513072

research-article2013

JHLXXX10.1177/0890334413513072Journal of Human LactationRamakrishnan et al

Original Research

The Association between Maternal Perception of Obstetric and Pediatric Care Providers’ Attitudes and Exclusive Breastfeeding Outcomes

Journal of Human Lactation 2014, Vol 30(1) 80­–87 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334413513072 jhl.sagepub.com

Rema Ramakrishnan, MPH1, Charles N. Oberg, MD, MPH2, and Russell S. Kirby, PhD, MS, FACE3

Abstract Background: Exclusive breastfeeding is recommended for 6 months. Successful breastfeeding requires support from family members, peers, and health care professionals. Objective: This study aimed to determine the association between maternal perception of the attitudes of obstetric and pediatric care providers about infant feeding during the neonatal period and exclusive breastfeeding at 1, 3, and 6 months. Methods: The study sample consisted of 1602 women from the Infant Feeding Practices Study II (2005-2007), a longitudinal study of women in the United States. Analyses included chi-square and Fisher’s exact tests and logistic regression models. Results: Mothers who perceived that the obstetric care provider favored exclusive breastfeeding were significantly more likely to exclusively breastfeed their infants at 1 and 3 months (odds ratio [OR] = 1.73, 95% confidence interval [CI], 1.33-2.24; and OR = 1.41, 95% CI, 1.09-1.80, respectively) as compared to mothers who perceived that the obstetric care provider was neutral about the type of infant feeding. Similarly, mothers who perceived that the pediatric care provider favored exclusive breastfeeding had higher odds of exclusively breastfeeding their infants at 1 and 3 months (OR = 1.53, 95% CI, 1.17-1.99; and OR = 1.51, 95% CI, 1.17-1.95, respectively) as compared to mothers who perceived that the pediatric care provider was neutral about the type of infant feeding. The association was no longer significant at 6 months. Conclusion: Maternal perception of obstetric and pediatric care providers’ preference for exclusive breastfeeding during the neonatal period is associated with exclusive breastfeeding until 3 months. Keywords breastfeeding, breastfeeding attitudes, breastfeeding support, breast milk

Well Established The association between perceived physician preference for breastfeeding and exclusive breastfeeding is unclear.

Newly Expressed We found a positive association between perceived attitudes of obstetric and pediatric care providers’ preference for exclusive breastfeeding and exclusive breastfeeding at 1 and 3 months.

Background The benefits of breastfeeding have been well-established.1 Exclusive breastfeeding confers greater benefits than partial breastfeeding.2 The American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend exclusive breastfeeding for the first 6 months of life.1,3 The AAP

further recommends to continue breastfeeding in addition to supplementary foods until at least 12 months of age and “continue breastfeeding as long as mutually desired by mother and baby,”1 whereas the WHO’s recommendation is to continue breastfeeding along with supplementary foods until 24 months 1

Department of Epidemiology & Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA 2 Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA 3 Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL, USA Date submitted: May 11, 2013; Date accepted: October 22, 2013. Corresponding Author: Rema Ramakrishnan, Department of Epidemiology & Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B. Downs Boulevard, MDC 56, Tampa, FL 33612, USA. Email: [email protected]

Downloaded from jhl.sagepub.com by guest on March 27, 2015

81

Ramakrishnan et al of age.3 According to the 2010-2011 National Immunization Survey, 76.5%, 37.7%, and 16.4% of infants in the United States were ever breastfed, exclusively breastfed at 3 months, and exclusively breastfed at 6 months, respectively.4 Maternal characteristics are associated with initiation, duration, and exclusivity of breastfeeding. Prominent among these are mother’s prenatal intention to breastfeed,5 maternal age,6 race/ethnicity,7 education, marital status,6 parity,8 and smoking status.6,9,10 Support and encouragement from health care professionals are associated with increased duration of breastfeeding.11 A qualitative study found that pediatricians were supportive of breastfeeding and believed that their clinics were “generally supportive” of breastfeeding. They felt that their “support roles should be minimal because of the busy nature of the practice and the need to appear nonbiased.” They further thought that being more supportive of breastfeeding mothers would make “those who weaned feel guilty.”12 The mothers in the same study felt this to be a passive reaction.12 Some obstetricians and pediatricians are not sure whether they can provide help due to lack of confidence, knowledge, or experience, and sometimes due to hesitancy regarding whether their support would be beneficial.5,11,13 On the other hand, studies have found that physicians who have a personal experience with breastfeeding have positive attitudes toward breastfeeding14,15 that are greater with increased duration of personal breastfeeding experience. A dilemma about who is really responsible for providing support to breastfeeding mothers may lead to a “communication disconnect” among these health care professionals.13 For many, time is a constraint to providing support to breastfeeding mothers,11,13 whereas mothers feel that what they need is not more time but “quality time.”12 A mother is more likely to exclusively breastfeed her infant for a longer period if she discusses breastfeeding options with her obstetrician during the neonatal period.16 Even though very few pediatricians have the opportunity to promote breastfeeding in the prenatal period, there may be missed opportunities during the neonatal period.17 It is, however, not known whether maternal perception of the attitudes of obstetric and pediatric care providers during the neonatal period has an association with exclusive breastfeeding outcomes until 6 months. A study using the 1993-1994 Infant Feeding Practices Study (IFPS) found no significant association between maternal perception of physicians’ attitudes about infant feeding and breastfeeding at 6 weeks after birth.18 The aim of our study was to determine the association between maternal perception of the attitudes of obstetric and pediatric care providers about infant feeding during the neonatal period and exclusive breastfeeding at 1, 3, and 6 months.

Methods Infant Feeding Practices Study II We used data from the IFPS II study, a longitudinal study of women from the third trimester of pregnancy through their

infant’s first year of life. This study was conducted by the US Food and Drug Administration and the Centers for Disease Control and Prevention from May 2005 through June 2007.19 The sampling frame consisted of a consumer opinion panel of more than 50 000 households throughout the United States. Data were collected through 3 types of questionnaires: infant questionnaires including prenatal, birth screener, neonatal, and 9 postnatal questionnaires, demographic data from the panel database or a separate demographic questionnaire, and a diet history questionnaire. This study was limited to English-speaking participants only. The details of the IFPS II study methods, including eligibility criteria and response rates, have been previously published.19 This study was considered exempt by the University of Minnesota’s Institutional Review Board.

Study Sample The sample size included 1602 mothers with complete data on exclusive breastfeeding at 1, 3, and 6 months after birth and for the independent variables—maternal perception of the attitudes of obstetric and pediatric care providers about infant feeding. Mothers were included even if there were missing data for covariates—maternal age, ethnicity, race, maternal education, marital status, employment status of mother prenatally, whether mother planned to work during her infant’s first year of life, prenatal smoking status, whether obese/overweight at the start of pregnancy, parity, whether mother was ever breastfed, mother’s prenatal intention about type of infant feeding, whether prenatal care was given by an obstetrician, gender of infant, cesarean delivery, and whether the infant had stayed in the neonatal intensive care unit for at least 3 days.

Independent Variable The independent variables were maternal perception of the attitudes of obstetric and pediatric care providers about infant feeding. In the neonatal questionnaires that were mailed from July 2005 to April 2006 and completed at 1 month after birth, mothers were asked, “In your opinion, which statement best describes the attitudes of the following people about feeding your baby? your doctor, baby’s doctor.” The options were (1) favored breastfeeding only, (2) favored formula feeding only, (3) favored mixed formula and breastfeeding, (4) had no preference for either method of feeding, and (5) don’t know. We named the response “favored mixed formula and breastfeeding” as “mixed feeding.” We combined the responses “had no preference for either method of feeding” and “don’t know” into a single variable called “neutral” since we assumed that either response meant the obstetric or the pediatric care provider was being neutral about the type of feeding preferred. Mothers who had indicated in the prenatal questionnaire that they did not have obstetric and pediatric care providers were excluded from the analyses.

Downloaded from jhl.sagepub.com by guest on March 27, 2015

82

Journal of Human Lactation 30(1)

Dependent Variable The dependent variable was exclusive breastfeeding at 1, 3, and 6 months. In the IFPS II study, the definition of exclusive breastfeeding was based on the food frequency chart. If the infant received breast milk but no other food including water, sugar water, or formula at the particular period, he or she was coded as being exclusively breastfed. The variables for exclusive breastfeeding at 1, 3, and 6 months were from the list of composite variables that were constructed by the data analysts of the original study.

Statistical Analysis Data were analyzed using STATA version 11.20 A P value of < .05 was considered to be significant. All continuous variables were converted to categorical variables for the analyses. After examining the frequencies for each variable, we conducted chi-square tests to describe the study sample and to examine the association between characteristics of mothers and infants and the dependent variable. We used Fisher’s exact test for variables that had an expected value of less than 5 in more than 20% of the cells in the contingency table. Any variable that had a significant P value (α < .05) in the chi-square or Fisher’s exact test was entered into a multivariate logistic regression model (Table 1). We conducted 6 logistic regression analyses—3 for the perceived attitudes of obstetric care providers about infant feeding during the neonatal period and exclusive breastfeeding at 1, 3, and 6 months and another 3 for the perceived attitudes of pediatric care providers. Using STATA 11.0, we performed step-wise regression analyses starting with a full model. The Pearson chi-square goodness-of-fit test was used to predict the best model. For the covariates, the information about the mothers came from the demographic and prenatal questionnaires, whereas the information about infants— gender, type of delivery, and whether the infant was admitted to the neonatal intensive care unit for more than 3 days—was from the neonatal questionnaire. Infant’s weight was not included in the analyses since all the infants weighed more than 5 lbs. Overall, 359 observations (22.4%) had at least 1 missing value. Any covariate that had more than 10% missing values was excluded. We used the missing-indicator method for variables that had less than 10% missing values and included them in the logistic regression analyses.

Results Table 1 summarizes the characteristics of 1602 women and infants who were included in this study. The majority of women were 25 to 34 years old, were non-Hispanic white, had more than a high school education, were married, were non-smokers, were non-obese, were multiparous, and had prenatally planned to exclusively breastfeed their infants.

The rates for exclusive breastfeeding at 1, 3, and 6 months were 44.6%, 39.8%, and 4.6%, respectively (not included in the table). This is further illustrated in Table 1 where the rates of exclusive breastfeeding at 1, 3, and 6 months are given by maternal and infant characteristics. During the neonatal period, the majority of mothers perceived that the obstetric care provider was neutral about the type of infant feeding. An almost equal number of mothers perceived that the child’s pediatric care provider favored exclusive breastfeeding and mixed feeding (Table 2). The unadjusted logistic regression analyses showed a significant association between maternal perception of the attitudes of obstetric and pediatric care providers during the neonatal period and exclusive breastfeeding at 1, 3, and 6 months (Tables 3 and 4). The association between obstetric or pediatric care provider’s preference for formula and exclusive breastfeeding outcomes was either insignificant or could not be tested due to insufficient numbers. The unadjusted analysis for perceived preference for mixed feeding and being exclusively breastfed at 6 months was insignificant. In the adjusted regression model, there was a significant association between maternal perception of the attitudes of obstetric care providers and exclusive breastfeeding at 1 and 3 months (Table 3). Mothers who perceived that their obstetric care provider favored exclusive breastfeeding had higher odds of exclusively breastfeeding their infants at 1 and 3 months as compared to mothers who perceived that their obstetric care provider was neutral about the type of feeding preferred. Mothers who perceived that their obstetric care provider favored mixed feeding had lower odds of exclusively breastfeeding their infants at 1 and 3 months. There was, however, no significant association between maternal perception of the attitudes of obstetric care providers and exclusive breastfeeding at 6 months (Table 3). In the adjusted regression model, there was a significant association between maternal perception of the attitudes of pediatric care providers and exclusive breastfeeding at 1 and 3 months (Table 4). Mothers who perceived that the pediatric care provider favored mixed feeding had lower odds of exclusively breastfeeding their infants as compared to mothers who perceived that the pediatric care provider was neutral about infant feeding. On the other hand, mothers who perceived that the pediatric care provider favored exclusive breastfeeding had 53% higher odds of exclusively breastfeeding their infants at 1 month as compared to mothers who perceived that the pediatric care provider was neutral about infant feeding. Similarly, there was a significant association between maternal perception of the attitudes of pediatric care providers and exclusive breastfeeding at 3 months (Table 4). At 6 months, there was no association between maternal perception of the attitudes of pediatric care providers and exclusive breastfeeding (Table 4).

Downloaded from jhl.sagepub.com by guest on March 27, 2015

83

Downloaded from jhl.sagepub.com by guest on March 27, 2015

Maternal age, No. (%), y  18-24  25-34   ≥ 35 Hispanic, No. (%)  No  Yes Race, No. (%)  White  Black   Asian/Pacific Islander  Other Maternal education, No. (%)   Less than high school/high school   College graduate  Post-graduate Marital status, No. (%)  Married  Single Employment status of mother prenatally, No. (%)  Unemployed  Employed Plan to work, No. (%)  No  Yes Prenatal smoking status, No. (%)  No  Yes Obese/overweight at start of pregnancy, No. (%)  No  Yes

  218 (24.6) 525 (59.3) 143 (16.1) 839 (94.5) 49 (5.5) 750 (86.6) 35 (4.0) 25 (2.9) 56 (6.5) 186 (22.3) 571 (68.5) 77 (9.2) 682 (81.1) 159 (18.9)

341 (43.9) 435 (56.1) 328 (37.1) 557 (62.9) 782 (88.6) 101 (11.4)

568 (70.5) 238 (29.5)

1526 (95.3) 76 (4.7) 1400 (89.2) 43 (2.7) 45 (2.9) 81 (5.2) 260 (16.9) 1089 (70.9) 187 (12.2) 1322 (85.7) 220 (14.3)

656 (45.7) 780 (54.3) 671 (42.0) 926 (58.0) 1480 (92.7) 116 (7.3)

1063 (73.0) 393 (27.0)

No

326 (20.4) 1044 (65.2) 230 (14.4)

Total

495 (76.2) 155 (23.8)

698 (97.9) 15 (2.1)

343 (48.2) 369 (51.8)

315 (47.7) 345 (52.3)

640 (91.3) 61 (8.7)

518 (73.8) 110 (15.7)

74 (10.5)

650 (92.5) 8 (1.1) 20 (2.8) 25 (3.6)

687 (96.2) 27 (3.8)

108 (15.1) 519 (72.7) 87 (12.2)

Yes

.02

< .001

< .001

.15

< .001

< .001

< .001

.10

< .001

P Value

Exclusive Breastfeeding at 1 Month

624 (71.4) 250 (28.6)

857 (89.4) 102 (10.6)

348 (36.2) 614 (63.8)

349 (41.3) 496 (58.7)

741 (81.1) 173 (18.9)

626 (68.9) 87 (9.6)

195 (21.5)

815 (86.8) 36 (3.8) 31 (3.3) 57 (6.1)

910 (94.4) 54 (5.6)

231 (24.0) 590 (61.3) 141 (14.7)

No

439 (75.4) 143 (24.6)

623 (97.8) 14 (2.2)

323 (50.9) 312 (49.1)

307 (51.9) 284 (48.1)

581 (92.5) 47 (7.5)

463 (73.7) 100 (15.9)

65 (10.4)

585 (92.9) 7 (1.1) 14 (2.2) 24 (3.8)

616 (96.6) 22 (3.5)

95 (14.9) 454 (71.2) 89 (13.9)

Yes

.09

< .001

< .001

< .001

< .001

< .001

.001

.05

< .001

P Value

Exclusive Breastfeeding at 3 Months

Table 1.  Maternal and Infant Characteristics by Exclusive Breastfeeding at 1, 3, and 6 Months (n = 1602).a

1010 (72.8) 378 (27.2)

1408 (92.5) 114 (7.5)

624 (41.0) 899 (59.0)

614 (44.9) 753 (55.1)

1251 (85.1) 219 (14.9)

1037 (70.9) 172 (11.7)

254 (17.4)

1327 (88.8) 43 (2.9) 44 (2.9) 81 (5.4)

1452 (95.0) 76 (5.0)

313 (20.5) 991 (64.9) 222 (14.6)

No

53 (77.9) 15 (22.1)

72 (97.3) 2 (2.7)b

47 (63.5) 27 (36.5)

42 (60.9) 27 (39.1)

71 (98.6) 1 (1.4)b

52 (71.2) 15 (20.6)

6 (8.2)

73 (98.6) 0 (0.0)b 1 (1.4) 0 (0.0)b

74 (100.0) 0 (0.0)b

13 (17.6) 53 (71.6) 8 (10.8)

Yes

(continued)

.35  

.17  

< .001  

.01  

< .001  

   

.02

.04      

.05  

.48    

P Value

Exclusive Breastfeeding at 6 Months

84

Downloaded from jhl.sagepub.com by guest on March 27, 2015

218 (24.9) 657 (75.1) 466 (56.6) 357 (43.4)

362 (40.9) 209 (23.6) 278 (31.4) 36 (4.1)

114 (12.8) 774 (87.2) 445 (50.2) 442 (49.8) 603 (68.1) 283 (31.9)

858 (96.6) 30 (3.4)

758 (50.1) 754 (49.9)

1010 (63.2) 209 (13.1) 334 (20.9) 45 (2.8)

247 (15.4) 1355 (84.6) 790 (49.4) 810 (50.6) 1147 (71.7) 453 (28.3)

1555 (97.1) 47 (2.9)

No

360 (22.7) 1225 (77.3)

Total

697 (97.6) 17 (2.4)

544 (76.2) 170 (23.8)

345 (48.4) 368 (51.6)

133 (18.6) 581 (81.4)

648 (90.9) 0 (0.0)b 56 (7.8) 9 (1.3)

292 (42.4) 397 (57.6)

142 (20.0) 568 (80.0)

Yes

.24

< .001

.48

.001

< .001

< .001

.02

P Value

Exclusive Breastfeeding at 1 Month

930 (96.5) 34 (3.5)

664 (68.9) 298 (30.9)

467 (48.5) 496 (51.5)

130 (13.5) 834 (86.5)

439 (45.6) 209 (21.7) 278 (28.9) 36 (3.7)

495 (55.5) 397 (44.5)

246 (25.9) 705 (74.1)

No

625 (98.0) 13 (2.0)

483 (75.7) 155 (24.3)

323 (50.7) 314 (49.3)

117 (18.3) 521 (81.7)

571 (89.8) 0 (0.0)b 56 (8.8) 9 (1.4)

263 (42.4) 357 (57.6)

114 (18.0) 520 (82.0)

Yes

.08

.01

.39

.01

< .001

< .001

< .001

P Value

Exclusive Breastfeeding at 3 Months

1483 (97.1) 45 (3.0)

1091 (71.5) 435 (28.5)

761 (49.9) 765 (50.1)

227 (14.9) 1301 (85.1)

940 (61.7) 209 (13.7) 330 (21.7) 45 (3.0)

732 (50.8) 708 (49.2)

348 (23.0) 1164 (77.0)

No

72 (97.3) 2 (2.7)

56 (75.7) 18 (24.3)

29 (39.2) 45 (60.8)

20 (27.0) 54 (73.0)

70 (94.6) 0 (0.0)b 4 (5.4) 0 (0.0)b

26 (36.1) 46 (63.9)

12 (16.4) 61 (83.6)

Yes

.90  

.44  

.07  

.01  

< .001      

.02  

.19  

P Value

Exclusive Breastfeeding at 6 Months

Abbreviation: NICU, neonatal intensive care unit. a Some percentages do not add to 100 due to rounding; all variables were self-reported by the mother. Results of chi-square tests; P value at .05 level of significance. b Fisher’s exact test.

Parity, No. (%)  Nulliparous  Multiparous Mother ever breastfed, No. (%)  No  Yes Mother’s prenatal intention about type of feeding, No. (%)   Breastfeeding only   Formula only   Mixed feeding   Not known Prenatal care given by obstetrician, No. (%)  No  Yes Gender of infant, No. (%)  Male  Female Cesarean delivery, No. (%)  No  Yes Baby stayed in NICU for at least 3 days, No. (%)  No  Yes



Table 1. (continued)

85

Ramakrishnan et al Table 2.  Attitudes of Obstetric and Pediatric Care Providers about Infant Feeding during the Neonatal Period (n = 1602). No. (%) Obstetric care provider’s attitude   Favors formula only   Favors exclusive breastfeeding   Favors mixed feeding   Neutral about type of feeding preferred Pediatric care provider’s attitude   Favors formula only   Favors exclusive breastfeeding   Favors mixed feeding   Neutral about type of feeding preferred

13 (0.8) 524 (32.7) 97 (6.1) 968 (60.4) 19 (1.2) 717 (44.8) 186 (11.6) 680 (42.4)

Table 3.  Odds of Exclusive Breastfeeding at 1, 3, and 6 Months by Maternal Perception of the Attitudes of Obstetric Care Providers during the Neonatal Period (n = 1602).a

1 month   Neutral about type of feeding preferred   Favors formula only   Favors exclusive breastfeeding   Favors mixed feeding 3 months   Neutral about type of feeding preferred   Favors formula only   Favors exclusive breastfeeding   Favors mixed feeding 6 months   Neutral about type of feeding preferred   Favors formula only   Favors exclusive breastfeeding   Favors mixed feeding

Crude OR (95% CI)

Adjusted OR (95% CI)

1.00

1.00

—b 2.26 (1.82-2.81)

—b 1.73 (1.33-2.24)

0.28 (0.16-0.49)

0.32 (0.17-0.61)

1.00

1.00

—b 1.79 (1.44-2.22)

—b 1.41 (1.09-1.80)

0.26 (0.15-0.48)

0.38 (0.19-0.73)

1.00

1.00

—b 1.85 (1.15-2.99)

—b 1.33 (0.80-2.22)

0.83 (0.25-2.73)

1.35 (0.39-4.69)

Abbreviations: CI, confidence interval; OR, odds ratio. a Adjusted for maternal age, race, education, marital status, employment status prenatally, prenatal smoking status, whether mother planned to work during her infant’s first year of life, parity, mother ever breastfed, mother’s prenatal intention about type of infant feeding, and prenatal care by obstetrician. P value at .05 level of significance. b Some observations dropped by STATA due to few observations for comparison.

Discussion Maternal perception about obstetric or pediatric care provider’s preference for exclusive breastfeeding is positively associated with duration of exclusive breastfeeding. Infants of mothers who perceived that the obstetric or pediatric care

Table 4.  Odds of Exclusive Breastfeeding at 1, 3, and 6 Months by Maternal Perception of the Attitudes of Pediatric Care Providers about Infant Feeding during the Neonatal Period (n = 1602).a

1 month   Neutral about type of feeding preferred   Favors formula   Favors exclusive breastfeeding   Favors mixed feeding 3 months   Neutral about type of feeding preferred   Favors formula   Favors exclusive breastfeeding   Favors mixed feeding 6 months   Neutral about type of feeding preferred   Favors formula   Favors exclusive breastfeeding   Favors mixed feeding

Crude OR (95% CI)

Adjusted OR (95% CI)b

1.00

1.00

0.32 (0.09-1.12) 2.50 (2.04-3.14)

0.27 (0.06-1.14) 1.53 (1.17-1.99)

0.42 (0.28-0.62)

0.30 (0.19-0.47)

1.00

1.00

0.38 (0.11-1.31) 2.24 (1.80-2.79)

0.34 (0.08-1.35) 1.51 (1.17-1.95)

0.44 (0.29-0.66)

0.39 (0.25-0.62)

1.00

1.00

—b 1.92 (1.16-3.17)

—b 1.31 (0.78-2.21)

0.45 (0.13-1.50)

0.51 (0.15-1.75)

Abbreviations: CI, confidence interval; OR, odds ratio. a Adjusted for maternal age, race, education, marital status, employment status prenatally, prenatal smoking status, whether mother planned to work during her infant’s first year of life, parity, mother ever breastfed, mother’s prenatal intention about type of infant feeding, and prenatal care by obstetrician. P value at .05 level of significance. b Some observations dropped by STATA due to few observations for comparison.

provider favored exclusive breastfeeding during the neonatal period were more likely to be exclusively breastfed at 3 months of age in comparison to infants of mothers who perceived that the obstetric or pediatric care provider was neutral about the type of feeding preferred. Mothers have increased contact with the obstetric care provider prenatally and during the neonatal period. The obstetric care provider’s preference for a particular type of infant feeding expressed implicitly or explicitly during the neonatal period may influence mothers’ decision to initiate and continue exclusive breastfeeding. Pediatric care providers have fewer opportunities to promote breastfeeding in the prenatal period, but there are opportunities during the neonatal period to inquire and counsel about infant feeding.17 During the neonatal period, the obstetric as well as the pediatric care provider are likely to be influential in mothers’ decision to initiate and continue exclusive breastfeeding until 3 months. The finding that the majority of mothers perceived that the obstetric care provider was neutral about infant feeding is in concordance with a previous study that found that most of the

Downloaded from jhl.sagepub.com by guest on March 27, 2015

86

Journal of Human Lactation 30(1)

physicians had no preference for a particular type of infant feeding.18 Studies have indicated that physicians believe that they are supportive of breastfeeding particularly if they have personal experience with breastfeeding. In this context, the current study results could indicate a gap between the obstetric/pediatric care provider’s beliefs and perceived attitudes that suggests the need for comprehensive breastfeeding education for these health care professionals.18

Strengths and Limitations The strengths of the IFPS II are its large sample size and longitudinal study design. The study is limited in that it was not wholly representative of the US population and hence the study results may have limited external validity. In this study, the prevalence of exclusive breastfeeding at 1, 3, and 6 months was 44.6%, 39.8%, and 4.6%, respectively. The rate at 3 months is almost the same as the Healthy People 2010 objective of 40%21 but higher than the Healthy People 2020 baseline rate of 33.6% for exclusive breastfeeding at 3 months.22 At 6 months, the rate is much lower than the Healthy People 2010 objective of 17%21 and the Healthy People 2020 baseline rate of 14.1% for exclusive breastfeeding at 6 months.22 The generalizability of the findings is limited because the study was based on information from a consumer mail survey with the majority of the women being white, able to read English, and of higher socioeconomic status.19 Another limitation to this study is that the method of mailing the questionnaires resulted in some infants being older or some younger when their mothers returned the questionnaires. This might have increased or decreased the breastfeeding rates to some extent for a particular period. In addition, self-report of variables like prevalence of obesity prior to pregnancy is subject to measurement bias. The study results may have been biased because maternal perception of the attitudes of obstetric and pediatric care providers was not confirmed by their respective physicians. However, knowing maternal perception of the attitudes of obstetric and pediatric care providers is important since it conveys how the messages are understood by mothers. If these are not in agreement with the actual opinions and recommendations of obstetric and pediatric care providers, then there is a communication gap that needs to be addressed.

Conclusion Maternal perception of obstetric and pediatric care providers’ preference for exclusive breastfeeding during the neonatal period is associated with exclusive breastfeeding until 3 months. Given this association, obstetric and pediatric care providers should clearly indicate that exclusive breastfeeding is the feeding of choice until 6 months of age and should reinforce this regularly. Obstetric and pediatric care providers should be trained to be supportive of exclusive breastfeeding

without appearing biased or neutral. The obstetric and pediatric care providers, the hospital staff, family, lactation consultants, employers, and policy makers should have a clear and common goal of increasing the rates of exclusive breastfeeding. Acknowledgments The authors wish to thank Sara B. Fein, PhD, from the Center for Food Safety and Applied Nutrition, Food and Drug Administration, for providing the study database. They also wish to thank Ms Jill Anderson for her editorial assistance and Ms Ambili Kariaparambil Rajan, MPH, for her valuable comments.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

References 1. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841. 2. Raisler J, Alexander C, O’Campo P. Breast-feeding and infant illness: a dose-response relationship? Am J Public Health. 1999;89(1):25-30. 3. World Health Organization. The optimal duration of exclusive breastfeeding: report of an expert consultation. http://www. who.int/maternal_child_adolescent/documents/nhd_01_09/ en/. Published 2001. Accessed November 3, 2013. 4. Department of Health and Human Services. Breastfeeding report card—United States, 2013. http://www.cdc.gov/breastfeeding/ pdf/2013BreastfeedingReportCard.pdf. Accessed October 20, 2013. 5. Colaizy TT, Saftlas AF, Morriss FH Jr. Maternal intention to breast-feed and breast-feeding outcomes in term and preterm infants: Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. Public Health Nutr. 2012;15(4): 702- 710. 6. Scanlon KS, Grummer-Strawn L, Shealy KR, Jefferds ME, Chen J. Breastfeeding trends and updated national health objectives for exclusive breastfeeding—United States, birth years 2000-2004. MMWR. 2007;56(30):760-763. 7. Belanoff CM, McManus BM, Carle AC, McCormick MC, Subramanian SV. Racial/ethnic variation in breastfeeding across the US: a multilevel analysis from the National Survey of Children’s Health, 2007. Matern Child Health J. 2012;16(suppl 1):S14-S26. 8. Agboado G, Michel E, Jackson E, Verma A. Factors associated with breastfeeding cessation in nursing mothers in a peer support programme in Eastern Lancashire. BMC Pediatrics. 2010;10:3. 9. Weiser TM, Lin M, Garikapaty V, Feyerharm RW, Bensyl DM, Zhu BP. Association of maternal smoking status with breastfeeding practices: Missouri, 2005. Pediatrics. 2009;124(6):1603-1610.

Downloaded from jhl.sagepub.com by guest on March 27, 2015

87

Ramakrishnan et al 10. Bailey BA, Wright HN. Breastfeeding initiation in a rural sample: predictive factors and the role of smoking. J Hum Lact. 2011;27(1):33-40. 11. Taveras EM, Li R, Grummer-Strawn L, et al. Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 2004;113(4):e283-e290. 12. Dillaway HE, Douma ME. Are pediatric offices “supportive” of breastfeeding? Discrepancies between mothers’ and healthcare professionals’ reports. Clin Pediatr. 2004;43(5):417-430. 13. Szucs KA, Miracle DJ, Rosenman MB. Breastfeeding knowledge, attitudes, and practices among providers in a medical home. Breastfeed Med. 2009;4(1):31-42. 14. Anchondo I, Berkeley L, Mulla ZD, et al. Pediatricians’, obstetricians’, gynecologists’, and family medicine physicians’ experiences with and attitudes about breast-feeding. South Med J. 2012;105(5):243-248. 15. Brodribb W, Fallon A, Jackson C, Hegney D. The relationship between personal breastfeeding experience and the breastfeeding attitudes, knowledge, confidence and effectiveness of Australian GP registrars. Matern Child Nutr. 2008;4(4):264-274. 16. Mansbach IK, Palti H, Pevsner B, Pridan H, Palti Z. Advice from the obstetrician and other sources: do they affect women’s

breast feeding practices? A study among different Jewish groups in Jerusalem. Soc Sci Med. 1984;19(2):157-162. 17. Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the promotion and support of breastfeeding. Arch Pediatr Adolesc Med. 2008;162(12):1142-1149. 18. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Do perceived attitudes of physicians and hospital staff affect breastfeeding decisions? Birth: Issues in Perinatal Care. 2003;30(2):94-100. 19. Fein SB, Labiner-Wolfe J, Shealy KR, Li R, Chen J, GrummerStrawn LM. Infant Feeding Practices Study II: study methods. Pediatrics. 2008;122(suppl 2):S28-S35. 20. StataCorp. STATA statistical software [computer program]. Release 11. College Station, TX: StataCorp; 2009. 21. Department of Health and Human Services. Breastfeeding report card—United States, 2010. http://www.cdc.gov/ breastfeeding/pdf/BreastfeedingReportCard2010.pdf. Accessed October 20, 2013. 22. Department of Health and Human Services. Maternal and child health, 2010. http://www.healthypeople.gov/2020/topics objectives2020/objectiveslist.aspx?topicId=26. Published 2012. Accessed October 20, 2013.

Downloaded from jhl.sagepub.com by guest on March 27, 2015

The association between maternal perception of obstetric and pediatric care providers' attitudes and exclusive breastfeeding outcomes.

Exclusive breastfeeding is recommended for 6 months. Successful breastfeeding requires support from family members, peers, and health care professiona...
306KB Sizes 0 Downloads 0 Views