LETTERS

Postpartum Length of Stay and Breastfeeding Duration

To the Editor:The tenuous conclusion by Heck et al that “womenwho leave the hospital earlier than the standardrecommended stay are at somewhat increasedrisk of terminating breastfeeding early” suffersfrom two methodological weaknesses that likelyundermine this result (1). First, breastfeeding anddischarge timing influence each other and are corre-lated with many of the same factors, such as age,education, and income. Therefore, it is essentialto utilize a simultaneous equations model thatmakes it possible to isolate and quantify the independ-ent effect of discharge timing from other determin-ants of breastfeeding behavior (2). Our analysisof 4,354 births from the 1988 National Maternaland Infant Health Survey, in which we used simultan-eous modeling to demonstrate, contrary to theconclusion of Heck et al, that mothers dischargedafter 1 night in the hospital were nearly twice aslikely to breastfeed (OR¼ 1.96, 95% CI 1.86–2.03)as those discharged after 2 or 3 nights. Second, itis not clear why Heck et al combined vaginal andcesarean delivery in defining the exposure to shortstay. If length of stay beyond 2 days somehowtranslates into more breastfeeding, the great major-ity of women who had cesarean deliveries werelikely to have spent at least 2 days in the hospital,resulting in a misclassification of the exposure towhatever positive effects the authors purport for hos-pital stay.

Although maternal and infant hospitalizationmay provide opportunities for productive exposure tohealth care, it does not appear warranted to suggest topractitioners that more time in the hospital maypromote breastfeeding. Indeed, the opposite may bethe case.

Lewis H. Margolis, MD, MPHAssociate Professor, Department of

Maternal and Child HealthThe University of North Carolina at Chapel Hill

Chapel Hill, NC 27599-7445

J. Brad Schwartz, PhDLecturer, Department of Economics

The University of North Carolina at Chapel HillChapel Hill, NC 27599-7445

References

1. Heck K, Schoendorf K, Chavez G, Braveman P. Does

postpartum length of stay affect breastfeeding duration? A

population-based study. Birth 2003;30:153–159.

2. Margolis LH, Schwartz JB. The relationship between the

timing of maternal postpartum hospital discharge and

breastfeeding. J Hum Lact 2000;16:121–128.

Reply:Drs. Margolis and Schwartz raise the question ofwhether short postpartum stays may actuallyimprove the likelihood of breastfeeding rather thanreducing it; data from the 1988 National Maternaland Infant Health Study (NMIHS) suggest a conclu-sion opposite to the one we found using data fromthe California Maternal and Infant Health Assess-ment (MIHA) of 1999–2001.

We believe the reason for the discrepancy is thatthe two datasets are not comparable. NMIHS uses a1988 national sample, whereas MIHA sampled birthsduring 1999 to 2001. There have been several changesin both breastfeeding rates and postpartum lengths ofstay since 1988. Breastfeeding has become more com-mon (1), and short stays have become routine (2)since 1988. The demographics of early discharge arealso very likely to have changed. Women who left thehospital early in 1988, when short stays were rare,were generally high income, well educated, and white(3); such women are more likely to breastfeed regard-less of length of stay. By 2000, most women weredischarged early in California (4) and other states(Lansky et al., unpublished 2000 data from Centersfor Disease Control’s Pregnancy Risk Assessmentand Monitoring System). In addition, within-hospitaldifferences, such as a greater likelihood of infants’rooming-in with mothers, may be more likely nowthan in the 1980s, which might have affected thedifference in outcomes. Many hospitals—at leastin California—may have become more supportiveof breastfeeding during the 1990s, in response toconcerted public health efforts.

We continue to believe that it is unlikely that shortpostpartum stays would be beneficial for breastfeed-ing, because many women need assistance gettingbreastfeeding started in the early postpartum period;without in-home follow-up care, mothers are more

BIRTH 31:1 March 2004 77

likely to receive lactation assistance in the hospitalthan at home. Unfortunately, postpartum follow-upcare for mothers and infants is relatively infrequent(4). Regardless of how women with cesarean sectionsare classified in terms of length of stay (2 or 4 days),the MIHA data show that women with short stayswere less likely to breastfeed, after adjusting fornumerous potential confounders.

Katherine E. Heck, MPHKenneth C. Schoendorf, MD, MPH

Gilberto F. Chavez, MD, MPHPaula Braveman, MD, MPH

Address correspondence to Katherine E. Heck, MPHAssociate Specialist

4-H Center for Youth DevelopmentUniversity of California, Davis, 3321 Hart Hall,

Davis, CA 95616

References

1. Beck LF, Morrow B, Lipscomb LE, et al. Prevalence of

selected maternal behaviors and experiences, Pregnancy Risk

Assessment Monitoring System (PRAMS), 1999. MMWR

Surveillance Summary 2002;51:1–27.

2. Danielsen B, Castles AG, Damberg CL, Gould JB. Newborn

discharge timing and readmissions: California, 1992–1995.

Pediatrics 2000;106:31–39.

3. Braveman P, Egerter S, Pearl M, Marchi K, Miller C. Early

discharge of newborns and mothers: A critical review of the

literature. Pediatrics 1995;96:716–726.

4. Galbraith A, Egerter S, Marchi K, Chavez G, Braveman P.

Newborn early discharge revisited: Are California newborns

receiving recommended postnatal services? Pediatrics

2003;111:364–371.

The Push Against Vaginal Birth

To the Editor:As an educated, informed consumer who activelyadvocates for breastfeeding, kangaroo care, co-bedding, and attachment parenting, I was concernedthat your editorial (Birth 2003;30(3):149–152) impliedthat any well-informed woman would naturallychoose not to have a cesarean birth. As a generallyhealthy woman professional, and based on my readingof the literature, I would choose a cesarean over aVBAC for myself.

Despite the claims of several well-meaning naturalchildbirth organizations that it is the woman’s rightto choose, a decision other than natural childbirth isoften labeled an error in her judgment, based onmisinformation, or worse, biased information, fromthe woman’s health care providers. Women makemedical decisions for many reasons: medical, social,and emotional. As a medical professional, I have aresponsibility to relay the risks and benefits of anytreatment as accurately and fairly as I can. Unfortun-ately (for me), risks and benefits are constantlymoving targets, and highly individual.

Please don’t label all of us who would choose anelective cesarean section (for our own personal andvaried reasons) as misinformed dupes of thehealthcare system.

Nancy E. Wight, MD, FAAP, IBCLCNeonatologist, Children’s Hospital and Sharp Mary

Birch Hospital for WomenMedical Director

Sharp HealthCare Lactation Service3003 Health Center Drive

San Diego, California 92123

Windows in Space and Time

To the Editor:I commend your editorial decision to publish thisprofoundly emotional and honest piece of writingby Robbie Davis-Floyd (Birth 2003;30(4):272–277).It was deeply moving to read, and somehow itenhances one’s humanity and is uplifting despite thesadness of the content. It is a wonderfully affectiveand effective personal testimony…and just amazingto see it published in an essentially research-orientatedjournal. Thank you.

Denis Walsh, RM, DPSM, PGDipE, MAIndependent Midwife Lecturer

366 Hinckley RoadLeicester LE3 0TN

United Kingdom

78 BIRTH 31:1 March 2004