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• Published: 25 March 2021

Factors influencing exclusive breastfeeding rates until 6 months postpartum: the Japan Environment and Children’s Study

• Hitomi Inano 1 ,
• Mariko Kameya 1 ,
• Kyoko Sasano 2 ,
• Kenta Matsumura 3 ,
• Akiko Tsuchida 3 , 4 ,
• Kei Hamazaki 3 , 4 ,
• Hidekuni Inadera 3 , 4 ,
• Tomomi Hasegawa 2 &

The Japan Environment and Children’s Study (JECS) Group

Scientific Reports volume  11 , Article number:  6841 ( 2021 ) Cite this article

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This research aimed to examine the efficacy of the early initiation of breastfeeding within 1 h of birth, early skin-to-skin contact, and rooming-in for the continuation of exclusive breastfeeding until 6 months postpartum. The research used data from the Japan Environment and Children’s Study (JECS), a nationwide government-funded birth cohort study. A total of 80,491 mothers in Japan between January 2011 and March 2014 who succeeded or failed to exclusively breastfeed to 6 months were surveyed in JECS. Multiple logistic regression model was used to analyse the data. The percentage of mothers who succeeded in exclusively breastfeeding to 6 months is 37.4%. Adjusted odds ratios were analysed for all 35 variables. Early initiation of breastfeeding (adjusted odds ratio [AOR]: 1.455 [1.401–1.512]), early skin-to-skin contact (AOR: 1.233 [1.165–1.304]), and rooming-in (AOR: 1.567 [1.454–1.690]) affected continuation of exclusive breastfeeding. Regional social capital (AOR: 1.133 [1.061–1.210]) was also discovered to support the continuation of breastfeeding. In contrast, the most influential inhibiting factors were starting childcare (AOR: 0.126 [0.113–0.141]), smoking during pregnancy (AOR: 0.557 [0.496–0.627]), and obese body type during early pregnancy (AOR: 0.667 [0.627–0.710]).

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Introduction.

Breastfeeding has been reported to lower a child’s risk of infectious disease and allergic illness while also being beneficial to the health of the mother 1 . Given that it contributes to the lifelong health of both mother and child, breastfeeding is widely encouraged throughout the world. The United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), and the American Academy of Pediatrics all recommend exclusive breastfeeding (EBF) 2 , 3 for the first 6 months postpartum. During EBF, breast milk must be the infant’s only intake, without additional food or drink, including water.

According to surveys conducted by the Ministry of Health, Labour and Welfare in Japan, more than 90% of pregnant women hope to breastfeed their children. Nevertheless, only 50% of mothers are able to continue EBF with their children up to even 3 months postpartum 4 .

Factors influencing breastfeeding rates include social demographic factors such as the mother’s age 5 , race 6 , level of education 7 , smoking habits 8 and presence or absence of obesity 9 . The list of “Ten Steps to Successful Breastfeeding” proposed by the WHO and UNICEF contains additional items such as early initiation of breastfeeding (within 30 min of birth), early skin-to-skin contact (Step 4) and 24-h rooming-in (Step 7). Rooming-in entails placing the infant in a stand-alone cot by the bedside of the mother or bed-sharing by attached side-car crib as opposed to keeping the infant in a hospital nursery or separate room (in case of home-deliveries). Large-scale surveys investigating whether these kinds of early postpartum mother–child care practices affect EBF up to 6 months postpartum are rare worldwide and do not exist within Japan.

Using data from the Japan Environment and Children’s Study (JECS), the present study aims to examine the efficacy of early initiation of breastfeeding, early skin-to-skin contact, and rooming-in for the continuation of EBF through to 6 months postpartum, and moreover this study aims to contribute to increasing the rate of EBF up to 6 months postpartum by identifying factors that sustain and inhibit EBF.

Materials and methods

Study population.

JECS is a nationwide government-funded birth cohort study that evaluates the impact of various environmental factors on children’s health and development. The pregnant women participating in JECS were recruited from 15 areas in Japan between January 2011 and March 2014 10 , 11 . Further information on the methods utilised within JECS have been previously published 10 , 11 . The present study is based on a dataset (jecs-an-20180131) that was released in March 2018. The full dataset contained 103,062 pregnancies. Of these, 5,647 data points were excluded because of multiple registrations, 949 were excluded because of multiple births, and 3676 were excluded because of miscarriages or stillbirths. Among the remaining 92,790 unique mothers with singleton live births, 9133 were excluded because of missing information for methods of feeding or missing answers and 3166 were excluded because of the exclusive use of infant formula at one month. As a result, data from 80,491 mothers were analysed in this study (Fig.  1 ).

Participants flow diagram. See text for details.

The JECS self-administered questionnaire is an instrument provided to enrolled mothers and their partners during the first trimester and second/third trimester of pregnancy. One month after birth, a questionnaire is answered by the mothers and/or partners. Thereafter, questionnaires are administered every six months. Each questionnaire contains a section designated to collect information about chemical exposure, socioeconomic status, lifestyle factors, and physical environment 10 .

JECS data items used

Data from medical record transcription forms were acquired for the following variables: maternal age, parity, fertilisation method, delivery method, presence or absence of obstetric complications, BMI before pregnancy (less than 18.5 kg/m 2 , 18.5 to 25 kg/m 2 , greater than 25 kg/m 2 ), gestational period of the child, gender of the child, presence or absence of birth defects, and presence or absence of analgesia use during delivery. In addition, the cut-off point for obesity in this study, that is, BMI > 25 kg/m 2 was the same as that in the profile paper 11 .

Daily caloric intake in the second/third trimester of pregnancy was determined by the Food Frequency Questionnaire, which is semi-quantitative and has been validated for use in large-scale Japanese epidemiologic studies 12 . Data were taken from maternal self-administrated questionnaires for the following variables: child nutrition method (e.g., breast milk, mixed, or formula), marital status, drinking habits, smoking habits, exercise habits, presence or absence of second-hand smoke exposure, use of cellular phone or SMS messaging while nursing, presence or absence of early initiation of breastfeeding within one hour of birth, presence or absence of early skin-to-skin contact, presence or absence of rooming-in, depression as assessed by the Edinburgh Postnatal Depression Scale (EPDS) at 1 month postpartum 13 , presence or absence of negative emotions related to pregnancy, social connections, presence or absence of an opportunity to return to one’s parents, person responsible for household work, presence or absence of starting childcare by the age of 6 months, father’s participation in parenting, presence or absence of confidence in the surroundings, regional social capital, mother’s employment status, household income and education levels of mother and father.

Data were also taken from maternal self-administrated questionnaires at 1 month postpartum for the presence or absence of experiences where the child’s condition worsened while breastfeeding. Worsening of the child’s condition was defined as urticaria, skin changes, redness in and around the mouth, and pallor within an hour of breastfeeding.

Data were also taken from maternal self-administrated questionnaires at 6 months postpartum for the presence or absence of a pet in the household. Presence of a pet was considered to be a factor that would increase the burden on mothers and also affect breastfeeding.

Measurements

Exclusive breastfeeding (ebf).

Mothers who indicated on the JECS self-administered questionnaire form at 6 months postpartum that they practiced continued, uninterrupted exclusive breastfeeding from the first month postpartum to the sixth were placed in the EBF group.

Early initiation of breastfeeding, early skin-to-skin contact, rooming-in

Mothers who responded with answer (1) to the following question on the JECS self-administered questionnaire at 1 month postpartum were regarded as having performed early initiation of breastfeeding: ‘When did you first hold your nipple in your child’s mouth? (1) Within 1 h of birth (2) More than one hour after birth (3) I have not yet had the chance to hold my nipple in my child’s mouth’.

Similarly, individuals who responded with answer (1) to the following question were regarded as having performed early skin-to-skin contact: ‘Did you hold your new-born baby in your arms soon after giving birth? (1) I held my baby so that our skin would touch. (2) I held my baby, but our skin did not touch. (3) I did not hold my baby soon after birth’.

Finally, we used the following question as a scale assessment of rooming-in: ‘In the facility in which you gave birth, how long were you able to stay in the same room as your new-born? (1) Almost no time (2) About a quarter of a day (3) About half of a day (4) About three-quarters of a day (5) We were nearly always together’.

Regional social capital

Social capital is a characteristic—similar to trust, norms, and network—of social organisations that refers to their ability to induce cooperative action in pursuit of a common goal.

The total point value of the responses of pregnant women to the following two questions on the JECS self-administered questionnaire was used to measure social capital: ‘1. The people of my neighbourhood trust each other’ and ‘2. The people of my neighbourhood help each other’. Both questions were asked during the second/third trimester and had the following four potential responses: ‘(1) I believe so (1 point); (2) I would assume so (2 points); (3) I would not assume so (3 points) (4) I do not believe so (4 points)’. Social capital was divided into the following four categories according to the total point values measured: high social capital—2–3 points; medium social capital—4 points; low social capital—5–6 points; very low social capital—7–8 points 14 .

Multiple logistic regression model was used to analyse the data. SAS version 9.4 (SAS institute Inc., Cary, NC) was used for all analyses. Adjusted odds ratios were analysed for all 35 variables. The threshold for statistical significance was 5%, and we performed two-tailed tests. Risk indices have been listed with odds ratios and 95% confidence intervals in the results tables.

Subject characteristics

The 80,491 individuals included in the study had an average age of 31.1 years (± 4.97 years). Of these, 43% were first-time mothers, 81.7% had a vaginal delivery, and 10.0% were obese. Of the total sample, 30,070 individuals (37.4%) continued EBF through to 6 months postpartum (EBF group). The average age of the EBF group was 30.9 years (± 4.74 years). In the EBF group, 36.3% were first-time mothers, 84.6% had a vaginal delivery, and 7.2% were obese.

Of the 35 items postulated to be factors affecting continuing EBF, statistically significant differences were found for 31 items.

Early postpartum nursing prolonged the period of EBF

According to Table 1 , the factors related to early postpartum mother–child care were early skin-to-skin contact, early initiation of breastfeeding, and rooming-in; these were extracted as continuation factors for EBF. Initiation of breastfeeding within one hour of birth contributed more strongly to the continuation of EBF than did initiation of breastfeeding more than one hour after birth. Rooming-in for 18–24 h also contributed to the continuation of EBF.

The child started childcare by the age of 6 months shortened the period of EBF

Table 2 shows that the following social factors possibly affected continuation of EBF: presence or absence of confidence in the surroundings, regional social capital, degree of second-hand smoke exposure, whether one’s child had started childcare by 6 months of age, whether there was a return to one’s parents’ house, degree of paternal participation in parenting and who in the household did most of the housework.

Among the 35 factors examined, the child starting childcare by the age of 6 months was found to be the most inhibiting. ‘Rarely available’ and ‘somewhat available’ confidences as compared to the absence of a confidence, were also inhibitory factors for EBF continuation. Further, close relatives’ smoking outside of the baby’s presence was an inhibiting factor. With regard to return to one’s parents’ house, a return for longer than 1 month or situations in which the mother lived with her parents were found to inhibit continuation of EBF. The greater the father’s participation in parenting, the more inhibitory it was for EBF continuation. Finally, situations in which the maternal grandfather was primarily responsible for housework were found to be inhibitory for EBF. The only social factor found to contribute to EBF continuation was medium to high regional social capital.

Full term and female babies were more likely to be breastfed

According to Table 2 , the following child related variables were found to support EBF continuation: gender, gestational period, and presence or absence of birth defects. Males were less likely than females to be exclusively breastfed to 6 months. The presence of birth defects was also found to be an inhibitory factor of EBF continuation. Additionally, the longer a child’s gestational period (measured in weeks), the more it contributed to the continuation of EBF.

Negative social demographic factors obstructed EBF

Table 3 shows that the following social demographic factors contributed to the continuation of EBF: maternal age, maternal education level, paternal education level, maternal employment status, and parental marital status. The higher a mother’s age was (to the nearest year), the more it contributed to the inhibition of EBF continuation. With regard to maternal education level, mothers that graduated from vocational school, community college or a university were more likely to continue EBF. Paternal education level was associated in the same way with EBF. Mothers who were housewives and on leave from work were more likely to continue EBF than full-time employed mothers. Finally, divorce from or death of the husband was an inhibitory factor of EBF continuation compared to being married.

Having a household pet reduced the period of EBF

Based on Table 3 , the following maternal lifestyle factors were found to be involved in the continuation of EBF: smoking habits, exercise habits, and having a household pet. Smoking was found to be an inhibitory factor of EBF continuation, even if the mother stopped smoking after discovering pregnancy. Engaging in a minimum of 10 min per week of light exercise (e.g., walking) was found to be a supporting factor of EBF continuation. Finally, the presence of a household pet was associated with a lower prevalence of EBF continuation. Each factor was tested for multicollinearity, and domestic violence was removed from the results because of the multicollinear relationship between smoking and domestic violence.

EBF mothers were more likely to have looked at a computer or cell phone while breastfeeding

Table 3 shows experience of the child’s condition worsening during breastfeeding, and the use of one’s mobile phone or PC during nursing were found to support the continuation of EBF. On the other hand, housework during nursing was found to be an inhibitory factor of EBF continuation.

Obesity in pregnancy reduced the period of EBF

Table 4 shows that the following maternal physical factors were found to influence EBF continuation: BMI and Parity. A BMI of 25 or greater indicating obesity was an inhibitory factor for EBF continuation. Multiparity was found to support EBF continuation.

An unsettled state of mind in pregnancy reduced the period of EBF

According to Table 4 , the following maternal psychological factors were found to be inhibitory toward EBF continuation: negative emotions toward pregnancy and a score of 9 or greater on the EPDS.

Medical intervention during the perinatal period tended to restrict EBF

Based on Table 4 , the following medical factors were found to be involved in EBF continuation: delivery method, use of analgesics during delivery, and engagement in infertility treatments. Caesarean section delivery (more so than vaginal delivery) tended to be positively associated with EBF at 6 months. Analgesic use during delivery and infertility medications were found to be inhibitory factors of EBF continuation.

This large-scale cohort study clarified the factors involved in EBF continuation through to 6 months postpartum. In particular, the early initiation of breastfeeding—within one hour of birth—was shown to contribute greatly. Many previous studies 15 have shown that early initiation of breastfeeding and early skin-to-skin contact are the keys to successful breastfeeding, and this study showed similar results. In addition, previously published research has indicated various factors as being effective in promoting the continuation of EBF including rooming-in 16 , 17 , education level 18 , presence of a child supporter 19 and Parity 20 and so on. In this study, as in the previous studies, the above factors were found to contribute to breastfeeding.

The higher the rate of EBF at 6 months, the greater the benefit to maternal and infant health and the greater the significance from a public health perspective. Therefore, the Global Breastfeeding Collective of UNICEF/WHO aims to increase the percentage of babies under 6 months old exclusively breastfed from 44 21 to 70% by 2030 22 . The prevalence of exclusive breastfeeding in Japan at 3 months is 54.7% 4 and at 6 months is 37.4%. These percentages are not high. However, the results of this study have provided several hints to increase the percentage of EBF.

The results of the present study revealed newly discovered factors influencing the continuation of EBF, such as regional social capital during pregnancy and ownership of a household pet. High regional social capital tends to associate with high levels of health among the residents of the region 23 . This study has revealed that high regional social capital was associated with a high breastfeeding rate, meaning that high regional social capital influences mother–child health. This discovery indicates that activities that seek to promote regional social capital may also have beneficial effects for maternal and child health.

Besides, previous research has shown that dog ownership has a positive effect on child development, so we considered it as a variable 24 . However, we found that pet ownership interfered with breastfeeding. Raising pets increases the burden on mothers, which results in mothers spending less time with their children. This also reduces the amount of time spent slowly feeding breast milk, which may have been extracted as a factor in reducing breastfeeding rates.

Regarding other factors, as reported in previously published research, our study found that the mother’s education level is positively associated with the continuation of EBF. According to literature, mothers who decide to engage in EBF inform themselves to a greater degree about nutrition and diet, consult more frequently with their doctors, and have better access to information on the health of nursing children than mothers who do not engage in EBF 25 . It may be the case that the higher a mother’s education level, the more aware she is of the merits of EBF and, therefore, her motivation to implement it is higher.

Regarding support in the parenting process, our research indicated that the father’s participation in parenting is negatively associated with continued EBF. This runs contrary to associations reported by other researchers 26 . It is very common for parents to supplement milk with a baby bottle, and this situation can make it easy for fathers to help with feeding. Therefore, it is thought that bottle feeding resulted in a higher rate of father participation in childcare, including with feeding. Nevertheless, in the context of the continuation of EBF, the importance of a childcare supporter has been made clear by previously published work 27 .

Regarding activities while nursing, it is generally believed that looking into the eyes of the child is beneficial from the perspective of forming an attachment with the child 28 , but the results of this study, there was no association between looking into the eyes of the child and the duration of EBF. Instead, we saw a trend that mothers who breastfed while looking at the newspaper or a mobile phone continued to EBF for longer. This suggests that for mothers who continue to EBF, breastfeeding itself is as integrated into their lives as looking at the newspaper or mobile phone. Since one hand is free while breastfeeding, simple actions that can be done with one hand can be done at the same time. However, for parents who are mixed feeding, it becomes difficult to look at the newspaper or a phone while feeding because both hands are required (to hold the baby and to hold the bottle). This may explain why the percentage of the EBF group who looked at a newspaper or mobile phone with one free hand while breastfeeding was higher than that for the mixed feeding group.

In this study, Caesarean sections were found to be positively associated with EBF at 6 months, which is inconsistent with the direction of association reported in most other studies. Many studies examining Caesarean sections and breastfeeding rates have examined breastfeeding rates less than 3 months postpartum as an endpoint 29 , but our study examined a relatively long breastfeeding period, with 6 months as an endpoint. The results of this study suggest that the period during which Caesarean section interferes with breastfeeding may be a relatively short period after delivery. In other words, mothers who gave birth by Caesarean section are likely to have difficulties in breastfeeding during the first 3 months after delivery, but after 3 months, they may be able to continue breastfeeding and the fact that they have undergone a Caesarean section does not interfere with EBF.

Reports on factors involved in the inhibition of EBF continuation include the following: low household income 30 , obesity 31 , 32 , engagement in smoking 33 , presence of domestic violence 34 , low birth weight 35 , use of epidural anaesthetics 36 and a high EPDS score 37 . These factors were found to inhibit EBF in our research as well.

Other factors found to inhibit EBF continuation in this study were that the child started childcare, mother smoking, and obesity in early pregnancy. Among these, the child starting childcare by the age of 6 months or younger was found to inhibit EBF continuation most profoundly. Previously published research has indicated that even if a mother is employed full-time—a factor known to affect breastfeeding—giving one’s child over to another’s care before 6 months of age is associated with the cessation of breastfeeding 37 , 38 . The primary reason that necessitates the handing over of one’s child to another’s care is a mother’s need to return to her workplace 39 . The Japanese maternity leave system offers 8 weeks after giving birth, with the possibility of focusing on childcare for up to 1 year with some degree of paid salary if the mother is able to obtain childcare leave. The International Labour Organization recommends providing mothers with at least 18 weeks of maternity leave and 100% payment of salary during that period 40 , but this practice is yet to be enforced within Japan 41 . The child starting childcare makes the continuation of EBF quite difficult; mothers should receive at least 6 months of maternal leave. Alternatively, arrangements ought to be made to allow mothers who return to work before 6 months postpartum to bring their children with them to the workplace. This is because children that are breastfed rely exclusively on breast milk for their nutrition and require frequent feeding. Besides, many nurseries do not accept breast milk for hygiene reasons in Japan 42 . This makes exclusive breastfeeding difficult. Furthermore, the main reason for starting childcare is the mother's return to work. While a mother's return to work is not in itself an impediment to breastfeeding, the fact that she will no longer be able to breastfeed as often as she has been able to in the workplace is a problem for her to continue breastfeeding.

The potential implications of providing new mothers with an environment in which they can respond to their infants’ needs quickly include the rise of birth rates. Society at large—not just mothers and children—will benefit greatly from the windfall of such a change. If Japan truly intends to bring its EBF rate in line with the global benchmark, it is necessary to improve early postpartum care and overhaul the current maternity leave system.

There were several limitations in our research. First, the questions polling about initiation of breastfeeding within one hour of delivery, early skin-to-skin contact, and mother–child rooming-in were asked one month after birth; the answers were therefore subject to errors in recall, and their accuracy cannot be guaranteed. Similarly, mothers were asked to declare whether they engaged in EBF 6 months postpartum—they needed to look back on 6 months of childcare and remember their habits. This, too, may have introduced some unreliability into our data. However, because the number of cases we examined is quite large, the unreliability of a few answers should not affect our results in any meaningful way. Second, our participants were all mothers living in Japan; thus, generalising our findings to the global situation is difficult. Third, because the answers to the factor items (the independent variables) and the answers reporting EBF (the dependent variable) were collected at different times, caution regarding their cause-and-effect relationship is essential to the proper interpretation of our results. Finally, because this was a large-scale survey, it is possible that some spurious findings were discovered.

In conclusion, early postpartum mother–child care—initiation of breastfeeding within one hour of birth, early skin-to-skin contact, and rooming-in—was found to contribute greatly to the continuation of EBF till 6 months postpartum. In addition, high social capital was found to effectively promote continuation of EBF. On the other hand, the child starting childcare was found to greatly inhibit continuation of EBF. Hence, these findings suggest a necessity to provide a minimum of 6 months maternity leave and to provide mother–child support in care protocols in order to raise the rate of Japanese EBF during 0–5 months of age up to 70%.

Ethics approval

The study protocol was approved by the Ministry of the Environment’s Institutional Review Board on Epidemiological Studies and by the Ethics Committee of all participating institutions. Written informed consent was obtained from all participants.

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Acknowledgements

We are grateful to the participants of JECS and to all individuals involved in data collection. The Japan Environment and Children’s Study was funded by the Ministry of the Environment, Japan. The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the above government agency.

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Department of Maternal Nursing, Graduate School of Medicine and Pharmaceutical Science for Education, University of Toyama, Toyama City, 930-0194, Japan

Hitomi Inano & Mariko Kameya

Division of Maternal Nursing, Graduate School of Medicine and Pharmaceutical Science for Research, University of Toyama, Toyama City, 930-0194, Japan

Kyoko Sasano & Tomomi Hasegawa

Toyama Regional Center for JECS, University of Toyama, Toyama City, 930-0194, Japan

Kenta Matsumura, Akiko Tsuchida, Kei Hamazaki & Hidekuni Inadera

Department of Public Health, Faculty of Medicine, University of Toyama, Toyama City, 930-0194, Japan

Akiko Tsuchida, Kei Hamazaki & Hidekuni Inadera

Graduate School of Medical Sciences Department of Occupational and Environmental Health, Nagoya City University, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan

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National Institute for Environmental Studies, Tsukuba, Japan

Shin Yamazaki

National Center for Child Health and Development, Tokyo, Japan

Yukihiro Ohya

Hokkaido University, Sapporo, Japan

Reiko Kishi

Tohoku University, Sendai, Japan

Nobuo Yaegashi

Fukushima Medical University, Fukushima, Japan

Koichi Hashimoto

Chiba University, Chiba, Japan

Chisato Mori

Yokohama City University, Yokohama, Japan

Shuichi Ito

University of Yamanashi, Chuo, Japan

Zentaro Yamagata

Kyoto University, Kyoto, Japan

Takeo Nakayama

Osaka University, Suita, Japan

Hiroyasu Iso

Hyogo College of Medicine, Nishinomiya, Japan

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Tottori University, Yonago, Japan

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Kochi University, Nankoku, Japan

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University of Occupational and Environmental Health, Kitakyushu, Japan

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Kumamoto University, Kumamoto, Japan

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H.I. and A.T. drafted the paper. M.K., T.H., K.S., and H.I. conceived and designed the study. K.M. and A.T. analysed the data. A.T., K.M., H.I., K.H., and JECS group critically reviewed the draft and checked the analysis. JECS group collected the data and obtained the funding. All authors approved the submission of the manuscript in its current form.

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Inano, H., Kameya, M., Sasano, K. et al. Factors influencing exclusive breastfeeding rates until 6 months postpartum: the Japan Environment and Children’s Study. Sci Rep 11 , 6841 (2021). https://doi.org/10.1038/s41598-021-85900-4

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Language: English | German

Psychological effects of breastfeeding on children and mothers

Psychologische effekte des stillens auf kinder und mütter, kathleen m. krol.

1 Department of Psychology, University of Virginia, 485 McCormick Road, 22903 Charlottesville, VA USA

Tobias Grossmann

2 Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany

While the nutritional and physical health benefits of breastfeeding are well established, accumulating research demonstrates the far-reaching psychological effects of breastfeeding on children and their mothers. Here, we provide a non-exhaustive review of the empirical evidence, showing that breastfeeding impacts children’s brain, cognitive, and socio-emotional development. In mothers, research is presented indicating that breastfeeding influences mood, affect, stress, and maternal care. The current review aims to provide a broad overview of existing findings on the psychological effects of breastfeeding, highlighting the important role that breastfeeding plays across several dimensions of psychological functioning. We also discuss the potential mechanisms that may underpin the observed effects, provide a constructive commentary on the limitations of the existing work, and put forth some considerations when evaluating this line of research.

Zusammenfassung

Während die Vorteile des Stillens im Hinblick auf Ernährung und körperliche Entwicklung gut belegt sind, zeigen Untersuchungen vermehrt die weitreichenden psychologischen Effekte des Stillens auf Kinder und ihre Mütter. Zu diesem Zwecke präsentieren wir einen Überblick der verfügbaren empirischen Befunde, die den Zusammenhang des Stillens mit der hirnphysiologischen, kognitiven und sozialen Entwicklung des Säuglings und Kindes in Verbindung setzen. Außerdem diskutieren wir empirische Untersuchungen zum Einfluss des Stillens auf Mütter mit einem besonderen Fokus auf Emotionen, Stress und mütterliches Verhalten. Dieser Übersichtsartikel vermittelt grundlegende Einblicke in den Stand der Forschung auf diesem Gebiet und unterstreicht die Komplexität des Zusammenspiels von physiologischen und psychologischen Faktoren in der Bestimmung des Einflusses des Stillverhaltens auf Kinder und Mütter. Zusammengenommen deuten die diskutierten Befunde darauf hin, dass das Stillverhalten einen Einfluss sowohl auf die psychologische Entwicklung des Kindes als auch auf das Erleben und Verhalten der Mütter hat. Der aktuelle Review gibt einen Überblick zu existierenden Ergebnissen im Hinblick auf psychologische Einflüsse des Stillens und hebt die wichtige Rolle hervor, die das Stillen in verschiedenen Bereichen psychologischer Funktionen spielt. Zudem diskutieren wir mögliche Mechanismen, die diese beobachteten Effekte stützen können, liefern einen konstruktiven Kommentar zu den Grenzen der vorhandenen Arbeit und bringen Überlegungen zur Evaluation in diesem Forschungsgebiet ein. Für eine exakte Beschreibung und kausale Vorhersage der Effekte des Stillens und damit der Anwendung, bedarf es eindeutig noch weiterer umfangreicher Untersuchungen.

Introduction

Lactation is a process characteristic of all mammalian species. It is the result of evolutionary forces shaping an optimal nutrient delivery system, involved in supplying all essential nutrients in the adequate amounts from mothers to their offspring [ 1 ]. In humans, breastfeeding is undoubtedly the “gold standard” food source in the first months of postnatal life. The World Health Organization and the American Academy of Pediatrics recommend at least six months of exclusive breastfeeding, which is defined by breastmilk as the only source of sustenance [ 2 ]. In addition to being a critical source of nutrition to the infant, research shows that breastfeeding is not simply a meal at the breast but also has significant and far-reaching effects on cognition, behavior, and mental health in children and mothers [ 3 ]. In this review, we examine existing findings on the psychological effects of breastfeeding in children and mothers. It should be noted that the current review is not exhaustive but is rather designed to provide a broad overview, intended to raise awareness of this growing body of research. Additionally, we discuss potential neurobiological mechanisms that undergird the reviewed psychological effects and point out limitations in the existing research.

Before we begin with the review, it is important to stress that how breastfeeding is measured varies greatly across studies. For example, while some studies treat breastfeeding as a qualitative measure and compare between breastfeeding and bottle feeding, others consider breastfeeding as a quantitative (continuous) variable and measure the duration of exclusive breastfeeding. This fact makes it somewhat difficult to compare studies. We have decided to organize this review according to overarching themes concerning child and maternal psychological effects and to always explicitly mention which breastfeeding measure was used (see Considerations concerning the effects of breastfeeding on children’s cognitive, social, and brain development for a discussion on this issue).

Psychological effects of breastfeeding in children

Breastfeeding and cognitive outcomes in children.

There is a body of research from different countries providing evidence for a link between breastfeeding experience and cognitive development later in life, including improved memory retention, greater language skills, and intelligence [ 4 – 9 ].

Longitudinal prospective designs are a useful method to assess the link between breastfeeding behavior and children’s cognitive development because they do not require retrospective self-report. In one such study, a higher frequency of breastfed meals and the duration of exclusive breastfeeding during the first year of life were found to be positively associated with measures of the Bayley Scales of Infant Development [ 10 ], including memory performance, early language, and motor skills at 14 months [ 11 ] and 18 months of age [ 12 ]. Importantly, these cognitive benefits of breastfeeding seen in infancy have been shown to endure into childhood and adolescence. Specifically, Bernard et al. [ 13 ] assessed cognitive and motor development in 2‑ and 3‑year-old children and found that breastfeeding experience was associated with improved cognitive development as measured by the Communicative Development Inventory [ 14 ] and Ages and Stages Questionnaire [ 15 ]. This study showed that improved problem-solving abilities in children were associated with prolonged duration of exclusive breastfeeding. Similarly, a large population-based cohort study reported significant benefits on executive function (cognitive control) at 4 years of age for those children who were exclusively breastfed for over 6 months after birth compared to those never breastfed as well as those exclusively breastfed for less than 6 months [ 16 ]. Quinn et al. [ 17 ] followed a cohort from infancy to 5 years of age and found a dose-dependent facilitation of breastfeeding duration on verbal intelligence abilities using the Revised Peabody Picture Vocabulary Test (PPVT-R) [ 18 ]. This study showed that at age 5, children who were breastfed for at least 6 months as infants had the highest verbal intelligence scores, while children who were never breastfed had the lowest scores. Another longitudinal study using the Wechsler Intelligence Scale for Children [ 19 ] to measure cognitive skills from 1 to 7 years reported persisting cognitive benefits across age as a function of prolonged exclusive breastfeeding duration during infancy [ 20 ]. Furthermore, when comparing children who were exclusively breastfed to children who received mixed feeding (formula combined with human milk), the exclusively breastfed children displayed a consistent increase in their intelligence scores from age 1 to age 7. Critically, another large-scale longitudinal study has shown that even when controlling for the intelligence of the mother, intelligence benefits as a function of exclusive breastfeeding experience can be seen among children [ 21 ].

The initiation of breastfeeding immediately after birth has also been argued to play a role in reducing the risk for cognitive impairment among children. For example, a clinical study compared the breastfeeding histories of 4‑ to 11-year-old children diagnosed with specific language impairment (SLI) to those of neurotypically developing children and observed that those with SLI were significantly less likely to have been breastfed directly after birth [ 22 ]. While this suggests a correlation between early breastfeeding experience and the development of a specific cognitive impairment, it would be premature and problematic to assign any causal influence to the lack of early breastfeeding on a specific cognitive impairment.

More compelling evidence relating breastfeeding to cognitive outcomes comes from a randomized controlled intervention study including over 13,000 mother–infant dyads [ 7 ]. In this study, mothers were randomly assigned to an exclusive breastfeeding promotion intervention, which led to a seven-fold increase in exclusive breastfeeding at 3 months of age. In this study, children were longitudinally followed and those children who had prolonged exclusive breastfeeding experience as infants showed higher intelligence scores and higher teacher ratings of academic proficiency at the age of 6.5 years [ 7 ]. A recent follow-up study with the same cohort of children at 16 years of age revealed a persistent impact of prolonged exclusive breastfeeding experience on verbal abilities, but not on any other neurocognitive measures [ 23 ]. The authors of this study suggest that over time, the effects of breastfeeding may be “diluted”, and other environmental factors such as peer influence and parental intellectual stimulation may become better predictors of cognitive function.

There is, however, some evidence to demonstrate that breastfeeding experience during infancy impacts cognitive abilities well beyond infancy, even into adulthood. For example, Mortensen et al. [ 4 ] investigated cognitive performance in two different cohorts using different intelligence tests. This study showed that across cohorts and measurement instruments, longer duration of breastfeeding during infancy was positively associated with cognitive performance as adults [ 4 ]. Similarly, recent findings from another cohort revealed that the duration of exclusive breastfeeding was positively associated with increased intelligence, educational attainment, and income at 30 years of age [ 24 ]. In fact, there is also work to show that breastfeeding duration during infancy is positively associated with reading ability at 53 years of age, as measured by the National Adult Reading Test [ 25 ].

It is crucial to highlight that the aforementioned studies controlled for a large range of potentially confounding maternal variables, including but not limited to education, employment, income, age, method of delivery, cigarette consumption during pregnancy, and infant birth weight. Indeed, one large-scale study, which included a multitude of potential confounds in their analysis such as maternal intelligence quotient (IQ), social class, and education level, as well as less commonly included confounding variables such as maternal psychopathology, attachment, and exposure to pollutants, still found a robust and independent positive impact of prolonged exclusive breastfeeding duration on neuropsychological function in children [ 16 ]. Yet, it is important to acknowledge that not all studies find such clear associations between breastfeeding and cognitive outcome measures when controlling for potential confounds. For example, a study by Jacobson et al. found an initial impact of breastfeeding on children’s intelligence scores at both 4 and 11 years of age, but this effect was much reduced when adjusting for maternal intelligence and parenting skills assessed during home observations using the Home Observation Measurement of the Environment (HOME) [ 26 ]. Similarly, when controlling for socio-economic status and gestational age, von Stumm and Plomin [ 27 ] report only a marginal impact of breastfeeding experience on girls’, but not boys’, IQ at 2 years of age and no impact at a follow-up visit at 16 years. More generally, due to the high number of potentially confounding factors and the difficulty of controlling for all of them effectively in one study, caution is needed when designing and interpreting studies investigating the effects of breastfeeding on cognitive development [ 28 , 29 ]. For a systematic and informative review of the role of confounding variables in breastfeeding research, see [ 30 ]. Nonetheless, the existing evidence reviewed in this section points to a beneficial effect of breastfeeding, especially prolonged exclusive breastfeeding, on children’s cognitive (intellectual) development.

This raises the question of what mechanism underpins these effects of breastfeeding on cognitive development. One possible mechanism may relate to specific nutrients such as the long-chain polyunsaturated fatty acids (LC-PUFAs), which are present in human milk but usually absent in formula [ 31 ]. Two major LC-PUFAs are docosahexaenoic acid (DHA) and arachidonic acid (ARA), which are involved in neurodevelopment by contributing to healthy neuronal growth, repair, and myelination [ 32 ]. Importantly, myelination predominately occurs postnatally within the first 18 months of life [ 33 , 34 ]. Infants produce a small quantity of DHA during the first 2 weeks of life, but are then unable to produce sufficient amounts on their own until about 6 months of age [ 34 ]. This suggests the possibility of a window in development during which human brain and cognitive development may be particularly sensitive to LC-PUFAs supplied through breastfeeding.

There is evidence to support the importance of LC-PUFAs as contributors to cognitive development. For example, Caspi et al. [ 35 ] investigated how individual differences in the ability to metabolize and produce LC-PUFAs influences the impact of breastfeeding on cognitive development. More specifically, they assessed two single-nucleotide polymorphisms (SNPs) on the FADS2 gene (rs174575 and rs1535), which encodes an enzyme that directly impacts metabolism of DHA and ARA. Children who were breastfed displayed higher intelligence scores from ages 5–13 years, in line with the aforementioned studies. Critically, FADS2 genotype further impacted this association such that breastfed carriers of the C allele on rs174575, associated with more efficient processing of fatty acids (i. e., LC-PUFAs), had the highest intelligence scores overall. This suggests that the impact of breastfeeding on cognitive development is greater among individuals genetically predisposed to more efficiently process LC-PUFAs. Additionally, there is evidence that formula supplemented with DHA can improve cognitive development [ 31 ]. Taken together, research reviewed in this section attests to the impact of breastfeeding on cognitive development and highlights potential mechanisms accounting for such effects. The next section will review existing research on how breastfeeding experience influences brain development during infancy and thereby helps us to better understand how breastfeeding impacts cognitive development.

Breastfeeding and brain development in children

Research into the potential impact of breastfeeding on brain development complements and extends work on cognitive development by using methodologies such as electroencephalography (EEG) and magnetic resonance imaging (MRI). One such study measured EEG spectral power longitudinally over the course of the first year of life in a group of typically developing infants and compared between breastfed and formula-fed infants [ 36 ]. This study showed that, within the frequency range thought to be most impacted by myelination (0.1–3 Hz), formula-fed infants displayed an earlier peak (at 6 months) than breastfed infants (at 9 months) in EEG power measured in this frequency range followed by a decline with age seen in both groups. This study suggests that breastfeeding influences the timing of myelination processes in the developing infant brain by prolonging the peak of myelination to a later age. While the authors of this study make no strong claims regarding a benefit of breastfeeding, they suggest that these different patterns of early neurodevelopment may set off differential trajectories in brain and cognitive development between breastfed and formula-fed infants.

Studies employing structural and diffusion-weighted MRI critically complement and extend the above-mentioned findings by directly measuring differences in brain structure. In line with the finding that breastfeeding impacts the timing of myelination, whole brain volume, cortical thickness, and white matter volume have all been found to be increased among children with longer durations of breastfeeding experience [ 33 , 37 – 39 ]. For example, in a cross-sectional design, Deoni et al. [ 33 ] investigated white matter maturation from 10 months to 4 years of age and found a positive association between the duration of exclusive breastfeeding and the development of white matter tracts. This study reported breastfeeding-related increases in white matter in regions that typically mature later in development, including frontal and temporal regions. Furthermore, this study reported that breastfeeding was associated with white matter in tracts commonly associated with higher-order cognition and socio-emotional functioning, including the superior longitudinal fasciculus [ 33 ]. Another critical follow-up study from the same group of researchers assessed changes in white matter volume in a longitudinal design [ 39 ]. In this study, breastfed children displayed a prolonged window of white matter development between 16 months and 2 years, resulting in an overall myelin increase detectable by 2 years of age that persisted through childhood. These findings corroborate the EEG spectral power analyses presented above [ 36 ], suggesting that breastfeeding influences the timing and duration of myelination processes in infancy. In comparison, formula-fed infants displayed a significantly slower rate of white matter development between 1 and 2 years of age, and the overall volume continued to remain below the volume measured for the breastfed infants. Furthermore, Deoni et al. [ 39 ] compared the brain development outcomes of infants fed different types of formula. Notably, infants fed with formulas with the highest levels of DHA and ARA showed the white matter development most similar to breastfed infants, albeit on a smaller scale. This suggests that adding DHA and ARA to formula can help reduce the effect that the absence of breastfeeding has on white matter development during infancy. At the same time, this study also shows that adding DHA and ARA to formula cannot completely restore the effects of breastfeeding, suggesting that there are other factors at play that contribute to the effects of breastfeeding on brain development.

Taken together, these findings regarding brain development suggest that elements of breast milk itself, particularly LC-PUFAs, likely contribute to enhanced patterns of myelination in the developing brain, but they do not fully account for the reported effects of breastfeeding on brain development. Therefore, there must be additional factors that contribute to the seen effects of breastfeeding. Such factors could potentially be aspects of the interaction between mother and infant such as touch and warmth, or other substrates contained in the breastmilk such as hormones that are not present in formula.

Breastfeeding and social and emotional development in children

In addition to the effects reported on children’s cognitive and brain development, there is evidence that breastfeeding also impacts social and emotional development in children. There is work to suggest that breastfeeding experience is associated with differences in infant temperament. For example, at 3 months of age, breastfed infants are reported to show greater negative affect than formula-fed infants [ 40 ]. Similarly, negative temperament, such as fussiness, has also been found to be associated with a prolonged duration of breastfeeding in infancy [ 41 ]. In contrast, another study found that breastfed infants were reported to have more “vigor” at 3 months of age, characterized by greater approach and activity, than formula-fed infants [ 42 ]. Thus, the evidence concerning the association between breastfeeding is mixed and may depend on the specific temperament characteristic examined. There is also research indicating a negative association between breastfeeding experience and aggressive behavior. For example, duration of breastfeeding experience has been shown to correlate negatively with parent-reported antisocial and aggressive behavior in children from 4 to 11 years of age [ 43 ]. These effects on antisocial behavior appear to extend well beyond childhood into adulthood. A longitudinal study following adults from 20 to 40 years of age found significantly greater amounts of hostile (aggressive) behavior in adults who were not breastfed as infants compared to those who were breastfed [ 44 ].

Furthermore, there is accumulating evidence to suggest that the absence or short duration of exclusive breastfeeding might be associated with the development of autism spectrum disorder (ASD), a neurodevelopmental disorder characterized by social impairments. A recent meta-analysis of over 2000 children reports that those diagnosed with ASD were significantly less likely to have been breastfed than neurotypical children [ 45 ]. Furthermore, it has been reported that children with over 6 months of exclusive breastfeeding or formula supplemented with DHA exhibit the lowest probability (measured as odds ratios) for subsequently being diagnosed with ASD [ 46 ]. Along the same lines, Al-Farsi and colleagues observed that exclusive breastfeeding duration significantly reduced the likelihood for developing ASD. This study further reported that the late initiation of breastfeeding increases likelihood for developing ASD, possibly related to the limited or lacking consumption of colostrum or first milk by the newborn infant, which is particularly rich in antibodies, immune cells, and protein content [ 47 ].

It is important to emphasize that some studies have not found an impact of breastfeeding on ASD diagnosis. For example, in a large phone survey of parents of 2‑ to 5‑year-old children, ASD diagnosis was not associated with any measure of breastfeeding history, including exclusive breastfeeding duration [ 48 ]. It is also critical to note that it is problematic to assign a causal role to breastfeeding in the development of ASD because infants later diagnosed with ASD as children may already display certain characteristics that make breastfeeding more difficult for the mothers. A study by Lucas and Cutler reports “dysregulated” breastfeeding patterns in infants later diagnosed with ASD, and cite potential mechanisms for atypical feeding patterns such as reduced joint attention during social interactions [ 49 ]. More generally, large prospective longitudinal studies that measure social development directly (experimentally) and comprehensively in children are needed to appropriately address this issue.

Empirical investigations into how breastfeeding experience impacts responses to social information processing during infancy have only recently been introduced. For example, Krol et al. [ 50 ] examined how exclusive breastfeeding duration affects infants’ brain responses to emotional body cues using event-related potentials (ERPs). This study showed that 8‑month-old infants who had been breastfed for longer durations (more than 5 months) displayed an enhanced attentional brain response to happy expressions while reducing attention to fearful expressions, suggesting that longer exclusive breastfeeding experience is associated with a greater attentional bias to positive emotion. Similarly, in another study using eyetracking with 7‑month-old infants, exclusive breastfeeding duration was associated with an increased attention to happy eyes and reduced attention to angry eyes [ 51 ]. Furthermore, the effect of breastfeeding depended upon genetic variation within the endogenous oxytocin system as indexed by a common SNP (rs3796863) on the gene encoding CD38, an ectoenzyme that mediates the release of oxytocin. This study showed that infants with the genotype linked to decreased levels of oxytocin and increased risk for ASD (CC genotype) [ 52 , 53 ] were most strongly impacted by the duration of exclusive breastfeeding experience. These findings from experimental work with typically developing infants show that individual variability in responding to emotional information is systematically linked to breastfeeding and might depend on endogenous factors related to the oxytocin system. It is thus possible that endogenous (genetic) and exogenous (breastfeeding) factors influencing the developing oxytocin system are at least partly responsible for shaping socio-emotional development in children.

Considerations concerning the effects of breastfeeding on children’s cognitive, social, and brain development

In general, breastfeeding experience has been associated with improved cognitive abilities, facilitated brain development, and a reduced risk for antisocial behaviors and atypical social development including ASD. However, there are several issues to keep in mind when considering this line of research.

First, breastfeeding as the independent variable is often measured differently across studies, which makes it difficult to compare between studies. Specifically, many of the studies reviewed above analyzed breastfeeding experience as a dichotomous categorical measure (qualitative)—breastfeeding versus no breastfeeding, whereas other studies employed a continuous (quantitative) breastfeeding measure such as the duration of exclusive breastfeeding, or the current percentage of meals still breastfed. Yet another set of studies used the timing of breastfeeding initiation and found that this critically contributes to the effects on certain outcome measures [ 54 ]. Given this issue, research is needed that compares these different measures of breastfeeding experience in order to better understand the exact relation between breastfeeding, its duration, and timing with the critical outcome measures regarding children’s development. Second, there is an issue concerning the specificity of the effects of breastfeeding that can be concluded from the reviewed studies. To date, there is no research that examines the effects of breastfeeding including brain, cognitive, and social development measures of children within the same study. In other words, research that examines multiple dependent variables combining brain, cognitive, and social data about children’s development is needed. Third, we are only beginning to elucidate the physiological (neurobiological) mechanisms that underpin the psychological (cognitive and social) effects seen in children.

With respect to those underlying mechanisms, we would like to briefly outline a working model as to how breastfeeding impacts child development (see Table  1 ). Based on the research reviewed above, we suggest the following two key processes to account for (a) cognitive development benefits and (b) social development benefits as they are related to breastfeeding. A: The LC-PUFAs contained in human breast milk critically contribute to white matter development during childhood which accounts for improved cognitive and intellectual functioning. B: Oxytocin contained in human breastmilk and further released during breastfeeding through suckling, touch, and warmth facilitates socio-emotional functioning in the infant by enhancing positive tendencies (approach) and reducing negative tendencies (withdrawal and anxiety). This likely accounts for improved social development and reduced antisocial and atypical social behaviors.

Working model a of how breastfeeding may impact neurocognitive and socio-emotional outcomes in children and mothers

LC-PUFAs  long-chain polyunsaturated fatty acids, DHA  docosahexaenoic acid, ARA arachidonic acid, IQ  intelligence quotient, ASD  autism spectrum disorder

a Here we outline potential mechanisms underlying the main psychological effects observed in this review. Please note that this list is not exhaustive and only serves to highlight potential underlying processes and mechanisms

Psychological effects of breastfeeding in mothers

The impact of breastfeeding on affect, mood, and stress in mothers.

Breastfeeding has been reported to impact mood and stress reactivity in mothers [ 55 ]. Specifically, breastfeeding mothers report reductions in anxiety, negative mood, and stress when compared to formula-feeding mothers [ 56 ]. These findings based on subjective self-report measures are supported by objective physiological measures indicative of a positive effect of breastfeeding on emotional well-being. For example, breastfeeding mothers have stronger cardiac vagal tone modulation, reduced blood pressure, and reduced heart rate reactivity than formula-feeding mothers have, indexing a calm and non-anxious physiological state [ 57 , 58 ]. Moreover, there is evidence to show that breastfeeding mothers have a reduced cortisol response when faced with social stress [ 55 ]. Breastfeeding mothers also display prolonged and higher quality sleep patterns than those who feed their infants formula. Specifically, there is research to show that at 3 months postpartum, breastfeeding was associated with an increase of about 45 minutes in sleep and reduced sleep disturbance [ 59 ]. Critically, breastfeeding also impacts mothers’ responses to emotions in others and may thereby improve social interactions and relationships. More specifically, recent work shows that prolonged durations of exclusive breastfeeding are linked to facilitated responses to inviting (happy) facial expressions and that more frequent breastfeeding on a given day is linked with reduced responsivity to threatening (angry) facial expressions [ 60 ].

In summary, there is research showing that breastfeeding has beneficial effects on mothers’ own mood, affect, and stress, and also that breastfeeding facilitates responses to positive emotions in others. Similar effects on affect and stress as seen here for breastfeeding are also observed in studies administering oxytocin intranasally compared to a placebo [ 61 , 62 ], suggesting that breastfeeding may affect (increase) endogenous oxytocin levels in the mothers. This is in line with the known role of oxytocin during breastfeeding and supported by research documenting a rise in maternal oxytocin levels during breastfeeding [ 63 ]. More evidence in support of this notion comes from a recent study which revealed that mothers’ genetic variation in oxytocin (as indexed through the CD38 rs3796863 SNP) impacts the rate at which cortisol decreases during a breastfeeding session. Specifically, mothers with the non-risk genotype, associated with higher oxytocin levels, showed a steeper reduction in cortisol. Strikingly, this differential reduction in cortisol was found in their infants as well [ 64 ]. It is thus likely that the positive effects of breastfeeding on the measures reviewed above have a physiological basis in an upregulation of endogenous oxytocin levels among breastfeeding mothers.

Breastfeeding and mother–infant attachment

Breastfeeding is also thought to facilitate maternal sensitivity and secure attachment between mother and child [ 65 – 67 ]. There is research to show that mothers who breastfeed tend to touch their infants more [ 68 ], are more responsive to their infants [ 69 ], and spend more time in mutual gaze with infants during feedings than bottle-feeding mother–infant dyads do [ 70 ]. Moreover, in a prospective longitudinal study of 675 mother–infant dyads, increased duration of breastfeeding was associated with maternal sensitive responsiveness, increased attachment security, and decreased attachment disorganization when infants were 14 months of age [ 71 ]. Brain imaging work also provides evidence for a positive influence of breastfeeding on the mother–child relationship. For example, in a functional MRI (fMRI) study, it was found that exclusively breastfeeding mothers exhibited greater brain activation in several limbic brain regions when listening to their own infant’s cries as compared to exclusive formula feeders, suggesting greater involvement of emotional brain systems in breastfeeding mothers [ 72 ].

In this context, it is important to note that breastfeeding has not always been found to be directly linked to attachment quality [ 73 ]. For example, Britton et al. [ 74 ] did not find an association between breastfeeding experience and mother-infant attachment at 12 months. However, this study did find that maternal sensitivity at 3 months of age significantly predicted the duration of breastfeeding during the first year of life. Additionally, maternal sensitivity in other studies has been linked to improved attachment quality [ 75 ]. Taken together, these findings suggest that the association between breastfeeding and attachment quality might be at least partly accounted for by more direct effects of breastfeeding on maternal sensitivity. This possibility is also supported by the findings reported above, indicating that breastfeeding mothers display more positive mood, less stress, and more effective emotional responding to others, which is likely to positively influence their maternal behaviors [ 55 , 60 ].

Breastfeeding and postpartum depression

There is a growing body of evidence indicating that breastfeeding behavior is linked to postpartum depression in mothers [ 76 , 77 ]. Hamdan and Tamim [ 78 ] showed in a prospective study that breastfeeding mothers had lower scores on the Edinburgh Postnatal Depression Scale (EPDS) at 2 and 4 months postpartum and were less likely to be diagnosed with postpartum depression at 4 months postpartum. Moreover, this study revealed that higher depression scores at 2 months postpartum were predictive of lower rates of breastfeeding at 4 months. In another prospective study, a significant decrease in depression scores was observed from the third trimester of pregnancy to 3 months postpartum in mothers who exclusively breastfed for more than 3 months when compared to mothers who breastfed for less than 3 months [ 2 ]. Importantly, this study showed that depression scores during the third trimester of pregnancy were linked to decreased exclusive breastfeeding duration postpartum, suggesting that maternal mood and affect predicts breastfeeding behavior in mothers.

Considering the complicated and potentially reciprocal association between breastfeeding and maternal depression, it is also possible that issues with breastfeeding, which may lead to earlier cessation of breastfeeding, could impact maternal mood and affect. For example, Brown et al. [ 79 ] found that breastfeeding cessation is correlated with high depression scores in mothers, but when examining this correlation more closely found that it was only present in mothers who stopped breastfeeding due to physical difficulty and pain when breastfeeding. Another study assessed breastfeeding complications and maternal mood at 8 weeks postpartum and found that breastfeeding problems alone, or co-morbid with physical problems, were associated with poorer maternal mood [ 80 ]. These findings highlight the importance of understanding the exact nature of problems with breastfeeding and also mothers’ reasons for ceasing to breastfeed, and how this impacts mood and affect in mothers, when studying the link between breastfeeding and postpartum depression. While breastfeeding is associated with maternal mood and postpartum depression, it is difficult to know whether it is breastfeeding or maternal mood or affect that is driving (causing) the effects due to the complex relation between breastfeeding and maternal mood and affect. For example, there is evidence to suggest that mothers with higher levels of anxiety and depression display reduced exclusivity and quicker cessation of breastfeeding, as well as a more negative attitude towards breastfeeding [ 81 , 82 ]. Nonetheless, the observed association between breastfeeding and depression is broadly in line with what is mentioned above regarding the effects of breastfeeding on maternal affect, mood, and stress.

Conclusions

The current review provides an overview of the critical and far-reaching psychological effects of breastfeeding in children and their mothers, and proposes potential physiological bases (substrates) accounting for these effects. In children, breastfeeding has been associated with improved cognitive performance and socio-affective responding. Improved cognitive performance in children is likely linked to the fatty acids (i. e., LC-PUFAs) contained in breastmilk and their potential beneficial effect on brain development during infancy, especially concerning the growth of white matter tracts (myelination). Heightened socio-affective responding seen in breastfed children is possibly connected to the stimulation of the oxytocin system and oxytocin’s known role in promoting positive affect and approach behaviors, while reducing stress and avoidance behavior. In mothers, breastfeeding significantly reduces physiological and subjective stress, facilitates positive affect, and improves maternal sensitivity and care. Again, the oxytocin system likely plays an important role in explaining the effects on maternal psychology and behavior.

In this context, it is important to acknowledge that the proposed framework of how to conceptualize the effects of breastfeeding on mothers and children does not fully capture the highly complex and interactive nature of how breastfeeding affects both the mother and the child. In fact, research is urgently needed to empirically address this issue by simultaneously studying the psychological effects in both mothers and their children in large-scale, prospective longitudinal designs with physiological measures. To undertake such comprehensive research in the future seems imperative given not only its potential for improving mental health of children and their mothers, but also because of its implications for clinical practice and social policy.

Open access funding provided by Max Planck Society.

Compliance with ethical guidelines

Conflict of interest.

K.M. Krol and T. Grossmann declare that they have no competing interests.

• Open access
• Published: 26 November 2021

Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature

• Bridget Beggs 1 ,
• Liza Koshy 1 &
• Elena Neiterman 1  

BMC Public Health volume  21 , Article number:  2169 ( 2021 ) Cite this article

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Despite public health efforts to promote breastfeeding, global rates of breastfeeding continue to trail behind the goals identified by the World Health Organization. While the literature exploring breastfeeding beliefs and practices is growing, it offers various and sometimes conflicting explanations regarding women’s attitudes towards and experiences of breastfeeding. This research explores existing empirical literature regarding women’s perceptions about and experiences with breastfeeding. The overall goal of this research is to identify what barriers mothers face when attempting to breastfeed and what supports they need to guide their breastfeeding choices.

This paper uses a scoping review methodology developed by Arksey and O’Malley. PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched utilizing a predetermined string of keywords. After removing duplicates, papers published in 2010–2020 in English were screened for eligibility. A literature extraction tool and thematic analysis were used to code and analyze the data.

In total, 59 papers were included in the review. Thematic analysis showed that mothers tend to assume that breastfeeding will be easy and find it difficult to cope with breastfeeding challenges. A lack of partner support and social networks, as well as advice from health care professionals, play critical roles in women’s decision to breastfeed.

While breastfeeding mothers are generally aware of the benefits of breastfeeding, they experience barriers at individual, interpersonal, and organizational levels. It is important to acknowledge that breastfeeding is associated with challenges and provide adequate supports for mothers so that their experiences can be improved, and breastfeeding rates can reach those identified by the World Health Organization.

Peer Review reports

Public health efforts to educate parents about the importance of breastfeeding can be dated back to the early twentieth century [ 1 ]. The World Health Organization is aiming to have at least half of all the mothers worldwide exclusively breastfeeding their infants in the first 6 months of life by the year 2025 [ 2 ], but it is unlikely that this goal will be achieved. Only 38% of the global infant population is exclusively breastfed between 0 and 6 months of life [ 2 ], even though breastfeeding initiation rates have shown steady growth globally [ 3 ]. The literature suggests that while many mothers intend to breastfeed and even make an attempt at initiation, they do not always maintain exclusive breastfeeding for the first 6 months of life [ 4 , 5 ]. The literature identifies various barriers, including return to paid employment [ 6 , 7 ], lack of support from health care providers and significant others [ 8 , 9 ], and physical challenges [ 9 ] as potential factors that can explain premature cessation of breastfeeding.

From a public health perspective, the health benefits of breastfeeding are paramount for both mother and infant [ 10 , 11 ]. Globally, new mothers following breastfeeding recommendations could prevent 974,956 cases of childhood obesity, 27,069 cases of mortality from breast cancer, and 13,644 deaths from ovarian cancer per year [ 11 ]. Global economic loss due to cognitive deficiencies resulting from cessation of breastfeeding has been calculated to be approximately USD $285.39 billion dollars annually [ 11 ]. Evidently, increasing exclusive breastfeeding rates is an important task for improving population health outcomes. While public health campaigns targeting pregnant women and new mothers have been successful in promoting breastfeeding, they also have been perceived as too aggressive [ 12 ] and failing to consider various structural and personal barriers that may impact women’s ability to breastfeed [ 1 ]. In some cases, public health messaging itself has been identified as a barrier due to its rigid nature and its lack of flexibility in guidelines [ 13 ]. Hence, while the literature on women’s perceptions regarding breastfeeding and their experiences with breastfeeding has been growing [ 14 , 15 , 16 ], it offers various, and sometimes contradictory, explanations on how and why women initiate and maintain breastfeeding and what role public health messaging plays in women’s decision to breastfeed.

The complex array of the barriers shaping women’s experiences of breastfeeding can be broadly categorized utilizing the socioecological model, which suggests that individuals’ health is a result of the interplay between micro (individual), meso (institutional), and macro (social) factors [ 17 ]. Although previous studies have explored barriers and supports to breastfeeding, the majority of articles focus on specific geographic areas (e.g. United States or United Kingdom), workplaces, or communities. In addition, very few articles focus on the analysis of the interplay between various micro, meso, and macro-level factors in shaping women’s experiences of breastfeeding. Synthesizing the growing literature on the experiences of breastfeeding and the factors shaping these experiences, offers researchers and public health professionals an opportunity to examine how various personal and institutional factors shape mothers’ breastfeeding decision-making. This knowledge is needed to identify what can be done to improve breastfeeding rates and make breastfeeding a more positive and meaningful experience for new mothers.

The aim of this scoping review is to synthesize evidence gathered from empirical literature on women’s perceptions about and experiences of breastfeeding. Specifically, the following questions are examined:

What does empirical literature report on women’s perceptions on breastfeeding?

What barriers do women face when they attempt to initiate or maintain breastfeeding?

What supports do women need in order to initiate and/or maintain breastfeeding?

Focusing on women’s experiences, this paper aims to contribute to our understanding of women’s decision-making and behaviours pertaining to breastfeeding. The overarching aim of this review is to translate these findings into actionable strategies that can streamline public health messaging and improve breastfeeding education and supports offered by health care providers working with new mothers.

This research utilized Arksey & O’Malley’s [ 18 ] framework to guide the scoping review process. The scoping review methodology was chosen to explore a breadth of literature on women’s perceptions about and experiences of breastfeeding. A broad research question, “What does empirical literature tell us about women’s experiences of breastfeeding?” was set to guide the literature search process.

Search methods

The review was undertaken in five steps: (1) identifying the research question, (2) identifying relevant literature, (3) iterative selection of data, (4) charting data, and (5) collating, summarizing, and reporting results. The inclusion criteria were set to empirical articles published between 2010 and 2020 in peer-reviewed journals with a specific focus on women’s self-reported experiences of breastfeeding, as well as how others see women’s experiences of breastfeeding. The focus on women’s perceptions of breastfeeding was used to capture the papers that specifically addressed their experiences and the barriers that they may encounter while breastfeeding. Only articles written in English were included in the review. The keywords utilized in the search strategy were developed in collaboration with a librarian (Table  1 ). PubMed, CINAHL, Sociological Abstracts, and PsychInfo databases were searched for the empirical literature, yielding a total of 2885 results.

Search outcome

The articles deemed to fit the inclusion criteria ( n  = 213) were imported into RefWorks, an online reference manager tool and further screened for eligibility (Fig.  1 ). After the removal of 61 duplicates and title/abstract screening, 152 articles were kept for full-text review. Two independent reviewers assessed the papers to evaluate if they met the inclusion criteria of having an explicit analytic focus on women’s experiences of breastfeeding.

Prisma Flow Diagram

Quality appraisal

Consistent with scoping review methodology [ 18 ], the quality of the papers included in the review was not assessed.

Data abstraction

A literature extraction tool was created in MS Excel 2016. The data extracted from each paper included: (a) authors names, (b) title of the paper, (c) year of publication, (d) study objectives, (e) method used, (f) participant demographics, (g) country where the study was conducted, and (h) key findings from the paper.

Thematic analysis was utilized to identify key topics covered by the literature. Two reviewers independently read five papers to inductively generate key themes. This process was repeated until the two reviewers reached a consensus on the coding scheme, which was subsequently applied to the remainder of the articles. Key themes were added to the literature extraction tool and each paper was assigned a key theme and sub-themes, if relevant. The themes derived from the analysis were reviewed once again by all three authors when all the papers were coded. In the results section below, the synthesized literature is summarized alongside the key themes identified during the analysis.

In total, 59 peer-reviewed articles were included in the review. Since the review focused on women’s experiences of breastfeeding, as would be expected based on the search criteria, the majority of articles ( n  = 42) included in the sample were qualitative studies, with ten utilizing a mixed method approach (Fig.  2 ). Figure  3 summarizes the distribution of articles by year of publication and Fig.  4 summarizes the geographic location of the study.

Types of Articles

Years of Publication

Countries of Focus Examined in Literature Review

Perceptions about breastfeeding

Women’s perceptions about breastfeeding were covered in 83% ( n  = 49) of the papers. Most articles ( n  = 31) suggested that women perceived breastfeeding as a positive experience and believed that breastfeeding had many benefits [ 19 , 20 ]. The phrases “breast is best” and “breastmilk is best” were repeatedly used by the participants of studies included in the reviewed literature [ 21 ]. Breastfeeding was seen as improving the emotional bond between the mother and the child [ 20 , 22 , 23 ], strengthening the child’s immune system [ 24 , 25 ], and providing a booster to the mother’s sense of self [ 1 , 26 ]. Convenience of breastfeeding (e.g., its availability and low cost) [ 19 , 27 ] and the role of breastfeeding in weight loss during the postpartum period were mentioned in the literature as other factors that positively shape mothers’ perceptions about breastfeeding [ 28 , 29 ].

The literature suggested that women’s perceptions of breastfeeding and feeding choices were also shaped by the advice of healthcare providers [ 30 , 31 ]. Paradoxically, messages about the importance and relative simplicity of breastfeeding may also contribute to misalignment between women’s expectations and the actual experiences of breastfeeding [ 32 ]. For instance, studies published in Canada and Sweden reported that women expected breastfeeding to occur “naturally”, to be easy and enjoyable [ 23 ]. Consequently, some women felt unprepared for the challenges associated with initiation or maintenance of breastfeeding [ 31 , 33 ]. The literature pointed out that mothers may feel overwhelmed by the frequency of infant feedings [ 26 ] and the amount as well as intensity of physical difficulties associated with breastfeeding initiation [ 33 ]. Researchers suggested that since many women see breastfeeding as a sign of being a “good” mother, their inability to breastfeed may trigger feelings of personal failure [ 22 , 34 ].

Women’s personal experiences with and perceptions about breastfeeding were also influenced by the cultural pressure to breastfeed. Welsh mothers interviewed in the UK, for instance, revealed that they were faced with judgement and disapproval when people around them discovered they opted out of breastfeeding [ 35 ]. Women recalled the experiences of being questioned by others, including strangers, when they were bottle feeding their infants [ 9 , 35 , 36 ].

Barriers to breastfeeding

The vast majority ( n  = 50) of the reviewed literature identified various barriers for successful breastfeeding. A sizeable proportion of literature (41%, n  = 24) explored women’s experiences with the physical aspects of breastfeeding [ 23 , 33 ]. In particular, problems with latching and the pain associated with breastfeeding were commonly cited as barriers for women to initiate breastfeeding [ 23 , 28 , 37 ]. Inadequate milk supply, both actual and perceived, was mentioned as another barrier for initiation and maintenance of breastfeeding [ 33 , 37 ]. Breastfeeding mothers were sometimes unable to determine how much milk their infants consumed (as opposed to seeing how much milk the infant had when bottle feeding), which caused them to feel anxious and uncertain about scheduling infant feedings [ 28 , 37 ]. Women’s inability to overcome these barriers was linked by some researchers to low self-efficacy among mothers, as well as feeling overwhelmed or suffering from postpartum depression [ 38 , 39 ].

In addition to personal and physical challenges experienced by mothers who were planning to breastfeed, the literature also highlighted the importance of social environment as a potential barrier to breastfeeding. Mothers’ personal networks were identified as a key factor in shaping their breastfeeding behaviours in 43 (73%) articles included in this review. In a study published in the UK, lack of role models – mothers, other female relatives, and friends who breastfeed – was cited as one of the potential barriers for breastfeeding [ 36 ]. Some family members and friends also actively discouraged breastfeeding, while openly questioning the benefits of this practice over bottle feeding [ 1 , 17 , 40 ]. Breastfeeding during family gatherings or in the presence of others was also reported as a challenge for some women from ethnic minority groups in the United Kingdom and for Black women in the United States [ 41 , 42 ].

The literature reported occasional instances where breastfeeding-related decisions created conflict in women’s relationships with significant others [ 26 ]. Some women noted they were pressured by their loved one to cease breastfeeding [ 22 ], especially when women continued to breastfeed 6 months postpartum [ 43 ]. Overall, the literature suggested that partners play a central role in women’s breastfeeding practices [ 8 ], although there was no consistency in the reviewed papers regarding the partners’ expressed level of support for breastfeeding.

Knowledge, especially practical knowledge about breastfeeding, was mentioned as a barrier in 17% ( n  = 10) of the papers included in this review. While health care providers were perceived as a primary source of information on breastfeeding, some studies reported that mothers felt the information provided was not useful and occasionally contained conflicting advice [ 1 , 17 ]. This finding was reported across various jurisdictions, including the United States, Sweden, the United Kingdom and Netherlands, where mothers reported they had no support at all from their health care providers which made it challenging to address breastfeeding problems [ 26 , 38 , 44 ].

Breastfeeding in public emerged as a key barrier from the reviewed literature and was cited in 56% ( n  = 33) of the papers. Examining the experiences of breastfeeding mothers in the United States, Spencer, Wambach, & Domain [ 45 ] suggested that some participants reported feeling “erased” from conversations while breastfeeding in public, rendering their bodies symbolically invisible. Lack of designated public spaces for breastfeeding forced many women to alter their feeding in public and to retreat to a private or a more secluded space, such as one’s personal car [ 25 ]. The oversexualization of women’s breasts was repeatedly noted as a core reason for the United States women’s negative experiences and feelings of self-consciousness about breastfeeding in front of others [ 45 ]. Studies reported women’s accounts of feeling the disapproval or disgust of others when breastfeeding in public [ 46 , 47 ], and some reported that women opted out of breastfeeding in public because they did not want to make those around them feel uncomfortable [ 25 , 40 , 48 ].

Finally, return to paid employment was noted in the literature as a significant challenge for continuation of breastfeeding [ 48 ]. Lack of supportive workplace environments [ 39 ] or inability to express milk were cited by women as barriers for continuing breastfeeding in the United States and New Zealand [ 39 , 49 ].

Supports needed to maintain breastfeeding

Due to the central role family members played in women’s experiences of breastfeeding, support from partners as well as female relatives was cited in the literature as key factors  shaping women’s breastfeeding decisions [ 1 , 9 , 48 ]. In the articles published in Canada, Australia, and the United Kingdom, supportive family members allowed women to share the responsibility of feeding and other childcare activities, which reduced the pressures associated with being a new mother [ 19 , 20 ]. Similarly, encouragement, breastfeeding advice, and validation from healthcare professionals were identified as positively impacting women’s experiences with breastfeeding [ 1 , 22 , 28 ].

Community resources, such as peer support groups, helplines, and in-home breastfeeding support provided mothers with the opportunity to access help when they need it, and hence were reported to be facilitators for breastfeeding [ 19 , 22 , 33 , 44 ]. An increase in the usage of social media platforms, such as Facebook, among breastfeeding mothers for peer support were reported in some studies [ 47 ]. Public health breastfeeding clinics, lactation specialists, antenatal and prenatal classes, as well as education groups for mothers were identified as central support structures for the initiation and maintenance of breastfeeding [ 23 , 24 , 28 , 33 , 39 , 50 ]. Based on the analysis of the reviewed literature, however, access to these services varied greatly geographically and by socio-economic status [ 33 , 51 ]. It is also important to note that local and cultural context played a significant role in shaping women’s perceptions of breastfeeding. For example, a study that explored women’s breastfeeding experiences in Iceland highlighted the importance of breastfeeding in Icelandic society [ 52 ]. Women are expected to breastfeed and the decision to forgo breastfeeding is met with disproval [ 52 ]. Cultural beliefs regarding breastfeeding were also deemed important in the study of  Szafrankska and Gallagher (2016), who noted that Polish women living in Ireland had a much higher rate of initiating breastfeeding compared to Irish women [ 53 ]. They attributed these differences to familial and societal expectations regarding breastfeeding in Poland [ 53 ].

Overall, the reviewed literature suggested that women faced socio-cultural pressure to breastfeed their infants [ 36 , 40 , 54 ]. Women reported initiating breastfeeding due to recognition of the many benefits it brings to the health of the child, even when they were reluctant to do it for personal reasons [ 8 ]. This hints at the success of public health education campaigns on the benefits of breastfeeding, which situates breastfeeding as a new cultural norm [ 24 ].

This scoping review examined the existing empirical literature on women’s perceptions about and experiences of breastfeeding to identify how public health messaging can be tailored to improve breastfeeding rates. The literature suggests that, overall, mothers are aware of the positive impacts of breastfeeding and have strong motivation to breastfeed [ 37 ]. However, women who chose to breastfeed also experience many barriers related to their social interactions with significant others and their unique socio-cultural contexts [ 25 ]. These different factors, summarized in Fig.  5 , should be considered in developing public health activities that promote breastfeeding. Breastfeeding experiences for women were very similar across the United Kingdom, United States, Canada, and Australia based on the studies included in this review. Likewise, barriers and supports to breastfeeding identified by women across the countries situated in the global north were quite similar. However, local policy context also impacted women’s experiences of breastfeeding. For example, maintaining breastfeeding while returning to paid employment has been identified as a challenge for mothers in the United States [ 39 , 45 ], a country with relatively short paid parental leave. Still, challenges with balancing breastfeeding while returning to paid employment were also noticed among women in New Zealand, despite a more generous maternity leave [ 49 ]. This suggests that while local and institutional policies might shape women’s experiences of breastfeeding, interpersonal and personal factors can also play a central role in how long they breastfeed their infants. Evidently, the importance of significant others, such as family members or friends, in providing support to breastfeeding mothers was cited as a key facilitator for breastfeeding across multiple geographic locations [ 29 , 34 , 48 ]. In addition, cultural beliefs and practices were also cited as an important component in either promoting breastfeeding or deterring women’s desire to initiate or maintain breastfeeding [ 15 , 29 , 37 ]. Societal support for breastfeeding and cultural practices can therefore partly explain the variation in breastfeeding rates across different countries [ 15 , 21 ]. Figure  5 summarizes the key barriers identified in the literature that inhibit women’s ability to breastfeed.

Barriers to Breastfeeding

At the individual level, women might experience challenges with breastfeeding stemming from various physiological and psychological problems, such as issues with latching, perceived or actual lack of breastmilk, and physical pain associated with breastfeeding. The onset of postpartum depression or other psychological problems may also impact women’s ability to breastfeed [ 54 ]. Given that many women assume that breastfeeding will happen “naturally” [ 15 , 40 ] these challenges can deter women from initiating or continuing breastfeeding. In light of these personal challenges, it is important to consider the potential challenges associated with breastfeeding that are conveyed to new mothers through the simplified message “breast is best” [ 21 ]. While breastfeeding may come easy to some women, most papers included in this review pointed to various challenges associated with initiating or maintaining breastfeeding [ 19 , 33 ]. By modifying public health messaging regarding breastfeeding to acknowledge that breastfeeding may pose a challenge and offering supports to new mothers, it might be possible to alleviate some of the guilt mothers experience when they are unable to breastfeed.

Barriers that can be experienced at the interpersonal level concern women’s communication with others regarding their breastfeeding choices and practices. The reviewed literature shows a strong impact of women’s social networks on their decision to breastfeed [ 24 , 33 ]. In particular, significant others – partners, mothers, siblings and close friends – seem to have a considerable influence over mothers’ decision to breastfeed [ 42 , 53 , 55 ]. Hence, public health messaging should target not only mothers, but also their significant others in developing breastfeeding campaigns. Social media may also be a potential medium for sharing supports and information regarding breastfeeding with new mothers and their significant others.

There is also a strong need for breastfeeding supports at the institutional and community levels. Access to lactation consultants, sound and practical advice from health care providers, and availability of physical spaces in the community and (for women who return to paid employment) in the workplace can provide more opportunities for mothers who want to breastfeed [ 18 , 33 , 44 ]. The findings from this review show, however, that access to these supports and resources vary greatly, and often the women who need them the most lack access to them [ 56 ].

While women make decisions about breastfeeding in light of their own personal circumstances, it is important to note that these circumstances are shaped by larger structural, social, and cultural factors. For instance, mothers may feel reluctant to breastfeed in public, which may stem from their familiarity with dominant cultural perspectives that label breasts as objects for sexualized pleasure [ 48 ]. The reviewed literature also showed that, despite the initial support, mothers who continue to breastfeed past the first year may be judged and scrutinized by others [ 47 ]. Tailoring public health care messaging to local communities with their own unique breastfeeding-related beliefs might help to create a larger social change in sociocultural norms regarding breastfeeding practices.

The literature included in this scoping review identified the importance of support from community services and health care providers in facilitating women’s breastfeeding behaviours [ 22 , 24 ]. Unfortunately, some mothers felt that the support and information they received was inadequate, impractical, or infused with conflicting messaging [ 28 , 44 ]. To make breastfeeding support more accessible to women across different social positions and geographic locations, it is important to acknowledge the need for the development of formal infrastructure that promotes breastfeeding. This includes training health care providers to help women struggling with breastfeeding and allocating sufficient funding for such initiatives.

Overall, this scoping review revealed the need for healthcare professionals to provide practical breastfeeding advice and realistic solutions to women encountering difficulties with breastfeeding. Public health messaging surrounding breastfeeding must re-invent breastfeeding as a “family practice” that requires collaboration between the breastfeeding mother, their partner, as well as extended family to ensure that women are supported as they breastfeed [ 8 ]. The literature also highlighted the issue of healthcare professionals easily giving up on women who encounter problems with breastfeeding and automatically recommending the initiation of formula use without further consideration towards solutions for breastfeeding difficulties [ 19 ]. While some challenges associated with breastfeeding are informed by local culture or health care policies, most of the barriers experienced by breastfeeding women are remarkably universal. Women often struggle with initiation of breastfeeding, lack of support from their significant others, and lack of appropriate places and spaces to breastfeed [ 25 , 26 , 33 , 39 ]. A change in public health messaging to a more flexible messaging that recognizes the challenges of breastfeeding is needed to help women overcome negative feelings associated with failure to breastfeed. Offering more personalized advice and support to breastfeeding mothers can improve women’s experiences and increase the rates of breastfeeding while also boosting mothers’ sense of self-efficacy.

Limitations

This scoping review has several limitations. First, the focus on “women’s experiences” rendered broad search criteria but may have resulted in the over or underrepresentation of specific findings in this review. Also, the exclusion of empirical work published in languages other than English rendered this review reliant on the papers published predominantly in English-speaking countries. Finally, consistent with Arksey and O’Malley’s [ 18 ] scoping review methodology, we did not appraise the quality of the reviewed literature. Notwithstanding these limitations, this review provides important insights into women’s experiences of breastfeeding and offers practical strategies for improving dominant public health messaging on the importance of breastfeeding.

Women who breastfeed encounter many difficulties when they initiate breastfeeding, and most women are unsuccessful in adhering to current public health breastfeeding guidelines. This scoping review highlighted the need for reconfiguring public health messaging to acknowledge the challenges many women experience with breastfeeding and include women’s social networks as a target audience for such messaging. This review also shows that breastfeeding supports and counselling are needed by all women, but there is also a need to tailor public health messaging to local social norms and culture. The role social institutions and cultural discourses have on women’s experiences of breastfeeding must also be acknowledged and leveraged by health care professionals promoting breastfeeding.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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BB was responsible for the formal analysis and organization of the review. LK was responsible for data curation, visualization and writing the original draft. EN was responsible for initial conceptualization and writing the original draft. BB and LK were responsible for reviewing and editing the manuscript. All authors read and approved the final manuscript.

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Beggs, B., Koshy, L. & Neiterman, E. Women’s Perceptions and Experiences of Breastfeeding: a scoping review of the literature. BMC Public Health 21 , 2169 (2021). https://doi.org/10.1186/s12889-021-12216-3

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Getting breastfeeding started under pandemic visiting restrictions: lessons learned in Germany

• Mathilde Kersting 1 ,
• Erika Sievers 2 ,
• Nele Hockamp 1 ,
• Hermann Kalhoff 1 , 3 &
• Thomas Lücke 1  

International Breastfeeding Journal volume  19 , Article number:  64 ( 2024 ) Cite this article

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The COVID-19 pandemic contact restrictions considerably changed maternal visiting contacts during the time in which breastfeeding is initiated. We wanted to know how maternity ward staff and mothers rated the conditions of starting breastfeeding under contact restrictions.

In the Breastfeeding in North Rhine-Westphalia (SINA) study, Germany, 2021/22, chief physicians as well as ward staff from 41 (out of 131) maternity hospitals (82 members of the healthcare sector in total) were surveyed by telephone concerning structural and practical conditions for breastfeeding support before and during the pandemic; 192 (out of 426 eligible) mothers answered an online-questionnaire about their breastfeeding experiences at 2 weeks and 2 months after birth.

In almost all of the hospitals, visits were restricted due to the pandemic, with the exception of the primary support person. After more than one year of pandemic experience, the ward staff were convinced that the restrictions were mostly positive for the mothers (97.6%) and for the ward staff themselves (78.0%). A total of 80.5% of the ward staff would maintain the restrictions beyond the pandemic. The mothers themselves mostly rated the restrictions in the hospital as being just right; moreover, many mothers voluntarily maintained the restrictions at home, at least in part.

Conclusions

The unprecedented visiting restrictions in hospitals during the pandemic were like an “experiment” born out of necessity. Restricting visiting arrangements may be an underestimated beneficial component for the development of the mother-infant dyad in perinatal breastfeeding care, particularly in healthcare systems where almost all births occur in the maternity hospital.

Trial registration

German Clinical Trials Register (DRKS) (DRKS00027975).

The early postnatal period is important for the establishment of successful breastfeeding [ 1 , 2 ]. In Germany, almost all births (98%) occur in hospitals providing maternity services [ 3 ]. There are currently approximately 600 maternity hospitals in Germany [ 4 ]. Approximately 100 hospitals (17%) are designated ‘Baby-friendly’ [ 5 ]. In the last 20 years, postpartum stay in the hospital has decreased from a median of 5.3 days in 1997/98 to 3.0 days in 2017-19, as reported in the national surveys on “breastfeeding and infant nutrition in Germany”, which are known as SuSe I and SuSe II [ 6 ].

Before the COVID-19 pandemic, generous regulations on the number and duration of visitors were common in German hospitals. COVID-19 led to strict short-term contact restrictions beginning in April 2020. Hospitals had to comply with nationwide and state-specific regulations, such as in North Rhine-Westphalia (NRW), and were basically free to regulate visits themselves within this framework [ 7 ]. In maternity hospitals, visitors from outside the hospital were generally no longer allowed, but exceptions were permitted for the primary support person [ 7 ]. Considering the physiological course of breastfeeding initiation and the psychological course of parent-child interaction it seems obvious that such fundamental interventions in maternal social contacts could have an impact on breastfeeding.

In the first year of the pandemic, 6,201 research articles were published on COVID-19 and ‘maternal and child health, and nutrition’, including 445 articles on breastfeeding [ 8 ]. Most of them dealt with infection issues [ 8 ]. Later, studies more often addressed risks for maternal mental health and wellbeing [ 9 , 10 ]. Surprisingly, the impact of perinatal contact restrictions on breastfeeding have been rarely addressed [ 10 , 11 ], and when it is addressed, it is mostly limited to the special case of the support person being present at birth [ 12 ].

The 2021/22 SINA (Breastfeeding in North Rhine-Westphalia) study examined hospital breastfeeding management and maternal breastfeeding behaviors during the COVID-19 pandemic in the federal state of North Rhine-Westphalia, Germany [ 13 ]. Using the COVID-19 pandemic as an “experiment” born out of necessity, the aim of this data analysis was to explore how maternity ward staff and mothers rated the conditions for starting breastfeeding under contact restrictions.

The SINA study was performed in NRW, which is the most populated of the 16 federal states in Germany. The study comprised two parts: a state-wide cross-sectional quantitative survey of maternity hospitals focusing on perinatal breastfeeding management and experiences before and during the pandemic (‘hospital study’) and a regional prospective survey of mothers during the first 2 months after birth focusing on breastfeeding practices and pandemic experiences (‘mother study’) [ 13 ]. The data were collected between October 2021 and March 2022, i.e., during a period in which hospitals had experienced the pandemic for more than one year. No major changes to official COVID-19 hospital visit regulations occurred during the data collection period [ 14 ].

The study design and the data assessments in SINA were based on the nationwide SuSe II study 2017-19 [ 6 ]. Obligatory for participation was the written informed consent of hospitals and mothers. The SINA study was approved by the Ethics Committee of the Medical Faculty of the Ruhr University Bochum (Reg-Nr. 21-7322, 28.08.2021) and registered at German Clinical Trials Register (DRKS) (DRKS00027975).

Hospital study

Recruitment.

All maternity hospitals in NRW were eligible for participation. The heads of the gynecological departments were invited by postal letter. In the case of missing feedback, hospitals were reminded by phone calls and additionally reminded by fax and a video invitation from the person in charge of the study. Study participation included a telephone interview of the head of the department and separately of a person who was responsible for breastfeeding support on the maternity ward. In recognition, the ward was offered a gift worth 30 Euros.

Telephone interviews.

The main topics of the survey were agreed in advance with the heads of department of four large maternity hospitals in Bochum and Dortmund. The interview questionnaire for SINA was developed on the basis of the SuSe II study [ 6 ]. It included mostly closed questions and some open questions. Closed questions concerned various factors such as the percentage of Caesarean sections and skin-to-skin contact between mother and child soon after birth (yes/no). Open questions concerned various parameters such as potential consequences of the pandemic for pre- and postnatal breastfeeding information for mothers or the practice of supplemental feeding on the ward. The heads of department were mainly interviewed about structural aspects of breastfeeding management including the availability of a breastfeeding coordinator, the offer of staff training on breastfeeding support, and potential changes due to the pandemic. In total, 66 questions including sub-questions were asked. The interviews with ward staff mainly focused on practical issues of breastfeeding support for mothers, such as helping mothers to latch their baby and availability of breastfeeding aids on the ward. In total, 67 questions including sub-questions were asked in the questionnaire.

The interviews also addressed pre-pandemic routines and changes during the pandemic. Participants were also asked about their views on the impact of the pandemic on breastfeeding support. The interviews lasted about 45 min. The interviews with the heads of department were conducted by the person in charge of the study, and the interviews with the ward staff by the same study member. In addition to the interviewer, a second member was present and entered the answers into the data system. The interviews were recorded to enable subsequent validity checks.

Mother study

Mothers were recruited from the four large abovementioned maternity hospitals in the Ruhr Area (Bochum, Dortmund), which is an industrial centre in NRW. Three of the four hospitals had a catchment area with predominantly low socioeconomic status. Mothers who were eligible for participation in the study were consecutively invited on the maternity ward by study personnel. The inclusion criteria were: a healthy, fullterm newborn (birthweight ≥ 2500 g, gestational age ≥ 37 weeks, no admittance to a neonatal intensive care unit), maternal age of at least 18 years, no maternal health problems, sufficient maternal knowledge of the German language, internet access, and an email address.

Study participation required participants to complete a web-based questionnaire 2 weeks and 2 months after birth. In recognition, mothers were offered a brochure from the Research Department of Child Nutrition (FKE) with recommendations for infant feeding.

Online questionnaires

The digital questionnaires were sent by email and administered by the Fraunhofer Institute for Software and System Technology ISST, Dortmund. The questions addressed the current nutrition of the infant at the time of interest such as at 2 weeks of age. All liquids that the child received were asked individually, e.g. “What does your child receive at present?” Based on this information, exclusive breastfeeding was defined by the study staff as: No liquids or solids other than breastmilk (except for prescribed medicines, oral rehydration solution, vitamins and minerals) as defined by the WHO [ 15 ] and the German National Breastfeeding Committee [ 16 ].

The 2-week questionnaire additionally asked retrospectively about the infant’s feeding status during hospital stay and at discharge. In addition, maternal characteristics were assessed at 2 weeks, variables such as breastfeeding problems, reasons for stopping breastfeeding, type and timing of breastfeeding information before and after birth were assessed as well. In both surveys, mothers were also asked about their experiences with breastfeeding support, especially during the pandemic. If the questionnaires were not answered within a predefined time frame, mothers received an email as a reminder, followed by a phone call. Questionnaires that were not returned on time led to the exclusion of the mother from further participation in the study.

Data presentation

Responses from the hospital interviews were categorized into predefined categories (inductively) or via the grouping of free answers afterwards according to their meaning (deductively).

Descriptive data analysis was performed by using the IBM ® SPSS ® Statistics Version 25.0 software package for Windows 2016 (IBM Corp.). Percentages for categorical variables or frequencies for continuous variables were used for data presentation. To determine differences between categorical characteristics of mothers, the Fisher’s exact test or the Fisher-Freeman-Halton exact test of independence if the contingency table was larger than 2 × 2 was used. P - values < 0.05 (two-sided) were considered to indicate statistical significance.

Hospital characteristics

Of the 135 invited maternity hospitals, four hospitals had to be excluded (currently no maternity services/hospital management, being merged with another hospital); of the 131 eligible hospitals, n  = 41 (31%) agreed to participate and provided a full interview with the head of department and the person responsible for the ward.

The participating hospitals most often had an annual birth rate between 1000 and 1999 births and were located in a region with a medium socioeconomic background (Table  1 ). The proportion of hospitals with a Baby-friendly designation was greater than nationwide in Germany (29% vs. 17%, respectively). Mothers stayed in the hospital for (median) 2.5 days after vaginal birth and 3.5 days after Caesarean section. The recommendations for breastfeeding support in hospitals from WHO and UNICEF [ 17 ], which have been adapted to Germany [ 18 ], were met in a wide range, as shown by the examples of breastfeeding on demand (in 100% of hospitals) and early initiation of breastfeeding in Caesarean births (in 30% of hospitals).

Visiting regulations

Before the pandemic, visits by the mother’s primary support person were practically unrestricted in almost all of the hospitals and in the vast majority also for other relatives or friends (other person). With the outbreak of the pandemic, the situation fundamentally changed: specifically, in almost all of the hospitals, the primary support person was still allowed to visit, but mostly only for a limited amount of time 76, whereas other visitors were completely excluded in the vast majority of hospitals (Fig.  1 ).

- Visiting regulations in hospitals before and during the pandemic

Perceived consequences

In 78% (32/41) of hospitals, the ward staff perceived positive effects of the visiting restrictions for themselves, for example, supporting mothers with infant feeding was found to be easier and the staff felt more satisfied. Almost all of the ward staff (98%, 40/41) perceived effects for mother and the newborn to be positive, specifically, mothers were able to concentrate on their baby and they felt relaxed.

Ward staff were also asked about their assessment of pre-pandemic breastfeeding rates at discharge. They estimated the proportion of any breastfeeding to be 85% on average (range: 60–99%) (out of n  = 40) and the proportion of exclusive breastfeeding to be 67% on average (range: 20–98%) (out of n  = 39). A total of 38% (15/40) of ward staff perceived an increase in breastfeeding at discharge during the pandemic.

From the ward staff perspective, 81% (33/41) considered it desirable to maintain the visiting restrictions after the pandemic, at least to a limited extent; for the others, this scenario was discussed (7%, 3/41) or there was no interest or competence to decide on a change in visiting practices (12%, 5/41).

Maternal characteristics

Of the total 612 births in the four maternity hospitals during the recruitment period, 426 mother-infant-pairs met the inclusion criteria. Of the eligible mothers, 61.0% ( n  = 260) agreed to participate. Of those, 45.1% ( n  = 192) answered the first questionnaire 2 weeks postpartum and 42.3% ( n  = 180) also answered the second questionnaire 2 months postpartum, which corresponds to a follow-up of 93.8%. Finally, a total sample of 174 mothers having tried to breastfeed was analyzed here (Fig.  2 ).

- Flow chart of recruiting and selecting the sample of mothers

Most of these mothers were aged between 30 and 34 years (mean: 32.2, range: 19–42 years), had a higher level of education, were primiparous, had a vaginal birth and stayed in the hospital for 2 or 3 days (Table  2 , first column). The rate of exclusive breastfeeding at 2 weeks after birth was 71.8%. + multiple answers possible.

Perception of visiting regulations in hospitals

In the 2-week questionnaire, mothers were asked about their experiences with visiting restrictions since birth. More breastfeeding mothers (66.7%) felt that the visiting restrictions at the hospital were generally just right, whereas for a smaller proportion (33.3%) they were too strict. Stratification of mothers according to their perception of the visiting restrictions (Table  2 ) showed, that mothers for whom the restrictions were too strict were younger, often not married, less often employed before maternity leave, and more often had a shared room at hospital than mothers who perceived the visiting restrictions to be just right.

With regard to breastfeeding, 59.2% of mothers rated the visiting restrictions in the hospital as being positive: they had plenty of rest and reported that they were generally able to breastfeed well. For a smaller proportion (27.6%), the restrictions were only partially positive: mothers were able to breastfeed well but often felt alone, or they had plenty of rest but received less breastfeeding support. Explicit negative effects were less frequently reported (7.5%), mainly feeling lonely and insecure about breastfeeding. A small proportion of mothers (4.0%) did not feel any impact of the restrictions on breastfeeding.

At home, most breastfeeding mothers had continued to restrict visits (54.6%) or had relaxed the restrictions (17.8%), whereas others (27.6%) no longer restricted visits.

This data analysis highlights a very specific consequence of the COVID-19 contact restrictions in the perinatal breastfeeding environment. After more than a year of pandemic experience, maternity ward staff clearly viewed the visiting restrictions as being positive for both, mothers and staff. The fact that staff reported having more time to support mothers may have made it easier for mothers to focus on breastfeeding.

The mothers’ views on the hospital visiting restrictions confirm the results from the hospitals: mothers experienced a calm hospital atmosphere and often felt that they could breastfeed well. These positive experiences in the hospital may also have motivated mothers to maintain visiting restrictions, at least partially, at home. Despite the more permissive contact opportunities at home, a catch-up effect of missed hospital visits does not appear to have occurred.

The desire of the ward staff to at least partially maintain the restrictions beyond the pandemic confirms their positive assessment of the restrictions on breastfeeding success.

Overall, some important aspects of our findings for hospitals and mothers are reflected in the pandemic experiences reported by lactation consultants in hospitals in the US [ 19 ]. They reported that babies tended to be poorly breastfed when visitors were around and mothers did not rest. In contrast, when no visitors were around, mothers felt comfortable with the baby and parents attempted to breastfeed for longer periods of time before asking for supplemental feeding to be introduced. At the same time, lactation consultants found it difficult to find a good compromise of visiting arrangements that would ensure both optimal professional breastfeeding support and the satisfaction of the families.

Experience from other studies

The COVID-19 pandemic has led to various interventions that could be relevant for breastfeeding, thus making it difficult to compare research results. Clearly describable measures such as official contact restrictions have rarely been addressed in relation to breastfeeding [ 20 ]. In particular, the experiences of hospitals in limiting visits have not been adequately studied, although these policy factors of hospitals have a significant influence on the initiation of breastfeeding [ 1 , 12 ].

Similar to our quantitative survey, the authors of a qualitative study in Spain reported that visiting restrictions tended to be positively perceived in relation to breastfeeding outcomes [ 21 ]. Mothers perceived contact restrictions as predominantly positive for breastfeeding and bonding with the child because disturbances from outside were eliminated. However, as in our study, feelings of loneliness and missing the family were also expressed [ 21 ].

The severity of hospital visit restrictions also seems to play a role, as two studies from Italy have suggested [ 11 , 22 ]. In one hospital in which partners had no access, breastfeeding rates after birth and in the following three months were lower than those reported several years earlier [ 22 ]. In another hospital where the presence of the partner was only partially restricted, breastfeeding rates at discharge were not affected, although mothers felt more anxious and less supported by hospital staff [ 11 ].

In a nationwide online survey of maternity hospitals in the US in 2020, hospital self-assessed breastfeeding rates at discharge remained approximately the same in 68.9% of hospitals and increased in 11.3% of hospitals since the outbreak of the pandemic [ 23 ]. Although this is only an estimation, the ward staff of our hospitals were more optimistic (37.5%) that breastfeeding rates at discharge increased during the pandemic.

Lessons learned

Forced experiment.

The COVID-19 pandemic, with its unprecedented and stringent visiting restrictions in hospitals is akin to an ‘experiment’ born out of necessity, wherein there were interferences with the social life of patients and the daily work of medical and care staff. Such clearly defined and abrupt interventions in the breastfeeding environment would neither be feasible as a formal research study, nor ethically acceptable under Western perinatal conditions. Therefore, the experience with the pandemic could help to identify favorable and unfavorable social conditions for a smooth breastfeeding initiation. Moreover, our ‘mother study’ suggests that younger, single and non-employed women might be target groups for specific research on the influence of social factors in the perinatal situation on maternal wellbeing.

Short postnatal hospital stay

In the SINA study, the hospital stay after a vaginal birth was 2.5 days before the pandemic and was estimated to be even shorter by 60% of hospitals during the pandemic [ 13 ]. In the US, the vast majority of hospitals (72.9%) have shortened their hospital stays to less than 48 h due to the pandemic [ 23 ], which is a duration defined as ‘shortened stay’ [ 24 ] and which requires increased breastfeeding support.

With approximately 50% of mothers in Germany reporting breastfeeding problems in the first two weeks postpartum [ 13 , 25 ], the need to improve early breastfeeding support is evident. Breastfeeding problems have been associated with a shortened duration of exclusive breastfeeding [ 26 ]. It would be interesting to have data on whether effective perinatal breastfeeding support would be enhanced by limitation of visitors in the immediate postpartum period and whether avoidable disturbances of the maternal-child interaction would be less frequent, and could help to prevent the development of problems around breastfeeding.

Strengths and weaknesses

One of the strengths of the study is the transferability of the findings to countries with similar social and healthcare systems. Although the rather low participation rates of hospitals and mothers may have favored an overrepresentation of breastfeeding friendliness, the pandemic restrictions equally applied to all hospitals and mothers, thus the consequences are likely to be transferable.

A further limitation of the data is that the changes in breastfeeding rates perceived by maternity ward staff during the pandemic could not be verified because a control situation was not feasible. Data reported by hospital staff may have resulted in social desirability bias. Confirmation of the findings in further studies is needed.

Future prospects

Visiting arrangements may be one of the underestimated socioemotional components of breastfeeding support, as they may have an impact on maternal wellbeing thus affecting the probability of successful breastfeeding initiation.

Further studies are needed to distinguish the specific role of postnatal visiting regulations from other factors of breastfeeding support. At present, it can be suggested that visiting regulations in the maternity ward should combine the clinical and social needs of the young family. Practically, this could mean that visiting arrangements in the maternity ward should be reasonably channeled, even if this may seem surprising in a liberal social environment. In this way, new perspectives for postpartum breastfeeding support could be developed from the pandemic experience.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Research Department of Child Nutrition

North Rhine-Westphalia

Breastfeeding in North Rhine-Westphalia

Breastfeeding and infant nutrition in Germany

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Acknowledgements

The authors would like to kindly thank Fiona Abram and Stefanie Voss for their valuable support in recruiting and data collection and to thank the participating hospitals and mothers for their conscientious and patient responses to the interviews and questionnaires. We would like to thank the Fraunhofer Institute for Software and System Technology (ISST) Dortmund for managing the online questionnaires in the mother study.

Ministry of Labor, Health and Social Affairs of North Rhine-Westphalia (Grant No 24.03.05-9111307 FP Stillen).

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Mathilde Kersting, Nele Hockamp, Hermann Kalhoff & Thomas Lücke

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M.K., E.S.: SINA Study design, M.K.: draft manuscript, funding acquisition; N.H.: data presentation; E.S., N.H., H.K.: interpretation, T.L.: review, funding acquisition; all authors have accepted responsibility for the entire content of this manuscript and approved its submission.

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Kersting, M., Sievers, E., Hockamp, N. et al. Getting breastfeeding started under pandemic visiting restrictions: lessons learned in Germany. Int Breastfeed J 19 , 64 (2024). https://doi.org/10.1186/s13006-024-00664-7

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Received : 08 November 2023

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DOI : https://doi.org/10.1186/s13006-024-00664-7

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