title: Opinions and practices of clinicians associated with continuation of exclusive breastfeeding.
abstract: BACKGROUND
  The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life. Recent statistics indicate that initiation and maintenance of exclusive breastfeeding are low in the United States. Unfortunately, little information is available on how clinicians and health care organizations can best promote continuation of exclusive breastfeeding.
  
  
  OBJECTIVE
  To identify clinicians' opinions and management practices that are associated with continuation of exclusive breastfeeding.
  
  
  METHODS
  We conducted a prospective cohort study of low-risk mother-newborn pairs in a large, multispecialty group practice in which the mother was breastfeeding at 4 weeks. Mothers completed telephone interviews at 4 and 12 weeks postpartum, and their data were linked with their obstetric and pediatric clinicians' responses to a cross-sectional mailed survey conducted during the same time period. Obstetric and pediatric clinicians included medical doctors, nurse practitioners, and nurse midwives. Overall response rates were 63% for mothers and 82% for clinicians (54 obstetric and 67 pediatric clinicians). Bivariate and multivariate analyses were conducted to identify the characteristics of clinicians and mothers that predicted exclusive breastfeeding at 12 weeks.
  
  
  RESULTS
  Of the 288 mothers who were breastfeeding at 4 weeks and had a complete 12-week interview, 152 (53%) were exclusively breastfeeding their infants at 12 weeks. Mothers who discontinued exclusive breastfeeding were more likely to have experienced problems with their infant latching on or sucking (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 1.5-9.7) or report that a health care provider recommended formula supplementation (OR: 2.3; 95% CI: 1.1-5.0). Clinicians reported limited time during preventive visits to address breastfeeding problems as a very important barrier to promoting breastfeeding. Obstetric providers were least confident in resolving problems with mothers not producing enough breast milk. Pediatric providers were least confident in resolving problems with breast pain or tenderness or cracked or painful nipples. In the final multivariate model, mothers whose pediatric providers recommended formula supplementation if an infant was not gaining enough weight (OR: 3.2; 95% CI: 1.04, 9.7) or who considered their advice to mothers on breastfeeding duration to be not very important (OR: 2.2; 95% CI: 1.2-3.9) were more likely to have discontinued exclusive breastfeeding by 12 weeks postpartum. Black mothers were significantly more likely to discontinue exclusive breastfeeding by 12 weeks.
  
  
  CONCLUSIONS
  Clinicians' practices regarding formula supplementation of healthy infants and their opinions about the importance of their breastfeeding advice are associated with the likelihood that mothers will continue exclusive breastfeeding. Policies to enhance clinicians' abilities to address breastfeeding problems within the constraints of busy practices could improve their ability to support exclusive breastfeeding.
authors.affiliation: Department of Ambulatory Care and Prevention, Center for Child Health Care Studies, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts 02215, USA. elsie.taveras@tch.harvard.edu
authors.forename: Elsie M
authors.initials: EM
authors.lastname: Taveras
authors.forename: Ruowei
authors.initials: R
authors.lastname: Li
authors.forename: Laurence
authors.initials: L
authors.lastname: Grummer-Strawn
authors.forename: Marcie
authors.initials: M
authors.lastname: Richardson
authors.forename: Richard
authors.initials: R
authors.lastname: Marshall
authors.forename: Virginia H
authors.initials: VH
authors.lastname: Rêgo
authors.forename: Irina
authors.initials: I
authors.lastname: Miroshnik
authors.forename: Tracy A
authors.initials: TA
authors.lastname: Lieu
mesh_terms: D001291:Attitude of Health Personnel; D001942:Breast Feeding; D002983:Clinical Competence; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D041943:Infant Formula; D007231:Infant, Newborn; D015999:Multivariate Analysis; D009721:Nurse Midwives; D009722:Nurse Practitioners; D009774:Obstetrics; D010372:Pediatrics; D010820:Physicians; D011446:Prospective Studies; D014481:United States