Tuesday, July 19, 2016

The Influence of Obesity Stigma on Breastfeeding Rates

Artwork by Lajos Tihanyi, 1908
Image from Wikimedia Commons
A number of studies over the years have consistently found lower breastfeeding rates in high-BMI women. The question is, why? 

Typically, most authors speculate that there is some biological disturbance and that this is the main reason for lower breastfeeding rates in "obese" women. In other words, as always, researchers see our bodies as defective and blame our weight for every problem we encounter. 

However, a recent study found that there may be subtle obesity stigma at work as well. In the study, high-BMI women were consistently given less information about breastfeeding, less help in getting breastfeeding started, less opportunity to breastfeed within the first hour after birth, less access to breastfeeding support resource phone numbers, less rooming-in, and less encouragement to breastfeed on demand. 

My best guess is that there are multiple factors at work in lower breastfeeding rates in heavier women. Although many women of size breastfeed without any problems, it's possible that for some there may be biological factors like Polycystic Ovarian Syndrome (PCOS) or other hormonal differences that impact milk supply.

In addition, researchers rarely control for the effect of birth interventions on breastfeeding rates in obese women, despite the fact that unconscionably high cesarean rates in this group may be a strong factor impacting breastfeeding rates as well. Furthermore, as we have written about before, other factors such as subtle thyroid disturbances, greater postpartum blood loss leading to increased anemia, and psychosocial factors may also influence breastfeeding rates in obese women.

In all likelihood, the breastfeeding rate in women of size is influenced by many complex factors. No one answer is likely to fix the rate completely.

But one factor that would be easy to fix is improving the consistency and quality of breastfeeding support offered to high-BMI women. 

How sad that differences in quality of support even exist in the first place.


Matern Child Health J. 2016 Mar;20(3):593-601. doi: 10.1007/s10995-015-1858-z. Obese Mothers have Lower Odds of Experiencing Pro-breastfeeding Hospital Practices than Mothers of Normal Weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008.
Kair LR1, Colaizy TT2. PMID: 26515471 DOI: 10.1007/s10995-015-1858-z
OBJECTIVES: This study examines the extent to which a mother's pre-pregnancy body mass index (BMI) category is associated with her exposure to pro-breastfeeding hospital practices.  METHODS: Data from the 2004-2008 CDC PRAMS were analyzed for three states (Illinois, Maine, and Vermont) that had administered an optional survey question about hospital pro-breastfeeding practices. RESULTS: Of 19,145 mothers surveyed, 19 % were obese (pre-pregnancy BMI ≥ 30). Obese mothers had lower odds than mothers of normal weight of initiating breastfeeding [70 vs. 79 % (unweighted), p < 0.0001]. Compared with women of normal weight, obese mothers had lower odds of being exposed to pro-breastfeeding hospital practices during the birth hospitalization. Specifically, obese mothers had higher odds of using a pacifier in the hospital [odds ratio (OR) 1.31, 95 % confidence interval (CI) (1.17-1.48), p < 0.0001] and lower odds of: a staff member providing them with information about breastfeeding [OR 0.71, 95 % CI (0.57-0.89), p = 0.002], a staff member helping them breastfeed [OR 0.69, 95 % CI (0.61-0.78), p < 0.0001], breastfeeding in the first hour after delivery [OR 0.55, 95 % CI (0.49-0.62), p < 0.0001], being given a telephone number for breastfeeding help [OR 0.65, 95 % CI (0.57-0.74), p < 0.0001], rooming in [OR 0.84, 95 % CI (0.73-0.97), p = 0.02], and being instructed to breastfeed on demand [OR 0.66, 95 % CI (0.58-0.75), p < 0.0001]. Adjusting for multiple covariates, all associations except rooming in remained significant. CONCLUSIONS: Obesity stigma may be a determinant of breastfeeding outcomes for obese mothers. Breastfeeding support should be improved for this at-risk population.


Janeen said...

Here are a few other thoughts having been a successful obese breastfeeding mother:

*Large breasts and lack of easy to find nursing bras. Being an H cup, nursing bras were VERY hard for me to find. I usually had to buy them online and guess (though really, just tended to go with the largest cup size I could find to buy) the size hoping that it would fit.

*Large breasts and comfortable nursing positions. My nursing positions were also limited. With my oldest, I couldn't lie down to nurse for a good four months. For some reason, we just couldn't get it to work. For the most part, I was nursing her (and her sister later on) by having her lie on her back on my lap in kind of a modified football hold.

*Being comfortable nursing in public. I was NOT comfortable nursing in public. Here, you have two different things that tend to attract unwanted attention (nursing in public and being obese) and combining them. If I had to nurse in public, I was horrendously self-conscious about it, expecting someone to say something at anytime especially since it was extremely hard for me to do it in a discreet way (see point above regarding large breasts and position). I usually would try to bring a bottle of pumped milk but it didn't always work out.

And yes, interventions definitely can cause issues, especially with a firstborn baby and especially if that firstborn is born via cesarean as mine was. By the time my second was born, via VBAC, I had had over 4 years of nursing under my belt and it had only been about 10 weeks since I had last nursed her sister so it went much easier the second time around other than that bit where she lost weight at around 4 months old but we got past that and she went on to nurse for a total of three years.

I also have to wonder if some of it isn't also economical status based. As in, where you would find some of the obese mothers would be in a lower social economic class and therefore, maybe needing to return to work or other issues like that. I wasn't working when I had my two but we definitely struggled with money because we did rely on only one income. I have no doubt that if I was working breastfeeding would have been even harder to accomplish especially with my first considering the pain I had with her for the first 14 weeks after she was born.

Anonymous said...

When I had my twins, no one could give me any advice on how to breastfeed with very, very large pendulous breasts. Kept getting advise that would have worked fine for someone with a B or C cup but not for someone with K cups (Ha!) headed far south. We finally figured it out but it was a test of commitment for sure!