JOGNN R E S E A R C H

The Effect of Delivery Method onBreastfeeding Initiation from the TheOntario Mother and Infant Study(TOMIS) IIISusan Watt, Wendy Sword, Debbie Sheehan, Gary Foster, Lehana Thabane, Paul Krueger, andChristine Kurtz Landy

CorrespondenceSusan Watt, DSW, RSW,School of Social Work,McMaster University,KTH-3091280 Main Street,West Hamilton, ON L8S4M4, Canada.wattms@mcmaster.ca

Keywordsbreastfeedingcesareandelivery methodbirth plans

ABSTRACT

Objective: To report on the relationship between delivery method (cesarean vs. vaginal) and type (planned vs. un-

planned) and breastfeeding initiation in hospital and continuation to 6 weeks postpartum as self-reported by study

participants.

Design: Quantitative sequential mixed methods design.

Setting: Women were recruited from 11 hospital sites in Ontario, Canada.

Participants: Participants included 2,560 women age 16 years or older who delivered live, full-term, singleton infants.

Methods: Data were collected from an in-hospital questionnaire, hospital records, and a 6-week postpartum interview.

Results: Ninety-two percent of women reported initiating breastfeeding, and 74% continued to 6 weeks. The method of

delivery, when defined as cesarean versus vaginal, was not a determining factor in breastfeeding initiation in hospital or in

the early postdischarge period. An unexpected delivery method (i.e., unplanned cesarean or instrument-assisted vaginal

deliveries) was associated, at a statistically significant level, with an increased likelihood of initiating breastfeeding and

continuation to 6 weeks postdischarge.

Conclusion: Breastfeeding can be considered a coping strategy that serves to normalize an abnormal experience

and allows the individual to once again assume control. These unexpected results warrant further investigation to

understand why women make the decision to initiate breastfeeding, why they choose to continue breastfeeding, and

how they can be supported to achieve exclusive breastfeeding as recommended for infants in the first 6 months.

JOGNN, 00, 1-10; 2012. DOI: 10.1111/j.1552-6909.2012.01394.x

Accepted March 2012

Susan Watt, DSW, RSW, isprofessor in the School ofSocial Work, McMasterUniversity, Hamilton, ON,Canada.

(Continued)

Experts view breastfeeding as the preferredmethod of newborn feeding (Boerma, Bryce,

& Axelson, 2008; Horta, Bahl, Martines, & Vic-tora, 2007). Exclusive breastfeeding is endorsedby pediatric and public health experts as the foodsource of choice for the first 6 months of an infant’slife (World Health Organization [WHO], 2003). Dur-ing the 1970s, the WHO recognized that breast-feeding rates were declining. Canada endorsedthe WHO/United Nations International ChildrensEmergency Fund (UNICEF) International Code ofMarketing of Breast Milk Substitutes (WHO, 1981)and the Baby-Friendly Hospital Initiative (BFHI)(Dennis, 2002) but has taken a voluntary ver-sus legislative approach to implementation. Ef-forts have been directed to increasing breastfeed-

ing initiation and continuation rates through theimplementation of “baby-friendly” hospital prac-tices (Chalmers et al., 2009) and postpartum sup-port services such as the Ontario’s Healthy Ba-bies Healthy Children program (Anderson, Moore,Hepworth, & Bergman, 2003; Sheehan, Krueger,Watt, Sword, & Bridle, 2001; Sword, Sheehan,Watt, & Krueger, 2006).

Delivery methods used in Canada can be clas-sified into four essential types: unassisted vagi-nal delivery, assisted vaginal delivery includingforceps and vacuum assistance, planned ce-sarean, and unplanned cesarean. To appreciatethe complex picture of breastfeeding, it is im-portant to understanding the impact of delivery

Disclosure: The authors re-port no conflict of interestor relevant financial rela-tionships.

http://jognn.awhonn.org C© 2012 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 1

R E S E A R C H The Effect of Delivery Method on Breastfeeding Initiation

The effects of delivery method on breastfeeding initiation andduration are unclear in the research literature.

method on breastfeeding initiation and duration(WHO & UNICEF, 1989).

Wendy Sword, RN, PhD, isa professor in the School ofNursing, Faculty of HealthSciences, McMasterUniversity, Hamilton, ON,Canada.

Debbie Sheehan, MSW,RN, is a senior nursingconsultant in the BritishColumbia Nurse-FamilyPartnership ScientificEvaluation Team Children’sHealth Policy Centre,Faculty of Health Sciences,Simon Fraser University,Burnaby, BC, Canada.

Gary Foster, PhD, is anassistant professor in theDepartment of ClinicalEpidemiology &Biostatistics, McMasterUniversity and aBiostatisticiain in the FatherSean O’Sullivan ResearchCentre, St. Joseph’sHealthcare Hamilton,Hamilton, ON, Canada.

Lehana Thabane, PhD, is aprofessor and associatechair in the Department ofClinical Epidemiology &Biostatistics, McMasterUniversity, Hamilton, ON,Canada.

Paul Krueger, PhD, is anassociate professor andassociate director in theDepartment of Family andCommunity Medicine,University of Toronto,Toronto, ON, Canada.

Christine Kurtz Landy, RN,PhD, is an assistantprofessor in the School ofNursing, Faculty of Health,York University, Toronto,ON, Canada.

Investigators report mixed findings in relation tothe effects of delivery method on breastfeeding ini-tiation and duration. In some studies women whohad cesareans reported that they were less likelyto breastfeed their infants (Cakmak & Kuguoglu,2007; Chalmers et al., 2010; Chien & Tai, 2007; Di-Matteo et al., 1996; Perez-Rios, Ramos-Valencia,& Ortiz, 2008; Procianoy, Fernandes-Filho, Lazaro,& Sartori, 1984; Rowe-Murray & Fisher, 2001;Sword et al., 2006; Victora, Huttly, Barros, &Vaughan, 1990). Cesareans have also been as-sociated with delayed initiation of breastfeedingand suboptimal breastfeeding behavior in the first24 hours after birth (Chapman & Perez-Escamilla,1999; Dewey, Nommsen-Rivers, Heinig, & Cohen,2003). Other investigators found no associationbetween delivery method and breastfeeding out-come, including no difference between womenwho had an assisted vaginal birth and those whohad a cesarean birth (Lawson & Tulloch, 1995;Patel, Liebling, & Murphy, 2003).

The literature does appear to be consistent inshowing that the initiation of breastfeeding is de-pendent on the nature and severity of the mater-nal trauma associated with delivery (Banapurmath& Selvamuthukumarasamy, 1995; Rowe-Murray &Fisher, 2001). Assisted vaginal birth has been as-sociated with not breastfeeding (Leung, Lam, &Ho, 2002). Cesarean deliveries have been foundto delay mother/infant skin-to-skin contact, whichhas been associated with lower initiation rates(Kearney, Cronewett, & Reinhardt, 2009). There-fore, it is important to determine if and how deliverymethod is associated with breastfeeding initiationand continuation to ensure that particular atten-tion is paid to ameliorating any negative impact ofdelivery method on breastfeeding behaviors.

Data for this study were generated as part of TheOntario Mother and Infant Study (TOMIS) III. Thepurpose of the study was to examine relationshipsbetween the method of delivery and maternal andinfant health, service utilization, and cost of care at6 weeks, 6 months, and 1 year following hospitaldischarge. This study did not have breastfeedingas a primary focus but did reveal some impor-tant information about breastfeeding. In the cur-

rent analysis, we examined the relationship amongdelivery method and self-reported breastfeedinginitiation and continuation to 6 weeks postpartum,exclusive and supplemented, in Ontario, Canada.Our findings will contribute to the small body ofresearch evidence regarding breastfeeding ratesof women experiencing other than an unassistedvaginal birth.

MethodsTOMIS III used a quantitative sequential mixedmethods design and recruited women from 11hospital sites in Ontario, Canada. Inclusion crite-ria for participants were as follows: age 16 yearsor older, delivery of a single live infant, gestationalage ≥37 completed weeks, mother assuming careof infant when discharged, mother competent togive consent, and mother can be contacted bytelephone. Women were ineligible to participate iftheir infant required admission to a neonatal in-tensive care or special care nursery for more than24 hours or were unable to communicate in oneof the four study languages (English, French, Chi-nese, and Spanish).

Data collection began in April 2006 and endedin October 2008. A detailed description of themethodology has been published (Sword et al.,2009). Data reported in this article were drawnfrom an in-hospital Mothers’ Questionnaire, la-bor and delivery chart extraction, and a follow-upstructured telephone interview 6 weeks after hos-pital discharge. The self-report Mothers’ Question-naire included questions about infant birth weightand gender, infant feeding, infant health problems,obstetrical history, chronic health problems, preg-nancy complications, delivery method, medicalproblems post delivery, perceptions of adequacyof help and support at home, readiness for dis-charge, concerns related to self and infant, andsociodemographic characteristics. Breastfeedingincluded exclusive and supplemented breast-feeding and was determined by the mother’sresponse to to the question “How are you cur-rently feeding your baby?” Two response op-tions, breastfeeding and formula feeding, wereprovided; both could be selected. Data extractedfrom labor and delivery records included gesta-tion, use of forceps/vacuum extraction, integrity ofthe perineum, use of anesthesia, excessive bleed-ing, and APGAR scores.

At 6 weeks after the woman’s discharge fromhospital, trained telephone interviewers col-lected health information about the respondents’

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Watt, S. et al. R E S E A R C H

breastfeeding experiences. The questions askedabout breastfeeding included the following:

1. Did you breastfeed this baby even if only fora short period?

2. Are you still breastfeeding?3. How old was the baby when you stopped

breastfeeding?4. Please tell me the MAIN reason you stopped

breastfeeding.5. How long do you intend to continue breast-

feeding?

The study was approved by the Hamilton HealthSciences/McMaster University Faculty of HealthSciences Research Ethics Board and by the re-search ethics board of each participating hospital.Participation was voluntary, and refusal to partici-pate did not affect the care received.

In determining the sample size, we assumed thatwomen with a vaginal birth and women with acesarean delivery were equally likely to agree toparticipate in the study. Parity was accounted forin the sample size calculation. These calculationswere performed using Power and Precision soft-ware (Cohen, Rothstein, & Borenstein, 2001). Theoverall sample was inflated to account for theanticipated intraclass correlation (ICC) structurewithin a hospital (Donner & Klar, 2000). The calcu-lations were based on ICC of 0.018 from previousstudies.

Statistical analysis was conducted using SAS ver-sion 9. Statistical comparisons were obtained fromsingle and multiple predictor generalized estimat-ing equations (GEE) analysis assuming an ex-changeable correlation structure (Bhutta, 2004).GEE allowed us to take into account possible clus-tering within a hospital. All statistical tests wereperformed using two-sided tests at the 0.05 levelof significance. The results are expressed as oddsratios (OR), corresponding two-sided 95% confi-dence intervals and associated p values. p valuesare reported to four decimal places with valuesless than 0.0001 reported as <0.0001. Additionaldetails on analysis methods can be found in thestudy protocol (Sword et al., 2009).

ResultsThe study sample included data on 2,560 womenin hospital and 1,897 (74.1%) at 6 weeks post-partum. Data about delivery method were avail-able for 2,494 (97.5%) women. Breastfeeding data

were available for 2,559 (99.6%) women in hospi-tal and 2,307 women (90.1% of initial sample) at 6weeks postpartum. For the purposes of this study,6 weeks postpartum was defined as 6 weeks fol-lowing discharge from hospital. Because hospitalstays were brief, these terms can be seen to beapproximately equivalent.

Although we conducted 1,897 interviews at 6weeks postpartum, we were able to ascertainbreastfeeding status for many more participants.If breastfeeding information was not available fromdata collected in the 6-week postpartum interview,we were able to determine 6-week breastfeed-ing status for many women using information col-lected at the 6-month postpartum interview. If awoman reported that she was still breastfeeding at6 months, we presumed that she must have beenbreastfeeding at 6 weeks. If she indicated that shewas no longer breastfeeding at the 6-month in-terview but noted that she had stopped breast-feeding after the 6-week time point, we acceptedthis as evidence that she was breastfeeding at 6weeks postpartum. Using this approach, the num-ber of women for whom we had information aboutthe method of delivery and breastfeeding initiationand continuation at 6 weeks postpartum are 2,494(97.4%) and 2,248 (87.8%), respectively. The so-ciodemographic characteristics of the 2,560 studyparticipants recruited in hospital are presented inTable 1.

Delivery Method and TypeIn our sample, 33.1% had a cesarean, 51.7% ofwhich were planned before labor began (Table 2).Of women having vaginal deliveries, 86.3% wereunassisted. Almost 75% (74.8%) of the sample de-livered as planned (unassisted vaginal delivery orplanned cesarean), 9.2% experienced a forcepsor vacuum-assisted vaginal delivery, and 16% hadan unplanned cesarean.

BreastfeedingBreastfeeding intiation was reported by 92.3% ofthe sample. According to the mother’s reports,16% of these infants received formula supple-mentation in hospital. Data were not collectedconcerning other forms of fluid supplementation.Breastfeeding continuation declined to 74.3% by 6weeks postpartum. Data on formula or water sup-plementation were not collected at 6 weeks post-partum.

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R E S E A R C H The Effect of Delivery Method on Breastfeeding Initiation

Table 1: Characteristics of The Ontario Mother and Infant Study III Study Participants(N = 2,560)

Vaginal Birth Cesarean Total SampleCharacteristic (n = 1,733) (n = 827) (n = 2,560)

Age in Years (M ± SD) (n = 2,521)a 30.6 ± 5.4 32.6 ± 4.9 31.3 ± 5.3

n (%) n (%) n (%)

Marital Status (n = 2,542)a

Married 1,292 (75.1) 678 (82.6) 1,970 (77.5)

Common-law/living with partner 308 (17.9) 103 (12.6) 411 (16.2)

Separated/widowed/divorced 18 (1.1) 10 (1.2) 28 (1.1)

Never married 103 (6.0) 30 (3.7) 133 (5.2)

Household Income (n = 2,473)a

<$20,000 187 (11.2) 67 (8.3) 254 (10.3)

$20,000–$39,999 193 (11.6) 77 (9.6) 270 (10.9)

$40,000–$59,999 273 (16.4) 100 (12.4) 373 (15.1)

$60,000–79,000 265 (15.9) 148 (18.4) 413 (16.7)

≥$80,000 751 (45.0) 412 (51.2) 1,163 (47.0)

Born in Canada (n = 2,545)a 1,221 (70.9) 581 (70.6) 1,802 (70.8)

Self-reported ethnicity (n = 2,544)a

English Canadian 955 (55.5) 430 (52.3) 1,385 (54.4)

French Canadian 90 (5.2) 36 (4.4) 126 (4.9)

Aboriginal Canadian 49 (2.9) 9 (1.1) 58 (2.3)

Chinese 161 (9.4) 68 (8.3) 229 (9.0)

Other 467 (27.1) 279 (33.9) 746 (29.3)

Language Spoken at Home (n = 2,552)a

English 1,370 (79.3) 664 (80.6) 2,034 (79.7)

French 47 (2.7) 10 (1.2) 57 (2.2)

Chinese 131 (7.6) 56 (6.8) 187 (7.3)

Other 180 (10.4) 94 (11.4) 274 (10.7)

Highest Level of Education (n = 2,547)a

Less than high school 124 (7.2) 25 (3.0) 149 (5.9)

High school 168 (9.7) 63 (7.7) 231 (9.1)

Some community college/tech. school 130 (7.5) 59 (7.2) 189 (7.4)

Completed community college/tech. school 400 (23.2) 179 (21.8) 579 (22.7)

Some university 108 (6.3) 52 (6.3) 160 (6.3)

Completed university 794 (46.1) 445 (54.1) 1,239 (48.7)

aDue to missing data for these variables the n is fewer than 2,560.

Delivery Method/Type andBreastfeeding InitiationThe delivery method, in and of itself, was notrelated to initiation. Women who had cesareanswere no more or less likely to initiate breast-

feeding than women with vaginal deliveries (seeTables 3 and 4) (OR = 0.9731, 95% CI[ [0.7651,1.2377], p value = .8242). What does distinguishthe groups is a statistically different level of breast-feeding initiation between women who had an

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unanticipated method of delivery (see Tables 3and 4) (OR = 1.5612, 95% CI( [1.1894, 2.0492],p value = .0013). Specifically, women who had anassisted vaginal delivery or unplanned cesareanwere more likely to initiate breastfeeding than werewomen who had either an unassisted vaginal de-livery or a planned cesarean.

Delivery Method/Type and BreastfeedingContinuation at 6 WeeksBreastfeeding at 6 weeks was not associated withthe method of delivery (vaginal vs. cesarean), norwas it associated with vaginal or cesarean deliverysubtypes (see Table 5) for cesareans (OR = .9190,[95% CI [0.7592, 1.1124], p value = 0.3860). Onceagain, an unanticipated type of delivery ratherthan a specific delivery method accounted for dif-ferent outcomes between these groups (see Ta-bles 5 and 6) (OR = 1.2217, [95% CI [1.0577,1.4112], p value = .0065). Women who had anunexpected delivery method were more likely tohave continued breastfeeding to 6 weeks thanwere women who had experienced their antici-pated delivery method.

Hospital Length of Stayand BreastfeedingData on hospital length of stay (LOS) were col-lected during the 6-week structured interview, andLOS was defined as the number of hours or daysbetween the baby’s birth and the time of dis-charge. Most women in our sample (98.4%) lefthospital within 120 hours after delivery, 19.3%were discharged within 24 hours. Only 5.8%stayed longer than 4 days.

Most often, women with a planned type of deliveryreported a <48 hour LOS (62%) whereas women

Table 2: Delivery Method and Typea

Delivery Method Delivery Type n %

Vaginal Unassisted 1439 57.7

Assisted 229 9.2

Subtotal 1668 66.9

Cesarean Planned 427 17.1

Unplanned 399 16.0

Subtotal 826 33.1

Total 2494 100.0

aData on type of delivery is missing for 66 women; 1,733 vaginaldeliveries (67.7%) and 827 (32.3%) cesareans occurred in thetotal sample of 2,560.

The method of delivery, when defined as cesarean versusvaginal, is not a determining factor in breastfeeding initiation.

with an unplanned type of delivery most often re-ported a LOS of ≥48 hours (69%). Comparingmean LOS for each group, no statistically signif-icant difference was reported in LOS for womenwho did or did not initiate breastfeeding in hospital(p = .8928) or for women who continued breast-feeding to 6 weeks (p = .4324). Neither breast-feeding initiation (p = .5226) nor breastfeeding to6 weeks (p = .7854) was associated with LOSwhen LOS was split into greater than or fewer than48 hours. Maternal LOS was not found to be asso-ciated with initiating breastfeeding or with contin-uation to 6 weeks (see Table 7).

DiscussionThe maternal characteristics reported are compa-rable to data available for Ontario women in the16- to 44-year-age group. No significant devia-tion was found in the percentage of respondentsin relation to age subgroups, marital status, self-reported ethnicity, language spoken at home, fam-ily income, or education (Statistics Canada, 2010).Parity data in this study is comparable to the paritydata reported in the most recent national breast-feeding study (Chalmers et al., 2010).

The cesarean rate in this study sample (33.1%)is higher than the 28.4% reported in The OntarioPerinatal Surveillance System Report 2008 (Pub-lic Health Agency of Canada, 2008). The 92.3%breastfeeding initiation rate is slightly higher thanthe 87.7% national rate in 2007 and 2008 (Breast-feeding Committee for Canada, 2004), and therate of 90.0% found in the national study byChalmers (Chalmers et al., 2010). Both differencesare within the accepted 5% variance range of so-cial science studies of this type and reflect thewider provincial picture.

At the time of the introducton of the BFHI byWHO and UNICEF in 1989, breastfeeding initia-tion rates in Canada were at 80%. Ontario prena-tal care providers and hospitals in collaborationwith community-based programs have placed anincreasing emphasis on promoting breastfeeding.The higher initiation rates found in this study sug-gest that the renewed emphasis on breastfeedingas the best-choice feeding option has been heardand is being acted upon by women in Ontario.

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R E S E A R C H The Effect of Delivery Method on Breastfeeding Initiation

Table 3: Delivery Method, Type, and Breastfeeding Initiation

Breastfeeding Initiation

Yes No Total

Delivery Method Delivery Type n (row %) n (row %) n (col %)

Vaginal Unassisted 1,317 (91.6) 121 (8.4) 1,438

Assisted 218 (95.2) 11 (4.8) 229

Subtotal 1,535 (92.1) 132 (7.9) 1,667 (66.9)

Cesarean Planned 386 (90.4) 41 (9.6) 427

Unplanned 380 (95.2) 19 (4.8) 399

Subtotal 766 (92.7) 60 (7.3) 826 (33.1)

Total 2,301 (92.3) 192 (7.7) 2,493 (100.0)

Our results support previous findings that deliverymethod, when defined as cesarean versus vagi-nal, is not a determining factor in breastfeedinginitiation. Nevertheless, our findings do suggestthat delivery type provides some clue to the ef-fects of unanticipated interventions on breastfeed-ing. A planned versus unplanned delivery type,be it vaginal or cesarean, differentiates groups

of women who initiate or sustain breastfeeding to6 weeks from those who do not initiate or sus-tain breastfeeding. Having an unanticipated typeof delivery can be viewed as a disruption in awoman’s vision of a planned sequence of eventsleading to a safe delivery. These plans are oftenrehearsed in a woman’s mind and with significantothers in her life, thereby establishing them as

Table 4: Generalized Estimating Equations Resultsa

Predictorb Estimate SE Odds Ratio 95% Confidence Interval p

Cesarean Planned −0.2513 0.1367 0.7778 [0.5950, 1.0167] 0.0660

Cesarean Unplanned 0.3939 0.1502 1.4828 [1.1047, 1.9902] 0.0087

Vaginal Assisted 0.3512 0.2182 1.4208 [0.9264, 2.1792] 0.1075

aReference group is vaginal unassisted.bInformation on breastfeeding in hospital was not available for one woman for whom delivery method/type was known.

Table 5: Delivery Method, Type and Breastfeeding at 6 Weeks Postpartum

Breastfeeding to 6 weeks

Yes No Total

Delivery Method Delivery Type n (row %) n (row %) n (col %)

Vaginal Unassisted 970 (75.3) 319 (24.8) 1,289

Assisted 174 (82.5) 37 (17.5) 211

Subtotal 1,144 (76.3) 356 (23.7) 1,500 (66.7)

Cesarean Planned 293 (73.8) 104 (26.2) 397

Unplanned 277 (78.9) 74 (21.1) 351

Subtotal 570 (76.2) 178 (23.8) 748 (33.3)

Total 1,714 (76.3) 534 (23.8) 2,248 (100.0)

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Table 6: Generalized Estimating Equations Resultsa

Predictor Estimate SE Odds Ratio 95% Confidence Interval p

Cesarean planned −0.1485 0.1292 0.8620 [0.6691, 1.1105] 0.2505

Cesarean unplanned 0.0829 0.1095 1.0864 [0.8765, 1.3465] 0.4493

Vaginal assisted 0.3038 0.1694 1.3550 [0.9722, 1.8886] 0.0729

aReference group is vaginal unassisted.

the normal or anticipated course of events for thepregnant woman and her support system.

Lazarus and Folkman (1996) argued that a disrup-tion in planned events generates stress for the in-dividual. That stress may be appraised as a threatnot only to the woman but also, by extension, toher infant. The circumstances leading to unantici-pated types of delivery meet the criteria of nov-elty, unpredictability, and uncertainty describedby stress theorists as prerequisites to the definingof an event as stressful. In addition, though thetemporal factors including imminence, duration,and temporal uncertainty will vary from situationto situation, usually they are immediate, short induration, and time restricted. Therefore, it is likelythat, at least briefly, women will experience greaterstress in these unanticipated circumstances thanin those that were expected and for which theyhad prepared themselves.

Health professionals are likely to have differentperspectives on high risk or danger from their pa-tients’ perceptions. Having assessed an imminentrisk, professionals can act. They cope by doing

either an assisted vaginal delivery or a cesarean.Women, on the other hand, necessarily becomepassive participants in what, for them, is a risk-laden drama with the well-being of their infantsand themselves at stake. A successful outcomeallows women to test the reality of their situationsand to gain an appreciation that “it was all worthit.”

Often women express relief that the outcome, ahealthy mother and infant, was a reasonable trade-off for the disruption, fear, and pain that they ex-perienced. Folkman’s (2008) work on the role ofpositive emotions in resolving stress helps us tounderstand that gratitude to health providers, re-lief at being well, and joy in having a healthy babyall coalesce to support restoration and give posi-tive meaning to the experience.

From the point of view of stress theory, breast-feeding initiation becomes a coping strategy. It isa behavior that serves to normalize an abnormalexperience and allows the mother to resume con-trol in her own life. She is, once again, a decisionmaker and regains a central role in the nurturing

Table 7: Length of Stay (LOS) by Breastfeeding Initiation and Continuation to 6 WeeksPostpartum

Breastfeeding Initiationa Breastfeeding at 6 Weeksb

Yes No Yes No Total

Length of stay n (row %) n (row %) n (row %) n (row %) n (col %)

≤48 hours 979 65 828 216 1,044

(93.8) (6.2) (79.3) (20.7) (55.1)

>48 hours 803 47 669 180 850

(94.5) (5.5) (78.8) (21.2) (44.9)

Total 1782 112 1,497 396 1894

(94.1) (5.9) (79.1) (20.9) (100.0)

aχ(1) = 0.4087; p value = .5226.bχ(1) = 0.0741; p value = .7854.

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Breastfeeding can be considered a coping strategy that servesto normalize an abnormal experience and allows the individual

to once again assume control.

of her newborn infant. It gives her control over her-self and her infant and is likely to generate posi-tive feedback from health care providers, therebyeasing the sense of failure often associated witha delivery method other than planned vaginal orcesarean delivery.

It is reasonable to see breastfeeding continuationto 6 weeks postdischarge as another aspect ofcoping with a disruption in the birthing plan. Ifcoping with stress is a process that continues be-yond the time limit of the actual threat (Lazarus &Folkman, 1996) and if breastfeeding is initiated,at least in part, as a way of coping with stressfulevents, then higher rates of continuation shouldfollow. Continuing to breastfeed, despite obsta-cles, becomes a way of asserting that all is welland that women have been successful in fulfillingtheir traditional birthing and nurturing roles.

The finding that maternal LOS is not a signifi-cant factor in either initiation or continuation ofbreastfeeding to 6 weeks postdischarge is con-sistent with the results of TOMIS II in which neitherLOS nor community support following dischargewas found to have statistically significant effectson breastfeeding rates or breastfeeding duration(Sword et al., 2006; Watt, Sword, & Krueger, 2005).With the wide availability of breastfeeding clinics,private lactation consultants, early primary carefollow-up, and public health nurses throughout theprovince, women have ready access to profes-sional breastfeeding assistance after discharge.In Ontario, access is not a function of the individ-ual’s ability to pay for services; services are avail-able from the publically insured and private sec-tors. It would appear that, despite concerns to thecontrary, shortened hospital stays have not jeop-ardized breastfeeding initiation and initial continu-ation.

LimitationsAs previously mentioned, the findings reported donot come from a study that focused specificallyon breastfeeding. Although we discovered someinteresting associations, we do not have detailson how women experience changes in birthingplans or make breastfeeding decisions. We alsodo not have sufficient information to track exclu-

sive versus supplemented breastfeeding patterns,and we lack external verification of women`s self-reported breastfeeding behavior. It is possible thatbreastfeeding self-reports, especially at 6 weekspostpartum, are exaggerated in response to thesocial pressure to be seen as conforming to thiswidely publicized standard. Finally, we would cau-tion that these results may not be generalizableto jurisdictions in which there is limited access tobreastfeeding supports in hospital or in the com-munity and respectfully suggest that the intensivepublic campaign in Ontario, supporting breast-feeding as the preferred infant feeding method,may have influenced the results.

Conclusions and ImplicationsIn this study, we found that it is not the methodof delivery that influences breastfeeding initiationand continuation but rather the change in antic-ipated delivery method that is an important pre-dictor. The findings from TOMIS III demonstratedthat overall those women who undergo cesare-ans as a method of delivery were equally likelyto initiate and continue breastfeeding to 6 weekspostpartum as women who have vaginal deliver-ies. However, women who had an unanticipatedtype of delivery (assisted vaginal delivery or un-planned cesarean) were more likely to breast-feed than women who had an anticipated deliverymethod (unassisted vaginal delivery or plannedcesarean). Health providers need to support themessage that breastfeeding should be initiatedand maintained regardless of delivery method.

In 2006, the World Health Assembly endorsed theWHO Global Strategy for Infant and Young ChildFeeding (WHO, 2003), which builds upon pastinitiatives aiming to revitalize efforts to promote,protect, and support breastfeeding. This globalstrategy urges member states to renew their com-mitment to implementation of the WHO Code andto revitalizing and expanding the Baby-FriendlyHospital Initiative.

The Ontario Ministry of Health and Long-Term Careintroduced revised Ontario Public Health Stan-dards (OPHS) in 2007 (2007). The new OPHS stan-dards do not embrace all breastfeeding best prac-tice recommendations; however, they do providean opportunity to influence policy developmentto guide public health practitioners and othersin implementing evidence-informed breastfeedingstrategies. Under the Healthy Babies Healthy Chil-dren program, all consenting mothers in Ontarioare to receive a telephone call from a public health

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Watt, S. et al. R E S E A R C H

nurse within 48 hours of discharge from hospitalwith the offer of a follow-up home visit. However,health units develop their own criteria to priori-tize who receives a home visit using variable cri-teria. The new Ontario public health accountabil-ity agreements that were introduced in 2011 haveBaby Friendly Initiative Status as the sole indica-tor for the Family Health Standard demonstratinga strong commitment to promoting breastfeeding(Ontario Ministry of Health and Long-Term Care,2011). Our results suggest that, despite an intu-itive sense to the contrary, public health units thatwant to focus on breastfeeding do not need togive prioity to women with unanticipated deliverymethods.

We have presented the hypothesis that breast-feeding serves the function of reducing maternalstress and normalizing an unanticipated birth ex-perience. Breastfeeding provides women the op-portunity to reassert control and gives positivemeaning to a difficult experience. Researchersneed to examine if this is an effective stress re-duction mechanism. If breastfeeding is effectivein helping women to regain control, health careproviders need to understand and support breast-feeding because of not only its proven benefits forinfants but also as a positive coping strategy forwomen.

Although the outcome of increased breastfeedingis a positive one, the stressful event of an unan-ticipated method of delivery is not an optimal wayof achieving the goal. Providing expectant moth-ers with more information about the possibility ofeither an assisted vaginal delivery or cesarean aspart of prenatal education could help a woman toretain a sense of control. The more the expectantmother can be included in possible changes to herbirth plan, the less negative the impact of any un-planned intervention, including an unanticipateddelivery method, may be. A structured approachto including consideration of alternatives in birthplanning should be tested.

Research about other mechanisms used bywomen to normalize their birthing experiencesmay reveal helpful ways for providers to assistwith the coping process. Not all women decideto breastfeed nor will they select breastfeedingas a coping mechanism in the circumstancesdescribed. Some will find breastfeeding to beyet another stressful demand. To be helpful, weneed to find out for whom and under what cir-cumstances breastfeeding serves as a successfulcoping strategy. We recommend undertaking ad-

ditional qualitative research studies to better un-derstand how women use breastfeeding in copingwith the stresses associated with their birth expe-riences.

AcknowledgmentFunded by the Canadian Institute for Health Re-search (CIHR).

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