Capstone Project Change Proposal

Benchmark Capstone Change Proposal

In this assignment, students will pull together the change proposal project components they have been working on throughout the course to create a proposal inclusive of sections for each content focus area in the course. At the conclusion of this project, the student will be able to apply evidence-based research steps and processes required as the foundation to address a clinically oriented problem or issue in future practice.

Students will develop a 1,250-1,500 word (word count does not include references) paper that includes the following information as it applies to the problem, issue, suggestion, initiative, or educational need profiled in the capstone change proposal:


Problem statement

Purpose of the change proposal


Literature search strategy employed

Evaluation of the literature

Applicable change or nursing theory utilized

Proposed implementation plan with outcome measures

Identification of potential barriers to plan implementation, and a discussion of how these could be overcome

Appendix section, if tables, graphs, surveys, educational materials, etc. are created (I am not sure what an appendix section is but if you know please add something. I do know it should come AFTER the references)

All reference resources are attached. Please use the Literature Review paper as just a REFERENCE.

Prepare this assignment according to APA Style Guidelines. An abstract is not required.

This assignment uses a rubric (ATTACHED). Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective Analysis Katy B. Kozhimannil1*, Judy Jou1, Laura B. Attanasio1, Lauren K. Joarnt2, Patricia McGovern3

1 Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America, 2 Harvard University,

Cambridge, Massachusetts, United States of America, 3 Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis,

Minnesota, United States of America


Background: Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor- related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.

Methods: We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011–2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status.

Results: More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52–0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with .30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47–0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81– 8.94; and AOR = 2.68; 95% CI, 1.70–4.23, respectively).

Conclusions: Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

Citation: Kozhimannil KB, Jou J, Attanasio LB, Joarnt LK, McGovern P (2014) Medically Complex Pregnancies and Early Breastfeeding Behaviors: A Retrospective Analysis. PLoS ONE 9(8): e104820. doi:10.1371/journal.pone.0104820

Editor: Katariina Laine, Oslo University Hospital, Ullevål, Norway

Received April 2, 2014; Accepted July 16, 2014; Published August 13, 2014

Copyright: � 2014 Kozhimannil et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. The authors obtained the Listening to Mothers III data from the Childbirth Connection program that commissioned the survey. Prior versions of this survey are freely available for analysis through the Odum Institute Dataverse Network at the University of North Caroline at this location: The data that the authors used for this analysis come from the third wave of the survey which is currently being placed in this public repository.

Funding: This research was supported by a grant from the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD; grant number R03HD070868) and the Building Interdisciplinary Research Careers in Women’s Health Grant (grant number K12HD055887) from NICHD, the Office of Research on Women’s Health, and the National Institute on Aging, at the National Institutes of Health, administered by the University of Minnesota Deborah E. Powell Center for Women’s Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: The authors have declared that no competing interests exist.

* Email:


Breastfeeding has many advantages to infants [1]. In 2010,

approximately 77% of US infants were breastfed at least once, a

substantial increase from 64% in 1998 [2,3]. Despite this progress,

breastfeeding continues to fall short of national goals for duration

and exclusivity set in initiatives such as Healthy People 2020 [2,4].

One possible reason for failure to consistently meet these goals is

the rise in complications women face as they enter pregnancy,

including diabetes, obesity, and hypertension. Breastfeeding

initiation rates are lower and breastfeeding duration is generally

shorter among women with these conditions [5–8]. Six percent of

births are complicated by diabetes [9], 3%–5% of pregnant

women have hypertensive disorders [10–12], and 19%–39% of are

obese when they become pregnant [13]. Clinical management of

these conditions and associated complications may necessitate

greater intrapartum or neonatal intervention, which could affect

care for the woman or infant in the immediate postpartum period,

including breastfeeding [14–19].

The decision to breastfeed is highly personal and affected by

many factors, including anticipated barriers to or support for

breastfeeding, hospital practices, medical issues occurring either

PLOS ONE | 1 August 2014 | Volume 9 | Issue 8 | e104820
before or during pregnancy, and complications during labor and

delivery [1,20–26]. One program that has been successful in

encouraging breastfeeding is the Baby-Friendly Hospital Initiative

(BFHI), a global program to encourage and recognize hospitals

that have policies to provide evidence-based care to support infant

feeding and mother-baby bonding [1,20,24,25,27]. The program,

for example, instructs mothers on breastfeeding, allows babies to

spend the first hour after birth in their mothers arms; provides

newborns no food or drink other than breast milk, unless medically

indicated; practices ‘‘rooming in’’ by allowing mothers and infants

to remain together 24 hours per day; gives no pacifiers or artificial

nipples to breastfeeding infants; and refer mothers to breastfeeding

support groups on discharge from the hospital or clinic. Greater

adoption of these practices is also a focus of Healthy People 2020

[28]. Yet despite the success of these measures, fewer than 7% of

U.S. births currently occur in facilities with an official BFHI

designation [28]. This study examines the relationship between

entering pregnancy with complicating health conditions and early

infant feeding behaviors, focusing on women’s breastfeeding

intentions and supportive hospital practices as potential mediators.

Materials and Methods

Conceptual Model Figure 1 presents the conceptual model for the analysis. The

model focuses on women’s breastfeeding intentions and hospital

support practices during the intrapartum period and how these

factors and their effects may differ for women who enter

pregnancy with diabetes, hypertension or obesity.

Data Data are from the Listening to Mothers III survey, a nationally

representative sample of women who gave birth to a singleton in a

US hospital between July 1, 2011, and June 30, 2012 (N = 2400).

The survey was commissioned by Childbirth Connection and

conducted by Harris Interactive between October and December

2012. The survey documented pregnancy, labor, and birth

experiences in US hospitals, including information about breast-

feeding decisions and pre-existing medical conditions. Data from

this survey have been widely used in clinical and public health

research, including studies of breastfeeding and the role of

supportive hospital practices [26,29,30]. However, this was the

first wave of the survey to include information about medical

conditions prior to pregnancy. Detailed information about the

survey’s methodology, implementation, and questionnaires is

available at

The data used in this analysis were de-identified. Therefore, the

University of Minnesota Institutional Review Board granted this

study exemption from review (Study No. 1011E92983).

Variable Measurement Pregnancy Complexity. We defined pregnancy complexity

from available survey data relating to 3 common medical risk

factors: (1) taking prescription medication for blood pressure

during the month before pregnancy, (2) having either type 1 or

type 2 diabetes before pregnancy or gestational diabetes, or (3)

having a prepregnancy body mass index higher than 30. Our main

analysis included a dichotomous measure of pregnancy complexity

for women reporting any of these 3 conditions. We also

constructed indicators for each of the conditions for separate

analysis (see following description of sensitivity analyses).

Breastfeeding Intention. Women were asked at the time of

the survey to recall their intentions about infant feeding at the end

of pregnancy. We created dichotomous variables indicating (1) any

intent to breastfeed (exclusively or not) and (2) women’s intent to

breastfeed exclusively. Supportive hospital practices and infant

feeding status were assessed among women who reported any

intention to breastfeed (n = 1990), and exclusive breast milk

feeding status at 1 week postpartum was assessed among women

who intended to exclusively breastfeed (n = 1418).

Supportive Hospital Practices. Among women who in-

tended to breastfeed, we examined supportive hospital practices

consistent with BFHI standards. We measured supportive hospital

practices using an 8-point composite measure corresponding to 7

of the 10 BFHI steps. Measures for the remaining 3 steps were not

assessed in the Listening to Mothers surveys because they require

knowledge of hospital administrative policies beyond the scope of

women’s knowledge and experiences. However, data from these

Figure 1. Conceptual Model. doi:10.1371/journal.pone.0104820.g001

Medically Complex Pregnancies and Early Breastfeeding

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surveys have previously been used to successfully approximate

BFHI hospital practices [26,30]. See Table 1 for detailed

information about the 10 BFHI steps and the 8 items assessed in

the data and used in this analysis.

To assess general concordance with supportive breastfeeding

practices in the hospital, we created a composite measure in which

higher scores indicate that the woman perceived a higher level of

breastfeeding-supportive hospital practices. Scores were not

normally distributed, so we constructed a dichotomous variable

on the basis of the top quintile of responses. Scores of 7 to 8 were

categorized as ‘‘high hospital support,’’ indicating practices

broadly consistent with BFHI standards. We also assessed the

distribution of the items in the composite measure and tested the

stability of the measure by modeling hospital support as a

continuous variable (0–8) and by using a lower threshold (i.e.,

scores of 6–8 for high levels of support from the hospital). Results

were robust to alternative specifications.

Feeding Status 1 Week Postpartum. Two dichotomous

measures of infant feeding status were based on women’s responses

to questions regarding (1) whether they were feeding their

newborn any breast milk (either exclusively or in combination

with formula) 1 week postpartum, and (2) whether they were

feeding their newborn breast milk only 1 week postpartum. This

definition allows for both direct breastfeeding and feeding

expressed breast milk to infants.

Control Variables. We controlled for labor and delivery

factors that may affect the initiation of breastfeeding, including

cesarean delivery, epidural use, and admission to a neonatal

intensive-care unit [31–34]. We assessed these variables from

maternal self-report. We also included several self-reported

sociodemographic and birth-related covariates, including age;

race/ethnicity (white, black, Hispanic, or other/multiple race);

education (high school or less, some college, bachelor’s degree, or

graduate education); 4-category census region (Northeast, South,

Midwest, West); nativity (foreign- or US-born); partnership status

(unmarried with no partner, unmarried with partner, or married);

parity (first-time pregnancy); pregnancy intention (unintended or

intended pregnancy); agreement with the statement ‘‘birth is a

process that should not be interfered with unless medically

necessary;’’ doula support; and primary payer for maternity care

(private, public, or out-of-pocket).

Analysis We first explored associations between the predictors, outcomes,

and covariates for the overall sample using 1- and 2-way

tabulation. We used Pearson’s x2 tests to determine whether differences based on pregnancy complexity were statistically

significant. We used logistic regression to estimate the adjusted

odds of breastfeeding intention based on pregnancy complexity.

Among women intending to breastfeed, we estimated the adjusted

odds of breastfeeding status 1 week postpartum. To test for

mediation by hospital support, we added a variable indicating high

levels of support for breastfeeding at the hospital. In the final

multivariate models of breastfeeding status 1 week postpartum, we

included only covariates that were statistically significantly

associated with the outcomes. We conducted sensitivity analyses,

estimating the same regression models using indicator variables for

prepregnancy obesity, hypertension, and diabetes as the predictors

rather than the combined ‘‘complex pregnancy’’ variable; results

were substantively unchanged. All analyses used a p-value of 0.05

to determine statistical significance, were conducted using Stata

v.12, and weighted to be nationally representative.


Table 2 presents the characteristics of the study population by

pregnancy complexity. Overall, 36.3% of respondents had 1 or

more conditions indicating a complex pregnancy (n = 871). About

8% of women were taking blood pressure medications in the

month before pregnancy, 19.7% were obese, and 20.4% were

diagnosed with diabetes prior to or during pregnancy. There was

some overlap between conditions, particularly for diabetes and

hypertension (r = 0.25), diabetes and obesity, (r = 0.09), and for hypertension and obesity (r = 0.04).

Table 3 shows the distribution of breastfeeding intentions,

supportive hospital practices, and infant feeding outcomes by

Table 1. Baby Friendly Health Initiative Composite Measure Components.

Baby Friendly Hospital Practices Corresponding question(s) used to construct Baby Friendly Hospital Initiative Composite measure

Help mothers initiate breastfeeding within 1 hour of birth. Baby spent 1st hour in mother’s arms.

Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.

Hospital staff helped get started breastfeeding.

Hospital staff showed how to position baby for breastfeeding.

Give newborn infants no food or drink other than breast milk, unless medically indicated.

Hospital staff did not provide water or formula supplements.

Practice ‘‘rooming in’’—allow mothers and infants to remain together 24 hours per day.

Baby roomed with mother.

Encourage breastfeeding on demand. Hospital staff encouraged breastfeeding on demand.

Give no pacifiers or artificial nipples to breastfeeding infants. Hospital staff did not give baby a pacifier.

Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Hospital staff told about breastfeeding resources in the community.

Inform all pregnant women about the benefits and management of breastfeeding.

Not Applicable

Have a written breastfeeding policy that is routinely communicated to all health care staff.

Not Applicable

Train all health care staff in skills necessary to implement this policy. Not Applicable


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pregnancy complexity. In bivariate associations, women with

complex pregnancies were less likely to report that they intended

to breastfeed (77.2% intended to do so) than women without

complex pregnancies, (83.3%; P = .012) but there was no difference between groups in intention to exclusively breastfeed

(55.7% vs. 51.0%). Overall levels of hospital breastfeeding support

among women who intended to breastfeed differed by pregnancy

complexity, with 14.8% of women with complex pregnancies

reporting high levels of hospital support, compared with 20.4% of

women without complex pregnancies (P = .030). The only two statistically significant findings among the specific support

measures were that women with complex pregnancies were less

likely to report that their baby had spent the first hour after birth

in their arms (P = .017) and that the hospital staff had helped them to start breastfeeding (P = .008). Among women planning to breastfeed, about 90% reported feeding their newborn either

partially or exclusively breast milk 1 week postpartum, regardless

of pregnancy complexity. Of those who intended to breastfeed

exclusively, 79.5% of those without complex pregnancies and

69.4% of those with complex pregnancies were doing so

(P = .002).

Table 2. Percentage of Women in the Study Sample (N = 2400), With a Specific Characteristic, by Pregnancy Complexity.

Complex Pregnancy

No Yes P Value

Total 63.7 36.3 —

Sociodemographic Characteristics

Age category .667

18–24 31.9 31.6

25–29 27.3 30.1

30–34 25.7 23.1

35+ 15.0 15.2

Race .023

White 57.8 48.8

Black 13.9 17.9

Hispanic 22.2 24.8

Other/multiple race 6.2 8.5

Education .040

High school or less 40.0 46.2

Some college/associate’s degree 28.9 28.0

Bachelor’s degree 18.4 16.9

Graduate education/degree 12.8 8.9

Region .520

Northeast 14.5 16.4

Midwest 23.5 21.2

South 38.8 41.2

West 23.2 21.2

Foreign born 8.0 5.4 .107

Partnership status .003

Unmarried with no partner 5.9 11.5

Unmarried with partner 32.7 29.7

Married 61.4 58.8

Pregnancy Characteristics

First-time mother 39.5 42.9 .249

Unintended pregnancy 36.1 34.1 .487

Belief that childbirth is a process that should only be interfered with if medically necessary 58.7 57.9 .797

Had doula support during labor 5.3 7.0 .281

Health Insurance Status .045

Private 48.2 40.6

Public 44.3 50.5

Out-of-pocket 7.5 8.8

Note: Percentages are weighted to be nationally representative. Bold values indicate statistically significant difference (P#.05). P values are based on Pearson’s x2 tests. doi:10.1371/journal.pone.0104820.t002

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After controlling for sociodemographic and other factors

(Table 4), women with more complex pregnancies were approx-

imately 30% less likely to intend to breastfeed at all (adjusted odds

ratio [AOR] = 0.71; 95% confidence interval [CI], 0.52–0.98),

compared with women who had no complications entering

pregnancy. However, pregnancy complexity had no independent

association with intention to breastfeed exclusively.

In multivariate analysis we found no relationship between

complex pregnancy and whether the infant was being fed breast

milk exclusively or partially 1 week postpartum (Table 5) after

controlling for the same sociodemographic and clinical covariates.

In subsequent models, we also controlled for supportive hospital

practices to examine potential mediation. Babies whose mothers

received high levels of hospital support for breastfeeding were 4

times more likely to receive at least some breast milk 1 week

postpartum. Among women who intended to exclusively breast-

feed, those with complex pregnancies had more than 30% lower

odds of feeding their infants breast milk only (AOR = 0.68; 95%

CI, 0.47–0.98). High levels of hospital support for breastfeeding

were associated with nearly 3 times the odds of exclusive

breastfeeding 1 week postpartum (AOR = 2.79; 95% CI, 1.77–

4.39). When these factors were included simultaneously, the

association between pregnancy complexity and lower odds of

exclusive breastfeeding remained similar (AOR = 0.69; 95% CI,



The study examined the effect of entering pregnancy with

medical complications on infant feeding practices among those

who intended to breastfeed either at all or exclusively, and the

influence of hospital practices on those decisions. Women with

hypertension or diabetes or those who were obese when they

became pregnant were less likely to intend to breastfeed than

women whose pregnancies were not complicated by these

Table 3. Percentage of Women in the Study Population (N = 2400) With Specific Breastfeeding Behaviors, as Well as Intentions and Hospital Support, by Pregnancy Complexity.

Complex Pregnancy

No Yes P Value

Breastfeeding intentions (among all women n = 2400)

Intention to breastfeed, any 83.3 77.2 .012

Intention to breastfeed, exclusive 55.7 51 .115

Hospital Breastfeeding Support Composite Measure (among women planning to breastfeed, n = 1990)

Low (0–6 steps) 79.6 85.2

High (7–8 steps) 20.4 14.8 .030

Hospital Breastfeeding Support Composite Measure Components

Baby in mother’s arms during 1st hour after birth 51.4 43.4 .017

Baby roomed in with mother 63.6 59.4 .193

Hospital staff helped start breastfeeding 81.6 74.4 .008

Hospital staff showed how to position baby for breastfeeding 64.8 62.4 .432

Hospital encouraged breastfeeding on demand 66.4 64.6 .570

Hospital staff did NOT provide water or formula supplements 65.6 61.2 .298

Hospital staff gave information on community resources 52.2 48.7 .294

Hospital staff did NOT give baby a pacifier 58.4 62.2 .245

Outcomes: Infant Feeding 1 Week Postpartum (among women intending to breastfeed)

Breastfeeding at 1 week, any (n = 1990) 91.9 89.0 .156

Breastfeeding at 1 week, exclusive (n = 1418) 79.5 69.4 .002

Note: Percentages are weighted to be nationally representative. Bold values indicate statistically significant difference (P#.05). P values are based on Pearson’s x2 tests. doi:10.1371/journal.pone.0104820.t003

Table 4. Controlled Odds of Breastfeeding Intentions by Pregnancy Complexity (N = 2400).

Any intention to breastfeed

AOR 95% CI

Complex pregnancy 0.71 (0.52–0.98)

Intention to exclusively breastfeed

AOR 95% CI

Complex pregnancy 0.90 (0.70–1.16)

Note: Models are weighted to be nationally representative. Models control for age, race/ethnicity, education, census region, nativity, partnership status, parity, unintended pregnancy, birth attitudes, and health insurance status. Bold text indicates statistically significant (P#.05). doi:10.1371/journal.pone.0104820.t004

Medically Complex Pregnancies and Early Breastfeeding

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conditions. Our results also show that women with complex

pregnancies who planned to exclusively breastfeed were substan-

tially less likely to do so 1 week postpartum than women without

pregnancy complications, even after accounting for supportive

hospital practices.

The findings point to clear opportunities for intervention and

support during pregnancy and immediately after giving birth.

Obstetricians, midwives, family physicians, and pediatricians

should be aware that women with complex pregnancies are less

likely to plan to breastfeed and are less likely to receive

recommended hospital-based support.

Multiple research studies and systematic reviews confirm that

simply counseling women to breastfeed is not sufficient for

encouraging women to breastfeed; rather, tailored support offered

both prenatally and postpartum is most effective in supporting

pregnant women to set and attain breastfeeding goals [35–37].

Clinicians should discuss breastfeeding intentions when establish-

ing relationships with patients prenatally, including consultation

on plans for the use of anti-diabetic or anti-hypertensive

medications compatible with a mother’s intentions, and follow

up to ensure that women with complicated pregnancies have

access to breastfeeding support in the hospital [38]. It is also

important to address breastfeeding intentions and provide

encouragement and support at the time of delivery, given that

delivery third of US women lack a prior relationship with the

clinician attending their delivery [39]. Providing encouragement

and support at the time of delivery may be particularly important

for women with complex pregnancies who may be transferred to

higher acuity care teams at delivery [40–42]. The results of our

analysis suggest that women who are nonwhite, less educated,

unmarried with no partner, and using public health insurance are

more likely to be obese or to develop hypertension or diabetes

prior to pregnancy, so it may be helpful to target outreach and

support efforts to these groups.

Our findings are consistent with prior research showing that

BFHI-consistent hospital practices help to promote early breast-

feeding success [24–27]. Women who reported a high number of

BFHI-consistent hospital practices were 3 times more likely to

exclusively breastfeed than were those who reported a lower

number of BFHI-consistent practices. Women who entered

pregnancy with hypertension, diabetes, or obesity were signifi-

cantly less likely to report experiencing the BFHI-consistent

hospital practices of having their baby in their arms during the first

hour after birth and having hospital staff help them start

breastfeeding. Therefore, hospitals and clinicians alike should

pay particular attention to showing women with complex

pregnancies how to breastfeed (including expressing breast milk

for bottle or syringe feeding [43]) and supporting early breastfeed-

ing efforts, including after cesarean delivery [44,45].

Breastfeeding support should be incorporated into clinical and

hospital policies, with emphasis on women with complex

pregnancies [46]. Postpartum care management or obstetric/

neonatal discharge guidelines for obese women and those with

diabetes or hypertension could explicitly include discussions of

breastfeeding and information about community-based resources.

In addition, compliance with BFHI steps should be promoted in

more hospitals, consistent with the federal Healthy People 2020

goals, as should practices that have been shown to improve

breastfeeding outcomes despite not being part of the BFHI scale,

such as skin-to-contact between women and their infants

immediately after birth [47,48]. Hospital should also be aware

of well-intentioned practices to support breastfeeding that women

may in fact experience negatively. Hands-on-breast approaches to

breastfeeding support, for instance, may be considered unpleasant

and disrespectful by some women [49]. Hospitals and staff should

continue to maintain open communication with women about the

best ways to support their breastfeeding intentions.

Limitations Although providing a rich source of data on breastfeeding from

a patient perspective, the Listening to Mothers surveys have

certain limitations that warrant discussion. These data are based

on retrospective self-reports, leaving room for potential recall bias

and social desirability bias. Although the survey contained some

information about health conditions, assessment of these condi-

tions is based on maternal self-report. In addition to the

complications we included in our analysis, other maternal, fetal,

and neonatal medical conditions or complications that arise during

labor and delivery could also be associated with breastfeeding

intention and practices. Finally, our construction of the BFHI

composite measure relied on maternal perception of proxies for 7

of the 10 BFHI steps. However, several of the 10 BFHI steps

include questions about hospital policy, of which many women

may not be aware.


Breastfeeding is beneficial for women and infants, and medical

contraindications are rare. Complications that occur during

pregnancy, labor, and delivery may hinder breastfeeding, but

Table 5. Controlled Odds of Infant Feeding Status at 1 Week by Pregnancy Complexity and Supportive Hospital Practices.

Any Breastfeeding 1 Week Postpartum (n = 1990)

AOR 95% CI AOR 95% CI

Complex pregnancy 0.81 (0.49–1.34) 0.82 (0.50–1.36)

High supportive hospital practices 4.03 (1.81–8.94)

Exclusive Breastfeeding 1 Week Postpartum (n = 1418)

AOR 95% CI AOR 95% CI

Complex pregnancy 0.68 (0.47–0.98) 0.69 (0.48–1.00)

High supportive hospital practices 2.68 (1.70–4.23)

Note: Models are weighted to be nationally representative. Models control for age, race/ethnicity, education, census region, nativity, partnership status, parity, unintended pregnancy, birth attitudes, health insurance status, cesarean delivery and doula support. Bold text indicates statistically significant (P#.05). doi:10.1371/journal.pone.0104820.t005

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supportive hospital practices may facilitate breastfeeding for

women who intend to breastfeed.

We distinguished breastfeeding intentions and early feeding

patterns for women with complex pregnancies and found lower

odds of intending to breastfeed and decreased chances of early

exclusive breastfeeding, even after accounting for supportive

hospital practices, which were associated with greater breastfeed-

ing success. Therefore, it is important to support women with

medically complex pregnancies in overcoming potential challenges

to breastfeeding.


The authors are grateful for helpful input provided by Eugene Declercq,

PhD; Valerie Flaherman, MD, MPH; Dwenda Gjerdingen, MD; Pamela

Jo Johnson, PhD, MPH; and Carol Sakala, PhD.

Author Contributions

Conceived and designed the experiments: KBK LBA PM. Performed the

experiments: LBA JJ LKJ. Analyzed the data: LBA JJ KBK. Contributed

reagents/materials/analysis tools: KBK PM. Contributed to the writing of

the manuscript: KBK LBA JJ LKJ.


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Medically Complex Pregnancies and Early Breastfeeding

PLOS ONE | 7 August 2014 | Volume 9 | Issue 8 | e104820




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