Science You Can Use: With education and support, can overweight and obese moms beat the breastfeeding odds?

A few weeks ago I wrote about the plethora of research in 2012 on breastfeeding and maternal obesity.

One of the conclusions I think you could reach in reading this new research is that, while obesity does seem to be associated with poorer breastfeeding outcomes, due at least in part to things like delayed lactogenesis II, it can’t all be physiologic.  Several studies I wrote about showed an effect of educational level, prior breastfeeding experience, or other demographic variables on breastfeeding outcomes.  The headline:  Obesity seems to increase the risk of breastfeeding problems, but it’s also not destiny.

So I was especially interested in a new study on an educational breastfeeding intervention for obese and overweight women.

This study, conducted by the University of Connecticut, the Hispanic Health Council of Hartford, and the Baby Friendly Hartford Hospital (a remarkable partnership I’ve profiled before), involved 154 overweight/obese, low income women who planned to breastfeed and were randomly chosen to receive either standard breastfeeding care and support or specialized peer counseling support.  The participating mothers were predominately (82%) Latina and half of the Latinas were of Puerto Rican heritage.

The peer counseling support included 3 prenatal visits, daily in-hospital support, and up to 11 postpartum home visits which promoted exclusive breastfeeding and addressed obesity-related issues.

The peer counselors who provided this support received 20 hours of specialized training on obesity and exclusive breastfeeding, in addition to the standard peer counselor training.  Obesity-related topics included: “breastfeeding after cesarean delivery, delayed lactogenesis, body image sensitivity, positioning for large breasts, discreet breastfeeding techniques, and research updates on maternal weight loss and childhood obesity in relation to breastfeeding.”

The results:

Breastfeeding initiation was 99% in both study groups.  The specialized breastfeeding peer counselor intervention, targeting overweight/obese low-income women, had no significant impact on exclusive breastfeeding rates during the first 6 months, and was associated with an increased rate of any breastfeeding only at 2 weeks after birth. Analysis of secondary outcomes reveals that the intervention was associated with increased breastfeeding intensity at 2 weeks after birth and lower rates of infant hospitalization at 3 and 6 months.

This result was positive, but a far cry from the results of a prior study  of this intervention with a general population (not all overweight or obese), which found that moms who got this support were 15 times more likely to breastfeed exclusively for three months than those who didn’t.

One thing to note is that the “standard breastfeeding care and support” the mothers in the control group received is not what most of us would think of as standard.  Hartford Hospital is Baby Friendly and also employs peer counselors to support mothers, so the care the control group received was likely significantly superior to the “standard care” mothers receive in the U.S. as a whole.  This raises a question about whether there was a ‘victim of one’s own success’ factor at play.

So, what to make of the current study’s results?  The authors state that “Our results…suggest that the breastfeeding barriers experienced by overweight and obese women have not been fully addressed and that further research is needed to understand the etiology of their poor breastfeeding outcomes.”

I had the opportunity to pose a few questions to Dr. Donna Chapman, study co-author and Associate Research Scientist in Chronic Disease Epidemiology at Yale University.

You write that this study demonstrates that “further research is needed to understand the etiology of [overweight and obese women's] poor breastfeeding outcomes.”  What are some factors you’d like to see investigated? 

We need to identify the barriers faced by these overweight and obese, low-income women.  For example, is body image a factor which limits their breastfeeding success?  Are there concerns about privacy and the adequacy of support in the hospital?  In addition to understanding these barriers, we really need to further explore how hormonal differences in overweight and obese women are related to breastfeeding success.

Was there any indication that mothers appreciated having support from peer counselors who understood obesity-related breastfeeding issues, such as delayed lactogenesis, body image sensitivity, or positioning for large breasts? 

Although we didn’t have the space to address this in the manuscript, the mothers were asked to rate their satisfaction with the peer counselors.  The overwhelming majority were very appreciative of the specialized support they received. 

Was there any indication that extent of pre-pregnant overweight or obesity was a factor?  In other words, did mothers with lower BMI scores have different outcomes that mothers with higher BMI scores?  

Our statistical analyses controlled  for maternal BMI, but showed no relationship between BMI and breastfeeding success in this population of overweight and obese women.  It is possible that obese women may have more breastfeeding difficulty than overweight women, but our study was not designed to test this hypothesis.

Image credit:  Wikimedia Commons



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3 Comments | Last revised on 12/27/2012


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3 Responses to Science You Can Use: With education and support, can overweight and obese moms beat the breastfeeding odds?

  1. Lori says:

    I am a size 3x shirt, 42J bra and between my two children I have nursed for a total of 3 years 8 months. As an obese woman who has successfully breast fed both of my children I would like to point out that some of the support needed is of a more practical nature. Affordable plus size (and large cup size) nursing bras, nursing shirts and other accessories would go a long way to bigger moms being successful. No woman likes to wear an ill-fitting, uncomfortable bra. Large women (at least those that I know) are more concerned with showing belly fat than a glimpse of nipple so a good nursing shirt or clothing strategy can make a big difference! Also, for plus size, pumping moms just having information about flange size would make a difference! While the medical concerns with being overweight do effect some women the lack of available supplies and the social stigma effect all of us.

  2. Stephanie says:

    Lori, I could not agree more. I’ve nursed all 3 of my children. I’ve been nursing for almost 10 years of my life. I’m currently nursing a 2 1/2 year old. I usually wear a 44DD when I’m nursing and 3X size shirts as well. The biggest obstacle I’ve found is exactly what you describe. With my third child, I’ve finally given up using expensive nursing shirts, I just wear shirts with elastic or stretchy necklines and pull them down and throw something small over my shoulder to cover up the top of my breast. I feel exactly the same way, I’d much prefer a nipple be glimpsed than show belly fat any day.

    When I shop for nursing bras, I notice the sizes that are always already sold out are close to mine, and the tiny 34Bs are always sitting there. 99% of nursing mothers aren’t going to be wearing a B or even C cup nursing bra — that’s why they’re still sitting there. Breasts increase greatly when nursing, especially in the first few months. There are even times I’ve converted my own regular bras into nursing bras because I could not find affordable bras. Affordable is not a $75 nursing bras.

    I think another huge obstacle is in the portrayal of breastfeeding. Overweight moms don’t realize there are other ways to hold a baby to nurse than the cradle hold. The football hold, under my arm, made it so much easier for me to nurse, especially after a c-section. If you have ample breasts, you feel like your baby is going to suffocate on your breast when you nurse. It is extremely difficult to maneuver a baby, latch them on and keep your breast tissue pulled back for them to breathe. I can’t tell you how many times I’ve wished for smaller breasts while nursing.

    However, after reading this article, I don’t think you can take a study that was 82% Hispanic and relate it to other cultures. Culturally, women of Hispanic descent look down on nursing women. It’s viewed as something poor people do, not anyone in higher classes. I am curious if you this study with women equally from different races and backgrounds, if this study would be different?

    • Tanya Lieberman, IBCLC says:

      Stephanie (and Lori, too), thanks so much for these comments. I think that more understanding and sensitivity to these issues is really important, and I appreciate what you’ve shared here!

      One note about the study and its applicability to a broader population. You’re absolutely right that what works and doesn’t work in a low income, urban, Latina sample of women may not reflect what works in a different population. In fact, research I highlighted a few weeks ago shows that factors like higher income are associated with more breastfeeding success among overweight/obese women. But the interesting thing about this study is that the prior study was of the same sample population (Latina/predominately Puerto Rican, low income, urban) but not overweight/obese. So the weight issue was essentially isolated in this study, and the fact that the intervention didn’t achieve the same results does tell you that there’s something going on here. We just don’t know what yet! That’s one reason why your comments are really helpful.

      I want to note one more thing about your comment about Latina mothers and breastfeeding. Latinas as a whole actually have a very high breastfeeding initiation rate – higher than white mothers, actually. The majority of Latinas are of Mexican heritage, and breastfeeding is viewed quite favorably in the Mexican American community (though exclusivity is an issue). The population in this study was more Puerto Rican in background, and the rates in the Puerto Rican community are very different. I say all this to point out that Latina moms do in fact breastfeed at very high rates but that there is a lot of cultural diversity when it comes to this issue as well.

      Again, thanks so much for the comments!

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