Research Article
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Abstract
Background: The objective of this study was to test a breastfeeding history questionnaire to predict inhospital formula supplementation.
Methods: A breastfeeding questionnaire named BAP, an abbreviation based on three questions, was conceptualized and implemented in clinical practice. Primary outcome was formula supplementation during the postpartum hospital stay.
Results: Multiparous women with BAP scores of 1 or less were over four times more likely to use formula during the postpartum hospital stay than women with BAP scores of 2 or greater (RR = 4.35, 95% CI [2.47, 7.65]; p < .001). Additionally, multiparous mothers with BAP scores of 1 or less were more likely to use formula than primiparous mothers (RR = 1.93, 95% CI [1.47, 2.52]; p < .001). The adjusted odds of formula use were eight times greater for women with the lower BAP score (aOR 8.04, 95% CI [3.10, 20.86]; p < .001).
Conclusions: The BAP tool can be used to identify multiparous women most at risk for early formula use, thereby allowing targeted referral to breastfeeding support services.
Breastfeeding is a public health priority. The American Academy of Pediatrics, the Centers for Disease Control and Prevention (CDC), and the World Health Organization advocate for exclusive breastfeeding for all infants for the first 6 months of life and continued breastfeeding throughout at least the first year and for up to 2 years due to well-documented health benefits (American College of Obstetricians and Gynecologists, 2013; Centers for Disease Control, 2013; Lamberti, Fischer Walker, Noiman, Victora, & Black, 2011; Luan et al., 2013; Oddy, 2001, 2002, 2004; Oddy, de Klerk, Sly, & Holt, 2002; Patelarou et al., 2012; Sadauskaite-Kuehne, Ludvigsson, Padaiga, Jasinskiene, & Samuelsson, 2004; Section on Breastfeeding, 2012). Despite these recommendations, many mothers do not breastfeed for the recommended duration even when they desire to do so. Additionally, many of those women who continue to breastfeed do not do so exclusively (CDC, 2016; Perrine, Scanlon, Li, Odom, & Grummer-Strawn, 2012).
The Joint Commission and the Baby Friendly Hospital Initiative (BFHI) are committed to providing obstetrician–gynecologists (OBGYNs) and pediatricians with the tools they need to support breastfeeding mothers. Furthermore, the Affordable Care Act mandates coverage for both inpatient and outpatient lactation services. One Healthy People 2020 Goal is a reduction in the percentage of infants receiving formula during the postpartum hospital stay from 19.4% to 14.2% (US Department of Health and Human Services, 2016). The BFHI has outlined 10 steps for successful breastfeeding. Step six states, “Give infants no food or drink other than breast-milk, unless medically indicated.” The introduction of formula is associated with shorter breastfeeding duration and, by definition, nonexclusive breastfeeding (Chantry, Dewey, Peerson, Wagner, & Nommsen-Rivers, 2014; Parry, Ip, Chau, Wu, & Tarrant, 2013). Therefore, formula supplementation is considered a barrier to the formation of a functional breastfeeding relationship between mother and infant. The 2016 CDC Breastfeeding Report Card found that 17% of breastfeeding mothers in the U.S. use formula during the first two days after birth (Centers for Disease Control, 2016). Another study of over 90,000 breastfeeding newborns found only 61% of them to be exclusively breastfed at hospital discharge (Lutsiv et al., 2013).
Women often decide early in pregnancy how they will feed their infant (Ekwo, Dusdieker, & Booth, 1983; LeFevre, Kruse, & Zweig, 1987; Lutsiv et al., 2013). Providers of prenatal care are, therefore, in an optimal position to influence and support this decision-making process. A 2006 survey of prenatal care providers found that most providers only asked about the feeding plan at the first-prenatal visit and did not mention it in subsequent visits (Dusdieker, Dungy, & Losch, 2006). Furthermore, only 68% of OBGYNs reported doing any breastfeeding counseling (Dusdieker et al., 2006). A 2013 study of 69 healthcare providers and 377 patients at their initial prenatal appointment reported that only 29% of providers discussed breastfeeding, and the average duration of that discussion was only 29 seconds (Demirci et al., 2013). This is concerning, since it has been demonstrated that healthcare providers are able to influence a mother’s feeding choice and that one-on-one prenatal breastfeeding education can significantly improve outcomes (Noel-Weiss, Rupp, Cragg, Bassett, & Woodend, 2006).
Clinicians may ask about breastfeeding history as a dichotomous question where a mother’s options would be to have or not have had the experience. We suggest that taking a detailed breastfeeding history in an objective, systematic way would lead to more useful information than just asking the traditional question, “Have you breastfed?” Multiparous women may answer “yes” to that question without much elaboration into their previous experience. Taking a more detailed breastfeeding history, including previous negative or unsuccessful experiences, could elicit more specific risk factors for formula supplementation among multiparous women.
The purpose of this study was to design and test a simple and quick history-taking tool to be used by healthcare providers to detect those women most at risk of supplementing formula during their postpartum hospital stay. We hypothesized that women with prior successful breastfeeding experiences would be less likely to give their infants formula, while in the hospital compared to women with a history of prior breastfeeding problems.
Method
Tool Development
The initial desire was to create a tool that mirrored the universally accepted GTPAL method of describing a patient’s gravidity and parity. This acronym is used by maternal healthcare providers to describe a patient’s obstetric history as follows: Gravidity, Term deliveries, Preterm deliveries, Abortions, and Living children. By designing a tool similar to GTPAL, our desire was for OBGYNs to feel familiar with the concept and comfortable using it in their prenatal and hospital practice. We wanted our tool to capture a mother’s breastfeeding history in terms of experience, problems, and successes.
For the development of this breastfeeding history-taking tool, we created questions that are variations of those that some providers utilize to take a breastfeeding history. These items were further refined based on feedback from a panel of pediatricians, nurses, lactation consultants, and mothers. The questions were then pilot-tested in the postpartum unit and in the prenatal clinic by study team members.
The tool was named BAP which is an abbreviation based on the questions about breastfeeding history seen in Table 1. The answer to each question is a number reported by the patient. A total BAP score was calculated by adding B and A then subtracting P. For example, a woman who had breastfed three infants (B = 3), felt successful with each of those children (A = 3) but had some engorgement problems with her first child (P = 1) would have a score of 5. A woman who had breastfed two infants (B = 2) but felt unsuccessful with both (A = 0) secondary to issues with supply with both children (P = 2) would get a score of 0. Giving equal weight to the problems and successes was intentional given the importance of breastfeeding confidence on attaining breastfeeding goals (Brockway, Benzies, & Hayden, 2017).
Table 1.
BAP Questionnaire and Formula
| B | Number of babies mother has previously breastfed |
| A | Number of infants mother felt she was able to breastfeed successfully |
| P | Number of infants mother had problems breastfeeding |
| BAP score | (B + A)–P |
Data Collection
Following Institutional Review Board (IRB) approval and after incorporation of the BAP history-taking tool as part of routine care, we conducted a chart review of the electronic medical record (EMR) for all women delivering a live infant at a large academic medical center in the southeastern U.S. between June 15 and October 1, 2013. At the time of this study, this hospital had not yet earned a Baby-Friendly designation. Women were excluded if they delivered multiple live children, delivered a baby requiring admission to the neonatal intensive care unit (NICU), or had a contraindication to breastfeeding. Multiple gestations and infants requiring admission to the NICU were excluded due to an assumed baseline higher risk of formula supplementation. Women with contraindications to breastfeeding were excluded due to the medical necessity of formula supplementation in these women. Answers to the three BAP questions discussed above were extracted from the infant’s admission history and physical (H&P), and the scores were calculated. If no response was recorded for one or more of the three BAP questions, we attempted to extract the missing answer(s) from the lactation notes.
The primary outcome in this study was the occurrence of nonmedically indicated formula feeding in the postpartum hospital stay. We examined newborn medical records for the introduction of formula during this time period and recorded reasons for formula introduction. Infants who received only medically indicated formula for issues, such as hypoglycemia or excess weight gain, were treated as if supplementation had not occurred; if these issues ultimately required NICU admission these infants were excluded as described above.
Data Analysis
We computed descriptive statistics for the demographic characteristics of the mother–infant dyads that satisfied the inclusion criteria and had a complete BAP score. In order to test predictive validity, we computed relative risk (RR) for inhospital formula use for groups defined by BAP score and parity. Two-sided tests of the null hypothesis: RR = 1 were based on a normal approximation to the distribution of loge (RR). Logistic regression was then used to estimate the relationship between the dichotomized BAP score and formula use while controlling for other factors associated with formula use. In addition, the sensitivity, specificity, positive predictive value, and negative predictive values of the tool were calculated. The sample size (reported below) exceeded the minimum size of 30, based on Nunnally’s recommendation of 10 subjects per item for instrument development (Nunnally, 1978). Post-hoc power was calculated using the formula for z in Woodward (Woodward, 1992). For a two-sided test of the null hypothesis RR = 1 at = .05 level of significance, power for the principal result, reported in Table 2, exceeded 99%. Power for the remaining four tests ranged from 70% to 99%.
Table 2.
Rates and Risk of Inhospital Formula Use Based on Parity BAP Scores (N = 331)
| Parity BAP score | Any formula use? | Relative riska [95% CI] | |
|---|---|---|---|
| No (n = 203) | Yes (n = 128) | ||
| Primiparousb BAP = 0 | 101 (66.9%) | 50 (33.1%) | 2.26* [1.25, 4.08] |
| Multiparousb (1) BAP = 0 | 24 (29.3%) | 58 (70.7%) | 4.82** [2.75, 8.47] |
| (2) BAP = 1 | 14 (60.9%) | 9 (39.1%) | 2.67*** [1.26, 5.63] |
| (3) BAP ≤ 1 | 38 (36.2%) | 67 (63.8%) | 4.35** [2.47, 7.65] |
| (4) BAP ≥ 2 | 64 (85.3%) | 11 (14.7%) | 1 |
a Compared to multiparous group (4).
b A comparison of the rates of formula use for multiparous women with BAP ≤1 to primiparous women gives RR = 1.93, 95% CI [1.47, 2.52], p < .001.
* p = .007.
** p < .001.
*** p = .01.
Results
A total of 482 women experienced the live birth of one or more infants at this hospital between June 15 and October 1, 2013. Of these, 127 women were excluded (20 subjects due to multiple live births, 16 due to contraindications to breastfeeding, and 91 due to infant NICU admissions). In 44 of the 355 cases meeting the inclusion criteria, the BAP score was incomplete. Data from lactation notes were available for 20 of those women for a total of 331 women with complete BAP scores.
The demographics of the study sample by parity status are presented in Table 3. The majority were non-Hispanic white, English-speaking women. The majority (78.5%) of women intended to breastfeed their infant exclusively, while 70 (21.1%) planned to use at least some formula. Just over 80% of infants received breastmilk at the first feeding. Two hundred and three (61.3%) infants were exclusively breastfed, while 128 (38.7%) infants received some formula during their hospital stay. Feeding practices by parity status are presented in Table 4.
Table 3.
Demographic Characteristics of Mother–Infant Dyads (N = 331)
| Characteristica | n (%) | Multiparous (n = 180) | Primiparous (n = 151) |
|---|---|---|---|
| Race** White African American Hispanic Asian Other | 172 (52.0) 70 (21.1) 64 (19.3) 13 (3.9) 12 (3.6) | 79 (43.9) 37 (20.6) 54 (30.0) 4 (2.2) 6 (3.3) | 93(61.6) 33 (21.9) 10 (6.6) 9 (6.0) 6 (4.0) |
| Insurance type** Medicaid Private Unknown/Self-pay | 140 (42.3) 130 (39.3) 61 (18.4) | 77 (42.8) 55 (30.6) 48 (26.7) | 63 (41.7) 75 (49.7) 13 (8.6) |
| Primary language** English Spanish Other | 261 (78.9) 54 (16.3) 16 (4.8) | 123 (68.3) 49 (27.2) 8 (4.4) | 138 (91.4) 5 (3.3) 8 (5.3) |
| Gravidity** 1 2 3 4 5 ≥6 | 122 (36.9) 82 (24.8) 46 (13.9) 37 (11.2) 23 (6.9) 21 (6.3) | 0 (0.0) 58 (32.2) 42 (23.3) 36 (20.0) 23 (12.8) 21 (11.7) | 122 (80.8) 24 (15.9) 4 (2.6) 1 (0.7) 0 (0.0) 0 (0.0) |
| Living children** 0 1 2 3 4 ≥5 | 155 (46.8) 89 (26.9) 51 (15.4) 22 (6.6) 7 (2.1) 7 (2.1) | 4 (2.2) 89 (49.4) 51 (28.3) 22 (12.2) 7 (3.9) 7 (3.9) | 151 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) |
| Delivery method* Spontaneous vaginal delivery Forceps Vacuum Cesarean section | 228 (68.9) 8 (2.4) 11 (3.3) 84 (25.4) | 126 (70.0) 2 (1.1) 2 (1.1) 50 (27.8) | 102 (67.5) 6 (4.0) 9 (6.0) 34 (22.5) |
| Maternal complicationb Yes No | 181 (54.7) 150 (45.3) | 98 (54.4) 82 (45.6) | 83 (55.0) 68 (45.0) |
| Neonatal complicationc Yes No | 97 (29.3) 234 (70.7) | 49 (27.2) 131 (72.8) | 48 (31.8) 103 (68.2) |
a Asterisks indicate significance of a χ2 test of the variable vs. parity (primiparous/multiparous).
b Maternal complications include diabetes (n = 38), pre-eclampsia (n= 12), infection (n = 11), polycustic ovary syndrome (n = 11), postpartum hemorrhage (n = 7), preterm premature rupture of membranes (n = 3), placental abruption (n = 1), and other (n = 143). Some women had more than one complication.
c Neonatal complications include congenital anomalies (n = 36), hyperbilirubinemia (n = 35), prematurity (n = 15), abstinence syndrome (n = 1), and other (n = 30). Some had more than one complication.
* p < .05.
** p < .001.
Table 4.
Inhospital Feeding Practices of Mother–Infant Dyads (N = 331)a
| Characteristicb | n (%) | Multiparous (n = 180) | Primiparous (n = 151) |
|---|---|---|---|
| Feeding intent Breastfeeding Formula Both Unknown | 260 (78.5) 62 (18.7) 8 (2.4) 1 (0.3) | 136 (75.6) 38 (21.1) 6 (3.3) 0 (0) | 124 (82.1) 24 (15.9) 2 (1.3) 1 (0.7) |
| First feeding* Breastmilk Formula | 272 (82.2) 59 (17.8) | 141 (78.3) 39 (21.7) | 131 (86.8) 20 (13.2) |
| Any formula use?** Yes No | 128 (38.7) 203 (61.3) | 78(43.3) 102 (56.7) | 50 (33.1) 101 (66.9) |
a Reasons for formula use include maternal preference (103, 80.5%); inadequate milk supply (4, 3.1%); medically indicated (16, 12.5%); other including maternal fatigue, maternal perception, maternal pain (9, 7.0%).
b Asterisks indicate significance of a chi-square test of the variable vs. parity (primiparous/multiparous).
* p = .060.
** p = .070.
Among multiparous women, BAP scores ranged from 0 to 10; the 151 primiparous women, by definition, all had BAP scores of 0. The relationship of scores to formula feeding is presented in Table 2. The rate of formula use among primiparous women was 33.1%. By comparison, 82 multiparous women also had BAP scores of 0, and their rate of formula use was significantly higher at 70.7% (RR = 2.14, 95% CI [1.64, 2.79]; p < .001). The rate of formula use among multiparous women with a BAP score <1 was almost twice that of primiparous women (RR = 1.93, 95% CI [1.47, 2.52]; p < .001). Multiparous women with BAP scores of 1 and >2 had a 39.1% and 14.7% rate of formula use, respectively.
Table 5.
Logistic Regression of Formula Use During Postpartum Hospital Stay (1 = Yes; 0 = No) (N = 331)
| Predictora | Odds ratio [95% CI] | p |
|---|---|---|
| BAP (1 = BAP ≤ 1; 0 = BAP ≥ 2) | 8.04 [3.10, 20.86] | <.001 |
| Intended to feed some or all formula | 46.40 [15.10, 142.64] | <.001 |
| Primiparous | 0.36 [0.185, .706] | <.01 |
| Neonatal complication | 2.01 [1.07, 3.76] | 0.03 |
| African American | 2.12 [0.97, 4.60] | 0.06 |
| English speaking | 0.60 [0.23, 1.59] | 0.31 |
| Cesarean delivery | 1.39 [0.72, 2.70] | 0.33 |
| Medicaid insurance | 1.54 [0.55, 4.30] | 0.41 |
| Private insurance | 0.96 [0.33, 2.84] | 0.95 |
a All but BAP are (1 = Yes; 0 = No) variables that indicate the presence of the characteristic.
Analysis of just multiparous women yielded a clear cut-off score for the BAP as a tool to predict inhospital formula supplementation (see Table 2). Compared to multiparous women with BAP scores of 2 or more, multiparous women with BAP scores of 0 or 1 were significantly more likely to use formula (RR = 4.35, 95% CI 2.47, 7.65; p < .001). Both sensitivity and negative predictive value of a BAP score of <1 were over 85%, while specificity and positive predictive value were over 60%.
Logistic regression was used to test the predictive validity of the tool as a means of predicting inhospital formula supplementation after controlling for other factors thought to be associated with formula use in the general population (Table 5). Because pairwise correlations between parity, number of living children, and gravidity were too high for them all to be included in the model, only parity (dichotomized as primiparous/multiparous) was included in the final model. The overall rate of correct classification was 79.7%. The contributions of the variables BAP score, intention to feed some/all formula, parity, and neonatal complications were each significant. African American race nearly reached statistical significance. When other factors in the model were held constant, the odds of using formula increased by an estimated factor of eight if the BAP score of ≤1 was compared to BAP scores of ≥2 (aOR = 8.04, 95% CI 3.10-20.86, p < .001).
Discussion
The purpose of this study was to test a simple and quick history-taking tool to enable prenatal care providers to easily identify those women most likely to supplement formula in the immediate postpartum period. Using this tool to identify risk, in addition to implementing changes to prenatal breastfeeding education and hospital practices, may help reduce barriers to successful breastfeeding.
In this study, nearly 40% of women had already used formula prior to hospital discharge despite the fact that almost 80% of them planned to exclusively breastfeed. This supports prior research indicating that many women are not reaching their breastfeeding goals even while still in the hospital and need increased support in order to do so (CDC, 2014; Perrine et al., 2012). One-on-one education of women on the benefits, practice, and potential difficulties of breastfeeding has been proven to be effective in increasing both breastfeeding exclusivity and duration (Kronborg, Maimburg, & Væth, 2012). The identification and referral of multiparous women in need of breastfeeding support may increase their likelihood of breastfeeding initiation and exclusivity (Kruse, Denk, Feldman-Winter, & Rotondo, 2006). Until now, there has not been a reproducible, quantitative way to identify multiparous women most at risk for breastfeeding nonexclusivity.
Several other instruments to predict breastfeeding success have been created but none have been universally adopted. Two explored attitudes about infant feeding, one assessed prior experiences, three examined perceived self-efficacy, and one evaluated attitudes and control surrounding feeding (Ho & McGrath, 2010). These instruments range in size from 6 to 52 items, and rely upon self-information reported by the mother (Ho & McGrath, 2010). These tools were administered in a paper format rather than asked by a provider and have primarily been used in research. In contrast, the BAP is designed for clinical use and engages the provider in a discussion with the patient about her prior breastfeeding history and, to the best of our knowledge, is the only tool that assesses the likelihood of inhospital breastfeeding exclusivity which is the strongest predictor of breastfeeding duration (Perrine et al., 2012).
The BAP tool enables the identification, with an estimated 86% sensitivity, of women who could and should be targeted for increased breastfeeding interventions, namely multiparous women who have a BAP score of 1 or less. This tool could be included in the newborn admission assessment and used to identify those in need of immediate and/or intensive breastfeeding support. It could also potentially be completed by OBGYNs and other prenatal care providers during an early prenatal visit and communicated to lactation consultants and pediatric providers prior to hospitalization for delivery.
This was a preliminary study. Further research on the applicability and practicality of the BAP tool will also be necessary to assess the feasibility of its use as part of routine clinical care and incorporating the tool into prenatal care. Additional psychometric analysis will be needed to further test the reliability and validity of this tool among a variety of settings and populations as well as determine whether use of the tool does indeed affect clinical care and breastfeeding outcomes. Lastly, the ability of the BAP tool to predict duration of breastfeeding exclusivity could be assessed in future studies.
In summary, multiparous women with BAP scores of 1 or less were much more likely to use formula during the postpartum hospital stay than multiparous women with BAP scores of 2 or greater. Multiparous women with BAP scores of 0 or 1 were found to be even more likely to use formula than primiparous women. Our results support the use of BAP as a promising new tool for identifying at-risk women, so that they may receive the breastfeeding support needed to increase rates of breastfeeding initiation, duration, and exclusivity.
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Tables
Table 1.
BAP Questionnaire and Formula
| B | Number of babies mother has previously breastfed |
| A | Number of infants mother felt she was able to breastfeed successfully |
| P | Number of infants mother had problems breastfeeding |
| BAP score | (B + A)–P |
Table 2.
Rates and Risk of Inhospital Formula Use Based on Parity BAP Scores (N = 331)
| Parity BAP score | Any formula use? | Relative riska [95% CI] | |
|---|---|---|---|
| No (n = 203) | Yes (n = 128) | ||
| Primiparousb BAP = 0 | 101 (66.9%) | 50 (33.1%) | 2.26* [1.25, 4.08] |
| Multiparousb (1) BAP = 0 | 24 (29.3%) | 58 (70.7%) | 4.82** [2.75, 8.47] |
| (2) BAP = 1 | 14 (60.9%) | 9 (39.1%) | 2.67*** [1.26, 5.63] |
| (3) BAP ≤ 1 | 38 (36.2%) | 67 (63.8%) | 4.35** [2.47, 7.65] |
| (4) BAP ≥ 2 | 64 (85.3%) | 11 (14.7%) | 1 |
a Compared to multiparous group (4).
b A comparison of the rates of formula use for multiparous women with BAP ≤1 to primiparous women gives RR = 1.93, 95% CI [1.47, 2.52], p < .001.
* p = .007.
** p < .001.
*** p = .01.
Table 3.
Demographic Characteristics of Mother–Infant Dyads (N = 331)
| Characteristica | n (%) | Multiparous (n = 180) | Primiparous (n = 151) |
|---|---|---|---|
| Race** White African American Hispanic Asian Other | 172 (52.0) 70 (21.1) 64 (19.3) 13 (3.9) 12 (3.6) | 79 (43.9) 37 (20.6) 54 (30.0) 4 (2.2) 6 (3.3) | 93(61.6) 33 (21.9) 10 (6.6) 9 (6.0) 6 (4.0) |
| Insurance type** Medicaid Private Unknown/Self-pay | 140 (42.3) 130 (39.3) 61 (18.4) | 77 (42.8) 55 (30.6) 48 (26.7) | 63 (41.7) 75 (49.7) 13 (8.6) |
| Primary language** English Spanish Other | 261 (78.9) 54 (16.3) 16 (4.8) | 123 (68.3) 49 (27.2) 8 (4.4) | 138 (91.4) 5 (3.3) 8 (5.3) |
| Gravidity** 1 2 3 4 5 ≥6 | 122 (36.9) 82 (24.8) 46 (13.9) 37 (11.2) 23 (6.9) 21 (6.3) | 0 (0.0) 58 (32.2) 42 (23.3) 36 (20.0) 23 (12.8) 21 (11.7) | 122 (80.8) 24 (15.9) 4 (2.6) 1 (0.7) 0 (0.0) 0 (0.0) |
| Living children** 0 1 2 3 4 ≥5 | 155 (46.8) 89 (26.9) 51 (15.4) 22 (6.6) 7 (2.1) 7 (2.1) | 4 (2.2) 89 (49.4) 51 (28.3) 22 (12.2) 7 (3.9) 7 (3.9) | 151 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) |
| Delivery method* Spontaneous vaginal delivery Forceps Vacuum Cesarean section | 228 (68.9) 8 (2.4) 11 (3.3) 84 (25.4) | 126 (70.0) 2 (1.1) 2 (1.1) 50 (27.8) | 102 (67.5) 6 (4.0) 9 (6.0) 34 (22.5) |
| Maternal complicationb Yes No | 181 (54.7) 150 (45.3) | 98 (54.4) 82 (45.6) | 83 (55.0) 68 (45.0) |
| Neonatal complicationc Yes No | 97 (29.3) 234 (70.7) | 49 (27.2) 131 (72.8) | 48 (31.8) 103 (68.2) |
a Asterisks indicate significance of a χ2 test of the variable vs. parity (primiparous/multiparous).
b Maternal complications include diabetes (n = 38), pre-eclampsia (n= 12), infection (n = 11), polycustic ovary syndrome (n = 11), postpartum hemorrhage (n = 7), preterm premature rupture of membranes (n = 3), placental abruption (n = 1), and other (n = 143). Some women had more than one complication.
c Neonatal complications include congenital anomalies (n = 36), hyperbilirubinemia (n = 35), prematurity (n = 15), abstinence syndrome (n = 1), and other (n = 30). Some had more than one complication.
* p < .05.
** p < .001.
Table 4.
Inhospital Feeding Practices of Mother–Infant Dyads (N = 331)a
| Characteristicb | n (%) | Multiparous (n = 180) | Primiparous (n = 151) |
|---|---|---|---|
| Feeding intent Breastfeeding Formula Both Unknown | 260 (78.5) 62 (18.7) 8 (2.4) 1 (0.3) | 136 (75.6) 38 (21.1) 6 (3.3) 0 (0) | 124 (82.1) 24 (15.9) 2 (1.3) 1 (0.7) |
| First feeding* Breastmilk Formula | 272 (82.2) 59 (17.8) | 141 (78.3) 39 (21.7) | 131 (86.8) 20 (13.2) |
| Any formula use?** Yes No | 128 (38.7) 203 (61.3) | 78(43.3) 102 (56.7) | 50 (33.1) 101 (66.9) |
a Reasons for formula use include maternal preference (103, 80.5%); inadequate milk supply (4, 3.1%); medically indicated (16, 12.5%); other including maternal fatigue, maternal perception, maternal pain (9, 7.0%).
b Asterisks indicate significance of a chi-square test of the variable vs. parity (primiparous/multiparous).
* p = .060.
** p = .070.
Table 5.
Logistic Regression of Formula Use During Postpartum Hospital Stay (1 = Yes; 0 = No) (N = 331)
| Predictora | Odds ratio [95% CI] | p |
|---|---|---|
| BAP (1 = BAP ≤ 1; 0 = BAP ≥ 2) | 8.04 [3.10, 20.86] | <.001 |
| Intended to feed some or all formula | 46.40 [15.10, 142.64] | <.001 |
| Primiparous | 0.36 [0.185, .706] | <.01 |
| Neonatal complication | 2.01 [1.07, 3.76] | 0.03 |
| African American | 2.12 [0.97, 4.60] | 0.06 |
| English speaking | 0.60 [0.23, 1.59] | 0.31 |
| Cesarean delivery | 1.39 [0.72, 2.70] | 0.33 |
| Medicaid insurance | 1.54 [0.55, 4.30] | 0.41 |
| Private insurance | 0.96 [0.33, 2.84] | 0.95 |
a All but BAP are (1 = Yes; 0 = No) variables that indicate the presence of the characteristic.
Article usage
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| Dec 2020 | 3 | 24 | 0 | 27 |
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| May 2020 | 9 | 28 | 0 | 37 |
| Apr 2020 | 10 | 43 | 0 | 53 |
| Mar 2020 | 6 | 18 | 0 | 24 |
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| Jan 2020 | 10 | 22 | 0 | 32 |
| Dec 2019 | 9 | 18 | 0 | 27 |
| Nov 2019 | 4 | 5 | 0 | 9 |
| Oct 2019 | 7 | 13 | 0 | 20 |
| Sep 2019 | 11 | 8 | 0 | 19 |
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| Jul 2019 | 2 | 9 | 0 | 11 |
| Jun 2019 | 0 | 20 | 0 | 20 |
| May 2019 | 0 | 19 | 0 | 19 |
| Apr 2019 | 5 | 8 | 0 | 13 |
| Mar 2019 | 8 | 4 | 0 | 12 |
| Feb 2019 | 18 | 0 | 0 | 18 |
| Jan 2019 | 12 | 2 | 0 | 14 |
| Dec 2018 | 16 | 4 | 0 | 20 |
| Nov 2018 | 21 | 0 | 0 | 21 |
| Oct 2018 | 12 | 2 | 0 | 14 |
| Sep 2018 | 18 | 1 | 0 | 19 |
| Aug 2018 | 9 | 0 | 0 | 9 |
| Jul 2018 | 6 | 3 | 0 | 9 |
| Jun 2018 | 0 | 2 | 0 | 2 |
| May 2018 | 0 | 1 | 0 | 1 |
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