Journal of Midwifery & Womens Health

www.jmwh.org

Original Research

Womens Prenatal Concerns Regarding

Breastfeeding: Are They Being Addressed?
Karen Archabald, MD, MS, Lisbet Lundsberg, PhD, Elizabeth Triche, PhD, Errol Norwitz, MD, PhD,
Jessica Illuzzi, MD, MS

Introduction: This study sought to identify womens concerns regarding breastfeeding during the prenatal period and determine whether women
thought that health care providers addressed these concerns.
Methods: A structured interview with both open-ended and closed-ended questions addressing the study objectives was administered to a crosssectional sample of 130 English-speaking or Spanish-speaking postpartum women at Yale-New Haven Hospital.
Results: When asked an open-ended question regarding whether they had concerns about breastfeeding while making their decisions about
feeding their infants, 81.5% of women identified at least 1 concern. Of these women, only 25.4% reported that this concern was addressed by the
provider during prenatal care. When prompted with 8 common concerns regarding breastfeeding during the prenatal period, 95.4% of women
identified at least 1 of these preidentified concerns. Only 17.4% of women who identified any of these 8 concerns reported that the concerns had
been discussed with a provider.
Discussion: Womens recall of prenatal health care discussions strongly suggests that providers are not adequately addressing womens concerns
about breastfeeding.
c 2011 by the American College of Nurse-Midwives.
J Midwifery Womens Health 2011;56:27 
Keywords: breastfeeding, concerns, counseling, prenatal care

INTRODUCTION

METHODS

The benefits of breastfeeding to infants and mothers are welldocumented.1 The American College of Nurse-Midwives and
the American Congress of Obstetricians and Gynecologists
recommend that providers encourage breastfeeding.2,3 As
providers for women from the preconception period through
postpartum, midwives, obstetrician-gynecologists, and family medicine practitioners have a unique opportunity to promote breastfeeding throughout womens lives and particularly
in the prenatal period. National as well as various local surveys
indicate that 75% to 100% of prenatal care providers report
recommending breastfeeding to their patients, and a similar
percentage believe they play an important role in womens decisions regarding infant feeding.46,7
In contrast, patients report being advised to breastfeed by
their providers only 40% to 60% of the time (estimates range
from 23% to 73%).812 One possible explanation for the difference in perception of breastfeeding advice is the method
of communication used by providers. Communication centered on patients and their concerns rather than on biomedical information has been shown to be more effective at increasing patients abilities to synthesize information and make
decisions.13
The aims of this study are to describe womens concerns
about breastfeeding during the prenatal period and to determine whether women perceived that their prenatal care
providers addressed these concerns.

Design and Participants

We conducted a cross-sectional study with convenience sampling. Eligible participants included all English-speaking or
Spanish-speaking postpartum women who had a live birth
at Yale-New Haven Hospital between October 20, 2006, and
January 9, 2007. Women with medical conditions such as
HIV, in which breastfeeding is not recommended, or with infants unable to suckle secondary to congenital anomalies or
other medical conditions such as extreme prematurity were
excluded from participation. The Human Investigation Committee at Yale University approved this study.

Measures

Address correspondence to Jessica Illuzzi, MD, MS, Center for Perinatal,

Pediatric and Environmental Epidemiology, 1 Church Street, 6th Floor,
New Haven, CT 06510. E-mail: Jessica.illuzzi@yale.edu

An oral questionnaire was developed specifically for this study

by the authors because no existing surveys were identified in
the literature that addressed these topics. The questionnaire
consisted of 51 open-ended and closed-ended questions designed to obtain information about the participants decisionmaking process regarding feeding practices, her concerns
about breastfeeding, and the content of prenatal discussion of
these topics. The open-ended questions were developed with
the research question in mind; closed-ended questions addressing specific concerns were based on a review of the literature, which documents common concerns of pregnant and
postpartum women regarding breastfeeding.1418
The primary open-ended question for this study is as follows: While making your decision about how to feed your
baby, did you have concerns about breastfeeding? The 8
closed-ended questions regarding concerns were in a yes-no


c 2011 by the American College of Nurse-Midwives

1526-9523/09/$36.00 doi:10.1111/j.1542-2011.2010.00006.x

format and regarded whether the woman had the concern as

well as whether the concern was addressed by the provider.
These 8 concerns were identified by a search of the literature and included ability to work/attend school, inadequate
milk supply, pain, difficulty sharing feeding responsibility,
anxiety/embarrassment, difficulty in maintaining mothers
diet/health, restriction of social life, and body image.1418
Feeding choice was defined based on the stated feeding
choice on the day of the interview. Participants who were planning to exclusively feed only human milk were defined as
breastfeeders. Participants who were planning to exclusively
feed their infants formula, without any supplementation with
breast milk, were defined as formula feeders. Participants who
were planning to use both breast milk and formula were defined as mixed feeders. This would allow a mother whose
infant received a supplemental feeding of formula for some
medical indication to still be categorized as planning to exclusively breastfeed if she so stated, despite a solitary formula
feeding during the hospital stay.
Information on demographic characteristics including
age, socioeconomic status, ethnicity/race, education, marital
status, country of origin, type of care provider, and setting of
prenatal care was also obtained. A copy of the questionnaire
is available on request.
Procedure

After consent was obtained from participants, the first author

(K.A.) administered an oral questionnaire during the postpartum period in the patients hospital room. Following the
open-ended question regarding concerns, women were then
directly asked if they shared any of 8 specific concerns about
breastfeeding commonly mentioned in other studies. If the
participant had already indicated 1 of these specific concerns
in the open-ended portion of the questionnaire, she was not
asked about that topic again in the directed portion of the
questionnaire.
Analysis

Data analysis was performed with the SAS 9.1 (SAS Institute Inc, Cary, NC) statistical analysis software package.
Bivariate analyses were performed to describe associations
between maternal characteristics, feeding choice, concerns
about breastfeeding, and provider communication about concerns. Categorical variables were compared by use of chisquare tests and the Fisher exact test, when appropriate. Responses to the open-ended and closed-ended questions were
analyzed separately. Statistical significance was defined as a
P value less than or equal to .05.
RESULTS

During the study period, 146 women meeting inclusion criteria were approached during postpartum hospitalization,
which ranged from postpartum day 1 through 4. Four women
(3%) declined participation, and 12 (8%) deferred the interview to a later time but were subsequently not able to be interviewed. A total of 130 women completed the study, yielding
a participation rate of 89%. Because of the convenience samJournal of Midwifery & Womens Health r www.jmwh.org

pling methodology, the sample contains a higher proportion

of women who had cesarean births, because these women typically spend more days in the hospital than women who give
birth vaginally. However, there was no significant difference in
feeding choice between women who had vaginal or cesarean
births (P = .618).
Of women in the study (see Table 1, Total column), 60%
chose to breastfeed exclusively, 20% to formula feed, and
20% to use both methods. The mean maternal age was 29.5
years. The majority were white (55.3%), with minorities of
African American (17.7%) and Hispanic (16.9%) women.
Most (65.4%) women had a household income of greater than
$24,000 per year, and just over half (52.4%) had graduated
from college or had a postgraduate degree. Private providers
cared for 69.2% of the women, whereas hospital physicians,
midwives, and residents provided care to the remainder.
When asked during the interview the open-ended question regarding whether they had concerns about breastfeeding while making their feeding choice, the majority of women
(81.5%) identified at least 1 concern (Table 2). Responses fell
into 15 thematic groups that were subsequently consolidated
into the following 5 categories, based on their similarities, for
analysis: 1) lifestyle/flexibility issues (difficult to share responsibility for feeding, maintaining diet, not enough time, difficulty sleeping, frequent feeding, nipple confusion, inability to
wean, social isolation, body image), 2) pain (nipple discomfort), 3) confidence (not producing enough milk, baby not getting enough milk, baby not latching on), 4) work (difficult to
go back to work because of demands of feeding), and 5) medications (perceived medicine interactions with breastfeeding).
Breastfeeders most commonly identified the primary concern as confidence (44.9%), formula feeders were most concerned about social/lifestyle issues (30.8%), and mixed feeders
expressed equal concern about confidence and work (23.1%
each). The percentage of women who identified a concern
about breastfeeding did not vary by ultimate feeding choice
(P = .903). Overall, 25.4% of women had their primary concerns addressed by their providers (Table 2). There was no
statistically significant difference between the percentage of
women who had their primary concerns addressed in the
mixed-feeding and formula-feeding groups (30.8% each) and
the breastfeeding group (21.8%) (P = .512).
Women were then asked closed-ended questions regarding whether they shared any of 8 common concerns about
breastfeeding, which have been previously identified in the literature (Table 3). Women shared at least 1 of these preidentified concerns 95.4% of the time. Overall, the most common
concern was that breastfeeding would influence the mothers
ability to go back to work or school (46.9%). This concern
was more common among mixed feeders (61.5%) and formula
feeders (61.5%) than breastfeeders (37.2%) (P = .024). Inadequate milk supply was the second most common concern
(43.9%) and was equally prevalent across groups (P = .321).
Pain associated with breastfeeding was a concern for 42.3%
of women, with similar frequency in all 3 groups (P = .657).
A higher percentage of women who chose to formula feed
were concerned about sharing feeding responsibility with
their partners, family, and friends (53.9%), compared with
mixed feeders (34.2%) or breastfeeders (28.2%) (P = .059). A
significantly larger number of women (35.9%) who chose to
3

Table 1. Characteristics of Women Whose Concerns About Breastfeeding Were and Were Not Addressed During Prenatal Care.

Concerns Addressed
Total
Characteristic

(N = )

Age, mean (SD), y

29.5 (6.3)

Yes (n = )a
26.3 (6.6)

No (n = )a

P valueb

31.0 (5.6)

.001
.054

Parity, n (%)
Nulliparous

63 (48.5)

26 (60.5)

37 (42.5)

Multiparous

67 (51.5)

17 (39.5)

50 (47.5)

Yes

50 (38.5)

9 (20.9)

41 (47.1)

No

80 (61.5)

34 (79.1)

46 (52.9)

.004

Prior breastfeeding experience, n (%)

.001

Race/ethnicity, n (%)
White

72 (55.3)

15 (34.9)

57 (65.5)

African American

23 (17.7)

15 (34.9)

8 (9.2)

Hispanic

22 (16.9)

7 (16.3)

15 (17.2)

Asian

7 (5.4)

0 (0)

7 (8.1)

Other

6 (4.6)

6 (14.0)

0 (0)
.246

Country of birth, n (%)

United States

101 (77.7)

36 (83.7)

65 (74.7)

29 (22.3)

7 (16.3)

22 (25.3)

Yes

88 (67.7)

21 (48.8)

67 (77.0)

No

42 (32.3)

22 (51.2)

20 (23)

Other

0.001

Married, n (%)

0.412

In workforce or school, n (%)

Yes

97 (74.6)

34 (79.1)

63 (72.4)

No

33 (25.4)

9 (20.9)

24 (38.1)

Private

90 (69.2)

22 (51.2)

68 (78.2)

Hospital clinic

40 (30.7)

21 (48.8)

19 (21.8)

.002

Prenatal care, n (%)

.081

Provider, n (%)
Physician

47 (36.2)

16 (37.2)

31 (35.6)

Midwife

21 (16.2)

11 (25.6)

10 (11.5)

Both

62 (47.7)

16 (37.2)

46 (52.9)
.002

Education, n (%)
High school or less

37 (28.5)

21 (48.8)

16 (18.4)

Some college

25 (19.2)

8 (18.6)

17 (19.5)

College graduate

35 (26.9)

6 (14.0)

29 (33.3)

Postgraduate

33 (25.4)

8 (18.6)

25 (28.7)

$10,000

29 (22.3)

12 (27.9)

17 (19.5)

$10,000-$24,000

16 (12.3)

13 (30.2)

3 (3.5)

$24,000

85 (65.4)

18 (41.9)

67 (77.0)

.001

Income, n (%)

.337

Feeding choice, n (%)

Breast

78 (60)

22 (51.2)

56 (64.4)

Formula

26 (20)

10 (23.3)

16 (18.4)

Mixed

26 (20)

11 (25.6)

15 (17.2)

a
Percentages
b

may not sum to 100% because of rounding.

P value is for t test (continuous variable, age) and 2 or Fisher exact test (categorical variables).

Volume 56, No. 1, January/February 2011

Table 2. Primary Concern Regarding Breastfeeding by Feeding Choice.a

Total

Breastfeeding

Formula Feeding

Mixed Feeding

N = n ()

n = n ()

n = n ()

n = n ()

P Value

106 (81.5)

63 (80.8)

22 (84.6)

21 (80.8)

.903

Lifestyle/flexibility

21 (16.2)

9 (11.5)

8 (30.8)

4 (15.4)

Pain

17 (13.1)

9 (11.5)

3 (11.5)

5 (19.2)

Confidence

47 (36.2)

35 (44.9)

6 (23.1)

6 (23.1)

Work

17 (13.1)

8 (10.3)

3 (11.5)

6 (23.1)

4 (3.1)

2 (2.6)

2 (7.7)

0 (0.0)

24 (18.5)

15 (19.2)

4 (15.4)

5 (19.2)

33 (25.4)

17 (21.8)

8 (30.8)

8 (30.8)

Any concern identified

Yes

.138

Primary concern

Medications
None identified

.512

Primary concern addressed

Yes
a

Responses in this table come from the open-ended question, While making your decision about how to feed your baby, did you have concerns about breastfeeding?

breastfeed reported anxiety or embarrassment about feeding

in public places than women who chose to mixed feed or formula feed (P = .007). Women who chose to formula feed were
more likely to be worried about maintaining their own health
while breastfeeding (P = .006). Restriction of social life and
body image were less frequently identified as concerns and did
not vary among the different feeding groups. Overall, 17.4%
(range 0%-27%) of participants who had these 8 specific concerns perceived that they were addressed by their providers
during prenatal care (Table 3).
Maternal characteristics of women who reported that
their concerns were addressed were significantly different
from women who reported that concerns were not addressed
(Table 1). Women who had their concerns about infant feeding solicited and addressed during prenatal care were more
likely to be younger (P .001), African American (P .001),
have a high school education or less (P = .002), have no previous breastfeeding experience (P = .004), and receive their

care at the hospital clinic (P = .002), compared with women

who did not have their concerns addressed. Although 52%
of women who received their care exclusively from midwives
compared with 34% of those who received their care from
physicians reported discussing their concerns about breastfeeding during their prenatal care, this finding did not reach
statistical significance (P = .081).
DISCUSSION

The overwhelming majority of women have concerns regarding breastfeeding during prenatal care. Although 81.5%
of women initially identified a primary concern regarding
breastfeeding, 95.4% reported sharing at least 1 of the 8
common concerns identified in the literature. The concerns
women identified in this study were similar to those previously identified. The majority of the literature on this topic
comes from qualitative focus groups and interviews. A focus group of upper-middle-class and middle-class women

Table 3. Prevalence of 8 Common Concerns Regarding Breastfeeding by Feeding Choice and Percentage of Women Who Reported That These
Concerns Were Addressed in Prenatal Care.a

Total
Reporting

Concern

Breastfeeding

Formula Feeding

Mixed Feeding

Reporting

Reporting

Reporting

Concern N =

Addressed

Concern n =

Concern n =

Concern n =

Valuec

Ability to work/attend school

61 (46.9)

13 (21.3)

29 (37.2)

16 (61.5)

16 (61.5)

.024

Inadequate milk supply

57 (43.9)

12 (21.1)

37 (47.4)

8 (30.8)

12 (46.2)

.321

Pain

55 (42.3)

15 (27.3)

31 (39.7)

11 (42.3)

13 (50.0)

.657

Difficulty sharing

45 (34.6)

6 (13.3)

22 (28.2)

14 (53.9)

9 (34.2)

.059

Anxiety/embarrassment

42 (32.3)

0 (0.0)

28 (35.9)

12 (46.2)

2 (7.7)

.007

Difficulty maintaining

31 (23.9)

8 (25.8)

12 (15.4)

12 (46.2)

7 (26.9)

.006

Restriction of social life

19 (14.6)

1 (5.3)

9 (11.5)

6 (23.1)

4 (15.4)

.351

Body image

18 (13.9)

2 (11.1)

12 (15.4)

4 (15.4)

2 (7.7)

.597

Concern, n ()

feeding responsibility

mothers diet/health

a
Responses in this table come from
b
Among total reporting concern.
c

responses to directed questions regarding 8 common concerns of breastfeeding mothers.

Chi-square analysis comparing the percentage reporting this concern by infant feeding choice postpartum.

Journal of Midwifery & Womens Health r www.jmwh.org

revealed that women were concerned about the ability to

successfully breastfeed and balance breastfeeding with returning to work as well as about physical changes and breast pain
attributed to breastfeeding.14 Lower income populations have
been more extensively studied, but these studies reveal similar concerns, including the ability to attend work/school, adequacy of milk supply, pain, difficulty sharing feeding responsibility, anxiety/embarrassment, restrictions on maternal
diet/health, restriction of social life, and body image.1518
During the prenatal period, one-quarter of the women
in our study sample perceived that their primary concerns
about breastfeeding had been addressed, whereas the 8 concerns identified in the literature were addressed from 0.0%
to 27.3% of the time. Although providers may think they are
discussing breastfeeding with their patients,7 the difference
in the perception of discussions regarding breastfeeding between providers and patients has been clearly identified in
a study of physician/patient dyads, which found that among
women whose obstetricians said they usually or always discussed breastfeeding duration during prenatal visits, only 16%
of women reported that it was discussed.19
There is a significant gap between the rates at which
providers report their commitment to promoting breastfeeding and patient-reported rates of being counseled. This
disparity may be related to how providers and patients interpret these interactions. Patient-focused communication
addressing individual concerns is effective in medicine in general and in promotion of breastfeeding specifically.13,20,21 Results of a model breastfeeding education program in Ohio, in
which providers focused on eliciting and acknowledging individual concerns, was associated with an increase in breastfeeding initiation rates from 15% to 31% over the period of
1 year.20,21 In a randomized, controlled trial in Singapore,
women who were given a chance to ask a lactation counselor
questions about breastfeeding were more likely to practice exclusive breastfeeding at 3 and 6 months than those receiving
standard care.22
The low rate at which women report that their concerns
were addressed during prenatal care in this study clearly
indicates a gap in communication between providers and
patients. Although providers often report that they lack
knowledge regarding breastfeeding counseling, the concerns
commonly listed in this study are practical rather than complex medical issues. The majority of women who ultimately
chose breastfeeding were most concerned about the ability to succeed and having an adequate milk supply, whereas
those who chose formula feeding worried about possible social or lifestyle issues as well as going back to work. Those
who chose mixed feeding methods expressed concerns about
the ability to succeed and going back to work. Returning
to work was the most common concern among all participants, yet many women reported not ever having discussed
breast pumping and milk storage with their providers. Because of the basic nature of many of these questions, the
majority of providers are likely able to address these concerns with reassurance about maternal physiology, practical
advice about breast pumping in the workplace, and assurance
about the increasing social acceptability of breastfeeding as
medical evidence regarding the importance of breastfeeding
accumulates.
6

Many of these more practical concerns could likely be

elicited with an open-ended approach such as the question
asked in this study: Do you have any concerns about breastfeeding? Several women reported that they were not comfortable bringing up more personal concerns such as body
image or sexuality with their providers but would have discussed these issues if the provider had started the conversation. None of the participants in the study reported discussing
sexuality and breastfeeding with their providers, yet several
reported needing someone to talk to about these issues. Although not all patients may wish to discuss concerns with
their providers, the small percentage who had their concerns
addressed in this study suggests that the opportunity for dialogue with providers is often not created during prenatal care
and that simple, open-ended questions are enough to elicit
discussion of most concerns.
We found significant differences in the maternal characteristics of women who reported perceiving that their
concerns were addressed. A review of survey results from
the National Institute of Child Health and Human Development regarding whether women were advised to consider
breastfeeding by a nurse or doctor during prenatal care suggests that women who are black, unmarried, and poorly educated are less likely to be advised to breastfeed than others,11
with other large studies showing similar results.1416,23 In our
study, counseling efforts appear to be focused on women who
have historically had low rates of breastfeeding initiation, including women who are single, low income, African American, and have a high school education or less. Although it is
encouraging that women with historically low rates of breastfeeding are being targeted, our data also suggest that the majority of women, regardless of demographics, have concerns
about breastfeeding. It appears that providers may be assuming that women who are well-educated and middle income
do not need further counseling; however, our data suggest
otherwise.
Interpretation of this cross-sectional study should consider that the retrospective design introduces the possibility of recall bias. Participants were asked immediately postpartum about their interactions with their providers during
pregnancy; therefore, the maximum time patients were asked
to recall was 36 weeks, because most women do not initiate
prenatal care until sometime after 4 weeks in a 40-week gestation. Research suggests that womens recall of events during pregnancy and birth is both accurate and reproducible.24
Furthermore, this study is most interested in what women
recall regarding prenatal interactions at the point they are
implementing their intention to breastfeed or formula feed.
Therefore, if, at the time of birth, a woman does not recall a
discussion during prenatal care regarding infant feeding, the
discussion may be unlikely to have made an impact on her
decision. Therefore, we believe the categorization of these
women as not perceiving that their concerns were addressed
by providers is appropriate. This study, however, did not assess
whether women attended prenatal classes or had their concerns about breastfeeding addressed in prenatal classes, nor
did it confirm counseling habits of their individual providers,
which remains a limitation. The study does not specifically
differentiate discussions about feeding concerns that were initiated by the clinician versus by the patient but rather whether
Volume 56, No. 1, January/February 2011

the topic was perceived to be covered at all during prenatal

care.
The size of this study sample precluded us from analyzing
the effect of addressing concerns on feeding choice. A larger
study focused on determining causality is warranted.
This study was conducted in a large, academic institution
with a mix of private and clinic providers as well as a racially
and sociodemographically diverse group of patients. A larger
multiple-site study would increase the generalizability of our
results.
This study indicates that many health care providers do
not routinely address womens concerns about breastfeeding,
regardless of ultimate feeding choice. Meaningful discussions
with patients about feeding choice are essential, not only to
possibly increase breastfeeding rates but to strengthen the
provider-patient relationship and support mothers feeding
goals.
AUTHORS

Karen Archabald, MD, MS, is a resident in the Department

of Obstetrics and Gynecology, Brown University School of
Medicine, Women and Infants Hospital.
Lisbet Lundsberg, PhD, is a research scientist in the Department of Epidemiology and Public Health at Yale School of
Medicine, New Haven, Connecticut.
Elizabeth Triche, PhD, is an assistant professor of medical science at the BioMed Center for Population Health & Clinic
Epidemiology in the Department of Epidemiology and Public
Health at Brown University School of Medicine.
Errol Norwitz, MD, PhD, is a professor and Chair of Obstetrics and Gynecology at Tufts University School of Medicine.
Jessica Illuzzi, MD, MS, is an assistant professor and Director of Medical Studies in Obstetrics and Gynecology at Yale
School of Medicine.
CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

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