Barriers to Breastfeeding – A Global Survey on Why Women Start and Stop Breastfeeding


the reported breastfeeding rates of 90 % at one year and 73 % at two years.17


In part, this may be explained by the fact that our survey included only women in urban areas – a factor that has been associated with lower breastfeeding rates.17


For the US, our results for


breastfeeding initiation (95 %) and over six months (55 %) are higher than the 75 % and 44 % reported in the US National Immunization Survey (NIS) for 2006–2008,36


although both were telephone surveys


that sampled the general population using a comparable question (the NIS included more respondents – about 16,000 – yet was restricted to parents with infants aged 19–35 months). No comparative data for Brazil, Egypt or South Africa could be found in the literature.


Cessation


Our findings are largely consistent with other studies also reporting perceived breast milk insufficiency,18,23,26,28,40 wanting to nurse23,28


and the need to return to work18,26


the child no longer among the key


reasons for discontinuing exclusive or any breastfeeding.


Most recently, Tarrant et al. gave the primary reasons reported for mothers in Ireland discontinuing breastfeeding before six months as: tiredness/lack of freedom, returning to work, perceived insufficient breast milk supply and planned discontinuation.26


reported that the most frequently used arguments were perceived supply insufficiency and self-weaning of the infant.28


In a review of


studies from China, Xu et al. reported primary reasons to include breast milk insufficiency, returning to work, disliking or feeling uncomfortable with breastfeeding and maternal or child illness.18 Incidentally, breastfeeding problems in the first month,21 problems41


nipple or poor latch-on42 have also been reported as being associated with early breastfeeding cessation.


Insufficient milk supply is mostly a perceived problem because, from a physiological perspective, a decrease in supply should not be expected with regular and effective breastfeeding. This suggests that antenatal preparation should be aimed at setting realistic expectations about breastfeeding, relieving women of their concerns about their milk supply and helping them to continue breastfeeding.


An alternative explanation is that supply issues may have been raised by healthcare providers based on their interpretation of infants’ growth judged according to older infant growth charts. Previously, infant growth charts were based mostly on formula-fed infants, who have been demonstrated to grow differently compared with exclusively breastfed babies. In 2006, the WHO released updated growth charts to reflect the growth of breastfed infants, but these have not yet been fully implemented.43


Thus when a breastfed infant’s


growth is lagging behind according to older charts, healthcare providers may be tempted to blame an insufficient breast milk supply and recommend breastfeeding cessation or supplemental feeds. If that were the case, the implementation of growth charts that better reflect the growth of breastfed infants would need to be accelerated and healthcare professionals would need to be informed concurrently.


In comparing arguments used by women in studies before and after the UNICEF/WHO Baby-friendly Hospital Initiative had been adopted and public awareness of the importance of breastfeeding had been raised, they noted a significant shift from “disliking or feeling uncomfortable with breastfeeding” to “insufficient supply”.


Another potential explanation was suggested by Xu et al., who also found insufficient supply as a prevalent reason in studies reported for China.18


EUROPEAN OBSTETRICS & GYNAECOLOGY SUPPLEMENT Initiation and Continuation


To mitigate anxiety around breastfeeding, professional support programmes exist (see Table 6). Breastfeeding class completion was associated with longer breastfeeding duration, but class attendance fell short. This was also apparent for other classes such as antenatal classes.29


They postulated that the latter might now be a (more) socially acceptable reason for mothers to use when they want to stop breastfeeding, thus skewing recent data towards insufficient supply.


Thus further promotion of classes educating mothers about breastfeeding seems justified. It also appeared that hospitals have an opportunity to improve their support, beyond ‘labour and delivery’, in initiating breastfeeding – a finding that seems to be confirmed by Cattaneo et al., who evaluated the support of health providers towards breastfeeding and reported low compliance with the Baby-friendly Hospital Initiative in Europe,15


despite the fact that the initiative has been For the US, Li et al.


shown to lead to higher breastfeeding rates and longer duration.44,45 Availability of lactation consultants was associated with longer breastfeeding duration. Although women with no access to lactation consultants may be turning to other resources, this finding highlights the potentially crucial role of both professional and lay one-to-one breastfeeding support in improving the healthy development of children – a finding recently corroborated by Tarrant et al., who found a strong positive association between breastfeeding support from public health nurses and any breastfeeding over six weeks.26


the fact that most Egyptian mothers were not working, economic reasons (e.g., alternative feeding too expensive) and social acceptance of breastfeeding (only 5 % felt it was awkward to breastfeed outside the home). These local factors and changes therein need to be understood as well in order to devise successful local strategies towards breastfeeding prolongation.


Nevertheless, taken together, our findings highlight the importance of professional support. This seems to be confirmed in a recent series of papers summarised by Lawrence, stating that prenatal education, an established hospital programme and community-based, out-of-hospital support programmes are shown to increase the initiation and duration of breastfeeding.46


Strengths and Limitations


The major strength of our study is that it explored women’s own perceptions and reported reasons for the initiation and discontinuation of breastfeeding using a standardised approach across seven culturally and economically diverse countries worldwide, thus providing comparable perspectives on the challenges associated with breastfeeding globally. One limitation is the retrospective nature of recalling actual breastfeeding duration – an issue commonly observed in studies on breastfeeding prevalence.


29


While class attendance and availability of lactation consultants were related to longer breastfeeding durations within countries, this was not the case across countries. The US had the highest class attendance and availability of lactation consultants (and the least worried women), yet breastfeeding duration was about average. Egypt, in contrast, had a low availability of lactation consultants, low breastfeeding class completion (and high anxiety around breastfeeding), yet most women managed to continue breastfeeding for more than 12 months, indicating that other cultural factors must be at play as well. These could include support from other healthcare practitioners (e.g., paediatricians)29 their mothers),22,29


or family members (especially


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