Association Between Method of Delivery and Exclusive Breastfeeding at Hospital Discharge

David Kling; Zelalem T. Haile; John Francescon; Ilana Chertok

doi:10.7556/jaoa.2016.087

Abstract

Context: Studies have shown that exclusive breastfeeding at hospital discharge is associated with longer duration of breastfeeding. Method of delivery (MOD) is a barrier that may hinder breastfeeding practices. However, research examining the association between MOD and exclusive breastfeeding at hospital discharge is lacking.

Objective: To examine the association between MOD and exclusive breastfeeding at hospital discharge.

Methods: We used a cross-sectional study design to conduct a secondary data analysis of 1494 women who participated in the Infant Feeding Practices Study II between 2005 and 2007. Multiple logistic regression was conducted to estimate the OR and 95% CI for the association between MOD and exclusive breastfeeding at hospital discharge, after adjusting for potential confounding variables.

Results: The crude prevalence rates of vaginal delivery and cesarean delivery were 74.8% and 25.2%, respectively. The prevalence of exclusive breastfeeding at hospital discharge was 70.6% among respondents who gave birth by cesarean delivery compared with 79.9% of women who gave birth vaginally (P=.001). After adjusting for sociodemographic, behavioral, and anthropometric factors, the odds of exclusive breastfeeding at hospital discharge were lower among women who gave birth by cesarean delivery compared with women who gave birth vaginally (OR, 0.41; 95% CI, 0.24-0.71).

Conclusion: Women who give birth by cesarean delivery may require additional attention, assistance, and encouragement during their hospital stay to improve rates of exclusive breastfeeding at discharge. Health care professionals should address the issue of MOD when promoting exclusive breastfeeding to maximize the potential for longer-term breastfeeding success.

Cesarean delivery is typically indicated as a method of delivery (MOD) when it is considered safer than vaginal delivery. Although the World Health Organization recommends a 10% to 15% cesarean delivery rate, most countries exceed the recommendation.^1,2 Since the late 1990s, the rate of elective cesarean deliveries has increased worldwide, mainly to avoid damage to the pelvic floor.³ The cesarean delivery rate in the United States increased from 20.7% in 1996 to 32.9% in 2009; however, this rate has declined slightly from 32.9% in 2009 to 32.7% in 2013.^1,4 The high rates of cesarean deliveries in the United States highlight the importance for health care professionals and pregnant women to understand the possible effects of the operation, including breastfeeding practices. Although medically indicated cesarean deliveries can be lifesaving for the mother and newborn, several studies have shown complications and negative health outcomes associated with this MOD.^5-7

The World Health Organization recommends that newborns and infants be exclusively breastfed for the first 6 months, with continued breastfeeding for at least 12 months.⁸ A 2007 review examining breastfeeding and maternal and infant health outcomes in developed countries found a substantial association between breastfeeding and reduced risk of many diseases in mothers and infants.⁹ The benefits of breastfeeding have been widely studied and include notable declines in childhood obesity,¹⁰ hypertension, type 2 diabetes mellitus, and high cholesterol, as well as increased rate of brain development.^9,11 Also, in a 2010 study, mothers who exclusively breastfed at hospital discharge were more likely to continue breastfeeding.¹²

To our knowledge, few studies have examined the association between MOD and breastfeeding in the United States. Previous studies that examined this association have reported contradicting results.^13-16 Systematic reviews^11,13 have found a substantial delay in initiating breastfeeding when mothers have cesarean delivery compared with mothers who deliver vaginally. Other studies have found no statistically significant association between MOD and breastfeeding initiation.^10,12 None of these studies^10-13 examined the association between MOD and exclusive breastfeeding at hospital discharge. In this context, we examined the association between MOD and exclusively breastfeeding at hospital discharge after adjusting for potential confounders.

Methods

We used data from the Infant Feeding Practices Study II (IFPS II)¹⁷ that was collected by the Centers for Disease Control and Prevention and the US Food and Drug Administration between 2005 and 2007. In the IFPS II, a longitudinal survey was distributed to a national consumer opinion panel of 500,000 households. The survey comprised 1 prenatal and 1 neonatal questionnaire and a series of 9 postnatal questionnaires; all questionnaires were sent via regular mail. A brief birth screening telephone interview was administered to achieve the sample goals of healthy-term or near-term singleton newborns. Of the 4900 respondents in the IFPS II study, approximately 3000 answered the neonatal questionnaire. In total, 2560 responded to the question pertaining to the type of feeding at hospital or birth center discharge (herein “hospital discharge”). Questionnaires that were either missing data about their MOD or other covariates adjusted in the multivariable model were excluded.

The main outcome of interest was exclusive breastfeeding at hospital discharge. The questionnaire asked, “When you left the hospital or birth center, how were you feeding your baby?” Options included “breastfeeding only,” “formula feeding only,” or “both breast and formula feeding.” A dichotomous exclusive breastfeeding variable was created by coding breastfeeding only responses as “yes” for exclusive breastfeeding and formula feeding only or both breast and formula feeding responses as “no” for exclusive breastfeeding.

The primary independent variable was MOD, which was coded as a dichotomous variable. The questionnaire asked “How was your baby delivered?” Responses indicating vaginally and not induced or vaginally and induced were categorized as “delivering vaginally,” and responses indicating a planned cesarean delivery or an unplanned or emergency cesarean delivery were categorized as “cesarean delivery.”

Covariates included mother’s age, marital status, race or ethnicity, education, prenatal smoking, gestational age, neonatal intensive care unit (NICU) stay, previous cesarean delivery, and prenatal intention to exclusively breastfeed. The percentage of federal poverty level in IFPS II was calculated using the household size and income. We calculated body mass index (BMI) using the formula BMI=(weight, lb/[height, in])²×703. To determine the gestational weight gain during pregnancy, we used the Institute of Medicine’s revised cutoffs for gestational weight gain: underweight (BMI<18.5; recommended weight gain: 12.5-18 kg), normal weight (BMI=18.5-24.9; recommended weight gain, 11.5-16 kg), overweight (BMI=25.0-29.9; recommended weight gain, 7-11.5 kg), and obese (BMI≥30; recommended weight gain, 5-9 kg).¹⁸

Statistical Analysis

Frequencies and proportions were used to describe the data. The association between MOD and exclusive breastfeeding was examined using a χ² test. To determine the independent association of MOD and exclusive breastfeeding, we used multivariable logistic regression analyses and adjusted for potential confounders. We determined which covariates to include in the multivariable logistic regression analyses on the basis of known relationships between those variables and exclusive breastfeeding. We also examined pairwise interactions between MOD and each covariate adjusted in the multivariable model. None of the interaction terms was significant. The OR, 95% CIs for ORs, and P values were calculated for each of the independent variables. Additionally, we conducted a subgroup analysis among respondents who had a cesarean delivery to examine the association between type of cesarean delivery (planned vs unplanned) and exclusive breastfeeding at hospital discharge. We considered a value of P<.05 to be statistically significant. To assess for potential collinearity, regression diagnostics were used. The variance inflation factor and tolerance values were all within acceptable limits. All statistical analyses were conducted using SAS software (version 9.3; SAS Institute).

Results

Overall, 7 respondents were excluded because of missing data about their MOD, and 1059 respondents were excluded because of other covariates adjusted in the multivariable model, resulting in a final sample of 1494 respondents. The overall characteristics of the study sample are displayed in Table 1. Of 1494 respondents, 1117 (74.8%) gave birth vaginally and 377 (25.2%) gave birth by cesarean delivery. Among the overall respondents, 1159 (77.6%) exclusively breastfed at hospital discharge. A total of 666 respondents (44.6%) had a normal BMI, and 698 (46.7%) had an above-average gestational weight gain according to the Institute of Medicine’s revised guidelines for weight gain during pregnancy.

Table 1.

Overall Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Method of Delivery^a

Characteristic	Overall (N=1494)	Method of Delivery		P Value^b
Characteristic	Overall (N=1494)	Vaginal (n=1117)	Cesarean (n=377)	P Value^b
Age, y
18-24	202 (13.5)	167 (15.0)	35 (9.3)
25-34	1016 (68.0)	783 (70.1)	233 (61.8)	<.001
>34	276 (18.47)	167 (15.0)	109 (28.9)
Marital Status
Never married	131 (8.8)	99 (8.9)	32 (8.5)
Currently married	1299 (87.0)	971 (86.9)	328 (87.0)	.948
Other	64 (4.3)	47 (4.2)	17 (4.5)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	955 (85.5)	320 (84.9)
Non-Hispanic black	58 (3.9)	45 (4.0)	13 (3.5)	.171
Hispanic	94 (6.3)	74 (6.6)	20 (5.3)
Other	67 (4.5)	43 (3.9)	24 (6.4)
Education
High school or less	257 (17.2)	201 (18.0)	56 (14.9)
Some college	634 (42.4)	473 (42.4)	161 (42.7)	.339
College graduate	603 (40.4)	443 (39.7)	160 (42.4)
Income, % of Poverty Level
<185	655 (43.8)	515 (46.1)	140 (37.1)
185-349	610 (40.8)	442 (39.6)	168 (44.6)	.007
>349	229 (15.3)	160 (14.3)	69 (18.3)
Body Mass Index
Underweight	61 (4.1)	51 (4.6)	10 (2.7)
Normal	666 (44.6)	546 (48.9)	120 (31.8)	<.001
Overweight	406 (27.2)	299 (26.8)	107 (28.4)
Obese	361 (24.2)	221 (19.8)	140 (37.1)
Gestational Weight Gain^c
Below recommendation	319 (21.4)	255 (22.8)	64 (17.0)
At recommendation	477 (31.9)	369 (33.0)	108 (28.7)	.002
Above recommendation	698 (46.7)	493 (44.1)	205 (54.4)
Prenatal Smoking
No	1392 (93.2)	1047 (93.7)	345 (91.5)	.139
Yes	102 (6.8)	70 (6.3)	32 (8.5)
Gestational Age, wk
35-38	185 (12.4)	140 (12.5)	45 (11.9)	.761
≥38	1309 (87.6)	977 (87.5)	332 (88.1)
NICU, ≤3 d
No	1457 (97.5)	1093 (97.9)	364 (96.6)	.160
Yes	37 (2.5)	24 (2.2)	13 (3.5)
Previous Cesarean Delivery
No	1143 (76.5)	1069 (95.7)	74 (19.6)
Yes	351 (23.5)	48 (4.3)	303 (80.4)	<.001
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	311 (27.8)	123 (32.6)	.077
Yes	1060 (71.0)	806 (72.2)	254 (67.4)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	224 (20.1)	111 (29.4)	<.001
Yes	1159 (77.6)	893 (79.9)	266 (70.6)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c These are calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

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Table 1.

Overall Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Method of Delivery^a

Characteristic	Overall (N=1494)	Method of Delivery		P Value^b
Characteristic	Overall (N=1494)	Vaginal (n=1117)	Cesarean (n=377)	P Value^b
Age, y
18-24	202 (13.5)	167 (15.0)	35 (9.3)
25-34	1016 (68.0)	783 (70.1)	233 (61.8)	<.001
>34	276 (18.47)	167 (15.0)	109 (28.9)
Marital Status
Never married	131 (8.8)	99 (8.9)	32 (8.5)
Currently married	1299 (87.0)	971 (86.9)	328 (87.0)	.948
Other	64 (4.3)	47 (4.2)	17 (4.5)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	955 (85.5)	320 (84.9)
Non-Hispanic black	58 (3.9)	45 (4.0)	13 (3.5)	.171
Hispanic	94 (6.3)	74 (6.6)	20 (5.3)
Other	67 (4.5)	43 (3.9)	24 (6.4)
Education
High school or less	257 (17.2)	201 (18.0)	56 (14.9)
Some college	634 (42.4)	473 (42.4)	161 (42.7)	.339
College graduate	603 (40.4)	443 (39.7)	160 (42.4)
Income, % of Poverty Level
<185	655 (43.8)	515 (46.1)	140 (37.1)
185-349	610 (40.8)	442 (39.6)	168 (44.6)	.007
>349	229 (15.3)	160 (14.3)	69 (18.3)
Body Mass Index
Underweight	61 (4.1)	51 (4.6)	10 (2.7)
Normal	666 (44.6)	546 (48.9)	120 (31.8)	<.001
Overweight	406 (27.2)	299 (26.8)	107 (28.4)
Obese	361 (24.2)	221 (19.8)	140 (37.1)
Gestational Weight Gain^c
Below recommendation	319 (21.4)	255 (22.8)	64 (17.0)
At recommendation	477 (31.9)	369 (33.0)	108 (28.7)	.002
Above recommendation	698 (46.7)	493 (44.1)	205 (54.4)
Prenatal Smoking
No	1392 (93.2)	1047 (93.7)	345 (91.5)	.139
Yes	102 (6.8)	70 (6.3)	32 (8.5)
Gestational Age, wk
35-38	185 (12.4)	140 (12.5)	45 (11.9)	.761
≥38	1309 (87.6)	977 (87.5)	332 (88.1)
NICU, ≤3 d
No	1457 (97.5)	1093 (97.9)	364 (96.6)	.160
Yes	37 (2.5)	24 (2.2)	13 (3.5)
Previous Cesarean Delivery
No	1143 (76.5)	1069 (95.7)	74 (19.6)
Yes	351 (23.5)	48 (4.3)	303 (80.4)	<.001
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	311 (27.8)	123 (32.6)	.077
Yes	1060 (71.0)	806 (72.2)	254 (67.4)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	224 (20.1)	111 (29.4)	<.001
Yes	1159 (77.6)	893 (79.9)	266 (70.6)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c These are calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Table 2 includes the bivariate association between the characteristics of the study sample by the newborn feeding status. The 266 respondents who delivered by cesarean birth (23.0%) were less likely to exclusively breastfeed at hospital discharge compared with the 893 respondents who delivered vaginally (77.1%) (P<.01). Additionally, the 962 respondents (83.0%) who stated that they had prenatal intentions to exclusively breastfeed in the first few weeks were significantly more likely to exclusively breastfeed at hospital discharge compared with the 197 respondents (17.0%) who had no intention (P<.01). Exclusively breastfeeding at hospital discharge differed by status of previous cesarean delivery. The 258 respondents who had a previous cesarean delivery (22.3%) were less likely to exclusively breastfeed than the 901 respondents who never had a previous cesarean delivery (77.7%) (P=.037). With the exception of income, gestational age, and NICU stay, all other covariates were statistically significantly associated with exclusive breastfeeding at hospital discharge.

Table 2.

Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Newborn Feeding Status (N=1494)^a

Characteristic	Exclusive Breastfeeding at Hospital Discharge		P Value^b
Characteristic	Yes (n=1159)	No (n=335)	P Value^b
Age, y
18-24	142 (12.3)	60 (17.9)
25-34	802 (69.2)	214 (63.9)	.027
>34	215 (18.6)	61 (18.2)
Marital Status
Never Married	86 (7.4)	45 (13.4)
Currently Married	1028 (88.7)	271 (80.9)	.001
Other	45 (3.9)	19 (5.7)
Race or Ethnicity
Non-Hispanic white	1034 (89.2)	241 (71.9)
Non-Hispanic black	32 (2.8)	26 (7.8)	<.001
Hispanic	51 (4.4)	43 (12.8)
Other	42 (3.6)	25 (7.5)
Education
High school or less	171 (14.8)	86 (25.7)
Some college	488 (42.1)	146 (43.6)	<.001
College graduate	500 (43.1)	103 (30.8)
Income, % of Poverty Level
<185	498 (43.0)	157 (46.9)
185-349	480 (41.4)	130 (38.8)	.446
>349	181 (15.6)	48 (14.3)
Body Mass Index
Underweight	49 (4.2)	12 (3.6)
Normal	534 (46.1)	132 (39.4)	.045
Overweight	314 (27.1)	92 (27.5)
Obese	262 (22.6)	99 (29.6)
Gestational Weight Gain^c
Below recommendation	223 (19.2)	96 (28.7)
At recommendation	380 (32.8)	97 (29.0)	.001
Above recommendation	556 (48.0)	142 (42.4)
Prenatal Smoking
No	1090 (94.1)	302 (90.2)	.013
Yes	69 (6.0)	33 (9.9)
Gestational Age, wk
35-38	134 (11.6)	51 (15.2)	.073
≥38	1025 (88.4)	284 (84.8)
NICU, ≤3 d
No	1135 (97.9)	322 (96.1)	.061
Yes	24 (2.1)	13 (3.9)
Previous Cesarean Delivery
No	901 (77.7)	242 (72.2)	.037
Yes	258 (22.3)	93 (27.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	197 (17.0)	237 (70.8)	<.001
Yes	962 (83.0)	98 (29.3)
Method of Delivery
Vaginal	893 (77.1)	224 (66.9)	.001
Cesarean	266 (23.0)	111 (33.1)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

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Table 2.

Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Newborn Feeding Status (N=1494)^a

Characteristic	Exclusive Breastfeeding at Hospital Discharge		P Value^b
Characteristic	Yes (n=1159)	No (n=335)	P Value^b
Age, y
18-24	142 (12.3)	60 (17.9)
25-34	802 (69.2)	214 (63.9)	.027
>34	215 (18.6)	61 (18.2)
Marital Status
Never Married	86 (7.4)	45 (13.4)
Currently Married	1028 (88.7)	271 (80.9)	.001
Other	45 (3.9)	19 (5.7)
Race or Ethnicity
Non-Hispanic white	1034 (89.2)	241 (71.9)
Non-Hispanic black	32 (2.8)	26 (7.8)	<.001
Hispanic	51 (4.4)	43 (12.8)
Other	42 (3.6)	25 (7.5)
Education
High school or less	171 (14.8)	86 (25.7)
Some college	488 (42.1)	146 (43.6)	<.001
College graduate	500 (43.1)	103 (30.8)
Income, % of Poverty Level
<185	498 (43.0)	157 (46.9)
185-349	480 (41.4)	130 (38.8)	.446
>349	181 (15.6)	48 (14.3)
Body Mass Index
Underweight	49 (4.2)	12 (3.6)
Normal	534 (46.1)	132 (39.4)	.045
Overweight	314 (27.1)	92 (27.5)
Obese	262 (22.6)	99 (29.6)
Gestational Weight Gain^c
Below recommendation	223 (19.2)	96 (28.7)
At recommendation	380 (32.8)	97 (29.0)	.001
Above recommendation	556 (48.0)	142 (42.4)
Prenatal Smoking
No	1090 (94.1)	302 (90.2)	.013
Yes	69 (6.0)	33 (9.9)
Gestational Age, wk
35-38	134 (11.6)	51 (15.2)	.073
≥38	1025 (88.4)	284 (84.8)
NICU, ≤3 d
No	1135 (97.9)	322 (96.1)	.061
Yes	24 (2.1)	13 (3.9)
Previous Cesarean Delivery
No	901 (77.7)	242 (72.2)	.037
Yes	258 (22.3)	93 (27.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	197 (17.0)	237 (70.8)	<.001
Yes	962 (83.0)	98 (29.3)
Method of Delivery
Vaginal	893 (77.1)	224 (66.9)	.001
Cesarean	266 (23.0)	111 (33.1)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

The unadjusted and multivariable adjusted odds of exclusively breastfeeding are shown in Table 3. After adjusting for potential confounders, respondents who delivered by cesarean birth were 59% less likely to exclusively breastfeed at hospital discharge compared with respondents who delivered vaginally (OR, 0.41; 95% CI, 0.24-0.71). The subgroup analysis shows that among respondents who delivered by cesarean birth, no statistically significant differences in the odds of exclusive breastfeeding exist between those who had a planned cesarean delivery and those who had an unplanned cesarean delivery (unadjusted OR, 1.03; 95% CI, 0.61-1.74) (multivariate adjusted OR, 0.99; CI, 0.46-2.10).

Table 3.

Demographic Characteristics and Association Between Method of Delivery and Exclusive Breastfeeding (N=1494)

Characteristic	Unadjusted OR (95% CI)	Multivariable Adjusted OR (95% CI)
Age,y
18-24	1	1
25-34	1.58 (1.13-2.22)^a	1.26 (0.82-1.94)
>34	1.49 (0.98-2.26)	1.27 (0.74-2.17)
Marital Status
Never married	1	1
Currently married	1.99 (1.35-2.92)^b	1.08 (0.66-1.77)
Other	1.24 (0.65-2.37)	0.82 (0.36-1.84)
Race or Ethnicity
Non-Hispanic white	1	1
Non-Hispanic black	0.29 (0.17-0.49)^b	0.58 (0.30-1.12)
Hispanic	0.28 (0.18-0.43)^b	0.38 (0.23-0.65)^b
Other	0.39 (0.23-0.66)^b	0.40 (0.21-0.75)^a
Education
High school or less	1	1
Some college	1.68 (1.22-2.31)^b	1.44 (0.97-2.12)
College graduate	2.44 (1.75-3.41)^b	1.62 (1.04-2.48)^c
Body Mass Index
Underweight	1.01 (0.52-1.95)	1.43 (0.65-3.14)
Normal	1	1
Overweight	0.84 (0.63-1.14)	0.85 (0.58-1.23)
Obese	0.65 (0.49-0.88)^a	0.75 (0.52-1.10)
Gestational Weight Gain^d
Below recommendation	0.59 (0.43-0.82)^a	0.60 (0.40-0.89)^c
At recommendation	1	1
Above recommendation	1.00 (0.75-1.34)	1.03 (0.72-1.46)
Prenatal Smoking
No	1	1
Yes	0.58 (0.38-0.89)^c	1.06 (0.61-1.82)
Gestational Age, wk
35-38	0.73 (0.51-1.03)	0.63 (0.41-0.96)^c
≥38	1	1
NICU, ≥3 d
No	1	1
Yes	0.52 (0.26-1.04)	0.54 (0.23-1.23)
Previous Cesarean Delivery
No	1	1
Yes	0.75 (0.565-0.98)^c	1.55 (0.88-2.73)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	1	1
Yes	11.81 (8.92-15.64)^b	11.03 (8.19-14.84)^b
Method of Delivery
Vaginal	1	1
Cesarean	0.60 (0.46-0.78)^b	0.41 (0.24-0.71)^a

^a P<.01.

^b P<.001.

^c P<.05.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

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Table 3.

Demographic Characteristics and Association Between Method of Delivery and Exclusive Breastfeeding (N=1494)

Characteristic	Unadjusted OR (95% CI)	Multivariable Adjusted OR (95% CI)
Age,y
18-24	1	1
25-34	1.58 (1.13-2.22)^a	1.26 (0.82-1.94)
>34	1.49 (0.98-2.26)	1.27 (0.74-2.17)
Marital Status
Never married	1	1
Currently married	1.99 (1.35-2.92)^b	1.08 (0.66-1.77)
Other	1.24 (0.65-2.37)	0.82 (0.36-1.84)
Race or Ethnicity
Non-Hispanic white	1	1
Non-Hispanic black	0.29 (0.17-0.49)^b	0.58 (0.30-1.12)
Hispanic	0.28 (0.18-0.43)^b	0.38 (0.23-0.65)^b
Other	0.39 (0.23-0.66)^b	0.40 (0.21-0.75)^a
Education
High school or less	1	1
Some college	1.68 (1.22-2.31)^b	1.44 (0.97-2.12)
College graduate	2.44 (1.75-3.41)^b	1.62 (1.04-2.48)^c
Body Mass Index
Underweight	1.01 (0.52-1.95)	1.43 (0.65-3.14)
Normal	1	1
Overweight	0.84 (0.63-1.14)	0.85 (0.58-1.23)
Obese	0.65 (0.49-0.88)^a	0.75 (0.52-1.10)
Gestational Weight Gain^d
Below recommendation	0.59 (0.43-0.82)^a	0.60 (0.40-0.89)^c
At recommendation	1	1
Above recommendation	1.00 (0.75-1.34)	1.03 (0.72-1.46)
Prenatal Smoking
No	1	1
Yes	0.58 (0.38-0.89)^c	1.06 (0.61-1.82)
Gestational Age, wk
35-38	0.73 (0.51-1.03)	0.63 (0.41-0.96)^c
≥38	1	1
NICU, ≥3 d
No	1	1
Yes	0.52 (0.26-1.04)	0.54 (0.23-1.23)
Previous Cesarean Delivery
No	1	1
Yes	0.75 (0.565-0.98)^c	1.55 (0.88-2.73)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	1	1
Yes	11.81 (8.92-15.64)^b	11.03 (8.19-14.84)^b
Method of Delivery
Vaginal	1	1
Cesarean	0.60 (0.46-0.78)^b	0.41 (0.24-0.71)^a

^a P<.01.

^b P<.001.

^c P<.05.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Discussion

Among the respondents who participated in IFPS II, cesarean delivery was negatively associated with exclusive breastfeeding at hospital discharge. This association was independent of age, marital status, education, income, BMI, gestational weight gain, prenatal smoking, gestational age, NICU stay, previous cesarean delivery, and prenatal intent to exclusively breastfeed. However, among those who delivered by cesarean birth, the odds of exclusive breastfeeding at hospital discharge did not differ by the type of cesarean delivery, indicating that any cesarean delivery (planned or unplanned) was negatively associated with exclusive breastfeeding at discharge.

Our findings are consistent with and add to existing literature that has reported a negative association between cesarean delivery and breastfeeding.^11,13 The mechanisms for having lower odds of exclusive breastfeeding at hospital discharge could be multifactorial, including hormonal, social, or procedural causes.^19-22 For example, several studies have shown that certain types of anesthesia can affect lactation.^23-25 Other possible causes include delayed breastfeeding initiation after cesarean delivery, maternal-newborn separation, and possible delayed lactogenesis.^26-28

The 2 widely known hormones that play a major role in lactation are the pituitary hormones prolactin and oxytocin.²⁹ Milk production is controlled by prolactin levels, and milk ejection occurs in response to a surge in oxytocin.²⁹ Prolactin periodically surges to stimulate many processes during pregnancy, including lactation and breast tissue development.³⁰ Several studies have explored the specific roles and mechanism of action of the hormone prolactin during pregnancy and postpartum period.^31-33 After delivery of the placenta, the inhibitory factors of prolactin decrease, including progesterone and other placental hormones.³⁴ Further investigation of the biochemical mechanism of action associated with MOD on hormonal changes that affect lactation is important.

The current study found other factors that showed statistically significant associations with increased odds of exclusive breastfeeding at hospital discharge. These factors included race or ethnicity, education, gestational age, and prenatal intention to exclusively breastfeed, all of which have been previously noted.^26,35-37 A strong positive association was found between maternal prenatal intention to breastfeed and breastfeeding at hospital discharge (OR, 11.03; 95% CI, 8.19-14.84), supporting the need for education about breastfeeding. Several studies evaluating the effectiveness of prenatal breastfeeding education have found that prenatal breastfeeding education has a potential to improve breastfeeding rates.^38-41 Providing extra prenatal education for mothers who are planning to have a cesarean delivery could improve exclusive breastfeeding by increasing their intentions to breastfeed. Mothers need to be aware of the possible effect cesarean deliveries have on breastfeeding before making a decision. Early postnatal breastfeeding education and assistance for women who have either a planned or emergency cesarean delivery can also support improved breastfeeding outcomes.

A limitation of the current study is that the IFPS II data were collected by women volunteering to complete a mailed survey, which makes it susceptible to volunteer bias, recall bias, and selection bias. This problem is further exacerbated by a loss of 41% of the eligible study sample due to incomplete information. The final analytical sample statistically significantly differed from those with incomplete data by key sociodemographic characteristics, indicating that the results may not be generalizable to the IFPS II study sample (Table 4). However, IFPS II is not a nationally representative dataset and may not produce results that can be generalized to all newborns, pregnant women, and new mothers in the United States. In addition, IFPS II data did not make any distinction between “exclusive breastfeeding at the time of maternal discharge” and “exclusive breastfeeding at the time of infant discharge.” The lack of this distinction could lead to a potentially misleading assumption that newborns who were discharged after their mothers would have the same access to breastfeeding as those who were discharged with their mothers. Likewise, the dichotomous variable of NICU stay (≤3 days) assumes that newborns who spent 3 days or fewer in the NICU could have similar access to breastfeeding as newborns who did not spend any time in the NICU.

Table 4.

Demographic Characteristics Comparing Respondents in the Final Analytic Sample With Respondents Who Were Excluded^a

Characteristic	Analytic Sample (n=1494)	Incomplete Data (n=1059)^b	P Value^c
Age, y
18-24	202 (13.5)	361 (34.2)
25-34	1016 (68.0)	570 (54.0)	<.001
>34	276 (18.5)	124 (11.8)
Marital Status
Never married	131 (8.8)	242 (27.2)
Currently married	1299 (86.9)	616 (69.4)	<.001
Other	64 (4.3)	30 (3.4)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	797 (80.6)
Non-Hispanic black	58 (3.9)	60 (6.1)	.010
Hispanic	94 (6.3)	72 (7.3)
Other	67 (4.9)	60 (6.1)
Education
High school or less	257 (17.2)	175 (20.0)
Some college	634 (42.4)	336 (38.4)	.090
College graduate	603 (40.4)	365 (41.7)
Body Mass Index
Normal	61 (4.1)	51 (4.9)	.094
Underweight	666 (44.6)	501 (48.6)
Overweight	406 (27.2)	259 (25.1)
Obese	361 (24.2)	219 (21.3)
Gestational Weight Gain^d
At recommendation	319 (21.4)	151 (15.9)	<.001
Below recommendation	477 (31.9)	258 (27.2)
Above recommendation	698 (46.7)	538 (56.8)
Prenatal Smoking
No	1392 (93.2)	953 (90.4)	.011
Yes	102 (6.8)	101 (9.6)
Gestational Age, wk
35-38	185 (12.4)	132 (12.5)	.951
≥38	1309 (87.6)	927 (87.5)
NICU, ≤3 d
No	1457 (97.5)	1031 (97.4)	.791
Yes	37 (2.5)	28 (2.6)
Previous Cesarean Delivery
No	1143 (76.5)	170 (75.2)	.672
Yes	351 (23.5)	56 (24.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	247 (25.4)	.050
Yes	1060 (70.9)	726 (74.6)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	371 (35.0)	<.001
Yes	1159 (77.6)	688 (65.0)
Method of Delivery
Vaginal	1117 (74.8)	739 (69.8)	.005
Cesarean	377 (25.2)	320 (30.2)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b Some participant responses were missing for age, marital status, race or ethnicity, body mass index, gestational weight gain, prenatal smoking, previous cesarean delivery, and prenatal intention to exclusively breastfeed in the first few weeks.

^c χ² test.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

View Large

Table 4.

Demographic Characteristics Comparing Respondents in the Final Analytic Sample With Respondents Who Were Excluded^a

Characteristic	Analytic Sample (n=1494)	Incomplete Data (n=1059)^b	P Value^c
Age, y
18-24	202 (13.5)	361 (34.2)
25-34	1016 (68.0)	570 (54.0)	<.001
>34	276 (18.5)	124 (11.8)
Marital Status
Never married	131 (8.8)	242 (27.2)
Currently married	1299 (86.9)	616 (69.4)	<.001
Other	64 (4.3)	30 (3.4)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	797 (80.6)
Non-Hispanic black	58 (3.9)	60 (6.1)	.010
Hispanic	94 (6.3)	72 (7.3)
Other	67 (4.9)	60 (6.1)
Education
High school or less	257 (17.2)	175 (20.0)
Some college	634 (42.4)	336 (38.4)	.090
College graduate	603 (40.4)	365 (41.7)
Body Mass Index
Normal	61 (4.1)	51 (4.9)	.094
Underweight	666 (44.6)	501 (48.6)
Overweight	406 (27.2)	259 (25.1)
Obese	361 (24.2)	219 (21.3)
Gestational Weight Gain^d
At recommendation	319 (21.4)	151 (15.9)	<.001
Below recommendation	477 (31.9)	258 (27.2)
Above recommendation	698 (46.7)	538 (56.8)
Prenatal Smoking
No	1392 (93.2)	953 (90.4)	.011
Yes	102 (6.8)	101 (9.6)
Gestational Age, wk
35-38	185 (12.4)	132 (12.5)	.951
≥38	1309 (87.6)	927 (87.5)
NICU, ≤3 d
No	1457 (97.5)	1031 (97.4)	.791
Yes	37 (2.5)	28 (2.6)
Previous Cesarean Delivery
No	1143 (76.5)	170 (75.2)	.672
Yes	351 (23.5)	56 (24.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	247 (25.4)	.050
Yes	1060 (70.9)	726 (74.6)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	371 (35.0)	<.001
Yes	1159 (77.6)	688 (65.0)
Method of Delivery
Vaginal	1117 (74.8)	739 (69.8)	.005
Cesarean	377 (25.2)	320 (30.2)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b Some participant responses were missing for age, marital status, race or ethnicity, body mass index, gestational weight gain, prenatal smoking, previous cesarean delivery, and prenatal intention to exclusively breastfeed in the first few weeks.

^c χ² test.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

The dataset also lacks important factors like timing of breastfeeding initiation. Furthermore, the cross-sectional design does not allow inference regarding causal relationships. In addition, given that this research is based on a secondary analysis of nearly decade-old data, the results should be interpreted with caution because guidelines for breastfeeding mothers, including those who have had a cesarean delivery, have improved after 2005 at most labor and delivery centers as a result of consumer demand, The Joint Commission, the Surgeon General’s Call to Action to Support Breastfeeding, the Centers for Disease Control and Prevention’s Maternity Practices in Infant Nutrition and Care, the World Health Organization, and the United Nations International Children’s Emergency Fund’s Baby-Friendly Hospital Initiative. A large national sample size, the diversity of the women who responded to the survey, and our ability to adjust for as many confounding variables as possible constitute some of the strengths of the current study.

Breastfeeding provides many nutritional, immunologic, and health benefits for newborns and infants.⁹ Regardless of the type of delivery, mothers and newborns should be able to take advantage of this natural form of nutrition. Future research should focus on identifying specific causes of poor breastfeeding rates in women who undergo cesarean delivery. Further research is needed to understand the mechanism of lactation among women who have undergone a cesarean delivery as well as the role of conditions surrounding unplanned cesarean delivery. Understanding this mechanism is important because it can lead to the development of techniques to improve exclusive breastfeeding among these mothers.

Conclusion

The current study demonstrated lower rates of exclusive breastfeeding at hospital discharge among women who underwent cesarean delivery compared with those who underwent vaginal delivery. More effort is needed to improve early initiation of breastfeeding in women who have cesarean deliveries, including developing and implementing hospital policies that support breastfeeding, training health care professionals to support breastfeeding after cesarean delivery, and providing prenatal and postnatal education and counseling on the importance of breastfeeding.

Acknowledgments

We thank the Centers for Disease Control and Prevention for providing us access to data from the Infant Feeding Practices Study II.

References

1.

Osterman MJ, Martin JA. Trends in low-risk cesarean delivery in the United States, 1990-2013. Natl Vital Stat Rep. 2014;63(6):1-16.

2.

Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary cesarean sections performed per year: overuse as a barrier to universal coverage. World Health Rep. 2010;(30):1-31.

3.

Lurie S. The changing motives of cesarean section: from the ancient world to the twenty-first century [published online March 15, 2005]. Arch Gynecol Obstet. 2005;271(4):281-285. doi:10.1007/s00404-005-0724-4. [CrossRef] [PubMed]

4.

Hamilton BE, Martin JA, Osterman MJ, Curtin SC. Births: preliminary data for 2013. Natl Vital Stat Rep. 2014;63(2):1-19. http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_02.pdf. Accessed June 8, 2016. [PubMed]

5.

Häger RM, Daltveit AK, Hofoss D, et al. . Complications of cesarean deliveries: rates and risk factors. Am J Obstet Gynecol. 2004;190(2):428-434. doi:10.1016/j.ajog.2003.08.037. [CrossRef] [PubMed]

6.

Rossi AC, Prefumo F. Pregnancy outcomes of induced labor in women with previous cesarean section: a systematic review and meta-analysis [published online September 2, 2014]. Arch Gynecol Obstet. 2015;291(2):273-280. doi:10.1007/s00404-014-3444-9. [CrossRef] [PubMed]

7.

Bodner K, Wierrani F, Grünberger W, Bodner-Adler B. Influence of the mode of delivery on maternal and neonatal outcomes: a comparison between elective cesarean section and planned vaginal delivery in a low-risk obstetric population [published online May 27, 2010]. Arch Gynecol Obstet. 2011;283(6):1193-1198. doi:10.1007/s00404-010-1525-y. [CrossRef] [PubMed]

8.

The World Health Organization’s infant feeding recommendation. WHO website. http://www.who.int/nutrition/topics/infantfeeding_recommendation/en/. Accessed July 10, 2015.

9.

Ip S, Chung M, Raman G, et al. . Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;(153):1-186. [PubMed]

10.

Moss BG, Yeaton WH. Early childhood healthy and obese weight status: potentially protective benefits of breastfeeding and delaying solid foods. Matern Child Health J. 2014;18(5):1224-1232. doi:10.1007/s10995-013-1357-z. [CrossRef] [PubMed]

11.

Long-term effects of breastfeeding: a systematic review. WHO website. http://www.who.int/maternal_child_adolescent/documents/breastfeeding_long_term_effects/en/. Accessed July 10, 2015.

12.

Barnes M, Cox J, Doyle B, Reed R. Evaluation of a practice-development initiative to improve breastfeeding rates. J Perinat Educ. 2010;19(4):17-23. doi:10.1624/105812410X530893. [CrossRef] [PubMed]

13.

Watt S, Sword W, Sheehan D, et al. . The effect of delivery method on breastfeeding initiation from the The Ontario Mother and Infant Study (TOMIS) III [published online June 23, 2012]. J Obstet Gynecol Neonatal Nurs. 2012;41(6):728-737. doi:10.1111/j.1552-6909.2012.01394.x. [CrossRef] [PubMed]

14.

Zanardo V, Svegliado G, Cavallin F, et al. . Elective cesarean delivery: does it have a negative effect on breastfeeding? Birth. 2010;37(4):275-279. doi:10.1111/j.1523-536X.2010.00421.x. [CrossRef] [PubMed]

15.

Ahluwalia IB, Li R, Morrow B. Breastfeeding practices: does method of delivery matter? Matern Child Health J. 2012;16 suppl 2:231-237. doi:10.1007/s10995-012-1093-9. [CrossRef] [PubMed]

16.

Rowe-Murray HJ, Fisher JR. Baby friendly hospital practices: cesarean section is a persistent barrier to early initiation of breastfeeding. Birth. 2002;29(2):124-131. [CrossRef] [PubMed]

17.

Infant feeding practices study II and its year six follow-up. CDC website. http://www.cdc.gov/breastfeeding/data/ifps/index.htm. Accessed July 16, 2015.

18.

Institute of Medicine. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: National Academy of Sciences; 2009. http://iom.nationalacademies.org/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx. Accessed May 13, 2016.

19.

Vogl SE, Worda C, Egarter C, et al. . Mode of delivery is associated with maternal and fetal endocrine stress response [published online February 20, 2006]. BJOG. 2006;113(4):441-445. doi:10.1111/j.1471-0528.2006.00865.x. [CrossRef] [PubMed]

20.

Ochedalski T, Lachowicz A. Maternal and fetal hypothalamo-pituitary-adrenal axis: different response depends upon the mode of parturition. Neuro Endocrinol Lett. 2004;25(4):278-282. [PubMed]

21.

Volmanen P, Valanne J, Alahuhta S. Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Int J Obstet Anesth. 2004;13(1):25-29. doi:10.1016/S0959-289X(03)00104-3. [CrossRef] [PubMed]

22.

Zanardo V, Savona V, Cavallin F, D’Antona D, Giustardi A, Trevisanuto D. Impaired lactation performance following elective delivery at term: role of maternal levels of cortisol and prolactin [published online February 6, 2012]. J Matern Fetal Neonatal Med. 2012;25(9):1595-1598. doi:10.3109/14767058.2011.648238. [CrossRef] [PubMed]

23.

Kutlucan L, Seker İS, Demiraran Y, et al. . Effects of different anesthesia protocols on lactation in the postpartum period. J Turk Ger Gynecol Assoc. 2014;15(4):233-238. doi:10.5152/jtgga.2014.14111. [CrossRef] [PubMed]

24.

Lie B, Juul J. Effect of epidural vs. general anesthesia on breastfeeding. Acta Obstet Gynecol Scand. 1988;67(3):207-209. [CrossRef] [PubMed]

25.

Akbas M, Akcan AB. Epidural analgesia and lactation. Eurasian J Med. 2011;43(1):45-49. doi:10.5152/eajm.2011.09. [CrossRef] [PubMed]

26.

Scott JA, Binns CW, Oddy WH. Predictors of delayed onset of lactation. Matern Child Nutr. 2007;3(3):186-193. doi:10.1111/j.1740-8709.2007.00096.x. [CrossRef] [PubMed]

27.

Nommsen-Rivers LA, Chantry CJ, Peerson JM, Cohen RJ, Dewey KG. Delayed onset of lactogenesis among first-time mothers is related to maternal obesity and factors associated with ineffective breastfeeding [published online June 23, 2010]. Am J Clin Nutr. 2010;92(3):574-584. doi:10.3945/ajcn.2010.29192. [CrossRef] [PubMed]

28.

Chapman DJ, Pérez-Escamilla R. Identification of risk factors for delayed onset of lactation. J Am Diet Assoc. 1999;99(4):450-454. doi:10.1016/S0002-8223(99)00109-1. [CrossRef] [PubMed]

29.

Gardner D, Shoback D. Greenspan’s Basic & Clinical Endocrinology. 9th ed. New York, NY: McGraw Hill; 2011.

30.

Gabbe SG, Niebyl JR, Galan HL, et al. . Obstetrics Normal and Problem Pregnancies. 6th ed. Philadelphia, PA: Saunders; 2012.

31.

Grattan DR. The actions of prolactin in the brain during pregnancy and lactation. Prog Brain Res. 2001;133:153-171. [PubMed]

32.

Grattan DR, Pi XJ, Andrews ZB, et al. . Prolactin receptors in the brain during pregnancy and lactation: implications for behavior. Horm Behav. 2001;40(2):115-124. doi:10.1006/hbeh.2001.1698. [CrossRef] [PubMed]

33.

Voogt JL, Lee Y, Yang S, Arbogast L. Regulation of prolactin secretion during pregnancy and lactation. Prog Brain Res. 2001;133:173-185. [PubMed]

34.

Beckmann CRB, Herbert W, Laube D, Ling F, Smith R. Obstetrics and Gynecology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

35.

Al-Sahab B, Lanes A, Feldman M, Tamim H. Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey. BMC Pediatr. 2010;10:20. doi:10.1186/1471-2431-10-20. [CrossRef] [PubMed]

36.

McDonald SD, Pullenayegum E, Chapman B, et al. . Prevalence and predictors of exclusive breastfeeding at hospital discharge. Obstet Gynecol. 2012;119(6):1171-1179. doi:10.1097/AOG.0b013e318256194b. [CrossRef] [PubMed]

37.

Zaghloul S, Harrison GG, Fendley HF, Pierce R, Morrisey C. Correlates of breastfeeding initiation in southeast Arkansas. South Med J. 2004;97(5):446-450. [CrossRef] [PubMed]

38.

Martens PJ. Does breastfeeding education affect nursing staff beliefs, exclusive breastfeeding rates, and Baby-Friendly Hospital Initiative compliance? The experience of a small, rural Canadian Hospital. J Hum Lact. 2000;16(4):309-318. doi:10.1177/089033440001600407. [CrossRef] [PubMed]

39.

Rosen IM, Krueger MV, Carney LM, Graham JA. Prenatal breastfeeding education and breastfeeding outcomes. MCN Am J Matern Child Nurs. 2008;33(5):315-319. doi:10.1097/01.NMC.0000334900.22215.ec. [CrossRef] [PubMed]

40.

Saleem AF, Mahmud S, Baig-Ansari N, Zaidi AK. Impact of maternal education about complementary feeding on their infants’ nutritional outcomes in low- and middle-income households: a community-based randomized interventional study in Karachi, Pakistan. J Health Popul Nutr. 2014;32(4):623-633. [PubMed]

41.

Wiles LS. The effect of prenatal breastfeeding education on breastfeeding success and maternal perception of the infant. JOGN. 1984;13(4):253-257. doi:10.1111/j.1552-6909.1984.tb01136.x. [CrossRef]

Table 1.

Overall Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Method of Delivery^a

Characteristic	Overall (N=1494)	Method of Delivery		P Value^b
Characteristic	Overall (N=1494)	Vaginal (n=1117)	Cesarean (n=377)	P Value^b
Age, y
18-24	202 (13.5)	167 (15.0)	35 (9.3)
25-34	1016 (68.0)	783 (70.1)	233 (61.8)	<.001
>34	276 (18.47)	167 (15.0)	109 (28.9)
Marital Status
Never married	131 (8.8)	99 (8.9)	32 (8.5)
Currently married	1299 (87.0)	971 (86.9)	328 (87.0)	.948
Other	64 (4.3)	47 (4.2)	17 (4.5)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	955 (85.5)	320 (84.9)
Non-Hispanic black	58 (3.9)	45 (4.0)	13 (3.5)	.171
Hispanic	94 (6.3)	74 (6.6)	20 (5.3)
Other	67 (4.5)	43 (3.9)	24 (6.4)
Education
High school or less	257 (17.2)	201 (18.0)	56 (14.9)
Some college	634 (42.4)	473 (42.4)	161 (42.7)	.339
College graduate	603 (40.4)	443 (39.7)	160 (42.4)
Income, % of Poverty Level
<185	655 (43.8)	515 (46.1)	140 (37.1)
185-349	610 (40.8)	442 (39.6)	168 (44.6)	.007
>349	229 (15.3)	160 (14.3)	69 (18.3)
Body Mass Index
Underweight	61 (4.1)	51 (4.6)	10 (2.7)
Normal	666 (44.6)	546 (48.9)	120 (31.8)	<.001
Overweight	406 (27.2)	299 (26.8)	107 (28.4)
Obese	361 (24.2)	221 (19.8)	140 (37.1)
Gestational Weight Gain^c
Below recommendation	319 (21.4)	255 (22.8)	64 (17.0)
At recommendation	477 (31.9)	369 (33.0)	108 (28.7)	.002
Above recommendation	698 (46.7)	493 (44.1)	205 (54.4)
Prenatal Smoking
No	1392 (93.2)	1047 (93.7)	345 (91.5)	.139
Yes	102 (6.8)	70 (6.3)	32 (8.5)
Gestational Age, wk
35-38	185 (12.4)	140 (12.5)	45 (11.9)	.761
≥38	1309 (87.6)	977 (87.5)	332 (88.1)
NICU, ≤3 d
No	1457 (97.5)	1093 (97.9)	364 (96.6)	.160
Yes	37 (2.5)	24 (2.2)	13 (3.5)
Previous Cesarean Delivery
No	1143 (76.5)	1069 (95.7)	74 (19.6)
Yes	351 (23.5)	48 (4.3)	303 (80.4)	<.001
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	311 (27.8)	123 (32.6)	.077
Yes	1060 (71.0)	806 (72.2)	254 (67.4)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	224 (20.1)	111 (29.4)	<.001
Yes	1159 (77.6)	893 (79.9)	266 (70.6)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c These are calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

View Large

Table 1.

Overall Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Method of Delivery^a

Characteristic	Overall (N=1494)	Method of Delivery		P Value^b
Characteristic	Overall (N=1494)	Vaginal (n=1117)	Cesarean (n=377)	P Value^b
Age, y
18-24	202 (13.5)	167 (15.0)	35 (9.3)
25-34	1016 (68.0)	783 (70.1)	233 (61.8)	<.001
>34	276 (18.47)	167 (15.0)	109 (28.9)
Marital Status
Never married	131 (8.8)	99 (8.9)	32 (8.5)
Currently married	1299 (87.0)	971 (86.9)	328 (87.0)	.948
Other	64 (4.3)	47 (4.2)	17 (4.5)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	955 (85.5)	320 (84.9)
Non-Hispanic black	58 (3.9)	45 (4.0)	13 (3.5)	.171
Hispanic	94 (6.3)	74 (6.6)	20 (5.3)
Other	67 (4.5)	43 (3.9)	24 (6.4)
Education
High school or less	257 (17.2)	201 (18.0)	56 (14.9)
Some college	634 (42.4)	473 (42.4)	161 (42.7)	.339
College graduate	603 (40.4)	443 (39.7)	160 (42.4)
Income, % of Poverty Level
<185	655 (43.8)	515 (46.1)	140 (37.1)
185-349	610 (40.8)	442 (39.6)	168 (44.6)	.007
>349	229 (15.3)	160 (14.3)	69 (18.3)
Body Mass Index
Underweight	61 (4.1)	51 (4.6)	10 (2.7)
Normal	666 (44.6)	546 (48.9)	120 (31.8)	<.001
Overweight	406 (27.2)	299 (26.8)	107 (28.4)
Obese	361 (24.2)	221 (19.8)	140 (37.1)
Gestational Weight Gain^c
Below recommendation	319 (21.4)	255 (22.8)	64 (17.0)
At recommendation	477 (31.9)	369 (33.0)	108 (28.7)	.002
Above recommendation	698 (46.7)	493 (44.1)	205 (54.4)
Prenatal Smoking
No	1392 (93.2)	1047 (93.7)	345 (91.5)	.139
Yes	102 (6.8)	70 (6.3)	32 (8.5)
Gestational Age, wk
35-38	185 (12.4)	140 (12.5)	45 (11.9)	.761
≥38	1309 (87.6)	977 (87.5)	332 (88.1)
NICU, ≤3 d
No	1457 (97.5)	1093 (97.9)	364 (96.6)	.160
Yes	37 (2.5)	24 (2.2)	13 (3.5)
Previous Cesarean Delivery
No	1143 (76.5)	1069 (95.7)	74 (19.6)
Yes	351 (23.5)	48 (4.3)	303 (80.4)	<.001
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	311 (27.8)	123 (32.6)	.077
Yes	1060 (71.0)	806 (72.2)	254 (67.4)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	224 (20.1)	111 (29.4)	<.001
Yes	1159 (77.6)	893 (79.9)	266 (70.6)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c These are calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Table 2.

Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Newborn Feeding Status (N=1494)^a

Characteristic	Exclusive Breastfeeding at Hospital Discharge		P Value^b
Characteristic	Yes (n=1159)	No (n=335)	P Value^b
Age, y
18-24	142 (12.3)	60 (17.9)
25-34	802 (69.2)	214 (63.9)	.027
>34	215 (18.6)	61 (18.2)
Marital Status
Never Married	86 (7.4)	45 (13.4)
Currently Married	1028 (88.7)	271 (80.9)	.001
Other	45 (3.9)	19 (5.7)
Race or Ethnicity
Non-Hispanic white	1034 (89.2)	241 (71.9)
Non-Hispanic black	32 (2.8)	26 (7.8)	<.001
Hispanic	51 (4.4)	43 (12.8)
Other	42 (3.6)	25 (7.5)
Education
High school or less	171 (14.8)	86 (25.7)
Some college	488 (42.1)	146 (43.6)	<.001
College graduate	500 (43.1)	103 (30.8)
Income, % of Poverty Level
<185	498 (43.0)	157 (46.9)
185-349	480 (41.4)	130 (38.8)	.446
>349	181 (15.6)	48 (14.3)
Body Mass Index
Underweight	49 (4.2)	12 (3.6)
Normal	534 (46.1)	132 (39.4)	.045
Overweight	314 (27.1)	92 (27.5)
Obese	262 (22.6)	99 (29.6)
Gestational Weight Gain^c
Below recommendation	223 (19.2)	96 (28.7)
At recommendation	380 (32.8)	97 (29.0)	.001
Above recommendation	556 (48.0)	142 (42.4)
Prenatal Smoking
No	1090 (94.1)	302 (90.2)	.013
Yes	69 (6.0)	33 (9.9)
Gestational Age, wk
35-38	134 (11.6)	51 (15.2)	.073
≥38	1025 (88.4)	284 (84.8)
NICU, ≤3 d
No	1135 (97.9)	322 (96.1)	.061
Yes	24 (2.1)	13 (3.9)
Previous Cesarean Delivery
No	901 (77.7)	242 (72.2)	.037
Yes	258 (22.3)	93 (27.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	197 (17.0)	237 (70.8)	<.001
Yes	962 (83.0)	98 (29.3)
Method of Delivery
Vaginal	893 (77.1)	224 (66.9)	.001
Cesarean	266 (23.0)	111 (33.1)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

View Large

Table 2.

Demographic Characteristics, Gestational Information, and Intent to Breastfeed by Newborn Feeding Status (N=1494)^a

Characteristic	Exclusive Breastfeeding at Hospital Discharge		P Value^b
Characteristic	Yes (n=1159)	No (n=335)	P Value^b
Age, y
18-24	142 (12.3)	60 (17.9)
25-34	802 (69.2)	214 (63.9)	.027
>34	215 (18.6)	61 (18.2)
Marital Status
Never Married	86 (7.4)	45 (13.4)
Currently Married	1028 (88.7)	271 (80.9)	.001
Other	45 (3.9)	19 (5.7)
Race or Ethnicity
Non-Hispanic white	1034 (89.2)	241 (71.9)
Non-Hispanic black	32 (2.8)	26 (7.8)	<.001
Hispanic	51 (4.4)	43 (12.8)
Other	42 (3.6)	25 (7.5)
Education
High school or less	171 (14.8)	86 (25.7)
Some college	488 (42.1)	146 (43.6)	<.001
College graduate	500 (43.1)	103 (30.8)
Income, % of Poverty Level
<185	498 (43.0)	157 (46.9)
185-349	480 (41.4)	130 (38.8)	.446
>349	181 (15.6)	48 (14.3)
Body Mass Index
Underweight	49 (4.2)	12 (3.6)
Normal	534 (46.1)	132 (39.4)	.045
Overweight	314 (27.1)	92 (27.5)
Obese	262 (22.6)	99 (29.6)
Gestational Weight Gain^c
Below recommendation	223 (19.2)	96 (28.7)
At recommendation	380 (32.8)	97 (29.0)	.001
Above recommendation	556 (48.0)	142 (42.4)
Prenatal Smoking
No	1090 (94.1)	302 (90.2)	.013
Yes	69 (6.0)	33 (9.9)
Gestational Age, wk
35-38	134 (11.6)	51 (15.2)	.073
≥38	1025 (88.4)	284 (84.8)
NICU, ≤3 d
No	1135 (97.9)	322 (96.1)	.061
Yes	24 (2.1)	13 (3.9)
Previous Cesarean Delivery
No	901 (77.7)	242 (72.2)	.037
Yes	258 (22.3)	93 (27.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	197 (17.0)	237 (70.8)	<.001
Yes	962 (83.0)	98 (29.3)
Method of Delivery
Vaginal	893 (77.1)	224 (66.9)	.001
Cesarean	266 (23.0)	111 (33.1)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b χ² test.

^c Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Table 3.

Demographic Characteristics and Association Between Method of Delivery and Exclusive Breastfeeding (N=1494)

Characteristic	Unadjusted OR (95% CI)	Multivariable Adjusted OR (95% CI)
Age,y
18-24	1	1
25-34	1.58 (1.13-2.22)^a	1.26 (0.82-1.94)
>34	1.49 (0.98-2.26)	1.27 (0.74-2.17)
Marital Status
Never married	1	1
Currently married	1.99 (1.35-2.92)^b	1.08 (0.66-1.77)
Other	1.24 (0.65-2.37)	0.82 (0.36-1.84)
Race or Ethnicity
Non-Hispanic white	1	1
Non-Hispanic black	0.29 (0.17-0.49)^b	0.58 (0.30-1.12)
Hispanic	0.28 (0.18-0.43)^b	0.38 (0.23-0.65)^b
Other	0.39 (0.23-0.66)^b	0.40 (0.21-0.75)^a
Education
High school or less	1	1
Some college	1.68 (1.22-2.31)^b	1.44 (0.97-2.12)
College graduate	2.44 (1.75-3.41)^b	1.62 (1.04-2.48)^c
Body Mass Index
Underweight	1.01 (0.52-1.95)	1.43 (0.65-3.14)
Normal	1	1
Overweight	0.84 (0.63-1.14)	0.85 (0.58-1.23)
Obese	0.65 (0.49-0.88)^a	0.75 (0.52-1.10)
Gestational Weight Gain^d
Below recommendation	0.59 (0.43-0.82)^a	0.60 (0.40-0.89)^c
At recommendation	1	1
Above recommendation	1.00 (0.75-1.34)	1.03 (0.72-1.46)
Prenatal Smoking
No	1	1
Yes	0.58 (0.38-0.89)^c	1.06 (0.61-1.82)
Gestational Age, wk
35-38	0.73 (0.51-1.03)	0.63 (0.41-0.96)^c
≥38	1	1
NICU, ≥3 d
No	1	1
Yes	0.52 (0.26-1.04)	0.54 (0.23-1.23)
Previous Cesarean Delivery
No	1	1
Yes	0.75 (0.565-0.98)^c	1.55 (0.88-2.73)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	1	1
Yes	11.81 (8.92-15.64)^b	11.03 (8.19-14.84)^b
Method of Delivery
Vaginal	1	1
Cesarean	0.60 (0.46-0.78)^b	0.41 (0.24-0.71)^a

^a P<.01.

^b P<.001.

^c P<.05.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

View Large

Table 3.

Demographic Characteristics and Association Between Method of Delivery and Exclusive Breastfeeding (N=1494)

Characteristic	Unadjusted OR (95% CI)	Multivariable Adjusted OR (95% CI)
Age,y
18-24	1	1
25-34	1.58 (1.13-2.22)^a	1.26 (0.82-1.94)
>34	1.49 (0.98-2.26)	1.27 (0.74-2.17)
Marital Status
Never married	1	1
Currently married	1.99 (1.35-2.92)^b	1.08 (0.66-1.77)
Other	1.24 (0.65-2.37)	0.82 (0.36-1.84)
Race or Ethnicity
Non-Hispanic white	1	1
Non-Hispanic black	0.29 (0.17-0.49)^b	0.58 (0.30-1.12)
Hispanic	0.28 (0.18-0.43)^b	0.38 (0.23-0.65)^b
Other	0.39 (0.23-0.66)^b	0.40 (0.21-0.75)^a
Education
High school or less	1	1
Some college	1.68 (1.22-2.31)^b	1.44 (0.97-2.12)
College graduate	2.44 (1.75-3.41)^b	1.62 (1.04-2.48)^c
Body Mass Index
Underweight	1.01 (0.52-1.95)	1.43 (0.65-3.14)
Normal	1	1
Overweight	0.84 (0.63-1.14)	0.85 (0.58-1.23)
Obese	0.65 (0.49-0.88)^a	0.75 (0.52-1.10)
Gestational Weight Gain^d
Below recommendation	0.59 (0.43-0.82)^a	0.60 (0.40-0.89)^c
At recommendation	1	1
Above recommendation	1.00 (0.75-1.34)	1.03 (0.72-1.46)
Prenatal Smoking
No	1	1
Yes	0.58 (0.38-0.89)^c	1.06 (0.61-1.82)
Gestational Age, wk
35-38	0.73 (0.51-1.03)	0.63 (0.41-0.96)^c
≥38	1	1
NICU, ≥3 d
No	1	1
Yes	0.52 (0.26-1.04)	0.54 (0.23-1.23)
Previous Cesarean Delivery
No	1	1
Yes	0.75 (0.565-0.98)^c	1.55 (0.88-2.73)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	1	1
Yes	11.81 (8.92-15.64)^b	11.03 (8.19-14.84)^b
Method of Delivery
Vaginal	1	1
Cesarean	0.60 (0.46-0.78)^b	0.41 (0.24-0.71)^a

^a P<.01.

^b P<.001.

^c P<.05.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Table 4.

Demographic Characteristics Comparing Respondents in the Final Analytic Sample With Respondents Who Were Excluded^a

Characteristic	Analytic Sample (n=1494)	Incomplete Data (n=1059)^b	P Value^c
Age, y
18-24	202 (13.5)	361 (34.2)
25-34	1016 (68.0)	570 (54.0)	<.001
>34	276 (18.5)	124 (11.8)
Marital Status
Never married	131 (8.8)	242 (27.2)
Currently married	1299 (86.9)	616 (69.4)	<.001
Other	64 (4.3)	30 (3.4)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	797 (80.6)
Non-Hispanic black	58 (3.9)	60 (6.1)	.010
Hispanic	94 (6.3)	72 (7.3)
Other	67 (4.9)	60 (6.1)
Education
High school or less	257 (17.2)	175 (20.0)
Some college	634 (42.4)	336 (38.4)	.090
College graduate	603 (40.4)	365 (41.7)
Body Mass Index
Normal	61 (4.1)	51 (4.9)	.094
Underweight	666 (44.6)	501 (48.6)
Overweight	406 (27.2)	259 (25.1)
Obese	361 (24.2)	219 (21.3)
Gestational Weight Gain^d
At recommendation	319 (21.4)	151 (15.9)	<.001
Below recommendation	477 (31.9)	258 (27.2)
Above recommendation	698 (46.7)	538 (56.8)
Prenatal Smoking
No	1392 (93.2)	953 (90.4)	.011
Yes	102 (6.8)	101 (9.6)
Gestational Age, wk
35-38	185 (12.4)	132 (12.5)	.951
≥38	1309 (87.6)	927 (87.5)
NICU, ≤3 d
No	1457 (97.5)	1031 (97.4)	.791
Yes	37 (2.5)	28 (2.6)
Previous Cesarean Delivery
No	1143 (76.5)	170 (75.2)	.672
Yes	351 (23.5)	56 (24.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	247 (25.4)	.050
Yes	1060 (70.9)	726 (74.6)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	371 (35.0)	<.001
Yes	1159 (77.6)	688 (65.0)
Method of Delivery
Vaginal	1117 (74.8)	739 (69.8)	.005
Cesarean	377 (25.2)	320 (30.2)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b Some participant responses were missing for age, marital status, race or ethnicity, body mass index, gestational weight gain, prenatal smoking, previous cesarean delivery, and prenatal intention to exclusively breastfeed in the first few weeks.

^c χ² test.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

View Large

Table 4.

Demographic Characteristics Comparing Respondents in the Final Analytic Sample With Respondents Who Were Excluded^a

Characteristic	Analytic Sample (n=1494)	Incomplete Data (n=1059)^b	P Value^c
Age, y
18-24	202 (13.5)	361 (34.2)
25-34	1016 (68.0)	570 (54.0)	<.001
>34	276 (18.5)	124 (11.8)
Marital Status
Never married	131 (8.8)	242 (27.2)
Currently married	1299 (86.9)	616 (69.4)	<.001
Other	64 (4.3)	30 (3.4)
Race or Ethnicity
Non-Hispanic white	1275 (85.3)	797 (80.6)
Non-Hispanic black	58 (3.9)	60 (6.1)	.010
Hispanic	94 (6.3)	72 (7.3)
Other	67 (4.9)	60 (6.1)
Education
High school or less	257 (17.2)	175 (20.0)
Some college	634 (42.4)	336 (38.4)	.090
College graduate	603 (40.4)	365 (41.7)
Body Mass Index
Normal	61 (4.1)	51 (4.9)	.094
Underweight	666 (44.6)	501 (48.6)
Overweight	406 (27.2)	259 (25.1)
Obese	361 (24.2)	219 (21.3)
Gestational Weight Gain^d
At recommendation	319 (21.4)	151 (15.9)	<.001
Below recommendation	477 (31.9)	258 (27.2)
Above recommendation	698 (46.7)	538 (56.8)
Prenatal Smoking
No	1392 (93.2)	953 (90.4)	.011
Yes	102 (6.8)	101 (9.6)
Gestational Age, wk
35-38	185 (12.4)	132 (12.5)	.951
≥38	1309 (87.6)	927 (87.5)
NICU, ≤3 d
No	1457 (97.5)	1031 (97.4)	.791
Yes	37 (2.5)	28 (2.6)
Previous Cesarean Delivery
No	1143 (76.5)	170 (75.2)	.672
Yes	351 (23.5)	56 (24.8)
Prenatal Intention to Exclusively Breastfeed in the First Few Weeks
No	434 (29.1)	247 (25.4)	.050
Yes	1060 (70.9)	726 (74.6)
Exclusive Breastfeeding at Hospital Discharge
No	335 (22.4)	371 (35.0)	<.001
Yes	1159 (77.6)	688 (65.0)
Method of Delivery
Vaginal	1117 (74.8)	739 (69.8)	.005
Cesarean	377 (25.2)	320 (30.2)

^a Data are given as No. (%) unless otherwise indicated. Some percentages do not total 100 because of rounding.

^b Some participant responses were missing for age, marital status, race or ethnicity, body mass index, gestational weight gain, prenatal smoking, previous cesarean delivery, and prenatal intention to exclusively breastfeed in the first few weeks.

^c χ² test.

^d Calculated based on the Institute of Medicine’s revised guidelines for gestational weight gain.

Abbreviation: NICU, neonatal intensive care unit.

Association Between Method of Delivery and Exclusive Breastfeeding at Hospital Discharge

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