complications [yes / no] and birth type [Vaginal versus Caesarean]. Maternal age, years in education, marital status and

11 parity were controlled for. Effect size was calculated from the SPSS output for

MANCOVA.

Validity and Reliability

Items in the questionnaire were based on preliminary qualitative interviews exploring influences on mothers’ decisions to breast or formula feed (Brown et al,

2011b; Brown et al, 2011c), and recurring themes in the current literature as to why women cease breastfeeding such as pain, difficulty, embarrassment and exhaustion

(Li, Fein, Chen & Grummer-Strawn, 2008; Scott, Binns, Oddy & Graham; Thulier &

Mercer, 2009 ). Items were with 40 women as part of an unpublished PhD thesis

(Brown, 2010). When Factor analysis had grouped variables into factors, Cronbach’s alpha was computed for each factor to examine internal consistency of the factors produced.

FINDINGS

Of 602 survey respondents, the 284 who had initiated and stopped breastfeeding were eligible for inclusion in this study. Mean age of participants was 29.19 (SD:

5.65) [range 17 to 42 years]; the mean number of years in education was 13.69 (SD:

2.89) [range 10 to 17 years]; 53.9% were married; 38.7% had degree level or above qualifications; 80.1% were primiparous. Mean duration of any breastfeeding was

13. 32 days (SD: 17.29) with a range from 2 days to 12 weeks. 58.5% of mothers stopped breastfeeding within the first week postpartum with 73.2% having stopped by two weeks.

12 52.2% of participants (N = 148) experienced one or more complication in labour and

47.8% (136) experienced none. The most frequently occurring complications were foetal distress (N = 63), assisted delivery (N = 43), failure to progress requiring augmentation of labour (N = 27), severe tearing of the perineum (N = 21) and post partum haemorrhage (N = 16). Nineteen participants experienced more than one of these complications. Overall 110 participants gave birth via a caesarean delivery and

174 vaginally. Mode of birth was considered separately to ‘any complication’.

Mothers were split into two groups; those who experienced any birth complication and those who did not. Mothers who experienced birth complications breastfed for a significantly shorter time than those who did not [F (1, 282) = 10.00, p = 0.002]

(Table 2). Mothers listed all complications they experienced. Mothers who reported a greater number of birth complications breastfed for a shorter duration

(Spearman’s rho = -0.197, p < 0.001). In terms of individual complications, mothers who experienced foetal distress, failure to progress or a post partum haemorrhage breastfed for a significantly shorter duration than mothers who did not experience these complications. Mothers who gave birth via caesarean delivery also breastfed for a significantly shorter duration than those who had a vaginal delivery. No significant difference was seen in breastfeeding duration between mothers who experienced or did not experience a severe tear or assisted delivery (Table 2).

Reasons for breastfeeding cessation

13 Principal components factor analysis was performed on all items examining breastfeeding cessation. A loading factor of 0.5 was used. Forty one of the forty four items loaded onto eight factors. Four items did not load [I was fed up of breastfeeding; I wanted to diet; Other babies appeared more settled on formula;

Nursing bras were unattractive]. The rotated component matrix explained 49.93% of the variance [Table 1]. Internal validity for each factor was good, with Cronbach’s alpha ranging from 0.65 to 0.81. Factors included body image concerns (worries about appearance and leaking milk), embarrassment (not wanting to feed in front of others or in public), difficulty (problems with latch and positioning), pain (from cracked nipples or mastitis), impact upon lifestyle (lack of routine and difficulties socialising), pressure from others to stop (from friends, family and partner), lack of support (difficulties getting advice or support with problems) and medical reasons

(taking medication or advised to stop by a professional).

Regression scores from the factor analysis were saved as variables for each factor describing reasons for stopping breastfeeding. Participants were therefore scored along a continuum from -1 to +1 for each factor. A higher score on the factor represented a stronger agreement with the reason given for stopping breastfeeding e.g. pain. Significant correlations were seen between breastfeeding duration and reasons for cessation. Mothers who scored highly on the variables of stopping for lifestyle reasons [Spearman’s rho = 0.157, p = 0.006), pressure from others

(Spearman’s rho = 0.128, p = 0.20) or a lack of support (Spearman’s rho = 0.211, p =

0.000) breastfed for longer. Conversely, mothers who scored more highly on

14 stopping breastfeeding for reasons of difficulty (Spearman’s rho = -0.20, p = 0.001) or pain (Spearman’s rho =-.208, p = 0.00) breastfed for a shorter time.

MANCOVA showed significant differences in reasons given for stopping breastfeeding between mothers who experienced birth complications and those who did not [F (8, 248 = 2.498, p = 0.01, effect size, cohen’s d = 0.9). Mothers who experienced complications were significantly more likely to report stopping breastfeeding for reasons associated with pain and the difficulty of breastfeeding than mothers who did not experience birth complications. No significant difference was seen between the two groups due to finding breastfeeding embarrassing, impact upon lifestyle, body image, pressure from others, lack of support or medical reasons (Table 3).

Some complications were associated with specific reasons for stopping breastfeeding. Discontinuing breastfeeding because it was too difficult was more common amongst mothers who experienced foetal distress [F (1, 255) = 11.373, p =

0.001, d = 0.9), failure to progress leading to augmentation of labour [F (1, 255) =

4.616, p = 0.03, d = 0.6), a post partum haemorrhage [F (1, 255) = 4.239, p = 0.01, d =

0.7) or who gave birth via caesarean delivery [F (1, 255) = 19.17, p = 0.00, d = 0.9) compared to mothers who did not experience these complications.

stopping breastfeeding due to pain was reported more frequently by mothers who experienced a post partum haemorrhage [F (1, 255) = 4.51, p = 0.03, d = 0.6), failure to progress leading to augmentation of labour F (1, 255) = 6.73, p = 0.01, d = 0.7) or

15 giving birth via caesarean delivery [F (1, 255) = 5.314, p = 0.02, d = 0.6) compared to mothers who did not experience these difficulties.

No significant difference was seen for any reason given for stopping breastfeeding between mothers who experienced severe tearing or had an assisted delivery or not.

No significant differences were found between individual complication groups for believing breastfeeding to be embarrassing, lifestyle reasons, lack of support, pressure from others, body image or medical reasons.

Discussion

Key Findings

When compared to those who experienced no complications, mothers who experienced complications during labour and birth breastfed for a shorter time and gave different reasons for breastfeeding cessation. Caesareans, foetal distress, failure to progress and post partum haemorrhage were each associated with a shorter breastfeeding duration. Mothers who experienced complications were more likely to discontinue breastfeeding for reasons of pain and difficulty than mothers who did not experience complications, yet no difference was seen between groups for social reasons such as embarrassment or a lack of support.

Study Limitations

The main limitations of this study are sample size and single location. Management of complications may be different in other centres and other countries, and transferability of these findings will be based on logical, rather than statistical,

16 inferences. Our findings are based on reported data: we have no indications as to the clinical severity of the complications experienced, and we cannot exclude the possibility that women who made light of any complications, to the extent of not reporting them, would also dismiss any discomforts associated with breastfeeding.

However, it is unlikely that some complications, such as Caesareans, would be forgotten. We excluded premature births and low birth weight infants both these conditions are are associated with complicated births and breastfeeding difficulties

(Nyqvist, 1999; Vohr, Poindexter & Dusick, 2007). This group would prove an interesting addition to exploring the relationship between birth experience and subsequent breastfeeding duration.

Numbers were sufficient for comparison when considering the impact of any complication during labour and birth upon breastfeeding duration and reasons for cessation. However, when exploring the impact of individual complications, although numbers were in line with expected frequency (RCOG, 2009), complication groups were small for comparison, especially in relation to complications such as PPH (N =

16). It should be emphasised that these calculations are exploratory but do raise interesting questions about the relationship between specific birth complications, breastfeeding duration and reasons for breastfeeding cessation which have not been previously explored. It is recommended that these findings are now explored amongst a larger population.

17 Understanding Breastfeeding Difficulties

It appears that complications during birth, and perhaps subsequent interventions, may increase physical problems with breastfeeding such as finding breastfeeding difficult or painful. There are a number of physiological explanations for this.

Interventions and complications during birth increase the likelihood that the mother will receive drugs and/or be separated from her infant after birth. Drugs received during labour can sedate the infant (Jordan et al, 2005) or disrupt the mother’s or infant’s hormonal balance (Jordan et al 2009) which can affect the infants ability to latch onto the nipple. This in turn can lead to sore or cracked nipples. Moreover, correct positioning and latch is critical for establishing breastfeeding and increasing milk supply (Woolridge, 1980). Poor suckling behaviour is associated with infant weight loss and in turn the belief that milk supply is poor or the infant needs more than breast milk(Dewey, Nommsen-Rivers, Heinig & Cohen, 2003). Each of these reasons are commonly cited in relation to breastfeeding discontinuation (Smith

The relationship between complications, breastfeeding duration and reasons for stopping breastfeeding was not consistent. it appeared that caesarean delivery, foetal distress, failure to progress and post partum haemorrhage were associated with a reduced breastfeeding duration and stopping breastfeeding for reasons of difficulty or pain, whilst severe tears or assisted deliveries were not.

Differences in the impact and treatment of these complications may explain later perceived difficulties in establishing breastfeeding. Research has shown that

18 breastfeeding is best established if started as soon as possible after delivery alongside immediate skin to skin contact (Anderson et al. 2003; Rojas et al. 2003).

Delaying breastfeeding can lead to problems with the infant latching onto the breast and subsequently a delay in milk production, both of which would increase the likelihood of actual or perceived difficulties with breastfeeding (DiGirolamo et al.

2008). If a woman has had a caesarean delivery, is exhausted by the birth or requires treatment for a haemorrhage it is likely that skin to skin contact and breastfeeding will be delayed. In cases of complications such as a severe tear or assisted delivery, although the woman is likely to need stitching or further care, treatment may be less urgent, and there is little reason to delay skin to skin contact, allowing initial feeding to take place. This initial delay of breastfeeding can affect infant latch and therefore cause pain and perception of inadequate milk supply leading, to breastfeeding cessation. If however these issues are overcome breastfeeding may continue. Indeed one study showed that if mothers who received a caesarean delivery were able to breastfeed for the first month postpartum, they continued to breastfeed for as long as mothers who did not receive a caesarean delivery (Perez-Escamilla, Maulen-

Radovan & Dewey, 1996).

Mode of birth can also affect the infant. Emergency caesarean delivery is associated with higher risk of neonatal depression and respiratory insufficiency than vaginal birth, although this may be explained through events leading to the caesarean rather than the caesarean itself (Liston, Allen, O’Connell & Jangaard, 2007). Infants who are sedated or needing further care are unlikely to breastfeed immediately after birth.

Furthermore, a caesarean delivery is associated with greater levels of pain,

19 exhaustion and other health problems during the postnatal period than a vaginal birth (Declercq, Cunningham, Johnson & Sakala, 2008; Borders, 2006; Thompson,

Roberts, Currie & Ellwood, 2002). Potentially this may impact upon maternal perceptions of ability to breastfeed or to cope with the feeding patterns of a breastfed infant.

Is breastfeeding cessation an adverse drug reaction?

Complications during labour usually increase maternal need for medication, which may subsequently affect breastfeeding initiation. The impact of epidurals and uterotonics has been reviewed elsewhere (Jordan 2006, Jordan et al 2009, Jordan

2010). Epidural analgesia has been associated with a delayed onset of breastfeeding

(Torvaldsen et al 2006, Wiklund et al. 2009) and a perception of poor milk supply

(Volmanen et al. 2004). Women undergoing caesareans will normally receive either an epidural or a general anaesthetic and are also more likely to be delayed in feeding their infants. Mothers whose infants suffer foetal distress may be more likely to receive additional analgesia in association with prolonged labour or in preparation for emergency caesarean. Opioids are associated with infant breathing difficulties, increased sedation and poorer suckling behaviour (Dewey et al, 2003; Jordan et al.

2005). Conversely, a perineal tear would not normally be managed with systemic medication, and any drugs administered would postdate delivery, and not be transferred to the infant.

Although numbers in this sample are low, women who experienced a postpartum haemorrhage had a shorter breastfeeding duration and particular issues with

20 difficulty of breastfeeding and pain. PPH may adversely affect milk supply (Willis &

Livingstone, 1995), which may explain respondents’ perceptions that breastfeeding is difficult in terms of poor milk supply. Further explanations that support this finding are however emerging. Treatment for a PPH will primarily involve ergometrine or a large dose of oxytocin to try and stem bleeding. Intravenous ergometrine reduces breastfeeding, which is consistent with its biological properties (as an dopamine agonist) (Begley et al 1990). ergometrine and oxytocin, separately and together, administered during the third stage of labour may lead to decreased breastfeeding duration (Jordan et al. 2009). Administration of oxytocin may reduce endogenous prolactin and oxytocin (Jonas et al 2009), disrupt feedback mechanisms (Leng et al

2005) and the hormonal balance needed for optimum mother-infant bonding (Jonas et al 2008, 2009, Leng et al 2008; Jordan et al 2009).

Mothers who experienced an assisted delivery appeared unaffected in terms of breastfeeding duration or reasons for stopping breastfeeding. However, the sample size in this study was only sufficient to detect a relatively large effect. Interventions such as forceps or vacuum extraction may interfere with the infants’ ability to latch and suck (Ransjo-Arvidson et al. 2001; Wall & Glass, 2006; Smith, 2007) which in turn can impact upon breastfeeding initiation. Perhaps although the birth has been complicated, women in this group receive lower levels of medication than women experiencing other complications which increases their chances of successful initiation of breastfeeding. Future research needs to examine birth complications in more depth, in particular collecting data about the type of medication a woman

21 receives during the labour and birth and specifically how this might affect her experience of breastfeeding.

A further area to explore in relation to this finding is the psychological impact of birth experience upon breastfeeding duration. Intervention during birth increases risks of psychological birth trauma and postnatal depression (Mancini et al 2007), which in turn has been associated with decreased breastfeeding duration (Dennis &

McQueen, 2009). Although here it appears that birth complications are associated with physical rather than social influences upon breastfeeding cessation, the two may be interlinked. Low maternal confidence and increased anxiety about milk intake, both of which are associated with maternal mental health, can affect beliefs about ability to breastfeed and concerns for milk supply (Thulier & Mercer, 2009).

Where the dominant cultural norm is formula feeding, any difficulties encountered in breastfeeding are likely to prompt a return to that norm. A wider picture is needed.

Conclusion

This study offers insight into the impact of birth experience on breastfeeding experience. It highlights potential breastfeeding difficulties that might arise as a consequence of birth complications allowing support and resources to be targeted to

‘at risk’ women. For example if experience of foetal distress is linked to increased risk of pain and difficulty when breastfeeding, support with regard to latch and establishment of breastfeeding could be offered to such mothers. The demographic characteristics of women culturally indisposed to breastfeeding are well known to

22 midwives. Busy clinicians are forced, by time constraints, to target support. We suggest that complications and drugs administered in labour would serve as an accessible and convenient marker (available at the end of the bed on the drugs’ chart) for high risk of difficulties with latching, which, if not addressed, will lead to early discontinuation and dissatisfaction.

Funding

No funding was received for this work

Conflict of interest

No conflict of interest

Author contributions

AB designed the study, collected data, performed initial data analysis and drafted the manuscript. SJ advised on data analysis. Both AB and SJ were responsible for critical revisions, intellectual content and discussion.

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26 Table One: Items and factor structure of questionnaire examining reasons for stopping breastfeeding: l t y e e e n d r l i a t r g e l y c o a u s i a t u p s P s s d c s i p m a e e f i e r f u

f i r r i S y M L P a D d b o B m E

Breastfeeding was ruining my breasts .64 .13 .05 .12 .23 .05 .01 .25 I wasn’t losing weight .62 .31 .32 .25 .15 -.06 .20 .29 My breasts kept leaking .62 .32 .19 .14 .42 .20 .17 -.02 I wanted my body back for me .58 .18 .03 .15 -.06 .06 -.01 -.06 I didn’t like feeding in public .10 .78 .22 .14 .20 -.04 -.01 -.08 I didn’t like feeding in front of others .01 .71 .09 .25 .06 -.07 .06 -.32 I was stuck in the house breast feeding .30 .76 -.14 .05 .14 .06 .09 .04 I didn’t know anyone else who breast fed .04 .54 .47 .05 .06 .25 .19 .18 The baby wouldn’t latch on properly .24 .17 .69 .10 .04 .17 .13 .12 The baby was feeding all the time .27 .05 .80 .26 .20 .25 .33 .10 My baby wasn’t gaining enough weight -.03 .03 .67 .12 .14 .24 .19 -.09 I didn’t have enough milk -.08 .07 .64 .06 .04 .09 .01 .06 I couldn’t breastfeed .08 .08 .54 .28 .06 .20 .22 .01 I had a very hungry baby .27 .12 .51 .07 .07 .20 .12 .04 Baby didn’t want to breastfeed anymore -.07 .09 .62 -.03 .06 .09 .06 -.03 It was too painful .05 .16 .02 .74 .25 .10 .07 -.10 My nipples were cracked .11 -.18 .07 .69 .11 .69 .10 -.01 I got mastitis, thrush or another similar problem .09 .09 .04 .72 .25 .80 .02 .06 It was too difficult -.12 .20 .07 .84 .48 .22 .04 .05 I never knew when the baby was going to feed -.01 .08 -.13 .31 .78 .23 .15 .10 I didn’t like being responsible for all the feeds .05 .20 .13 .08 .64 .23 .40 .05 I couldn’t keep track of milk intake .15 .10 .32 .29 .65 .40 .22 .01 I couldn’t leave the baby .04 -.10 .13 .18 .59 .16 .07 .01 I couldn’t go out and socialise .15 .26 -.05 .02 .88 -.08 .33 -.06 I couldn’t drink alcohol .20 .08 .05 -.04 .78 .10 .08 .03 I wanted a more predictable routine .19 .18 .24 .29 .68 .28 .29 -.12 I had breast fed for long enough .04 .07 .20 .08 .72 .01 .16 .40 My partner wanted me to stop .02 .20 .08 .02 .20 .81 .39 .13 My mother wanted me to stop .08 .09 .01 .41 .16 .76 .42 .23 Friends wanted me to stop .02 .26 .19 .06 -.08 .66 .29 .10 Other people made negative comments -.04 15 -.05 .12 .10 .78 .45 .11 Other people felt excluded .15 .24 .16 -.05 .04 .67 .25 .13 I couldn’t get any help with problems .10 .32 .22 -.05 .28 .02 .82 .01 I didn’t have enough support .47 .18 .19 .04 .28 .19 .56 .20 I couldn’t get any professional advice .08 .32 .54 .13 .11 -.18 .63 .37 I was exhausted .40 .13 .72 .21 .03 .15 .54 .82 I wasn’t well .28 .12 .66 .0 .02 -.02 .22 .58 The baby wasn’t well .33 .08 .15 .15 .02 .20 .05 .78 I was taking medication .05 .29 .18 .41 .19 -.13 .32 .62 A health professional advised me to stop .22 .28 -.05 .22 .25 .15 -.11 .88 Percentage of variance explained 20.86 6.99 5.12 4.74 3.74 3.09 2.76 2.63

Cronbach’s alpha .81 .78 .72 .67 .65 .75 .65 .72 Table one shows regression scores for each item and how they load onto each factor produced. Items in bold signify items which group strongly on each factor

27 Table two: Differences in breastfeeding duration by experience (yes/no) of specific birth complications

Complication Breastfeeding duration in days Significance Effect size Cohen’s d Yes No

Severe tear 10.95 (1.08) 13.50 (2.92) F (1, 282) = .424, p = .52 .09 (n = 21) (n = 263)

Foetal 8.93 (2.19) 14.52 (1.15) F (1, 282) = 5.07, p = .02 .61 distress (n = 62) (n = 223)

Failure to 7.92 (2.21) 13.88 (1.10) F (1, 282) = 5.21, p = .02 .62 progress (n = 27) (n = 257)

Assisted 10.23 (1.60) 13.87 (1.17) F (1, 282) = 1.62, p = .21 .25 delivery (n = 43) (n = 241)

Post partum 3.43 (.87) 13.91 (1.07) F (1, 282) = 5.63, p = .02 .66 haemorrhage (n = 16) (n = 268)

Caesarean 9.42 (1.01) 15.78 (1.23) F (1, 282) = 9.36, p = .002 .86 delivery (n = 110) (n = 174)

Any 10.02 (1.12) 16.02 (1.03) F (1, 282) = 10.00, p = .002 .88 complication (n = 148) (n = 136)

Table shows mean breastfeeding duration in days and standard deviations for those who experienced the complication or did not. Data were normally distributed.

28 Table Three: Reasons for stopping breastfeeding by experience of birth complications

Reason for Complications No complications Significance Effect stopping size

Too difficult 4.34 (.49) 3.16 (.50) F (1, 255) = 7.46 p = .01 .63

Pain 4.58 (.42) 3.22 (.48) F (1, 255) = 6.30, p = 0.01 .70

Pressure from 3.62 (.47) 3.14 (.47) F (1, 255) = 3.90, p = .04 .39 others

Impact upon 2.64 (.47) 2.85 (.41) F (1, 255) = .91, p = .34 .15 lifestyle

Body image 1.66 (.48) 1.65 (.44) F (1, 255) = .052, p = .82 .05

Lack of support 2.33 (.48) 2.27 (.49) F (1, 255) = .61, p = .44 .12

Medical reasons 1.78 (.41) 1.80 (.40) F (1, 255) = 0.53, p = .88 .05

Embarrassed 1.57 (.50) 1.53 (.48) F (1, 255) = .20, p = .20 .10

Table 3 shows both the mean scores (for reasons for discontinuing breastfeeding) for each group. The scores displayed are used for ease of comparison and are based on the mean score (as per likert scale response 1 to 5) for each of the items that clustered on each factor. Means and standard deviations are shown. A higher score represents a strong agreement. Data were normally distributed.