FACTS Spotlight: National Breastfeeding Month
How First-Time Mothers Can Improve Their Milk Supply – and Why They Should
By Jennifer Shuey, DO
Editor’s Note: To kick off National Breastfeeding Month, we are featuring a cross-sectional study that examines the relationship between perceived milk supply and exclusive breastfeeding during the first six months postpartum. Dr. Jennifer Shuey, a former FACTS elective student and FACTS Ambassador, summarized the study, which specifically looked at women in Indonesia. If you’re a regular reader of our blogs, don’t let your learning stop here! Our fourth and final conference session will feature a presentation on the postpartum transition period by Dr. Summer Holmes Mason. Today is the LAST day to register for the FACTS Conference to join us THIS Saturday, August 6th, either virtually or in Lancaster, PA. Sign up now!
Introduction
Breast milk is widely considered the optimal nutrition source for newborn and infant wellbeing, [1] and exclusive breastfeeding practices are particularly important to the health and wellbeing of infants. Currently, an average of just 30 to 40 percent of women exclusively breastfeed — that is, they feed their babies with breast milk only, either directly or expressed, with no additional foods. The World Health Organization (WHO) announced their goal to have 50% of mothers exclusively breastfeeding for the first six months of life by 2025. This goal is particularly oriented towards countries such as Indonesia that have seen a decrease in breastfeeding rates. In 2009, Indonesian legislation was passed mandating all babies be breastfed for the first six months exclusively, and hospitals also implemented 10 steps to successful breastfeeding, consistent with the Baby-Friendly Hospital Initiative (BFHI). Despite hospital initiatives and legislation, these rules alone did little to dispel the concerns of many mothers who perceived their milk supply was low and therefore stopped breastfeeding early.
However, perceived milk supply is a modifiable factor and can be targeted for optimal breastfeeding. Mothers who perceive their milk supply as inadequate often base this perception on more unreliable signs of adequacy, such as infant cries, as opposed to the number of wet or stool diapers. With this misperception, many delay breastfeeding and use more formula supplementation, further depleting their milk supply. Previous studies have been conducted to examine modifiable factors and identify at-risk mothers earlier. Results found the employed, the less educated, and the mothers with low confidence in breastfeeding had higher reports of perceived low milk supply. The concern of milk supply is a global problem but is even more concerning in developing countries such as Indonesia where breastfeeding is a health necessity for the infant.
Methodology
This cross-sectional study was conducted in 2015 in Yogyakarta City, Indonesia. Five health centers were selected based on low exclusive breastfeeding rates. To participate, mothers had to be at least 17-years-old, speak Indonesian, have an infant less than six months of age, have had a singleton pregnancy, and have had a baby carried to term with a birth weight over 2500 g (about 5.5 lbs). Mothers with breast surgeries, postpartum complications, NICU admission, or neonatal anomalies were excluded. To accommodate for projected scope of the study and potential incompletion, 230 mothers would be recruited to guarantee significance levels.
All participants were given a self-reported questionnaire based on the Hill and Humenick (H&H) Lactation Scale, Breastfeeding Self-Efficacy Scale (BSES) Short Form, and infants’ sucking behaviors. These forms were translated, reconciled, and back translated by a team of bilingual and native experts in breastfeeding and postpartum care. The H&H scale assesses 20 items on a 7-point Likert scale, with high scores representing a high perceived supply. The scores were then split into high-supply and low-supply groups. The BSES includes 14 items on a 5-point Likert scale, with high scores representing high levels of breastfeeding self-efficacy, and mothers were again divided into two groups, scores over 50 and under 50. Infant-sucking behaviors were divided into five groups based on infant engagement in breastfeeding; these were further divided into positive and negative behaviors. The data gathered was analyzed using t-test or ANOVA to compare perceived milk supply vs. factors that included maternal, obstetric, hospital procedures, infant factors and breastfeeding self-efficacy. To be included in the regression model, their bivariate association p-value had to be ≤0.10. The data was then analyzed through multivariate logistic regression to determine relationship between supply and practices only if their univariate logistic analysis had a p ≤ 0.10.
Results
Two hundred and thirty-seven mothers, averaging 30 years old, completed the questionnaires. Most were high school educated, not working, and Muslim. More than half the mothers were multiparous, having had a normal vaginal delivery in a hospital, where they practice rooming-in and skin-to-skin contact within one hour of birth. The average age of the infant was 2.7 months, with a weight of 3172 g (about 7 lbs). Most were girls and demonstrated positive-sucking behaviors. Only about a third of moms started breastfeeding within one hour, but two-thirds exclusively breastfed up to five months. The others practiced predominant breastfeeding, defined as receiving breast milk as the primary source of nourishment, with some additional liquids such as water or fruit juice. The average perceived milk supply was 122.4 with a standard deviation of 10. Breastfeeding efficacy had an average of 56.4, and nearly 90% of the mothers reported high breastfeeding self-efficacy.
Factors significantly associated with a mother’s perceived supply included rooming-in, skin-to-skin contact, breastfeeding self-efficacy, and infant-sucking behavior.
The mother’s age, education, employment, parity, delivery mode and location, infant’s age, gender and birth weight did not reveal any statistically significant differences between groups. All variables showed inflation factors less than 10 and tolerance values above 0.16, which indicated no multicollinearity between the variables.
Perceived milk supply and early initiation of breastfeeding were examined using logistic regression analysis. Perceived milk supply scores were divided into high and low using a cutoff of 122. The odds ratio was found to be 1.46, indicating a nearly 50% increase in the likelihood of high perceived milk supply among women initiating breastfeeding early. Cesarean delivery and skin-to-skin contact were also significantly associated with early initiation of breastfeeding.
Perceived milk supply was found to be significantly associated with exclusivity of breastfeeding, as was skin-to-skin contact. Working mothers were less likely to practice exclusive breastfeeding. The remaining factors were not significant.
Discussion
Exclusive breastfeeding is associated with many health benefits for the mother and infant. Improving exclusive breastfeeding rates is beneficial in the developed world but a necessity in regions where access to high-quality infant formula is nonexistent. Mothers who exclusively breastfeed for the first six months of a child’s life and have not experienced a return of menses may also use this method–the Lactational Amenorrhea Method–to postpone pregnancy. Both exclusive breastfeeding and spacing children provide additional health benefits for mother and infant.
Improving exclusive breastfeeding rates is beneficial in the developed world but a necessity in regions where access to high-quality infant formula is nonexistent.
The Indonesian study gives valuable insight into modifiable factors for women to encourage higher rates of exclusive breastfeeding. Studies that draw data exclusively from self-report may raise some concerns about honesty and accuracy of the participant. However, the extra care taken to translate the scales, modify for cultural appropriateness, and then back translate to ensure no meaning was lost lend credence to the questionnaire and the study.
Breastfeeding is often portrayed as natural and easy, leaving many mothers feeling ashamed to ask for help because they feel as if they are a failure as a woman and mother. This study sheds light on the fact that breastfeeding takes work and myriad factors contribute to successful breastfeeding. Although this study highlights mothers in Indonesia, first-time mothers in developed countries such as America may face similar concerns about perceived milk supply:
“How much are they getting?”
“Is it enough?”
“How long should I be breastfeeding?”
The research conducted by Sandhi et al. gives rise to a number of related research opportunities. This study could be reproduced across different cultures to identify more patterns and investigate whether or not culture makes a difference in the perceived milk supply. Highlighting comparisons between developing and developed nations may also be useful to examine the role of maternal resources on a mother’s perceived milk supply.
Lastly, as a baseline study, the exclusion of women with complications or prematurity is appropriate. However, further research on this group would be impactful; breastfeeding is arguably even more important in complicated and preterm infants.
Sources
[1] Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;8:CD003517
[2] Sandhi A, Lee GT, Chipojola R, Huda MH, Kuo S. The Relationship between Perceived Milk Supply and Exclusive Breastfeeding during the First Six Months Postpartum: a Cross-Sectional Study. Int Breastfeed J. 2020;15(65). https://doi.org/10.1186/s13006-020-00310-y
ABOUT THE AUTHOR
Jennifer Shuey, DO
Jennifer Shuey, DO is a second year family medicine resident at Resurrection in Chicago after graduating from Chicago College of Osteopathic Medicine. She recently completed 2 fertility awareness electives through FACTS to learn more about FABMs.
