Family Practice Vol. 20, No. 5, 528-530
© Oxford University Press 2003
Child health |
Intention to breastfeed and other important health-related behaviour and beliefs during pregnancy
Institute of Work, Health and Organisations, University of Nottingham, William Lee Buildings 8, Nottingham Science and Technology Park, University Boulevard, Nottingham NG7 2RQ and
a MRC Environmental Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton SO16 6YD, UK.
Correspondence to Cheryl Haslam; E-mail: cheryl.haslam{at}nottingham.ac.uk
Haslam C, Lawrence W and Haefeli K. Intention to breastfeed and other important health-related behaviour and beliefs during pregnancy. Family Practice 2003; 20: 528–530.
Received 31 October 2002; Revised 25 April 2003; Accepted 19 May 2003.
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Abstract |
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Background. It is widely accepted that breastfeeding is the best form of infant feeding for the first 4–6 months of life.
Objective. This study explored whether intention to breastfeed is associated with other positive maternal health-related behaviours and beliefs during pregnancy.
Method. A cross-sectional survey was carried out with 789 women attending antenatal clinics at Leicester Royal Infirmary NHS Trust. A structured questionnaire assessed feeding intention, use of folic acid, vitamin and iron supplementation, smoking status, smoking stage of change, and fetal health locus of control during pregnancy.
Results. Forty percent of the women stated that they intended to breastfeed exclusively, 27% planned to bottle feed, 23% intended to combine breast and bottle feeding and 10% were undecided. Women planning to breastfeed (either exclusively or in combination with bottle feeding) were more likely than those with alternative feeding plans to: have increased their folic acid intake, taken vitamin/iron supplements and have a primarily internal locus of control (perceive themselves to have control over the health of their unborn baby). Women intending to breastfeed were also less likely to smoke. Of the women who did smoke, those planning to breastfeed were more likely to be either considering or preparing to quit smoking during their pregnancy.
Conclusion. In addition to educating pregnant smokers about the risks of maternal smoking, primary health care practitioners could also usefully address their knowledge, health beliefs and feeding intentions during antenatal care.
Keywords. Breastfeeding, fetal health locus of control, maternal smoking, vitamin and iron supplementation.
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Introduction |
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Government policy recommends breastfeeding for 4–6 months,1 and a recent review of the literature finds no evidence to refute this recommendation.2 However, the UK has one of the lowest breastfeeding rates in Europe, with only 25% breastfeeding up to 4 months.3 Younger, single, less educated mothers are less likely to breastfeed.4 Women who smoke are less likely to initiate breastfeeding and more likely to discontinue breastfeeding.5
Prochaska and DiClemente’s stages of change model6 states that when people change health-compromising behaviour, they progress through a series of stages. Haslam and Draper7 showed that pregnant women’s stage of change is associated with their perceptions of risk relating to maternal smoking. This study assessed women’s feeding intentions, smoking stage of change, folate intake and use of vitamin and iron supplements. The Fetal Health Locus of Control (FHLC) Scale8 was used to measure the extent to which women feel responsible for the health of their unborn child. Women with high internal FHLC scores show more positive health behaviours during pregnancy.9 The aim of this study was to examine whether women intending to breastfeed were more likely to engage in positive health behaviours and have more internal FHLC than those not intending to breastfeed.
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Method |
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A structured, self-completion questionnaire examined socio-demographic variables, feeding intentions, smoking status and stage of change, folic acid intake (supplements and/or increased dietary intake), vitamin/iron supplement usage and items from the FHLC scale. The questionnaire was piloted, refined and administered to all women attending an antenatal clinic at Leicester Royal Infirmary over a 2 month period.
Those who answered ‘Breastfeed only’ or ‘Breast and bottle feed’ were ascribed to the intention to breastfeed group, while those answering ‘Bottle feed only’, or ‘Have not decided’ were assigned to the alternative feeding plan group. A smoker was defined as someone who smokes at least one cigarette per day. The algorithm for stage of change has been described previously.7
No previous research has looked at feeding intention, FHLC, smoking and supplement use during pregnancy. As multiple comparisons were to be carried out, it was decided that the significance level should be set at 
= 0.01. The study had sufficient power (at least 0.80) to detect medium or large effects at this level. Chi-square analyses were conducted to investigate possible associations between demographic data, feeding intention, FHLC and other maternal health behaviour.
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Results |
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A total of 789 women returned the questionnaire. Forty percent intended to breastfeed exclusively, 23% intended to combine breast and bottle feeding, 27% planned to bottle feed only, and 10% were undecided. This indicated that 63% intended exclusively or partly to breastfeed their baby, with the remaining 37% having alternative, or undecided, feeding intentions. Fifty percent of women aged <25 years planned to breastfeed compared with 67% of women aged between 25 and 34 and 68% of women over the age of 35 years (P < 0.001). Of those planning to breastfeed, 50% were of social classes I or II (higher social class), 33% were of social classes III or IIIm, and 17% were of social classes IV or V (P < 0.001). Women planning to breastfeed were more likely to be living with their partner (P < 0.001) and have continued full-time education beyond the age of 16 years (P < 0.001).
Women were rated as primarily internal, primarily external or combined in terms of FHLC. Those planning to breastfeed were significantly more internal (70% versus 30%, P < 0.001) (Fig. 1
). Fifty-two percent of women taking vitamin/iron supplements were rated as primarily internal compared with 32% of women who were not (P < 0.005). Non-smokers were also more likely than smokers to be rated as primarily internal (84% versus 16%, P < 0.001).
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While 86% of women planning to breastfeed had increased their folic acid intake, the comparable figure for women with alternative feeding plans was 77% (P < 0.001). Women intending to breastfeed were more likely to be taking iron/vitamin supplements (48% versus 35%, P < 0.001).
Twenty-one percent were smokers, 30% ex-smokers and 49% never smokers. Of the smokers, 45% were pre-contemplative, i.e. not intending to quit, 16% were contemplating quitting and 39% were preparing to stop. Eighty-six percent of those planning to breastfeed were non-smokers. The comparable figure for women with alternative feeding plans was 66% (P < 0.001). Of the pre-contemplators (not intending to quit), only 25% planned to breastfeed, compared with 48% of those contemplating and 55% of those preparing to quit (P < 0.001).
To assess the interaction between the 10 variables found to be significantly associated with feeding intentions, a binary logistic regression was calculated. Variables shown to be non-significant in this regression were then removed one by one in order of their P-values, from largest to smallest, leaving six significantly associated with feeding intentions. These were (in order of significance) previous breastfeeding experience, education, current smoking status, FHLC, supplement intake and socio-economic status (SES). Those intending to breastfeed were therefore more likely to have previously breastfed, have more education, be non-smokers, have internal FHLC, be taking supplements and have higher SES. These variables successfully predicted 71% of the sample’s feeding intentions.
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Discussion |
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Intention to breastfeed, taking vitamin/iron supplements and not smoking were all associated with internal FHLC scores, suggesting a greater sense of personal responsibility for the health of the unborn infant. Women not intending to breastfeed were more likely to smoke and less likely to increase folic acid and vitamin/iron intake, which may mean their infants experience a relatively impoverished environment in utero. Such infants are also likely to be exposed to household tobacco (associated with sudden infant death syndrome10 and infant health problems) as well as being denied the benefits of breastfeeding.
Smokers considering or preparing to quit were more likely to intend to breastfeed, and women with internal FHLC were more likely to engage in recommended health behaviours. This implies that, as well as educating pregnant smokers about the risks of smoking, primary care practitioners need to explore pregnant smokers’ health beliefs relating to nutrition during pregnancy and their feeding intentions.
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References |
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1 Department of Health and Social Security. Present Day Practice in Infant Feeding. Report on Health and Social Subjects 9. London: HMSO; 1974.
2 Lanigan JA, Bishop JA, Kimber AC, Morgan J. Systematic review concerning the age of introduction of complementary foods to the healthy full-term infant. Eur J Clin Nutr 2001; 55:309–320.[CrossRef][Web of Science][Medline]
3 Foster K, Lader D, Cheesbrough S. Infant Feeding 1995. London: The Stationery Office; 1997.
4 Yngve A, Sjööström M. Breastfeeding in countries of the European Union and EFTA: current and proposed recommendations, rationale, prevalence, duration and trends. Public Health Nutr 2001; 4:631–645.[Medline]
5 Scott JA, Binns CW. Factors associated with the initiation and duration of breastfeeding: a review of the literature. Breastfeeding Rev 1999; 7:5–16.
6 Prochaska JO, DiClemente CC. Transtheoretical therapy: toward a more integrative model of change. Psychother Res Pract 1982; 19:276–288.
7 Haslam C, Draper ES. Stage of change is associated with assessment of the health risks of maternal smoking among pregnant women. Soc Sci Med 2000; 51:1189–1196.[Medline]
8 Labs SM, Wurtele SK. Fetal health locus of control scale: development and validation. J Consult Clin Psychol 1986; 54:814–819.[Medline]
9 Bielawska-Batorowicz E. The effect of previous obstetric history on women’s scores on the Fetal Health Locus of Control Scale (FHLC). J Reprod Infant Psychol 1993; 11:103–106.
10 Blair PS, Fleming PJ, Bensley D et al. Smoking and the sudden infant death syndrome: results from 1993–5 case–control study for confidential inquiry into stillbirths and deaths in infancy. Br Med J 1996; 313:195–198.
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