Breastfeeding
Breastfeeding has many advantages to infants [1]. In 2010,
approximately 77% of US infants were breastfed at least once, a
substantial increase from 64% in 1998 [2,3]. Despite this progress,
breastfeeding continues to fall short of national goals for duration
and exclusivity set in initiatives such as Healthy People 2020 [2,4].
One possible reason for failure to consistently meet these goals is
the rise in complications women face as they enter pregnancy,
including diabetes, obesity, and hypertension. Breastfeeding
initiation rates are lower and breastfeeding duration is generally
shorter among women with these conditions [5–8]. Six percent of
births are complicated by diabetes [9], 3%–5% of pregnant
women have hypertensive disorders [10–12], and 19%–39% of are
obese when they become pregnant [13]. Clinical management of
these conditions and associated complications may necessitate
greater intrapartum or neonatal intervention, which could affect
care for the woman or infant in the immediate postpartum period,
including breastfeeding [14–19]. Breastfeeding
The decision to breastfeed is highly personal and affected by
many factors, including anticipated barriers to or support for
breastfeeding, hospital practices, medical issues occurring either
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before or during pregnancy, and complications during labor and
delivery [1,20–26]. One program that has been successful in
encouraging breastfeeding is the Baby-Friendly Hospital Initiative
(BFHI), a global program to encourage and recognize hospitals
that have policies to provide evidence-based care to support infant
feeding and mother-baby bonding [1,20,24,25,27]. The program,
for example, instructs mothers on breastfeeding, allows babies to
spend the first hour after birth in their mothers arms; provides
newborns no food or drink other than breast milk, unless medically
indicated; practices ‘‘rooming in’’ by allowing mothers and infants
to remain together 24 hours per day; gives no pacifiers or artificial
nipples to breastfeeding infants; and refer mothers to breastfeeding
support groups on discharge from the hospital or clinic. Greater
adoption of these practices is also a focus of Healthy People 2020
[28]. Yet despite the success of these measures, fewer than 7% of
U.S. births currently occur in facilities with an official BFHI
designation [28]. This study examines the relationship between
entering pregnancy with complicating health conditions and early
infant feeding behaviors, focusing on women’s breastfeeding
intentions and supportive hospital practices as potential mediators. Breastfeeding
Materials and Methods
Conceptual Model Figure 1 presents the conceptual model for the analysis. The
model focuses on women’s breastfeeding intentions and hospital
support practices during the intrapartum period and how these
factors and their effects may differ for women who enter
pregnancy with diabetes, hypertension or obesity.
Data Data are from the Listening to Mothers III survey, a nationally
representative sample of women who gave birth to a singleton in a
US hospital between July 1, 2011, and June 30, 2012 (N = 2400).
The survey was commissioned by Childbirth Connection and
conducted by Harris Interactive between October and December
2012. The survey documented pregnancy, labor, and birth
experiences in US hospitals, including information about breast-
feeding decisions and pre-existing medical conditions. Data from
this survey have been widely used in clinical and public health
research, including studies of breastfeeding and the role of
supportive hospital practices [26,29,30]. However, this was the
first wave of the survey to include information about medical
conditions prior to pregnancy. Detailed information about the
survey’s methodology, implementation, and questionnaires is
available at www.childbirthconnection.org/listeningtomothers/. Breastfeeding
The data used in this analysis were de-identified. Therefore, the
University of Minnesota Institutional Review Board granted this
study exemption from review (Study No. 1011E92983).
Variable Measurement Pregnancy Complexity. We defined pregnancy complexity
from available survey data relating to 3 common medical risk
factors: (1) taking prescription medication for blood pressure
during the month before pregnancy, (2) having either type 1 or
type 2 diabetes before pregnancy or gestational diabetes, or (3)
having a prepregnancy body mass index higher than 30. Our main
analysis included a dichotomous measure of pregnancy complexity
for women reporting any of these 3 conditions. We also
constructed indicators for each of the conditions for separate
analysis (see following description of sensitivity analyses). Breastfeeding
Breastfeeding Intention. Women were asked at the time of
the survey to recall their intentions about infant feeding at the end
of pregnancy. We created dichotomous variables indicating (1) any
intent to breastfeed (exclusively or not) and (2) women’s intent to
breastfeed exclusively. Supportive hospital practices and infant
feeding status were assessed among women who reported any
intention to breastfeed (n = 1990), and exclusive breast milk
feeding status at 1 week postpartum was assessed among women
who intended to exclusively breastfeed (n = 1418).
Supportive Hospital Practices. Among women who in-
tended to breastfeed, we examined supportive hospital practices
consistent with BFHI standards. We measured supportive hospital
practices using an 8-point composite measure corresponding to 7
of the 10 BFHI steps. Measures for the remaining 3 steps were not
assessed in the Listening to Mothers surveys because they require
knowledge of hospital administrative policies beyond the scope of
women’s knowledge and experiences. However, data from these
Figure 1. Conceptual Model. doi:10.1371/journal.pone.0104820.g001
Medically Complex Pregnancies and Early Breastfeeding
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PLOS ONE | www.plosone.org 2 August 2014 | Volume 9 | Issue 8 | e104820
surveys have previously been used to successfully approximate Breastfeeding
BFHI hospital practices [26,30]. See Table 1 for detailed
information about the 10 BFHI steps and the 8 items assessed in
the data and used in this analysis.
To assess general concordance with supportive breastfeeding
practices in the hospital, we created a composite measure in which
higher scores indicate that the woman perceived a higher level of
breastfeeding-supportive hospital practices. Scores were not
normally distributed, so we constructed a dichotomous variable
on the basis of the top quintile of responses. Scores of 7 to 8 were
categorized as ‘‘high hospital support,’’ indicating practices
broadly consistent with BFHI standards. We also assessed the
distribution of the items in the composite measure and tested the
stability of the measure by modeling hospital support as a
continuous variable (0–8) and by using a lower threshold (i.e.,
scores of 6–8 for high levels of support from the hospital). Results
were robust to alternative specifications. Breastfeeding
Feeding Status 1 Week Postpartum. Two dichotomous
measures of infant feeding status were based on women’s responses
to questions regarding (1) whether they were feeding their
newborn any breast milk (either exclusively or in combination
with formula) 1 week postpartum, and (2) whether they were
feeding their newborn breast milk only 1 week postpartum. This
definition allows for both direct breastfeeding and feeding
expressed breast milk to infants. Breastfeeding
Control Variables. We controlled for labor and delivery
factors that may affect the initiation of breastfeeding, including
cesarean delivery, epidural use, and admission to a neonatal
intensive-care unit [31–34]. We assessed these variables from
maternal self-report. We also included several self-reported
sociodemographic and birth-related covariates, including age;
race/ethnicity (white, black, Hispanic, or other/multiple race);
education (high school or less, some college, bachelor’s degree, or
graduate education); 4-category census region (Northeast, South,
Midwest, West); nativity (foreign- or US-born); partnership status
(unmarried with no partner, unmarried with partner, or married);
parity (first-time pregnancy); pregnancy intention (unintended or
intended pregnancy); agreement with the statement ‘‘birth is a
process that should not be interfered with unless medically
necessary;’’ doula support; and primary payer for maternity care
(private, public, or out-of-pocket). Breastfeeding
Analysis We first explored associations between the predictors, outcomes,
and covariates for the overall sample using 1- and 2-way
tabulation. We used Pearson’s x2 tests to determine whether differences based on pregnancy complexity were statistically
significant. We used logistic regression to estimate the adjusted
odds of breastfeeding intention based on pregnancy complexity.
Among women intending to breastfeed, we estimated the adjusted
odds of breastfeeding status 1 week postpartum. To test for
mediation by hospital support, we added a variable indicating high
levels of support for breastfeeding at the hospital. In the final
multivariate models of breastfeeding status 1 week postpartum, we
included only covariates that were statistically significantly
associated with the outcomes. We conducted sensitivity analyses,
estimating the same regression models using indicator variables for
prepregnancy obesity, hypertension, and diabetes as the predictors
rather than the combined ‘‘complex pregnancy’’ variable; results
were substantively unchanged. All analyses used a p-value of 0.05
to determine statistical significance, were conducted using Stata
v.12, and weighted to be nationally representative Breastfeeding
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