Breast-feeding and its relation to smoking and mode of delivery

Early initiation of breastfeeding up to six months among mothers after cesarean section or vaginal birth: A scoping review

Background

Early initiation of breastfeeding is important for establishing continued breastfeeding. However, previous research report that cesarean section (C-section) may hinder early initiation of breastfeeding. Despite this, there is currently a lack of literature that examines the rates of breastfeeding after both cesarean section and vaginal birth globally.

Research aims

The objective of this scoping review was to systematically assess the available literature on the rate of early initiation of breastfeeding within the first hour and exclusive breastfeeding up to 6 months after C-section and vaginal birth, as well as any other factors associated with initiation and exclusive breastfeeding.

Methods

We adhered to the PRISMA extension guidelines for scoping reviews in conducting our review. In August 2022, we carried out an electronic database search on CINALH, PubMed, EMBASE, and Cochrane Library, and also manually searched the reference list.

Results

A total of 55 articles were included in the scoping review. The majority of these studies found that mothers who delivered vaginally had higher rates of breastfeeding compared to those who underwent a C-section, at various time points such as breastfeeding initiation, hospital discharge, one month, three months, and six months postpartum. Notably, there was a significant difference in the rate of early initiation of breastfeeding between the two groups. However, at 3 and 6 months after delivery the gap of exclusive breastfeeding rate between C-section and vaginal delivery is narrow. Breastfeeding education, health care providers support, and mother and baby bonding are other factors associate with initiation and exclusive breastfeeding.

Conclusions

The rate of breastfeeding initiation after C-section has remained low to date. This is due in part to insufficient knowledge about and support for breastfeeding from healthcare providers.

Breastfeeding in Neonates Admitted to an NICU: 18-Month Follow-Up

Introduction: The admission of neonates to Neonatal Intensive Care Units (NICUs) has been identified as a primary inhibiting factor in the establishment of breastfeeding. The aims of this study were to (1) estimate the prevalence and duration of breastfeeding in infants/toddlers who had been admitted to an NICU in Greece and (2) to investigate factors, associated with the NICU stay, which affected the establishment and maintenance of breastfeeding in infants/toddlers previously admitted to the NICU. Materials and methods: Data for this cohort study were retrieved from interviews with mothers of infants/toddlers who had been admitted to our NICU as neonates during the period of 2017−2019. Interviews were conducted based on a questionnaire regarding the child’s nutrition from birth to the day of the interview, including previous maternal experience with breastfeeding. Information related to the prenatal period, gestation age, delivery mode, duration of NICU stay, and neonatal feeding strategies during their hospital stay were recorded. Results: The response rate to the telephone interviews was 57%, resulting in 279 mother−infant pairs being included in this study. The results showed that 78.1% of children received maternal milk during their first days of life. Of all infants, 58.1% were exclusively breastfed during their first month, with a gradual decrease to 36.9% and 19.4% by the end of the third and sixth months of life, respectively. The prevalence of breastfed children reached 14.7% and 7.5% at the ages of twelve and eighteen months, respectively. In the multivariate analysis, prematurity emerged as an independent prognostic factor for the duration of exclusive and any breastfeeding (aHR 1.64, 95% CI: 1.03−2.62; and 1.69, 95% CI: 1.05−2.72, respectively; p < 0.05). Additionally, the nationality of the mother, NICU breastfeeding experience, the administration of maternal milk during neonatal hospital stay, and previous breastfeeding experience of the mother were independent prognostic factors for the duration of breastfeeding. Conclusions: Although breastfeeding is a top priority in our NICU, the exclusive-breastfeeding rates at 6 months were quite low for the hospitalized neonates, not reaching World Health Organization (WHO) recommendations. Mothers/families of hospitalized neonates should receive integrated psychological and practical breastfeeding support and guidance.

Association Between Intrapartum Factors and the Time to Breastfeeding Initiation

Background/Objectives: Early breastfeeding initiation is strongly recommended. Reasons for delayed breastfeeding initiation often include intrapartum interventions such as induction of labor, opioid pain medication administration, epidural analgesia, and caesarean birth. The majority of existing studies examining the timeliness of breastfeeding initiation are from low- or middle-income countries. The objective of this study is to examine intrapartum interventions on the time to breastfeeding initiation in a cohort of mothers from a high-income country. Materials and Methods: A cohort of 1,277 new mothers was recruited within 24 hours after birth from 4 hospitals in Hong Kong from 2011 to 2012. Participants completed a self-administered questionnaire immediately after recruitment. The rates of intrapartum interventions and the time to the first breastfeed were collected from participants' hospital record. Results: Among participants, 575 (45.5%) initiated breastfeeding within 1 hour of birth and the median time to the first breastfeed was 1.5 hours. The use of opioid pain medication (adjusted hazard ratio [aHR]: 0.78, 95% confidence interval [CI]: 0.67-0.91), assisted vaginal birth (aHR: 0.74, 95% CI 0.56-0.97), and caesarean section (aHR: 0.30, 95% CI 0.25-0.36) were associated with delayed breastfeeding, whereas epidural analgesia and induction of labor had no effect on breastfeeding initiation. Natural birth (i.e., no intrapartum interventions) was also significantly associated with early breastfeeding initiation (aHR: 1.75, 95% CI 1.54-1.99). Conclusions: Breastfeeding initiation was delayed in participants who had a caesarean birth and who received opioid pain medication. These women may require additional support to initiate breastfeeding soon after birth.

Maternal Smoking and Psychosocial Functioning: Impact on Subsequent Breastfeeding Practices

Introduction: Breastfeeding is a protective factor for women and children. Women who smoke cigarettes during pregnancy are less likely to initiate or persist in breastfeeding. However, less is known about why this is the case. Materials and Methods: The present study (n = 247) prospectively examined maternal/child factors that influence breastfeeding in a low-income, racially diverse at-risk sample of smoking and nonsmoking women. Pregnant women were recruited at their first prenatal appointment in an urban hospital and followed through 24-month postnatally. Women reported on the average number of cigarettes smoked/day during pregnancy, psychopathology, breastfeeding behavior, and infant reactivity. Results: Although a greater number of cigarettes smoked/day during pregnancy was associated with a lower likelihood of initiating or persisting in breastfeeding, maternal age, education, and infant reactivity offered predictive utility above and beyond maternal smoking. Conclusion: Smokers were less likely to initiate breastfeeding and breastfed for shorter duration than demographically similar nonsmokers; however, one of the mechanisms for reduced breastfeeding may be the psychosocial factors of younger age and lower education. Further, infant reactivity was also found to reduce the likelihood of initiating and persisting with breastfeeding.

Information and Communication Systems to Tackle Barriers to Breastfeeding: Systematic Search and Review

Background

Breastfeeding has many benefits for newborns, mothers, and the wider society. The World Health Organization recommends mothers to feed newborns exclusively with breastmilk for the first 6 months after birth, but breastfeeding rates in many countries fail to align with the recommendations because of various barriers. Breastfeeding success is associated with a number of determinants, such as self-efficacy, intention to breastfeed, and attitudes toward breastfeeding. Information and communication technology (ICT) has been leveraged to support breastfeeding by means of improving knowledge or providing practical supports in different maternal stages. Previous reviews have examined and summarized the effectiveness and credibility of interventions; however, no review has been done from a human-computer interaction perspective that is concerned with novel interaction techniques and the perspective of end users.

Objective

The objective of this review was to provide a comprehensive overview of existing digital interventions that support breastfeeding by investigating systems’ objective, technology design, validation process, and quality attributes, both in terms of clinical parameters as well as usability and user experience.

Methods

A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following libraries: PubMed, Science Direct, Association for Computing Machinery Digital Library (ACM Digital Library), and Institute of Electrical and Electronics Engineers Xplore (IEEE Xplore).

Results

A total of 35 papers discussing 30 interventions were included. The main goals of these interventions were organized into 4 categories: breastfeeding education (n=12), breastfeeding promotion (n=8), communication support (n=6), and daily practical support (n=4). Of the interventions, 13 target mothers in the postnatal period. Most interventions come in forms of client communication systems (n=18), which frequently leverage Web technologies, text message, and mobile apps to provide breastfeeding support. Systems predominantly focus on mothers; validation strategies were rather heterogeneous, with 12 user studies concerning usability and user experience and 18 clinical validation studies focusing on the effects of the interventions on breastfeeding determinants; 5 papers did not report results. Generally, straightforward systems (eg, communication tools or Web-based solutions) seem to be more effective than complex interventions (eg, games).

Conclusions

Existing information and communication systems offer effective means of improving breastfeeding outcomes, but they do not address all relevant periods in parenthood (eg, the antenatal period) and often do not involve important stakeholders, such as partners. There is an opportunity to leverage more complex technical systems to open up avenues for the broader design of ICT to support breastfeeding; however, considering evaluation outcomes of existing support systems of higher complexity, such systems need to be designed with care.

Effect of Secondary Cigarette Smoke from Household Members on Breastfeeding Duration: A Prospective Cohort Study

OBJECTIVE

Maternal smoking and exposure to tobacco smoke is one modifiable risk factor that affects breastfeeding initiation and duration. We prospectively examine the effects of maternal and paternal smoking and other family members' smoking status on the duration of breastfeeding.

MATERIALS AND METHODS

A cohort of 1,277 mother-infant pairs admitted to the postpartum units of four major public hospitals in Hong Kong. Demographic data, maternal, paternal and household smoking habits, and other potential confounding variables were collected via self-reported questionnaires during the postnatal hospitalization. Breastfeeding status after hospital discharge was assessed through telephone follow-up up to 12 months postpartum, or until participants were no longer breastfeeding. If the participant had weaned during that follow-up interval, she was asked to report the total duration (in weeks) of both any and exclusive breastfeeding.

RESULTS

A total of 1,240 (97%) mother-infant pairs completed followed up, 2.5% were smokers, 29.2% of their partners smoked, and 11.3% had another smoker living in their home. Maternal and other family members' smoking predicted breastfeeding cessation. When compared with mothers in nonsmoking family, those exposed to two or more family members who smoked had approximately a 30% increased risk of breastfeeding cessation (adjusted hazard ratio [aHR] = 1.31; 95% CI 1.01-1.68).

CONCLUSION

Mothers who were exposed to two or more smokers in the household had a significantly shorter duration of any breastfeeding at 12-month follow-up.

Determinants of breastfeeding initiation among mothers in Sydney, Australia: findings from a birth cohort study

Background

Breastfeeding has short-term and long-term benefits for both the infant and the mother. The objective of this study was to identify the incidence of breastfeeding initiation among women in South Western Sydney, and the factors associated with the initiation of breastfeeding.

Methods

Child and Family Health Nurses recruited mother-infant dyads (n = 1035) to the Healthy Smiles Healthy Kids birth study in South Western Sydney, an ethnically and socio-economically diverse area, at the first post-natal home visit. A sample of 935 women completed a structured, interviewer-administered questionnaire at 8 weeks. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.

Results

In total, 92% of women (n = 860) commenced breastfeeding in hospital. Women who completed a university degree were more likely to initiate breastfeeding compared to those who did not complete high school (AOR = 7.16, 95% CI 2.73, 18.79). Vietnamese women had lower odds of breastfeeding initiation compared to Australian born women (AOR = 0.34. 95% CI 0.13, 0.87). Women who had more than one child were less likely to breastfeed than those who had one child (AOR = 0.38, 95% CI 0.19, 0.79). Women who gave birth via a caesarean section were less likely to breastfeed their baby compared to those who had a vaginal delivery (AOR = 0.27, 95% CI 0.14, 0.52). Women who drank alcohol during pregnancy had 72% lower odds to breastfeed compared to those who did not drink alcohol during pregnancy (AOR = 0.28, 95% CI 0.11, 0.71). Women who reported that their partner preferred breastfeeding were more likely to initiate breastfeeding (AOR = 11.77, 95% CI 5.73, 24.15) and women who had chosen to breastfeed before pregnancy had more than 2.5 times the odds of breastfeeding their baby compared to those women who made their decision either during pregnancy or after labour (AOR = 2.80, 95% CI 1.31, 5.97).

Conclusions

Women with lower levels of education, who consume alcohol during pregnancy, have more than one child, and make infant feeding decision after becoming pregnant, and those born in Vietnam should be targeted when implementing breastfeeding promotion programs. Further, women who deliver by caesarean section require additional breastfeeding support post-delivery and it is important to include fathers in breastfeeding related decisions and encourage them to participate in antenatal programs.

Incidence and determinants of neonatal morbidity after elective caesarean section at the national referral hospital in Kampala, Uganda

BACKGROUND

Elective caesarean sections (ECS) have been implicated in increased risk of adverse neonatal outcomes. The primary objective was to assess the incidence and determinants of neonatal morbidity after elective caesarean section deliveries. The secondary objective was to describe the maternal morbidity associated with elective caesarean section.

METHODS

This was a prospective cohort study of women admitted for ECS, as well as their newborns, conducted at Mulago hospital from March 1, 2013 to February 28, 2014. These were followed from the time of the operation until 6 weeks after hospitalization following the caesarean delivery. Data was collected using an interviewer-administered questionnaire and review of medical records for demographic characteristics, obstetric history, current pregnancy complications and pregnancy outcomes up to hospital discharge. Study outcomes were maternal and neonatal morbidity. The data was analyzed using Stata version 12.

RESULTS

There were 25,846 deliveries during the study period, of which 20,083 (77.7%) were vaginal deliveries or assisted deliveries, and 5763 (22.3%) were caesarean sections. Of the caesarean sections, 920 (15.9%) were ECS. The commonest maternal morbidity was hemorrhage (17.2%). A birth weight less than 2500 g (aRR 11.0 [95% CI 8.1-17.2]) or more than 4000 g (aRR 12.2 [95% CI 10.6-23.2]), delivery at gestation age less than or equal to 38 weeks (aRR 1.62 [95% 1.20-2.10]), multigravidity (aRR 1.70 [95% CI 1.20-2.90]) and using general anaesthesia (aRR 2.43 [95% CI 1.20-5.90]) were associated with risk of neonatal morbidity. The commonest neonatal morbidity is respiratory distress especially if delivery occurs at a gestation age of 37 weeks or lower, if the birth weight is less than 2500 g or more than 4000 g, and if general anesthesia is used.

CONCLUSION

Our study shows that at Mulago Hospital, ECS is associated with significant neonatal and maternal morbidity. We recommend that elective caesarean sections be performed after 39 weeks of gestation, and preferably avoid using general anaesthesia.

Active management of the third stage of labor may reduce breastfeeding duration due to pain and physical complications

BACKGROUND

Evidence is growing that active management of the third stage of labor using prophylactic uterotonics may be associated with lower breastfeeding rates. The reasons underlying this relationship are incompletely understood. The aim of this article is to examine the experiences of mothers who stopped breastfeeding in relation to administration of parenteral uterotonics for postpartum hemorrhage prophylaxis.

SUBJECTS AND METHODS

Two hundred eighty-eight mothers with an infant 0-6 months of age who had a vaginal birth completed a self-report questionnaire examining injections of uterotonics during the third stage of labor, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological.

RESULTS

No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.

CONCLUSIONS

These findings suggest that injection of prophylactic uteronics may reduce breastfeeding duration, but not initiation. This may be attributable to the effects of oxytocin or ergometrine on the physiology of lactation, leading to difficulties with infant latch and milk supply. If breastfeeding rates are to be optimized, this hypothesis needs to be explored in randomized controlled trials of third-stage management. Meanwhile, mothers who receive parenteral uterotonics may need additional support to establish breastfeeding.

Knowledge and beliefs about breastfeeding are not determinants for successful breastfeeding

A cross-sectional prospective study was performed to assess knowledge and attitude toward breastfeeding among mothers in a tertiary hospital in Malaysia and its influence on their breastfeeding practices. Two hundred thirteen women who had delivered healthy babies at term were enrolled. A structured questionnaire containing demographic data and the Iowa Infant Feeding Attitude Score were used, followed by a telephone interview after 8 weeks to determine the feeding outcome. Women of Malay ethnicity with higher education level who had received breastfeeding counseling had a significantly more favorable attitude toward breastfeeding. Ethnicity was found to be a significant determinant in the success of breastfeeding, whereas returning to work was a major reason for discontinuing breastfeeding. In ensuring a successful breastfeeding practice, apart from knowledge and attitude, issues surrounding culture and traditions as well as improving deliverance of readily available support should be addressed.

Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000-2008): a linked data population-based cohort study

OBJECTIVES

To examine the rates of obstetric intervention and associated perinatal mortality and morbidity in the first 28 days among low-risk women giving birth in private and public hospitals in NSW (2000-2008).

DESIGN

Linked data population-based retrospective cohort study involving five data sets.

SETTING

New South Wales, Australia.

PARTICIPANTS

691 738 women giving birth to a singleton baby during the period 2000-2008.

MAIN OUTCOME MEASURES

Rates of neonatal resuscitation, perinatal mortality, neonatal admission following birth and readmission to hospital in the first 28 days of life in public and private obstetric units.

RESULTS

Rates of obstetric intervention among low-risk women were higher in private hospitals, with primiparous women 20% less likely to have a normal vaginal birth compared to the public sector. Neonates born in private hospitals were more likely to be less than 40 weeks; more likely to have some form of resuscitation; less likely to have an Apgar <7 at 5 min. Neonates born in private hospitals to low-risk mothers were more likely to have a morbidity attached to the birth admission and to be readmitted to hospital in the first 28 days for birth trauma (5% vs 3.6%); hypoxia (1.7% vs 1.2%); jaundice (4.8% vs 3%); feeding difficulties (4% vs 2.4%) ; sleep/behavioural issues (0.2% vs 0.1%); respiratory conditions (1.2% vs 0.8%) and circumcision (5.6 vs 0.3%) but they were less likely to be admitted for prophylactic antibiotics (0.2% vs 0.6%) and for socioeconomic circumstances (0.1% vs 0.7%). Rates of perinatal mortality were not statistically different between the two groups.

CONCLUSIONS

For low-risk women, care in a private hospital, which includes higher rates of intervention, appears to be associated with higher rates of morbidity seen in the neonate and no evidence of a reduction in perinatal mortality.

Conception via in vitro fertilization and delivery by Caesarean section are associated with paediatric asthma incidence

BACKGROUND

The association between perinatal factors and asthma inception is under rigorous investigation. Nevertheless, evidence of a correlation between asthma, conception via in vitro fertilization (IVF) and delivery through Caesarean section (C-section) is inconclusive.

OBJECTIVE

We aimed to assess the relation of asthma incidence with IVF and C-section, after controlling for several potential confounding factors.

METHODS

Parent-reported wheeze in the last 12 months (current), wheeze ever, physician-diagnosed asthma, method of conception, and type of delivery were recorded from questionnaires filled in by the parents of 2016 Greek children aged 9-13, (the Healthy Growth Study population). Some perinatal data were recorded from children's medical records and others were reported by parents; anthropometric measurements were also conducted in children.

RESULTS

IVF was correlated with physician-diagnosed asthma (OR = 2.25; 95% CI = 1.11-4.56), but not with current/ever wheeze after adjustment for potential confounding factors. After adjustment, C-section was also associated with asthma (OR = 1.39; 95% CI = 1.04-1.87), but not with current/ever wheeze. When the association of both IVF and C-section with asthma was examined in the same multivariate logistic regression model, it was weakened to borderline significance (OR = 2.04; 95% CI = 1-4.15 and OR = 1.34; 95% CI = 1-1.81 respectively).

CONCLUSIONS AND CLINICAL RELEVANCE

Conception via IVF and delivery by C-section may predispose children to future asthma development. Either variable could also exert a confounding effect on the link of the other to asthma; this may partially be accountable for inconsistencies in the findings of pertinent studies.

Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants

AIM

To examine the rate and duration of breastfeeding in a cohort of women in opioid maintenance treatment (OMT) in Norway, as well as the effect of breastfeeding on the incidence and duration of neonatal abstinence syndrome (NAS).

METHODS

A national cohort of 124 women treated with either methadone or buprenorphine during pregnancy, and their neonates born between 1999 and 2009, was evaluated in three study parts. A standardized questionnaire was administered, and medical information from the hospitals and municipalities were collected to confirm self-reported data.

RESULTS

There were high initiation rates of breastfeeding (77%) for women in OMT, but also high rates of early cessation of breastfeeding. Breastfed neonates exposed to methadone prenatally had significantly lower incidence of NAS requiring pharmacotherapy (53% vs. 80%), and both the whole group of infants and the methadone-exposed neonates needed shorter pharmacological treatment of NAS (p < 0.05) than neonates who were not breastfed.

CONCLUSION

Breastfed neonates exposed to OMT medication prenatally, and methadone-exposed newborns in particular, have lower incidence of NAS and require shorter pharmacotherapy for NAS than infants who are not breastfed. The results add to the evidence regarding the benefits of breastfeeding for neonates prenatally exposed to OMT medications.

Breastfeeding and adolescent blood pressure: evidence from Hong Kong's "Children of 1997" Birth Cohort

Observationally, breastfeeding is associated with lower blood pressure in Western developed settings, whereas little association exists in developing settings. However, postnatal characteristics (e.g., breast milk substitutes, infection rates, underweight, and pubertal timing) differ between these settings. We examined the association of breastfeeding with blood pressure at ∼13 years, using multivariable linear regression, in 5,247 term births in 1997 from a population-representative Hong Kong Chinese birth cohort where socioeconomic patterning of breastfeeding differs from that of Western and developing settings but standard of living, social infrastructure, and postnatal characteristics are similar to those of Western settings. Higher education is associated with short-term breastfeeding but recent migration with longer-term breastfeeding. Compared with never breastfeeding, exclusive breastfeeding for ≥3 months was not associated with blood pressure (systolic mean difference = 0.82 mm Hg, 95% confidence interval (CI): -0.46, 2.11 and diastolic mean difference = 0.49 mm Hg, 95% CI: -0.22, 1.21), nor was partial breastfeeding for any length of time or exclusive breastfeeding for <3 months (systolic mean difference = 0.01 mm Hg, 95% CI: -0.64, 0.66 and diastolic mean difference = 0.16 mm Hg, 95% CI: -0.20, 0.52), adjusted for socioeconomic position and infant characteristics. Lack of association in a non-Western developed setting further suggests that observations concerning breastfeeding and blood pressure vary with setting, thereby casting doubt on causality.

The influence of mode of delivery on breastfeeding initiation in women with a prior cesarean delivery: a population-based study

OBJECTIVE

This study compared breastfeeding initiation following repeat cesarean delivery, successful vaginal birth after cesarean (VBAC), and unsuccessful trial of labor.

SUBJECTS AND METHODS

We performed a population-based retrospective cohort study of Ohio births (2006-2007) with a previous cesarean delivery. The primary outcomes were breastfeeding initiation rates among women with a previous cesarean delivery. Breastfeeding initiation rates were compared among three different delivery types: repeat cesarean delivery, successful VBAC, and unsuccessful trial of labor. Sociodemographic factors, medical risk factors, and pregnancy-related risk factors were also compared to assess influence on breastfeeding initiation rates.

RESULTS

Women delivered by successful VBAC were 47% more likely to initiate breastfeeding than women delivered by scheduled repeat cesarean (adjusted relative risk 1.47; 95% confidence interval 1.35, 1.60). Women who ultimately delivered by cesarean section with unsuccessful trial of labor were also more likely to breastfeed than women with a scheduled repeat cesarean section (61% vs. 58.7%, respectively) (adjusted relative risk 1.17; 95% confidence interval 1.04, 1.33).

CONCLUSIONS

Patients who undergo a scheduled repeat cesarean delivery are less likely to initiate breastfeeding. Women who attempt and succeed in achieving vaginal birth after a previous cesarean section are more likely to breastfeed than are women who deliver by repeat cesarean section. Also, those women who ultimately deliver by cesarean section after an unsuccessful trial of labor were also more likely to breastfeed than those women with a scheduled repeat cesarean section. This suggests there are influences on patient choice for delivery that also may influence the patient's decision to breastfeed.

Impact of birth complications on breastfeeding duration: an internet survey

AIM

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

BACKGROUND

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

DESIGN

An exploratory cross-sectional survey.

METHOD

Between January-May 2009, 284 mothers attending community groups in Swansea, Wales, and mothers participating in online parenting forums, who initiated breastfeeding but discontinued before 6 months postpartum, reported their birth experience, including complications and reasons for breastfeeding cessation in an internet survey.

RESULTS

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

CONCLUSION

Certain complications during labour may increase risk of specific physical difficulties with breastfeeding, possibly due to their association with medications received. Maternity health professionals should be alert to this possibility to offer enhanced attention and care to overcome these issues and prolong breastfeeding duration.

Breastfeeding initiation: is this influenced by maternal hepatitis B infection?

OBJECTIVE

To elucidate the effect of hepatitis B virus (HBV) infection on breastfeeding uptake in Chinese mothers in an endemic region.

PATIENTS AND METHODS

A retrospective cohort study on 63 885 consecutive pregnant delivered between January 1997 and June 2008, were extracted from computerized database to examine the relationship between breastfeeding uptake and maternal HBV status, adjusted for demographic factors.

RESULTS

A total of 6593 (10.3%) women were hepatitis B surface antigen (HBsAg)-positive, with an annual prevalence of around 10%. In the study period, 29 869 (46.8%) practised breastfeeding, and its prevalence ranged from 35.4 to 54.8% with an increasing trend throughout the years (p < 0.001). HBsAg-positive mothers had a significantly lower rate of breastfeeding (39.2 vs. 47.6% p < 0.001). Multiparas had higher incidence of HBV infection (10.9 vs. 9.8%, p < 0.001) and lower breastfeeding rate (42.2% versus 51.0%, p < 0.001) when compared with primiparas. Among those factors, maternal HBV infection had the strongest negative association with breastfeeding (adjusted odd ratio (aOR) = 0.726, 95% confidence interval (CI): 0.689-0.765).

CONCLUSIONS

Our results suggested maternal HBV infection was one of the factors for the persistently low breastfeeding rate in Hong Kong over the past decades. To promote breastfeeding, it is necessary to generate definitive data on its safety regarding to mother-to-child transmission (MTCT) of HBV in order to allay the fear and anxiety in HBsAg-positive mothers.

[Management of pregnancies with a previous cesarean]

The cesarean rate in France has reached 21% in 2010. With a maintained fertility rate, management of a pregnant woman with a previous caesarean scar is becoming a daily situation for most obstetrical teams. Considering the small rate of vaginal birth after cesarean (VBAC), we will try to establish an up-to-date review of the benefits and risks of encouraging trial of VBAC. This information can help professionals provide adequate counselling women or couples.

The association between cesarean delivery on maternal request and method of newborn feeding in China

Background

Cesarean delivery has increased significantly during the last decades. This study aimed to investigate the association between planned mode of delivery and method of feeding.

Methodology/Principal Findings

A cohort was created retrospectively using data from a population-based maternal and child health surveillance system, which covers 27 study sites in China from 1993 to 2006. The cohort consisted of 431,704 women for analysis, including 22,462 women with planned cesarean delivery on maternal request (CDMR) and 409,242 women with planned vaginal delivery (VD). Logistic regression models were used to examine the association between mode of delivery and method of feeding adjusting for selected covariates. In this cohort, 398,176 (92.2%) women exclusively breastfed their baby, 28,798 (6.7%) women chose mixed feeding, and 4,730 (1.1%) women chose formula feeding before hospital discharge. Women who planned CDMR were less likely to exclusively breastfeed and more likely to formula feed their babies than those who planned VD. After adjusting for covariates, the odds ratios were 0.85 (95% CI: 0.81–0.89) for exclusive breastfeeding and 1.61 (95% CI: 1.45–1.79) for formula feeding. Associations between planned mode of delivery and method of feeding in the south, north, rural and urban areas yielded similar results.

Conclusion

This study demonstrated that planned CDMR was associated with a lower rate of exclusive breastfeeding and a higher rate of formula feeding in a low-risk Chinese population.

Cesarean section and offspring's risk of inflammatory bowel disease: a national cohort study

BACKGROUND

Intestinal bacteria have been implicated in the etiology of the common inflammatory bowel diseases (IBD) ulcerative colitis and Crohn's disease. Because delivery by cesarean section disturbs the normal bacterial colonization of the newborn's intestine, we determined the risk of IBD according to mode of delivery.

METHODS

A register-based national cohort study of 2.1 million Danes born 1973-2008. The effect of mode of delivery on IBD incidence in the age-span 0-35 years was estimated by means of confounder-adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) obtained in Poisson regression analysis. Information on mode of delivery was obtained from the Danish Medical Birth Registry and cases of IBD were identified in the Danish National Patient Registry 1977-2008.

RESULTS

During 32.6 million person-years of follow-up, a total of 8142 persons were diagnosed with IBD before age 36 years. Cesarean section was associated with moderately, yet significantly, increased risk of IBD at age 0-14 years (IRR 1.29, 95% CI 1.11-1.49), regardless of parental disposition to IBD. Assuming causality, an estimated 3.2% of IBD cases before age 15 years were attributable to cesarean section.

CONCLUSIONS

Rates of IBD with onset in childhood are moderately increased after birth by cesarean section but underlying mechanisms remain unclear. Even if the association is causal, the possible impact of increasing cesarean section practices on the overall burden of IBD in childhood is small.

The health implications of birth by Caesarean section

Since the first mention of fetal programming of adult health and disease, a plethora of programming events in early life has been suggested. These have included intrauterine and postnatal events, but limited attention has been given to the potential contribution of the birth process to normal physiology and long-term health. Over the last 30 years a growing number of studies have demonstrated that babies born at term by vaginal delivery (VD) have significantly different physiology at birth to those born by Caesarean section (CS), particularly when there has been no exposure to labour, i.e. pre-labour CS (PLCS). This literature is reviewed here and the processes involved in VD that might programme post-natal development are discussed. Some of the effects of CS are short term, but longer term problems are also apparent. We suggest that VD initiates important physiological trajectories and the absence of this stimulus in CS has implications for adult health. There are a number of factors that might plausibly contribute to this programming, one of which is the hormonal surge or "stress response" of VD. Given the increasing incidence of elective PLCS, an understanding of the effects of VD on normal development is crucial.

Factors associated with breastfeeding cessation in nursing mothers in a peer support programme in Eastern Lancashire

Background

The UK has one of the lowest breastfeeding rates worldwide and in recent years the Government has made breastfeeding promotion one of its priorities. The UNICEF UK Baby Friendly Initiative is likely to increase breastfeeding initiation but not duration. Other strategies which involve provision of support for breastfeeding mothers in the early weeks after birth are therefore required to encourage UK mothers to breastfeed for the recommended duration. This paper examines the effects of maternal socio-demographic factors, maternal obstetric factors, and in-hospital infant feeding practices on breastfeeding cessation in a peer support setting.

Methods

Data on mothers from Blackburn with Darwen (BwD) and Hyndburn in Eastern Lancashire who gave birth at the Royal Blackburn Hospital and initiated breastfeeding while in hospital were linked to the Index of Multiple Deprivation (IMD). The data were analysed to describe infant feeding methods up to 6 months and the association between breastfeeding cessation, and maternal factors and in-hospital infant feeding practices.

Results

The mean breastfeeding duration was 21.6 weeks (95% CI 20.86 to 22.37 weeks) and the median duration was 27 weeks (95% CI 25.6 to 28.30 weeks). White mothers were 69% more likely to stop breastfeeding compared with non-White mothers (HR: 0.59; 95% CI, 0.52 to 0.67 [White mothers were the reference group]). Breastfeeding cessation was also independently associated with parity and infant feeding practices in hospital. There were no significant associations between breastfeeding cessation and marital status, mode of delivery, timing of breastfeeding initiation and socio-economic deprivation.

Conclusion

In this study ethnicity, parity and in-hospital infant feeding practices remained independent predictors of breastfeeding cessation in this peer support setting. However other recognised predictors such as marital status, mode of delivery, timing of breastfeeding initiation and socio-economic deprivation were not found to be associated with breastfeeding cessation.

Maternal tobacco use and shorter newborn nursery stays

OBJECTIVE

Nationally, 10%-15% of women report smoking during the last 3 months of pregnancy. Because the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) requires all U.S. hospitals to be smoke-free, and because tobacco is addictive, the maternal desire to smoke after childbirth could lead to requests for early hospital discharge for mothers and newborns. The authors hypothesized that maternal tobacco use would be associated with shorter newborn nursery hospital stays.

METHODS

Birth records from 405,622 singleton, "well" newborns, >or=35 weeks gestation born from 1998 to 2002 in Pennsylvania were merged with perinatal hospital record data and analyzed from 2006 to 2008. Perinatal data from 67,145 mothers self-reporting as having smoked cigarettes on the Certificate of Live Birth and data on their infants were compared 1:2 with data from mothers reporting to be nonsmokers and their infants via chi-square tests with odds ratios, 2-sample t-tests, and multiple linear regression.

RESULTS

In Pennsylvania, 16.6% of mothers smoked cigarettes during pregnancy. Tobacco-using mothers were more likely to be insured by Medicaid, unmarried, adolescent, not college educated, and have late onset of prenatal care. Their newborns were more likely to be low birth weight and be born at 35-36 weeks gestation. Nonetheless, these newborns had a significantly shorter mean length of stay (48.9 hours vs 52.4 hours; p<0.001), even after adjusting for confounders. A significant inverse relationship existed between number of cigarettes smoked per day by mothers and nursery length of stay for newborns.

CONCLUSIONS

Hospital smoking bans send a strong public health message regarding the risks of tobacco and protect patients and staff from secondhand smoke exposure. However, the association between maternal tobacco use and shorter newborn hospital stays may demonstrate an unintended consequence for the vulnerable population of newborns whose mothers smoke. This association should be considered during prenatal counseling, where smoking cessation can be emphasized, and at the time of mother and infant discharge. These findings are particularly important given the health and socioeconomic disparities between smoking mother-infant pairs and their nonsmoking counterparts.

Effect of delivery method and timing of breastfeeding initiation on breastfeeding outcomes in Taiwan

BACKGROUND

Few studies have examined the independent effect of delivery method and timing of breastfeeding initiation on the prevalence of breastfeeding. The objectives of this study were to examine the effect of method of delivery and timing of breastfeeding initiation on the prevalence of breastfeeding at 1 and 3 months after delivery using a national sample from Taiwan.

METHODS

The study population of 2,064 women who gave birth to infants without congenital anomalies at hospitals in Taiwan from June through October 2003, inclusively, participated in a postal questionnaire survey.

RESULTS

Multivariate ordinal logistic regression analysis showed that women with cesarean delivery had a lower odds of breastfeeding at 1 and 3 months after delivery. Women with assisted vaginal delivery had lower odds of breastfeeding at 3 months after delivery compared with women with unassisted vaginal delivery. Initiation of breastfeeding within 30 minutes of delivery was associated with higher odds of breastfeeding at 1 and 3 months after delivery. Women who did not initiate breastfeeding during hospital stay but breastfed at 1 month after delivery had lower odds of breastfeeding at 3 months after delivery.

CONCLUSIONS

The findings suggest the importance of conservative use of operative obstetrical intervention due to its negative impact on breastfeeding. Health professionals need to support mothers who have experienced cesarean and assisted vaginal delivery to increase their breastfeeding. Hospital staff should improve practice with respect to early initiation of breastfeeding.

Which women stop smoking during pregnancy and the effect on breastfeeding duration

BACKGROUND

Cigarette smoking during pregnancy increases the risk of adverse pregnancy outcomes and women who quit smoking at this time are able to reduce the risk of low birth weight, preterm labour, spontaneous abortion and perinatal death. This study investigates the socio-demographic characteristics of pregnant women who stop smoking during pregnancy and the association between stopping smoking and breastfeeding duration.

METHODS

A 12 month longitudinal study was conducted in two public maternity hospitals in Perth, Australia between mid-September 2002 and mid-July 2003. While in hospital, participating mothers completed a self-administered baseline questionnaire. Follow up telephone interviews were conducted at 4, 10, 16, 22, 32, 40 and 52 weeks.

RESULTS

A total of 587 (55%) mothers participated in the study. Two hundred and twenty six (39%) mothers reported smoking prior to pregnancy and 77 (34%) of these stopped smoking during pregnancy. Women who were pregnant for the first time were twice as likely (OR = 2.05; 95% CI 1.047 - 4.03; p < 0.05) to quit smoking as multiparous women. Women who smoked more than 10 cigarettes per day were significantly less likely to quit smoking during pregnancy (OR = 0.36; 95% CI 0.18 - 0.69; p < 0.05). Women who consumed alcohol before pregnancy were three times more likely to quit smoking (OR = 2.58; 95% CI 1.00 - 6.66; p < 0.05). Quitting smoking during pregnancy was significantly associated with breastfeeding for longer than six months (OR = 3.70; 95% CI 1.55 - 8.83; p < 0.05).

CONCLUSION

Pregnancy is a time when many women are motivated to quit smoking and providing targeted smoking cessation interventions at this time, which take into account factors predictive of quitting smoking, are more likely to be successful.

Caesarean section delivery and the risk of allergic disorders in childhood

BACKGROUND

The composition of the intestinal flora in young children, if unfavourable, may increase the susceptibility to allergic disorders. Beneficial intestinal microbes originate from the maternal vaginal tract and thus are more likely to be transferred during vaginal births than during Caesarean sections (C-sections).

OBJECTIVE

To determine whether children born by C-section have a different risk of allergic disorders compared with those delivered vaginally. We also tested the hypothesis that the risk of allergic disorders is highest for children born after 'repeat C-sections'.

METHODS

A retrospective cohort study of 8,953 children aged 3-10 years. Children diagnosed with allergic rhinoconjunctivitis (AR), asthma, atopic dermatitis (AD), or food allergies were identified from the Kaiser Permanente Northwest Region electronic records. The children's sex, birth weight, birth order, postnatal exposure to antibiotics as well as the mothers' age, ethnicity, education, marital status, smoking status during pregnancy, and use of asthma or hayfever medications were identified through the mothers' medical records or through the Oregon Birth Registry.

RESULTS

The risk of being diagnosed with AR was significantly higher in the children born by C-section than in those delivered vaginally: adjusted odds ratio (OR)=1.37%, 95% confidence interval (CI)=1.14-1.63. Delivery by C-section was also associated with the subsequent diagnosis of asthma (OR=1.24%, 95% CI=1.01-1.53); this association was gender specific, with a positive association restricted to girls (OR for asthma in girls: OR=1.53%, 95% CI=1.11-2.10; in boys: OR=1.08%, 95% CI=0.81-1.43). There was no significant association between mode of delivery and AD. If children born in a 'repeat C-section' were considered separately the risk of being diagnosed with AR increased further (OR=1.78%, 95% CI=1.34-2.37). The same increase was noted for asthma in girls (OR=1.83%, 95% CI=1.13-2.97) but not in boys.

CONCLUSION

Caesarean sections may be associated with an increased risk of developing AR in childhood.

Becoming a role model: the breastfeeding trajectory of Hong Kong women breastfeeding longer than 6 months

While a substantial proportion of breastfeeding women stop early in the postpartum period, some women are able to breastfeed for longer periods. The aim of this research was to explore the experience of breastfeeding with a subsample of Hong Kong women who have breastfed for longer than 6 months. Participants (n=17) were recruited from a larger infant-feeding study (n=360) conducted in tertiary-care hospitals in Hong Kong. In-depth qualitative interviews were conducted and content analysis was used to analyse the data. Data analysis revealed four themes that encompassed the women's experiences: (1) making the decision, (2) maintaining family harmony, (3) overcoming barriers, and (4) sustaining lactation. Antenatally, participants anticipated that breastfeeding would be very 'difficult' and described how the practice did not fit with the image of a professional woman in Hong Kong. Despite family opposition, frequently from their mother-in-law, and lack of societal acceptance, difficulties were overcome by what the Chinese people call hung-sum or determination. This study highlights unique cultural and social findings affecting breastfeeding women in Hong Kong which may be useful to health-care providers working with Chinese women locally and internationally.

Effect of operative delivery in the second stage of labor on breastfeeding success

BACKGROUND

Operative delivery rates are currently rising in many countries, but the effects of this factor on the initiation and duration of breastfeeding are unclear. The purpose of this study was to evaluate breastfeeding success after instrumental vaginal delivery or cesarean section at full dilatation, and to investigate whether timing of discharge after operative delivery affects breastfeeding rates.

METHODS

A prospective cohort study was conducted of 393 women with term, singleton, live, cephalic pregnancies who required delivery in theater during the second stage of labor between February 1999 and February 2000. Postal questionnaires were mailed to participants at 6 weeks and 1 year. Logistic regression models were used to explore the relationships between infant feeding and mode of delivery, controlling for factors previously correlated with breastfeeding success.

RESULTS

Rates of exclusive breastfeeding at discharge and 6 weeks postpartum were 70 and 44 percent, respectively. No significant differences occurred when instrumental vaginal delivery was compared with cesarean section, adjusted OR 0.84 (95% CI 0.50, 1.41) and 1.15 (95% CI 0.69, 1.93) respectively. Breastfeeding rates after failed instrumental delivery were similar to those after immediate cesarean section, adjusted OR 0.99 (95% CI 0.72, 1.38) and 1.28 (95% CI 0.91, 1.78). Women who had a longer in-patient stay after cesarean section were more likely to achieve exclusive breastfeeding at hospital discharge (78% vs 66%, p = 0.03).

CONCLUSIONS

Method of operative delivery in the second stage of labor does not appear to influence initiation or duration of exclusive breastfeeding. A longer inpatient stay may help cesarean-delivered women to initiate breastfeeding.

Maternal, paternal and environmental tobacco smoking and breast feeding

The effects of environmental tobacco smoke (ETS) on breast-feeding patterns are poorly understood, while those of parental smoking on breast-feeding initiation vs. duration have not been clearly delineated. We conducted a prospective, population-based birth cohort study to examine the independent effects of maternal, paternal and ETS on breast-feeding initiation and duration. A total of 6747 Hong Kong Chinese infants were recruited and followed up in 1997-8. We obtained detailed household smoking history and recorded breast-feeding patterns in three follow-up interviews over 9 months. We found that both maternal and paternal smoking were associated with not initiating breast feeding (odds ratio [OR] for ever maternal smoking = 2.51, 95% confidence interval [CI] = 1.63, 3.86; OR for ever paternal smoking = 1.22, 95% CI = 1.08, 1.39). Exposure to ETS in utero and post partum were also related to not starting breast feeding (OR(ETS in utero) = 1.10, 95% CI = 0.99,1.24; OR(ETS post partum) = 1.21, 95% CI = 1.08, 1.36). These effects, however, did not persist for breast-feeding duration of < or = 4 months. Cox proportional hazards modelling confirmed the lack of association between any form of smoking and breast-feeding duration. Our findings suggest that smoking of any kind, during or after pregnancy, is a strong risk indicator for not initiating breast feeding. Smoking as a risk indicator for underlying socio-economic, demographic and psychosocial factors is probably responsible for most of the observed adverse effects, although we cannot rule out direct contributions from pathophysiological mechanisms. Public health strategies directed at these underlying factors should be vigorously pursued to reduce the adverse effects of tobacco on breast feeding and infant health in general.