Maternal Body Mass Index and Breastfeeding Non-Initiation and Cessation: A Quantitative Review of the Literature

Association of pre-pregnancy body mass index and gestational weight gain with continued breastfeeding until 6 months postpartum in Japanese women: the Japan Environment and Children's Study

BACKGROUND

The relationship of pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with continued breastfeeding (BF) in Japanese women remains unclear. To evaluate different maternal pre-pregnancy BMI and GWG categories according to the initial BMI, we conducted an analysis of continued BF until 6 months postpartum in a large Japanese cohort.

METHODS

This study used data from the Japan Environment and Children's Study, which included approximately 100,000 pregnant women. Pre-pregnancy BMI (kg/m2) was categorized as underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), and overweight (BMI 25.0-29.9). GWG was categorized as insufficient, optimal, and excessive based on the 2021 criteria from the Japanese Society of Obstetrics and Gynecology. Continued BF for the first 6 months postpartum was categorized into 3 patterns: exclusive BF (EBF), non-EBF type-I (6 months of BF with formula), and non-EBF type-II (< 6 months of BF). Logistic regression analysis was conducted to evaluate the association of pre-pregnancy BMI and GWG with continued BF. Normal BMI and optimal GWG and EBF were used as reference values while controlling for covariates.

RESULTS

Of 82,129 women with singleton pregnancies, BMI was categorized as underweight in 16.6%, normal weight in 75.3%, and overweight in 8.1%. The rate of EBF in these groups was 37.1% for underweight, 37.2% for normal weight, and 26.8% for overweight. In underweight women, both insufficient and excessive GWG were associated with higher rates of non-EBF type-II. In normal-weight women, insufficient and excessive GWG were associated with higher rates of non-EBF type-II. Overweight women showed higher rates of non-EBF type-I and type-II, irrespective of GWG.

CONCLUSIONS

Our results indicate that the effects of GWG on continued BF were associated with pre-pregnancy BMI. Adequate GWG should be recommended to underweight and normal-weight women to promote BF. Efforts toward the prevention of overweight prior to pregnancy should be encouraged to enhance BF.

Nutrition for Optimal Lactation

BACKGROUND

Breastfeeding is the ideal method of feeding for all newborns and is associated with multiple positive health outcomes. Human milk provides all essential nutrients and bioactive molecules needed for optimal infant health and development. Maternal nutrition during lactation plays an important role in supporting breastfeeding and in preventing nutrition and metabolic imbalances. The aim of this narrative review was to describe the most prevalent nutrition issues in lactating women and provide a summary of current diet recommendations as well as controversies on supplementation, in order to facilitate the information for clinicians and health professionals.

SUMMARY

Breastfeeding is a nutritionally demanding stage and adequate nutrition is key to avoid alterations in maternal nutritional status, to produce an adequate quantity of milk with good quality, and to avoid nutrition programming of diseases. Anemia and vitamin D, A, iodine, and iron deficiencies are common, while obesity and metabolic diseases keep rising. Inadequate maternal intake of many nutrients is also frequent in this stage.

Synopsis of the 2023 U.S. Department of VA and U.S. DoD Clinical Practice Guideline for the Management of Pregnancy

INTRODUCTION

This Clinical Practical Guideline provides recommendations based on a systematic review of the evidence to address critical decision points in the management of pregnancy. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG is based on a systematic review of both clinical and epidemiological evidence and was developed by a panel of multidisciplinary experts. The Work Group provides clear and comprehensive evidence-based recommendations incorporating current information and practices targeting practitioners throughout the DoD and VA Health Care systems. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG does not address every aspect of routine pregnancy care and is not intended to be a comprehensive guide to all care needed in pregnancy. It also addresses some clinically important and generally accepted standards of pregnancy care interventions that do not have sufficient high-quality evidence to support standalone recommendations. Additionally, it highlights emerging topics that have the potential to impact pregnancy care in the future and identifies gaps in the literature that warrant further research.

MATERIALS AND METHODS

The development of all VA/DoD guidelines is directed by the Evidence-Based Practice Guideline Work Group and adheres to the standards for trustworthy guidelines that were set by the National Academy of Medicine. A patient focus group was convened to assess important aspects of treatment for patients and to gain information about patient values and preferences. The Lewin Group, a contracted third party with expertise in CPG development, facilitated meetings and the development of key questions using the population, intervention, comparison, outcome, timing, and setting format. Consensus was achieved among the Work Group through an iterative process involving discussions on conference calls and in person during the recommendation development meeting. An independent third party, ECRI, conducted the systematic evidence review, which the guideline Work Group then used to develop recommendations using the Grading of Recommendations Assessment, Development and Evaluation system (7-9). The search methods and results are detailed in the full guideline.

RESULTS

This CPG provides 28 clinical practice recommendations that cover selected topics that the Work Group deemed had high priority need for evidence-based standards. The recommendations are divided into 3 main categories: routine care, complicated obstetrics, and mental health. An algorithm delineating recommended interventions and appropriate timing of these interventions over the course of the pregnancy and postpartum period was also created.

CONCLUSION

The CPG is not intended to define standards of care nor address all care needed in pregnancy; it does provide comprehensive guidance for routine pregnancy care. It aligns with the VA and DOD's goal of providing care that is consistent in quality and utilization of resources in efforts to reduce errors and inappropriate variations in practices. In total, the Work Group identified 71 items needing further study, including areas requiring stronger evidence to support current recommendations and newer topics that will guide future guideline development.

The impact of exclusive breastfeeding on breastfeeding duration

BACKGROUND

While breastfeeding is globally recommended, its duration still represents a public health issue.

AIM

To examine the association between the period of exclusive breastfeeding (EBF) and the duration of overall human milk nutrition, and to identify determinants associated with the duration of EBF and overall human milk nutrition length.

STUDY DESIGN

The presented study is a cross-sectional study. A total of 209 healthy Polish women of Caucasian origin, aged 19-42 years, who were the mother of a child aged 3-12 months, were enrolled in the study. Data were collected from 2018 to 2020 using an anonymous questionnaire. Statistical analyses included one way ANOVA and liner regression.

RESULTS

After birth almost all newborns were exclusively breastfed (96.7 %), but the supply of mother's milk declined as the children's ages increased. The duration of breastfeeding is strongly associated with EBF, especially until the child is six months old (p < 0.001). Mother's breastfeeding self-efficiency and her will for breastfeeding, comfortable latch, younger infant age, avoiding of a pacifier and excluding additional food may explain 36 % of variation of EBF duration (p < 0.001) and could be useful information for exclusive breastfeeding support.

CONCLUSIONS

The practice of exclusive breastfeeding strongly affects overall breastfeeding duration. The promotion of exclusive breastfeeding, rather than of overall breast milk supply, is crucial.

Prenatal intention to human milk feed in the native Hawaiian population: predictors of any human milk feeding from birth to six months postpartum

BACKGROUND

Rates of non-communicable diseases are disproportionately high among Native Hawaiian (NH) people, and the proportion of NH infants being fed human milk (HM) is the lowest among all ethnicities within the state of Hawai'i. The aim of this study was to explore biological, socio-economic, and psychosocial determinants of the initiation and duration of human milk feeding (HMF) among a study of NH mothers and infants.

METHODS

A sample of 85 NH mother-infant dyads who were participating in a larger prospective study were involved in this research. Recruitment for the parent was delayed due to the COVID-19 pandemic. Recruitment started in November 2020 and continued until April 2022. Questionnaires were distributed at birth, two-months, four-months, and six-months postpartum. Questionnaires addressed topics relating to maternal and infant characteristics and infant feeding practices. Descriptive statistics, comparative analysis, and multivariate logistic regression tests were conducted.

RESULTS

The majority of participating mothers were aged between 31 and 35 years, had some college education or more, were employed, and multiparous. The majority of infants were receiving HM at each timepoint (94% at birth, 78% at two-months postpartum, and 76% at four and six-months postpartum). Factors found to be significantly associated with HMF initiation and duration were prenatal intention to HMF, maternal educational attainment, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation, and Supplemental Nutrition Assistance Program (SNAP) recipiency. A prenatal intention to HMF was found to be a strong predictor of HMF at birth (aOR = 64.18, 95% CI 2.94, 1400.28) and at two-months postpartum (aOR = 231.55, 95% CI 2.18, 2418.3). Participants not involved with WIC were more likely to be HMF at four-months postpartum (aOR = 6.83, 95% CI 1.01, 46.23).

CONCLUSION

This research supports existing evidence that prenatal intention to HMF and higher maternal educational attainment are positive predictors of HMF. WIC participation and being a SNAP recipient were found to be negatively associated with HMF which suggests a need for more culturally tailored support. Further research is required to reduce the gap in knowledge related to the determinants of HMF in NH.

Utility of the capability, opportunity, and motivation behaviour (COM-B) model in explaining the negative association between pre-pregnancy body mass index and exclusive breastfeeding at six weeks postpartum

The mechanisms underlying the negative associations between pre-pregnancy body mass index (BMI) and exclusive breastfeeding remain poorly understood. Thus, the study aimed to determine whether the negative associations between high pre-pregnancy BMI and exclusive breastfeeding at six weeks postpartum are mediated by components of the capability, opportunity, and motivation behaviour (COM-B) model. In this prospective observational study, we assigned 360 primiparous women to a pre-pregnancy overweight/obese group (n = 180) and a normal-BMI group (n = 180). A structural equation model was designed to study how capabilities (onset of lactogenesis II, perceived milk supply, breastfeeding knowledge, and postpartum depression), opportunities (pro-breastfeeding hospital practices, social influence, social support), and motivations (breastfeeding intention, breastfeeding self-efficacy, and attitudes towards breastfeeding) affected exclusive breastfeeding at six weeks postpartum in groups of women with different pre-pregnancy BMIs. In all, 342 participants (95.0%) possessed complete data. Women with high pre-pregnancy BMI were less likely to exclusively breastfeed at six weeks postpartum than women with a normal BMI were. We observed a significant negative direct effect of high pre-pregnancy BMI on exclusive breastfeeding at six weeks postpartum and a significantly negative indirect effect of high pre-pregnancy BMI via the explanatory mediating variables of capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy) on exclusive breastfeeding at six weeks postpartum. Our findings support certain capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy), partially explaining the negative association between high pre-pregnancy BMI and exclusive breastfeeding outcome. We suggest that interventions aimed at promoting exclusive breastfeeding among women with high pre-pregnancy BMI should address the capacity and motivation factors specific to this population.

Major maternal related determinants of non-breastfeeding among mothers in Ethiopia: A multilevel analysis from DHS Ethiopia 2016

INTRODUCTION

In Ethiopia, the burden of non-breastfeeding is still high despite substantial improvements in breastfeeding. However, the determinants of non-breastfeeding were poorly understood. Therefore, the aim of this study was to identify the maternal -related factors associated with non-breastfeeding.

METHODS

An in-depth analysis of data from the Ethiopian Demographic and Health Survey 2016 (EDHS 2016) was used. A total weighted sample of 11,007 children was included in the analysis. Multilevel logistic regression models were fitted to identify factors associated with non-breastfeeding. A p-value < of 0.05 was used to identify factors significantly associated with non-breastfeeding.

RESULTS

The prevalence of non-breastfeeding in Ethiopia was 5.28%. The odds of not breastfeeding were 1.5 times higher among women aged 35to 49 years (AOR = 1.5 CI: 1.034, 2.267) than among women aged 15to 24 years. The odds of not breastfeeding were higher among children whose mothers had BMIs of 18.5-24.9 (AOR = 1.6 CI: 1.097, 2.368) and 25-29.9 (AOR = 2.445 CI: 1.36, 4.394) than among women with BMIs of < 18.5. In addition, not breastfeeding was also significantly associated with ANC follow-up, where mothers who had 1-3 ANC follow-up had a 54% decreased odds (AOR = 0.651 CI: 0.46,0.921) compared to mothers who had no ANC follow-up. Demographically, mothers from Somalia region were five times (AOR = 5.485 CI: 1.654, 18.183) and mothers from SNNP region were almost four times (AOR = 3.997 CI: 1.352, 11.809) more likely to not breastfeed than mothers residing in Addis Ababa.

CONCLUSIONS

Although breastfeeding practices are gradually improving in Ethiopia, the number of children not breastfed remains high. Individual-level characteristics (women's age, body mass index, and ANC follow-up) and community-level characteristics (geographic region) were statistically significant determinants of non-breastfeeding. Therefore, it is good for the federal minister of Health, planners, policy and decision- makers, and other concerned child health programmers to prioritize both individual and community factors.

Association between maternal multimorbidity and preterm birth, low birth weight and small for gestational age: a prospective birth cohort study from the Japan Environment and Children's Study

OBJECTIVES

Multimorbidity is defined as the coexistence of two or more chronic physical or psychological conditions within an individual. The association between maternal multimorbidity and adverse perinatal outcomes such as preterm delivery and low birth weight has not been well studied. Therefore, this study aimed to investigate this association.

METHODS

We conducted a prospective cohort study using data from the Japan Environment and Children's Study of pregnant women between 2011 and 2014. Those with data on chronic maternal conditions were included in the study and categorised as having no chronic condition, one chronic condition or multimorbidities. The primary outcomes were the incidence of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). Adjusted logistic regression was performed to estimate ORs (aORs) and 95% CIs.

RESULTS

Of the 104 062 fetal records, 86 885 singleton pregnant women were analysed. The median maternal age and body mass index were 31 years and 20.5 kg/m², respectively. The prevalence of pregnant women with one or more chronic conditions was 40.2%. The prevalence of maternal multimorbidity was 6.3%, and that of PTB, LBW, and SGA were 4.6%, 8.1%, and 7.5%, respectively. Pre-pregnancy underweight women were the most common, observed in 15.6% of multimorbidity cases, followed by domestic violence from intimate partner in 13.0%. Maternal multimorbidity was significantly associated with PTB (aOR 1.50; 95% CI 1.33-1.69), LBW (aOR 1.49; 95% CI 1.35-1.63) and SGA (aOR 1.33; 95% CI 1.20-1.46).

CONCLUSION

Maternal multimorbidity was associated with adverse perinatal outcomes, including PTB, LBW and SGA. The risk of adverse perinatal outcomes tends to increase with a rise in the number of chronic maternal conditions. Multimorbidity becomes more prevalent among pregnant women, making our findings important for preconception counselling.

Impact of excessive gestational weight gain on exclusive breastfeeding among women with Type 1 and Type 2 diabetes and obesity

BACKGROUND

Pregestational diabetes, obesity and gestational weight gain (GWG) are associated with adverse perinatal outcomes, however, the influence of excessive GWG on lactation at discharge is less known. Our aim is to evaluate the impact of excessive GWG using the LifeCycle project guidelines on exclusive breastfeeding (EBF) and any BF rates at discharge among 171 women with Type 1 and 294 Type 2 diabetes and obesity who intended to BF.

METHODS AND FINDINGS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). GWG was categorized as adequate, inadequate or excessive according to the 2019 LifeCycle Project guidelines. Women with Type 1 were younger (30 vs 33y), primiparous (51 vs 32%), delivered earlier (37 vs 38w) than women with Type 2 andwere different in grade 1 (40 vs 26%), grade 3 obesity (19 vs 49%) and median GWG (15 vs 11kg). Of all 465 women with Type 1 and Type 2 combined, 365 (78%) who had excessive GWG and 100 (22%) who had non-excessive GWG showed similar EBF (27 vs 25%) and any BF (72 vs 72%) rates. Regression analysis showed that after adjusting for potential confounders excessive GWG was not a predictor of EBF or any BF at discharge.

CONCLUSION

Type 1 and Type 2 diabetes, obesity and excessive GWG are associated with low EBF, however, excessive GWG is not an independent predictor of low EBF or any BF at discharge.

Relationship between Child Care Exhaustion and Breastfeeding Type at Two and Six Months in a Cohort of 1210 Japanese Mothers

This study investigated whether parenting stress is associated with breastfeeding type (exclusive or partial). Between 2014 and 2019, we recruited 1210 healthy mothers (mean age, 31.2 years; 65%, multiparity) from 73 obstetric institutions across all prefectures of Japan. Among these, 1120 mothers at two months and 1035 mothers at six months were investigated for parenting stress and breastfeeding type: exclusive versus otherwise (partial). Parenting stress was measured by a validated Japanese scale consisting of childcare exhaustion, worry about child's development, and no partner support. Exclusive breastfeeding prevalence was 75% at two and 78% at six months. The total scores for childcare exhaustion and worry about child development were statistically higher in the partial breastfeeding group than in the exclusive breastfeeding group at two months but not at six months. A logistic regression model demonstrated that childcare exhaustion was significantly associated with an increased risk of having partial breastfeeding at two months after adjusting for the maternal Body Mass Index, parity, and baby's current weight. However, the association was no longer significant at six months. The present study suggests that intervention for parenting stress at two months postpartum may promote prolonged exclusive breastfeeding.

Why do first-time mothers not intend to breastfeed? --A qualitative exploratory study on the decision-making of non-initiation in Jingzhou, China

Background

Although breastfeeding is one of the top priorities for public health in China, the rate of breastfeeding is still low and a large number of women do not initiate breastfeeding due to various reasons. Hence, this study aimed to understand the decision-making of non-initiation and reveal the underlying reasons in order to protect, support, and promote breastfeeding.

Methods

In-depth, exploratory interviews were carried out with 13 new mothers who did not initiate breastfeeding. The collected data were analyzed by inductive content analysis.

Results

Although mothers generally understood the protective effects of breastfeeding, they believed that formula milk is a good alternative to human milk and even better in some aspects. Five core themes related to non-initiation decision-making emerged: (1) expected breastfeeding stress; (2) maladjustment to the maternal role; (3) concerns about physiological issues; (4) the lack of knowledge about the risks of artificial feeding; (5) belief that it is better not to initiate than to interrupt.

Conclusions

The environment for mothers to breastfeed in China is not supportive enough, and the medical staff and families should be held responsible for the non-initiation of breastfeeding. More professionals are needed to support mothers to solve their problems and breastfeeding education should be further expanded.

Exclusive Breastfeeding and Factors Influencing Its Abandonment During the 1st Month Postpartum Among Women From Semi-rural Communities in Southeast Mexico

INTRODUCTION

In this study we describe breastfeeding practices among women from semi-rural communities in southeast Mexico, and explore which factors, modifiable or not, are associated with such practices.

MATERIALS AND METHODS

This was a formative cross-sectional study that included 143 mothers with infants 4-6 months old, from semi-rural communities in Tabasco, Mexico. We collected data on two categories of factors: (1) women's sociodemographic characteristics, and (2) maternal / infant factors. We first analyzed the frequency of various breastfeeding practices. Then, we classified participants into the up to 1 month of exclusive breastfeeding group ( ≤ 1 m-EBF) and the beyond 1 month EBF group (>1 m-EBF), if they practiced EBF for less or more than 1 month, respectively. We compared the two categories of factors between groups and then, using logistic regression models, explored which factors were associated with practicing >1 m-EBF.

RESULTS

By the end of the 1st month postpartum, 51.7% of participants had abandoned EBF, introduced milk formula (35%), other food (9.1%), non-nutritive liquids (7.7%), or had stopped breastfeeding completely. In the next months, EBF practice fell sharply and mixed feeding grew importantly.Logistic regression models showed that women were more likely to be in the >1 m-EBF group if they lived with the baby's father, had complications during pregnancy, delivered vaginally and attended a health center at least three times postpartum. To the contrary, women were less likely to be practice >1 m-EBF if they gave infants other liquids during their hospital stay; experienced pain or discomfort in breasts/nipples, or used a pacifier after hospitalization; had larger bodies (i.e., higher BMI); and believed that you should give the infant powdered milk or some other food when the baby is not full.

CONCLUSION

Many factors associated with abandoning EBF, particularly in the early postpartum period, are modifiable and can be altered through timely interventions that include giving correct information and ensuring its comprehension; assertive personal counseling and accompaniment must be provided to mothers; and reinforcement during the early postpartum at health facilities and other settings.