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DOI 10.1007/s10995-016-2130-x
BRIEF REPORTS
Abstract Objectives To evaluate the impact of counseling using paired t tests. Multivariable logistic regression was
regarding the maternal health effects of lactation on preg- used to examine the impact of increases in knowledge of
nant women’s intentions to breastfeed. Methods Women MHBL on participants’ intentions to breastfeed. Results
seeking prenatal care at an urban university hospital com- The average age of the 65 participants was 24 ± 6 years.
pleted surveys before and after receiving a 5-min coun- Most (72 %) were African-American and few (9 %) had
seling intervention regarding the maternal health effects of college degrees. Half (50 %) had previously given birth,
breastfeeding. The counseling was delivered by student but few (21 %) had previously breastfed. Before counsel-
volunteers using a script and one-page infographic. Par- ing, few were aware of any benefits of lactation for
ticipants were asked the likelihood that breastfeeding maternal health. After counseling, knowledge of MHBL
affects maternal risk of multiple chronic conditions using increased (mean knowledge score improved from 19/35 to
7-point Likert scales. We compared pre/post changes in 26/35, p \ 0.001). Improvement in MHBL knowledge
individual item responses and a summary score of knowl- score was associated with increased intention to try
edge of the maternal health benefits of lactation (MHBL) breastfeeding (aOR 1.20, 95 % CI 1.02–1.42), of wanting
to breastfeed (aOR 1.45, 95 % CI 1.13–1.86), and feeling
that breastfeeding is important (aOR 1.21, 95 % CI
Poster presented at: International Society for Research in Human 1.03–1.42). Conclusions for Practice Brief structured
Milk and Lactation Conference, Oct 23-27, 2014, Kiawah Island,
counseling regarding the effects of lactation on maternal
South Carolina, USA.
health can increase awareness of the maternal health ben-
Electronic supplementary material The online version of this efits of breastfeeding and strengthen pregnant women’s
article (doi:10.1007/s10995-016-2130-x) contains supplementary intentions to breastfeed.
material, which is available to authorized users.
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Matern Child Health J (2017) 21:234–241 235
predict actual infant feeding practices, this approach to Ovarian cancer risk is also markedly reduced by lacta-
lactation counseling deserves attention and further tion. A meta-analysis of 35 studies concluded that breast-
investigation. feeding initiation and a longer duration of lactation are
What this study adds? This study demonstrates that both associated with lower risk of endothelial ovarian
highlighting the maternal health benefits of lactation when cancer (Luan et al. 2013). Autoimmune diseases, particu-
counseling mothers about infant feeding significantly larly rheumatoid arthritis, also appear less commonly
increased the strength of mothers’ intentions to breastfeed. among mothers who ever breastfed (Adab et al. 2014).
As mothers’ breastfeeding intentions have been found to Estrogen plays a key role in the development of autoim-
strongly predict actual infant feeding practices, this mune diseases, which are more common among women
approach to lactation counseling deserves attention and than men. Lactation, which lowers estrogen levels, would
further investigation. then be expected to result in immunomodulation, lowering
risk of rheumatoid arthritis among mothers who lactated.
A mother’s risk of cardiovascular disease and cardiac
Introduction death are also affected by her duration of lactation (Natland
Fagerhaug et al. 2013). This is plausible because lactation
Breastfeeding is widely recognized as playing a critical affects postpartum weight retention, and lactation has been
role in infant health and development (Ip et al. 2007). beneficially linked to multiple components of the metabolic
Unfortunately, only 22 % of US women currently adhere to syndrome, including visceral adiposity (McClure et al.
infant feeding recommendations (American Academy of 2012), diabetes (Jager et al. 2014), hyperlipidemia, and
Pediatrics Section on Breastfeeding 2012). Barriers to hypertension (Lupton et al. 2013). In addition, an animal
breastfeeding are particularly common among low income model recently demonstrated that lactation significantly
and black mothers (Chapman and Perez-Escamilla 2012), affects maternal visceral adiposity, blood pressure, and
who may face workplace challenges to pumping and stor- cardiac function (Poole et al. 2014).
ing breast milk, and lack community social support for Although many women know that breastfeeding
breastfeeding (Ware et al. 2014; Johnson et al. 2015). improves infant health outcomes (Ip et al. 2007), we
Mothers with strong prenatal intentions to breastfeed are hypothesized that informing pregnant women of the
most likely to overcome these hurdles and successfully maternal health effects of lactation would strengthen their
breastfeed (Bai et al. 2010; Donath et al. 2003; Wambach intentions to breastfeed. We therefore developed and
1997). Thus, it is important to identify counseling strate- evaluated a structured counseling intervention designed to
gies that impact pregnant women’s breastfeeding inten- inform pregnant women about the maternal health benefits
tions. Interventions are particularly needed to promote of lactation, while recognizing that lactation has downsides
strong intentions to breastfeed among poor, African- such as adverse effects on libido (Leeman and Rogers
American mothers, who face the greatest risk of barriers to 2012) and risk of mastitis.
breastfeeding (Johnson et al. 2015).
Although currently rarely discussed with pregnant
women (Demirci et al. 2013), a growing body of literature Materials and Methods
indicates that lactation plays an important role in maternal
recovery from pregnancy, and can determine multiple Women seeking prenatal care were recruited from the
aspects of maternal health in later life (Stuebe and Schwarz waiting room of an urban clinic affiliated with a large
2010). For example, since the link between breastfeeding maternity care hospital in Pittsburgh, Pennsylvania. All
and breast cancer was first hypothesized over 60 years ago women visiting the clinic were invited to participate. Par-
(Gross 1947), over 47 epidemiologic studies conducted in ticipants completed surveys before and immediately after
30 countries have linked lactation to lower rates of breast receiving a structured counseling intervention. This study
cancer (Collaborative Group on Hormonal Factors in was determined to be exempt by the University of Pitts-
Breast, C 2002). The African-American Breast Cancer burgh Institutional Review Board.
Epidemiology and Risk (AMBER) consortium, has specif- The structured counseling intervention we developed
ically examined parity, lactation, and breast cancer subtypes addressed the relationships between lactation and nine
in African-American women, and found the link between maternal conditions: diabetes, hypertension, hyperlipi-
lactation and triple-negative breast cancer to be particularly demia, heart disease, breast cancer, ovarian cancer, uterine
strong (Palmer et al. 2014). Most recently, detailed genetic cancer, rheumatoid arthritis, and postpartum weight loss.
analyses of breast cancer subtypes have indicated that breast The counseling also discussed some of the obstacles
cancer prognosis and survival are both affected by a women may face when trying to breastfeed, such as mas-
woman’s history of lactation (Kwan et al. 2015). titis and decreased libido. The structured counseling was
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delivered by student volunteers with no prior clinical participants were assumed to have a lack of knowledge;
training. Project volunteers received a 1 h orientation thus, missing data was re-coded as ‘‘1 = very unlikely to
which included guidance on how to reach an on-call clin- lower risk.’’ The scale’s internal consistency was tested
ician if women had questions after receiving the structured with Cronbach’s alpha (pre-intervention, alpha = 0.80;
counseling. The counseling script was written at a fifth post-intervention, alpha = 0.79) and indicated accept-
grade reading level and took approximately 5 min to read able scale reliability.
(Appendix 1 of ESM). Participants were given a one-page We hypothesized that women receiving the counseling
infographic (Fig. 1) to look at while listening to the intervention would increase their understanding of the
scripted counseling which was delivered one-on-one in a maternal health benefits of lactation and would report
semi-private area of the waiting room. The images that stronger intentions of trying to breastfeed, desire to
formed the infographic included an image developed in breastfeed, and feelings that breastfeeding is important.
2002 by the Ad Council designed to convey a link between Further, we hypothesized that the likelihood a woman
bottle-feeding and insulin use, and images developed reported strong intentions to breastfeed would be related
specifically for this project. both to her baseline knowledge of the maternal health
The primary outcome of interest was women’s inten- benefits of lactation as well as change in her knowledge
tions to breastfeed; to assess these intentions, we adapted a from before to after the counseling intervention. We used
validated questionnaire developed by Bai et al. The ques- t tests for paired samples to compare pre/post differences
tionnaire assesses three constructs identified by the Theory in means of individual survey items as well as
of Planned Behavior (Ajzen 2011) which may contribute to improvements in the summary score of knowledge of the
mothers’ decision-making about infant feeding (Bai et al. maternal health benefits of lactation. We then used
2011). These constructs include subjective norms (external multivariable logistic regression to examine the signifi-
pressures to perform a behavior), attitudes (internal feel- cance of the impact of increases in knowledge of the
ings regarding a behavior) and perceived behavior control maternal health benefits of lactation on participants’
(degree to which an individual feels empowered to make intentions to breastfeed, while controlling for baseline
her own decisions). The central premise of the Theory of knowledge of maternal health benefits (modeled as a
Planned Behavior is that a performed behavior’s immediate continuous variable), education (dichotomized as college
antecedent is the intention to perform that behavior. Prior educated vs. less than college educated), race/ethnicity
literature which examines this theory has shown that (dichotomized as African-American vs. others), parity
intention to breastfeed significantly increases breastfeeding (dichotomized as prior pregnancy vs none), and prior
behavior (Bai et al. 2010; Wambach 1997). experience breastfeeding (vs. none). Outcome variables
For this study, women’s intentions to breastfeed were were dichotomized into positive intentions versus nega-
assessed using a seven-category Likert scale (anchored from tive intentions to breastfeed by grouping neutral with
strongly disagree to strongly agree) for three statements: ‘‘It negative responses.
is likely that I will try to breastfeed after my baby is born,’’ ‘‘I
want to breastfeed my baby,’’ and ‘‘Breastfeeding my baby is
important.’’ Women were also asked to estimate, using a Results
seven-category Likert scale (anchored from extremely
unlikely to extremely likely), the likelihood that lactation In total, 65 women completed both pre- and post-inter-
would affect their future risk of breast cancer, ovarian can- vention surveys. Most participants were African-American
cer, diabetes, hypertension, and arthritis. In addition, women (72 %) and currently unemployed (58 %). Few participants
were asked about aspects of breastfeeding some women may (9 %) had college degrees; 81 % had high school degrees.
fear such as difficulty with weight loss, headaches, breast The average age of participating women was 24 ± 6 years
infections, and decreased libido. Questions about the benefits of age. Most (66 %) were married or in a committed
and downsides of breastfeeding were interspersed in the relationship. While half (50 %) had previously given birth,
survey instrument. The full wording of all study questions is only 21 % of all participants had previously breastfed
available in the Appendix 2 of ESM. (Table 1).
The primary predictive variable of interest was Before counseling, few women felt lactation was likely
improvement in women’s overall knowledge of the to affect maternal health (Table 2). When we calculated a
maternal health benefits of lactation. We created a sum- summary score of participants’ pre-intervention knowledge
mary score using responses to the five items for which of the maternal health benefits of lactation, we found the
lactation has a beneficial effect on maternal health: reduced mean score was 19 out of a possible 35 points. Small
risk of breast cancer, ovarian cancer, diabetes, hyperten- percentages of participants indicated that breastfeeding was
sion, and arthritis. When questions were left unanswered, ‘‘extremely likely’’ to lower risk of: breast cancer (17 %),
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ovarian cancer (11 %), diabetes (5 %), hypertension (3 %), that lactation can affect maternal health (Table 2). Post-
or rheumatoid arthritis (0 %). intervention, participants’ summary score of knowledge of
After counseling, participants showed statistically sig- the maternal health benefits of lactation had a mean of 26
nificant changes in their understanding of the likelihood out of a possible 35 points, representing a significant
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Table 1 Characteristics of study participants, n = 65 intervention survey (mean = 6.0/7, 71 % Strongly Agree)
Demographic and reproductive characteristics Number (%)
and the increase did not reach significance (p = 0.06).
(n = 65) In multivariable models, we found that increases in
knowledge of the maternal health benefits of lactation
Age (years) 24 ± 6
were significantly associated with intentions to breastfeed
Race even after controlling for other important covariates. Each
African-American 47 (72) unit increase in knowledge of the maternal health benefits
White 18 (28) of lactation corresponded to 20 % greater odds that par-
Education ticipants intended to try to breastfeed, 45 % greater odds
Less than 8th grade 2 (3) that participants wanted to breastfeed, and 21 % greater
Some high school 11 (16) odds that participants felt breastfeeding was important
High school or GED 22 (32) (Table 3).
Some college 26 (39)
College degree 6 (9)
Employment Discussion
Not employed 39 (58)
Employed, part-time 15 (22) Few of the pregnant women who participated in this study
Employed, full-time 13 (29) were initially aware of the ways lactation benefits a
Relationship status mother’s health. However, providing brief structured
Married 11 (16) counseling with a one-page infographic significantly
Committed relationship but not married 34 (50) increased awareness of the maternal health benefits of
Single 22 (33) lactation. More importantly, this structured counseling
Gestation at time of survey (weeks) 24 ± 10 significantly increased the strength of pregnant women’s
Ready to have a baby when became pregnant 29 (45) intentions to breastfeed their baby. As prior studies have
Not sure 15 (23) found that mothers with strong prenatal intentions to
Previous birth 33 (50) breastfeed most frequently manage to breastfeed (Bai et al.
Previous breastfeeding 14 (21) 2010; Donath et al. 2003; Wambach 1997), this approach
to lactation counseling has the potential to meaningfully
impact infant feeding behaviors and improve health out-
comes across two generations.
increase from the mean pre-intervention knowledge score The American College of Obstetrics and Gynecology
(p \ 0.0001). After receiving this structured counseling, identifies counseling about infant feeding as a core com-
more participants felt that breastfeeding was ‘‘extremely ponent of prenatal care (‘‘American College of Obstetri-
likely’’ to lower risk of breast cancer (69 %), ovarian cians and Gynecologists (ACOG) Committee on Health
cancer (69 %), diabetes (68 %), hypertension (48 %), and Care for Underserved Women & Committee on Obstetric
rheumatoid arthritis (50 %). No significant changes were Practice. Special report from ACOG. Breastfeeding:
seen in women’s expectations regarding an effect of lac- maternal and infant aspects’’ 2007) and recommends that
tation on headaches, libido, or weight loss (Table 2). A this guidance start at the first prenatal appointment and be
small but significant number of women learned breast reinforced and expanded on in subsequent visits. This is
infections are more common with breastfeeding. consistent with a systematic review which found that pre-
After receiving this brief structured counseling inter- natal educational interventions were more successful in
vention, there were also significant increases in the strength promoting breastfeeding than postpartum lactation support
of participants’ intentions to breastfeed (Table 2). After (Guise et al. 2003). Yet, in a recent study of initial prenatal
counseling, 73 % of participants said they were extremely visits, breastfeeding counseling was found to be infrequent
likely to try to breastfeed (mean of responses = 5.9/7, (29 % of visits) and brief (Demirci et al. 2013). This is
standard deviation (SD) = 1.9) compared to 66 % previ- unfortunate as prior studies have found that clinician
ously (mean of responses = 6.5/7, SD = 1.3); p = 0.002. counseling about breastfeeding is an important predictor of
The strength of agreement to the statements ‘‘I want to both breastfeeding initiation and continuation (Jarlenski
breastfeed’’ also showed a significant increase (p = 0.05). et al. 2014). However, clinician training on breastfeeding
The strength of agreement to the statement ‘‘Breastfeeding and lactation support is frequently incomplete (Freed et al.
my baby is important’’ also increased (Table 2), although it 1995). To this end, the scripted counseling tested in this
started at a high rate of endorsement on the pre- study may facilitate effective prenatal counseling about the
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Table 2 Women’s perceptions of the impact of breastfeeding on maternal health and breastfeeding intentions, n = 65
Pre-intervention Post-intervention Change
Mean SD Mean SD Mean SD p value*
Positive effects
Summary score of knowledge of maternal health benefits of lactationa 19.4 5.9 26.1 6.0 6.8 6.7 \0.0001
Breast cancer 4.8 1.6 6.5 1.1 1.7 1.7 \0.0001
Ovarian cancer 4.5 1.5 6.5 1.1 2.0 1.6 \0.0001
Diabetes 4.0 1.6 6.4 1.2 2.4 1.8 \0.0001
Hypertension 3.9 1.5 5.7 1.7 1.9 1.8 \0.0001
Arthritis 3.1 1.4 5.6 2.0 2.0 1.6 0.01
Potential negative effects
Difficulty losing weight 2.2 1.6 2.4 2.2 -0.3 2.4 0.36
Cause headaches 3.3 1.8 3.8 2.0 -0.5 2.0 0.06
Cause breast infections 3.4 1.9 4.1 2.1 -0.7 2.7 0.04
Lower sex drive/libido 3.3 1.7 3.6 2.0 -0.4 2.3 0.20
Breastfeeding intentions
Breastfeeding my baby is important 6.3 1.3 6.5 1.1 0.2 0.8 0.06
It is likely that I will try to breastfeed 5.9 1.9 6.5 1.3 0.6 1.4 \0.001
I want to breastfeed my baby 6.0 1.8 6.2 1.5 0.2 0.9 0.05
* p- value from paired t test
a
The summary score for the Knowledge of the Maternal Health Benefits of Lactation scale was calculated using responses to the following five
items which assessed participants knowledge that lactation lowers risk of: breast cancer, ovarian cancer, diabetes, hypertension, and arthritis on a
7-point Likert scale. The summary score has a minimum of five points (if breastfeeding was felt to be extremely unlikely to lower risk of any of
the five conditions) and a maximum score of 35 points (if breastfeeding was felt to be extremely likely to lower risk of all five conditions)
Table 3 Association between improvement in knowledge of the maternal health benefits of lactation and women’s intentions to breastfeed,
n = 65
Outcome measures
Want to breastfeed Intend to try Breastfeeding is
breastfeeding important
Adj 95 % CI Adj 95 % CI Adj 95 % CI
ORa ORa ORa
Improvement in summary score of knowledge of maternal health 1.45 1.13–1.86 1.20 1.02–1.42 1.21 1.03–1.42
benefits of lactationb
Baseline summary score of knowledge of maternal health benefits of 1.57 1.15–2.14 1.34 1.05–1.71 1.17 0.97–1.42
lactationb
Prior lactation versus none 57.62 0.92 to 3.58 0.28–45.36 2.93 0.23–36.95
[999.99
Prior birth versus nulliparous 0.06 0.01–0.62 0.09 0.01–1.20 0.30 0.04–2.47
Black versus others 1.19 0.12–12.14 5.85 0.56–60.96 12.82 0.93–175.92
College versus less educated 0.34 0.03–4.23 0.31 0.02–5.29 2.73 0.17–43.41
a
Multivariable logistic regression models adjusted for all variables shown in table
b
The summary score for the Knowledge of the Maternal Health Benefits of Lactation scale was calculated using responses to the following five
items which assessed participants knowledge that lactation lowers risk of: breast cancer, ovarian cancer, diabetes, hypertension, and arthritis on a
7-point Likert scale. The summary score has a minimum of five points (if breastfeeding was felt to be extremely unlikely to lower risk of any of
the five conditions) and a maximum score of 35 points (if breastfeeding was felt to be extremely likely to lower risk of all five conditions)
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