breastfeeding experiment

• Research article
• Open access
• Published: 24 July 2019

The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment

• S. A. van Dellen 1 , 2 ,
• B. Wisse 1 , 3 ,
• M. P. Mobach 2 , 4 &
• A. Dijkstra 1  

BMC Public Health volume  19 , Article number:  993 ( 2019 ) Cite this article

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Breastfeeding has important positive long-term health consequences for infants and mothers. The World Health Organization recommends that all infants should be exclusively breastfed for six months or longer, and advises continuation of breastfeeding for two years or beyond. However, these recommendations are not met in many countries. This study examined whether a comprehensive, evidence-based breastfeeding intervention, the Breastfeeding Support Programme (BSP), promotes prolonged duration and exclusivity of breastfeeding among its participants.

A quasi-experimental design was used to compare breastfeeding duration and exclusivity in the BSP group ( N  = 66) to breastfeeding duration and exclusivity in a control group ( N  = 72). Participants who followed the BSP were provided with 6 consults delivered by a lactation consultant. The consults started during pregnancy and continued up until 10 weeks after delivery. Participants in the control group did not follow the BSP. Pretest and posttest questionnaires were administered through the internet. A Cox proportional hazards regression analysis was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for cessation of any and exclusive breastfeeding, while controlling for differences at baseline.

The effect of the BSP on survival rates for any and exclusive breastfeeding were significant while controlling for differences between the two groups at baseline (respectively HR = 0.34, p  < .001 [95% CI = 0.18–0.61] and HR = 0.46, p  < .001 [95% CI = 0.29–0.72]). Among mothers in the BSP group there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time compared to those in the control group.

Conclusions

The BSP appears to be an effective means to delay cessation of any and exclusive breastfeeding cessation and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because earlier cessation of breastfeeding than desired is a common problem in many countries. Future research into the effectiveness of the BSP could consider random assignment to conditions and test the effectiveness of the intervention in other populations to investigate further whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Peer Review reports

Due to the development and subsequent commercialization of infant formula in the eighteenth, nineteenth and twentieth centuries, there has been a strong decline in breastfeeding rates worldwide [ 1 , 2 ]. However, an increasing body of research shows that breastfeeding has important positive long-term health consequences for infants and mothers. A 2016 meta-analysis of research into the health consequences of breastfeeding for mothers and children concluded that infants who are breastfed for longer periods have lower infectious morbidity and mortality, fewer dental malocclusions and higher intelligence than infants who are not breastfed or breastfed for shorter periods [ 2 ]. Furthermore, breastfeeding may also protect against sudden infant death syndrome (SIDS), decrease the risk of necrotising enterocolitis (NEC) for premature babies, and protect children against overweight and diabetes later in life [ 2 ]. The beneficial effects of breastfeeding for mothers include protection against breast cancer, improved birth spacing, and potential protection against diabetes and ovarian cancer [ 2 ]. Moreover, it was estimated that scaling up breastfeeding to near universal levels could prevent approximately 823,000 child deaths and 20,000 deaths due to breast cancer worldwide annually. Breastfeeding therefore plays an important role in public health for mothers and children around the globe ([ 2 ]; also see [ 3 , 4 , 5 , 6 ]). As a consequence increasing the prevalence and duration of breastfeeding are important health goals in most nations. The World Health Organization (WHO) recommends that all infants should be exclusively breastfed (i.e., receive only breast milk and no other food or drink) for the first 6 months of life to achieve optimal growth, development, and health. Infants should receive complementary foods from 6 months, while breastfeeding should be continued for up to 2 years or beyond [ 7 ]. However, these recommendations are not met in many countries. Recent research by the WHO found in a sample of 194 nations, that only 40% of children younger than 6 months are breastfed exclusively [ 8 ]. Research findings also suggest that many mothers would like to breastfeed for longer, and that approximately 60% of US mothers stopped breastfeeding earlier than they desired [ 9 ]. Mothers stopped breastfeeding prematurely mainly because they had concerns about maternal or child health and concerns about the breastfeeding process (e.g., lactation and milk-pumping problems). The researchers concluded that professional support could help to address these challenges and help mothers to attain their breastfeeding goals [ 9 ]. Although some women cannot breastfeed for physical or medical reasons [ 10 ], many women could benefit from breastfeeding support.

In the Netherlands, breastfeeding rates also leave ample room for improvement. Although Dutch breastfeeding rates have gradually increased in the past decades, and 80% of Dutch mothers initiate breastfeeding, only 39% of Dutch babies are exclusively breastfed at 6 months Footnote 1 , according to a recent study [ 11 ]. Moreover, many women in the Netherlands report difficulties with breastfeeding and do not maintain the practice for as long as they intended [ 12 ]. In the past decades, national campaigns, emphasising the health benefits of breastfeeding, have been developed to extend the duration of breastfeeding [ 13 ]. As part of these campaigns, virtually all hospitals and maternity organisations in the Netherlands have received Baby Friendly Hospital Initiative (BFHI) certification [ 14 ], as developed by WHO in 1991 [ 15 ]. With regard to breastfeeding recommendations, Dutch guidelines initially followed the WHO guidelines, advising to breastfeed exclusively for at least six months. However, in 2011 the Dutch breastfeeding recommendations were adjusted, in an attempt to prevent the development of food allergies in children [ 16 , 17 ]. Since 2011 it is therefore advised that mothers should breastfeed for at least six months [ 18 ], but should start with complementary foods when the baby is between 4 and 6 months old, if possible [ 19 ]. Therefore, exclusive breastfeeding until six months is no longer recommended in the Dutch breastfeeding guidelines; also no mention is made of continuation of breastfeeding for two years or beyond. These deviating national guidelines may partly explain why the prevalence of (exclusive) breastfeeding in the Netherlands is relatively low, and why breastfeeding support and education is especially important in the Netherlands.

Systematic reviews and meta-analyses on breastfeeding promotion interventions have shown that breastfeeding education and/or support can effectively increase breastfeeding rates [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. For instance, a recent meta-analysis, including 27 randomized controlled trials (RCT’s) and 36,051 mothers, found that breastfeeding support interventions aiming to increase exclusive breastfeeding for 6 months were indeed effective. A subgroup analysis looking into the effects of different types of interventions found that a BFHI intervention, an intervention combining education and support, a professional provider led intervention, an intervention that has a protocol available for the provider training program, and an intervention that takes place both during the prenatal and postnatal periods, all increased the rate of exclusive breastfeeding for 6 months [ 26 ]. Likewise, a recent systematic review, focussing specifically on professional support interventions, found that interventions spanning from pregnancy to the postnatal period were more effective than interventions that took place in a shorter period, and that interventions using various methods of education and support were more effective than interventions concentrating on a single method [ 22 ]. Moreover, it was found that during pregnancy, the BFHI as well as teaching combined with support were effective approaches. During the postnatal period effective approaches included home visits, telephone support, and the use of breastfeeding centres combined with peer support [ 22 ].

The current study examines the effectiveness of a comprehensive, evidence-based, professional support intervention for breastfeeding that was implemented in the Netherlands: the Breastfeeding Support Program (BSP). The BSP was developed by two International Board Certified Lactation Consultants (IBCLC), based on theoretical findings and practical experiences. The Theory of Planned Behaviour (TPB) [ 27 ] constitutes the theoretical framework for the BSP. The TPB states that human behaviour is predicted by three kinds of considerations: a person’s general evaluation of a given behaviour (attitude); a person’s beliefs about how relevant others will view the behaviour in question (subjective norm); and a person’s perceived ease or difficulty in performing the behaviour (perceived behavioural control). The attitude, subjective norm and perceived behavioural control combined lead to the formation of a behavioural intention to display a certain behaviour. As a general rule, the more favourable the attitude and subjective norm, and the higher the perceived control, the stronger the person’s intention to perform the behaviour in question. Finally, intention is assumed to be the immediate antecedent of behaviour. The TPB is a well-known framework for designing behavioural change interventions [ 28 ], and several studies have shown that the TPB can be successfully applied to breastfeeding [ 29 , 30 , 31 , 32 ].The BSP applies the TPB by aiming to influence positively a mother’s attitude towards breastfeeding, the subjective norm and her perceived behavioural control. The BSP is not only based on the TPB, but also integrates the empirical research findings from systematic reviews of support interventions for breastfeeding promotion [ 22 , 26 ], suggesting that the most effective interventions are usually delivered by well-trained professionals, combine education and support, and are long-term and intensive, spanning both the prenatal and postnatal period. Although evidence suggests that all these separate elements should increase the effectiveness of a breastfeeding intervention [ 22 , 26 ], studies that investigate their combined effect are still largely lacking.

The research question we will answer in this study is: do the mothers enrolled in the BSP engage in prolonged breastfeeding in terms of duration and exclusivity compared to mothers in a control group? Based on the accumulated research into the effectiveness of breastfeeding promotion interventions [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ], and on studies showing the successful application of the TPB to breastfeeding [ 29 , 30 , 31 , 32 ], we hypothesized that the BSP is an effective intervention in principle. A test of this hypothesis further facilitates the elimination of unsound or ineffective practices in favour of those that have better outcomes, and as such this study aims to support the implementation of evidence-based practice.

Design and recruitment

The study had a quasi-experimental design (with one experimental group and one control group) with pre- and posttest. This design is common in studies aiming to establish the effectiveness of health-related interventions and is considered to be of relatively high quality in the hierarchy of quasi-experimental study designs [ 33 ]. Notably, a quasi-experiment may be preferable over a true experiment (or Randomized Controlled Trial; RCT) for testing the effectiveness of interventions, when randomisation is considered to be not ethical, expedient, or possible [ 33 , 34 , 35 ], or to create unwanted bias (e.g., low compliance, selective attrition, and questionable ecological validity) [ 36 ]. For the current study, we opted for a quasi-experimental design because randomisation was impractical (a Dutch health insurance company offered the BSP to their clients at the time of the research; we were able to carefully monitor the effects, but had no possibility to intervene), and moreover randomisation was considered to limit the ecological validity (women usually make a personal choice to participate in a breastfeeding programme or not; limiting personal choice could create unwanted bias in testing the effectiveness of such a programme). Because in a quasi-experiment allocation to conditions is not randomized, treatment and control groups may not be comparable at baseline. That is, selection effects can lead to pre-existing differences between treatment groups, which can pose a threat to internal validity [ 35 ]. We therefore thoroughly screened and controlled for a broad range of possibly confounding factors (see control variables in the Measurements Section).

Our experimental group consisted of pregnant women who were planning to breastfeed and who made a personal decision to enrol in the BSP (supported by their health insurance) on the BSP website. These women were recruited for this study through the enrolment form for the BSP, where they were asked to indicate if they were interested in participating in a study on breastfeeding experiences. The control group consisted of an independently recruited cohort of pregnant women with breastfeeding intentions, who were recruited through primary care facilities (obstetrician/general practitioner). At those facilities we made an enrolment form available for women who were planning to breastfeed. On this form the women could indicate whether they were interested in participating in a study on breastfeeding experiences. Thus, although women in the intervention group and the control group were recruited separately, they all were pregnant, they all planned to breastfeed and they all self-enrolled on the basis of the same written information. Recruitment for this study was conducted in the period of March 2013 to December 2014 Footnote 2 . Final inclusion criteria were (1) being pregnant; (2) planning to breastfeed; (3) having access to the internet; (4) having singleton gestation; (5) non-missing data for breastfeeding duration.

All the women who indicated an interest in participating in the study received an e-mail with further instructions and a link to complete an online pretest questionnaire. Invitations to complete the pretest questionnaire were sent from month 6 of pregnancy, making sure participants had some time to consider their breastfeeding plans. Invitations for the posttest questionnaire were sent from 28 weeks after the due date, thus making sure that at least 26 weeks had passed since delivery (health policy in the Netherlands aims to achieve that delivery is never more than 2 weeks after the due date). Both the pretest and posttest questionnaires emphasized that participation in the study was voluntary, that responses would be treated confidentially, that results would be reported anonymously, and that it was possible to withdraw from the study at any time without penalty. To encourage participation in the study, prizes were raffled among the participants. The pretest and posttest questionnaires were linked with the use of participants’ e-mail addresses. All the participants provided their informed consent. The research was approved by the Ethical Committee of Psychology of the University of Groningen, the Netherlands.

Intervention

The BSP tries to increase the proportion of mothers who breastfeed exclusively for six months or longer by positively influencing 1) the mother’s attitude towards breastfeeding (by focussing on the positive effects of exclusive breastfeeding for 6 months or longer for mother and child), 2) the subjective norm (by explicitly involving the father and by forming a reliable source of support and positive messages about breastfeeding throughout the programme) and 3) the mother’s perceived behavioural control (by providing information, encouragement and practical support to improve breastfeeding skills). As such, the BSP uses most of the behavioural change techniques proven to be effective in health interventions [ 37 ]. The BSP combines both education and support, extends from pregnancy to the postnatal period, and uses a protocolled series of six individual consults delivered by an IBCLC.

The protocol for the six consults within the BSP is as follows. 1) The programme begins with an intake consult at the lactations consultant’s office during pregnancy. This consult incorporates the following topics: medical history and breast check-up, breastfeeding experience, information about breastfeeding effects on mother and child, advice about breast care during pregnancy, information about the breastfeeding process, food, smoking, alcohol and drugs, the provision of written information about breastfeeding, and the opportunity to discuss questions and problems. 2) The second consult is held during the first week after delivery, either in the hospital or at the family home and focusses on the breastfeeding process as experienced up to that point. 3) The third consult is conducted by telephone on day 14 after delivery to discuss the breastfeeding process. 4) The fourth consult is again conducted by telephone on day 28 after delivery to discuss the breastfeeding process. 5) The fifth consult is held five weeks after delivery at the lactations consultant’s office and consists of a weighing of the baby, discussion of possible problems, breast check-up, and preparation for return to work if applicable. It also provides an opportunity to ask other questions. 6) The sixth and final consult is held 10 weeks after delivery by telephone and focuses on further support for returning to work (if applicable) and other possible questions and issues that mothers may wish to discuss. The number of in-person consults is fixed, but the timing of the consults can be adjusted if necessary (e.g., in case of urgent breastfeeding problems). Moreover, for the duration of the BSP, participants can always contact their IBCLC by phone for questions. The length of the BSP (until 10 weeks after the baby’s birth) is appropriate because most mothers who discontinue breastfeeding early do so during the first three months, mostly due to lactation problems [ 27 ]. Before the start of the program a day-long calibration session was organized for all the participating IBCLCs. The protocol was discussed and an example case was used to agree on its practical application. The fact that all lactation consultants in the BSP were IBCLCs contributed to the consistency of the information.

Measurements

Dependent variables.

Two dependent variables were used to assess the effectiveness of the intervention: 1) duration of any breastfeeding and 2) duration of exclusive breastfeeding. We measured these variables by asking three questions in the posttest questionnaire: ‘How many weeks old was your baby when he/she received breast milk for the last time?’ (breast milk was defined in the questionnaire as ‘mother’s milk from the breast or expressed breast milk’), ‘How many weeks old was your baby when he/she received artificial feeding for the first time?’ and ‘How many weeks old was your baby when he/she received solid food for the first time?’

Control variables

To screen and control for the comparability of participants in the BSP group and the control group, a total of 45 possible confounders was measured at pretest and at posttest (perinatal variables). We arrived at the list of 45 potential confounders after scrutinizing review articles which focus on the determinants of the duration and exclusivity of breastfeeding [ 11 , 38 , 39 , 40 , 41 ]. These possible confounders included psychosocial variables (attitudes, subjective norms, perceived control, prenatal intention, breastfeeding knowledge, maternal work conditions, social and professional support for breastfeeding and/or artificial feeding), demographic variables (age, level education, relationship status and nationality), and biomedical variables (parity, method of delivery, BMI-index, alcohol usage and smoking). To be exhaustive, maternal or paternal asthma, eczema, hay-fever or other allergies were added to this list. It is explicitly advised in the Netherlands to breastfeed babies at increased risk of these health issues [ 42 , 43 ], which might result in increased motivation to breastfeed. See Additional file  1 for a complete overview of the 45 possible confounders we measured, including a description of the operationalization.

Comparability between the BSP group and the control group was assessed by comparing both groups on the 45 possible confounding variables by means of univariate analyses. Because the data on breastfeeding duration were censored (some of the mothers were still breastfeeding or breastfeeding exclusively at the time of the post-test) Survival Analysis was most suited for the analysis [ 44 ]. Cessation of any and exclusive breastfeeding were taken as the final events for the analysis. The week the infant received breast milk for the last time was considered to be the time to event for cessation of any breastfeeding. The week the infant received artificial feeding or solid food Footnote 3 for the first time was considered to be the time to event for cessation of exclusive breastfeeding. First, Kaplan-Meier plots were used to assess survival for any breastfeeding and exclusive breastfeeding in the BSP and the control group, without controlling for differences between the two groups at baseline. Second, a Cox proportional hazards regression analysis was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) of breastfeeding cessation, controlling for variables that differed between both groups at baseline. Visual examination of survival plots was carried out to check the proportional hazard assumption [ 45 ]. All analyses were performed using the Statistical Package for the Social Sciences (SPSS Version 23). See Additional file 2 for the data set; see Additional file  3 , Additional file 4 , and Additional file 5  for the analyses performed.

Response and attrition

A total of 234 women enrolled in the BSP programme (Fig.  1 ). Of these 234 women, 112 (48%) indicated that they were interested in participating in our study on breastfeeding experiences. In the control group 133 women indicated interest in participation. All of these 245 women received an invitation to participate. We obtained a final sample of 138 women (66 mothers in the BSP group and 72 mothers in the control group), due to non-response at the pretest ( N  = 28 in the BSP group, N  = 40 in the control group) or posttest ( N  = 12 in the BSP group, N  = 18 in the control group), missing data on breastfeeding duration ( N  = 5 in the BSP group, N  = 2 in the control group) or multiple births ( N  = 1 in the BSP group, N  = 1 in the control group). The response rates in the BSP group and the control group did not differ significantly in the pretest (75.0% versus 69.91%, χ 2 (1) = 0.781, p  = .377) or the posttest (58.9% versus 54.1%, χ 2 (1) = 0.568, p  = .451).

The attrition rates in the BSP group and the control group

Sample description

In the pretest sample 3.5% of the participants reported a lower level education, 22.1% a medium level education and 74.4% a higher level education, and the average age was 31.5 years ( SD  = 4.39). In the posttest sample 1.4% of the participants reported a lower level education, 18.8% a medium level education and 79.7% a higher level education, and their average age was 31.7 years ( SD  = 4.29). The women who dropped out at follow-up had reported mainly lower or medium level education, increasing the proportion of higher educated women in the posttest. Furthermore, the mean age at the time of delivery increased by 0.2 year from pretest to posttest, meaning some of the younger women dropped out. Finally, breastfeeding initiation was almost universal (99.3%) and did not differ significantly between the BSP group and the control group (100% versus 98.6%, χ 2 (1) = 0.92, p  = .337).

Differences between the two groups at baseline

To check for comparability between the BSP group and the control group, the two groups were compared on 45 possibly confounding variables (see Additional file 1 ) by means of univariate analyses. Eleven differences between the BSP group and the control group were found at baseline with a p -value lower or equal to .10 (see Table  1 ). The mothers in the BSP group experienced more social support for artificial feeding ( p  = .045), had a lower perceived control for breastfeeding ( p  = .039), and would find it more difficult to breastfeed in various situations than the mothers in the control group at baseline ( p  = .062). Furthermore, the mothers in the BSP group were more likely to have been first-time mothers than the mothers in the control group ( p  = .010), had on average less breastfeeding experience ( p  = .003) and had experienced previous breastfeeding less positively than the mothers in the control group at baseline ( p  < .001). The mothers in the BSP group planned to work more hours than the mothers in the control group after their babies were born ( p  = .041). They were also better educated than mothers in the control group ( p  = .002) and the same was true of their partners ( p  = .036). Finally, the mothers in the BSP group were more likely to suffer from asthma ( p  = .011) and were more likely not to have been born in the Netherlands than the mothers in the control group ( p =  .039). A mixed picture emerges: compared to the control group, mothers in the BSP group were mostly characterized by factors which can be expected to have a negative effect on breastfeeding duration and exclusivity (such as experiencing more social support for artificial feeding, having a lower perceived control for breastfeeding, finding it more difficult to breastfeed in various situations, being more likely to be a first-time mother, having less and less positive experiences with previous breastfeeding, planning to work more working hours after the baby is born), but also by some factors which can be expected to have a positive effect on breastfeeding duration and exclusivity (such as being better educated and having better educated partners, a higher asthma incidence and being more likely not to have been born in the Netherlands). The differences between the two groups at baseline were statistically controlled for by including these variables as covariates in the Cox proportional hazards regression analysis.

The effects of the BSP without controlling for differences between groups

First, we used Kaplan-Meier plots to compare the survival curves in the BSP and the control group for duration of any breastfeeding and duration of exclusive breastfeeding, without controlling for differences between the two groups (Figs.  2 and 3 ). Breastfeeding survival rates were significantly higher in the BSP group than in the control group for any breastfeeding (log-rank test: χ 2 (1) = 4.79, p  = .029) and for exclusive breastfeeding (log-rank test: χ 2 (1) = 4.07, p  = .044). The survival curves showed that mothers in the BSP group had a higher probability of breastfeeding and breastfeeding exclusively than mothers in the control group at each point in time. The mean duration of any breastfeeding was 25.08 weeks in the BSP group versus 20.51 weeks in the control group and the mean duration of exclusive breastfeeding was 15.52 weeks in the BSP group versus 12.81 weeks in the control group.

Kaplan-Meier survival estimates for duration of any breastfeeding

Kaplan-Meier survival estimates for duration of exclusive breastfeeding

The effects of the BSP when controlling for differences between groups

A Cox proportional hazards regression analysis was performed, including variables which differed between the two groups at baseline Footnote 4 , to correct for potential confounding (see Table 1 ). The effect of the BSP on survival rates for any breastfeeding was significant while controlling for differences between the two groups at baseline (HR = 0.34, p  < .001 [95% CI = 0.18–0.61]). The effect of the BSP on survival rates for exclusive breastfeeding was also significant while controlling for differences between the two groups at baseline (HR = 0.46, p  < .001 [95% CI = 0.29–0.72]). See Table  2 . The HRs of 0.34 for any breastfeeding and 0.46 for exclusive breastfeeding indicate that there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point in time among mothers in the BSP group compared to those in the control group.

The effects of the BSP among nulliparous women only

To further strengthen the evidence for the effectiveness of the BSP, we attempted to create more comparable groups at baseline by selecting first-time mothers only. This sample of nulliparous women consisted of 72 participants in total ( n  = 42 in the BSP group, and n  = 30 in the control group). To check for comparability between the BSP group and the control group, the two groups were again compared on 45 possibly confounding variables (see Additional file 1 ) by means of univariate analyses. Among the nulliparous women, six differences between the BSP group and the control group were found at baseline with a p -value lower or equal to .10. The mothers in the BSP group experienced less professional support for breastfeeding (by their obstetrician or course instructor) ( p  = .027), had experienced less stress during the pregnancy ( p  = .069), planned to work more hours after their babies were born ( p  = .017), and planned for a longer pregnancy leave than the mothers in the control group ( p  = .081). Finally, they were better educated than mothers in the control group ( p  = .004) and the same was true of their partners ( p <  .001). First, we used Kaplan-Meier plots to compare the survival curves in the BSP and the control group for duration of any breastfeeding and duration of exclusive breastfeeding, without controlling for differences between the two groups. Breastfeeding survival rates were significantly higher in the BSP group than in the control group for any breastfeeding (log-rank test: χ 2 (1) = 7.85, p  = .005) and for exclusive breastfeeding (log-rank test: χ 2 (1) = 13.63, p  < .001). The survival curves showed that mothers in the BSP group had a higher probability of breastfeeding and breastfeeding exclusively than mothers in the control group at each point in time. The mean duration of any breastfeeding was 27.52 weeks in the BSP group versus 19.45 weeks in the control group, and the mean duration of exclusive breastfeeding was 16.76 weeks in the BSP group versus 10.50 weeks in the control group. Finally, a Cox proportional hazards regression analysis was performed, including variables which differed between the two groups at baseline, to correct for potential confounding effects. The results show that the effect of the BSP on survival rates for any breastfeeding was still in the expected direction, but no longer significant (HR = 0.42, p  = .113 [95% CI = 0.15–1.23]). The effect of the BSP on survival rates for exclusive breastfeeding however was still significant while controlling for differences between the two groups at baseline (HR = 0.35, p  = .006 [95% CI = 0.17–0.74]). In conclusion, we find similar effects as in our main analysis when assessing the effectiveness of the BSP among nulliparous women only. Although for any breastfeeding the results did not reach significance, the results for exclusive breastfeeding did reach significance, despite a limited sample size.

This study examined whether mothers enrolled in the BSP engage in longer and more exclusive breastfeeding compared to mothers in a control group. Controlling for differences at baseline, there was on average 66% less risk of cessation of any breastfeeding and on average 54% less risk of cessation of exclusive breastfeeding at any point of time among mothers in the BSP group compared to those in the control group. A subgroup analysis, including nulliparous women only, showed similar results, providing evidence for the robustness of the findings. In the current population, the BSP therefore appears to be an effective means to delay cessation of any and exclusive breastfeeding, and therefore to increase breastfeeding duration and exclusivity. This is an important finding, because breastfeeding rates are suboptimal in many countries [ 8 ], and interventions which could increase breastfeeding rates are valuable given the positive effects of breastfeeding on the mothers’ and children’s health and well-being [ 2 , 3 , 4 , 5 , 6 ]. Notably, our findings are in line with findings from systematic reviews and meta-analyses showing that breastfeeding promotion interventions can indeed effectively increase breastfeeding rates [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ].

A strong point of the BSP is that it is a very comprehensive breastfeeding intervention: it combines support and education, is led by a professional provider, has a protocol available, and is implemented during both the prenatal and postnatal periods. The programme is also evidence based, incorporating elements which have been proven to increase the effectiveness of a breastfeeding intervention [ 22 , 26 ]. Finally, the BSP has a firm theoretical foundation in the Theory of Planned Behaviour [ 27 ].

The number of studies evaluating breastfeeding interventions in the Netherlands is very limited: only two other studies are known to us. One study evaluated a breastfeeding intervention aimed at extending the continuation of breastfeeding until at least 3 months by educating postpartum health professionals, but found no significant effect [ 46 ]. Another study evaluated an educational programme to promote exclusive breastfeeding for 6 months in families with a history of asthma: breastfeeding exclusively at 6 months was significantly higher in the intervention group than in the control group [ 47 ]. In comparison to this last study, the BSP offers the added benefit that it is not tailored to a specific group, but is in principle applicable to the general population. Therefore, the BSP might be deployed as an effective general support measure for mothers intending to breastfeed, to improve the relatively low breastfeeding rates in the Netherlands [ 11 ].

An important limitation of the current research is that no randomization was performed, which led to pre-existing differences between groups. Although we believe we had valid reasons to opt for a quasi-experimental design (basing our decision on practical and ecological grounds), the lack of randomization could have resulted in pre-existing differences between the control and the intervention group that affected our findings [ 33 ]. Pre-existing differences can pose a threat to internal validity, mainly if they are related to the outcome variable of interest, and can thus provide an alternative explanation for the effect of the intervention. Therefore, the quality of any quasi-experiment is dependent on the degree of comparability between treatment groups, and it is essential to screen and control for possibly confounding factors [ 33 ]. In the current study we used post-hoc adjustment to control for potential confounders; another possibility is to prospectively match treatment groups on important confounding variables to create more comparable groups [ 35 ]. However, matching can be difficult and sometimes impractical, for example when the sample size is limited compared to the number confounding factors [ 48 ], as in the current study. Furthermore, controlling for differences has its limits, in the sense that one cannot control for unmeasured or imperfectly measured confounders [ 35 ]. Although we carefully measured and controlled for a broad range of possibly confounding variables in this study, future studies testing the effectiveness of the BSP may consider using alternative designs, most notably those in which participants are randomly assigned to conditions. For example, a RCT where all participants receive some form of BSP, but in different forms or intensities, could prevent selection bias, while at the same time precluding unwanted bias from randomisation (such as low compliance or selective attrition [ 36 ]). Studies focussing on the effectiveness of the current intervention at different intensities (e.g., more or fewer consults) and on the effectiveness of its various elements (i.e., which of the elements – information, practical advice or the role of the father etc. – contribute most to the programme’s effectiveness) could also help fine-tune the BSP, potentially making it more effective and efficient.

Another important limitation of the current research (related to the previous point) is that it is unclear to what extent the current findings are generalizable to other populations. The present research focussed explicitly on testing the effectiveness of the BSP among the current participants, and the sample of women in the BSP group was therefore self-selected. As a consequence, it is possible that certain characteristics of the current sample serve as moderators for the effectiveness of the intervention [ 33 ]. Two characteristics of our sample seem noteworthy in this respect. First, the women in the BSP group can be characterized by a relatively high education level, and second, it seems that women in the BSP group may have anticipated breastfeeding problems or were planning to return to work. Although we controlled for these differences (making it unlikely that they compromised our results), future research may want to zoom in on their potential effects. For example, the BSP seems to be effective for the women that we investigated, but perhaps it is less effective for, for instance, lower educated women, women who do not anticipate breastfeeding problems, or women who do not plan to return to work. It seems likely that mothers encountering difficulties during breastfeeding could particularly benefit from participating in a BSP. Evidence to this effect could point towards the effectiveness of targeting pregnant women with a higher propensity towards breastfeeding problems. Because the present research showed promising effects in the current population, future research could consider sampling from a broader set of populations to test the differences of BSP effectiveness between sub-groups of women and to test the generalizability of the current findings. Finally, future studies could include more dependent variables, such as whether women sought additional breastfeeding support or the extent to which breastfeeding problems are perceived as effectively handled, to provide greater insight into the effects and working mechanisms of the programme.

Given the important positive long-term health consequences of breastfeeding for infants and mothers [ 2 , 3 , 4 , 5 , 6 ], knowledge about effective breastfeeding support programmes is highly relevant. This research demonstrated that mothers enrolled in the BSP engage in prolonged breastfeeding in terms of duration and exclusivity compared to mothers in a control group. Therefore, we found empirical support for the BSP being effective in its current form and for the current client group. Future research should test the effectiveness of the intervention in other populations and use randomization to determine whether wide-scale implementation of this intervention could be useful to promote breastfeeding.

Availability of data and materials

All the data generated or analysed during this study are included in this published article and its additional files.

In this research exclusive breastfeeding was defined as still receiving breast milk, without artificial feeding. No information was recorded in this research on complementary feeding (i.e.: consumption of other foods or drinks alongside breastfeeding or artificial feeding).

Since the BSP is a relatively small-scale programme, recruitment was spread out over a longer period to ensure sufficient participants for a reliable effect measurement.

Since questions about drinks other than infant formula were not included in our questionnaire, this was not included in our operationalization of exclusive breastfeeding. However, we estimate that it is unlikely that children would have received other drinks than formula, unless they had also begun to receive solid foods and/or formula, since the Dutch Nutrition Centre advises introducing solid foods from month 4-6, and not to introduce water or other drinks until after month 6 [ 18 , 19 ]. If parents had taken the step not to introduce solid foods or formula before 6 months, then they would most likely not have introduced other drinks either before 6 months. The operationalization used therefore offers a good approximation of exclusive breastfeeding according to the WHO definition.

A negative experience with previous breastfeeding is the only variable which differed at baseline but was not controlled for in the Cox proportional hazards regression analyses. We decided not to control for this variable because first-time mothers were unable to answer this question. Note that a negative experience with previous breastfeeding was negatively correlated to breastfeeding duration in the current sample ( r  = -.40, p  = 0.001). Since the participants in the BSP group scored higher on this variable than participants in the control group, not controlling for this variable leads to a more conservative estimate. The decision not to control for this variable therefore seems justified. Furthermore, because there were almost no individuals with low-level education, we dichotomized education level and education level of the partner into low-medium versus high level to improve reliability of the estimates.

Abbreviations

Baby Friendly Hospital Initiative

Breastfeeding Support Program

International Board Certified Lactation Consultant

Randomized controlled trial

Theory of Planned Behaviour

World Health Organisation

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Acknowledgements

We would like to thank all the participants for taking part in this research. Furthermore we would like to thank MAKIBO and the primary care facilities involved for their help in the recruitment of participants.

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SvD conceived and designed the study and was responsible for the data acquisition, analysed and interpreted the data, and wrote and revised the manuscript. BW contributed to the analysis and interpretation of the data and helped revise the manuscript. MM contributed to the analysis and interpretation of the data and helped revise the manuscript. AD supervised the conception and design of the study and contributed to the analysis and interpretation of the data. All the authors read and approved the final manuscript.

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This study was approved by the Ethical Committee of Psychology (ECP) of the University of Groningen (reference number ppo-012-062). Participants were fully informed and gave their permission for participation in this research by indicating their informed consent in the online questionnaire, in accordance with the ECP’s guidelines.

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The authors declare that they have no competing interests. The author SvD received a gift for the birth of her child (<EUR 30) from MAKIBO, the company which developed and commercially exploits the BSP. Except for the above, the authors declare they were not paid or rewarded by MAKIBO.

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Additional file 1:.

An overview of the 45 possible confounders, including a description of the operationalisation. (DOCX 16 kb)

Additional file 2:

Data file BSP anonymized data. (CSV 151 kb)

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Spss syntax for preparation of the data file. (DOCX 16 kb)

Additional file 4:

Spss syntax for Cox regression. (DOCX 12 kb)

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Spss syntax for Cox regression nulliparous women only. (DOCX 14 kb)

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van Dellen, S.A., Wisse, B., Mobach, M.P. et al. The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: a quasi-experiment. BMC Public Health 19 , 993 (2019). https://doi.org/10.1186/s12889-019-7331-y

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Jordyn T. Wallenborn , Gillian A. Levine , Angélica Carreira dos Santos , Sandra Grisi , Alexandra Brentani , Günther Fink; Breastfeeding, Physical Growth, and Cognitive Development. Pediatrics May 2021; 147 (5): e2020008029. 10.1542/peds.2020-008029

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Video Abstract

Breastfeeding is an evidence-based recommendation for all countries, but breastfeeding rates have been declining in many middle-income settings. One reason behind this decline is the perception that breastfeeding may not be necessary in modern urban settings, where clean water is available and alternative foods are abundant. We investigate the importance of breastfeeding for early childhood development in the modern urban context of São Paulo, Brazil.

In our study, we used data from the ongoing prospective Western Region Birth cohort in São Paulo, Brazil. Children were recruited at birth and managed for 3 years. Durations of exclusive and mixed breastfeeding were our primary independent variables. Our secondary independent variable was an indicator for compliance with World Health Organization (WHO) breastfeeding recommendations. Our primary outcomes of interest were indicators of children’s physical, cognitive, language, and social-emotional development at 3 years of age. Adjusted estimates and 95% confidence intervals were calculated by using linear and logistic regression.

Complying with WHO recommendations to exclusively breastfeed for 6 months followed by complementary feeding until 2 years of age was associated with a 0.4-SD increase in overall child development (β: .38; confidence limit = 0.23 to 0.53), a 0.6-SD increase in height-for-age z score (β: .55; confidence limit = 0.31 to 0.79), and a 67% decrease in the odds of stunting (odds ratio = 0.33; 95% confidence interval = 0.20 to 0.54).

Our results suggest that even in settings with easy access to complementary foods, complying with WHO breastfeeding recommendations is important for healthy physical growth and cognitive development.

As countries develop economically and reach middle-income levels, breastfeeding often becomes more challenging, and rates of breastfeeding significantly drop. Evidence on the importance of continued breastfeeding for child development in upper middle-income countries with abundant food access is limited.

Our results suggest that in the upper-middle–income settings of Brazil, complying with the World Health Organization breastfeeding recommendations is likely beneficial for children’s physical and cognitive development.

Currently, >250 million children worldwide do not reach their full developmental potential. 1   Two Lancet series on early childhood development highlighted critical consequences of delayed childhood development and identified risk and protective factors that help children reach their full potential. 2   Breastfeeding is among the factors that help children’s healthy physical and cognitive development 3   and is actively promoted by the World Health Organization (WHO) worldwide. 4   In a recent systematic review, authors found breastfeeding to be consistently associated with improved intelligence tests, schooling performance, and adult income earnings 5   ; for social-emotional functioning, evidence appears more mixed. 6   For physical growth, the majority of studies from high-income countries reveal leaner growth and slower weight gain trajectories in exclusively breastfed infants compared with formula-fed infants, 7 – 11   implying that breastfeeding could also be a key protective factor for obesity and cardiovascular diseases. 12 , 13  

Today, the extent to which mothers engage in breastfeeding varies widely across country income groups. 14   In most low-income countries, breastfeeding is almost universal. 15   However, as countries develop economically and reach middle-income levels, breastfeeding often becomes more challenging or is perceived as less necessary, and rates of breastfeeding drop significantly. 15 – 18   Although the critical importance of breastfeeding for early childhood development seems obvious in low-income settings where safe alternative foods are scarce, 19   this is not necessarily true in higher-income settings where alternative feeding choices are abundant, affordable, relatively safe, and easily accessible. A lack of regulatory frameworks for sales and marketing of breast milk substitutes, such as the WHO Code of Marketing of Breast-milk Substitutes, may also lead to lower breastfeeding rates and higher rates of complementary feeding with infant formula. 20  

In Brazil, the prevalence of breastfeeding decreased drastically during the 1970s. 21   Factors contributing to these declines included increasingly affordable alternative feeding options, changing social norms, and a rise in mothers’ formal labor commitments without sufficient parental leave or breastfeeding support. 22   The Brazilian National Breastfeeding Program was a major turning point for the prevalence of exclusive breastfeeding in infants <6 months of age, increasing rates from 5% in 1986 to 37% in 2013. 21   However, the prevalence of exclusive breastfeeding varies, with the highest rates seen in capital cities and higher socioeconomic groups. 23  

In this study, we aim to investigate the association between breastfeeding and children’s physical, cognitive, language, and social-emotional development in this setting. Our study population of mothers living in a large metropolitan area of Brazil, a dynamic and rapidly growing modern middle-income country, represents large urban environments that are home to a growing share of families in low- and middle-income countries. 24   Our research directly responds to a previous Pediatrics study in which authors called for research on a dose-response relationship between breastfeeding and infant development that could adequately control for confounders. 25   We respond to this call by using a prospective cohort of children growing up in poor urban neighborhoods of São Paulo, Brazil, while controlling for essential confounding factors overlooked in previous studies (ie, home stimulation). On the basis of our a priori data analysis plan, we hypothesized that (1) breastfeeding duration is associated with a higher level of cognitive and social-emotional development, (2) this association will be more apparent in exclusively breastfed children, with smaller estimates seen in children who had mixed feeding, and (3) height-for-age z score (HAZ) will be smaller among exclusively breastfed children compared with nonbreastfed or mixed-fed children. Post hoc, we added childhood obesity, which had been omitted in the original preanalysis plan but was deemed an important outcome by local coinvestigators given the rising rates of child obesity in this setting. 26  

Data used for our prospective cohort study were collected as part of the São Paulo Western Region Birth Cohort (ROC) located in the Butantã-Jaguaré region of São Paulo municipality, Brazil. The cohort comprises all resident children born at São Paulo’s university hospital between April 1, 2012, and March 31, 2014. Birth outcomes were obtained from electronic medical records. Additional information on mother-infant dyads was collected at 36 months postpartum by study staff at the child’s home through structured interviews. Data were collected on socioeconomic status, health standing, breastfeeding practices and other infant feeding behaviors, and childhood development indicators. Additional details on the ROC can be found elsewhere. 27  

The original study population included 3620 mothers that were interviewed at 3 years postpartum. Our study excluded mother-infant dyads who were not selected for the 3-year breastfeeding module ( n = 1239), had a multiple birth (ie, twins) ( n = 21), or had a child with a malformation or disability ( n = 72) ( Fig 1 ). Our final study population consisted of 2288 mother-infant dyads. The breastfeeding module that consisted of 5 breastfeeding questions was added ∼6 months after launching the 36-month follow-up. As a result, ∼1000 mother-infant dyads were not administered the breastfeeding module.

Consolidated Standards of Reporting Trials flow diagram for sample population.

Our primary exposure of interest, breastfeeding duration, was parameterized multiple ways to explore the mechanisms between breastfeeding and our outcomes of interest. We investigated both exclusive breastfeeding duration and total breastfeeding duration in months. Mothers self-reported breastfeeding duration by answering the following questions: “For how many months did the child exclusively receive breast milk?” and “For how many months did the child receive any breast milk?” In addition to the continuous measure, exclusive breastfeeding was also categorized as follows: exclusive breastfeeding for ≤3 months, 4 to 5 months, and at least 6 months. Lastly, we combined exclusive breastfeeding and any breastfeeding duration to create an indicator that signifies accordance with WHO international breastfeeding recommendations, defined as follows: does not comply with recommendations, only complies with exclusive breastfeeding for at least 6 months, only complies with providing breast milk for at least 24 months, and complies with both (at least 6 months of exclusive breastfeeding and total breastfeeding duration of at least 24 months). 28  

Our primary outcomes for cognitive and physical development were children’s overall development as assessed by the Regional Project on Child Development Indicators (PRIDI) (Engle scale) and HAZ. PRIDI is a tool used to collect high-quality and regionally comparable data on the overall development of children aged 2 to 5 years in Latin America, capturing cognitive, language, social-emotional, and motor development. 29   We also analyzed a dichotomous (yes or no) indicator of child stunting (HAZ <−2) and child weight status using BMI z scores, categorized into underweight (less than the fifth percentile), normal weight (fifth percentile to less than the 85th percentile), overweight (85th to less than the 95th percentile), and obese (≥95th percentile). The total PRIDI score (range: 0–61) was normalized within the study sample to a mean of 0 and SD of 1. At 36 months, both the mother and trained interviewer measured the child’s height in centimeters. Weight was measured by trained staff only. HAZ and weight-for-height z score were computed by using the WHO’s Anthro software package. 30  

Our secondary outcomes for social-emotional development included z scores on the Early Childhood Behavior Questionnaire (ECBQ) and the Strengths and Difficulties Questionnaire (SDQ). The ECBQ is a parent report of toddler (1.5–3 years) temperament consisting of 18 items, with higher scores representing better social-emotional development. 31   The SDQ is an emotional and behavioral screening tool for children, comprising 25 questions for caregivers. Scores range from 0 to 30, with lower scores representing fewer behavioral difficulties. We reversed the SDQ scale so higher scores represent better outcomes to facilitate comparability with the PRIDI estimates. In our a priori data analysis plan, we specified an additional secondary outcome: the Caregiver Reported Early Development Instruments (CREDI). However, CREDI was dropped as a secondary outcome because of the high rate of missing information (67.4%; n = 1542) and potential biases created by parents reporting on their own children. All cognitive and social-emotional development indicators, including PRIDI, ECBQ, and SDQ, are indicators for overall child development and do not directly identify children with developmental difficulties. These indicators were normalized to a mean of 0 and SD of 1 to facilitate interpretation of estimated group differences.

A literature search was conducted to identify the following potential confounding factors 32 – 35   : household food insecurity score, social support score, caregiver’s highest educational attainment, income (in Brazilian real), Multiple Indicator Cluster Surveys (MICS) (home stimulation score), preterm birth, low birth weight, presence of father or father figure at home, hours per week the caregiver works outside of the home, maternal age at birth, age at child assessment, child care attendance, child sex, couples conflict, and the Edinburgh Postnatal Depression score. Couples conflict is the sum score of 4 domains (eg, assault, sexual coercion, injury, and psychological aggression) from a revised couples conflict tactics scale. Respondents could answer between 0 and 3, from none of the time to all of the time. The social support score consists of 4 domains aimed at quantifying the level of support for companionship, assistance, or other support systems: (1) someone to confide in or talk to about problems, (2) someone to take them to the doctor, (3) someone to help with daily chores if they are sick, and (4) some to loan small amounts of money if needed. We calculated a sum score for the social support scores (from 0, being no social support, to 16, being the highest level of social support). Categorization schematics are found in Table 1 .

Description of Sample Population Overall and By Exclusive Breastfeeding Duration

Categorical variables are presented as n (column %). Because of rounding, percentages may not add to 100. R$, Brazilian real; —, not applicable.

Continuous variable. Data are presented as mean (SD).

Significant P value.

Descriptive statistics were used to describe the study population by using frequencies and percentages for categorical variables and means and SDs for continuous variables. Characteristics were also described by exclusive breastfeeding duration category coupled with a χ 2 or t test to identify significant differences between groups. Because of the high attrition rate from baseline to 36 months, we examined differences in maternal-infant characteristics to evaluate the risk of potential selection bias. We also examined differences between mothers who completed the breastfeeding module and those who did not. Kernel density plots were created to display the empirical distribution of PRIDI and HAZ by exclusive breastfeeding duration.

To investigate associations between breastfeeding and physical growth and childhood development indicators, linear regression was used to obtain β estimates and 95% confidence limits (CLs) for PRIDI, ECBQ, SDQ, and HAZ. Logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals (CIs) for childhood stunting and obesity. Logistic regression was also used in an additional analysis focusing on children with a PRIDI score >1 SD below the sample mean. Child sex and the Edinburgh Postnatal Depression score were tested for effect modification by using an interaction term in the initial analysis. After finding no evidence of effect modification, we included both variables as confounders in our empirical models. Additionally, all models investigating mixed breastfeeding controlled for preceding exclusive breastfeeding duration. A P value of .05 signified statistical significance. SAS version 9.4 (SAS Institute, Inc, Cary, NC) was used for all analyses. This study was approved by the Faculdade de Medicina da Universidade de São Paulo Institutional Review Board (9 01604312.1.0000.0065).

From the ROC data, we identified 2288 mother-infant dyads for our study. As shown in Supplemental Table 5 , overall, children not assessed in the 3-year survey had a slightly higher prevalence of low birth weight (9.1% vs 6.1%) and preterm birth (10.7% vs 8.9%) as well as slightly more supportive home environments compared with children managed until 3 years of age. Similarly, among all participants at 3 years postpartum, those who did not complete the breastfeeding module had slightly higher levels of caregiver educational attainment, MICS home stimulation scores, low birth weight, stunting, and HAZ scores ( Supplemental Table 6 ).

Among study participants ( N = 2288), 4.9% of children were born low birth weight (<2500 g) and 8.1% were born prematurely (<37 weeks’ gestation). At 3 years of age, almost 1 in 4 children were stunted (23.9%). The majority of children attended child care at least once a week (82.6%) and had a father or father figure in the household (85.2%) ( Table 1 ). Characteristics stratified by reported exclusive breastfeeding duration categories are also displayed in Table 1 . We found significant differences between exclusive breastfeeding duration categories and HAZ, stunted growth, PRIDI, postnatal depression score, child age at development assessment, levels of caregiver educational attainment, social support score, MICS home stimulation score, house presence of father or father figure, and preterm birth.

Supplemental Figures 2 and 3 display the distribution of exclusive and total breastfeeding duration. A quarter of mothers exclusively breastfed 3 to 5 months. Almost half of women exclusively breastfed 6 months or more ( Supplemental Fig 2 ). The majority (∼55%) of mothers provided at least some breast milk for at least 6 months ( Supplemental Fig 3 ).

The relationship between child development indicators and exclusive breastfeeding duration categories is shown in Table 2 . Compared with mother-infant dyads who exclusively breastfed ≤3 months, infants exclusively breastfed at least 6 months had a 0.3-SD higher PRIDI score (CL = 0.16 to 0.34) and 0.4 higher HAZ score (CL = 0.16 to 0.54). Similarly, the odds of child stunting at 36 months were 38% lower with exclusive breastfeeding for at least 6 months (OR = 0.62; 95% CI = 0.45 to 0.84). Our exploratory analysis confirms that children who were exclusively breastfed ≥6 months had 44% lower odds (OR = 0.56; 95% CI = 0.39 to 0.81) of having a PRIDI score >1 SD below the sample mean compared with children exclusively breastfed ≤3 months (results not shown). We did not find evidence of a relationship between childhood weight status, ECBQ, or SDQ. Density plots of PRIDI ( Supplemental Fig 4 ) and HAZ ( Supplemental Fig 5 ) suggest that the improvements in these 2 outcomes affect all parts of the distribution (ie, that average improvements are not driven by children with extremely positive or negative outcomes).

Adjusted Associations Between Exclusive Breastfeeding and Child Outcomes

All models adjusted for child sex, maternal age at birth, caregiver highest educational attainment, income, presence of the father or father figure at home, preterm birth, low birth wt, child care attendance, age at child assessment, household food insecurity score, social support score, couples conflict, hours caregiver works away from the home, and depression and MICS stimulation score. —, not applicable.

Adjusted also for maternal BMI.

P < .05; *** P < .0001.

The association between current WHO breastfeeding recommendations and child development indicators is shown in Table 3 . Compared with maternal-infant pairs who did not comply with WHO recommendations, maternal-infant pairs only complying with the recommendation to exclusively breastfeed for at least 6 months were associated with a 0.4-SD increase in PRIDI score (β: .41; CL = 0.23 to 0.58). Results were largely the same for compliance with exclusive breastfeeding for the first 6 months followed by complementary feeding until 2 years of age (β = .38; CL = 0.23 to 0.53) and only providing complementary breast milk for at least 24 months (β = .30; CL = 0.03 to 0.58). All other behavioral indicators revealed weaker associations with breastfeeding ( P > .05). For physical growth, complying with the recommendation to exclusively breastfed for 6 months only was associated with a 0.7-SD increase (CL = 0.44 to 0.99) in HAZ. Similar associations were found for complying with both exclusive and complementary feeding guidelines (β = .55, CL = 0.31 to 0.79) or only providing complementary breast milk for at least 24 months (β = .54; CL = 0.10 to 0.99). The odds of child stunting were lowest for children who were exclusively breastfed for 6 months and received breast milk for at least 24 months (OR = 0.33; 95% CI = 0.20 to 0.54); however, exclusive breastfeeding for at least 6 months was also associated with reduced odds of child stunting (OR = 0.49; 95% CI = 0.28 to 0.85). No associations were found between WHO breastfeeding recommendations and childhood weight status.

Relationship Between WHO Breastfeeding Recommendations and Child Outcomes

All models were adjusted for child sex, maternal age at birth, caregiver highest educational attainment, income, presence of the father or father figure at home, preterm birth, low birth wt, child care attendance, age at child assessment, household food insecurity score, social support score, couples conflict, hours caregiver works away from the home, depression, and MICS stimulation score.

Adjusting for the additional confounder of maternal BMI.

P < .05; ** P < .01; *** P < .0001.

The adjusted associations between months of exclusive and mixed breastfeeding duration and child development indicators are shown in Table 4 . Our fully adjusted models revealed an increase of 0.03 in the PRIDI standardized score for every month increase in exclusive breastfeeding (CL = 0.02 to 0.04). For mixed breastfeeding, the estimate remained significant but slightly attenuated (β = .01; CL = 0.002 to 0.01). The same trend can be seen in physical growth outcomes. A 1-month increase in exclusive breastfeeding resulted in a significant increase of 0.04 in our HAZ standardized score (CL = 0.02 to 0.05), whereas a 1-month increase in any breastfeeding duration increased the HAZ standardized score by 0.01 (CL = 0.01 to 0.02). The odds of child stunting were lowest for exclusive breastfeeding (OR = 0.93; 95% CI = 0.89 to 0.97) but attenuated for mixed breastfeeding (OR = 0.96; 95% CI = 0.95 to 0.98). We did not find evidence to support a relationship between breastfeeding duration and SDQ or childhood weight status. Supplemental Table 7 provides support that each additional month of mixed breastfeeding after cessation of exclusive breastfeeding increased PRIDI, ECBQ, SDQ, and HAZ scores and decreased the odds of child stunting. No association was found between mixed breastfeeding duration and childhood weight status.

Fully Adjusted Associations Between Months of Exclusive and Mixed Breastfeeding and Child Development Indicators

All mixed breastfeeding models control for preceding exclusive breastfeeding duration.

Also adjusting for the additional confounder of maternal BMI.

The first 1000 days of life are fundamental for cognitive, social-emotional, and physical development. 36   Our results support existing evidence that exclusive and mixed breastfeeding is a critical component in ensuring healthy cognitive development and physical growth, even in a middle-income country. We investigated breastfeeding and early childhood development indicators in a region that, like many middle-income countries, has been struggling to improve breastfeeding rates. We provide evidence that exclusively breastfeeding for 6 months alone or in combination with complementary feeding for at least 24 months is important for physical and cognitive development. In addition, each additional month of exclusive or mixed breastfeeding appears to have a positive impact on early childhood development.

Our findings that breastfeeding is associated with better child development could be partially explained through maternal-infant bonding rather than the nutritional influence of breast milk alone. Research has revealed that children with strong maternal-infant bonding have better cognitive and social-emotional development. 37   In fact, an infant’s brain development has been linked to the parental attachment relationship, 38   which may be promoted by breastfeeding. Research suggests that breastfeeding lowers maternal levels of stress, 39   increases bonding, 40   and increases mother-infant relationships more generally. 41   However, it is also plausible that lower stress levels enable women to breastfeed longer and reach their breastfeeding goals. 42  

Our evidence on increased breastfeeding duration and better child development outcomes may also be explained through responsive feeding and parenting behavior. A systematic review found a consistent relationship between prolonged breastfeeding and responsive feeding, which is an indicator for responsive caregiving 43   (ie, the ability to properly respond to situations that promote child development). 44   In several studies, researchers also report that breastfeeding duration is linked to positive parenting practices in later childhood. 43   Authors of a study based in the United Kingdom reported that formula use or short breastfeeding duration was associated with low levels of nurturance, 45   which is a critical component of parental care that helps children achieve their full developmental potential. 46  

We also found evidence that breastfeeding is associated with physical growth at 3 years of age. Specifically, we found lower odds of child stunting (ie, higher HAZ score) among breastfed infants. Research has revealed a direct relationship between hormones and growth factors found in breast milk and healthy infant body composition, 47   which could help explain our findings. The method of breast milk feeding may also relate to physical growth. Emerging evidence suggests that feeding infants breast milk from a bottle has a weaker association with healthy weight compared with exclusive direct breastfeeding. 48  

We found no association between breastfeeding duration and child obesity. Yet, the estimates trended toward increased odds of overweight or obesity for children who were breastfed longer. This counterintuitive trend could be explained through the high prevalence of overweight and obesity in our study population. It is estimated that >50% of Brazilian populations are overweight or obese. 49   Our trends between breastfeeding and child overweight or obesity may be a reflection of parental preference for heavier infants 50 , 51   in a setting with rapidly growing obesity rates 52   but are concerning from a public health perspective and warrant further research.

To our knowledge, this study is the first used to investigate breastfeeding and early childhood development indicators among a unique population in which middle- and high-income characteristics are blended. The prospective birth cohort enabled extensive data collection and allowed us to control for important confounding factors, such as parent-child interactions and home stimulation, which are likely to confound the general associations between breastfeeding and child outcomes. However, our study may suffer from selection bias because not all participants completed the 3-year breastfeeding module. Our study is also not representative of the entire Brazilian population or other middle-income countries, although large urban areas have become home to the majority of children in many low- and middle-income countries. Additionally, as with any breastfeeding measure, report of breastfeeding is prone to recall and social desirability bias; nevertheless, recall of breastfeeding duration has been shown to be reliable. 53   Albeit relying on a recall at 36 months, the families were managed since the child’s birth, which may result in a trusting relationship with research staff and, consequently, less biased responses during the interview. Emerging evidence suggests that feeding infants breast milk from a bottle has a weaker association with healthy weight compared with exclusive direct breastfeeding. 48   With our study, we could not consider direct breastfeeding compared with bottle-feeding of human milk, a food frequency list for complementary breastfeeding including vitamin supplementation, parental height, the role of maternal-infant bonding, responsive feeding, or parenting behavior as possible confounders or mediating factors because these variables were not collected; future research can hopefully address these. In our study, we did however control for an extensive set of variables capturing home environments, which may at least partially capture these aspects.

The results of this article suggest large and robust associations between both exclusive and nonexclusive breastfeeding and children’s cognitive and physical development. Further efforts are needed to increase breastfeeding rates to support children’s healthy development.

Dr Wallenborn conceptualized and designed the study, conducted the initial analyses, and drafted the initial manuscript; Dr Fink conceptualized and designed the study, designed data collection instruments, and coordinated and supervised data collection; Dr Levine and Dr Carreira dos Santos reviewed the manuscript for important intellectual content; Dr Brentani conceptualized the cohort design, designed data collection instruments, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; Dr Grisi coordinated and supervised data collection and critically reviewed the manuscript for important intellectual content; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

confidence interval

confidence limit

Early Childhood Behavior Questionnaire

height-for-age z score

Multiple Indicator Cluster Surveys

Regional Project on Child Development Indicators

São Paulo Western Region Birth Cohort

Strengths and Difficulties Questionnaire

World Health Organization

Competing Interests

Supplementary data.

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• Published: 06 January 2021

Effectiveness of a breastfeeding program for mothers returning to work in Japan: a quasi-experimental study

• Kaori Nakada   ORCID: orcid.org/0000-0003-0584-4619 1  

International Breastfeeding Journal volume  16 , Article number:  6 ( 2021 ) Cite this article

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Maternal employment has been described as a barrier to breastfeeding in many countries. In Japan, many mothers quit breastfeeding after returning to work because they do not know how to continue breastfeeding. The primary objective of this study was to investigate the effectiveness of a breastfeeding support program for mothers. The secondary objective was to explore the effectiveness of a pamphlet for mothers returning to work.

This was a quasi-experimental design study with a program group ( n  = 48), pamphlet group ( n  = 46) and comparison group ( n  = 47) that took place from February 2017 to August 2018. Participants in the program and pamphlet groups were women who planned to return to work within 4–12 months after giving birth, while the comparison group included women who had been back at work for at least 3 months. The program involved a 90-min breastfeeding class, a pamphlet, a newsletter, and email consultation. The pamphlet group was sent only the pamphlet, while the comparison group received no intervention. The outcome was breastfeeding continuation rate at 3 months after returning to work.

The breastfeeding continuation rate 3 months after returning to work was significantly higher in the program group than in the comparison group (79.2% vs. 51.1%, p  = 0.004). After adjusting for background factors, the program intervention had an effect on breastfeeding rates (adjusted odds ratio = 4.68, 95% confidence interval: 1.57, 13.96; p  = 0.006). However, comparing the pamphlet and comparison groups revealed no significant differences in breastfeeding continuation rates at 3 months after returning to work (69.6% vs. 51.1%, p  = 0.07).

Conclusions

Program intervention was associated with a significant increase in breastfeeding continuation rates 3 months after returning to work. Randomized controlled trials are needed to make this program applicable in practice. Pamphlet intervention resulted in no significant difference. Further study is necessary after examining the contents of the pamphlet.

The benefits of breastfeeding for mothers and infants are widely recognized [ 1 , 2 ]. Nevertheless, early cessation of breastfeeding is common in many developed countries [ 2 , 3 ]. Maternal employment has been described as a barrier to breastfeeding in numerous studies across many countries and cultures [ 4 ]. In addition, the challenge of balancing breastfeeding and employment has been identified as a major barrier to continuation of breastfeeding [ 2 ].

Factors affecting working women’s continued breastfeeding include early return to work or timing of return to work, maternal behaviors and characteristics, support at the workplace [ 2 , 5 ], policy and law [ 5 ]. Specifically, returning to work earlier than 6 months postpartum has been identified as a workplace barrier [ 5 , 6 ]. Type of employment, lower workload [ 7 ], shorter working hours [ 2 , 5 , 7 , 8 ], increasing maternal age, higher education level [ 5 , 7 , 8 , 9 ], and mother’s positive attitude towards breastfeeding [ 5 ] have been related to longer duration of breastfeeding. Workplace lactation support enhances working mothers’ capacity to continue breastfeeding with employment [ 5 , 10 ]. A dedicated lactation room, allowance of breast pumping breaks [ 3 , 5 , 7 ], availability of a refrigerator [ 10 ], and encouragement from colleagues and supervisors to take breast pumping breaks have been cited as workplace supports [ 5 , 11 ]. Labor policy on job-protected maternity/paternal leave has the potential to positively influence the duration of exclusive breastfeeding [ 5 , 6 , 12 ]. Work environment strategies targeted at mothers themselves, such as providing options for extended maternity leave and part-time work, and childcare options such as on-site childcare may act as facilitators for breastfeeding continuation [ 3 ].

Providing a lactation space and breastfeeding breaks were the two most common breastfeeding supports reported in a previous systematic review [ 3 ]. One intervention showed that in person or telephone return-to-work consultations were related to longer duration of breastfeeding [ 4 ]. It was suggested that the more support available for mothers, the better the chances of continued breastfeeding [ 3 , 10 ].

In Japan, many mothers stop breastfeeding shortly after returning to work or before returning to work [ 13 ]. This may be because mothers do not know how to continue breastfeeding while working [ 13 ]. According to the one study in Japan, after returning to work, the rate of breastfeeding decreases from 44.2 to 7.0% and the rate of infant formula use increases from 7.0 to 46.5% [ 14 ]. The reason why breastfeeding does not continue after returning to work is due to the lack of an appropriate workplace and childcare environment [ 14 ].

According to one survey, 58.3% of workplaces had a lactation room and 50.0% had a refrigerator to store breast milk [ 14 ]. Many daycare centers allow children to drink only artificial milk and do not accept expressed breast milk [ 14 ].

The situation of childbirth and return to work in Japan is different from that in other countries. Hospital stay for childbirth is usually 5 days for vaginal delivery. After discharge, if mothers want to receive midwifery support for breastfeeding, they must go to a paid outpatient clinic. Breastfeeding rates have been on the rise for the past 10 years, with 2015 breastfeeding rates reaching 48.4% at 0 months, 51.3% at 1 month, and 53.8% at 6 months [ 15 ]. However, in Japan, the term “breastfeeding rate” does not refer to the rate of exclusive breastfeeding. Breastfeeding a baby at the time of the survey is adequate to be considered “breastfeeding”. The number of working women is on the rise, and the number of women who continue working after their first childbirth has increased [ 16 ]. In Japan, up to 2 years of childcare leave can be taken after an 8-week maternity leave. According to 2015 statistics, about 35% of women have returned to work within 1 year of giving birth [ 17 ]. Breastfeeding support for working women is expected to become increasingly important in the future.

A breastfeeding support program and a pamphlet were developed with information about continuing to breastfeed after returning to work. The primary objective of this study was to investigate the effectiveness of this breastfeeding support program for mothers. The secondary objective was to explore the effectiveness of the pamphlet for mothers returning to work.

The hypothesis of this study was that intervention through the program or pamphlet would increase the rate of breastfeeding 3 months after returning to work compared to no intervention.

Study design

This study used a quasi-experimental design with a program group, pamphlet group and comparison group in an urban area of Japan and was conducted from February 2017 to August 2018. In the program group, the intervention was delivered before returning to work and measured 3 months after returning to work. The program involved a breastfeeding class (90 min), use of a pamphlet, distribution of a newsletter upon returning to work, and email consultation up to 3 months after returning to work. In the pamphlet group, this was sent before returning to work and breastfeeding continuation rate was measured at 3 months after returning to work. The pamphlet was the same one that was used in the program group. No consultation was given to the pamphlet group. Breastfeeding continuation rate was measured in the comparison group only at 3 months after returning to work without intervention. The outcome measure was breastfeeding continuation rate after returning to work.

Participants and setting

The inclusion criteria of the program group and the pamphlet group were: 1) women who planned to return to work within 4–12 months after giving birth; 2) women who were breastfeeding at the time of recruitment; and 3) women who could communicate and read and write in Japanese. There were no exclusion criteria. The reasons why returning to work after at least 4 months after childbirth was included were as follows. First, breastfeeding rates in Japan rise up to 4 months after birth and are maintained for up to 6 months [ 18 ]. Second, since complementary food is started from the age of 6 months, it was thought that women who did not have enough breast milk could continue breastfeeding while using complementary food. To recruit participants for the program group, cooperation was requested from medical and childcare facilities near the program venue. Posters and leaflets requesting participation in the study were distributed at these facilities, and women interested in cooperating were asked to contact the researcher. As a result, program group participants were recruited from seven clinics, four health centers, 19 childcare support centers, five maternity care houses, and four daycares. Prior to the implementation of the program, the purpose of the research was explained verbally and in writing, and consent to participate in the research was obtained. Participants for the pamphlet group were also recruited with the cooperation of medical and childcare facilities. Posters and leaflets requesting participation in the research were distributed at these facilities. As a result, pamphlet group participants were recruited from one hospital, one clinic, nine childcare support centers, five maternity care houses, five daycares, and one private company. The pamphlet was distributed by postal mail, along with a document explaining the purpose of the research, and consent to cooperate was obtained from all participants.

The comparison group included women who returned to work within 4–12 months after giving birth, had been back at work for at least 3 months, were breastfeeding before returning to work, and could read and write in Japanese. There were no exclusion criteria. Comparison group participants were recruited from 22 daycare facilities. A document explaining the research was enclosed with the questionnaire, and returning the questionnaire was interpreted as consent to participate in the research.

In Japan, it is not common for mothers to receive breastfeeding support before returning to work. Therefore, the breastfeeding status of mothers who had already returned to work should reflect the general breastfeeding status.

Description of the breastfeeding support program

The framework of the program was transformative learning [ 19 ], adult learning theory, and empowerment [ 20 ]. The program involved a 90-min breastfeeding class, a pamphlet, a newsletter, and email consultation. The purpose of the class was to empower women returning to work by providing knowledge about the continuation of breastfeeding, allowing mothers to discuss breastfeeding with their peers, and for mothers to choose to continue breastfeeding after returning to work. Participants reflect on their breastfeeding experience, recognize the value of breastfeeding, and increase their self-efficacy. This leads to the behavior of choosing to continue breastfeeding after returning to work. At the end of the class, the women wrote an action plan on what to prepare before returning, and how to continue breastfeeding after returning to work.

Adults have a need to be independent in learning, and often realize the need for learning when trying to fulfill developmental tasks and social roles. It is presumed that the participants of this program who are about to return to work have high learning needs. Transformative learning is the process of critically self-reflecting and questioning values. Each participant had experienced breastfeeding since childbirth. After returning to work, when the mothers spent more time separated from their babies, they thought about what they wanted to do with respect to breastfeeding and what was best for the baby. Through small group discussions, mothers were able to share their feelings and worries with each other.

Peer support is effective for breastfeeding support [ 21 , 22 , 23 ]. In the class, participants watched a 10-min video presenting the experience of two women who continued breastfeeding after returning to work. One of them fed her child only breast milk, and the other used mixed nutrition. The video showed mothers’ ideas of breastfeeding and the actual conditions before and after returning to work.

The number of participants was limited to 10 people at one time, and group discussions were limited to about five in consideration of group dynamics. Each class was run by two midwives and two support staff with experience in caring for babies. A researcher was in charge of class progress, and another midwife assisted. If there were 10 participants, they were divided into two groups with each midwife facilitating a discussion. If there were fewer than five participants, both midwives participated in the group.

The two support staff took care of the babies and maintained their safety so that the participants could concentrate on the class with confidence. The room environment was arranged so that women and infants could relax together.

Program participants were able to consult with the researcher by email for up to 3 months before returning to work. A newsletter was sent once to the participants before and once after returning to work. The purpose of the newsletter was to share the results of consultations with the participants and prevent them from dropping out of the study. The newsletter was one double-sided, A4-size page printed in color. The contents included bullet-point advice such as preventing problems regarding continuation of breastfeeding.

Pamphlet structure and contents

The pamphlet contents presented information that could be used before and immediately after returning to work. The pamphlet was in color and consisted of eight, A6-size pages and a cover. The information in the pamphlet included the long-term effects of breastfeeding, how to express breast milk, how to take medications while breastfeeding, weaning, laws related to mothers’ rights in the workplace and the web address of a breastfeeding support organization. In addition, the pamphlet included examples of two women who continued breastfeeding after returning to work. These examples were created based on a previous study [ 24 ] that included interviews with 10 women who continued breastfeeding while working and clearly showed preparation and ingenuity to continue breastfeeding, and the actual situation of breastfeeding after returning to work. The contents of the class and the pamphlet were approved by two midwives with extensive breastfeeding experience. The content validity of the pamphlet was reviewed by two midwifery researchers and two women with breastfeeding experience, and was subsequently revised based on their feedback.

The outcome was breastfeeding continuation rate at 3 months after returning to work. In this study, breastfeeding continuation was defined as breastfeeding at least once a day. The sample size was calculated assuming that the rate of breastfeeding continuation after returning to work was 60 and 30% in the program and comparison groups, respectively, and that the difference between the two groups was 30%. A power analysis was performed using two-sided analysis with an α error of 0.05 and a power of 0.8. Forty-two participants were needed for each group [ 25 ].

The demographic variables were maternal age, month of birth, parity, employment status, education level, smoking status, and previous breastfeeding experience. Breastfeeding-related variables were timing of return to work postpartum, working hours per day, partner’s support in child care, presence of a peer to assist with breastfeeding, consultation with midwifes, and workplace environment for breastfeeding (milk expression breaks, lactation room, refrigerator to store breast milk), and daycare environment for breastfeeding (acceptance of expressed milk). Mothers were also asked about how they were feeding their infant with response choices of breast milk only, infant formula only, and mixed feeding.

Data analysis

Data were analyzed using descriptive statistics. One-way analysis of variance was used for continuous variables. The chi-square analysis was used for comparison of categorical variables. When the expected frequency was five or less, Fisher’s exact test was performed.

Since it was assumed that background factors of the study participants in each group would influence the intervention outcomes, adjusted results using logistic regression analysis were obtained. The dependent variable was the breastfeeding continuation rate at 3 months after returning to work, and the intervention variable was the program intervention. There were eight independent variables considered to affect the continuation of breastfeeding after returning to work: maternal age, timing of return to work, working hours per day, education level, breastfeeding experience, partner’s support in child care, presence of a peer to assist with breastfeeding, and consultation with midwives. Statistical analyses were conducted using SPSS version 25.0 with a two-sided 5% level of significance.

Ethical considerations

This study was approved by the Research Ethics Committee of St. Luke’s International University (No. 16-A076) and Kanagawa University of Human Services (No. 10–57). The participants provided written informed consent before study participation.

Program participation and questionnaire collection rate

The program was held 12 times with a total of 52 participants. Three months after returning to work, 52 questionnaires were mailed, and 48 were returned (recovery rate, 92.3%). There were 49 participants in the pamphlet group and 48 questionnaires were collected immediately after the intervention. Three months after returning to work, 48 questionnaires were mailed, and 46 were returned (recovery rate, 93.8%). In the comparison group, a total of 123 questionnaires were mailed to 22 facilities, and 67 were returned (response rate, 54.5%). As a result, 47 sets of valid answers (effective response rate, 70.1%) were obtained. There were 48 participants in the program group, 46 participants in the pamphlet group and 47 participants in the control group for a total of 141 included in the final analyses. Missing values included one maternal age in the comparison group. Missing values were included in the analyses as missing without substitution.

Demographic characteristics

The characteristics of the participants are shown in Table  1 . The mean age was 34.0 years [standard deviation ( SD ) = 3.5, n  = 48] in the program group, 34.8 years ( SD  = 3.9, n  = 46) in the pamphlet group and 34.2 years ( SD  = 3.9, n  = 46) in the comparison group, with no significant difference ( p  = 0.58). Parity status ( p  = 0.08) and previous breastfeeding experience ( p  = 0.08) was significantly different among the three groups. Participants in the program group received interventions on average 6.8 months after giving birth ( SD  = 2.3), and the pamphlet group on average 8.2 months after giving birth ( SD  = 2.4).

The characteristics of breastfeeding after returning to work are shown in Table  2 . The average return to work after giving birth was 9.3 months in the program group ( SD  = 2.6), 9.9 months in the pamphlet group ( SD  = 2.3) and 8.8 months in the comparison group ( SD  = 2.5). The working hours per day were 7.0 ( SD  = 1.1) in the program group, 7.3 ( SD  = 1.2) in the pamphlet group and 6.9 ( SD  = 1.0) in the comparison group. Consultation with midwives before and after returning to work was significantly different between the three groups ( p  = 0.03).

The percentage of daycare centres that accepted expressed breast milk was low, at 45.8% in the program group, 39.1% in the pamphlet group and 42.6% in the comparison group. At the workplace, few participants were guaranteed a lactation room and milk expression breaks. Many participants in the program group could make these arrangements by themselves, but the mothers in the comparison group could not. The proportion of participants who had a refrigerator at the workplace to store expressed breast milk was lower in the comparison group (25.5%) than in the program (60.4%) and in the pamphlet (58.7%) groups.

Primary outcomes are shown in Table  3 . The breastfeeding continuation rate at 3 months after returning to work was significantly higher in the program group than in the comparison group (79.2% vs. 51.1%, p  = 0.004). After adjusting for background factors, the program intervention (adjusted odds ratio [AOR] 4.68, 95% confidence interval [CI] 1.57, 13.96; p  = 0.0060) and maternal age (AOR 1.20, 95% CI 1.02, 1.40; p  = 0.03) had an effect on breastfeeding rates (Table  4 ). Secondary outcomes are shown in Table  5 . The breastfeeding continuation rates at 3 months after returning to work were not significantly different between the pamphlet group and comparison group (69.6% vs. 51.1%, p  = 0.07).

In the program group, the mothers could receive consultation with midwives by e-mail. There were eight consultations in six participants ( n  = 48, 12.5%). The consultation topics included methods of cessation breastfeeding at night, methods of disinfecting the breast pump at the workplace, nipple problems, methods of expressing the breast, reduced breast milk production, and how to deal with infants playing with the nipples.

This is the first intervention study on breastfeeding continuation among working women in Japan. The breastfeeding continuation rate at 3 months after returning to work was significantly higher in the program group compared to the comparison group. After adjusting for background factors, the program intervention had an effect on breastfeeding continuation rates and there was an association with breastfeeding continuation 3 months after returning to work.

According to 2017 statistics, the average maternal age at birth of the first child is 30.7 years in Japan, and that of the second child is 32.6 years [ 26 ]. Even several months after giving birth, the mothers in the present study were older than the national average. In Japan, the proportion of part time and contract employment is rising and in 2018, 56% of working women were not permanent employees [ 27 ]. However, there was a high percentage of full-time workers among the present participants, suggesting that it was relatively easy for them to take maternity and childcare leave. Returning to work 6 months after birth is a factor promoting continuation of breastfeeding [ 5 ]. The timing to return to work in this study was 9.3 months in the program group, 9.9 months in the pamphlet group and 8.8 months in the comparison group, suggesting that timing of returning to work was a factor promoting breastfeeding continuation.

Before returning to work, there are specific worries about the condition of the breast and the feeding of the infant that mothers want information and advice about. Other studies have reported that consultation to address these worries before returning to work can be effective in continuing exclusive breastfeeding as well as any breastfeeding after returning to work [ 4 ]. In this study, the participants in the program group received intervention on average 6.8 months after giving birth ( SD  = 2.3), and the average return to work after giving birth was 9.3 months ( SD  = 2.6). Therefore, the intervention took place 2–3 months before returning to work. It was speculated that the consultation just before returning to work affected the effectiveness of the program. Face-to-face support has been shown to be more effective than telephone support, and it provides the opportunity to discuss and respond to the mothers’ questions [ 21 ]. In this study, individual advice with consideration of the mother’s lactation status and workplace was possible because of face-to-face consultation.

The intervention combined the wisdom of experienced people and the knowledge of professionals. Consultations provided details about the kind of preparations women who continued breastfeeding while working actually made, and when and how they were able to breastfeed and express breast milk while at home, at work, and at daycare. Midwives provided knowledge and information about breast changes after returning to work, and about common problems that mothers face. Before returning to work, it was recommended that mothers check if milk expression and storage could be done at their workplace. The proportion of women who managed to secure a lactation room or milk expression breaks and store their breast milk at the workplace was higher in the program and pamphlet groups than in the comparison group. Participants in the program group knew how to manage breastfeeding continuation after returning to work, which led to them being able to continue breastfeeding.

Returning to work is a major turning point for breastfeeding mothers and children, so it is important to help mothers make choices that they will not regret [ 23 ]. If women decide how long and how to continue breastfeeding on their own and make choices they do not regret, they will feel accomplishment in breastfeeding, which will lead to confidence in subsequent childcare.

Expressing breast milk and breastfeeding at the workplace are factors that promote continued breastfeeding after returning to work [ 28 ]. In Japan, while long childcare leave is available, women who return to work within 1 year after birth often do not have enough support to continue breastfeeding. There is often no lactation room available at the workplace, so many women express in the rest room, and some women discard expressed milk because there is no refrigerator for storage [ 24 ]. A working mother’s decision to continue or discontinue breastfeeding is highly dependent on the support available to her in the workplace [ 5 ]. Thus, a comprehensive strategy is required to encourage the practice of breastfeeding in working women from pregnancy to after returning to work [ 6 , 22 ]. In order for women returning to work in Japan to continue breastfeeding, it is important that employers and daycare centres understand and cooperate with women as they continue to breastfeed. In this study, giving knowledge and information to women led to them being able to continue to breastfeed (behavior change); however, improving the environment of workplaces and daycare centres is an issue that should be addressed immediately.

Limitations and implications

This study had a selection bias because participants were not randomly assigned to the program, pamphlet and comparison groups. Mothers in the program and pamphlet groups responded to posters requesting participation in the study and volunteered to cooperate, there was the possibility that mothers with a desire to continue breastfeeding were included in the program and pamphlet groups.

There were no statistically significant differences in the demographic data of the participants in the three groups, but there were more multiparous women who had breastfed previously in the comparison group. There were also differences in the work environment after returning to work between the program group and the comparison group which may have affected the results. When assessing the effectiveness of a program, it is necessary to consider that these non-program factors affect outcomes.

Implications for practice

Program intervention was associated with a significant increase in breastfeeding continuation rates at 3 months after returning to work; however, pamphlet intervention alone resulted in no significant difference. The program was effective but time consuming, and costly due to the personnel needed to run the intervention. It is difficult for women with children to participate in a 90-min program. In the future, it will be necessary to consider a simplified version of the program in consideration of cost and time effectiveness. In addition, with respect to cost-effectiveness, pamphlets are a good tool for providing knowledge and information, and it is important to improve the pamphlet and conduct randomized controlled trials to see the effects. For practical application of the intervention, it is necessary to consider cost performance and media, such as computer and smartphone applications suitable for younger generations who will give birth in the future.

Program intervention resulted in a significant increase in breastfeeding continuation rates at 3 months after returning to work; and pamphlet intervention alone resulted in no significant differences. Randomized controlled trials are needed to make this program applicable in practice.

Availability of data and materials

The datasets used and/or analyzed during the current study area available from the corresponding author on reasonable request.

Abbreviations

Adjusted odds ratio

Confidence interval

Standard deviation

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Acknowledgments

I would like to express my deepest appreciation to the mothers and facility staff who cooperated with this study. This paper is a part of a St. Luke’s International University Doctoral dissertation. Part of this paper was presented at the 23rd East Asian Forum of Nursing Scholars.

This study was supported by research grants from Kanagawa University of Human Services in 2016 and 2017. The funding source had no involvement in the design of the study; in the collection, analysis, and interpretation of data; or in writing the manuscript.

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Breastfeeding 101: Q&A with Lactation Expert Nadine Rosenblum

Reviewed By:

Nadine Rosenblum R.N., I.B.C.L.C.

If you are a mom-to-be, you’re probably busy planning for the arrival of your baby. When it comes to feeding your baby, research has widely shown the advantages of  breastfeeding  for both baby — providing baby with balanced nutrition and reducing baby’s risk of developing asthma, diabetes and other conditions — and mother — aiding in postpartum recovery and lowering her risk for developing certain cancers, among other benefits. Many hospitals, including Johns Hopkins, are reworking their infant care models to be more “ baby-friendly ”— that is, encouraging mother-baby bonding through skin-to-skin contact and breastfeeding — based on this research.

To help explain the benefits of breastfeeding, Nadine Rosenblum, perinatal lactation program coordinator at The Johns Hopkins Hospital, answers some commonly asked questions about breast milk, common struggles women face and what resources women can tap into to increase their likelihood of nursing success. “There are still so many misconceptions about breastfeeding and a general lack of support,” says Rosenblum, “that many women discontinue breastfeeding or add formula when they don’t necessarily need to.”

What makes breast milk so effective?

During pregnancy, a baby’s immune system readies itself for that unique food source his or her mom produces: breast milk. “It’s what a baby’s body expects to eat, consume and utilize most effectively,” says Rosenblum.

And breast milk isn’t a homogenous substance. Hundreds of nutrients have already been identified in breast milk, and researchers are still discovering more. The exact combination of these nutrients is dynamic. The composition of nutrients changes based on a baby’s unique needs on a daily basis, at every meal and every stage of life. If it’s hot outside, the milk will have a higher water content to keep a baby hydrated. If a baby is in a growth spurt, breast milk will have more protein and fat. This specialized diet fuels a baby’s developmental growth and helps lay the foundation for a baby’s immune system. As Rosenblum puts it, “You can’t manufacture what mom makes new for baby every day.”

The bottom line? “Babies who are fed only breast milk for their first six months of life are the healthiest,” says Rosenblum. The American Academy of Pediatrics suggests women continue breastfeeding, with the addition of complimentary (solid) foods starting at 6 months, for at least 12 months. Other organizations, such as the World Health Organization, recommend women continue nursing, with the addition of solid foods after 6 months, until the child is 2 years of age for the best health outcomes.

What are the advantages of breastfeeding for babies?

There are a wide range of benefits for babies who drink breast milk. Babies who breastfeed are less likely to develop:

• Upper & lower respiratory diseases
• Digestive diseases such as acute diarrhea, long term Crohn’s disease and colitis
• Diabetes types 1 and 2
• Childhood leukemia

Additionally, babies who drink breast milk are also at reduced risk for sudden infant death syndrome (SIDS) and are less likely to be overweight or obese.

How do moms benefit from nursing?

Nursing not only benefits a baby — nursing also promotes immediate and future wellness and good health in breastfeeding moms.

Nursing right after delivery helps improve postpartum recovery by bolstering many natural processes, including:

• Expelling the placenta
• Slowing postpartum bleeding (and thus decreasing the likelihood of postpartum hemorrhage)
• Reducing the size of the uterus (to revert to pre-pregnancy size and shape)
• Burning calories (to lose the weight gained during pregnancy)

Beyond physical benefits, breastfeeding may also promote good mental health, as nursing has been linked to lower incidences of postpartum depression in new mothers.

Breastfeeding also helps with longer term health outcomes. Women who breastfeed have lower rates of developing:

• Certain cancers including breast cancer, ovarian cancer and endometrial cancer
• Osteoporosis
• Heart disease/high blood pressure

What are common breastfeeding struggles moms face?

According to Rosenblum, it is normal for women to feel many anxieties around breastfeeding, at all stages and experience levels.

Women who have not yet breastfed are often concerned they may not make enough milk to sustain their baby. They may also worry about experiencing discomfort or pain when breastfeeding.

Moms new to breastfeeding are commonly uncertain about whether their eating habits are ideal for milk production or how any medications, drugs or alcohol may interact with the milk. They may also fret over not seemingly connecting with their baby when nursing, and be concerned their baby is not getting enough milk.

Working, nursing moms can be apprehensive about managing the transition from home to work and what that disruption might mean for their breastfeeding process.

What is Rosenblum’s main suggestion? Women should seek out help from lactation experts and other support groups in their communities to help ease many of these concerns and empower them in their breastfeeding journey.

What are some tips for successful breastfeeding?

• Keep baby with you . “It’s easier to learn about your baby when the baby is with you,” Rosenblum says. Essentially, the more time you spend with your baby, the easier it becomes to distinguish the many different needs of the baby and ensure good nursing.
• Get the right information from experts . Don’t get overwhelmed with internet resources and friends, says Rosenblum. Lactation experts can direct women to good information and provide hands-on help at the hospital. If women aren’t able to meet at the hospital, nurses are also available to answer questions over the phone or by email.
• Go to a prenatal breastfeeding class . These classes cover the benefits of breastfeeding, basics of milk supply, how to maintain milk when mom and baby are apart, how to understand baby behavior and gauge when a baby is well-fed, and positions for a good latch. Classes are often interactive and include a variety of teaching methods such as videos and baby models to accommodate all kinds of learners.
• Find a local support group . Many hospitals, including Johns Hopkins , coordinate support groups for breastfeeding women, where mothers can share stories, learn from each other’s experiences and practice breastfeeding in a group setting. There are also many other organizations that are dedicated to helping women successfully breastfeed. Rosenblum suggests women find a group that they feel most comfortable with.

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Science experiment shows the amazing powers of breastmilk

A viral photo of a science project showcases the healing power of breast milk, and it makes a compelling case for breastfeeding well beyond a baby's first birthday.

Vicky Greene, a first-year biosciences student at South Devon College in the U.K., put breast milk from the mother of a 15-month-old and a 3-year-old in Petri dishes containing the bacteria M. Luteus. 

She posted a photo of the experiment on Facebook which showed space between the bacteria and the breast milk, almost like a wall keeping the bacteria from getting too close to milk. Greene said she used the experiment as a way to showcase that breastmilk's antimicrobial properties may persist well beyond the age many end breastfeeding.

“The white spots in the middle are discs soaked in two samples of breastmilk,” she said. “See the clear bit around the discs? That's where the proteins in the milk have inhibited the bacteria…It also worked with E. coli and had a fairly good go at MRSA too.”

Babies who breastfeed tend to have fewer infections and lower rates of asthma and obesity, according to Rebecca Starck an OB/GYN at the Cleveland Clinic.

"It's phenomenal to recognize this is a natural product...We try to mimic breast milk with formula, but there is no way to recreate what breast milk can provide the infant," Starck said pointing to breast milks antibacterial characteristics.

Are 'angel shots' the answer to preventing date rape?

The American Academy of Pediatrics  recommends that babies be breastfed exclusively for six months, and continue to breastfeed along with food for a year after that or as long as desired. In the U.K., it's recommended that women breastfeed exclusively for the first six months and give breast milk along with food for the next two years,  according to the U.K.'s National Health Services.

Greene, who is the mother of three children, told the Huffington Post   that she is still breastfeeding her 3-year-old.

“I have been on the wrong end of judgment about my breastfeeding choices, and I’m fed up of it," she told the Huffington Post. 

But is there a time to stop?  There's a lot that goes into the decision of whether a woman will continue breastfeeding or stop, including whether she is actually able to produce enough milk or other health reasons, according to  Angela Mattke,  M.D. in Community Pediatric and Adolescent Medicine at Mayo Clinic in Rochester. 

"If it’s working for both the mother and child and the child is also getting good nutrients from their diet because they can’t survive on breast milk alone ... I think it’s something they can do and there is no reason to stop in most cases," Mattke said.

In the United States and other countries, the practice of breastfeeding in public has become much less taboo, but there is still some stigma around breastfeeding toddlers.

"Often times women are hard on each other and will be almost critical of those folks, friends or other women who decide to breastfeed for extended periods of time beyond 1 to 2 years. It’s a personal choice and there is no right or wrong answer," Starck said.

These 'health foods' may be bad for you

Pushes for breastfeeding longer should in no way make women who are unable to breastfeed feel like they aren't adequately providing for their children, both doctors agree.

"Formula will provide the nutrients they need," Mattke said. "They are unable to match formula exactly to the same benefits you get from the immune defense standpoint and GI perspective, but it will provide the nutrition they need to grow and thrive. The guilt needs to be put away, the judgement needs to be put away because everyone's choice is personal."

Follow Mary Bowerman on Twitter: @MaryBowerman 

This Social Experiment Puts the Spotlight on Breastfeeding in Public

Breastfeeding in public remains one of the most talked-about and heated topics in the parenting world. In another one of his social experiments (remember the playground abductions ?), Joey Salads joins the conversation by teaming up with a woman named Emily and a fake baby to see how the general public would respond to his "wife" feeding their "son" in public .

In the video — which has gained more than 13 million views in just a few days on Facebook — Emily takes out her breast and begins feeding her baby in a variety of public places. In each clip, the people around her and Joey have some kind of reaction, ranging from "You disgust me" to "I mean he has to eat, right?"

Watch the video to see the reactions for yourself.

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Effects of lactation room quality on working mothers' feelings and thoughts related to breastfeeding and work: a randomized controlled trial and a field experiment

Affiliations.

• 1 Department of Psychology, University of Groningen, Groningen, The Netherlands. [email protected].
• 2 NoorderRuimte, Research Centre for Built Environment, Hanze University of Applied Sciences, Groningen, The Netherlands. [email protected].
• 3 Department of Psychology, University of Groningen, Groningen, The Netherlands.
• 4 NoorderRuimte, Research Centre for Built Environment, Hanze University of Applied Sciences, Groningen, The Netherlands.
• 5 Faculty of Management and Organization, The Hague University of Applied Sciences, The Hague, The Netherlands.
• PMID: 35945573
• PMCID: PMC9361273
• DOI: 10.1186/s13006-022-00499-0

Background: The challenging combination of breastfeeding and work is one of the main reasons for early breastfeeding cessation. Although the availability of a lactation room (defined as a private space designated for milk expression or breastfeeding) is important in enabling the combination of breastfeeding and work, little is known about the effects of lactation room quality on mothers' feelings and thoughts related to breastfeeding and work. We hypothesized that a high-quality lactation room (designed using the Theory of Supportive Design) would cause mothers to experience less stress, have more positive thoughts about milk expression at work, perceive more organizational support, and report more subjective well-being, than a low-quality lactation room.

Methods: In an online randomized controlled trial (Study 1), Dutch mothers (N = 267) were shown either a high-quality or a low-quality lactation room (using pictures and descriptions for the manipulation) and were then asked about their feelings and thoughts. In a subsequent field experiment (Study 2) we modified the lactations rooms in a large organization in Groningen, the Netherlands, to manipulate lactation room quality, and asked mothers (N = 61) who used either a high-quality or low-quality lactation room to fill out surveys to assess the dependent variables.

Results: The online study showed that mothers exposed to the high-quality lactation room anticipated less stress, more positive cognitions about milk expression at work, more perceived organizational support, and more subjective well-being than mothers exposed to the low-quality lactation room (p < 0.05). Moreover, the effect of lactation room quality on perceived organizational support was especially pronounced for mothers who were higher in environmental sensitivity. The field experiment showed that use of the high-quality room led to less reported stress than use of the low-quality room (p < 0.05). We also found that mothers who were higher in environmental sensitivity perceived more control over milk expression at work and experienced more subjective well-being in the high-quality condition than in the low-quality condition (p < 0.05).

Conclusion: The current studies show that not only the availability, but also the quality of lactation rooms is important in facilitating the combination of breastfeeding and work.

Keywords: Breastfeeding; Environmental sensitivity; Facility management; Lactation room quality; Nursing facilities; Relaxation; Stress reduction; Theory of supportive design.

© 2022. The Author(s).

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Conflict of interest statement

The authors declare that they have no competing interests.

Conceptual model and hypotheses

Moderating effect of environmental sensitivity…

Moderating effect of environmental sensitivity in the relationship between lactation room quality and…

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Breastfeeding experiment – level 2.

08-08-2023 15:00

People created a social experiment to see how others really react to breastfeeding in public spaces. Part of the experiment showed a situation on the tube in London.

An actress started breastfeeding on the train and a man, also an actor, was not happy about it. He told her that she was making him feel uncomfortable, and he asked her to stop.

The man became increasingly louder and one of the passengers stepped in . He took a seat between the man and the woman to show his support for the mother. A moment afterwards, a person with a camera entered the carriage and told everyone about the experiment.

Difficult words: increasingly (more and more), step in (to get involved in a situation), carriage (one part of the train).

You can watch the original video in the Level 3 section.

What inspired the passenger to step in and show support for the mother?

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Birth Experiences, Breastfeeding, and the Mother-Child Relationship: Evidence from a Large Sample of Mothers

Abi m. b. davis.

1 School of Psychology, University of Lincoln, Lincoln, UK

Valentina Sclafani

Associated data.

Supplemental material, sj-docx-1-cjn-10.1177_08445621221089475 for Birth Experiences, Breastfeeding, and the Mother-Child Relationship: Evidence from a Large Sample of Mothers by Abi M. B. Davis and Valentina Sclafani in Canadian Journal of Nursing Research

It is a priority for public health professionals to improve global breastfeeding rates, which have remained low in Western countries for more than a decade. Few researchers have addressed how maternal perceptions of birth experiences affect infant feeding methods. Furthermore, mixed results have been shown in research regarding breastfeeding and mother-child bonding, and many studies are limited by small sample sizes, representing a need for further investigation.

We aimed to examine the relationship between subjective birth experiences and breastfeeding outcomes, and explored whether breastfeeding affected mother-infant bonding.

3,080 mothers up to three years postpartum completed a cross – sectional survey.

Mothers who had more positive birth experiences were more likely to report breastfeeding their babies. Moreover, mothers who perceived their birth as more positive were more likely to breastfeed their child for a longer period (over 9 months) than those who had more negative experiences. In line with recent research, breastfeeding behaviours were not associated with reported mother-infant bonding.

Conclusions

Mothers who reported better birth experiences were most likely to breastfeed, and breastfeed for longer. We find no evidence to suggest that feeding methods are associated with bonding outcomes.

Introduction

Childbirth is a profound and life-changing event, and it is essential that mothers feel safe and supported throughout ( World Health Organisation, 2018 ). Although all who bear children undergo the same basic biological events – a vaginal birth or a Caesarean section – its impacts on each mother are complex and unique ( Beck & Watson, 2008 ). “Birth experiences” are characterised not only by medical procedures that may occur during the event, or a lack thereof, but also by less quantifiable feelings and circumstances, exclusive to a mother and her birth ( Bell & Andersson, 2016 ). When a childbirth is perceived as negative, it can have short- and long-term psychological impacts, including postnatal depression and post-traumatic stress disorder (PTSD). Medical interventions and mode of delivery during childbirth have also been shown to affect breastfeeding initiation ( Brown & Jordan, 2013 ; Saeed et al., 2011 ). Despite a focus on medical procedures across research, obstetric interventions are only one facet of childbirth. Several authors have argued that understanding a mother's perceptions of her experience is essential to interpret the outcomes of the event, and that these perceptions are not always based on medical complications or interventions ( Beck & Watson, 2008 ; Muldoon et al., 2019 ). Indeed, Blüml and colleagues (2012) demonstrated that obstetric interventions are not universally regarded as negative by mothers, and studies have shown that perceptions of trauma surrounding childbirth can increase feelings of dissatisfaction, independent of emergency obstetric procedures ( Fenaroli et al., 2019 ; Larsson et al., 2011 ). Further, a meta-analysis by Taheri et al. (2018) showed that positive labour experiences can prevent medical interventions, further suggesting a distinction between objective obstetric experiences and maternal perceptions of childbirth.

Although a relationship has been established between birth interventions and breastfeeding behaviours, the question of whether birth perceptions are associated with breastfeeding initiation and continuation remains under-researched. Moreover, most literature on the topic has focussed on ‘severe’ experiences and outcomes following birth, particularly post-traumatic stress disorder (e.g., Hairston et al., 2018 ; McDonald et al., 2011 ). Establishing whether negative birth experiences more broadly can affect infant feeding methods could be a key factor in improving breastfeeding rates. If they do, policymakers would be justified in extending their feeding support focus to all women who perceive their birth experience as negative, regardless of intervention status.

Additionally, it is important to determine any potential mother-child bonding consequences for women who choose not to, or are unable to, breastfeed. Better bonding as perceived by the mother, and secure infant attachment to the mother, are both associated with better cognitive, emotional, and behavioural outcomes for the child ( De Cock, 2017 ; Richter, 2004 ). Systematic reviews have demonstrated a relationship between breastfeeding and secure infant attachment. However, the authors argue that evidence is mixed, and more studies with larger sample sizes are needed to draw conclusions about this relationship ( Jansen et al., 2008 ; Linde et al., 2020 ). Recently, Hairston et al. (2019) found no relationship between feeding behaviours and bonding in Israeli mothers. The authors note that it would be beneficial to replicate this finding using other measures of bonding, and with the inclusion of more specific feeding groups, including a distinction between breast and combination feeding mothers. Further, significant cultural variability necessitates explorations across countries before claims of universality can be made ( Keller, 2018 ). Given that the link between breastfeeding and bonding remains unclear, further explorations are warranted.

For practitioners to prioritise breastfeeding support in certain groups, with a view to improving global breastfeeding rates, we must first understand the experiences that affect a mother's likelihood of breastfeeding success. In the UK, approximately 81% of mothers in the UK initiate breastfeeding at birth, and by 5 weeks, only 55% continue to do so ( Fox et al., 2015 ). This represents a significant discrepancy between planned or initiated feeding and later behaviours. Indeed, it may be that many more than 81% of mothers plan to feed their infants prior to birth (e.g., in 2003, Donath and Amir showed a 96.6% planned initiation rate in a cohort of 10,000 pregnant women in the UK). Thus, there is a clear need to establish predictors of breastfeeding cessation, to provide interventions designed to improve breastfeeding rates and outcomes.

Therefore, the first aim of this study was to investigate whether differences in birth experiences reported by mothers (comprising both perceptions of the birth and satisfaction with clinical care) were linked to different infant feeding methods. Further, we aimed to explore whether mothers in different feeding groups varied in their perceived relationships with their children. Our research questions were as follows: [RQ1] Do mothers’ feeding methods differ depending on their feelings about their birth experience? [RQ2] Is birth experience associated with the length of time an infant receives breast milk? [RQ3] Do mothers’ feelings about their relationship with their child differ depending on infant feeding method? [RQ4] Do mothers’ feelings about their relationship with their child differ depending on the length of time an infant received any breast milk?

The target population were mothers who had given birth in the last three years, with a view to later separating cohorts (those who gave birth under 12 months prior, and those who gave birth between 1–3 years prior). Following other researchers (e.g., Branjerdporn et al., 2019 ; Brown, 2014 ; Brown et al., 2014 ; DiTomasso et al., 2022 ), mothers were recruited through mother and baby forums online. As DiTomasso and colleagues note, as well as Wagg et al. (2019) , thousands of mothers utilise online support groups for breastfeeding and parenting support, and these support groups can compensate for a lack of face-to-face or community services ( Robinson et al., 2019 ). Over 60 parenting group administrators were contacted, and 37 of these groups advertised the survey.

Before data cleaning, 3,416 responses were collected. Some mothers indicated that their child was over 36 months old, and thus were excluded. Responses from duplicate IP addresses were also removed before data anonymisation. After data cleaning, 3,080 responses were retained. All participants were required to be mothers of children under 36 months of age, and no further exclusion criteria were applied. Maternal age ranged from 16–49 years, and the mean age of mothers was 28.17 years.

To assess infant feeding and the mother-child relationship, as well as infant feeding and birth experiences, an a priori G*Power analysis ( Faul et al., 2009 ) for analyses of variance (ANOVA) was conducted. To achieve 95% power at an alpha of.05, and to detect a small effect ( f  = .10) with three feeding groups, a sample size of 1,548 (or 516 per feeding group) was required.

As we were interested in multiple categories within the population, we employed an oversampling strategy. This was required due to significant feeding method disproportions within the population, particularly for breastfeeding and long-term breastfeeding mothers ( UNICEF, 2019 ).

Measurements

Demographic information.

Respondents reported maternal age, ethnicity, location, and the age category of their child (0–12 months or 12–36 months).

Perceptions of birth experiences

The Childbirth Perception Scale (CPS; Truijens et al., 2013 ) was used to measure participants’ birth experiences. This scale demonstrates good overall internal reliability (α = .82), and each subscale is adequately reliable (perception of delivery, α = .81; perception of the first postpartum week, α = .79). Participants respond using a 4-point Likert scale (fully agree to completely disagree). Scoring for the delivery subscale used in this manuscript ranges from 0–18. This scale was initially developed to assess experiences with vaginal births. However, Derya et al. (2019) have shown that it is reliable and valid when assessing childbirth experiences in samples of women who had both vaginal and caesarean births, and so the current study utilised this scale for all mothers.

Satisfaction with clinical care

Satisfaction with clinical care at the time of birth was measured using The Six Simple Questions (SSQ; Harvey et al., 2002 ). Reliability scores for this measure are high (α = .86), and the SSQ correlates with similar measures to an acceptable degree, r  = .51 ( Sawyer et al., 2013 ). The SSQ comprises six questions which are answered using a 7-point Likert scale, and scores range from 7–42. The questionnaire was adapted for the specific purpose of this study, and so the word “pregnancy” was replaced with “birth” where appropriate (e.g., “I would choose the same type of care for my next birth”). Authors have identified this method as acceptable when using the scale ( Sawyer et al., 2013 ).

Maternal-infant relationship in the second and third postpartum year

To measure the quality of maternal-toddler relationships, mothers with children over one year of age completed the Child-Parent Relationship Scale (CPRS; Driscoll & Pianta, 1992 ), which has been validated as a measure for children in their second year and beyond ( Simkiss et al., 2013 ). The CPRS is composed of 30 items measured using 5-point Likert scales, with options ranging from “definitely does not apply” to “definitely applies”. Scores are separated into three subscales: conflict (α = .83), closeness (α = .72), and dependence (α = .50).

Further information

Finally, participants indicated whether they fed their child with formula milk (FF), breast milk (BF), or a combination of the two (CF). If the child was not exclusively fed formula, mothers reported how long their child received any breast milk using predetermined categories (see Table S1 for categorisations and incidence).

To measure attachment in the first postpartum year, mothers completed the Maternal Postnatal Attachment Scale (MPAS; Condon & Corkindale, 1998 ). However, we did not include mothers in their first postpartum year in our analyses of breastfeeding behaviours, due to the potential for incorrect categorisations (e.g., a mother with a three-week-old infant could report “exclusively breastfed for under four weeks” and continue breastfeeding for two years).

Responses were also collected for the Hospital Anxiety and Depression Scale (HADS) ( Zigmond & Snaith, 1983 ). However, this scale was not directly relevant to our research focus on this instance, and was therefore only used as a control variable. The HADS has been used extensively in research, and it has been shown to be reliable and valid across multiple populations (α = .89, r  = .83–.86; Boxley et al., 2016 ).

Data collection

Data were collected over 6 consecutive weeks in April 2020. The questionnaire was hosted through Qualtrics ( www.qualtrics.com ). After giving consent, respondents completed the questionnaire.

All participation was voluntary and not incentivised, and participants were free to modify their answers or exit the survey at any time. The survey took approximately ten minutes to complete. All data were kept in a secure, password-protected university OneDrive account to ensure confidentiality.

This study was granted ethical approval by the university's ethics committee (Approval number: 1920314). All ethical requirements for work with human participants were followed. Participants were introduced to the study prior to participation, and were debriefed upon completion.

Data analysis

Data were analysed using SPSS version 24.0 (SPSS Inc., Chicago, IL, USA), R (R Foundation for Statistical Computing), and JASP ( Love et al., 2019 ). One-way, between-subjects ANOVAs were conducted to determine whether childbirth perceptions as measured by the CPS and the SSQ differed across infant feeding method groups (exclusive breastfeeding, combination, or exclusive formula).

To assess feeding group differences for mother-child bonding as measured by the CPRS, one-way, between-subjects ANOVAs were performed for each of the CPRS subscales (“conflict”, “closeness”, and “dependence”).

A Bayesian ANOVA was conducted as a confirmatory test for findings related to breastfeeding and bonding outcomes, and a linear regression was conducted to determine the relationship between SSQ and CPS scores.

Seventeen mothers reported that they exclusively breastfed their child, without formula inclusion, for 1–9 months. As guidance states that mothers should feed their infants either breast, formula milk, or a combination of both, for at least 12 months, these mothers may have mis-categorised themselves or changed feeding methods. To avoid the inclusion of miscategorised data, we excluded these responses from our analysis.

All items from the CPS were reverse coded during analysis for clarity, so that higher scores indicated better experiences.

Participants were all female as assigned at birth. Descriptive statistics for participants are presented in Table 1 .

Table 1.

Demographic Characteristics of the Sample.

Most mothers fed their children formula milk or breastfed their children for over 12 months (representing 66.9% of the total sample). Feeding categories and reported incidence are illustrated in Table S1 in the Supporting Information file.

Preliminary/exploratory analyses

Breastfeeding and age differences.

Analyses exploring age differences across feeding groups revealed a significant main effect, F (2, 2,334) = 102.08, p  < .001, Cohen's f   =  .69. Those who exclusively breastfed their infants were the oldest group in the cohort ( M  = 30.22 years, SD  = 5.43). The CF group younger than BF ( M  = 28.50 years, SD  = 5.65, f  = .36), and younger still were the FF group ( M  = 26.45 years, SD  = 5.21, Cohen's f vs. BF = .69; f vs. CF = .29). All p s < .001.

Satisfaction with care and birth experiences

When controlling for age, depression, and anxiety, and CPRS subscales, a multiple regression showed that satisfaction with care (SSQ) significantly predicted better birth experiences (CPS), F (6, 1,281) = 63.00, p   <   . 001), with a large effect (Cohen's d  = 1.00).

Results for Rq1–4

Infant feeding behaviours and birth experiences [rq1].

The data for this analysis are summarised in Figure 1 .

Responses for the CPS by feeding method. Responses are expressed in terms of mean ratings on the 0–4-point Likert scale. Error bars represent 95% confidence intervals. *** p  < .001.

First, we compared feeding groups and CPS birth experiences. Results showed a significant main effect of feeding method , F (2, 2,235) = 26.94, p  < .001, Cohen's f  = .30. Post-hoc Tukey HSD comparisons revealed that the ‘BF’ group reported significantly higher scores on the CPS, representing a better birth experience ( M  = 11.13, SD  = 3.94), in comparison with both the ‘CF’ group ( M  = 9.94, SD  = 3.82, p  < .001, f  = .23) and the ‘FF’ group ( M  = 9.81, SD  = 3.89, p  < .001, f  = .28). There were no significant differences in CPS scores between the formula and combination feeding groups ( p  = .802).

For satisfaction with clinical care, a main effect of feeding type was found, F (2, 2,297) = 13.42, p  < .001, Cohen's f  = .31. Those who exclusively breastfed reported higher levels of satisfaction with clinical care ( M  = 32.78, SD   =  8.22) in comparison with both those who combination fed ( M  = 30.59, SD   =  8.51, f  = .08) and those who formula fed their children ( M  = 31.21, SD  = 8.62, f  = .29), both p s < .001. In this case, only the ‘breast versus formula’ comparison yielded a practically significant effect size. There was no significant difference in satisfaction with care between the ‘combination’ and ‘formula’ feeding groups ( p  = .337).

Given that birth experiences precede infant feeding, we conducted a multinomial logistic regression to establish the predictive and clinically relevant nature of birth experiences. Results are outlined in Table 2 . First, we compared the intercept only model with a model in which the CPS was a predictor variable, and confirmed that the CPS model was significantly better, χ 2 (2) = 53.29, p  < .001.

Table 2.

Multinomial Logistic Regression Results.

Reference category: breast; values in brackets represent the standard error; p values for Wald's z-test.

The odds ratios outlined in Table 2 illustrate that a decrease in one unit (or point) on the CPS scale was associated with an 8% increase in the likelihood of formula or combination feeding (respectively) in comparison with breastfeeding. When comparing mean scores from each feeding group, the data represent a 9.5% actual increase in the odds of combination feeding, and a 10.5% decrease in the likelihood of formula feeding.

Birth experiences and infant feeding durations [RQ2]

The data for this analysis are summarised in Figure 2 .

Responses for the CPS by feeding duration. FF = formula fed; CF = combination fed (‘mo’ represents number of months the child received any breast milk); BF = breastfed. Responses are expressed in terms of mean ratings on the 0–4-point Likert scale. Error bars represent 95% confidence intervals. *** p  < .001.

For birth experience (CPS) scores and ‘feeding duration’ groups, a significant main effect was found, F (5, 1,352) = 9.93, p  < .001, Cohen's f  = .38. Post-hoc tests showed that the only ‘durations’ group which differed significantly from others for CPS scores was the ‘exclusive breastfeeding->12 months’ group, which differed from the formula group ( p  < .001), the ‘CF- 1–3 months’ ( p  < .001) and ‘CF- 8–12+ months’ ( p  = < .001) groups. Cohen's f effect sizes and significance varied for comparisons between this group and other feeding duration groups. (See Table S2 for between-group comparisons and more information.)

Next, we compared infant feeding duration groups’ satisfaction with clinical care as measured by the SSQ. A significant main effect was found, F (5, 1,377) = 5.05, p  < .001, Cohen's f  = .40. Again, the only group which significantly differed from others was the ‘breastfeeding- >12 months’ group ( M  = 32.63) Mothers in this category differed from the ‘formula’ group ( M  = 30.64, p  = .011, f  = .28) and the ‘combination- 1–3 months’ group. ( M  = 28.83, p  < .001, f  = .36). Table S3 shows detailed between-group comparisons and effect sizes.

We next sought to identify how age might influence the relationship between breastfeeding and birth experiences. As we found an association between the three feeding methods and age, the assumption of independence between independent variables for ANCOVA analysis was violated (for a discussion, see Owen & Froman, 1998 ). Therefore, we could not include age as a covariate in an ANCOVA model. Instead, we conducted linear regressions to establish whether age predicted CPS birth experience scores for each individual feeding group, respectively. No significant associations were found in these individual models, or a model which included all three groups (all p s > .05), suggesting that age did not influence this relationship.

Breastfeeding and the child-parent relationship in mothers with infants 1–3 years old [RQ3]

First, we treated ‘feeding type’ as a trichotomous variable, comparing formula, breast, and combination feeding groups. Responses on the CPRS did not significantly differ based on feeding type for either the ‘conflict’, F (2, 1,398) = 1.94, p  = .144, Cohen's f  = .02, or ‘closeness’ subscales, F (2, 1,379) = 2.26, p  = .105, Cohen's f  = .02. A statistically significant main effect of feeding type for the dependence subscale was found, F (2, 1,394) = 3.54 p  = .029, with breastfeeding mothers scoring higher ( M  = 3.15, SD  = .60) than mothers who fed their infants formula milk ( M  = 3.05, SD  = .62, p  = .022). However, the effect size was negligible (Cohen's f  = .06). The combination and formula feeding groups did not significantly differ ( p  = .565), nor did the breast and combination groups ( p  = .219).

Breastfeeding duration and mother-child relationship outcomes [RQ4]

Next, we explored whether mothers reported differences in their perceived relationship with their child based on the amount of time their infant received breast milk. Analyses showed no main effect for the CPRS ‘conflict’, F (7, 1,390) = .99, p  = .418 or CPRS ‘dependence’ subscales, F (5, 1,388) = 1.64, p  = .145. A significant main effect was found for the ‘closeness’ subscale, F (5, 1,371) = 2.57, p  = .025, showing that the ‘combination feeding- received breast milk for 0–3 months’ group received higher closeness scores. However, post-hoc Tukey tests did not show any statistically significant group differences. Further, effect sizes for between-group comparisons were statistically negligible, with Cohen's f effect sizes ranging from .00–.04. No significant between-group differences were found when assessing differences in our three ‘combined’ feeding groups (as outlined under the ‘Data analysis’ subheading) for scores on the CPRS subscales (‘closeness’, p  = .365; ‘conflict’, p  = 409; ‘dependence’, p  = .507).

Bayesian confirmation

To test the likelihood of not rejecting the null hypothesis given the data, a Bayes Factor (BF) ANOVA was conducted, with breastfeeding groups as fixed factors, and the CPRS subscales as dependent variables. This analysis supported our previous ANOVA results, showing that the likelihood of the null hypothesis given the data for the ‘dependence’ subscale was 3.78 times greater than for the alternative hypothesis. For the ‘conflict’ subscale, the likelihood of the null hypothesis was 17.94 times greater, and for ‘closeness’, 13.04 times greater. The former represents moderate evidence for the null hypothesis, and the latter two, strong evidence ( Lee & Wagenmakers, 2014 ).

Researchers have shown that birth interventions may prevent breastfeeding initiation ( Brown & Jordan, 2013 ; Saeed et al., 2011 ). However, literature which investigates a mother's perceptions of her birth experience and subsequent breastfeeding behaviours remains scant. We sought to address this gap in the literature by surveying a large sample of mothers, focussing on their subjective childbirth experiences. Moreover, we investigated whether mother-infant bonding was associated with different infant feeding methods.

Findings showed that mothers who were more satisfied with clinical care at the time of birth, and who perceived their birth experiences as more positive, were more likely to report breastfeeding their children. Better satisfaction and more positive perceptions were also associated with breastfeeding past the child's first birthday. Consistent with Hairston et al.’s (2019) findings, which showed that feeding type was not associated with bonding, we also found no relationships between infant feeding method and mother-child relationship outcomes.

Birth experiences and breastfeeding

Our data suggest that a positive birth experience is associated with the care received by healthcare staff, therefore highlighting the importance of good clinical care for maternal birth satisfaction. This is in line with previous investigations (e.g., Blüml et al., 2012 ). Our findings are also in line with Goyal et al. (2014) , who demonstrated that better hospital care can facilitate breastfeeding initiation. Given this relationship between clinical care and overall perceptions of birth experiences when exploring subjective experiences of childbirth, researchers should be cautious in utilising assessment tools which focus solely or primarily on obstetric interventions or surgical procedures.

Our analyses showed that mothers who had better birth experiences were more likely to breastfeed their children, and that those who breastfed their children for over 12 months had better birth experiences than formula feeding mothers and some combination feeding mothers. Odds ratios revealed a 9.5% increase in the likelihood of combination feeding for our cohort, and a 10.5% increase in the likelihood of formula feeding, based on lower average birth experience scores when compared with mothers who exclusively breastfed. Results from this study suggest that childbirth experiences may be an area of interest for predicting breastfeeding initiation. As suggested by Beck and Watson (2008) , negative birth experiences can impede breastfeeding initiation and continuation. In the short-term, perceived birth trauma, obstetric interventions, and physical pain can prevent initiation, leading women to introduce formula milk. In the longer term, negative birth experiences can increase the risk of flashbacks, PTSD, low postpartum mood, and detachment from the child. Klein and colleagues (2014) also discussed how negative birth experiences can contribute to feelings of inadequacy in mothers to care for and breastfeed their child, further increasing the likelihood of formula introduction.

As well as emotional consequences, the introduction of formula has various associated health risks. Breastfeeding decreases the risk of several illnesses for both mother and child, including maternal breast and ovarian cancers, and child allergies, asthma, and gastric issues (for an overview, see Davis et al., 2021 ; Dieterich et al., 2013 ). A recent meta – analysis conducted by Su et al. (2021) demonstrated a 23% reduction in the likelihood of childhood leukaemia when an infant was breastfed or occasionally breastfed versus being formula fed, and a 23% decreased risk between the longest and shortest breastfeeding durations. It is clear based on evidence that there is a significant need to improve breastfeeding rates in the United Kingdom. By understanding which factors influence feeding behaviours, interventions can be applied with a view to facilitating breastfeeding for mothers who wish to do so.

As well as the impact of a negative birth on breastfeeding directly, several factors might contribute to both birth experiences and longer-term breastfeeding, including socioeconomic status (SES) and access to resources. Mothers who have fewer economic barriers are more likely to have successful breastfeeding journeys than those with lower socioeconomic backgrounds ( Gebrekidan et al., 2020 ; Oakley et al., 2013 ). We did not include SES as a variable in the current study, and therefore we cannot make any assumptions about whether mothers’ SES had an influence on their birth experiences, or their decision to breastfeed. Future studies should control for this variable and explore whether higher SES and access to resource can affect mothers’ birth experience and breastfeeding behaviours.

Maternal age may also contribute to both better birth experiences and longer-term breastfeeding ( Oakley et al., 2013 ). However, our findings suggest that, independent of their age, longer-term breastfeeding mothers perceived their birth experiences as more positive. Interestingly, although no age effect was found, longer-term breastfeeding mothers were the oldest group in the cohort, on average four years older than formula feeding mothers. As shown by Smith and colleagues (2012) , younger mothers can have more negative perceptions of breastfeeding and suffer more social stigma than older mothers ( Smith et al., 2012 ). Although beyond the specific scope of our study, our findings highlight the importance of future breastfeeding research and support for younger mothers, who should be considered an at-risk group for early breastfeeding cessation.

Although we found that breastfeeding mothers and those who combination fed for 4–7 months did not differ in their birth experiences, this finding may be an issue of statistical power, rather than a true lack of differences (i.e., the relatively small sample of n  = 70 was sufficient to detect medium, but not small, differences between groups). Further research is necessary to determine any differences in experiences between longer-term breastfeeding and combination feeding mothers. More generally, very few explorations have assessed the behaviours of mothers who continue to offer breast milk alongside formula milk for longer periods, representing a clear need for further inquiry.

Formula feeding mothers and those who combination fed their child for 0−3 months reported experiencing lower satisfaction with care at the time of birth than breastfeeding mothers. This finding suggests that it is critical for care providers to ensure support throughout the birth experience to facilitate breastfeeding. A wealth of qualitative research has shown that care from midwives can be crucial in the formative stages of breastfeeding initiation ( see Battersby, 2014 , for an overview), and midwives in Great Britain are experiencing staffing issues, heavy workloads, and a lack of time to focus on person – centred care ( Edwards et al., 2018 ; Royal College of Midwives, 2018 ).

Our results suggest that facilitating good birth experiences and prioritising adequate patient support should be deemed vital for healthcare staff, for the wellbeing of mothers ( Leeds & Hargreaves, 2008 ), and for the potential benefits it may offer for breastfeeding initiation and continuation.

Breastfeeding and mother-child bonding

Next, we explored whether feeding methods were associated with the mother-child relationship. In line with Hairston et al. (2019) , we found no bonding differences between mothers who used different feeding methods. Further, the length of time an infant received breast milk was not associated with any differences in bonding.

Studies regarding the mother-child relationship and feeding methods have yielded mixed results and are often complicated by social and scientific assumptions about breastfeeding and mother-infant bonding. A body of scientific and lay literature on the topic is predicated on the notion that breastfeeding facilitates bonding, and these assumptions have informed public health policies globally (e.g., WHO, 2013, National Health Service, 2020 ). Despite this, only limited and often underpowered studies have shown such an association ( Jansen et al., 2008 ; Linde et al., 2020 ). Our study aligns with the few well-powered empirical studies which do not show this association (following Hairston et al., 2019 , and Else-Quest et al., 2003 ). We therefore extended previous findings to include mothers of 1–3-year-old infants, showing a consistent null effect of feeding type on bonding outcomes across the first three years of an infant's life.

This finding supports early understandings of attachment and bonding. In his seminal study, Harlow & Harlow (1962) showed that in rhesus macaques, infant monkeys who had warm, comforting terry cloth mothers fared better behaviourally than those who had wire mothers, even when the monkeys consumed the same amount of milk. Harlow concluded that normal development can only occur when comfort is available to an animal, and this was true regardless of the availability of milk. Harlow's studies were the basis for Bowlby's widely accepted ethological theory of attachment, which relies on the idea that that attachment is not inherently based on physiological feeding needs, but on responsive caregiving (see Bretherton, 1992 for a discussion). Our finding that breastfeeding was not associated with bonding is consistent with these theoretical arguments, suggesting that bonding is not necessarily a product of feeding method.

It is important to note that there is a distinct lack of literature which explores the relationship between perceived bonding and objective measures of attachment. Therefore, although we show no relationship between breastfeeding behaviours and perceived bonding, it remains important to continue work exploring breastfeeding and attachment security ( Linde et al., 2020 ). Nevertheless, our findings add to a growing body of literature which suggests that whilst breastfeeding remains important for global health, it may not be essential for mother-child bonding.

Limitations

This research was exploratory, and many covariates were not accounted for. These included parity status, infant gender differences, maternal socio-economic status, and indeed, obstetric interventions. All these factors have been shown to influence birth experiences or breastfeeding ( Brown & Jordan, 2013 ; Goyal et al., 2017 ; Oakley et al., 2013 ; Rijnders et al., 2008 ). Further studies are needed to determine the primary reasons for the relationship between childbirth perceptions and breastfeeding outcomes. Here, we argue that perceptions of a birth experience may not be due to obstetric interventions alone. To confirm this, an exhaustive study which encompasses all aspects of a birth experience is necessary.

The retrospective nature of this study may be a limitation. However, a longitudinal study conducted by Takehara and colleagues (2014) showed that mothers remember their birth experiences (both subjective perceptions and objective circumstances) clearly and accurately across at least a five-year period, likely due to the significance of the event. Mothers who participated in the current study were a maximum of three years postpartum, thus falling within Takehara's scope for accurate recollection.

Most mothers in the sample self-reported as white (94.8%). Caution should be applied when generalising these findings, though we provide support for Hairston et al. (2019) 's data showing a lack of association between birth experiences and bonding in Israeli mothers. It is critical that the experiences of mothers of colour are investigated, given the unique challenges that they can face during childbirth, including an increased risk of death ( Knight et al., 2019 ; Lister et al., 2019 ). Future research should consider the experiences of underrepresented groups as a matter of priority.

Finally, mothers were recruited in April 2020, during the COVID-19 pandemic. Although our primary analyses did not include mothers who gave birth in the preceding 12-month period, some analyses (e.g., the effects of satisfaction with care on birth perceptions) included mothers who may have given birth at the start of the pandemic. Although it is beyond the scope of this particular project to account for the effects of the pandemic on birth experiences, this remains an important area for exploration.

Implications for practice and future research

The results from this study support research which shows that staff can influence birth experiences in several ways. Individualised care and continuity of care can be important for a mother's perception of her experience ( Dahlberg & Aune, 2013 ), and perceptions of choice in a care context can promote better subjective experiences ( Cook & Loomis, 2012 ; Jelly et al., 2020 ). It is important for future researchers to explore the complex interplay between subjective perceptions of birth, feelings and perceptions around clinical care at the time of birth, and objective obstetric experiences. This in turn will help obstetricians to better understand the factors which improve childbirth perceptions, regardless of obstetric intervention status, and to ultimately empower women throughout childbirth.

Global breastfeeding rates in 2020 represent a significant public health issue. As well as the risks associated with breastfeeding cessation, mothers who wish to breastfeed but do not can be vulnerable to feelings of guilt related to their experiences ( Ayton et al., 2019 ). By identifying women who perceive their childbirth as a negative event, practitioners can provide early support, and thus alleviate, potential barriers to breastfeeding. Nevertheless, if a mother chooses not to, or cannot, breastfeed, we did not find evidence to suggest that their relationship with their child will be affected.

Supplemental Material

Acknowledgments.

The researchers would like to thank Robin Kramer for his critical comments on the manuscript.

Author Biographies

Abi M. B. Davis , Bsc, MSc, is a PhD researcher at the University of Lincoln. Her work involves lots of time spent with mums and babies, and her research focuses on bonding, early mother-infant relationships, and later language development.

Valentina Sclafani , BSc, MSc, PhD, AFHEA, is a senior lecturer in Developmental Psychology at the University of Lincoln UK. Her research focuses on infant development in both human and non-human primates. In particular, she explores how early mother-infant interactions affect infant socio-cognitive and emotional development.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Abi M. B. Davis https://orcid.org/0000-0002-0966-2954

Supplemental material: Supplemental material for this article is available online.