Breastfeeding Initiation and Continuation by Employment Status among Korean Women

Breastfeeding is the best nutritional choice for infants and mothers. Breast milk not only provides all of the nutrients that infants need during the first six months, but also consists of immunologic components that protect against acute illnesses during childhood. Exclusive breastfeeding and a longer continuation of breastfeeding have been demonstrated to be associated with better health outcomes for mothers as well as for infants[1, 2]. The World Health Organization (WHO) and UNICEF recommend mothers to breastfeed exclusively for the first six months of life, starting complementary feeding in the sixth month, and to continue breastfeeding for two years or more[3].

The National Survey on Fertility, Family Health & Welfare in Korea reported that the breastfeeding rate in Korea was 90% in 1970, but had a continuous decrease to 10.2% in 2000, and slowly increased thereafter[4]. In 2012, the exclusive breastfeeding rates were 56.7% at 1~2 months and 36.2% at 5~6 months. However, the Korean Health Plan 2020 objectives for exclusive breastfeeding are 70% during the first month and 60% at six months[5]. In order to achieve these objectives, effective strategies need to be designed to increase the proportion of women who initiate and who continue breastfeeding for longer durations.

Previous studies have identified a number of factors that are associated with initiation and duration of breastfeeding in different countries or for different ethnic groups[6, 7, 8, 9, 10]. These factors can be categorized into demographic, psycho-social, health care-related, community attributes and public policy[11]. Among these various factors, maternal employment was found to be the most common barrier to breastfeeding[12, 13]. Although the employment rate of married women in Korea has been increasing 53.1% in 2012[4], there are limited studies that examine the determinants of breastfeeding initiation and continuation among Korean women, especially among employed women.

The results of this study demonstrate that maternal employment is the strongest barrier to breastfeeding continuation, but not for initiation. This result indicates that many working mothers start breastfeeding, but continuation is difficult after returning to work. This result is consistent with the findings of other studies[15, 16]. With the increasing numbers of mothers in the workforce, it is important to create baby-friendly workplace environments so that mothers can continue to breastfeed.

Some studies have shown that maternity leave or a friendly working environment are important factors in the initiation and continuation of breastfeeding for employed women[12, 16, 17, 18, 19]. In Korea, 12-week maternity leave is provided, but in 2014, only 31 workplaces were designated as "baby-friendly workplaces" by the WHO and UNICEF. This implies that employers generally may not care about creating working environments suitable for breastfeeding even though the employment rate of married women has been increasing.

Many women fail to continue breastfeeding at the first month postpartum. Participants in this study had difficulties in breastfeeding due to insufficient milk supply, ineffective positioning and latch-on, engorged breasts, and these reasons were similar to those found in previous studies[9, 15, 20]. The 2011 Surgeon General's Call to Action to Support Breastfeeding identified numerous barriers to breastfeeding, including a lack of knowledge, lactation problems, poor family and social support, and inappropriate care received from health professionals[21]. Lisien et al.[9] emphasized the role of nursing personnel in providing women with methods of breast milk production and secretion, and reminding their families to give assistance and support. Postpartum breastfeeding education during hospital stay and telephone counseling from a nurse after discharge for four times during the first month were more effective to promote breastfeeding continuation at 6 months than was postpartum education alone[22]. Therefore, in order to overcome the barriers to breastfeeding from the start, both breastfeeding education and supportive care from healthcare professionals are critically important. For the working mothers, education proved to be effective for initiating and continuing breastfeeding, hence advertisement for facilitation of pre- and postpartum education is deemed important to increase the mothers' participation in the educational classes. Breastfeeding education programs should also be offered in a variety of settings such as in schools and public health agencies, as well as in hospitals, to allow women to obtain accurate and practical information regarding breastfeeding.

Not only that, for the mothers who do not work, the result showed that rooming-in is a factor that influenced breastfeeding initiation. Therefore, health professionals in the hospital should promote change to provide rooming-in for every mother at a reasonable price and thus support breastfeeding. Such change should not be limited to certain rooms in the maternity wards, but to every room. Mothers should be able to choose rooming-in without any financial pressure, which is the case due to the price that usually demanded for rooming-in rooms. Such changes will have to include concerns about room organization within the ward, so that rooming-in will no longer be an individual room with high prices, but a communal facility to which everyone could have access.

Rooming-in is practically helpful for breastfeeding initiation because it allows mothers to feed their babies on demand. Although 79.2% of the participants breastfed during the hospital stay after delivery, only 34.8% of the mothers stayed in the same room as their infants (Table 1). Rooming- in was associated with initiation, but breastfeeding during the hospital stay was the more significant determinant of longer continuation than rooming-in. Therefore, hospitals can profoundly influence mothers to breastfeed by establishing effective breastfeeding behaviors during the hospital stay. Healthcare professionals including nurses should educate and support the benefits of mothers' rooming in with their babies from delivery until discharge. Also, normal postpartum mothers with normal babies should stay together in the same room day and night, except for periods of up to an hour for hospital procedures. It should start no later than one hour after normal vaginal deliveries. In many hospitals in Korea, newborns are kept in nurseries after delivery. When considering rooming-in vs. nursery care, the results indicate that hospitals should encourage mothers and babies to enjoy rooming-in.

More than 20,000 hospitals in 156 countries have been designated by the WHO and UNICEF as "baby-friendly hospitals" as they adhere to the "ten steps to successful breastfeeding" that include rooming-in and initiation of breastfeeding within a half hour after birth[23]. However by 2014, only 32 hospitals in Korea were designated as "baby-friendly hospitals". In order to promote breastfeeding initiation and continuation, health care professionals should recognize the impact of breastfeeding behaviors during the hospital stay and should make every effort to follow the guidelines of the WHO and UNICEF.

Mothers who had infants with atopic dermatitis were more likely to continue breastfeeding for a longer period of time. There has been considerable controversy with respect to the effects of breastfeeding on preventing or developing atopic dermatitis[24, 25, 26]. The cause-and-effect relationship between breastfeeding practice and atopic dermatitis was not clear in this study. As breastfeeding is recommended for infants who have a family history of atopic diseases, mothers who knew that their infants had or were at risk of atopic diseases were more likely to breastfeed.

Many researchers have shown that maternal age is associated with the initiation and continuation of breastfeeding, and that women aged older than 25 years are more likely to initiate or to continue breastfeeding than younger women[13, 27]. However, in our sample with the exception of 12 mothers all the women were 25 years old or older. This age distribution may be the reason why there were no differences in breastfeeding practice with respect to age. While a higher educational level of the mother has been shown to be positively associated with breastfeeding initiation and continuation in developed countries, an inverse relationship was found in developing countries[23, 28, 29]. Korean women who were college graduates or had a higher educational level were reported to have significantly lower breastfeeding rates compared to women with a lower educational status [14]. In this study, however, there were no differences in initiation and continuation of breastfeeding with respect to educational status, showing that such a trend might be changing since a low breastfeeding rate has been a public health concern and efforts to enhance breastfeeding rates have been made by many organizations and public health agencies during the last decade in Korea. In our study, receiving breastfeeding education or higher breastfeeding knowledge scores were found to be more important factors than mother's educational level to continue breastfeeding.

The first limitation may be a sampling bias. We recruited the women from one popular internet site that provides information on infants. Therefore, our population was limited to internet users. However, it is not of great concern because 99.7%, and 98.8% of Korean adults aged 20~29 years and 30~39 years, respectively, were reported to use the internet in 2009[30]. Another limitation was a low response rate which is common for internet recruitment. It may be difficult to convince mothers who received the email explaining the study to voluntarily visit the website in order to participate in the research. Electronic mail has become a large part of the communication system that we endorse; hence this survey method deserves special attention. In particular, the basic ethical issues discussed should be duly considered by researchers. Even though e-mail surveys tend to have greater response rates, researchers still do not fully grasp the data as who responded is not necessarily known. This issue challenges the external validity of the study. An electronic response is never truly anonymous, however, as researchers know the respondents' e-mail addresses. Not only that, the research and scientific integrity itself must be consciously considered.

The other limitation was that the breastfeeding rate was calculated from cross-sectional data, so the rate could be different in a longitudinal study, and also our data do not allow for conclusions on causal relationships.

Despite these limitations, as far as we understand, this is the first large study that has examined the potential factors associated with the initiation and continuation of breastfeeding in Korean mothers for 6 and 12 months postpartum in relation to the employed status of the mothers. In order to increase the breastfeeding rate of Korean women, intervention programs and policies should be developed to practically support women and promote breastfeeding in hospitals and in workplaces.

Breastfeeding initiation rates were similar regardless of the employment status of the mothers. The continuation rates decreased for both groups of mothers, but they were significantly lower among employed mothers at 1, 6 and 12 months. Mothers who were able to keep their babies in the same room during the hospital stay were more likely to initiate breastfeeding. Breastfeeding practice during the hospital stay was consistently associated with breastfeeding continuation at 1, 6 and 12 months among unemployed mothers. Having higher knowledge scores and having an infant with atopic dermatitis were also associated with breastfeeding continuation for unemployed mothers, and receiving education on breastfeeding was associated with a longer continuation for employed mothers.

The results of this study reinforce the significant roles that hospitals play in placing infants with their mothers in the same room and helping the mothers feed breast milk during the hospital stay after delivery to facilitate breastfeeding initiation and continuation. Breastfeeding education is also found to be essential to prolong the continuation of breastfeeding. Therefore, supports in baby-friendly hospitals and workplaces can be effective strategies to increase the proportion of women who initiate and continue breastfeeding. In addition, as data on the types of maternal jobs, timing of return to work, time of rooming-in, and breastfeeding practices during the hospital stay were not collected in this study, further research to determine factors associated with initiation and continuation considering those various factors is needed.