Hospital Care and Early Breastfeeding Outcomes Among Late Preterm, Early-Term, and Term Infants Neera K. Goyal, MD, MSc, Laura B. Attanasio, BA, and Katy B. Kozhimannil, MPA, PhD ABSTRACT: Background: Compared with term infants (39–41 weeks), early-term
(37–38 weeks) and late preterm (34–36 weeks) infants have increased breastfeeding difﬁculties. We evaluated how hospital practices affect breastfeeding by gestational age. Methods: This Listening to Mothers III survey cohort included 1,860 mothers who delivered a 34–41-week singleton from July 2011 to June 2012. High hospital support was deﬁned as at least seven practices consistent with the Baby-Friendly Hospital Initiative’s Ten Steps for United States hospitals. Logistic regression tested mediating effects of hospital support on the relationship between gestational age and breastfeeding at 1 week postpartum. Results: High hospital support was associated with increased exclusive breastfeeding (AOR 2.21 [95% CI 1.58–3.09]). Just 16.4 percent of late preterm infants experienced such support, compared with early-term (37.9%) and term (30.7%) infants (p = 0.004). Although overall breastfeeding rates among late preterm, early-term, and term infants were 87, 88, and 92 percent, respectively, (p = 0.21), late preterm versus term infants were less likely to exclusively breastfeed (39.8 vs. 62.3%, p = 0.002). Inclusion of hospital support in multivariable modeling did not attenuate the effect of late preterm gestation. Discussion: Differences in practices do not account for decreased exclusive breastfeeding among late preterm infants. Hospital supportive practices increase the likelihood of any breastfeeding. (BIRTH 2014) Key words: Baby-Friendly Hospital Initiative, breastfeeding, early-term, hospital practices, late preterm
Given known maternal and infant health beneﬁts of breastfeeding, efforts such as The Joint Commission’s Perinatal Care Core Quality Measures and the BabyFriendly Hospital Initiative include a strong emphasis on supportive practices during childbirth hospitalization to promote breastfeeding (1,2). For late preterm infants, delivered at 34–36 weeks’ gestation and representing 70 percent of all preterm infants, breastfeeding may be
particularly important for long-term physical and developmental health (3). However, this population is at risk for poorer breastfeeding outcomes, including early breastfeeding cessation, parental feeding-related anxiety, and rehospitalization for feeding issues compared with infants born at 37 weeks’ or greater gestation (3–6). It is not yet known whether these infants have differential access to evidence-based supportive hospital practices (7).
Neera K. Goyal is an Assistant Professor of Pediatrics at the Division of Neonatology and Division of Hospital Medicine, Cincinnati Children’s Research Foundation and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Laura B. Attanasio is a Doctoral student at the Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA; Katy B. Kozhimannil is an Assistant Professor at the Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
Address correspondence to: Neera K. Goyal, Cincinnati Children’s Hospital Medical Center Department of Pediatrics, 3333 Burnet Ave., ML# 7009, Cincinnati, OH 45229, USA.
Accepted August 25, 2014 © 2014 Wiley Periodicals, Inc.
2 More recently, evidence has emerged that even among early-term infants, delivered at 37–38 weeks, feeding difﬁculty and other complications are more likely than for those born at 39–41 weeks (8). Like late preterm infants, early-term infants are less likely than term infants to initiate breastfeeding and less likely to continue breastfeeding after discharge (9). Additional research demonstrates higher risk of rehospitalization for feeding-related issues compared with term infants (10), suggesting a relative physiologic immaturity that may have important implications at a population level. Prior studies have conclusively demonstrated the importance of hospital practices, such as limiting formula supplementation and rooming-in of infants with their mothers, for both short-term and long-term breastfeeding success (11,12). However, only limited evidence is there for how such aspects of hospital care contribute to early outcomes among infants born at earlier gestational ages (7). Among late preterm infants in particular, who are more likely than term and earlyterm infants to be cared for in neonatal intensive care unit (NICU) settings (13), variation in hospital management including feeding policies and protocols for length of stay may contribute to differential breastfeeding outcomes (14,15). At least one prior study has demonstrated that NICU admission for late preterm infants may be protective against readmission after discharge, although the extent to which the admission is due to differences in formula supplementation or other interventions is unclear (14). The purpose of the current study is to determine whether supportive hospital practices mediate the relationship between gestational age at birth and breastfeeding outcomes at 1 week postpartum among late preterm, early-term, and term newborns, adjusting for
Comorbidities Obstetrical complications Social factors
Methods Data Data for this analysis came from the Listening to Mothers III survey, a national sample of women who gave birth to a singleton baby in a United States hospital between July 1, 2011, and June 30, 2012 (N = 2,400). Commissioned by Childbirth Connection and conducted by Harris Interactive, this survey addresses the labor and birth experience, including questions about breastfeeding plans, hospital practices, and feeding patterns. Women completed the survey at an average of 11 months postpartum (range 4–18 months). Potential respondents were drawn from the Harris Poll Online, GMI, Research Now/E-Rewards, and Offerwise Hispanic panels. Eligible participants completed the survey online using a secure server with advanced webassisted interviewing technology. Survey responses were weighted using propensity score methods to adjust for potential biases associated with the online survey mode, and further weighted to match the demographic characteristics of the sample to those of the target population (16). The ﬁnal, weighted sample approximates nationally representative estimates, and weights are used throughout the analysis to retain this feature.
Maternal factors • •
demographic and clinical factors. As shown in the conceptual model presented in Fig. 1, we hypothesized that, compared with term newborns, early-term and late preterm newborns may have a lower likelihood of exclusive breastfeeding, but that this effect could be partially mediated by differences in access to supportive practices during hospitalization.
Delivery prior to 37 weeks
Decreased likelihood of breastfeeding
? Differences in care, i.e., NICU admission, late preterm feeding protocols
Limited in-hospital breastfeeding support
Fig. 1. Conceptual model for mediating effect of in-hospital support. Arrows depict hypothesized casual relationships. Question mark indicates primary study question. Text in bold represents the key independent variable tested as a mediator of relationship between late preterm birth and decreased likelihood of breastfeeding.
Further details about the survey methodology and questionnaire are available at the website www.childbirthconnection.org/listeningtomothers/. This study was approved by the University of Minnesota Institutional Review Board.
Study Population All 2,400 respondents were asked at the time of the survey to recall how they intended to feed their infant as they approached the end of pregnancy. Hospital practices and breastfeeding outcomes were assessed among women who reported intending to breastfeed (either exclusively or in combination with formula); therefore, the sample was limited to infants whose mothers intended to breastfeed. The ﬁnal study population included 126 late preterm, 355 early-term, and 1,379 term infants, totaling 1,860.
Variable Measurement Gestational age was calculated based on maternal report of due date and the infant’s date of birth. This calculation was then categorized as late preterm (34 0/7–36 6/ 7 weeks), early-term (37 0/7–38 6/7 weeks), or term (39 0/7–41 6/7 weeks) (8). As per the most recent gestational age deﬁnitions from the American College of Obstetrics and Gynecology, our categorization of term infants includes both term (39 0/7–40 6/7 weeks) and late-term (41 0/7–41 6/7 weeks) infants (17). Our two primary outcomes were breastfeeding at 1 week postpartum (either exclusively or in combination with formula) and exclusive breastfeeding at 1 week. Breastfeeding outcomes for other speciﬁed time intervals were not available in the survey. We also examined women’s experiences of hospital practices consistent with the Baby-Friendly Hospital Initiative’s Ten Steps for United States Hospitals (1,18), which have been shown to be positively associated with breastfeeding initiation and duration (11,12). The survey included measures for the following BabyFriendly practices: infant in mother’s arms during ﬁrst postpartum hour, rooming-in, hospital staff helped initiate breastfeeding, hospital staff demonstrated infant positioning for breastfeeding, hospital encouraged breastfeeding on demand, hospital staff did not provide water or formula supplements, hospital staff provided information on community breastfeeding resources, and hospital staff did not offer a paciﬁer. Baby-Friendly practices not available in the survey were the availability of a written breastfeeding policy for hospital staff and training of hospital staff in policy implementation.
We also measured whether the woman reported having skin-to-skin contact the ﬁrst time she held her baby. Often called “Kangaroo Care,” this practice is also associated with breastfeeding success (19) and may be particularly important for late preterm infants (20). We created a series of indicator variables for each practice, and a composite measure, which we calculated by assigning one point for each practice and adding up the total (range 0–9). Women with scores of 7–9 on the measure were categorized as having experienced a high level of hospital support for breastfeeding (21). Sociodemographic and birth-related covariates were based on the conceptual model and available evidence on factors associated with breastfeeding (22,23). These included maternal age, race-ethnicity, payer source, education level, marital status, and parity. Obstetrical covariates included delivery mode (vaginal or cesarean) and a composite variable for pregnancy risk factors which included prepregnancy hypertension requiring medication, preexisting or gestational diabetes, and prepregnancy obesity (body mass index ≥ 30). An indicator variable for complications of labor or delivery represented when cesarean delivery was indicated for malpresentation, fetal distress, macrosomia, placentation disorders, failed induction, disproportion, or other major health concerns. Labor and delivery was also classiﬁed as complicated if labor was induced for macrosomia, premature rupture of membranes, oligohydramnios, fetal distress, or other major health concern. An indicator variable for NICU admission was also assigned. Finally, intention to exclusively breastfeed was also included as a measure of high maternal motivation level.
Analysis We ﬁrst examined bivariate associations between breastfeeding outcomes and gestational age category, high hospital support, and other covariates. Using multivariable logistic regression, we then conducted a mediation analysis, ﬁrst testing whether gestational age category was independently associated with differences in likelihood of receiving a high level of hospital support (Step 1). We then used a similar regression model to estimate the independent effect of gestational age category on odds of any and exclusive breastfeeding at 1 week (Step 2). Next, we estimated the independent effect of experiencing a high level of supportive hospital practices on odds of any and exclusive breastfeeding at 1 week (Step 3). Finally, both gestational age category and high hospital support were included in the multivariable models of any and exclusive breastfeeding to assess changes in the absolute value of the coefﬁcient for gestational age category (Step 4) (24). In a sensitivity analysis, we tested multiple different model
4 speciﬁcations and added interaction terms to these models to determine whether the relationship between supportive hospital practices and breastfeeding outcomes varied by gestational age. Somers’ D values were used to provide valid C-statistic estimates for the weighted data (25). All analyses were conducted using Stata v.12.
Step 2 of the analysis, also shown in Table 2, demonstrated the independent effect of late preterm gestational age on breastfeeding outcomes at 1 week postpartum. Compared to term infants, late preterm infants had less than half the odds of being breastfed exclusively at 1 week of life (AOR 0.38 [95% CI 0.23–0.65]). C-statistic values for the any breastfeeding and exclusive breastfeeding models were 0.73 and 0.76, respectively.
Results Covariates, key predictors, and breastfeeding outcomes of the sample by gestational age category are reported in Table 1. Sample characteristics generally mirror those of the United States childbearing population, with late preterm infants generally experiencing greater prevalence of clinical complications of pregnancy and delivery, including cesarean delivery and admission to the NICU. Fewer mothers of late preterm infants experienced several hospital practices intended to promote breastfeeding. For example, 29.9 percent reported holding their infants during the ﬁrst hour after birth, compared with 51.6 percent of term infants. Just over a third (36.7%) of late preterm infants roomed in with their mothers, versus 67.6 percent of early-term and 64.7 percent of term infants. However, more mothers of late preterm infants and early-term infants (58.6 and 60.6%, respectively) reported receiving information about community breastfeeding resources, compared with mothers of term infants (48.4%). Only 16.4 percent of mothers with late preterm infants experienced a high level of supportive breastfeeding practices (7–9 of the practices examined), compared with 37.9 percent of mothers with early-term infants and 30.7 percent of mothers with term infants.
Effects of Gestational Age on Hospital Support and Breastfeeding Outcomes Table 2 demonstrates Step 1 of the mediation analysis, in which we assessed the effect of gestational age on receipt of high hospital support after adjusting for NICU admission and other covariates. There was no signiﬁcant difference in odds of high hospital breastfeeding support for late preterm infants compared with term infants (adjusted odds ratio [AOR] 0.64 [95% conﬁdence interval (CI) 0.33–1.24]). There was a trend for early-term infants, however, to have a higher level of hospital support compared with term infants (AOR 1.44 [95% CI 1.00–2.04]). In this model, NICU admission was independently associated with a reduced likelihood of receiving high breastfeeding support, (AOR 0.34 [95% CI 0.20–0.62]).
Effect of Hospital Practices on Breastfeeding Outcomes Step 3 of the mediation analysis conﬁrmed the association between high hospital support and breastfeeding outcomes after controlling for covariates. We observed that a high level of hospital support for breastfeeding was independently associated with increased odds of any breastfeeding at 1 week (AOR 3.58 [95% CI 1.72– 7.50]) and exclusive breastfeeding at 1 week (AOR 2.32 [95% CI 1.67–3.24]).
Final Multivariable Model of Breastfeeding Outcomes For Step 4 of the mediation analysis, gestational age and high hospital support were included in a multivariable model of breastfeeding outcomes, adjusting for other covariates (Table 3). Including hospital practices in this model resulted in small increases in the C-statistic values for both any and exclusive breastfeeding, now 0.76 and 0.80, respectively. However, the effects of late preterm gestation were unchanged, such that late preterm infants still had less than half the odds of exclusive breastfeeding at 1 week postpartum compared with term infants (AOR 0.40 [95% CI 0.24–0.68]). Thus, results of this mediation analysis indicate that differential access to hospital supportive practices, although an important independent predictor, does not mediate the observed relationship between gestational age and breastfeeding outcomes. Lastly, to further characterize the impact of speciﬁc Baby-Friendly practices on breastfeeding outcomes, we repeated the mediation analysis with each of the nine practices as individual variables (Table 4). Adjusting for other covariates, late preterm infants were less likely than term infants to be held in the mothers’ arms during the ﬁrst hour of life and to room in, and they were more likely to be offered a paciﬁer (Table 4, column 1). There were also trends for late preterm infants to have decreased likelihood of formula supplementation withheld and decreased likelihood of early skin-toskin contact; however, these did not achieve statistical signiﬁcance (p > 0.05). When these individual practices
Table 1. Characteristics and Outcomes by Gestational Age Category Among Women Who Intended to Breastfeed (N = 1,860)*
Covariates Socio demographic Age category 18–24 25–29 30–34 35 or older First-time mother Married Race/Ethnicity White, non-Hispanic Black/African-American, non-Hispanic Hispanic/Latina Other or multiple race Education High school or less Some college Bachelor’s degree Graduate school Pregnancy and delivery characteristics Intention to exclusively breastfeed Complications of labor or delivery† Delivery mode Vaginal Cesarean Pregnancy risk factors (prepregnancy obesity, diabetes, or hypertension) Baby was in NICU Outcomes Hospital breastfeeding support measure components Baby in mother’s arms during ﬁrst hour after birth Baby roomed in with mother Hospital staff helped start breastfeeding Hospital staff showed how to position baby for breastfeeding Hospital encouraged breastfeeding on demand Hospital staff did NOT provide water or formula supplements Hospital staff gave information re: community breastfeeding resources Hospital staff did NOT give baby a paciﬁer First time holding baby was skin-to-skin High level of hospital support (score 7–9) Any breastfeeding at 1 week Exclusive breastfeeding at 1 week
Late preterm (34–36 weeks)
Early term (37–38 weeks)
Term (39–41 weeks)
N = 126
N = 355
N = 1,379
37 32 34 23 42 94
(29.1) (25.5) (27.1) (18.3) (33.6) (74.8)
97 102 117 39 109 230
(27.4) (28.8) (32.9) (10.9) (30.8) (64.7)
449 386 329 215 625 870
(32.5) (28.0) (23.9) (15.6) (45.3)* (63.1)
64 18 42 2
(50.8) (14.1) (33.3) (1.8)
169 49 111 27
(47.4) (13.7) (31.3) (7.6)
773 196 308 102
(56.0) (14.2) (22.3) (7.4)
54 37 20 14
(42.9) (29.6) (16.1) (11.5)
146 107 63 40
(41.1) (30.1) (17.7) (11.2)
524 407 279 170
(38.0) (29.5) (20.2) (12.3)
79 (62.4) 49 (38.7)
266 (74.9) 124 (34.8)
895 (64.9) 329 (23.8)*
66 60 43 61
(52.6) (47.4) (34.3) (48.6)
238 117 125 51
(67.1) (32.9) (35.2) (14.3)
988 391 467 187
(71.6)* (28.4) (33.8) (13.5)*
38 46 95 79 80 59 74 50 67 21 110 50
(29.9) (36.7) (75.2) (62.5) (63.7) (46.5) (58.6) (40.0) (53.1) (16.4) (87.1) (39.8)
156 240 296 263 263 222 215 220 210 135 313 211
(44.0) (67.6) (83.3) (74.0) (74.1) (62.4) (60.6) (61.9) (59.2) (37.9) (88.0) (59.5)
711 893 1,102 867 897 898 668 844 866 423 1,272 859
(51.6)* (64.7)* (79.9) (62.9)* (65.0) (65.1)* (48.4)* (61.2)* (62.8) (30.7)* (92.3) (62.3)*
*Denote Chi-squared p < 0.05. †Complications of labor or delivery were coded if the reported reason for cesarean delivery was that the “baby was in wrong position,” “fetal distress,” “baby too big,” “placenta problem,” “health condition called for it,” “failed induction,” and “baby was having trouble ﬁtting”; or if the reason for labor induction was “concern about baby’s size,” “water had broken,” “low amniotic ﬂuid,” “baby not doing well,” or “health problem called for it.”
6 were included in the ﬁnal multivariable model of breastfeeding outcomes, the negative effect for late preterm status on exclusive breastfeeding persisted but was slightly attenuated (AOR 0.48 [95% CI 0.27– 0.87]) (Table 4, column 3).
exclusive breastfeeding between late preterm and term infants. Similar to prior studies, high levels of hospital support dramatically increase the likelihood of breastfeeding; our results also support that this bundle of practices is effective for infants at late preterm, early term, and term gestations.
Sensitivity Analysis We conducted sensitivity analyses with high hospital support deﬁned as scores of 8–9, and results were substantively unchanged. We also repeated the analysis using the hospital support variable as a continuous rather than binary measure, and results were substantively unchanged. In the full multivariable model including gestational age, NICU admission, and other covariates, increasing number of supportive practices was associated with higher odds of any and exclusive breastfeeding (AOR approximately 1.45 in both models, p < 0.001). We also tested for interaction terms between gestational age category and hospital support, which were not signiﬁcant, indicating that the effect of hospital support does not differ by gestational age (results not shown).
Discussion While the association between lower breastfeeding rates and late preterm birth has been previously described, the speciﬁc contribution of hospital practices to this relationship has not previously been investigated. We show that, although supportive practices are less frequent among late preterm infants, lower access to this support as a whole does not contribute to differences in
Table 3. Multivariable Logistic Regression of Gestational Age on Breastfeeding Outcomes Adjusting for High Hospital Support, AOR with 95% CI (N = 1,860)*
Gestational age Term (reference) Early term Late preterm Admission to NICU High level of support†
Any breastfeeding at 1 week postpartum‡
Exclusive breastfeeding at 1 week postpartum§
AOR (95% CI)
AOR (95% CI)
1.00 0.58 (0.31–1.07) 0.65 (0.22–1.89) 1.69 (0.82–3.47)
1.00 0.68 (0.46–1.02) 0.40 (0.24–0.68) 0.94 (0.61–1.46)
Bold values indicate p < 0.05. *Models are weighted to approximate the United States national population and are adjusted for maternal age, marital status, parity, race, ethnicity, labor and delivery complications, delivery mode, intention to exclusively breastfeed, and pregnancy risk factors. †Indicates receipt of 7–9 of the practices examined: infant in mother’s arms during ﬁrst postpartum hour, rooming-in, hospital staff helped initiate breastfeeding, hospital staff demonstrated infant positioning for breastfeeding, hospital encouraged breastfeeding on demand, hospital staff did not provide water or formula supplements, hospital staff provided information on community breastfeeding resources, hospital staff did not offer a paciﬁer, and early skin-to-skin contact. ‡C-statistic = 0.76. §C-statistic = 0.80.
Table 2. Multivariable Logistic Regression of Gestational Age on Receipt of High Hospital Support and Breastfeeding Outcomes, AOR With 95% CI (N = 1,860)*
Gestational age Term (reference) Early term Late preterm Admission to NICU
High hospital , support† ‡
Any breastfeeding at 1 week postpartum§
Exclusive breastfeeding at 1 week postpartum¶
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
1.00 1.43 (1.00–2.04) 0.64 (0.33–1.24) 0.34 (0.20–0.62)
1.00 0.63 (0.33–1.19) 0.60 (0.21–1.76) 1.46 (0.70–3.03)
1.00 0.72 (0.48–1.06) 0.38 (0.23–0.65) 0.84 (0.54–1.32)
Bold values indicate p < 0.05. *Models are weighted to approximate the United States national population and are adjusted for maternal age, marital status, parity, race, ethnicity, labor and delivery complications, delivery mode, and pregnancy risk factors. Breastfeeding outcome models are also adjusted for intention to exclusively breastfeed. †Indicates receipt of 7–9 of the practices examined: infant in mother’s arms during ﬁrst postpartum hour, rooming-in, hospital staff helped initiate breastfeeding, hospital staff demonstrated infant positioning for breastfeeding, hospital encouraged breastfeeding on demand, hospital staff did not provide water or formula supplements, hospital staff provided information on community breastfeeding resources, hospital staff did not offer a paciﬁer, and early skin-to-skin contact. ‡C-statistic = 0.66. §C-statistic = 0.73. ¶C-statistic = 0.78.
Hospital Supportive Practices for Late Preterm Infants Our analyses demonstrate that late preterm infants compared with term infants are less likely to experience several hospital practices intended to support breastfeeding, including being held in their mother’s arms during the ﬁrst hour of life, rooming-in, and withholding of a paciﬁer. Our results demonstrate that as a bundle of practices, high hospital support is strongly predictive of any breastfeeding and of exclusive breastfeeding. However, our analysis including each of the practices as individual factors demonstrates that early skin-to-skin contact may be particularly important for both any and exclusive breastfeeding, independent of gestational age, NICU admission, and other covariates.
Early Breastfeeding Outcomes of Late Preterm Infants Results of our mediation analysis demonstrate that although supportive practices are strongly predictive of higher breastfeeding rates, the relationship between late preterm birth and early breastfeeding is not substantively driven by differential access to these supportive
practices as a whole. The magnitude of the difference in rates of exclusive breastfeeding between late preterm and term infants is similar, whether or not these supports were provided. These results suggest that the physiologic challenges associated with late prematurity, that is, feeding dysfunction, hypoglycemia, and temperature instability, provide logistical barriers in this population that often supersede the beneﬁts of high-quality hospital supportive care. Our ﬁndings also suggest a trend toward decreased likelihood among late preterm infants of any breastfeeding, consistent with a recent report using 2000–2008 Pregnancy Risk Assessment Monitoring System (PRAMS) data, in which Hwang et al report a 5 percent lower likelihood of initiating breastfeeding between late preterm and term infants (9). Of note, differences in breastfeeding outcomes between late preterm and term infants persisted after adjustment for NICU admission. Our observation that NICU admission was associated with decreased likelihood of supportive practices likely reﬂects the impact of higher clinical severity. When included in the full multivariable models with gestational age, supportive practices, and covariates, NICU admission itself was not associated with signiﬁcant differences in either any or exclusive breastfeeding at 1 week.
Table 4. Multivariable Logistic Regression Analyses Using Individual Hospital Practices*
Individual support measures Baby in mother’s arms during ﬁrst hour Baby roomed in with mother Staff helped start breastfeeding Staff showed how to position baby for breastfeeding Encouraged breastfeeding on demand Staff did NOT provide water or formula supplements Staff gave information re: community breastfeeding resources Staff did NOT give baby a paciﬁer First time holding baby was skin-to-skin Gestational age Term (reference) Early term Late preterm NICU admission
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
AOR (95% CI)
0.40 (0.22–0.72) 1.40 (0.90–2.17) 1.11 (0.60–2.05)
1.07 (0.76–1.50) 0.82 (0.41–1.61) 1.90 (1.35–2.67)
1.84 (1.09–3.12) 1.29 (0.67–2.49) 1.39 (0.72–2.69)
1.30 (0.93–1.81) 1.29 (0.84–1.98) 1.17 (0.79–1.74)
1.23 (0.63–2.40) 0.58 (0.33–1.00)
1.53 (1.05–2.22) 0.91 (0.64–1.29)
1.91 (1.08–3.37) 1.32 (0.80–2.19)
1.10 (0.75–1.61) 2.69 (1.91–3.79)
0.40 (0.23–0.71) 0.58 (0.32–1.05)
0.98 (0.69–1.38) 0.92 (0.59–1.14)
1.55 (0.95–2.54) 1.90 (1.16–3.11)
1.11 (0.80–1.55) 1.68 (1.20–2.36)
1.00 0.62 (0.34–1.09) 0.86 (0.26–2.84) 1.82 (0.85–3.88)
1.00 0.72 (0.48–1.08) 0.48 (0.27–0.87) 1.01 (0.64–1.59)
Bold values indicate p < 0.05. *Models are weighted to approximate the United States national population and are adjusted for maternal age, marital status, parity, race, ethnicity, labor and delivery complications, delivery mode, and pregnancy risk factors. Breastfeeding outcome models are also adjusted for intention to exclusively breastfeed. AORs in columns 1 and 2 represent likelihood of each practice compared with the reference group of term infants. AORs in columns 3 and 4 represent associations of each variable with breastfeeding outcomes.
8 Early Breastfeeding Behaviors and Early-Term Infants We found that early-term infants were more likely to receive a high level of breastfeeding support compared with term infants. Possibly this difference reﬂects a perception of these infants as being more vulnerable compared with term infants, coupled with fewer logistical barriers compared with late preterm infants. Of note, although outcome differences between early-term and term infants were not statistically signiﬁcant, we did observe trends toward lower likelihood of any and exclusive breastfeeding. For the outcome of any breastfeeding, this trend was even more pronounced than for the late preterm infants, perhaps attributable to shorter lengths of stay and less follow-up support after discharge (9).
Implications for Clinical Care and Future Research Taken together, these ﬁndings highlight the impact of hospital support regardless of gestational age for mothers who intend to breastfeed in meeting their goals. Late preterm infants and their mothers may beneﬁt from adaptation of Baby-Friendly Hospital practices, particularly in Level 2 and Level 3 NICU settings as the clinical situation permits. Future research may focus further on hospital-level factors contributing to differential outcomes for late preterm infants, including policies for NICU admission and late preterm infant feeding protocols. Further research may also focus on how hospital support linked with high-quality follow-up support of breastfeeding (i.e., home visits) contributes to longterm breastfeeding within these gestational age categories (26).
Limitations The primary limitation of this study is our reliance on maternal self-report and lack of conﬁrmation of data through hospital records, further compounded by retrospective collection of information many months after the infant’s birth date. This limitation may contribute to recall or social desirability bias in reporting breastfeeding intention, particularly among women who were unable to successfully breastfeed. Success or lack of success in breastfeeding may also contribute to selective maternal recall bias about the availability of supportive hospital practices. Additional limitations of the study include sample size and lack of information on breastfeeding outcomes at other designated follow-up intervals (e.g., 3 months or 6 months). Moreover, analyses were limited to the outcomes reported in this study and did not contain details on
expression of breastmilk, paced feeding, or whether supplementation was clinically warranted. Finally, one hospital-level factor we lacked information on, in addition to establishment of a written breastfeeding policy and hospital staff training, is the level of NICU care provided at the birth hospital, that is Level 2 versus Level 3, which would help further characterize the impact of NICU admission on aspects of breastfeeding support. Strengths of this study include a sample of women from across the United States, data that reﬂect recent practices and experience of care, and the inclusion of variables not otherwise available in medical records or administrative data.
Conclusions Infants born late preterm have considerably higher risk of complications that must be balanced against the substantial beneﬁts of breastfeeding. Our analysis demonstrates that these infants, independent of other factors, are less likely to experience hospital practices supportive of breastfeeding. However, reduced access to this support does not substantially account for their lower exclusive breastfeeding rates compared with term infants. High levels of hospital support dramatically increase the likelihood of breastfeeding for infants regardless of gestational age, suggesting that such practices should be routinely provided as the clinical situation allows.
Acknowledgments This research was supported by grants from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD; grant number R03HD070868) and the Building Interdisciplinary Research Careers in Women’s Health program (grant numbers 5K12HD051953-07 and K12HD055887), cofunded by the NICHD, the Ofﬁce of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the Center for Clinical and Translational Science and Training at University of Cincinnati and the University of Minnesota Deborah E. Powell Center for Women’s Health. The content is solely the responsibility of the authors and does not necessarily represent the ofﬁcial views of the National Institutes of Health.
References 1. The Joint Commission. Perinatal Care. Accessed January 28, 2014, Available at: http://www.jointcommission.org/perinatal_care/.
2. World Health Organization. Baby-friendly Hospital Initiative. Accessed Feruary 7, 2014, Available at: http://www.who.int/ nutrition/topics/bfhi/en/. 3. Radtke JV. The paradox of breastfeeding-associated morbidity among late preterm infants. J Obstet Gynecol Neonatal Nurs 2011;40:9–24. 4. Lapillonne A, O’Connor DL, Wang D, Rigo J. Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge. J Pediatr 2013;162:S90–S100. 5. DeMauro SB, Patel PR, Medoff-Cooper B, et al. Postdischarge feeding patterns in early- and late-preterm infants. Clin Pediatr (Phila) 2011;50:957–962. 6. McDonald SW, Benzies KM, Gallant JE, et al. A comparison between late preterm and term infants on breastfeeding and maternal mental health. Matern Child Health J 2013;17(8):1468– 1477. 7. Nyqvist KH, Haggkvist AP, Hansen MN, et al. Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations. J Hum Lact 2013;29:300–309. 8. Spong CY. Deﬁning “term” pregnancy: Recommendations from the Deﬁning “Term” Pregnancy Workgroup. JAMA 2013;309:2445–2446. 9. Hwang SS, Barﬁeld WD, Smith RA, et al. Discharge timing, outpatient follow-up, and home care of late-preterm and early-term infants. Pediatrics 2013;132:101–108. 10. Ray KN, Lorch SA. Hospitalization of early preterm, late preterm, and term infants during the ﬁrst year of life by gestational age. Hosp Pediatr 2013;3:194–203. 11. Brodribb W, Kruske S, Miller YD. Baby-friendly hospital accreditation, in-hospital care practices, and breastfeeding. Pediatrics 2013;131:685–692. 12. Perrine CG, Scanlon KS, Li R, et al. Baby-Friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics 2012;130:54–60. 13. Melamed N, Klinger G, Tenenbaum-Gavish K, et al. Short-term neonatal outcome in low-risk, spontaneous, singleton, late preterm deliveries. Obstet Gynecol 2009;114:253–260.
9 14. Escobar GJ, Greene JD, Hulac P, et al. Rehospitalisation after birth hospitalisation: Patterns among infants of all gestations. Arch Dis Child 2005;90:125–131. 15. McCormick MC, Escobar GJ, Zheng Z, Richardson DK. Place of birth and variations in management of late preterm (“nearterm”) infants. Semin Perinatol 2006;30:44–47. 16. Declercq ER, Sakala C, Corry MP, et al. Listening to Mothers SM III: Pregnancy and birth/Appendix A: Methodology. New York: Childbirth Connection, 2013. 17. American College of Obstetricians and Gynecologists. Deﬁnition of term pregnancy. Committee Opinion No. 579. Obstet Gynecol 2013;122:1139–1140. 18. World Health Organization. UNICEF. Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Geneva, Switzerland: World Health Organization and UNICEF; 2009. 19. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skinto-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012;5:CD003519. 20. Jefferies AL. Kangaroo care for the preterm infant and family. Paediatr Child Health 2012;17:141–146. 21. Declercq E, Labbok MH, Sakala C, O’Hara M. Hospital practices and women’s likelihood of fulﬁlling their intention to exclusively breastfeed. Am J Public Health 2009;99:929–935. 22. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607–619. 23. Heck KE, Braveman P, Cubbin C, et al. Socioeconomic status and breastfeeding initiation among California mothers. Public Health Rep 2006;121:51–59. 24. MacKinnon DP, Fairchild AJ, Fritz MS. Mediation analysis. Annu Rev Psychol 2007;58:593–614. 25. Newson R. Conﬁdence intervals for rank statistics: Somers’ D and extensions. The Stata J 2006;6:309–334. 26. McKeever P, Stevens B, Miller KL, et al. Home versus hospital breastfeeding support for newborns: A randomized controlled trial. Birth 2002;29:258–265.