Reasons mothers give for stopping breastfeeding at various weaning ages Ruowei Li, MD, PhD, Sara B. Fein, PhD Jian Chen, MSc, Laurence Grummer-Strawn, PhD Centers for Disease Control and Prevention Food and Drug Administration

Research questions What are the predominant reasons mothers discontinue breastfeeding? Do the reasons mothers give for stopping breastfeeding vary by different weaning ages?

Methods: Infant Feeding Practice Studies II (IFPS II) Sample is drawn from an established consumer opinion panel in the US Women were followed from pregnancy through the entire first year after birth with 1 prenatal and 10 postpartum mail surveys on various issues related to infant feeding practices Total sample consists of 4,903 pregnant women and 3,033 new mothers of normal healthy infants born from May 2005 through March 2007 Sample for this analysis consists of 1,323 mothers who weaned in the first year and who completed the relevant questions

Methods: Data for this analysis At each postnatal questionnaire (months 2, 3, 4, 5, 6, 7, 9, 10.5, 12), mothers were asked whether they had completely stopped breastfeeding and pumping milk If ‘yes’, mothers were asked to rate each of 32 reasons for stopping breastfeeding on a 4-point scale from ‘not at all important’ to ‘very important’

Statistical analysis Factor analysis was used to group responses on a set of underlying factors. Multiple linear regression analysis was used to assess the association between reasons and weaning age, controlling for socio-demographic variables

Sample characteristics Weaning age in months <1 1-2 3-5 6-8 >=9 Sample Size (total N=1323) 320 302 268 183 250 Maternal Education,* % <=HS 28 23 16 13 Some college 48 44 39 33 35 College graduate 24 45 51 52 Race/ethnicity, % White 86 85 87 89 90 Black 7 6 5 3 4 Hispanic 9 8 * p<0.01 between demographic variable and weaning age

Factors for reasons of breastfeeding cessation Factors extracted Cronbach alpha % variance explained 1. Lactation (6 reasons): latch-on, nipple or breast problems 0.81 11.4 2. Psychosocial (7 reasons): attitudes and social support 0.82 9.9 3. Nutrition (5 reasons): concerns over milk supply 0.73 7.9 4. Lifestyle (5 reasons): diet, smoking, personal freedom 0.72 7.7 5. Medical (4 reasons): mother or baby’s sickness 0.44 6.2 6. Milk-pumping (2 reasons): could not, did not want to pump 0.55 5.7 7. Self-weaning (3 reasons): biting, baby lost interest, old enough 0.50 5.3

Top 3 reasons for breastfeeding cessation at each weaning age Weaning age in month <1 1-2 3-5 6-8 ≥9 My baby had trouble sucking or latching on, % 54 27 I didn’t have enough milk, % 52 44 Breast milk alone didn’t satisfy my baby, % 50 56 49 My baby lost interest in nursing or began to wean him/herself, % 33 48 47 My baby began to bite, % 32

Percent of mothers citing each lactational reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 My baby had trouble sucking or latching on* 54 27 11 3 2 My nipples were sore, cracked, or bleeding* 37 23 7 6 4 My breasts were overfull or engorged* 24 12 5 1 My breasts were infected or abscessed* 8 My breasts leaked too much* 14 Breastfeeding was too painful* 29 16 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent of mothers citing each psychosocial reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 Breastfeeding was too tiring* 20 17 11 8 5 Breastfeeding was too inconvenient * 22 19 13 4 I wanted to be able to leave my baby for several hours at a time* 24 18 16 7 I had too many household duties* 14 10 I wanted or needed someone else to feed my baby* 23 21 6 Someone else wanted to feed the baby* 12 3 I did not want to breastfeed in public* 15 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent of mothers citing each nutritional reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 Breast milk alone did not satisfy my baby 50 56 49 44 I thought that my baby was not gaining enough weight* 23 18 11 14 8 A health professional said my baby was not gaining enough weight* 20 15 9 10 5 I had trouble getting the milk flow to start* 41 6 I didn’t have enough milk* 52 54 26 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent of mothers citing each lifestyle reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 I did not like breastfeeding* 16 11 6 3 2 I wanted to go on a weight loss diet 7 10 I wanted to go back to my usual diet 5 I wanted to smoke again or more than I did while breastfeeding* 1 I wanted my body back to myself* 9 13 17 19 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent mothers citing each medical reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 My baby became sick and could not breastfeed* 10 7 6 2 I was sick or had to take medicine* 14 16 15 13 8 I was not present to feed my baby for reasons other than work 3 5 I became pregnant or wanted to become pregnant again* 12 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent of mothers citing each milk-pumping reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 I could not or did not want to pump or breastfeed at work* 11 22 21 14 5 Pumping milk no longer seemed worth the effort that it required* 17 24 18 12 *p<0.01 between reason and weaning age after adjusting for demographic variables

Percent of mothers citing each self-weaning reason at each weaning age Weaning age in months <1 1-2 3-5 6-8 ≥9 My baby began to bite* 5 6 13 39 32 My baby lost interest in nursing or began to wean him or herself* 20 33 48 47 My baby was old enough that the difference between breast milk and formula no longer mattered* 11 17 27 28 *p<0.01 between reason and weaning age after adjusting for demographic variables

Summary Perception of baby’s lack of satisfaction by breast milk alone and concerns about milk supply were consistently cited as important reasons for breastfeeding cessation across time Reasons for mothers stopping breastfeeding vary by different weaning ages

Summary < 1 mo: lactational and nutritional reasons were more important 3-5 mo: self-weaning reasons were more important at this age; all lactational reasons were much less cited >=6 mo: self-weaning reasons were most important at this age; nutritional and milk-pumping reasons remained high

Study limitations Findings cannot be generalized to the entire US population Disadvantaged groups are particularly underrepresented The reasons surveyed may not represent all the causes of breastfeeding cessation

Study strengths Prospective design Sample is well distributed throughout the US Large sample size Extensive questionnaire development Short recall period