JOGNN

IN REVIEW

Variables Associated With

Breastfeeding Duration
Diane Thulier and Judith Mercer

Correspondence
Diane Thulier, MS, RN,
IBCLC, University of Rhode
Island, College of Nursing, 2
Heathman Road, White Hall,
Kingston, RI 02881.
thuliers@cox.net

ABSTRACT

Keywords
breastfeeding
duration
variables

Data Extraction: Data included all variables, both positive and negative, that were found to influence the outcome of
breastfeeding duration.

Objective: To identify the variables associated with breastfeeding duration.

Data Sources: The health science reference databases of CINAHL, PubMed, and the Cochrane Database of
Systematic Reviews.
Study Selection: Meta-analyses, Cochrane reviews, literature reviews, and quantitative and qualitative studies
published in English from 1998 through 2008.

Data Synthesis: Demographic factors that influence breastfeeding duration are race, age, marital status, education,
socioeconomics, and Special Supplemental Nutrition Program for Women, Infants, and Children status. Biological
variables consisted of insufficient milk supply, infant health problems, maternal obesity, and the physical challenges of
breastfeeding, maternal smoking, parity, and method of delivery. Social variables included paid work, family support,
and professional support. Maternal intention, interest, and confidence in breastfeeding were psychological variables.
Conclusion: Human lactation is a complex phenomena and the duration of breastfeeding is influenced by many
demographic, physical, social, and psychological variables.

JOGNN, 38, 259-268; 2009. DOI: 10.1111/j.1552-6909.2009.01021.x

Accepted February 2009

Diane Thulier MS, RN,

IBCLC, is an assistant
clinical professor at the
University of Rhode Island,
College of Nursing,
Kingston, RI.
Judith Mercer, PhD, CNM,
FACNM, is a clinical
professor at the University
of Rhode Island, College of
Nursing, an adjunct
professor in the Department
of Pediatrics, Brown
University, and a research
scientist, Women and
Infants Hospital,
Providence, RI.

reastfeeding initiation rates in America are

currently higher than they have been since
the mid-20th century. Data released by the Centers
for Disease Control (CDC) in May 2008, indicated
that American infants who were ever breastfed increased to 77% among those born from the years
2005 to 2006. Therefore, the goal for the Healthy
People 2010 initiative of a 75% breastfeeding
initiation rate was met. Unfortunately, rising breastfeeding initiation rates have not been accompanied
by increased breastfeeding duration. The United
States continues to fall far below the breastfeeding
duration goal of the Healthy People 2010 initiative.
The national objective is that 50% of mothers will
be breastfeeding at 6 months and 25% will continue at 1 year. The latest statistics from the CDC
indicated that in 2004, the rate of exclusive breastfeeding at 6 months of age was 11%, and the rate of
any breastfeeding at 12 months was 20%.

In 2003, the Bellagio Child Survival Study Group

identied the promotion of exclusive breastfeeding
as one of the greatest life-saving strategies for
decreasing childhood mortality. The World Health

http://jognn.awhonn.org

Organization (WHO) (2002) recommended that infants be exclusively breastfed for the rst 6 months
and that breastfeeding continue into the second
year of life or longer. In 2005, the American Academy of Pediatrics issued its policy statement on
Breastfeeding and the Use of Human Milk (Gartner
et al., 2005). The Academy recommended that
breastfeeding be continued for at least the rst year
of life; continuing thereafter for as long as desired by
mother and child.
Anyone who works closely with new mothers and
infants recognizes the many complexities associated with infant feeding. Human lactation is not
strictly physiological ; social and emotional factors
play a role in how it is conducted. To reach the CDC
and WHO goals for duration of breastfeeding,
nurses and other allied health workers must recognize and use the variables associated with
breastfeeding duration to guide the care oered
to women and their families. It is also critical for
researchers to focus on early breastfeeding cessation in order to establish evidence-based practices
that will support prolonged duration.

& 2009 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses

259

IN REVIEW

Breastfeeding Duration

Breastfeeding initiation rates have greatly improved in the

United States, but duration of breastfeeding remains far
below national goals.

The purpose of this review was to identify variables

associated with breastfeeding duration. The criteria
for inclusion were English language articles that
were obtained from the health science reference
databases of CINAHL, PubMed, and the Cochrane
Database of Systematic Reviews. The key words
used in identifying these articles were breastfeeding, duration, and variables. Publications were
limited to the past 10 years, from 1998 through
2008. A variety of works were reviewed, including
quantitative and qualitative studies, Cochrane
reviews, and meta-analysis. In order to accurately
identify all of the variables, several literature reviews
relating directly to the topic of breastfeeding duration were included. National and international
publications were utilized, including works from
North and South America, Europe, Asia, Australia,
and the Middle East. Publications were limited to
those in which the authors intent was to identify or
explore one or more variables associated with
breastfeeding duration.
A comprehensive review of the literature identied
multiple variables that inuence breastfeeding duration. These variables were categorized into four
groups: demographic, biological, social, and psychological.

Demographic Variables
Demographic variables that may inuence breastfeeding duration are well established and include
race, maternal age, marital status, level of education, socioeconomic status, and eects of the

Special Supplemental Nutrition Program

Women, Infants, and Children (WIC) (Table 1).

for

According to Augstein (1996), race is dened as

a local geographic or global human population
distinguished as a more or less distinct group by genetically transmitted physical characteristics. There
is wide variation in breastfeeding practices and duration among women of dierent races. In 2004, the
CDC released data that showed that breastfeeding
rates at 6 months were highest among Asian women
(16.1%), White (11.7%), Hispanic (11.6%), and lowest
among Black women (7.9%). Forste, Weiss, and
Lippincott (2001) analyzed data from the National
Survey of Family Growth for 1995. This information
was collected by the CDC and included a national
sample of 1,088 women of childbearing age. Researchers found that race remained a strong
predictor of breastfeeding, and that Black women
were less likely to breastfeed than non-Black women. Forste et al. suggested that breastfeeding
is as important as low birth weight when accounting for the race dierence in infant mortality in
the United States. Despite the inuence of race,
Loiselle, Semenic, Cote, Lapointe, and Gendron
(2001) demonstrated that migration from one country to another may inuence breastfeeding duration. Hispanic immigrants have been found more
likely to breastfeed compared with their U.S.-born
counterparts (Harley, Stamm, & Eskenazi, 2007).
According to Gibson-Davis and Brooks-Gunn
(2006), every year of U.S. residency for these women decreased the odds of breastfeeding by 4%.
Maternal age is a strong demographic variable
that inuences breastfeeding duration. Evers,
Doran, and Schellenberg (1998) completed a study
to determine the inuences on breastfeeding
rates in communities in Ontario, Canada. Their data
revealed a positive association between breast-

Table 1: Variables That May Affect Breastfeeding Duration

Demographic Variables

Biological Variables

Social Variables

Psychological Variables

Race

Insucient milk Supply

Maternal work

Prenatal maternal intention

Age

Infant health problems

Support from signicant others

Maternal interest

Marital status

Maternal obesity

Inconsistent professional support

Maternal condence

Level of education

Physical challenges

Appropriate professional support

Socioeconomic Status

Maternal smoking

WIC status

Parity
Method of delivery

Note. WIC 5 Special Supplemental Nutrition Program for Women, Infants, and Children.

260

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IN REVIEW

Thulier, D. and Mercer, J.

feeding duration and maternal age. Information

from a comprehensive literature review that included multivariate analysis of data on breastfeeding initiation and duration also demonstrated
a strong and consistent association between duration of breastfeeding and maternal age (Scott &
Binns, 1999). More recently, Dubois and Girard
(2003) conducted a longitudinal study in Quebec
exploring the social inequalities that occurred in infant feeding during the rst year of life. Their work,
along with results of a previous study by Kuan et al.
(1999), suggested that maternal age is a predominant determinant of breastfeeding duration.
Marital status is another demographic variable
that inuences breastfeeding duration. Data from
research studies have shown that breastfeeding
occurs more frequently among married women
and that married women breastfeed for longer periods of time (Evers et al., 1998; Kuan et al., 1999;
Li, Ogden, Ballew, Gillespie, & Grummer-Strawn,
2002). Callen and Pinelli (2004) completed a comparative literature review of studies published
between 1990 and 2000. They compared the dierences in the incidence and duration of breastfeeding across Canada, the United States, Europe,
and Australia. They consistently found that married
women had a higher incidence and duration of
breastfeeding (Callen & Pinelli).
Researchers have also shown that educated women breastfeed more often and for longer periods
of time (Scott & Binns,1999; Susin et al.,1999). Hass
et al. (2006) completed an anonymous crosssectional survey of 934 women from a U.S. military
health care facility to assess factors associated with
breastfeeding rates and to determine those factors
contributing to successful breastfeeding duration.
Their data suggested that educated women breastfed for signicantly longer than less-educated
women. This variable has remained a constant
in breastfeeding studies (Hornell, Aarts, Kylber,
Hofvander, & Gebre-Medhin, 1999; Simard et al.,
2005).
Research data have shown that women from
lower socioeconomic groups have decreased incidence and duration of breastfeeding (Coulibaly,
Seguin, Zunzunegui, & Gauvin, 2006). Early cessation of breastfeeding has been more common
among low-income women (Dennis, 2003). Other
researchers have suggested that these results are
not absolute. Evers et al. (1998) found that lowincome women from Ontario who were successful
at breastfeeding possessed characteristics similar
to their more auent counterparts ; they were mar-

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ried, better educated, and more likely to attend

prenatal classes.
Another variable for women of lower socioeconomic status that cannot be overlooked is the
eects of the WIC program. Established in 1974,
this program provides federal grants to states for
supplemental foods, health care referrals, and
nutrition education. Those eligible for benets include low-income women, infants, and children
found to be at nutritional risk. Although breastfeeding rates among women enrolled in WIC have
increased through the years, these increases have
corresponded with increases in breastfeeding in
the general population. Breastfeeding initiation
and duration rates of WIC participants continue to
lag behind those of nonparticipants. Ryan and
Zhou (2006) compared rates of breastfeeding between women who participated in WIC and those
who did not from 1978 to 2003. Data were collected
using the Ross Laboratories Mothers Survey and
included mothers from all geographic areas and
demographic subgroups. Analysis revealed that
for mothers of infants 6 months of age, WIC status
was the strongest negative determinant of breastfeeding. Mothers not enrolled in the WIC program
were more than twice as likely to breastfeed at 6
months of age than mothers who participated in
WIC (Ryan & Zhou). Li, Darling, Maurice, Barker,
and Grummer-Strawn (2005) also reported that
breastfeeding was more common among infants
from families who were income eligible for WIC but
not enrolled. Free samples and the distribution of
formula may have a negative eect on breastfeeding initiation and duration, yet these items continue
to be distributed by WIC along with breastfeeding
advice.

Biological Variables
Biological variables that may inuence breastfeeding duration outcomes include insucient milk
supply, infant health problems, maternal obesity,
the physical challenges of breastfeeding, maternal
smoking, parity, and vaginal or Cesarean delivery
(Table 1). These issues are present in varying
degrees among all populations of women.
In an integrative literature review, Wambach et al.
(2005) summarized the major ndings of research
investigations associated with initiation and duration of breastfeeding. They found that women
reported insucient milk supply as the most common reason for weaning. In a study of pacier use
by breastfeeding mothers, Binns and Scott (2002)
suggested that insucient supply is a complex

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Breastfeeding Duration

Variables affecting breastfeeding duration are

demographic, biological, social, and psychological
in nature.
problem that crosses international, cultural, and
socioeconomic lines. There is little doubt that the
perception of inadequate supply occurs much more
often than the actual problem. Insucient milk supply, either real or perceived, is described as a
mother feeling that her milk supply is inadequate to
either satisfy her infants hunger or support adequate weight gain (Hill & Humenick, 1989). The
problem of insucient milk supply can be related
to primary or secondary causes. A primary inability
to fully lactate is related to anatomic breast abnormalities or hormonal aberration. These problems
may aect up to 5% of women. Secondary causes
of inadequate milk production are associated with
problems in breastfeeding management and are
much more common (Neifert, 2001).
In response to inadequate supply, mothers most
often provide supplementary formula or food. In
clinical studies, early formula supplementation has
unequivocally been associated with shorter duration of breastfeeding (Li, Zhang, Scott, & Binns,
2004; Simard et al., 2005). Bronner et al. (1999) suggested that a signicant relationship existed
between late introduction of solid foods and longer
duration of breastfeeding. In their study of breastfeeding duration, Ekstrom, Widstrom, and Nissen
(2003) noted that supplementation for medical reasons had no signicant inuence on breastfeeding
duration, but that supplementation without medical
reasons was negatively associated with a shorter
duration of exclusive breastfeeding. Despite the fact
that insucient supply has been identied as the
number one reason for early weaning, clinical trials
with the primary aim of preventing or treating
insucient milk have not been conducted (Wambach et al., 2005).
Signicant infant health problems can cause obvious breastfeeding diculties. For women whose
infants are in a neonatal intensive care unit (NICU),
lack of knowledge about the importance of human
milk, emotional distress, physical separation from
their infants, and the stressful NICU environment
can create multiple breastfeeding problems (Gonzalez et al., 2008). In a study of breastfeeding rates in
a U.S. NICU, Merewood, Philipp, Chawla, and Cimo
(2003) found that for some parents, lack of medical
insurance for breast pumps and diculty maintaining contact with hospitalized infants did present
extra barriers for women. In their study of lactation

262

support services, Gonzalez et al. indicated that

without adequate guidance and support, some
mothers of infants admitted to the NICU have felt
discouraged from providing their own milk to their
infants. It is these compromised, premature, and
high-risk infants to whom the benets of human
milk are of particular importance (Schanler, 2001).
Maternal obesity has been increasing worldwide
among women in their reproductive years (Linne,
2004). Baker, Michaelsen, Sorensen, and Rasmussen (2007) were able to demonstrate an
association between women with high prepregnant
body mass index and the early termination of
breastfeeding. In a study of maternal obesity before
conception, Rasmussen (2007) theorized that
excess maternal adiposity may interfere with the development of the mammary glands. Diculty
breastfeeding could also be related to hormonal
and metabolic abnormalities associated with excess maternal adiposity, resulting in a delay in the
onset of copious milk secretion (Rasmussen). In addition to these concerns, the increased size of the
breast or nipple often causes infants of obese women to have physical diculty latching onto the
breast. Linne studied the eects of obesity on womens reproduction and found that obese women
have a higher risk of complications during pregnancy, such as hypertension and gestational
diabetes, and delivery complications, such as higher rates of Cesarean deliveries and prolonged
delivery.
Breastfeeding diculties can occur as a result of
preterm birth or birth of a large baby (Rasmussen,
2007). The risk of preterm birth, shoulder dystocia,
and macrosomia rises progressively with the severity of maternal obesity (Cedergren, 2004). Baeten,
Bukusi, and Lambe (2001) studied the pregnancy
outcomes of obese women and found that infants
of obese women were susceptible to increased congenital abnormalities, head trauma, fractures of
the clavicle, and brachial plexus lesions, all of
which can interfere with an infants ability to breastfeed eectively.
For some women, the physical challenges of
breastfeeding negatively aect duration. Too often,
women assume breastfeeding is an innate skill and
are surprised by the associated pain and diculty
(Gatrell, 2007). Throughout the literature, women
have reported that discomfort and disruption
caused by sore nipples, engorgement, mastitis,
and plugged ducts are reasons for initiating weaning (Simard et al., 2005; Wambach et al., 2005).
Scott, Binns, Oddy, and Graham (2006) found that

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Thulier, D. and Mercer, J.

women who experienced diculties with breastfeeding at or before 4 weeks postpartum were
much more likely to wean before 6 months. A research study by Dykes, Moran, Burt, and Edwards
(2003) also showed that maternal sleep interruptions and fatigue could lead to weaning for some
women.
Maternal smoking has been negatively associated
with breastfeeding duration. Simard et al. (2005)
studied the factors that inuence the duration of
breastfeeding among women from the Canada Prenatal Nutrition Program. They found that smoking in
the postpartum period was associated with an 8
weeks shorter breastfeeding period. Interestingly, it
was only women who smoked continuously through
their pregnancy and postpartum that were most at
risk for early weaning. Liu, Rosenberg, and Sandoval
(2006) collected data from the Oregon Pregnancy
Risk Assessment Monitoring System during 2000
and 2001. A stratied, systematic random sample of
3,881 mothers participated in their study. Their results
also demonstrated that for women who quit or who
relapsed in the postpartum period, the risk of early
weaning did not signicantly dier from that of nonsmokers. Data from a previous study by Ratner,
Johnson, and Bottor (1999) demonstrated the
same results. Scott et al. (2006) found smoking to
be strongly associated with the discontinuation of
breastfeeding by 10 weeks.
There have been numerous studies on the relationship between parity and breastfeeding duration.
Some researchers have reported a longer duration
of breastfeeding with increased parity (Simard et al.,
2005). Hass et al. (2006) found that prior breastfeeding experience was a predictor of continued
breastfeeding at 6 weeks postpartum. In the Third
National Health and Nutrition Examination Survey,
Li et al. (2002) concluded that while multiparous
women were less likely to initiate breastfeeding,
they were more likely to breastfeed for a longer duration. Other work has failed to show a signicant
association between increased parity and duration
(Adams, Beger, Conning, Cruikshank, & Dore, 2001).
Findings about the relationship between route of
delivery and breastfeeding outcomes have changed over time. During the 1980s and 1990s,
researchers concluded that delivering by Cesarean
could delay a woman from putting her baby to
breast or interfere with her even attempting to nurse
(Chen, Nommsen-Rivers, Dewey, & Lonnerdal,1998;
Da Vanzo, Starbird, & Leibowitz, 1990; Samuels,
Margen, & Schoen, 1985). Data from a study by
Shawky and Abalkhail (2003) showed a negative

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relationship between Cesarean delivery, breastfeeding success, and duration. Other data have
suggested that a negative association exists
between Cesarean delivery and breastfeeding initiation, but not duration once breastfeeding has
started (Dennis, 2003). Scott, Landers, Hughes,
and Binns (2001) conducted a prospective cohort
study of 1,059 women to identify determinants of the
initiation and duration of breastfeeding among
Australian women. They found no correlation between route of delivery and breastfeeding. Women
who delivered by Cesarean in Australia were actually more likely to breastfeed for longer periods
than were women who had delivered vaginally. According to Li et al. (2004), women who had
a Cesarean delivery stayed longer in the hospital,
giving them more access to information and encouragement about breastfeeding from hospital
sta. Currently more than 30% of U.S. women deliver by Cesarean, therefore, more studies are
needed to determine the relationships between
route of delivery and breastfeeding outcomes.

Social Variables
Social variables are also important to consider
when studying breastfeeding duration, and relate
to interactions, attitudes, behaviors, and relationships that occur between people. The social
variables in this review included maternal work outside the home, number of working hours per week,
breastfeeding support from the signicant other,
maternal grandmother and close friends, and
inconsistent and appropriate support from health
care professionals.
Maternal work outside the home is a critical variable
with a potentially strong inuence on breastfeeding
duration. In a study that focused on early maternal
employment and child health and development in
the United States, Berger, Hill, and Waldfogel
(2005) showed that many mothers cease nursing
once they return to paid work, and other research
results conrmed a negative correlation between
working and breastfeeding (Rea & Morrow, 2004).
Scott et al. (2006) determined that women who returned to work before 6 months were less likely to
be fully breastfeeding at 6 months and less likely to
be still breastfeeding at 12 months. Additionally, the
amount of time a woman spends at work decidedly
aects nursing. Women working full time demonstrated a marked decrease in breastfeeding
duration (Taveras et al., 2003).
Researchers have shown that breastfeeding mothers miss less work than mothers who feed their

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Breastfeeding Duration

infants formula (Ball & Bennett, 2001; Celiac Sprue

Association, 2008). However, women reported that
they faced hostility if they breastfed their infants or
expressed milk in the workplace (McKinlay & Hyde,
2004). In a recent study, Gatrell (2007) indicated
that mothers who attempt to combine breastfeeding with paid work continue to do so with diculty.
As of 2008, 20 states had laws related to breastfeeding in the workplace (National Conference of
State Legislatures, 2008). The proposed Pregnancy
Discrimination Act Amendments of 2005 contained
provisions that would amend Title VII of the Civil
Rights Act of 1964. It would protect breastfeeding in
the workplace by providing tax incentives to employers for encouraging breastfeeding and provide
a performance standard for available breast pumps
(Congressional Research Report for Congress,
2008).
Support from signicant others is another factor
that contributes to breastfeeding success (Gill, Reifsnider, & Lucke, 2007). In a cohort study by Scott et
al. (2006), researchers identied positive associations between a fathers knowledge, attitudes, and
support and the likelihood of breastfeeding continuation. A controlled trial of 280 mothers and their
partners in Naples, Italy, was conducted to determine whether educating fathers to recognize the
relevance of their role in the success of breastfeeding would result in more women initiating
breastfeeding and improved duration (Pisacane,
Continisio, Aldinucci, DAmora, & Continisio, 2005).
Pisacane et al. found that teaching fathers how to
prevent and manage the most common lactation
diculties was associated with higher rates of full
breastfeeding at 6 months. Most of the research on
family relationships and breastfeeding, however,
has focused on fathers attitudes toward breastfeeding, not on the couples relationship or family
roles.
Sullivan, Leathers, and Kelley (2004) investigated
the association between relationship characteristics and parental gender roles with duration of
breastfeeding among a cohort of 115 American women. They found that high relationship distress is
predictive of early breastfeeding cessation. Women
who stopped breastfeeding before 4 months
postpartum reported signicantly greater relationship distress than did women who continued to
breastfeed. Distress in the couples relationship
undermined the mothers ability to attend to the demands of nursing. Mothers who reported that they
were solely responsible for many household tasks
were also more likely than are other women to
cease breastfeeding (Sullivan et al.).

264

For many women, social inuences extend

beyond the father to the maternal grandmother
and close friends. These groups have the potential
to inuence womens feeding choices (Scott et al.,
2006). Rempel (2004) conducted a longitudinal
study of 80 mothers who were breastfeeding at
9 months postpartum to understand determinants
of mothers decisions regarding long-term breastfeeding duration. Results indicated that in spite
of considerable support for breastfeeding in
the rst few months of life, all too frequently, the
longer mothers continue to breastfeed, the less
support they perceived from others for breastfeeding (Rempel).
In research studies worldwide, mothers have reported that inconsistent professional support has
a negative inuence on their breastfeeding eorts
(Hall & Hauck, 2006; Nelson, 2007). In exploring
the risk factors associated with breastfeeding duration, Taveras et al. (2003) reported that a lack of
skilled professional support was associated with
decreased breastfeeding duration. Many health
professionals are inadequately prepared to provide
prenatal education, perinatal support, and postpartum follow-up for breastfeeding women
(Wambach et al., 2005). Miracle, Meier, and Bennett
(2004) examined mothers decisions to change from
formula to mothers milk for very low birth weight infants. They found that at times, caregivers were
reluctant to encourage mothers to initiate or continue to breastfeed for fear of making mothers feel
guilty or coerced.
Nelson (2007) completed a study that investigated
maternal newborn nurses and their experiences
with breastfeeding women. Nurses in this study
reported that inconsistencies in care were often
related to a need for buy in of the newest recommendations, maternal need for individualized
support, and time constraints. Moreover, personal
and professional experiences signicantly inuenced professional behavior (Nelson). In a longitudinal survey of 1,620 U.S. women, DiGirolamo,
Grummer-Strawn, and Fein (2003) assessed the
perceived attitudes of health providers regarding
breastfeeding and the relationship of these attitudes to womens breastfeeding experiences. Results showed that even a perceived neutral attitude
toward breastfeeding from the hospital sta was
related to not breastfeeding beyond 6 weeks, especially among mothers who only intended to
breastfeed for a short time.
It has been suggested that prenatal education
about breastfeeding can prolong feeding duration.

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Dyson, McCormick, and Renfrew (2005) completed

a Cochrane review to evaluate the eectiveness of
interventions used to encourage women to breastfeed. A total of seven randomized-controlled trials
of breastfeeding promotion interventions involving
1,388 women were analyzed. The evidence showed
that prenatal education has had notable eects
on increasing breastfeeding initiation rates. Yet, in
another study of the eects of support on the initiation and duration of breastfeeding, data showed
that increased prenatal education did not necessarily translate into increased breastfeeding
duration (Gill et al., 2007).
Once breastfeeding has been initiated, professional
support can improve duration. In a study focused
on the antecedents of breastfeeding duration, Perez-Escamilla, Cobas, Balcazar, and Benin (1999)
specied that early supportive postpartum experiences in the hospital and during the rst 2 weeks
postpartum have been associated with increased
duration and length of exclusivity. Home visits from
a public health nurse soon after birth have also
been shown to prolong lactation (Gill et al., 2007;
Kang, Song, Hyun, & Kim, 2005). Britton, McCormick, Renfrew, Wade, and King (2007) conducted a
Cochrane review of randomized-controlled trials
that compared extra support for breastfeeding
mothers with usual maternity care. A total of 34 trials from 14 countries (29,385 mother-infant pairs)
were included in this review. The authors found that
appropriate professional support resulted in considerable improvements in breastfeeding duration.
Murray, Ricketts, and Dellaport (2006) calculated
breastfeeding duration rates for all Colorado mothers during 2002 to 2003. Duration rates for
recipients of baby-friendly hospital practices were
compared with rates for the nonrecipients of these
hospital practices. Results showed that duration
could be signicantly improved when mothers experienced several specic hospital practices of the
10 steps to successful breastfeeding: nursing within
the rst hour, providing breast milk only, infant
rooming-in, no pacier use, and referral to support
after discharge. In Switzerland, Merten, Dratva, and
Ackermann-Liebrich (2005) completed a random
sample of 2,861 mothers between April and
September 2003 to analyze the inuence of compliance with UNICEF guidelines on breastfeeding
duration. Similar to the U.S. studies, they found that
children born in baby-friendly health facilities were
more likely to have longer breastfeeding duration.
Thus, studies on duration of breastfeeding need to
monitor the quality and quantity of professional
support mothers receive, including whether or not
the birth environment actively supports the breast-

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Nurses and allied health workers must offer childbearing

women and their families appropriate and consistent
breastfeeding support during the prenatal, antenatal, and
postnatal periods.

feeding maternal-infant dyad through evidencedbased practice.

Psychological Variables
Several psychological variables are associated
with breastfeeding duration, including prenatal
maternal intention, interest in breastfeeding, and
maternal condence in ability to breastfeed. In their
study of psychosocial factors on the duration of
breastfeeding, Kronborg and Vaeth (2004) found
that positive intent, attitudes, and beliefs all increased breastfeeding duration. In an Australian
study to determine the factors associated with
breastfeeding at 6 months postpartum, Forster,
McLachlan, and Lumley (2006) reported that
prenatal maternal intention and interest in breastfeeding were the most important determining
factors that inuenced the success of breastfeeding. Other research results have been similar; Scott
et al. (2006) suggested that maternal infant feeding
attitude was a stronger independent predictor
of breastfeeding initiation than sociodemographic
factors. In an evaluation of predictors of continued
breastfeeding, higher risk of breastfeeding termination was associated with shorter intended
breastfeeding duration (DiGirolamo, Thompson,
Martorell, Fein, & Grummmer-Strawn, 2005). NoelWeiss, Rupp, Cragg, Bassett, and Woodend (2006)
completed a randomized-controlled trial in a large
tertiary hospital in Ontario, Canada. Results indicated that maternal condence in ability to
breastfeed correlated positively with breastfeeding duration. Over time, study data have shown
the same results: women at risk for premature
cessation decided to breastfeed later in their pregnancies, demonstrated negative attitudes toward
breastfeeding and positive attitudes about bottlefeeding, and had low condence in their ability
to breastfeed (Avery, Duckett, Dodgson, Savik, &
Henly,1998; Dennis, 2003).

Discussion
Breastfeeding initiation rates in America are currently 77%, higher than they have been since the
mid-20th century. The United States has met the
Healthy People 2010 initiative goal of a 75% breastfeeding initiation rate. Much research has focused
on improving this initiation rate with good results.

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This success, however, should not mask the reality

that rising initiation rates have not been accompanied by increased breastfeeding duration. Although
every infant benets from some breastfeeding,
gains are limited for those who are breastfed only a
few short days or weeks. In the United States,11% of
infants are breastfed exclusively at 6 months of age,
but it is not likely that the duration goal of 50%
breastfeeding at 6 months will be met by 2010. Contributing to this problem are the many variables
associated with breastfeeding duration, categorized in this review as demographic, biological,
social, and psychological.
The identication of variables related to breastfeeding duration provides many implications for
clinical practice. These variables must be recognized and understood as having the potential to
inuence breastfeeding practice. Health care providers can use this information to better identify
and target those at risk for early breastfeeding cessation, specically young, single, less-educated
women of low socioeconomic status. Interventions
can be designed that specically target women in
high-risk groups, for example Hispanic and Black
women. Peer counselor programs are an excellent
example of this type of care. Research studies that
focus on exploring ethnic inuences can also provide valuable insights regarding interventions that
may improve breastfeeding duration.
Biological variables such as obesity and maternal
smoking can be directly inuenced by health care
professionals. Women of childbearing age should
be counseled regarding weight loss and smoking
cessation. Nurses must convey to women how
these health promotion activities can positively inuence future breastfeeding experiences. Other
biological variables that inuence breastfeeding
duration include real or perceived inadequacies in
milk supply and the physical challenges of breastfeeding. Education about the process of
breastfeeding and breast milk production as well
as proper management of breastfeeding can help
to prevent both real and perceived inadequacies in
milk supplies. Baby-friendly hospital practices
should be embraced by health care administrators
and providers, and the 10 steps to successful
breastfeeding become the standard of care in facilities that manage the care of childbearing women.
These steps, some of which include advocating for
mothers to breastfeed during the rst hour after
birth, encouraging rooming in, and advising women
to avoid unnecessary supplementation for their infants, are interventions that nurses can implement
that will help women successfully breastfeed.

266

As noted, the social variables that inuence breastfeeding duration are maternal work, support from
signicant others, and professional support. Advocates of breastfeeding are encouraged to work with
their legislators to create and promote laws that
protect the rights of breastfeeding women nationwide and at state and local levels. The public must
be educated not only about the health benets for
women and infants but also regarding the environmental and economic benets of breastfeeding for
all of society. Health care workers must provide direct education and support not only to women but
also to womens signicant others. Most importantly, nurses and allied health workers must oer
childbearing women and their familys consistent
professional support during the prenatal, antenatal,
and postnatal periods. It is during these times, particularly during the postpartum period, when
professional support so vital to breastfeeding
success must be provided.
Finally, prenatal maternal intention, interest in
breastfeeding, and maternal condence are
psychological variables found to inuence breastfeeding duration. Appropriate professional support
can assist women who are coping with infant health
problems, or who lack condence in their ability
to breastfeed. In keeping with the 10 steps to successful breastfeeding, health care workers should
foster the establishment of breastfeeding support
groups and encourage mothers to attend. Nurses
must always be aware of the power they have, both
positively and negatively to inuence breastfeeding women and aect the outcomes of their
breastfeeding experiences. They must also keep
in mind that ambivalence or lack of support
from health care providers may result in a shorter
duration of breastfeeding for women and their
infants.

Conclusion
Human lactation is a complex phenomenon inuenced by factors that are demographic, biological,
social, and psychological. Identifying variables associated with breastfeeding duration provides
information and references for nurses and others
interested in prolonging breastfeeding experiences
for women and their infants. Recognizing these
variables can guide the interventions that are provided by nurses and health care workers. This
information may also be used to generate studies
that focus on early breastfeeding cessation and
seek to establish evidence-based interventions for
practice. The variables related to duration must be
acknowledged in breastfeeding research as they

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IN REVIEW

Thulier, D. and Mercer, J.

have the ability to inuence study results. It is the

hope of these authors that this information will be
useful to all those working to promote and prolong
successful breastfeeding experiences.

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