Why Mothers Stop Breastfeeding: Mothers' Self-reported Reasons for Stopping During the First Year

METHODS

RESULTS

Of 2586 IFPS II participants who initiated breastfeeding, 1669 mothers stopped breastfeeding during the study period, 437 were still breastfeeding after 12 months, and 480 were still breastfeeding when they dropped out of the study before 12 months. Of the 1669 who stopped breastfeeding while they remained in the study, 196 did not have complete sociodemographic data, and 150 did not answer the questions concerning why they stopped breastfeeding, which left us with 1323 mothers for our analyses. Among these women, we found that being younger, unmarried, primiparous, less educated, poorer, a WIC participant, and a resident of the Midwest or the South were each associated with early discontinuation of breastfeeding (Table 1).

The Scree test of factorial analysis yielded 7 factors that had eigenvalues of >1. As shown in Table 2, these 7 factors were (1) lactational (6 reasons related to latch-on and nipple or breast problems), (2) psychosocial (7 reasons related to breastfeeding attitudes and social support), (3) nutritional (5 reasons related to concerns about milk supply), (4) lifestyle related (5 reasons related to diet, smoking, and personal freedom), (5) medical (4 reasons related to the mother's or infant's sickness or to the mother's pregnancy or plan for her next pregnancy), (6) milk pumping (2 reasons related to mothers not being able to or not wanting to express breast milk), and (7) self-weaning (3 reasons related to infants' biting, losing interest, or otherwise indicating that they were old enough to be weaned). These 7 factors accounted for 54% of the total variance in mothers' responses to the reasons why they stopped breastfeeding.

For mothers who stopped breastfeeding within the first month and those who stopped between the first and second months after their child's birth, the 3 most frequently chosen reasons were “Baby had trouble sucking and latching on” (53.7% and 27.1%, respectively), “Breast milk alone didn't satisfy my baby” (49.7% and 55.6%), and “I didn't have enough milk” (51.7% and 52.2%). Among the mothers who discontinued breastfeeding when their infant was aged 3 to 8 months, perception of the infant's lack of satisfaction by breast milk alone (49.1%–49.5%) and concern about not having enough milk (43.8%–54.0%) continued to be important, and “My baby lost interest in nursing or began to wean himself or herself” became the third most frequent reason (33.1%–47.9%). Starting at 9 months, the 3 reasons most frequently described as important were “Breast milk alone didn't satisfy my baby” (43.5%), “My baby began to bite” (31.7%), and “My baby lost interest in nursing or began to wean himself or herself” (47.3%). The perception that their infant was not satisfied by breast milk alone was the only reason in the top 3 most frequently rated as important among mothers in all weaning-age categories (43.5%–55.6%).

Comparing the reasons cited over time, lactational and nutritional reasons were most frequently cited as important in the decision to stop breastfeeding among the mothers who did so within the first month, whereas psychosocial and milk-pumping reasons became more frequently cited among those who stopped between 1 and 2 months. Starting at the third month, self-weaning reasons progressively increased in importance, with the highest percentages for “My baby began to bite” (38.5%) and “My baby lost interest in nursing or began to wean himself or herself” (47.9%) among mothers who weaned their infant at 6 to 8 months. Generally speaking, all the reasons under the lactational, psychosocial, and milk-pumping factors were less frequently cited as important as weaning age increased. In contrast, the percentage of mothers who cited “I wanted my body back to myself,” “I became pregnant or wanted to become pregnant again,” and all the reasons in the self-weaning category as being important increased with infants' age at weaning. There are 4 reasons among the 32 items that had the same percentage of being cited as important across ages: “Breast milk alone did not satisfy my baby”; “I wanted to go on a weight-loss diet”; “I wanted to go back to my usual diet”; and “I was not present to feed my baby for reasons other than work.”

Table 3 shows the relationship between the mothers' sociodemographic status and the likelihood of their considering reasons to be important. There were no significant sociodemographic differentials in the reasons “I wanted or needed someone else to feed the baby” and “I was sick or had to take medicine.” However, primiparous mothers were more likely than multiparous mothers to cite “My baby had trouble sucking or latching on,” “Pumping milk no longer seemed worth the effort that it required,” and “My baby lost interest in nursing or began to wean himself or herself” as important reasons to stop breastfeeding, whereas primiparous mothers were 44% less likely than multiparous mothers to cite “I wanted my body back to myself” as an important reason. Hispanic mothers and those with a household income of <350% of the federal poverty level were more likely to cite “Breast milk alone did not satisfy my baby” than were white mothers and those with household income of at least 350% of the federal poverty level. Mothers with college degrees were more likely than those without degrees to cite “I wanted my body back to myself” and “Pumping milk no longer seemed worth the effort that it required” as important reasons for why they stopped breastfeeding.

DISCUSSION

Among mothers who stopped breastfeeding through the first 8 months of their infant's life, the perception of their child's dissatisfaction with breast milk alone and concerns about milk supply were both consistently cited as important reasons for stopping, and their child's dissatisfaction with breast milk was continuously cited as a top reason even among women who stopped breastfeeding after 8 months. When a mother does not have confidence that she is providing an adequate quantity or quality of milk for her infant, she is likely to stop breastfeeding regardless of her infant's age. Hispanic mothers and those with low household incomes were particularly likely to cite their child's lack of satisfaction with breast milk as a reason for stopping. Results of previous studies have similarly suggested that insufficient milk supply was a leading reason that mothers reported for their decision to stop breastfeeding.^26,27 Two studies from industrialized nations showed that >50% of breastfeeding women perceived their milk supply to be low during the early months of breastfeeding, although their infants seemed satisfied and were not underweight.^28,29 Because of difficulty in estimating the percentage of mothers whose milk supply is truly insufficient, data on the prevalence of insufficient milk supply among breastfeeding mothers are limited. However, in 4 studies of self-selected populations of women who decided to breastfeed exclusively for at least 3 to 4 months, <5% of the mothers were unable to produce enough milk to accomplish their infant's weight gain.^30–33 These results suggest that women's perception of having a low milk supply might, in many cases, be attributable to their lack of knowledge regarding the normal process of lactation or to technical difficulties in feeding rather than to an actual inability to produce a sufficient quantity of milk. They also suggest that most mothers can overcome temporary breastfeeding problems without resorting to supplementation if they receive appropriate guidance from health professionals, including reassurance that what they perceive to be a low milk supply is actually sufficient and that infant growth is uneven and often occurs in spurts.

Our data also suggest that the reasons why mothers stop breastfeeding vary with the age of their infant when they were weaned. The most frequently reported reasons for discontinuing breastfeeding within the first month were related to lactational and nutritional factors. This finding supports a recommendation by Taveras et al³⁴ that breastfeeding interventions should focus on lactational and nutritional counseling for mothers during their postpartum hospitalization and shortly after they are discharged. The Baby Friendly Hospital Initiative, a program designed to help mothers get a good start in nursing, has been shown to be effective in helping mothers initiate and maintain breastfeeding.³⁵

Although lactational and nutritional reasons for ceasing to breastfeed were still described as important most frequently by women who stopped breastfeeding during their infant's first or second month, reasons related to psychosocial and milk-pumping factors became more frequently cited. The large increases in the percentage of mothers who wanted to have someone else feed their infant or to leave their infant for several hours at a time point to the importance of a social support network for mothers with infants at this age. Paternal involvement in breastfeeding and household chores has been shown to be significantly associated with breastfeeding duration.³⁶ In addition, if society perceives breastfeeding in public as normal behavior, the need for mothers to leave infants at home might be eased.³⁷ Mothers' attitudes and concerns about pumping reflect, at least partially, the challenges that many mothers face when they return to work or school while still nursing. One reason that mothers with a college degree were more likely than less-educated mothers to cite “pumping milk no longer seemed worth the effort that it required” as a reason for weaning their infant is probably that they were more likely to pump milk from the beginning. For mothers who return to work or school, lactation programs, including flexible work schedules and easier access to a private lactation room, have been shown to have a significant impact on breastfeeding duration.³⁸

Among the mothers who stopped breastfeeding when their infant was aged 3 to 8 months, “Breast milk alone did not satisfy my baby” and “I didn't have enough milk” remained the most frequently cited reasons for doing so, whereas “My baby lost interest in nursing or began to wean himself or herself” replaced “My baby had trouble sucking or latching on” as the third most frequently cited. Among the mothers who stopped when their infant was 9 months old, self-weaning and “Breast milk alone did not satisfy my baby” were the most frequently cited reasons. Parity seems to play a role in the mothers' perception that their infant had begun self-weaning, because mothers who did not have older children were ∼40% more likely than multiparous mothers to consider “My baby lost interest in nursing or began to wean himself or herself” as being an important reason for their decision to stop breastfeeding. Sociocultural norms could also influence mothers' breastfeeding behaviors. Although breast milk alone cannot provide complete nutrition for infants older than 6 months who need to be introduced to complementary feeding, breast milk can continue to make a significant nutritional and protective contribution to their development.¹⁸ A dose-response association between breastfeeding duration and infant health has been documented previously,⁷ as have the health benefits of breastfeeding in later life.^39,40 However, despite the numerous benefits associated with extended breastfeeding, a large proportion of US adults think that 1-year-old children should not be breastfed.⁴¹ As a result, mothers may receive negative feedback for attempting to nurse older infants, and this negative feedback may tend to convince them that their infant has lost interest in nursing or has begun to wean himself or herself.

Overall, all the 32 reasons surveyed varied significantly according to weaning age except for 4 items: “Breast milk alone did not satisfy my baby”; “I wanted to go on a weight-loss diet”; “I wanted to go back to my usual diet”; and “I was not present to feed my baby for reasons other than work.” Although some reasons for ceasing to breastfeed were described as important only by a relatively small percentage of women, that may simply reflect the low prevalence of the problem rather than the importance of the problem. For example, although overall only 3.3% of the survey participants cited “I wanted to smoke again or more than I did while breastfeeding” and only 13.2% cited “I was sick or had to take medicine,” these low percentages are largely because most women do not smoke, get seriously sick while breastfeeding, or take medicines that interfere with breastfeeding. However, for those who do, these could be very important reasons to stop breastfeeding.

The strengths of this study include a minimization of recall bias through the use of data from a short-term retrospective survey that asked mothers to give their reasons for deciding to terminate breastfeeding within a month of doing so. In addition, the study sample was nationally distributed and relatively large, and the study addressed the mothers' reasons for ceasing to breastfeed for a full year postpartum.

However, the study also has at least 3 limitations: (1) the findings, drawn primarily from a study sample of white, middle-class, English-literate mothers, cannot be generalized to the entire US population; (2) the 32 reasons surveyed may not include all of the reasons why the mothers decided to discontinue breastfeeding; and (3) the closed-ended questionnaire did not allow us to explore the rationales for the reasons given, and so the reasons mothers rated as important were not necessarily a direct cause of their breastfeeding cessation.

Despite these limitations, we were able to show that the mothers' perception that “breast milk alone did not satisfy my baby” was consistently among the 3 reasons most frequently rated as important for ceasing to breastfeed, and this reason was cited more often by Hispanic mothers and those with a household income of <350% of the federal poverty level than by white mothers and those with a household income of at least 350% of the federal poverty level. We also showed that the reasons mothers described as important for their decision to stop breastfeeding varied according to the age of their child when they were weaned: reasons related to lactational and nutritional factors were described as important most often by women who stopped breastfeeding during the first 2 months postpartum, whereas reasons related to their infant's self-weaning were cited increasingly more often thereafter.

CONCLUSIONS

Our findings about why mothers are most likely to stop breastfeeding at various infant ages can be used by doctors, nurses, and lactation consultants to help mothers overcome breastfeeding barriers. They should be also useful to health officials when attempting to design targeted interventions to prolong breastfeeding by focusing on the issues that constitute the most important barriers to breastfeeding among mothers of infants of various ages.