Breastfeeding Experience Survey Outcomes
Authors: N. Brown, L. Geller, C. Kazbour & Members of the BABES Advisory Committee.
Last reviewed: 4/30/2014
Learning about our patients helps us tailor our education, clinical services and research to support breastfeeding families. This is especially important to us: in 2013, there were more than 9,000 babies new to PAMF.
The American Academy of Pediatrics recommends exclusive breastfeeding (breast milk with no solids or other liquids except vitamin/mineral supplements or medications) for the first six months of infancy, and then continued breastfeeding, along with the introduction of iron-rich foods, for at least the first year of an infant’s life.1
In the United States, 77 percent of babies begin breastfeeding after delivery. Unfortunately, by six months less than half are breastfeeding to any extent, and fewer than 27 percent are breastfeeding at all.2
Note: These results are not relevant for women who, for a variety of reasons, cannot breastfeed (or solely breastfeed) their babies. We still encourage these women to participate and share their experiences, which will help us develop more support services for women who 1) don't produce enough milk, 2) have health/medical issues that prevent breastfeeding, 3) have a baby in the NICU who needs supplements, 4) have a baby who does not latch (even with help from a variety of lactation consultants), or 5) cannot breastfeed for other reasons.
Disclaimer: These outcomes are provided for your general information and education only and should NOT be used for personal diagnosis or treatment. All data compiled for this project comes from a small number of Palo Alto Medical Foundation patient volunteers, and therefore is not representative of all populations or experiences. If you have questions, please contact your health care provider.
Summary of Outcomes
- First time moms who attend both prenatal childbirth and breastfeeding classes are more likely to breastfeed through the first year than moms who do not attend these classes.
Early Experience of Breastfeeding
- BABES participants who have a successful experience appear to be breastfeeding longer than they intended, overall.
- Especially for working mothers, breastfeeding is an important part of their bonding and relationship with their children, well past the first year.
- Some pain is normal within the first week (peaking at day five), and may be related to developing a good milk supply.
- Most of our participants reported having some trouble with nursing within the first two weeks. The most common problems with breastfeeding reported in the first two weeks include sore, cracked nipples (60 percent), engorgement (47 percent), trouble latching on (42 percent), weight concerns (28 percent), babies sleeping too long (26 percent), fussy baby (20 percent), not perceiving enough milk (19 percent) and slow milk coming in (18 percent).
Length of Breastfeeding
- There seems to be very little difference on length of breastfeeding between women based on the type (cesarean or vaginal) of birth experience they had or whether or not they are working outside the home.
- Most women grow more comfortable breastfeeding in public as they continue nursing.
- About half of the moms planning to return to work when the baby is 7 to 12 months old also intend to breastfeed that long, and about half of the moms not planning to return to work plan to breastfeed longer than 12 months.
- About 73 percent of BABES participants breastfeed through 12 months, although the American Academy of Pediatrics recommends all babies nurse for one year.
- The majority of participants reported that when the baby is young, if someone else had cared for the baby during the previous four weeks, it had been primarily the other parent or grandparent. As the babies age, there is a gradual shift towards non-family members caring for the children and an increase in the number of hours children spend in childcare.
- Across all surveys 75 percent of BABES participants reported that their childcare providers were very supportive of breastfeeding.
- More than 21 percent (range is 21 to 29 percent) of BABES participants report that babies sleep with their parents between 1 and 24 months of age, suggesting sleeping together facilitates breastfeeding. In fact, the most common reason given by people sharing their bed is that it facilitates nursing, followed closely by helps family sleep better, and bonding.
Working Outside the Home
- In spite of perceiving their workplaces as supportive of breastfeeding, 50 percent of women working at six months (N=205) reported that in the last four weeks they had found it difficult to arrange a break to pump, 25 percent worried that working would decrease their ability to continue breastfeeding and 24 percent had found it hard to find a place to pump at work.
Most Common Factors Supporting Breastfeeding Through the First Year
- Personal commitment and determination
- Social support (my family and husband are very supportive; information from LLL and Facebook groups)
- Workplace support/flexibility (I'm able to do it because I have a very flexible work schedule and often work from home)
- Mom and baby enjoyment and bonding (My daughter's desire to continue, my desire to continue, the special bond we shared in doing so; I didn't plan to breastfeed this long but I want to do what's best for my baby, and he clearly thinks he should still be nursing. So he probably should; One full-time working mom said: we co-sleep still and breastfeeding at night helps us sleep better and have bonding time at night that we don't get during the day; It is a time for me to bond, comfort and nourish him at the same time – it can't get any better than that!).
Reasons Participants Stopping Breastfeeding
- The most frequently reported reasons women report for stopping, change with the age of the baby. For example, the most common early reasons are sore, cracked or bleeding nipples and not enough milk, and after 13 months, baby losing interest.
These results, updated annually, are not comprehensive, but offer highlights of what we are learning.
- Demographics of BABES Survey Participants
- Breastfeeding: BABES Participants vs. the U.S. Average
- Intentions to Breastfeed
- Impact of OB/GYN Opinion
- Prenatal Class Attendance
- The Birth Experience & First Two Weeks
- Pumping Breast Milk
- Sleeping Habits
- Work and Breastfeeding
- Child Care
- Stopping Breastfeeding
- Key Factors for Breastfeeding through 12 Months
Demographics of BABES Survey Participants
As you can see below, BABES participants come from all five regions of PAMF. Table 1 shows that the majority of women participating (65 percent) are Caucasian, are over age 30, hold at least one college degree (87 percent), work outside the home (61 percent) and are first-time moms (61 percent). Women completing the demographic survey range from under 21 years of age to over the age of 46.
Table 1. Demographics of participants (N=497)
|Location of Prenatal Care (N=497)||Camino||167||34%|
|Not currently receiving prenatal care||35||7%|
|Altos Oaks Medical Group||5||1%|
|From a Non-PAMF Provider||33||7%|
|Age (N=494)||< 21 years||2||< 1%|
|21 – 25 years||22||4%|
|26 – 30 years||108||22%|
|31 – 35 years||214||43%|
|36 – 40 years||113||23%|
|41 – 45 years||31||6%|
|Education Level (N=494)||Graduate Degree||235||48%|
|High School/Trade School||7||1%|
|Employment Status (N=493)||Employed Full Time||263||53%|
|Employed Part Time||69||14%|
|Is this your first child? (N=493)||Yes||304||62%|
Table 2 describes the number of participants completing each survey. It reflects that 497 women have completed the demographic survey, and by 12 months only 53 percent are still completing surveys. We have added surveys, although few participants continue breastfeeding through 66 months.
Table 2. The number of BABES participants completing each survey and breastfeeding status
|Survey||Finished Survey||Still Breastfeeding|
Breastfeeding: BABES Participants vs. U.S. Average
Figures 1 & 2 below describe rates of any as well as exclusive breastfeeding by child’s age among BABES participants, women in California (CA) and in the U.S. Consistent with last year’s BABES data, the figures reflect the fact that BABES participants are breastfeeding more than the California and U.S. averages at every age. However, given the hope that babies are breastfed through 12 months, there are still opportunities to improve the rate of babies who breastfeed for a full year.
Figure 1. Any breastfeeding by age: BABES, CA and U.S. women
BABES Versus U.S. and CA Average: Any Breastfeeding – 2010-2013
Figures 2 reflects a similar trend for exclusive breastfeeding. Eighty percent of BABES participants were breastfeeding exclusively at three months, declining to 48 percent by six months. In comparison, the U.S. average started at 38 percent at three months and declined to about 16 percent exclusively breastfeeding by six months.
Figure 2. Exclusive breastfeeding by age: BABES, CA and U.S. women
BABES Moms Versus U.S. and CA Average – 2010-2013
Intentions to Breastfeed
We continue to see that BABES participants’ intended length of breastfeeding does not change dramatically after giving birth (Figure 3), although in 2013 there was a minor increase in women planning to breastfeed until their baby is older than 13 months.
In Figure 3 there are three lines describing BABES participants’ intentions to breastfeed at the time they completed the prenatal survey (green), the birth survey (blue) and the one-month survey (red). All three lines peak above 40 percent, reflecting intentions to breastfeed until baby is 7 to 12 months old. Given the connection between intention and behavior, the fact that fewer than half of our participants intend to breastfeed for 12 months suggests a need for messaging about the American Academy of Pediatrics recommendation about continued breastfeeding for at least the first year of an infant’s life.
The main difference is that moms at one month (after they had the baby) more often expect to breastfeed past one year.
Figure 3. Percent of women (at each survey point) who intend to breastfeed until a particular age.
BABES: Intention to Breastfeed
Impact of OB/GYN Opinion
Women who know their OB/GYN recommends breastfeeding only, without formula, are more likely to plan to breastfeed for at least 12 months, and are also much more confident that they can meet their breastfeeding goal. Figure 4 reflects the increased confidence of women that they can breastfeed if they believe their clinician believes "breast is best."
Figure 4. Reported OB/GYN opinion compared to BABES participants' confidence in their breastfeeding plans (N=388)
Mom's Prenatal Confidence to Breastfeed and Clinician's Belief About Breastfeeding
Prenatal Class Attendance
At PAMF, we continue to offer both childbirth preparation and breastfeeding classes. The good news is that both classes were attended more by first time parents than by parents who already had at least one child. Data in 2013 suggested that of the women who breastfed through one year, 88 percent of those who were first time parents had taken prenatal childbirth preparation class and 61 percent had attended a breastfeeding class (Figure 5).
Figure 5. Prenatal childbirth preparation and breastfeeding classes attended by first time parents
Moms Who Breastfed their First Child for 12+ Months and Class Attendance
The Birth Experience & the First Two Weeks
The Birth Experience
BABES participants had a variety of experiences with the birth process. Between 2010 and 2013, of the 383 women reporting how their babies were delivered, 263 (69 percent) reported a vaginal birth and 120 (31 percent) reported a cesarean birth (see Figure 6). For more than four years we have found no difference in the proportions of women breastfeeding through 12 months based on whether they reported a vaginal or cesarean birth.
Figure 6. Type of Delivery (N=383)
Cesarean vs. Vaginal Birth, 2010-2013
When asked to specify the interventions their births included, BABES participants most often reported the eight interventions in Table 3. Sixty-three percent had an epidural, 45 percent a vaginal tear, 33 percent were induced, 29 percent used pain medication, 18 percent were in labor for more than 20 hours, 17 percent had a spinal, 13 percent were pushing for more than two hours and 10 percent had an episiotomy.
Table 3. Most common interventions occurring during birth for BABES participants
|Did your birth include? (N=396)||#||%|
|A vaginal tear||179||45%|
|Pain medication (e.g. Demerol, Stadol or Fentanyl)||115||29%|
|More than 20 hours of labor||71||18%|
|More than two hours of pushing||53||13%|
The Most Common Problems with Breastfeeding Reported Within First Two Weeks
Within the first two weeks of giving birth, only 27 (7.8 percent) of moms reported having no problems with breastfeeding. For everyone else, Figure 7 reflects the most common problems with breastfeeding reported including sore, cracked nipples (60 percent), engorgement (47 percent), trouble latching on (42 percent), baby weight concerns (28 percent), babies sleeping too long (26 percent), fussy baby (20 percent), not perceiving they had enough milk (19 percent) and slow milk coming in (18 percent). Other reported issues (less than 17 percent of participants) included leaking breasts, baby nursing too often, choking baby, flat or inverted nipples and clogged milk duct.
Figure 7. Problems with breastfeeding reported within their baby’s first two weeks of life (N=325)
Most Common Reported Problems in First Two Weeks at One Month
Figure 8. Ranked best sources of information about breastfeeding identified by BABES moms in the three-month survey (N=343)
Most Common Reported Problems in First Two Weeks at One Month
According to BABES participants (N=343) at the three-month survey, personal support was the most valuable source of information about breastfeeding. Lactation Consultants and breastfeeding support group members, followed by nurses, the Internet and midwives were consistently reported as important (Figure 8).
Pumping Breast Milk
On the BABES three-month survey, 240 moms specified that they were pumping their breast milk. Figure 9 reflects that the majority of these moms 194 (81 percent) were pumping one to three times a day, 41 (17 percent) were pumping four to six times a day and 5 (2 percent) were pumping more than seven times a day.
Figure 9. Number of times a day moms are pumping breast milk when baby was 3 months old (N=240)
On an Average Day, How Many Times Do You Pump Your Breast Milk?
With a variety of reasons being reported at three months by 247 women, Figure 10 reports that the most common reason to pump included allowing others to feed the baby 12 (49 percent), returning to work 107 (43 percent), increasing milk supply 63 (26 percent), extended times away from baby 57 (23 percent), convenience 38 (15 percent), and having problems feeding at the breast 33 (13 percent).
Figure 10. Reasons why moms were pumping breast milk when baby was 3 months old (N=247)
Reasons for Pumping at Three Months
Sleeping habits are one of those touchy parenting issues that we are exploring in the BABES project. Figure 11 below reflects where parents expected their baby to sleep before s/he was born (green), compared to the reality reported at three months (blue).
Figure 11. Difference between prenatal expectations and actual sleeping habits at three months
Expected Sleeping Location (N=481) versus Actual Sleeping Location at Three Months (N=343)
Table 4 reflects the fact that most BABES participants have their babies sleeping in the parent’s bedroom (either in a separate bed or sharing a bed) until about 6 months of age, and the number of babies that share a bed with their parents remains steady during the first 24 months and is associated with the likelihood of breastfeeding for 12 months, particularly for women who work outside the home.
Table 4. Babies sleep locations over time
What is not reflected above are the reasons families reported for sharing a bed, which are, in order of frequency reported, to feed the baby (60 percent), to help the family sleep better (46 percent), to support bonding (41 percent) and to comfort fussy children (34 percent).
Figure 12. Hours of Sleep By Where the Baby Has Been Sleeping at Three Months (N=339, 3-month Survey)
Hours of Sleep Versus Where the Baby Slept
Figure 12 reports the average number of hours babies sleep at three months (N=339) by where they sleep. Babies sleeping with their parents seem to sleep on average less than four hours at a time, and babies sleeping the longest are most likely to sleep in a crib or bassinet in another room. We also know that parents sleeping with their babies report that they get more sleep if the baby sleeps in their bed.
Bed sharing continues to be highly controversial
The American Academy of Pediatricians recommends room-sharing without bed-sharing to decrease the risk of SIDS (risk factors for which include overheating, rebreathing or airway obstruction, head covering and exposure to tobacco smoke).
To reduce the risks:
- No pets in the bed.
- Remove duvets, quilts or pillows that might cover baby’s face.
- Place baby on his or her back.
- Make sure baby cannot fall out of bed or get stuck between wall and mattress.
- Use a firm mattress (no water beds sofas or soft surfaces).
- Do not leave baby unattended on bed.
- Do not share your bed if you or your partner smoke; are so tired you could not respond to baby; have drunk alcohol or taken any drug or medication that could make you extra sleepy.
Out of a total of 305 participants completing the three-month survey, 132 moms specified that their child had jaundice at some point before the baby was one month of age. Of the babies who had jaundice, 77 percent continued to nurse (see Figure 13).
Figure 13. Experiencing jaundice and breastfeeding practices, at age 1 month (N=132)
If Baby had Jaundice by 1 Month, was Mother still Breastfeeding?
Work and Breastfeeding
Figure 13 reflects that before birth, BABES participants were more likely to plan to breastfeed until the baby is older than 13 months if they were not intending to return to work in the baby’s first year. However, the graph shows that 49 percent of women who planned to return to work were planning to breastfeed for seven to 12 months in comparison to 35 percent of women who say they were not planning to return to work.
Figure 14. Comparison of how long moms plan to breastfeed by whether they plan to return to work during baby’s first year (N=482)
Comparison of How Long Moms Planned to Breastfeed and if They Planned to Return to Work During Baby's First Year
How Supportive of Breastfeeding is Your Place of Employment
Figure 15 reflects that, of surveys participants still breastfeeding, 59 percent (n=140) of BABES participants perceived their places of employment as very supportive or somewhat supportive (33 percent) of breastfeeding.
At three months we asked women who were working and pumping “Have you had any of the following experiences during the past four weeks?” Figure 16 reflects their answers. You can see that nearly half of the women working and pumping found it hard to arrange times (43 percent) or find a place (26 percent) to breastfeed or pump.
In spite of perceiving their workplaces as supportive of breastfeeding, 50 percent of women working at six months (N=205) reported that in the last four weeks they had found it difficult to arrange a break to pump, 25 percent worried that working would decrease their ability to continue breastfeeding, and 24 percent had found it hard to find a place to pump at work (results not shown).
Figure 16. Experiences Breastfeeding/Pumping at Work When Asked at Three Months (N=101)
As you can see in Figure 17, although there is no statistically significant correlation between moms returning to work and stopping breastfeeding, moms who had stopped breastfeeding were more likely to have worked in the previous four weeks.
Figure 17. A comparison of moms who have stopped breastfeeding at ages 6, 12 and 18 months and whether or not they had worked in the month prior to stopping (N=185)
Working and Non-Working Moms Who Stopped Breastfeeding Before 20 Months
Not shown is the data collected across surveys suggesting that 73 percent of BABES participants reported that their childcare providers were very supportive of breastfeeding. Table 5 reflects that the majority of participants reported that if someone else had cared for the baby, at younger ages, during the previous four weeks, it had been primarily the other parent or grandparent.
Table 5. Type of childcare through 24 months
As the babies age, there is a gradual shift towards non-family members caring for the children
and for more hours a week spent with a caregiver other than a parent (see Table 6).
Table 6. Amount of childcare through 24 months
In Figure 18 you can see that out of a total of 497 participants, 299 women have reported ending their breastfeeding experience. Of those 299 women, 254 continued breastfeeding through at
least seven months and 157 (44 percent) were still breastfeeding after 12 months.
This is a positive outcome given the American Academy of Pediatrics recommendation that babies be exclusively breastfed for about the first six months of life and continue to be breastfed until 12 months of age.
Figure 18. Age at which BABES participants report stopping breastfeeding completely (N=299)
Age of Child when BABES Mom Quit Breastfeeding
As you can see in Table 7 the most frequently reported reasons women report for stopping, change with the age of the baby. For example, the most common early reasons are sore, cracked or bleeding nipples and not enough milk, and after 13 months, baby losing interest.
Table 7. Reasons Women Report Stopping Breastfeeding (N=296)1
|My nipples were sore, cracked or bleeding||3.6|
|I didn't have enough milk||3.2||3.1||2.8|
|My baby had trouble sucking or latching on||2.6|
|Breast milk alone did not satisfy my baby||2.9|
|I could not pump enough breast milk||2.7|
|Pumping milk no longer seemed worth the effort that it required||2.5|
|My baby lost interest in nursing or began to wean himself or herself||2.9|
Figure 19 below shows that the longer a BABES participant breastfed, the more likely she was to report that she had nursed as long as she wanted to.
Figure 19. Did you breastfeed as long as you wanted by age stopped (N=260)
Did You Breastfeed as Long as You Wanted to?
The reluctance to stop breastfeeding is also reflected in Figure 20 showing that many women expected to nurse for fewer months than they actually do breastfeed. For example you can see that 50 percent of women planned to breastfeed for at least six months and only 37 percent planned to breastfeed after 13 months, whereas 50 percent actually did breastfeed past 12 months. The main reasons women reported stopping breastfeeding in the first two months were that they thought they did not have enough milk or that they had sore, cracked or bleeding nipples.
Figure 20. Comparison of mom’s intended length of breastfeeding (N=441) versus the actual behavior (N=388)
Intentional vs. Actual Length of Breastfeeding
Key Factors Supporting Breastfeeding through 12 Months
When asked to describe what key factors helped them make it to this milestone, moms outlined the reasons summarized in Figure 19. The top four reasons described were: mom’s commitment and determination to continue breastfeeding (19 percent); support from husband, family and friends (18 percent); a supportive work situation (14 percent); and when both mother and baby enjoyed it (13 percent).
Figure 21. Most common factors (N=543) helping moms (N=217) breastfeed for one year (2010-2013)
Most Common Factors (n=543) Helping Moms Breastfeed for One Year 2010-2013 (n-217)
Similarly, many of the comments we have received about what supports breastfeeding past one year reflect the same answers see Table 8 below.
Table 8. Selected comments received about what supports extended breastfeeding from women who nursed 18 to 24 months
Key Opportunities for People to Support Breastfeeding past 12 Months
When asked to describe what the barriers women face to nursing past one year, moms reported the issues summarized in Table 9. The top two barriers to extended nursing seem to be clinicians’ attitudes and a lack of social support – sadly none of which are mother and/or child related.
Table 9. Selected comments about the most common challenges faced when choosing to breastfeed for more than one year
1American Academy of Pediatrics 2012. AAP Policy on Breastfeeding. Last accessed 3/23/14.
2 CDC 2013. Breastfeeding Report Card: The United States. Last accessed 3/23/14