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Why Do Many Women Stop Breast Feeding Before Their Babies Are Six Months Old?

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Factors associated with cessation of exclusive breastfeeding at i and two months postpartum in Taiwan

  • Sin-Fong Li1  na1,
  • Hsin-Yi Yangtwo,
  • Li-Chu Wang1,
  • Cing-Ya Wengi,
  • Kuan-Fen Chenone,
  • Wei Chenthree &
  • Sheng-Yu Fan ORCID: orcid.org/0000-0001-7932-2405 4

International Breastfeeding Journal volume xiv, Article number:xviii (2019) Cite this article

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Abstract

Background

Breastfeeding benefits both mothers and infants. Fifty-fifty though Taiwan national policy promotes exclusive breastfeeding (EBF), the rates in Taiwan are beneath those in other developed countries. This written report aimed to investigate factors associated with EBF cessation at i and 2 months postpartum.

Methods

This study was conducted in a customs hospital in southern Taiwan between December 2016 and June 2017. Birth mothers (north = 1077) were interviewed by telephone at 1 and 2 months postpartum to collect information on infant feeding patterns (EBF since birth or non) and reasons for EBF cessation. Multivariate logistic regression models were used to make up one's mind risk factors associated with EBF abeyance at 1 and 2 months.

Results

At ane month, 432 participants (40.1%) maintained EBF. Factors associated with abeyance were lack of tertiary education, primiparity, perceived low milk quantity, mother/infant separation, medical status in mother, inconvenience/fatigue due to breastfeeding, and infant-centered factors. At 2 months, 316 participants (29.3%) maintained EBF. Factors associated with cessation were lack of tertiary education, primiparity, perceived low milk quantity, and return to piece of work.

Conclusions

Didactics level, primiparity, perceived low milk quantity, and return to work are associated with premature cessation of EBF in Taiwan. Strategies about health educational activity, family support, and baby-female parent friendly environment can be used to attain higher EBF charge per unit.

Background

Exclusive breastfeeding (EBF) refers to mothers providing only chest milk for their infants without any other liquids or solids [1]. In that location is evidence supporting the benefits of EBF for infants, children and mothers [2, 3]. The Earth Health Organization (WHO) and United Nations Children'south Fund (UNICEF) recommend breast milk every bit the ideal food for the newborn and that feeding should exist initiated within the first hour after nascence and continued to six months. With appropriate complementary foods, breastfeeding tin can continue up to ii years old and beyond [iv].

However, the WHO estimates that merely near one-3rd of infants are breastfed exclusively for the beginning 6 months of life [four]. The 3-month EBF rate in countries such as the United States, Tanzania, Brazil, Turkey, Commonwealth of australia and Thailand ranges from 21 to 68%, and the 6-month EBF rate from 15 to xxx% [four,5,vi,seven,8,nine]. In Taiwan, the EBF rates remain below the standards recommended past the WHO, with an EBF rate of 61.8% at ane months postpartum [ten], approximately 44% at 3 months [11] and 24.3% at 6 months [12].

Odom and colleagues surveyed 1177 mothers in the USA from pregnancy until their child was one yr erstwhile [thirteen]. Approximately 60% of women who stopped breastfeeding did so earlier than they had wanted. More than half of the mothers were unable to achieve their intended breastfeeding duration, citing reasons including difficulties with lactation, concerns about infant weight gain, sickness in mothers or babies and having to take medicine, and problems with milk expression [13]. Other factors related to EBF abeyance included younger maternal age [14], lower maternal educational level [14], unplanned pregnancy [15], maternal piece of work exterior the dwelling house [15,16,17], and lack of emotional back up, particularly from the baby'southward begetter [18].

In the Global Targets 2025, the WHO and UNICEF have set up a goal that in 2025 at least l% of infants will be breastfed exclusively for the kickoff 6 months [19]. In Taiwan, meaning women tend to work almost the expected date of childbirth, and and so have 8 weeks of official motherhood leave [20]. To improve the EBF rate in Taiwan, information technology is imperative to place the possible reasons mothers finish EBF. Studies regarding social demographic, mother-babe conditions, and piece of work-related factors associated with cessation of EBF are limited. Simply Lee et al. [12] has reported that certain ecology factors may be positively associated with EBF, including breastfeeding rooms in public places or workplaces and commitment in infant-friendly hospitals. Chen et al. plant that amid immigrant mothers, breastfeeding feel of mothers-in-law and the perceived level of acceptance of breastfeeding in Taiwan were positively associated with EBF at 3 months postpartum [21]. Still, neither of these studies explored factors associated with mothers' reasons for stopping EBF. Therefore, this study aimed to investigate factors associated with cessation of EBF at ane and 2 months postpartum in Taiwan.

Methods

Study design

This study enrolled postpartum women who had been maternity patients in the Obstetrics Department of Ditmanson Medical Foundation, Chiayi Christian Infirmary (CYCH), Chiayi, Taiwan from December 2016 to June 2017. The hospital participates in the Baby-Friendly Hospital Initiative (BFHI), which requires patients to reply to a postnatal survey. Inclusion criteria were that mothers aged over twenty years erstwhile, who gave birth after 24 gestational weeks, and delivered babies in this hospital. Mothers with medical contraindications for breastfeeding, with babies who required intensive intendance monitoring, or with babies who had malformations that interfered with breastfeeding were excluded. Birth mothers were followed upwards via a telephone interview at 1 and ii months postpartum to assess their infant's feeding patterns and mothers' reasons for breastfeeding abeyance.

Data collection

A specialized nurse who had midwifery, breastfeeding, and babe care knowledge interviewed all postpartum women well-nigh their breastfeeding practices past phone. Demographic data included gestational age, nationality, manner of birth, education level, and parity. Breastfeeding condition at 1 and two months postpartum were also recorded: either EBF and not-EBF (classified equally 'fully formula feeding' or 'partial breastfeeding') since nascency. Mothers who stopped breastfeeding before two months were besides questioned nigh the fourth dimension of weaning and the reason they discontinued all breastfeeding.

Ten categories addressing the main reasons for abeyance of EBF were developed based on previous studies [22,23,24]. These were: (1) "Perceived low milk quantity" divers as mother'southward self-reported perception that the infant was not getting enough milk and was showing signs of hunger; (2) "Sore breasts or nipples / Too painful" defined as painful nipples, full general or unspecified breastfeeding hurting, sore breasts, engorgement, breast hurting, mastitis or other breast infection, and biting; (3) "Mother/infant separation" defined as reduction or cessation of breastfeeding due to mother and baby not living together, baby being cared by grandparents, or other like issues; (iv) "Maternal option" or parent's decision to stop breastfeeding with no further explanation; (5) "Breastfeeding skills were not effective" defined equally problems with breastfeeding technique, existence uncomfortable with the human action or connotations of breastfeeding, and other uncertainties regarding breastfeeding ability every bit evaluated by specialized nurses; (6) "Mother's medical condition" which included references to medical weather not related to breastfeeding too every bit the communication of a doctor or healthcare professional; (7) "Inconvenience/fatigue due to breastfeeding" related to breastfeeding being tiring or demanding for the female parent also as lack of time to breastfeed while caring for other children; (viii) "Return to work" where the mother returned to work or planned to do so; (9) "Baby-centered factors" defined every bit issues with latching, infant drowsiness, going too long between feedings, the baby refusing to breastfeed/nipple confusion, the infant existence fussy or frustrated at the frequency or length of breastfeeding, the infant not feeding properly, and other difficulties of feeding at the breast; and (x) "Infant's medical condition" which included references to medical conditions not related to breastfeeding equally well as the communication of a doc or healthcare professional. The participants rated whether they had the problems (yes/no response), and more than than i reason could exist given for stopping breastfeeding.

Statistical analysis

In this report, continuous variables were presented every bit the hateful ± standard deviation (SD), and categorical data by percentages. Student's t test was used to test the differences in continuous variables between the participants with EBF and those with not-EBF, and chi-square test for categorical variables. Multivariate logistic regression analysis was used to determine which risk factors were significantly associated with breastfeeding cessation at 1 and 2 months postpartum. The status of EBF was considered as the dependent variable, and the pregnant variables in the univariate analyses were entered as predictors. All variables with p <  0.05 in the bivariate analysis were included in the model and those outside this range excluded. Variables were entered into the model stepwise, with entry benchmark of 0.05 and removal criterion of 0.x. The sample size was calculated based the formula: Due north = 10 K/P, where K represents the numbers of independent variables and P represents the proportion of positive cases in the population [25]. There were 15 independent variables (including demographic characteristics and reasons). The proportion, calculated equally the charge per unit of EBF at 3 months postpartum, was 0.44 [xi], and a minimum number of cases was 340. All statistical analyses were performed with SPSS for Windows version 21.0 (IBM Corp., Armonk, NY, USA). A 2-tailed p-value of equal to or less than 0.05 was considered as statistically significant.

Results

Baseline characteristics of the participants

A total of 1077 participants were recruited, and their demographic and clinical characteristics are described in Table 1. The mean age was 32.0 years (SD = 5.0). At 1 calendar month postpartum, 40.one% of mothers maintained EBF, which fell to 29.3% at two months postpartum.

Table one Sample characteristics Mean ± SD or, North (%)

Full size table

Reasons for breastfeeding cessation

The nearly frequent reasons given for breastfeeding abeyance in the kickoff month were perceived depression milk quantity (n = 471, 43.73%), baby-centered factors (due north = 76, seven.06%), and maternal choice (northward = 75, 6.96%). In the second month, the reasons for breastfeeding cessation were perceived low milk quantity (northward = 435, 40.39%), maternal choice (n = 94, 8.73%) and return to piece of work/school (n = 39, 3.62%).

Not-exclusive breastfeeding factors

Univariate analyses of all variables (i.e., sociodemographic factors, mode of birth, and reasons for breastfeeding cessation) that could possibly exist associated with EBF cessation at 1 and ii months postpartum are shown in Table two. Factors related to the abeyance of EBF at 1 month were mothers' higher age, cesarean nascence, having no higher degree, primiparity, perceived low milk quantity, mother/infant separation, maternal choice, mothers' medical status, inconvenience/fatigue due to breastfeeding, and baby-centered factors.

Table 2 Univariate analysis of factors associated with non-exclusive breastfeeding at ane month and 2 months

Full size tabular array

Factors related to the cessation of EBF at ii month were mothers' college age, cesarean birth, having no college degree, primiparity, perceived low milk quantity, maternal choice, inconvenience/fatigue due to breastfeeding, and return to work. Maternal choice at 1 and 2 months and inconvenience/fatigue due to breastfeeding at two month were not entered in multivariate logistic regression analysis due to the extreme proportion in EBF vs. non-EBF.

Multivariate logistic regression analysis

Multivariate logistic regression analysis revealed that factors related to EBF cessation at one month included having no higher caste (adjusted odd ratio [AOR] = 1.63, 95% confidence interval [CI] = one.thirteen, two.35), primiparity (AOR = one.53, 95% CI = 1.07, 2.19), perceived depression milk quantity (AOR = 65.35, 95% CI = 38.74, 110.26), mother/infant separation (AOR = 5.46, 95% CI = 2.49, 11.98), mother'due south medical status (AOR = 12.62, 95% CI = 3.53, 45.xi), inconvenience/fatigue due to breastfeeding (AOR = 14.27, 95% CI = iii.04, 66.96), and infant-centered factors (AOR = 2.12, 95% CI = 1.03, 4.36).

Factors related to EBF abeyance at ii month included having no higher degree (AOR = 1.76, 95% CI = ane.24, ii.49), primiparity (AOR = ii.28, 95% CI = one.62, 3.21), perceived low milk quantity (AOR = 212.38, 95% CI = 52.38, 861.17), and return to work (AOR = 10.61, 95% CI = iii.19, 35.33) (see Tables 3 and 4).

Table iii Multivariate logistic regression with factors associated with cessation of sectional breastfeeding at 1 month

Total size table

Tabular array 4 Multivariate logistic regression with factors associated with cessation of sectional breastfeeding at ii months

Full size table

Discussion

To the all-time of our noesis, this is the first report to investigate the reasons for EBF cessation at 1 and 2 months postpartum in Taiwan. The present study showed that the rates of EBF at the cease of the outset and second months postbirth were forty.1 and 29.3%, respectively. Instruction level, primiparity, perceived low milk quantity, and render to work were associated with the cessation of EBF.

Perceived low milk quantity was the most common problem for cessation of EBF in the present report, which is consistent with the results of previous studies that nutritional factors played an important role in breastfeeding cessation [23, 24, 26, 27]. Wagner et al. [24] reported that bug with depression milk quantity usually occur within the starting time two weeks postpartum, and Teich et al. [26] besides showed that the virtually common barrier during the early postpartum menstruum was the mother's perception of inadequate milk supply. In a study past Li et al., over 50% of mothers stated they stopped breastfeeding at ane or two months postpartum because they did not recall they had enough milk [22]. Lewallen and colleagues constitute that around thirty% of the mothers stopped EBF before eight weeks postpartum, and the well-nigh common reason was a perception of bereft milk supply. This business organization led to formula supplementation and so breastfeeding abeyance [28] and supports the finding that when mothers lack conviction to provide plenty milk for babies, they tend to cease breastfeeding [29].

A related study has shown that mothers who lacked knowledge about the normal lactation process or breastfeeding difficulties, worried about their ability to produce a sufficient quantity of milk [27]. Through appropriate instruction, virtually mothers can overcome temporary breastfeeding problems without resorting to supplementation Attending prenatal classes that address such issues every bit low milk supply and other lactational factors may enhance women's cocky-efficacy and the intention to breastfeed longer [23, 28].

In the present study, multiparous mothers who had a college degree tended to be exclusively breastfeeding EBF at 1 and ii months, which may relate to cognition and experience. Perrine et al. found that approximately 68% of women stopped EBF for personal reasons, without explaining further [30]. Even though those mothers did not disclose their reasons for stopping EBF, factors such every bit maternal perceptions of infirmary staff attitude, nipple soreness, breast engorgement, infant's restlessness, doubts about sufficient breast milk and beliefs regarding early termination of breastfeeding may be some of the underlying reasons. Lack of knowledge on the function of healthcare providers in approaching the problems related to breastfeeding is reported to be another main reason, and women who had professional or lay support for breastfeeding were more apt to continue EBF [31].

Therefore, to increase exclusive breastfeeding rates in Taiwan, meaning women could be given breastfeeding education during the antenatal menstruation and breastfeeding intendance and help from specialized nurses during the early postpartum period. The preparation may increase mothers' conviction in their ability to breastfeed and therefore result in a higher charge per unit of EBF [32, 33]. Although a previous randomized controlled study that compared two interventions (1.v-h for applied skills or 2-h for attitude) and a control group did non increment breastfeeding duration at 6 months postpartum [34], some researchers suggest that a multi-methods intervention may achieve a longer duration of EBF [33, 35]. For example, a combination of prenatal maternal teaching on the benefits of EBF and means to overcome barriers to breastfeeding, combined with the provision of workplace and infirmary breastfeeding rooms and specific policies to back up and encourage breastfeeding [35].

In the present study, female parent/infant separation was a meaning gene at one month. In Taiwan, some new mothers stay at postpartum care centers from ii to four weeks, some mothers cannot live together with their babies considering of accommodation reason, or babies were cared for by grandparents. However, a return to piece of work was significantly associated with cessation of EBF only at ii months postpartum. The official maternity leave in Taiwan is viii weeks, and most mothers have to make up one's mind whether return to piece of work and arrange the care of their baby, including breastfeeding.

Our findings are consistent with the results of previous studies [xiii, 36, 37]. Bai et al. [36] showed that only one-tertiary of women maintained breastfeeding subsequently 2 weeks of returning to work. Bear witness too shows that the sooner mothers render to piece of work, the shorter their duration of breastfeeding [36, 37]. For mothers who returned to work, lactation programs that included flexible work schedules and easier access to a private lactation room significantly influenced the elapsing of breastfeeding [38].

This study has some limitations that must be considered when interpreting the outcome. First, this was a retrospective written report, and the factors well-nigh environment and policy were non included. Second, the reasons for ceasing EBF were based on mothers' subjective judgements and some reasons might exist interchangeable. For example, 'perceived low milk supply' may be related to 'breastfeeding skills were not effective'. Accurate information collection with a clear definition and items would exist required for more than detailed description. Tertiary, this study was conducted in a single community hospital in southern Taiwan, which may limit the generalizability of the results to other populations and settings. Finally, this study only evaluated breastfeeding status up to 2 months postpartum. Therefore, our results cannot be compared to other studies evaluating breastfeeding duration over longer fourth dimension periods.

Conclusion

The EBF rate is all the same relatively low in Taiwan. Premature cessation of EBF was associated with non having a higher degree, parity, perceived depression milk quantity, mother/babe separation, personal conclusion, inconvenience due to breastfeeding, and return to work. Based on these findings, defining strategies that influence modifiable factors related to breastfeeding and promoting the protective factors provided by breast milk may help increase breastfeeding rates in Taiwan. These may include health pedagogy for improving knowledge and skills, family support for reducing mothers' burden, and continuous support for baby-mother friendly environment and policies in workplaces and the community. These strategies may be constructive in reaching the WHO Global Target 2025 of 50% of infants beingness exclusively breastfed to vi months of age.

Abbreviations

EBF:

Exclusive breastfeeding

FF:

Formula feeding

PBF:

Partial breastfeeding

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Acknowledgements

The authors gratefully acknowledge all the mothers who participated in this written report.

Funding

This article has not received funding from either public or individual institutions.

Availability of data and materials

Data used in this study are bachelor upon reasonable request. Please contact the corresponding author for data requests.

Writer information

Author notes

  1. Pei-Chi Chang and Sin-Fong Li contributed equally to this work.

Affiliations

  1. Division of Community Nursing, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan

    Pei-Chi Chang, Sin-Fong Li, Li-Chu Wang, Cing-Ya Weng & Kuan-Fen Chen

  2. Clinical Research Center, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan

    Hsin-Yi Yang

  3. Department of Customs Health, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan

    Wei Chen

  4. Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan

    Sheng-Yu Fan

Contributions

PCC, SFL, and WC were major contributors in the design of the study. All authors contributed in the design. SFL, LCW, CYW, and KFC contributed the data collection. PCC, SFL, HYY, and SYF analyzed and interpreted the data. WC and SYF were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sheng-Yu Fan.

Ethics declarations

Ethics approval and consent to participate

The study protocol was approved past the Ethics Committee of Ditmanson Medical Foundation Chiayi Christian Hospital (IRB number: 2018040). Signed informed consent was obtained from all eligible mothers who delivered good for you babies at term.

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Non applicable.

Competing interests

The authors declare that they take no competing interests.

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Chang, PC., Li, SF., Yang, HY. et al. Factors associated with abeyance of exclusive breastfeeding at 1 and 2 months postpartum in Taiwan. Int Breastfeed J xiv, eighteen (2019). https://doi.org/10.1186/s13006-019-0213-i

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Keywords

  • Breastfeeding cessation
  • Exclusive breastfeeding
  • Risk factors

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