Health system factors contributing to breastfeeding success

Objective. To identify and characterize health care system factors that con tribute to successful breastfeeding in the early postpartum period. Study Design. A prospective 8-week cohort study of 522 women at five area h ospitals who had a vaginal delivery of a healthy, full-term single child an d who intended to breastfeed. Mothers and infants had free access to each o ther for breastfeeding during the hospital stay. Data were obtained through chart review and surveys. In-person postpartum interviews in the hospital and 4- and 8-week telephone interviews were used to determine participants' perceptions of breastfeeding support by hospital personnel, home visit nur ses, and family and friends. The hospital in-person interview with each mot her was conducted before discharge to confirm maternal interest and intent to breastfeed. Questions were asked regarding breastfeeding information and support provided by medical and nursing personnel. Mothers were asked to r ate the quality of information, as well as the degree of support they recei ved for breastfeeding. Mothers also were asked to rate their hospital breas tfeeding experience. A second interview was conducted by telephone 4 weeks after birth. The focus of this interview was to ascertain the rating of the ir breastfeeding experience, the quality of their interactions with health care professionals, and whether supplemental formula was being provided to the infant. If supplemental formula was being provided, the mothers were as ked to quantify the volume and frequency of supplementation. A final teleph one interview was conducted when the infants were 8 weeks of age. This inte rview determined the continuance or cessation of breastfeeding and informat ion about formula supplementation, as in the 4- week interview. Mothers wer e given a journal and asked to note all telephone calls, clinic visits, and home nurse visits that related to breastfeeding issues and concerns. Demog raphic data examined included maternal age, marital status, highest level o f education reached, race, employment, insurance coverage, and length of st ay in the hospital. Pregnancy characteristics included prenatal care, parit y, and gravity. Infant characteristics included gestational age and birth w eight. Other factors examined included maternal rating of the support recei ved from the infant's father for the decision to breastfeed, the time the i nfant spent in the mother's hospital room, and whether the infant was breas tfed in the delivery room. Results. The women were mostly white (90%), educated (82% had some college education), married, older (mean maternal age of 29.3 years), and insured ( 92% commercial). The primary outcome of interest was success at breastfeedi ng. Success was determined based on each mother's initial estimate of the p lanned duration of breastfeeding. Of the participants, 76% breastfed succes sfully for at least as long as they had initially planned. Seventeen percen t of the mothers had stopped breastfeeding at the time of the 4-week interv iew, and 29% had stopped by the 8-week interview. Of the infants' fathers, 97% were reported by the mothers to be supportive of the decision to breast feed. Once discharged, 98% of mothers expected to have help with the househ old chores. Eighty percent rated their hospital breastfeeding experience as good or very good. However, only 56% rated hospital breastfeeding support as good or very good, and only 44% spoke with a lactation consultant while in the hospital. Of those who spoke with the lactation consultant, 85% felt more confident afterward. Hospital nurses talked with 82% of women, and 97 % of these found this helpful. Seventy-four percent reported receiving a ho me nursing visit after discharge, and of these, 82% found it helpful. Succe ssful mothers were significantly more likely to report that the visiting nu rse watched them breastfeed and asked how it was going. Mothers were more l ikely to call or visit family and friends with concerns about breastfeeding than other possible sources of support. Calls to family or friends to disc uss breastfeeding problems were made by 181 mothers (34.7%). Other calls we re to the lactation consultant (16.5%), pediatrician (8.8%), obstetrician o r midwife (8.2%), breastfeeding support group (5.9%), and birth hospital (2 .5%). Factors significantly associated with breastfeeding success were mate rnal graduate education (OR: 3.20), appraisal of the breastfeeding experien ce while in the hospital (OR: 1.49), and age (OR: 1.06). When only mothers who had a home nurse visit were included in the model, maternal graduate ed ucation (OR: 3.66), appraisal of hospital breastfeeding experience (OR: 1.4 2), and maternal rating of the home nurse visit (OR: 1.71) were significant ly associated with successful breastfeeding. Conclusion. Health system support of breastfeeding women during their hospi tal stay and early postdischarge period is an important factor in their suc cess. Hospitals should monitor closely the actual quality and quantity of c are provided by clinical support personnel and measure their impact on the outcomes on an ongoing basis.