Stressful life events during pregnancy negatively affect maternal and infant outcomes including breastfeeding initiation. Their impact on breastfeeding duration is uncertain. Given breastfeeding's important health benefits we analyzed stressful life event types and cessation of any and exclusive breastfeeding by 4 and 13 weeks.
Optimal breastfeeding duration and exclusivity practices contribute to significant short- and long-term health benefits for both mother and baby [
Numerous factors influence breastfeeding outcomes from institutional practices to individual characteristics and actions [
The extent to which mothers experience stressful life events and how these may be related to breastfeeding outcomes is less well understood. Stressful life events known to be associated with other negative or adverse perinatal outcomes include small for gestational age infants [
To our knowledge, only one study examined whether stressful life events during pregnancy influenced breastfeeding rates [
The purpose of this analysis was to examine the association between four types of stressful life events and breastfeeding outcomes (cessation of any and exclusive breastfeeding) among low-income mothers who initiated breastfeeding.
Mothers in this study resided in an upstate New York county, with a major metropolitan city and around 8000 births annually, of which approximately 40% occur to low-income mothers. We defined low-income as mothers prenatally enrolled in a food assistance program (Women’s, Infants and Children’s Supplemental Nutrition Program, WIC) and/or with deliveries paid for by publically funded health insurance programs (i.e., Medicaid). Four urban pediatric and one family medicine practice serving primarily low-income clientele assisted with survey distribution.
Eligible mothers were at least 5 months postdelivery of a live infant with residence in the county. Other than mothers’ name and address no other demographic or contact information was provided by the practices about the mothers or index infants.
Participating practices identified all eligible mothers and provided electronic files with contact names and addresses. Survey distribution occurred through mailings to all mothers with usable addresses. The first mailing occurred between 5 and 7 months postpartum. Followup was restricted to a second mailing at 3 weeks. Telephone numbers were not provided so other types of followup were not possible. To incentivize participation, respondents were eligible to participate in a raffle.
The “You and Your Baby” Survey (YYBS) gathered surveillance data from mothers. In addition to demographics, the YYBS captured prepregnancy, prenatal, and postpartum information, using items primarily from the US Centers for Disease Control’s Pregnancy Risk Assessment Monitoring System (version 6) [
Following the first year of distribution, the YYBS included additional questions such as an adapted version of the Wagnild and Young’s resiliency scale (16 items) [
The “Moods and Feelings during Pregnancy Life Events Self Evaluation” scale started with the question “Did any of these things happen during your pregnancy or in the first month of your baby’s life?” Each of the 33 events listed included three responses: “No,” “Yes, affected me a little,” or “Yes, affected me a lot.” Using a previously published methodology [
Mothers reported if they were currently breastfeeding and if not when they stopped (based on infant age). This information was used to calculate if the mother was still breastfeeding at 4 and 13 weeks (yes/no). Mothers also reported if and when the baby was introduced to formula, other liquids cereal, or solid foods. Using this information, exclusive breastfeeding duration was calculated at 4 and 13 weeks (yes/no) with exclusivity being defined as the infant receiving only breast milk and no other liquid or solid food.
We conducted an exploratory analysis using bivariate analyses and multivariable logistic regression models utilizing mothers who initiated breastfeeding that completed the modified survey. We first analyzed the crude relationship between each of the 4 types of stress categories and cessation of any or exclusive breastfeeding (at 4 and 13 weeks). Final regression models included the exposure (one of the stress categories) and maternal variables identified through previous breastfeeding research: demographics including maternal age, race, language, education, and inner-city residence (as defined by 9 urban zip codes with elevated levels of poverty, locally referenced to as “The Crescent”) [
Over the two years, 21.0% of all eligible mothers responded (
Maternal characteristics.
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Age | |
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325, 26.3 |
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Racea | |
White | 87 (26.1) |
Black | 132 (39.6) |
Hispanic | 84 (25.2) |
Mixed and other | 30 (9.0) |
Language spoken at homea | |
English only | 238 (70.6) |
English and Spanish | 56 (16.6) |
Spanish or other only | 22 (6.5) |
Other bi-multi-lingual | 21 (6.2) |
Educationa | |
<High school | 56 (16.4) |
≥High school | 254 (74.5) |
Unknown | 31 (9.1) |
Inner-City residenceb | |
Yes | 220 (64.5) |
BF Plana | |
Less than 3 months/none | 149 (44.1) |
4+ Months | 189 (55.9) |
Parity and BF | |
First baby | 157 (46.0) |
Breastfed prior Infant—Yes | 148 (43.4) |
Breastfed prior Infant—No | 36 (10.6) |
Self-Reported depression during or right after most recent pregnancy | |
Yes | 90 (26.4) |
Prepregnancy BMIa | |
<25.0 | 152 (46.6) |
25–29.9 | 87 (26.7) |
>30.0 | 87 (26.7) |
Alcohol usea | |
Never/previous | 170 (50.1) |
Current use | 169 (49.9) |
Smokinga | |
Not now/never | 251 (74.9) |
Current use | 84 (25.1) |
Overall stress | |
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325, 2.5 |
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Financial stressc | |
Yes | 224 (65.7) |
Emotional stressd | |
Yes | 100 (29.3) |
Traumatic stresse | |
Yes | 102 (29.9) |
Partner-Associated stressf | |
Yes | 169 (49.6) |
Abbreviations: BF: breastfeeding; BMI: Body mass index.
a
bDefined using 9 urban zip codes with elevated levels of poverty.
cFinancial stress defined as answering yes to one of the following occurring during or in the month after pregnancy: big problems with money, moved to a new address.
dEmotional stress defined as answering yes to one of the following occurring during or in the month after pregnancy: family member had serious accident/illness, husband/partner had serious accident/illness, husband/partner died, friend/relative died.
eTraumatic stress defined as answering yes to one of the following occurring during or in the month after pregnancy: stayed in a shelter or needed emergency shelter, physical fights with partner/husband or someone else, husband/partner had legal trouble and/or went to jail, mother had legal trouble and/or went to jail, someone very close had a problem with drinking or drugs.
fPartner-Associated stress defined as answering yes to one of the following occurring during or in the month after pregnancy: separated from husband/partner, argued with husband/partner more often, husband/partner said he did not want pregnancy.
When broken down by the four stress categories, the most common reported life stress was financial 65.7% (
As indicated on Table
Breastfeeding cessation outcomes across maternal stress categories (
Categories of stress experienced | ||||||||
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Financiala | Emotionalb | Traumaticc | Partner-Associatedd | |||||
Yes | No | Yes | No | Yes | No | Yes | No | |
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Cessation of any BF | ||||||||
by 4 Weeks | 58 (25.9) | 16 (13.9) | 20 (20.0) | 52 (22.5) | 26 (25.5) | 46 (19.7) | 46 (27.2) | 28 (16.3) |
by 13 Weeks | 126 (56.3) | 64 (55.7) | 60 (60.0) | 125 (54.1) | 61 (59.8) | 125 (53.6) | 107 (63.3) | 83 (48.3) |
Cessation of exclusive BFe | ||||||||
by 4 Weeks | 157 (70.1) | 70 (60.9) | 70 (70.0) | 151 (65.4) | 76 (74.5) | 148 (63.5) | 121 (71.6) | 107 (62.2) |
by 13 Weeks | 191 (85.3) | 90 (78.3) | 83 (83.0) | 190 (82.3) | 95 (93.1) | 182 (78.1) | 151 (89.3) | 131 (76.2) |
Abbreviations: BF: breastfeeding.
aFinancial stress defined as answering yes to one of the following occurring during or in the month after pregnancy: big problems with money, moved to a new address. (missing data from 2 mothers).
bEmotional stress defined as answering yes to one of the following occurring during or in the month after pregnancy: family member had serious accident/illness, husband/partner had serious accident/illness, husband/partner died, friend/relative died (missing data from 10 mothers).
cTraumatic stress defined as answering yes to one of the following occurring during or in the month after pregnancy: stayed in a shelter or needed emergency shelter, physical fights with partner/husband or someone else, husband/partner had legal trouble and/or went to jail, mother had legal trouble and/or went to jail, someone very close had a problem with drinking or drugs (missing data from 6 mothers).
dPartner-Associated stress defined as answering yes to one of the following occurring during or in the month after pregnancy: separated from husband/partner, argued with husband/partner more often, husband/partner said he did not want pregnancy (missing data from 0 mothers).
eBreastfeeding exclusivity was defined as the infant receiving only breast milk and no other liquid or solid food. This calculated outcome was based on mothers self-report of length of breastfeeding (infant age when last received breastmilk) and age when the infant first received formula, other liquids cereal, or solid foods.
As shown in Table
Comparison of stress categories and breastfeeding outcomes modeling for breastfeeding cessation.
Cessation of any BF by 4 weeks | Cessation of any BF by 13 weeks | Cessation of exclusivee BF by 4 weeks | Cessation of exclusivee BF by 13 weeks | |||||
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OR (95% CI) |
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OR (95% CI) |
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OR (95% CI) |
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OR (95% CI) |
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Financial stressa |
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0.68 | 0.13 | 0.17 | ||||
Yes | 2.26 (1.16, 4.40) | 1.11 (0.68, 1.80) | 1.47 (0.89, 2.43) | 1.55 (0.32, 2.89) | ||||
Emotional stressb | 0.34 | 0.30 | 0.32 | 0.79 | ||||
Yes | 0.73 (0.38, 1.39) | 1.31 (1.79, 2.18) | 1.32 (0.77, 2.28) | 1.10 (0.56, 2.15) | ||||
Traumatic stressc | 0.29 | 0.16 |
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Yes | 1.38 (0.76, 2.48) | 1.43 (0.86, 2.36) | 1.86 (1.07, 3.25) | 3.94 (1.61, 9.61) | ||||
Partner-Associated stressd | 0.06 |
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0.10 |
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Yes | 1.73 (0.98, 3.04) | 1.82 (1.15, 2.88) | 1.50 (0.92, 2.42) | 2.80 (1.46, 5.37) |
Note: Reference is “no” for all 4 types of stress. Modeling for breastfeeding cessation. OR score 1< indicates more likely to breastfeed; OR score 1> indicates less likely to breastfeed.
Abbreviations: BF: breastfeeding.
aFinancial stress (
bEmotional stress (
cTraumatic stress (
dPartner-Associated stress (
eBreastfeeding exclusivity was defined as the infant receiving only breast milk and no other liquid or solid food. This calculated outcome was based on mothers self-report of length of breastfeeding (infant age when last received breastmilk) and age when the infant first received formula, other liquids cereal, or solid foods.
As shown in Table
Stress logistic regression for breastfeeding duration and exclusivity outcomes modeling for breastfeeding cessation.
Cessation of any BF by 4 Weeks | Cessation of any BF by 13 Weeks | Cessation of Exclusiveg BF by 4 Weeks | Cessation of Exclusiveg BF by 13 Weeks | |||||
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OR (95% CI) |
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OR (95% CI) |
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OR (95% CI) |
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OR (95% CI) |
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Financial Stressb |
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Financial Stress [No] |
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0.29 | 0.18 | 0.80 | ||||
Yes | 2.76 (1.25, 6.06) | 0.70 (0.36, 1.35) | 1.51 (0.82, 2.78) | 1.11 (0.51, 2.42) | ||||
Race/Ethnicity |
NS | NS | NS |
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Black | — | — | — | 0.21 (0.08, 0.57) | ||||
Hispanic | — | — | — | 0.41 (0.12, 1.41) | ||||
Mixed/Other | — | — | — | 0.33 (0.08, 1.39) | ||||
Education [<High School] |
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NS | NS | NS | ||||
Unknown | 4.21 (0.85, 20.83) | — | — | — | ||||
≥High School | 2.54 (1.14, 5.64) | — | — | — | ||||
Breastfeeding Plan |
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4+ Months | 2.89 (1.52, 5.50) | 6.80 (3.71, 12.46) | 4.94 (2.65, 9.24) | 10.91 (3.54, 33.66) | ||||
Depressionc [No] | NS |
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NS | NS | ||||
Yes | — | 0.38 (0.19, 0.75) | — | — | ||||
BMI [<25.0] | NS | NS |
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NS | ||||
25.0–29.0 | — | — | 1.13 (0.58, 2.18) | — | ||||
>30.0 | — | — | 0.36 (0.17, 0.77) | — | ||||
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Emotional Stressd |
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Emotional Stress [No] | 0.11 | 0.91 | 0.53 | 0.79 | ||||
Yes | 0.56 (0.27, 1.14) | 1.04 (0.54, 1.99) | 1.23 (0.65, 2.33) | 0.89 (0.38, 2.09) | ||||
Race/Ethnicity |
NS | NS | NS |
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Black | — | — | — | 0.23 (0.09, 0.61) | ||||
Hispanic | — | — | — | 0.41 (0.12, 1.45) | ||||
Mixed/Other | — | — | — | 0.26 (0.06, 1.22) | ||||
Breastfeeding Plan |
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4+ Months | 2.82 (1.48, 5.39) | 6.65 (3.60, 12.29) | 4.56 (2.44, 8.52) | 10.60 (3.45, 32.63) | ||||
Depressionc [No] | NS |
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NS | NS | ||||
Yes | — | 0.45 (0.23–0.88) | — | |||||
BMI [<25.0] | NS | NS |
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NS | ||||
25.0–29.0 | — | — | 1.03 (0.52, 2.01) | — | ||||
>30.0 | — | — | 0.37 (0.17, 0.77) | — | ||||
Alcohol Use |
NS |
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NS | NS | ||||
Current Use | — | 0.66 (0.46, 0.95) | — | — | ||||
Smoking [Never/Not Now] | NS |
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NS | NS | ||||
Current Use | — | 0.37 (0.17, 0.76) | — | — | ||||
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Traumatic Stresse |
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Traumatic Stress [No] | 0.71 | 0.61 | 0.17 |
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Yes | 1.14 (0.57, 2.27) | 0.84 (0.43, 1.64) | 1.59 (0.82, 3.12) | 2.95 (1.04, 8.38) | ||||
Mom Age | NS |
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NS | NS | ||||
Continuous | — | 1.07 (1.00, 1.13) | — | |||||
Breastfeeding Plan |
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4+ Months | 2.66 (1.41, 5.01) | 7.24 (3.92, 13.39) | 5.24 (2.78, 9.85) | 12.50 (4.03, 38.77) | ||||
Depressionc [No] | NS |
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NS | NS | ||||
Yes | — | 0.38 (0.19, 0.76) | — | — | ||||
BMI [<25.0] | NS | NS |
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NS | ||||
25.0–29.0 | — | — | 1.11 (0.57, 2.17) | — | ||||
>30.0 | — | — | 0.40 (0.19, 0.83) | — | ||||
Smoking [Never/Not Now] | NS |
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NS | NS | ||||
Current Use | — | 0.37 (0.18, 0.77) | — | — | ||||
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Partner-Associated Stressf |
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Partner-Associated |
0.11 | 0.30 | 0.79 | 0.11 | ||||
Yes | 1.71 (0.88, 3.30) | 1.37 (0.76, 2.48) | 1.08 (0.61, 1.93) | 1.92 (0.86, 4.31) | ||||
Education [<High School] |
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NS | NS | NS | ||||
Unknown | 3.89 (0.77, 19.63) | — | — | — | ||||
≥High School | 2.53 (1.14, 5.60) | — | — | — | ||||
Breastfeeding Plan |
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4+ Months | 2.84 (1.51, 5.37) | 7.39 (4.01, 13.63) | 4.84 (2.61, 9.00) | 11.46 (3.72, 35.36) | ||||
Depressionc [No] | NS |
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NS | ||||
Yes | — | 0.46 (0.24, 0.92) | 0.50 (0.25, 0.99) | — | ||||
BMI [<25.0] | NS | NS |
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NS | ||||
25.0–29.0 | — | — | 1.09 (0.57, 2.11) | — | ||||
>30.0 | — | — | 0.38 (0.18, 0.80) | — | ||||
Smoking [Never/Not Now] | NS |
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NS | NS | ||||
Current Use | — | 0.37 (0.18, 0.77) | — | — |
Note: Reference is “no” for all 4 types of stress. Modeling for breastfeeding cessation. OR score 1< indicates more likely to breastfeed; OR score 1> indicates less likely to breastfeed.
Variables Included in Model: age (continuous), race, language, education, inner-city residence, breastfeeding plan, parity and breastfeeding, depression, BMI, alcohol use, smoking.
Abbreviations: BF: Breastfeeding; NS: not significant.
aGlobal
bFinancial stress defined as answering yes to one of the following occurring during or in the month after pregnancy: big problems with money, moved to a new address.
cSelf-reported depression during or right after pregnancy.
dEmotional stress defined as answering yes to one of the following occurring during or in the month after pregnancy: family member had serious accident/illness, husband/partner had serious accident/illness, husband/partner died, friend/relative died.
eTraumatic stress defined as answering yes to one of the following occurring during or in the month after pregnancy: stayed in a shelter or needed emergency shelter, physical fights with partner/husband or someone else, husband/partner had legal trouble and/or went to jail, mother had legal trouble and/or went to jail, someone very close had a problem with drinking or drugs.
fPartner-Associated stress defined as answering yes to one of the following occurring during or in the month after pregnancy: separated from husband/partner, argued with husband/partner more often, husband/partner said he did not want pregnancy.
gBreastfeeding exclusivity was defined as the infant receiving only breast milk and no other liquid or solid food. This calculated outcome was based on mothers self-report of length of breastfeeding (infant age when last received breastmilk) and age when the infant first received formula, other liquids cereal, or solid foods.
Among low income mothers who initiated breastfeeding, those experiencing financial stress were nearly three times more likely to have stopped any breastfeeding at 4 weeks (OR = 2.76; 95% CI: 1.25, 6.06). In addition those who planned to breastfeed longer and were high school educated were also at higher risk to stop any breastfeeding by 4 weeks (OR = 2.89; 95% CI: 1.52, 5.50; OR = 2.54; 95% CI: 1.14, 5.64, resp.). Financial stress was not significantly associated with any of the other breastfeeding outcomes although BF plan remained significant as it was in all of the 16 models.
The second model that showed a significant relationship to breastfeeding outcomes was traumatic stress. It was associated with cessation of exclusive breastfeeding by 13 weeks (OR = 2.95; 95% CI: 1.04, 8.38). Mothers with longer breastfeeding plans were also at higher risk for cessation (OR = 12.50; 95% CI: 4.03, 38.77), although this should be interpreted with caution given the wide confidence interval. Traumatic stress was not significantly associated with any of the other breastfeeding outcomes.
While controlling for stress, several maternal factors were found to
For the exclusivity models, while stress was not significant at 4 weeks cessation, higher BMI (>30.0) was also protective in all but financial stress (emotional: OR = 0.37; 95% CI: 0.17, 0.77; traumatic: OR = 0.40; 95% CI: 0.19, 0.83; partner associated: OR = 0.38; 95% CI: 0.18, 0.80). Similarly being of Black race also reduced the likelihood of cessation of exclusive breastfeeding by 13 weeks in both the financial and emotional stress models (OR = 0.21; 95% CI: 0.08, 0.57; OR = 0.23; 95% CI: 0.09, 0.61).
Among a convenience sample of over 340 low-income, primarily urban-dwelling mothers who initiated breastfeeding, not surprisingly over half reported financial stress and nearly half reported partner-associated stress. Across all four types, stress was associated with earlier cessation of any and exclusive breastfeeding. Crude relationships in three of the four stress categories had at least one statistically significant association with breastfeeding cessation. Once adjusted for other maternal factors (e.g., breastfeeding plan, depression, smoking, and alcohol use), the only significant relationships with breastfeeding outcomes were for mothers reporting financial or traumatic stress. Impact of stress on breastfeeding may differ by type of stress.
Despite methodological differences, our findings are consistent with the one breastfeeding and stress analysis by Li et al. (2008). [
Other significant relationships in all four models were found with the outcome of cessation of any breastfeeding at 13 weeks. Stressed mothers who were depressed, smoked, and, for emotional stress, used alcohol were less likely to stop breastfeeding. These findings were inconsistent with other studies [
The relationship between stressful life events and depression is likely complex [
Plans for longer breastfeeding were significantly and independently associated with earlier cessation of any and exclusive breastfeeding. This differs from other studies where having a specific goal for breastfeeding (e.g., 6 months), considered a proxy for maternal self-efficacy, was associated with delayed cessation of breastfeeding [
Black mothers are commonly found to have a lower breastfeeding and exclusivity rates [
The sample used for this analysis was drawn from a convenience sample of low-income mothers. Due to the relatively small sample, we may not have adequate power to detect statistically significant relationships for some outcomes. It is possible that some of the significant relationships were spurious findings particularly if a factor was a significant predictor at 4 but not at 13 weeks or vice versa. As this was an exploratory analysis, the stress categories did not adjust for the extent to which the respondent experienced physiologic stress (e.g., elevated cortisol levels). Data used in these analyses were self-report and are subject to the biases associated with these types of data. Breastfeeding outcomes assessed within 3 years are considered reliable, and our data collection was well within that timeframe [
Not all stressful life events may have an impact on cessation of any or exclusive breastfeeding among low-income women. Impact may differ by stress type. Stress may interfere with the achievement of the mother’s breastfeeding goal. The association of depression, smoking, and alcohol use on breastfeeding cessation after adjusted for stress may indicate that breastfeeding serves as a coping mechanism. More research is needed to understand the relationship between breastfeeding plan, stress, other maternal factors, and their impact on breastfeeding outcomes.
The authors wish to acknowledge the efforts of Holly Widanka, MA, for her efforts in overseeing the survey administration process. This project was funded through a National Institutes of Health PHS Grant no. RO1-HD055191, Community Partnership for Breastfeeding Promotion and Support.