Matern Child Health J (2017) 21:234–241

DOI 10.1007/s10995-016-2130-x

BRIEF REPORTS

Counseling About the Maternal Health Benefits of Breastfeeding

and Mothers’ Intentions to Breastfeed
Megan Ross-Cowdery1 • Carrie A. Lewis2 • Melissa Papic3 • Jennifer Corbelli1 •

Eleanor Bimla Schwarz2,4,5

Published online: 21 July 2016

Ó Springer Science+Business Media New York 2016

Abstract Objectives To evaluate the impact of counseling
regarding the maternal health effects of lactation on preg-
nant women’s intentions to breastfeed. Methods Women
seeking prenatal care at an urban university hospital com-
pleted surveys before and after receiving a 5-min coun-
seling intervention regarding the maternal health effects of
breastfeeding. The counseling was delivered by student
volunteers using a script and one-page infographic. Par-
ticipants were asked the likelihood that breastfeeding
affects maternal risk of multiple chronic conditions using
7-point Likert scales. We compared pre/post changes in
individual item responses and a summary score of knowl-
edge of the maternal health benefits of lactation (MHBL)
Poster presented at: International Society for Research in Human
Milk and Lactation Conference, Oct 23-27, 2014, Kiawah Island,
South Carolina, USA.
Electronic supplementary material The online version of this
article (doi:10.1007/s10995-016-2130-x) contains supplementary
material, which is available to authorized users.
using paired t tests. Multivariable logistic regression was
used to examine the impact of increases in knowledge of
MHBL on participants’ intentions to breastfeed. Results
The average age of the 65 participants was 24 ± 6 years.
Most (72 %) were African-American and few (9 %) had
college degrees. Half (50 %) had previously given birth,
but few (21 %) had previously breastfed. Before counsel-
ing, few were aware of any benefits of lactation for
maternal health. After counseling, knowledge of MHBL
increased (mean knowledge score improved from 19/35 to
26/35, p \ 0.001). Improvement in MHBL knowledge
score was associated with increased intention to try
breastfeeding (aOR 1.20, 95 % CI 1.02–1.42), of wanting
to breastfeed (aOR 1.45, 95 % CI 1.13–1.86), and feeling
that breastfeeding is important (aOR 1.21, 95 % CI
1.03–1.42). Conclusions for Practice Brief structured
counseling regarding the effects of lactation on maternal
health can increase awareness of the maternal health ben-
efits of breastfeeding and strengthen pregnant women’s
intentions to breastfeed.

& Eleanor Bimla Schwarz Keywords Lactation
Breastfeeding
Counseling

ebschwarz@ucdavis.edu Maternal health
1
University of Pittsburgh School of Medicine, Pittsburgh, PA,
USA
2
Significance
Center for Healthcare Policy and Research, University of
California, Davis, Sacramento, CA, USA
3
What is already known on this subject? Despite widespread
Department of Epidemiology, University of Pittsburgh,
Pittsburgh, PA, USA
acceptance of the pediatric benefits of breastfeeding, in
4
2012, only 22 % of US infants were breastfed as recom-
Division of General Internal Medicine, Department of
mended. This study demonstrates that highlighting the
Medicine, University of Pittsburgh, Pittsburgh, PA, USA
5
maternal health benefits of lactation when counseling
Present Address: Division of General Internal Medicine,
mothers about infant feeding significantly increased the
Department of Medicine, University of California, Davis,
4150 V Street, PSSB 2400 [room 2506], Sacramento, strength of mothers’ intentions to breastfeed. As mothers’
CA 95817, USA breastfeeding intentions have been found to strongly

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Matern Child Health J (2017) 21:234–241
predict actual infant feeding practices, this approach to
lactation counseling deserves attention and further
investigation.
What this study adds? This study demonstrates that
highlighting the maternal health benefits of lactation when
counseling mothers about infant feeding significantly
increased the strength of mothers’ intentions to breastfeed.
As mothers’ breastfeeding intentions have been found to
strongly predict actual infant feeding practices, this
approach to lactation counseling deserves attention and
further investigation.
Introduction
Breastfeeding is widely recognized as playing a critical
role in infant health and development (Ip et al. 2007).
Unfortunately, only 22 % of US women currently adhere to
infant feeding recommendations (American Academy of
Pediatrics Section on Breastfeeding 2012). Barriers to
breastfeeding are particularly common among low income
and black mothers (Chapman and Perez-Escamilla 2012),
who may face workplace challenges to pumping and stor-
ing breast milk, and lack community social support for
breastfeeding (Ware et al. 2014; Johnson et al. 2015).
Mothers with strong prenatal intentions to breastfeed are
most likely to overcome these hurdles and successfully
breastfeed (Bai et al. 2010; Donath et al. 2003; Wambach
1997). Thus, it is important to identify counseling strate-
gies that impact pregnant women’s breastfeeding inten-
tions. Interventions are particularly needed to promote
strong intentions to breastfeed among poor, African-
American mothers, who face the greatest risk of barriers to
breastfeeding (Johnson et al. 2015).
Although currently rarely discussed with pregnant
women (Demirci et al. 2013), a growing body of literature
indicates that lactation plays an important role in maternal
recovery from pregnancy, and can determine multiple
aspects of maternal health in later life (Stuebe and Schwarz
2010). For example, since the link between breastfeeding
and breast cancer was first hypothesized over 60 years ago
(Gross 1947), over 47 epidemiologic studies conducted in
30 countries have linked lactation to lower rates of breast
cancer (Collaborative Group on Hormonal Factors in
Breast, C 2002). The African-American Breast Cancer
Epidemiology and Risk (AMBER) consortium, has specif-
ically examined parity, lactation, and breast cancer subtypes
in African-American women, and found the link between
lactation and triple-negative breast cancer to be particularly
strong (Palmer et al. 2014). Most recently, detailed genetic
analyses of breast cancer subtypes have indicated that breast
cancer prognosis and survival are both affected by a
woman’s history of lactation (Kwan et al. 2015).
235
Ovarian cancer risk is also markedly reduced by lacta-
tion. A meta-analysis of 35 studies concluded that breast-
feeding initiation and a longer duration of lactation are
both associated with lower risk of endothelial ovarian
cancer (Luan et al. 2013). Autoimmune diseases, particu-
larly rheumatoid arthritis, also appear less commonly
among mothers who ever breastfed (Adab et al. 2014).
Estrogen plays a key role in the development of autoim-
mune diseases, which are more common among women
than men. Lactation, which lowers estrogen levels, would
then be expected to result in immunomodulation, lowering
risk of rheumatoid arthritis among mothers who lactated.
A mother’s risk of cardiovascular disease and cardiac
death are also affected by her duration of lactation (Natland
Fagerhaug et al. 2013). This is plausible because lactation
affects postpartum weight retention, and lactation has been
beneficially linked to multiple components of the metabolic
syndrome, including visceral adiposity (McClure et al.
2012), diabetes (Jager et al. 2014), hyperlipidemia, and
hypertension (Lupton et al. 2013). In addition, an animal
model recently demonstrated that lactation significantly
affects maternal visceral adiposity, blood pressure, and
cardiac function (Poole et al. 2014).
Although many women know that breastfeeding
improves infant health outcomes (Ip et al. 2007), we
hypothesized that informing pregnant women of the
maternal health effects of lactation would strengthen their
intentions to breastfeed. We therefore developed and
evaluated a structured counseling intervention designed to
inform pregnant women about the maternal health benefits
of lactation, while recognizing that lactation has downsides
such as adverse effects on libido (Leeman and Rogers
2012) and risk of mastitis.
Materials and Methods
Women seeking prenatal care were recruited from the
waiting room of an urban clinic affiliated with a large
maternity care hospital in Pittsburgh, Pennsylvania. All
women visiting the clinic were invited to participate. Par-
ticipants completed surveys before and immediately after
receiving a structured counseling intervention. This study
was determined to be exempt by the University of Pitts-
burgh Institutional Review Board.
The structured counseling intervention we developed
addressed the relationships between lactation and nine
maternal conditions: diabetes, hypertension, hyperlipi-
demia, heart disease, breast cancer, ovarian cancer, uterine
cancer, rheumatoid arthritis, and postpartum weight loss.
The counseling also discussed some of the obstacles
women may face when trying to breastfeed, such as mas-
titis and decreased libido. The structured counseling was
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delivered by student volunteers with no prior clinical
training. Project volunteers received a 1 h orientation
which included guidance on how to reach an on-call clin-
ician if women had questions after receiving the structured
counseling. The counseling script was written at a fifth
grade reading level and took approximately 5 min to read
(Appendix 1 of ESM). Participants were given a one-page
infographic (Fig. 1) to look at while listening to the
scripted counseling which was delivered one-on-one in a
semi-private area of the waiting room. The images that
formed the infographic included an image developed in
2002 by the Ad Council designed to convey a link between
bottle-feeding and insulin use, and images developed
specifically for this project.
The primary outcome of interest was women’s inten-
tions to breastfeed; to assess these intentions, we adapted a
validated questionnaire developed by Bai et al. The ques-
tionnaire assesses three constructs identified by the Theory
of Planned Behavior (Ajzen 2011) which may contribute to
mothers’ decision-making about infant feeding (Bai et al.
2011). These constructs include subjective norms (external
pressures to perform a behavior), attitudes (internal feel-
ings regarding a behavior) and perceived behavior control
(degree to which an individual feels empowered to make
her own decisions). The central premise of the Theory of
Planned Behavior is that a performed behavior’s immediate
antecedent is the intention to perform that behavior. Prior
literature which examines this theory has shown that
intention to breastfeed significantly increases breastfeeding
behavior (Bai et al. 2010; Wambach 1997).
For this study, women’s intentions to breastfeed were
assessed using a seven-category Likert scale (anchored from
strongly disagree to strongly agree) for three statements: ‘‘It
is likely that I will try to breastfeed after my baby is born,’’ ‘‘I
want to breastfeed my baby,’’ and ‘‘Breastfeeding my baby is
important.’’ Women were also asked to estimate, using a
seven-category Likert scale (anchored from extremely
unlikely to extremely likely), the likelihood that lactation
would affect their future risk of breast cancer, ovarian can-
cer, diabetes, hypertension, and arthritis. In addition, women
were asked about aspects of breastfeeding some women may
fear such as difficulty with weight loss, headaches, breast
infections, and decreased libido. Questions about the benefits
and downsides of breastfeeding were interspersed in the
survey instrument. The full wording of all study questions is
available in the Appendix 2 of ESM.
The primary predictive variable of interest was
improvement in women’s overall knowledge of the
maternal health benefits of lactation. We created a sum-
mary score using responses to the five items for which
lactation has a beneficial effect on maternal health: reduced
risk of breast cancer, ovarian cancer, diabetes, hyperten-
sion, and arthritis. When questions were left unanswered,
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Matern Child Health J (2017) 21:234–241
participants were assumed to have a lack of knowledge;
thus, missing data was re-coded as ‘‘1 = very unlikely to
lower risk.’’ The scale’s internal consistency was tested
with Cronbach’s alpha (pre-intervention, alpha = 0.80;
post-intervention, alpha = 0.79) and indicated accept-
able scale reliability.
We hypothesized that women receiving the counseling
intervention would increase their understanding of the
maternal health benefits of lactation and would report
stronger intentions of trying to breastfeed, desire to
breastfeed, and feelings that breastfeeding is important.
Further, we hypothesized that the likelihood a woman
reported strong intentions to breastfeed would be related
both to her baseline knowledge of the maternal health
benefits of lactation as well as change in her knowledge
from before to after the counseling intervention. We used
t tests for paired samples to compare pre/post differences
in means of individual survey items as well as
improvements in the summary score of knowledge of the
maternal health benefits of lactation. We then used
multivariable logistic regression to examine the signifi-
cance of the impact of increases in knowledge of the
maternal health benefits of lactation on participants’
intentions to breastfeed, while controlling for baseline
knowledge of maternal health benefits (modeled as a
continuous variable), education (dichotomized as college
educated vs. less than college educated), race/ethnicity
(dichotomized as African-American vs. others), parity
(dichotomized as prior pregnancy vs none), and prior
experience breastfeeding (vs. none). Outcome variables
were dichotomized into positive intentions versus nega-
tive intentions to breastfeed by grouping neutral with
negative responses.
Results
In total, 65 women completed both pre- and post-inter-
vention surveys. Most participants were African-American
(72 %) and currently unemployed (58 %). Few participants
(9 %) had college degrees; 81 % had high school degrees.
The average age of participating women was 24 ± 6 years
of age. Most (66 %) were married or in a committed
relationship. While half (50 %) had previously given birth,
only 21 % of all participants had previously breastfed
(Table 1).
Before counseling, few women felt lactation was likely
to affect maternal health (Table 2). When we calculated a
summary score of participants’ pre-intervention knowledge
of the maternal health benefits of lactation, we found the
mean score was 19 out of a possible 35 points. Small
percentages of participants indicated that breastfeeding was
‘‘extremely likely’’ to lower risk of: breast cancer (17 %),
Matern Child Health J (2017) 21:234–241 237

Fig. 1 Infographic used in conjunction with scripted counseling

ovarian cancer (11 %), diabetes (5 %), hypertension (3 %), that lactation can affect maternal health (Table 2). Post-
or rheumatoid arthritis (0 %). intervention, participants’ summary score of knowledge of
After counseling, participants showed statistically sig- the maternal health benefits of lactation had a mean of 26
nificant changes in their understanding of the likelihood out of a possible 35 points, representing a significant

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Table 1 Characteristics of study participants, n = 65 intervention survey (mean = 6.0/7, 71 % Strongly Agree)
Demographic and reproductive characteristics Number (%)
and the increase did not reach significance (p = 0.06).
(n = 65) In multivariable models, we found that increases in
knowledge of the maternal health benefits of lactation
Age (years) 24 ± 6
were significantly associated with intentions to breastfeed
Race even after controlling for other important covariates. Each
African-American 47 (72) unit increase in knowledge of the maternal health benefits
White 18 (28) of lactation corresponded to 20 % greater odds that par-
Education ticipants intended to try to breastfeed, 45 % greater odds
Less than 8th grade 2 (3) that participants wanted to breastfeed, and 21 % greater
Some high school 11 (16) odds that participants felt breastfeeding was important
High school or GED 22 (32) (Table 3).
Some college 26 (39)
College degree 6 (9)
Employment Discussion
Not employed 39 (58)
Employed, part-time 15 (22) Few of the pregnant women who participated in this study
Employed, full-time 13 (29) were initially aware of the ways lactation benefits a
Relationship status mother’s health. However, providing brief structured
Married 11 (16) counseling with a one-page infographic significantly
Committed relationship but not married 34 (50) increased awareness of the maternal health benefits of
Single 22 (33) lactation. More importantly, this structured counseling
Gestation at time of survey (weeks) 24 ± 10 significantly increased the strength of pregnant women’s
Ready to have a baby when became pregnant 29 (45) intentions to breastfeed their baby. As prior studies have
Not sure 15 (23) found that mothers with strong prenatal intentions to
Previous birth 33 (50) breastfeed most frequently manage to breastfeed (Bai et al.
Previous breastfeeding 14 (21) 2010; Donath et al. 2003; Wambach 1997), this approach
to lactation counseling has the potential to meaningfully
impact infant feeding behaviors and improve health out-
comes across two generations.
increase from the mean pre-intervention knowledge score The American College of Obstetrics and Gynecology
(p \ 0.0001). After receiving this structured counseling, identifies counseling about infant feeding as a core com-
more participants felt that breastfeeding was ‘‘extremely ponent of prenatal care (‘‘American College of Obstetri-
likely’’ to lower risk of breast cancer (69 %), ovarian cians and Gynecologists (ACOG) Committee on Health
cancer (69 %), diabetes (68 %), hypertension (48 %), and Care for Underserved Women & Committee on Obstetric
rheumatoid arthritis (50 %). No significant changes were Practice. Special report from ACOG. Breastfeeding:
seen in women’s expectations regarding an effect of lac- maternal and infant aspects’’ 2007) and recommends that
tation on headaches, libido, or weight loss (Table 2). A this guidance start at the first prenatal appointment and be
small but significant number of women learned breast reinforced and expanded on in subsequent visits. This is
infections are more common with breastfeeding. consistent with a systematic review which found that pre-
After receiving this brief structured counseling inter- natal educational interventions were more successful in
vention, there were also significant increases in the strength promoting breastfeeding than postpartum lactation support
of participants’ intentions to breastfeed (Table 2). After (Guise et al. 2003). Yet, in a recent study of initial prenatal
counseling, 73 % of participants said they were extremely visits, breastfeeding counseling was found to be infrequent
likely to try to breastfeed (mean of responses = 5.9/7, (29 % of visits) and brief (Demirci et al. 2013). This is
standard deviation (SD) = 1.9) compared to 66 % previ- unfortunate as prior studies have found that clinician
ously (mean of responses = 6.5/7, SD = 1.3); p = 0.002. counseling about breastfeeding is an important predictor of
The strength of agreement to the statements ‘‘I want to both breastfeeding initiation and continuation (Jarlenski
breastfeed’’ also showed a significant increase (p = 0.05). et al. 2014). However, clinician training on breastfeeding
The strength of agreement to the statement ‘‘Breastfeeding and lactation support is frequently incomplete (Freed et al.
my baby is important’’ also increased (Table 2), although it 1995). To this end, the scripted counseling tested in this
started at a high rate of endorsement on the pre- study may facilitate effective prenatal counseling about the

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Table 2 Women’s perceptions of the impact of breastfeeding on maternal health and breastfeeding intentions, n = 65
Pre-intervention Post-intervention Change
Mean SD Mean SD Mean SD p value*

Positive effects
Summary score of knowledge of maternal health benefits of lactationa 19.4 5.9 26.1 6.0 6.8 6.7 \0.0001
Breast cancer 4.8 1.6 6.5 1.1 1.7 1.7 \0.0001
Ovarian cancer 4.5 1.5 6.5 1.1 2.0 1.6 \0.0001
Diabetes 4.0 1.6 6.4 1.2 2.4 1.8 \0.0001
Hypertension 3.9 1.5 5.7 1.7 1.9 1.8 \0.0001
Arthritis 3.1 1.4 5.6 2.0 2.0 1.6 0.01
Potential negative effects
Difficulty losing weight 2.2 1.6 2.4 2.2 -0.3 2.4 0.36
Cause headaches 3.3 1.8 3.8 2.0 -0.5 2.0 0.06
Cause breast infections 3.4 1.9 4.1 2.1 -0.7 2.7 0.04
Lower sex drive/libido 3.3 1.7 3.6 2.0 -0.4 2.3 0.20
Breastfeeding intentions
Breastfeeding my baby is important 6.3 1.3 6.5 1.1 0.2 0.8 0.06
It is likely that I will try to breastfeed 5.9 1.9 6.5 1.3 0.6 1.4 \0.001
I want to breastfeed my baby 6.0 1.8 6.2 1.5 0.2 0.9 0.05
* p- value from paired t test
a
The summary score for the Knowledge of the Maternal Health Benefits of Lactation scale was calculated using responses to the following five
items which assessed participants knowledge that lactation lowers risk of: breast cancer, ovarian cancer, diabetes, hypertension, and arthritis on a
7-point Likert scale. The summary score has a minimum of five points (if breastfeeding was felt to be extremely unlikely to lower risk of any of
the five conditions) and a maximum score of 35 points (if breastfeeding was felt to be extremely likely to lower risk of all five conditions)

Table 3 Association between improvement in knowledge of the maternal health benefits of lactation and women’s intentions to breastfeed,
n = 65
Outcome measures
Want to breastfeed Intend to try Breastfeeding is
breastfeeding important
Adj 95 % CI Adj 95 % CI Adj 95 % CI
ORa ORa ORa

Improvement in summary score of knowledge of maternal health 1.45 1.13–1.86 1.20 1.02–1.42 1.21 1.03–1.42
benefits of lactationb
Baseline summary score of knowledge of maternal health benefits of 1.57 1.15–2.14 1.34 1.05–1.71 1.17 0.97–1.42
lactationb
Prior lactation versus none 57.62 0.92 to 3.58 0.28–45.36 2.93 0.23–36.95
[999.99
Prior birth versus nulliparous 0.06 0.01–0.62 0.09 0.01–1.20 0.30 0.04–2.47
Black versus others 1.19 0.12–12.14 5.85 0.56–60.96 12.82 0.93–175.92
College versus less educated 0.34 0.03–4.23 0.31 0.02–5.29 2.73 0.17–43.41
a
Multivariable logistic regression models adjusted for all variables shown in table
b
The summary score for the Knowledge of the Maternal Health Benefits of Lactation scale was calculated using responses to the following five
items which assessed participants knowledge that lactation lowers risk of: breast cancer, ovarian cancer, diabetes, hypertension, and arthritis on a
7-point Likert scale. The summary score has a minimum of five points (if breastfeeding was felt to be extremely unlikely to lower risk of any of
the five conditions) and a maximum score of 35 points (if breastfeeding was felt to be extremely likely to lower risk of all five conditions)

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maternal health benefits of lactation by clinicians, medical
assistants, or community volunteers without formal clinical
training.
This study has several strengths, including using a pre-
viously validated measure of women’s infant feeding
intentions (Bai et al. 2011) and finding significant
improvement in the strength of women’s intentions to
breastfeed among a population of pregnant women at high
risk for not breastfeeding. The scripted counseling we
studied addressed both health outcomes which are affected
positively (e.g. breast cancer) and negatively (e.g. breast
infections, libido) by lactation, and our surveys addition-
ally assessed health conditions that are not typically
affected by lactation (e.g. headaches). Of note, after
receiving the structured counseling, participants reported
that lactation is likely to improve some, but not all, health
outcomes, reducing concerns that social desirability bias
shaped these findings. However, as the infographic
addressed only a fraction of the information discussed in
the scripted counseling, these differences may also reflect
participants’ abilities for auditory and visual learning.
Although prior studies have found infant feeding intentions
are highly predictive of subsequent infant feeding behav-
iors (Bai et al. 2010; Donath et al. 2003; Wambach 1997),
future studies are needed to demonstrate that this coun-
seling intervention produces sustained intentions to
breastfeed and increases rates of breastfeeding as would be
expected. In addition, it will be important to confirm
whether the short-term improvements in knowledge noted
in this study produce long-term knowledge of the effects of
lactation on maternal health, and to formally assess the
validity and reliability of the modifications we made to the
instrument previously developed by Bai et al. (2010).
Finally, the relatively small population studied may not
allow generalization to other clinical settings.
Nonetheless, our results indicate that information about
the maternal health effects of lactation can play a sig-
nificant role in shaping pregnant women’s intentions to
breastfeed, and are thus important for clinicians to discuss
with the families they care for. As suboptimal breast-
feeding is estimated to cost the US $17 billion in maternal
health costs (Bartick et al. 2013) and $13 billion in
pediatric health costs, innovative approaches to increasing
rates of breastfeeding are urgently needed. This study
indicates that brief structured counseling about the
maternal health effects of lactation combined with a one-
page infographic significantly increases intentions to
breastfeed among a population of low-income, African-
American women.
Acknowledgments One of the images included in the infographic
was developed in 2002 by the Ad Council; the authors have no
conflict of interest or funding source to report.
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Matern Child Health J (2017) 21:234–241
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