Journal of Midwifery &Women’s Health www.jmwh.orgOriginal Research

Women’s Prenatal Concerns RegardingBreastfeeding: Are They Being Addressed?Karen Archabald, MD, MS, Lisbet Lundsberg, PhD, Elizabeth Triche, PhD, Errol Norwitz, MD, PhD,Jessica Illuzzi, MD, MS

Introduction: This study sought to identify women’s concerns regarding breastfeeding during the prenatal period and determine whether womenthought that health care providers addressed these concerns.

Methods: A structured interview with both open-ended and closed-ended questions addressing the study objectives was administered to a cross-sectional sample of 130 English-speaking or Spanish-speaking postpartum women at Yale-New Haven Hospital.

Results: When asked an open-ended question regarding whether they had concerns about breastfeeding while making their decisions aboutfeeding their infants, 81.5% of women identified at least 1 concern. Of these women, only 25.4% reported that this concern was addressed by theprovider during prenatal care. When prompted with 8 common concerns regarding breastfeeding during the prenatal period, 95.4% of womenidentified at least 1 of these preidentified concerns. Only 17.4% of women who identified any of these 8 concerns reported that the concerns hadbeen discussed with a provider.

Discussion: Women’s recall of prenatal health care discussions strongly suggests that providers are not adequately addressing women’s concernsabout breastfeeding.J Midwifery Womens Health 2011;56:2–7 c© 2011 by the American College of Nurse-Midwives.

Keywords: breastfeeding, concerns, counseling, prenatal care

INTRODUCTION

The benefits of breastfeeding to infants and mothers are well-documented.1 The American College of Nurse-Midwives andthe American Congress of Obstetricians and Gynecologistsrecommend that providers encourage breastfeeding.2,3 Asproviders for women from the preconception period throughpostpartum, midwives, obstetrician-gynecologists, and fam-ily medicine practitioners have a unique opportunity to pro-mote breastfeeding throughout women’s lives and particularlyin the prenatal period.National aswell as various local surveysindicate that 75% to 100% of prenatal care providers reportrecommending breastfeeding to their patients, and a similarpercentage believe they play an important role in women’s de-cisions regarding infant feeding.4−6,7

In contrast, patients report being advised to breastfeed bytheir providers only 40% to 60% of the time (estimates rangefrom 23% to 73%).8−12 One possible explanation for the dif-ference in perception of breastfeeding advice is the methodof communication used by providers. Communication cen-tered on patients and their concerns rather than on biomed-ical information has been shown to be more effective at in-creasing patients’ abilities to synthesize information andmakedecisions.13

The aims of this study are to describe women’s concernsabout breastfeeding during the prenatal period and to de-termine whether women perceived that their prenatal careproviders addressed these concerns.

Address correspondence to Jessica Illuzzi, MD, MS, Center for Perinatal,Pediatric and Environmental Epidemiology, 1 Church Street, 6th Floor,New Haven, CT 06510. E-mail: Jessica.illuzzi@yale.edu

METHODS

Design and Participants

We conducted a cross-sectional study with convenience sam-pling. Eligible participants included all English-speaking orSpanish-speaking postpartum women who had a live birthat Yale-New Haven Hospital between October 20, 2006, andJanuary 9, 2007. Women with medical conditions such asHIV, in which breastfeeding is not recommended, or with in-fants unable to suckle secondary to congenital anomalies orother medical conditions such as extreme prematurity wereexcluded from participation. The Human Investigation Com-mittee at Yale University approved this study.

Measures

Anoral questionnairewas developed specifically for this studyby the authors because no existing surveys were identified inthe literature that addressed these topics. The questionnaireconsisted of 51 open-ended and closed-ended questions de-signed to obtain information about the participant’s decision-making process regarding feeding practices, her concernsabout breastfeeding, and the content of prenatal discussion ofthese topics. The open-ended questions were developed withthe research question in mind; closed-ended questions ad-dressing specific concerns were based on a review of the lit-erature, which documents common concerns of pregnant andpostpartum women regarding breastfeeding.14−18

The primary open-ended question for this study is as fol-lows: “While making your decision about how to feed yourbaby, did you have concerns about breastfeeding?” The 8closed-ended questions regarding concerns were in a yes-no

2 1526-9523/09/$36.00 doi:10.1111/j.1542-2011.2010.00006.x c© 2011 by the American College of Nurse-Midwives

format and regarded whether the woman had the concern aswell as whether the concern was addressed by the provider.These 8 concerns were identified by a search of the litera-ture and included ability to work/attend school, inadequatemilk supply, pain, difficulty sharing feeding responsibility,anxiety/embarrassment, difficulty in maintaining mother’sdiet/health, restriction of social life, and body image.14−18

Feeding choice was defined based on the stated feedingchoice on the day of the interview. Participantswhowere plan-ning to exclusively feed only human milk were defined asbreastfeeders. Participants who were planning to exclusivelyfeed their infants formula, without any supplementation withbreastmilk, were defined as formula feeders. Participants whowere planning to use both breast milk and formula were de-fined as mixed feeders. This would allow a mother whoseinfant received a supplemental feeding of formula for somemedical indication to still be categorized as “planning to ex-clusively breastfeed” if she so stated, despite a solitary formulafeeding during the hospital stay.

Information on demographic characteristics includingage, socioeconomic status, ethnicity/race, education, maritalstatus, country of origin, type of care provider, and setting ofprenatal care was also obtained. A copy of the questionnaireis available on request.

Procedure

After consent was obtained from participants, the first author(K.A.) administered an oral questionnaire during the post-partum period in the patient’s hospital room. Following theopen-ended question regarding concerns, women were thendirectly asked if they shared any of 8 specific concerns aboutbreastfeeding commonly mentioned in other studies. If theparticipant had already indicated 1 of these specific concernsin the open-ended portion of the questionnaire, she was notasked about that topic again in the directed portion of thequestionnaire.

Analysis

Data analysis was performed with the SAS 9.1 (SAS In-stitute Inc, Cary, NC) statistical analysis software package.Bivariate analyses were performed to describe associationsbetween maternal characteristics, feeding choice, concernsabout breastfeeding, and provider communication about con-cerns. Categorical variables were compared by use of chi-square tests and the Fisher exact test, when appropriate. Re-sponses to the open-ended and closed-ended questions wereanalyzed separately. Statistical significance was defined as aP value less than or equal to .05.

RESULTS

During the study period, 146 women meeting inclusion cri-teria were approached during postpartum hospitalization,which ranged from postpartum day 1 through 4. Four women(3%) declined participation, and 12 (8%) deferred the inter-view to a later time but were subsequently not able to be inter-viewed. A total of 130 women completed the study, yieldinga participation rate of 89%. Because of the convenience sam-

pling methodology, the sample contains a higher proportionof womenwho had cesarean births, because these women typ-ically spend more days in the hospital than women who givebirth vaginally.However, therewas no significant difference infeeding choice between women who had vaginal or cesareanbirths (P = .618).

Of women in the study (see Table 1, Total column), 60%chose to breastfeed exclusively, 20% to formula feed, and20% to use both methods. The mean maternal age was 29.5years. The majority were white (55.3%), with minorities ofAfrican American (17.7%) and Hispanic (16.9%) women.Most (65.4%) women had a household income of greater than$24,000 per year, and just over half (52.4%) had graduatedfrom college or had a postgraduate degree. Private providerscared for 69.2% of the women, whereas hospital physicians,midwives, and residents provided care to the remainder.

When asked during the interview the open-ended ques-tion regarding whether they had concerns about breastfeed-ing while making their feeding choice, the majority of women(81.5%) identified at least 1 concern (Table 2). Responses fellinto 15 thematic groups that were subsequently consolidatedinto the following 5 categories, based on their similarities, foranalysis: 1) lifestyle/flexibility issues (difficult to share respon-sibility for feeding, maintaining diet, not enough time, diffi-culty sleeping, frequent feeding, nipple confusion, inability towean, social isolation, body image), 2) pain (nipple discom-fort), 3) confidence (not producing enoughmilk, baby not get-ting enough milk, baby not latching on), 4) work (difficult togo back to work because of demands of feeding), and 5) medi-cations (perceived medicine interactions with breastfeeding).

Breastfeedersmost commonly identified the primary con-cern as confidence (44.9%), formula feeders were most con-cerned about social/lifestyle issues (30.8%), andmixed feedersexpressed equal concern about confidence and work (23.1%each). The percentage of women who identified a concernabout breastfeeding did not vary by ultimate feeding choice(P = .903). Overall, 25.4% of women had their primary con-cerns addressed by their providers (Table 2). There was nostatistically significant difference between the percentage ofwomen who had their primary concerns addressed in themixed-feeding and formula-feeding groups (30.8% each) andthe breastfeeding group (21.8%) (P = .512).

Women were then asked closed-ended questions regard-ing whether they shared any of 8 common concerns aboutbreastfeeding, which have been previously identified in the lit-erature (Table 3). Women shared at least 1 of these preidenti-fied concerns 95.4% of the time. Overall, the most commonconcern was that breastfeeding would influence the mother’sability to go back to work or school (46.9%). This concernwasmore common amongmixed feeders (61.5%) and formulafeeders (61.5%) than breastfeeders (37.2%) (P = .024). Inad-equate milk supply was the second most common concern(43.9%) and was equally prevalent across groups (P = .321).Pain associated with breastfeeding was a concern for 42.3%of women, with similar frequency in all 3 groups (P = .657).A higher percentage of women who chose to formula feedwere concerned about sharing feeding responsibility withtheir partners, family, and friends (53.9%), compared withmixed feeders (34.2%) or breastfeeders (28.2%) (P = .059). Asignificantly larger number of women (35.9%) who chose to

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Table 1. Characteristics ofWomenWhose Concerns About BreastfeedingWere andWere Not Addressed During Prenatal Care.Concerns Addressed

Total

Characteristic (N = ) Yes (n = )a No (n = )a P valueb

Age, mean (SD), y 29.5 (6.3) 26.3 (6.6) 31.0 (5.6) � .001

Parity, n (%) .054

Nulliparous 63 (48.5) 26 (60.5) 37 (42.5)

Multiparous 67 (51.5) 17 (39.5) 50 (47.5)

Prior breastfeeding experience, n (%) .004

Yes 50 (38.5) 9 (20.9) 41 (47.1)

No 80 (61.5) 34 (79.1) 46 (52.9)

Race/ethnicity, n (%) � .001

White 72 (55.3) 15 (34.9) 57 (65.5)

African American 23 (17.7) 15 (34.9) 8 (9.2)

Hispanic 22 (16.9) 7 (16.3) 15 (17.2)

Asian 7 (5.4) 0 (0) 7 (8.1)

Other 6 (4.6) 6 (14.0) 0 (0)

Country of birth, n (%) .246

United States 101 (77.7) 36 (83.7) 65 (74.7)

Other 29 (22.3) 7 (16.3) 22 (25.3)

Married, n (%) 0.001

Yes 88 (67.7) 21 (48.8) 67 (77.0)

No 42 (32.3) 22 (51.2) 20 (23)

In workforce or school, n (%) 0.412

Yes 97 (74.6) 34 (79.1) 63 (72.4)

No 33 (25.4) 9 (20.9) 24 (38.1)

Prenatal care, n (%) .002

Private 90 (69.2) 22 (51.2) 68 (78.2)

Hospital clinic 40 (30.7) 21 (48.8) 19 (21.8)

Provider, n (%) .081

Physician 47 (36.2) 16 (37.2) 31 (35.6)

Midwife 21 (16.2) 11 (25.6) 10 (11.5)

Both 62 (47.7) 16 (37.2) 46 (52.9)

Education, n (%) .002

High school or less 37 (28.5) 21 (48.8) 16 (18.4)

Some college 25 (19.2) 8 (18.6) 17 (19.5)

College graduate 35 (26.9) 6 (14.0) 29 (33.3)

Postgraduate 33 (25.4) 8 (18.6) 25 (28.7)

Income, n (%) � .001

� $10,000 29 (22.3) 12 (27.9) 17 (19.5)

$10,000-$24,000 16 (12.3) 13 (30.2) 3 (3.5)

� $24,000 85 (65.4) 18 (41.9) 67 (77.0)

Feeding choice, n (%) .337

Breast 78 (60) 22 (51.2) 56 (64.4)

Formula 26 (20) 10 (23.3) 16 (18.4)

Mixed 26 (20) 11 (25.6) 15 (17.2)

aPercentages may not sum to 100% because of rounding.bP value is for t test (continuous variable, age) and � 2 or Fisher exact test (categorical variables).

4 Volume 56, No. 1, January/February 2011

Table 2. Primary Concern Regarding Breastfeeding by Feeding Choice.a

Total Breastfeeding Formula Feeding Mixed Feeding

N = n () n = n () n = n () n = n () P Value

Any concern identified

Yes 106 (81.5) 63 (80.8) 22 (84.6) 21 (80.8) .903

Primary concern .138

Lifestyle/flexibility 21 (16.2) 9 (11.5) 8 (30.8) 4 (15.4)

Pain 17 (13.1) 9 (11.5) 3 (11.5) 5 (19.2)

Confidence 47 (36.2) 35 (44.9) 6 (23.1) 6 (23.1)

Work 17 (13.1) 8 (10.3) 3 (11.5) 6 (23.1)

Medications 4 (3.1) 2 (2.6) 2 (7.7) 0 (0.0)

None identified 24 (18.5) 15 (19.2) 4 (15.4) 5 (19.2)

Primary concern addressed .512

Yes 33 (25.4) 17 (21.8) 8 (30.8) 8 (30.8)

aResponses in this table come from the open-ended question, “While making your decision about how to feed your baby, did you have concerns about breastfeeding?”

breastfeed reported anxiety or embarrassment about feedingin public places than women who chose to mixed feed or for-mula feed (P = .007).Womenwho chose to formula feed weremore likely to be worried about maintaining their own healthwhile breastfeeding (P = .006). Restriction of social life andbody imagewere less frequently identified as concerns and didnot vary among the different feeding groups. Overall, 17.4%(range 0%-27%) of participants who had these 8 specific con-cerns perceived that they were addressed by their providersduring prenatal care (Table 3).

Maternal characteristics of women who reported thattheir concerns were addressed were significantly differentfrom women who reported that concerns were not addressed(Table 1). Women who had their concerns about infant feed-ing solicited and addressed during prenatal care were morelikely to be younger (P � .001), African American (P � .001),have a high school education or less (P = .002), have no pre-vious breastfeeding experience (P = .004), and receive their

care at the hospital clinic (P = .002), compared with womenwho did not have their concerns addressed. Although 52%of women who received their care exclusively from midwivescompared with 34% of those who received their care fromphysicians reported discussing their concerns about breast-feeding during their prenatal care, this finding did not reachstatistical significance (P = .081).

DISCUSSION

The overwhelming majority of women have concerns re-garding breastfeeding during prenatal care. Although 81.5%of women initially identified a primary concern regardingbreastfeeding, 95.4% reported sharing at least 1 of the 8common concerns identified in the literature. The concernswomen identified in this study were similar to those previ-ously identified. The majority of the literature on this topiccomes from qualitative focus groups and interviews. A fo-cus group of upper-middle-class and middle-class women

Table 3. Prevalence of 8 Common Concerns Regarding Breastfeeding by Feeding Choice and Percentage of Women Who Reported ThatTheseConcernsWere Addressed in Prenatal Care.a

Total Breastfeeding Formula Feeding Mixed Feeding

Reporting Concern Reporting Reporting Reporting P

Concern, n () Concern N = Addressedb Concern n = Concern n = Concern n = Valuec

Ability to work/attend school 61 (46.9) 13 (21.3) 29 (37.2) 16 (61.5) 16 (61.5) .024

Inadequate milk supply 57 (43.9) 12 (21.1) 37 (47.4) 8 (30.8) 12 (46.2) .321

Pain 55 (42.3) 15 (27.3) 31 (39.7) 11 (42.3) 13 (50.0) .657

Difficulty sharing 45 (34.6) 6 (13.3) 22 (28.2) 14 (53.9) 9 (34.2) .059

feeding responsibility

Anxiety/embarrassment 42 (32.3) 0 (0.0) 28 (35.9) 12 (46.2) 2 (7.7) .007

Difficulty maintaining 31 (23.9) 8 (25.8) 12 (15.4) 12 (46.2) 7 (26.9) .006

mother’s diet/health

Restriction of social life 19 (14.6) 1 (5.3) 9 (11.5) 6 (23.1) 4 (15.4) .351

Body image 18 (13.9) 2 (11.1) 12 (15.4) 4 (15.4) 2 (7.7) .597

aResponses in this table come from responses to directed questions regarding 8 common concerns of breastfeeding mothers.bAmong total reporting concern.cChi-square analysis comparing the percentage reporting this concern by infant feeding choice postpartum.

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revealed that women were concerned about the ability tosuccessfully breastfeed and balance breastfeedingwith return-ing to work as well as about physical changes and breast painattributed to breastfeeding.14 Lower income populations havebeen more extensively studied, but these studies reveal simi-lar concerns, including the ability to attend work/school, ad-equacy of milk supply, pain, difficulty sharing feeding re-sponsibility, anxiety/embarrassment, restrictions onmaternaldiet/health, restriction of social life, and body image.15−18

During the prenatal period, one-quarter of the womenin our study sample perceived that their primary concernsabout breastfeeding had been addressed, whereas the 8 con-cerns identified in the literature were addressed from 0.0%to 27.3% of the time. Although providers may think they arediscussing breastfeeding with their patients,7 the differencein the perception of discussions regarding breastfeeding be-tween providers and patients has been clearly identified ina study of physician/patient dyads, which found that amongwomen whose obstetricians said they usually or always dis-cussed breastfeeding duration during prenatal visits, only 16%of women reported that it was discussed.19

There is a significant gap between the rates at whichproviders report their commitment to promoting breast-feeding and patient-reported rates of being counseled. Thisdisparity may be related to how providers and patients in-terpret these interactions. Patient-focused communicationaddressing individual concerns is effective inmedicine in gen-eral and in promotion of breastfeeding specifically.13,20,21 Re-sults of a model breastfeeding education program in Ohio, inwhich providers focused on eliciting and acknowledging in-dividual concerns, was associated with an increase in breast-feeding initiation rates from 15% to 31% over the period of1 year.20,21 In a randomized, controlled trial in Singapore,women who were given a chance to ask a lactation counselorquestions about breastfeeding were more likely to practice ex-clusive breastfeeding at 3 and 6 months than those receivingstandard care.22

The low rate at which women report that their concernswere addressed during prenatal care in this study clearlyindicates a gap in communication between providers andpatients. Although providers often report that they lackknowledge regarding breastfeeding counseling, the concernscommonly listed in this study are practical rather than com-plex medical issues. The majority of women who ultimatelychose breastfeeding were most concerned about the abil-ity to succeed and having an adequate milk supply, whereasthose who chose formula feeding worried about possible so-cial or lifestyle issues as well as going back to work. Thosewho chose mixed feeding methods expressed concerns aboutthe ability to succeed and going back to work. Returningto work was the most common concern among all partici-pants, yet many women reported not ever having discussedbreast pumping and milk storage with their providers. Be-cause of the basic nature of many of these questions, themajority of providers are likely able to address these con-cerns with reassurance about maternal physiology, practicaladvice about breast pumping in the workplace, and assuranceabout the increasing social acceptability of breastfeeding asmedical evidence regarding the importance of breastfeedingaccumulates.

Many of these more practical concerns could likely beelicited with an open-ended approach such as the questionasked in this study: “Do you have any concerns about breast-feeding?” Several women reported that they were not com-fortable bringing up more personal concerns such as bodyimage or sexuality with their providers but would have dis-cussed these issues if the provider had started the conversa-tion. None of the participants in the study reported discussingsexuality and breastfeeding with their providers, yet severalreported needing someone to talk to about these issues. Al-though not all patients may wish to discuss concerns withtheir providers, the small percentage who had their concernsaddressed in this study suggests that the opportunity for dia-logue with providers is often not created during prenatal careand that simple, open-ended questions are enough to elicitdiscussion of most concerns.

We found significant differences in the maternal char-acteristics of women who reported perceiving that theirconcerns were addressed. A review of survey results fromthe National Institute of Child Health and Human Devel-opment regarding whether women were advised to considerbreastfeeding by a nurse or doctor during prenatal care sug-gests that women who are black, unmarried, and poorly edu-cated are less likely to be advised to breastfeed than others,11with other large studies showing similar results.14−16,23 In ourstudy, counseling efforts appear to be focused on women whohave historically had low rates of breastfeeding initiation, in-cluding women who are single, low income, African Ameri-can, and have a high school education or less. Although it isencouraging that women with historically low rates of breast-feeding are being targeted, our data also suggest that the ma-jority of women, regardless of demographics, have concernsabout breastfeeding. It appears that providers may be assum-ing that women who are well-educated and middle incomedo not need further counseling; however, our data suggestotherwise.

Interpretation of this cross-sectional study should con-sider that the retrospective design introduces the possibil-ity of recall bias. Participants were asked immediately post-partum about their interactions with their providers duringpregnancy; therefore, the maximum time patients were askedto recall was 36 weeks, because most women do not initiateprenatal care until sometime after 4 weeks in a 40-week ges-tation. Research suggests that women’s recall of events dur-ing pregnancy and birth is both accurate and reproducible.24Furthermore, this study is most interested in what womenrecall regarding prenatal interactions at the point they areimplementing their intention to breastfeed or formula feed.Therefore, if, at the time of birth, a woman does not recall adiscussion during prenatal care regarding infant feeding, thediscussion may be unlikely to have made an impact on herdecision. Therefore, we believe the categorization of thesewomen as not perceiving that their concerns were addressedby providers is appropriate. This study, however, did not assesswhether women attended prenatal classes or had their con-cerns about breastfeeding addressed in prenatal classes, nordid it confirm counseling habits of their individual providers,which remains a limitation. The study does not specificallydifferentiate discussions about feeding concerns that were ini-tiated by the clinician versus by the patient but rather whether

6 Volume 56, No. 1, January/February 2011

the topic was perceived to be covered at all during prenatalcare.

The size of this study sample precluded us from analyzingthe effect of addressing concerns on feeding choice. A largerstudy focused on determining causality is warranted.

This study was conducted in a large, academic institutionwith a mix of private and clinic providers as well as a raciallyand sociodemographically diverse group of patients. A largermultiple-site study would increase the generalizability of ourresults.

This study indicates that many health care providers donot routinely address women’s concerns about breastfeeding,regardless of ultimate feeding choice. Meaningful discussionswith patients about feeding choice are essential, not only topossibly increase breastfeeding rates but to strengthen theprovider-patient relationship and support mothers’ feedinggoals.

AUTHORS

Karen Archabald, MD, MS, is a resident in the Departmentof Obstetrics and Gynecology, Brown University School ofMedicine, Women and Infants’ Hospital.Lisbet Lundsberg, PhD, is a research scientist in the Depart-ment of Epidemiology and Public Health at Yale School ofMedicine, New Haven, Connecticut.Elizabeth Triche, PhD, is an assistant professor of medical sci-ence at the BioMed Center for Population Health & ClinicEpidemiology in the Department of Epidemiology and PublicHealth at Brown University School of Medicine.Errol Norwitz, MD, PhD, is a professor and Chair of Obstet-rics and Gynecology at Tufts University School of Medicine.Jessica Illuzzi, MD, MS, is an assistant professor and Direc-tor of Medical Studies in Obstetrics and Gynecology at YaleSchool of Medicine.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

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