Introduction

Breastfeeding is the optimal infant nutrition contributing to reduced child under-five mortality and morbidity. Longer duration of breastfeeding is associated with lower risks for infections and chronic diseases, and with higher intelligence in children, as compared to shorter duration [1]. Breastfeeding mothers have reduced risks for breast and ovarian cancers, and for chronic diseases [1]. The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first six months, with continuation of breastfeeding until at least two years, supplemented with appropriate complementary foods. EBF is defined as feeding the baby mother’s milk only, with no other food or drink including water, but allowing oral rehydrating solutions, vitamins, minerals or other medicines when needed [2].

Lebanon, an upper middle income country has a low six-month EBF rate of 15% [3]. Barriers to EBF in Lebanon include maternal, socio-cultural, and legislative factors. In a qualitative study that followed mothers for one year after delivery, maternal perception of low milk supply, lack of family support, sleep deprivation, sore nipples, painful breastfeeding, and breast engorgement were identified as important barriers to breastfeeding continuation [4]. Moreover, Bou Diab and Werle in a more recent qualitative study found that ‘descriptive norms’ of the close community members and society at large may affect a mother’s decision to breastfeed or not as she would want to conform to these norms [5]. At the national legislative level, there is poor dissemination, implementation, and enforcement of policies and laws that protect breastfeeding [6], such as those pertaining to maternal employment, Baby Friendly Hospital Initiative (BFHI) [7], and the implementation of the International Code of Marketing of Breast milk Substitutes [6]. Moreover, hospitals and maternity clinics in Lebanon do not comply with the ten steps of BFHI, and health professionals who care for breastfeeding mothers lack the WHO, and United Nations International Children’s Emergency Fund (UNICEF) recommended training in the prevention and treatment of breastfeeding problems [8, 9]. Also, there are few International Board Certified Lactation Consultants (IBCLCs) in Lebanon, and they are not integrated within the national health system.

There is strong evidence on the effectiveness of breastfeeding promotion and support interventions in improving breastfeeding initiation and continuation rates [10–13]. For example, antenatal breastfeeding education, peer support, and professional lactation support, delivered as single interventions or in combinations, increase EBF and any breastfeeding rates [10–12, 14]. We recently reported similar findings from our multi-center, randomized controlled trial (RCT), in which a multi-component intervention of antenatal education, peer, and professional support improved six-month EBF in healthy Lebanese mothers [15]. Participants allocated to the multi-component intervention were twice as likely to EBF for 6 months, compared to controls (OR = 2.02; 95% CI: 1.20 to 3.39). Participants in the experimental group who complied with all three intervention components were six times more likely than controls to continue EBF for six months (OR = 6.63; 95% CI: 3.03 to 14.51). Of the three intervention components, participants were most compliant with professional lactation support (92.6%), received either as a single component, or in combination with prenatal education and/or peer support.

Despite the evidence on the effectiveness of professional lactation support in improving breastfeeding rates, there still remains a knowledge gap surrounding the optimal dose (frequency and duration), and form of support delivery needed to improve six-month EBF rates [13, 14]. In this study, we aimed to (1) investigate the association between professional lactation support (exposure) and six-month EBF (outcome), in terms of the support frequency, duration, or form of delivery (face-to-face versus telephone support), and to (2) explore the differences in breastfeeding barriers and facilitators between participants who continued six months of EBF, and those who stopped earlier. Face-to-face support is defined as support delivered during visits to the hospital or to the homes of the participants.

Materials and methods

Results

Characteristics of the sample

Of 159 mothers, 57 (35.8%) were exclusively breastfeeding at six months. Most participants (102 primi-gravid and 9 multi-gravid participants; 69.8%) had never breastfed previously. Tables 1 and 2 compare the baseline characteristics and breastfeeding support variables of participants who continued exclusive breastfeeding for six months, and those who stopped earlier. As compared to participants who stopped EBF early, mothers who continued for six months were younger, had better breastfeeding knowledge, more positive attitudes towards breastfeeding, breastfed more children, and had previously breastfed for a longer duration (for participants who had a previous breastfeeding experience). Moreover, more participants who continued EBF for six months belonged to site 2, were Muslims, had female obstetricians, had younger obstetricians, and received antenatal breastfeeding education, peer support, or professional lactation support (Table 2).

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Table 1. Characteristics of the cohort (N = 159).

https://doi.org/10.1371/journal.pone.0238735.t001

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Table 2. Frequency distribution of participants characteristics (N = 159).

https://doi.org/10.1371/journal.pone.0238735.t002

The association between professional lactation support and 6-month EBF

In bivariate analysis, participants who continued EBF for six months had a higher number of face-to-face contacts and telephone contacts with the IBCLCs. Also, the duration of face-to-face contacts with the IBCLCs was longer (Table 3).

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Table 3. Bivariate analysis of the association between six-month EBF and different exposures (N = 159).

https://doi.org/10.1371/journal.pone.0238735.t003

In the multivariate adjusted analyses, the overall number of IBCLC contacts (face-to-face plus telephone) was associated with higher odds for six-month EBF (OR = 1.15, 95% CI: 1.04 to 1.270), whereas face-to-face contacts alone were not. This suggests that home visits along with telephone contacts with the IBCLCs may be more effective than home visits alone. The number of IBCLC telephone contacts was associated with slightly higher odds for six-month EBF; OR = 1.12, 95% CI: 1.00 to 1.26, respectively). Neither the number, nor the duration of face-to-face IBCLC contact was associated with six-month EBF. Other positive predictors of six-month EBF were receipt of antenatal breastfeeding education, and having a female obstetrician (Table 4).

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Table 4. Predictors of six-month exclusive breastfeeding (N = 159).

https://doi.org/10.1371/journal.pone.0238735.t004

Discussion

In this observational study, we explored the association between the frequency, duration, and form of professional lactation support and six months exclusive breastfeeding. McFadden, et al. [13] reported that more than four postnatal contacts with professional lactation experts seemed to be most influential in reducing the odds of cessation of EBF before six months (OR = 0.89; 95% CI: 0.81 to 0.98). It is interesting to note that both of our groups had more than four overall contacts with the IBCLC, which implies that the additional telephone contact may have contributed to the success of EBF until six months. Lavender, et al. [20] reported that telephone support reduced the risk for cessation of EBF between three and six months by 50%, as compared to any other support, or to no telephone support (RR = 1.5; 95% CI: 1.19 to 1.93). The difference in IBCLC telephone support between our two groups could be because participants who were determined to continue EBF were more motivated to call the IBCLC when needed (as a need-based consultation), on top of utilizing more face-to-face contacts. This is further supported by the qualitative data reported by the IBCLCs in which they described participants who stopped EBF early as uncooperative and refusing IBCLC calls or visits. This may be because these participants were not convinced of breastfeeding, had more negative attitudes towards breastfeeding as evidenced by their lower IIFAS-A scores, or lacked self-confidence, and hence were distressed and frustrated with breastfeeding.

It is interesting to note that our participants who achieved six months of EBF had, in addition to more overall contacts with IBCLCs, better baseline breastfeeding knowledge than those who stopped earlier. This finding is in agreement with previous literature in which the combination of breastfeeding education and professional lactation support was reported to improve six-month EBF more than breastfeeding education alone (OR = 2.50; 95% CI: 1.00 to 6.25) [11, 12]. We hypothesize that participants with better baseline breastfeeding knowledge were more enthusiastic about breastfeeding, which may have motivated them to seek further knowledge by attending the antenatal breastfeeding educational session designed for the trial participants allocated to the experimental group. Hence, receipt of antenatal breastfeeding education in addition to having better baseline breastfeeding knowledge may have contributed to their success in achieving six months of EBF. This is in line with the IBCLC reports about participants who continued six months of EBF showing more self-confidence, and being excited, more determined, and very willing to continue EBF as much as they could.

The association of the obstetrician’s gender with six-month EBF has not been previously reported. However, a previous study from Lebanon reported a positive association between female gender of the pediatrician and breastfeeding for four months (OR = 1.49; 95% CI: 1.03 to 2.15) [21]. Moreover, a study reported the odds of EBF at three months to be higher among women whose birth was attended by a midwife or female nurse, as compared to birth by an obstetrician (OR = 1.87; 95% CI: 1.34 to 2.61) [22]. This may be because female obstetricians, who may have experienced motherhood and/or breastfeeding, would be more comfortable to address maternal concerns about infant nutrition, as compared to male obstetricians. Also breastfeeding mothers may feel more comfortable to discuss breastfeeding with female obstetricians. However, this needs to be better explored in future studies, given that the current recommendation for obstetricians is to advocate for, and support breastfeeding [23].

The finding that participants who were recruited from site 2 were more successful in achieving six months of EBF than those recruited from site 1 can be explained by the characteristics of the population at each site. When compared to site 1, site 2 serves mostly middle to low income Muslim communities. The Holy Quran asks women to breastfeed their infants for two years. Moreover, breastfeeding is more economic for families who have middle, or low income. Our finding is similar to a previous study from Lebanon that reported Muslim religion, and lower maternal and paternal education (as surrogates of lower SES), to positively predict breastfeeding for four months [21].

The association of six-month EBF with younger maternal age is in contrast to reports from Western countries where younger maternal age is associated with lower EBF rates [24]. We believe that our finding may be due to a generational change in attitude towards breastfeeding in Lebanon, in which younger women are more aware of breastfeeding and its benefits, and thus are more committed to EBF than older mothers.

Analysis of maternal breastfeeding concerns or problems, our study’s second aim, identified similar concerns in the two groups of participants: those who continued six months of EBF, and those who stopped earlier. However, the two groups differed in the type of concern, its severity, and the way to cope with it. For example, whereas nutritional maternal concerns of participants continuing six months of EBF were about the best diet to increase or maintain their milk, those who stopped EBF earlier were concerned about diets that will help them lose weight and regain their shape. Similarly, participants who stopped EBF early continued to express concerns about insufficiency of maternal milk, and were frustrated with the frequent night feeds that they interpreted as lack of infant’s satiety. Instead of breastfeeding on demand at night, they supplemented their infants with infant formula. This may explain why more participants in this group suffered from breast engorgement. The temporal grouping of themes generated from the qualitative data revealed that the first three months postpartum was a critical period for breastfeeding participants as they faced sleep deprivation, problems with positioning and latching, and struggled with nutritional concerns, sore nipples, breast engorgement and other medical problems. Participants who lacked self-confidence, good breastfeeding knowledge, and good lactation support easily succumbed to those challenges and discontinued breastfeeding early.

Comparison of the two groups of participants in this study helps us identify factors that describe those who are at risk of stopping exclusive breastfeeding before six months. Breastfeeding women who are inexperienced, have poor breastfeeding knowledge, express concerns about breastfeeding affecting their weight or shape, are anxious about their milk being insufficient for the infant, or have negative feelings towards night feeds are at high risk of discontinuing EBF before six months. Other red flags include maternal or infant health problems during the first three months postpartum, and specifically during the first week. We and others have reported on those factors as important barriers to breastfeeding continuation [4, 5, 24, 25]. Early identification of breastfeeding women facing difficulties with breastfeeding will alert the health care professional, be it a physician, a midwife, a nurse or an IBCLC to the different challenges they are struggling with, especially during the first three months postpartum.

Conclusion

Breastfeeding women may face several challenges during the first three months postpartum that may interfere with continuation of EBF until six months. The availability of close contact with professional lactation experts as face-to-face, complemented with unrestricted need-based telephone support may positively influence EBF for six months. Participants who continue to express concerns about milk insufficiency, weight concerns, night feeds, seem to be anxious, or lack self-confidence may be at risk of discontinuing EBF earlier than six months. Timely identification of these mothers by health professionals and lactation experts may help tailor interventions that specifically address their concerns, hence reducing the risk of early EBF cessation. Further research is needed to explore what interventions can effectively target those challenging concerns. Moreover, the superiority of face-to-face and need-based telephone lactation support over face-to-face support in our observational study may be skewed by selection bias; hence randomized clinical trials are needed to confirm this finding.

Supporting information

Acknowledgments

This study constituted the dissertation subject of Dr. Dayane Daou as a requirement for her Masters in the Scholars in HeAlth Research Program (SHARP), at the American University of Beirut. We are thankful to Dr. Ghada El-Hage Fuleihan, and to Dr. Tamar Kasholian-Kabalian for their advice and critical comments on the manuscript. We are indebted to all our participants without whom this study could not have been possible.