Maternal return to work and breastfeeding: A population-based

cohort study
Chao-Hua Chuang
a,
*, Pei-Jen Chang
b
, Yi-Chun Chen
c
, Wu-Shiun Hsieh
d
,
Baai-Shyun Hurng
e
, Shio-Jean Lin
f
, Pau-Chung Chen
g
a
Department of Nursing, Chang Jung Christian University, Tainan County, Taiwan
b
Department of Nursing, National Taipei College of Nursing, Taipei, Taiwan
c
School of Nutrition and Health Sciences, Taipei Medical University, Taipei, Taiwan
d
Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
e
Population and Health Research Center, Bureau of Health Promotion, Department of Health, Taichung, Taiwan
f
Department of Pediatrics, National Cheng-Kung University Hospital and National Cheng-Kung University College of Medicine, Tainan, Taiwan
g
Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
International Journal of Nursing Studies 47 (2010) 461474
A R T I C L E I N F O
Article history:
Received 10 April 2009
Received in revised form 14 August 2009
Accepted 6 September 2009
Keywords:
Return to work
Maternity leave
Breastfeeding
Population-based cohort study
A B S T R A C T
Background: In recent decades there has been a marked rise in the participation of women
with infants in the labour market, while there has been a decline in the prevalence rate of
breastfeeding.
Objective: To explore the relationship between maternal return to work and breastfeeding.
Design: An on-going prospective longitudinal study.
Setting and participants: Multistage stratied systematic sampling was designed to recruit
24,200 pairs, postpartumwomen and newborns, fromthe Taiwan national birth register in
2005. Participating women underwent two home interviews at 6 and 18 months after
giving birth, following structured questionnaires. A total of 21,248 and 20,172 women
were interviewed, and the completed interviewrate was thus 87.8% and 83.4% at 6 and 18
months, respectively. All study participants provided informed consent as approved by the
Ethics Review Board of the National Taiwan College of Public Health.
Results: The overall prevalence of initial breastfeeding was 83.7%. Postpartum women
returning to work less than or equal to 1 month had the lowest initiation of breastfeeding
rate (77.5%), but had a higher prevalence of breastfeeding duration less than or equal to 1
month (34.9%) than the overall population (26.8%). Overall 67.9%, 39.4%, 25.4%, and 12.7%
mothers who started breastfeeding still breastfed their infants at the age of 1, 3, 6 and 12
months, respectively. Women with maternal leave of less than or equal to 6 months ceased
breastfeeding earlier than those with maternal leave beyond 6 months and those who did
not return to work up to 18 months after birth. After adjustment for potential confounders,
odds ratios of initial breastfeeding seemed no different, except those for postpartum
women who returned to work less than or equal to 1 month and those who did not return
to work. Mothers returning to work within 1 year after giving birth were signicantly
earlier in weaning than those without return to work.
Conclusion: In our study, an early maternal return to work, especial within 6 months after
giving birth, was a barrier to the initiation and continuation of breastfeeding. Thus, a
comprehensive strategy is required to encourage the practice of breastfeeding in working
women from pregnancy to the return to work, and nurses should work to promote
breastfeeding in the different occasion.
2009 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Nursing, Chang Jung Christian University, 396, Sec. 1, Chang Jung Road, Kway Jen, Tainan 71101, Taiwan.
Tel.: +886 6 278 5123; fax: +886 6 278 5581.
E-mail address: chchuang@mail.cjcu.edu.tw (C.H. Chuang).
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
0020-7489/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.09.003
What is already known about the topic?
The number of women with young children in the
workforce has increased recently.
A potential conict exists between employment and
breastfeeding.
What this paper adds?
A large population-based cohort study designed to
explore the relationship between maternal return to
work and breastfeeding.
To measure the effects of different timings of maternal
return to work on the initiation and continuation of
breastfeeding.
1. Introduction
Labour force participation by married women in Taiwan
was 32% in 1979, but by 2006 it had risen to 53%
(Directorate-General of Budget, 2007). Moreover, the
number of women with young children in the workforce
also increased, with 59% of women with children under
three employed in 2007, up from40% in 1992 (Directorate-
General of Budget, 2008). By international standards, new
mothers return to work quickly after giving birth in
Taiwan. One study shows that the average maternity leave
is 56 days (Chen et al., 2006), which reects the fact that
local companies provide 8 weeks maternity (Council of
Labor Affairs, 2008).
In Taiwan, the National Health Insurance (NHI) system,
implemented in 1995, provides integrated maternal and
child health services. All pregnant women are eligible for
ten free prenatal care visits combined with comprehensive
health examinations, with two visits for pregnancies of less
than 17 weeks, two for pregnancies of 1729 weeks, and
six for pregnancies of over 29 weeks (Bureau of National
Health Insurance, 2009). Under this policy, the visiting rate
for prenatal care during the rst trimester increased from
86% in 1989 to 95% in 1996 (Chen et al., 1997), and most
pregnant women nowgive birth in hospitals. Women with
normal spontaneous delivery and with caesarean section
usually stay 3 and 6 days in hospitals, respectively, for
which the NHI covers the expense. For young children,
there are six free well-baby examination visits in National
Health Insurance Child Preventive Program, which pro-
vides four visits for children under one year old, one for
one-to three-year olds, and one for three-to four-year olds.
The health benets of breastfeeding have been widely
recognized, such as a reduced use of health services (Leung
et al., 2005), and fewer cases of postnatal death (Chen and
Rogan, 2004), acute respiratory infection and diarrhoeal
deaths (Arifeen et al., 2001; Mihrshahi et al., 2008), child
asthma and atopy (Oddy et al., 2004), childhood obesity
(Grummer-Strawn and Mei, 2004), and atherosclerosis
(Singhal et al., 2004). Exclusive breastfeeding is thus
recommended up to 6 months of age by the World Health
Organization (World Health Organization, 2008).
However, studies show that a potential conict exists
between maternal return to work after childbirth and
breastfeeding (Chuang et al., 2007; Kimbro, 2006; Noble,
2001), with obvious implications for the health of the child.
The purpose of this study is thus to explore the relationship
between maternal return to work and breastfeeding, in
order to provide a more comprehensive picture for health
staff when devising strategies or policies to promote
breastfeeding, and to provide better information for nurses
caring for perinatal women.
2. Methods
2.1. Study population and sampling strategy
This study was part of the Taiwan Birth Cohort Study
(TBCS), which is the rst national birth cohort and
prospective longitudinal study in Taiwan. TBCS started in
2003 with a 15-month pilot study (Chuang et al., 2007,
2009). In the current study, a multistage stratied
systematic sampling was designed to obtain representative
samples fromthe Taiwan national birth registration data in
2005. This data was gathered from the Bureau of Health
Promotion at the Department of Health in Taiwan, and
includes data on birth weight, gestation duration, and
characteristics of live born infants and their mothers, but no
information with regard to spontaneous abortions or
stillborn infants. A total of 369 towns in Taiwan were
divided into 12 strata according to the administrative
division(four strata), andthe total fertilityrate(three strata)
were ranked, and 90 towns out of the total were sampled.
Using the principle of proportion probability to size,
newborns, including singleton or multiple births, from
the birth registration data and their mothers were sampled
randomly from these 90 towns, for a total of 24,200 pairs.
2.2. Data collection
The Taiwan Birth Cohort Study is supported by grants
from the Bureau of Health Promotion, Department of
Health, Taiwan. One of the duties of the Population and
Health Research Center in the Bureau of Health Promotion
is the planning and implementation of community-based
population and health survey research. Hence, they have
trained a number of interviewers in different areas of
Taiwan. Consequently, the interviewers in the current
study were trained by the Population and Health Research
Center, and some of themparticipated in the pilot study. To
ensure consistent quality, every interviewer accepted the
standardized TBCS training programs before conducting
the interviews, and the completed questionnaires were
sampled randomly to double check them.
Before the home interview, the researchers rst
delivered a card to notify the women about the interview
and invite them to participate in the survey. The
interviewers then visited the women that agreed to
participate, and asked them to sign an informed consent
from after explaining the details of the study. Each visit
lasted about 40 min. The rst and second home interviews
were conducted at 6 and 18 months after the women gave
births, using a structured questionnaire, and were carried
out in July 2006 and July 2007, respectively.
There were a total of 4028 (2952 and 1076) women of
loss to follow-up in the two interviews because of refusal
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 462
to participate, loss contact, departure from Taiwan, infant
was adopted by others, infant death, and miscellaneous
reasons. A total of 21,248 and 20,172 women were
interviewed on the two occasions, and the completed
interview rate was thus 87.8% and 83.4%, respectively. The
process of data collection is shown in Fig. 1.
2.3. Variables
Data were obtained from the two interview question-
naires. Information about maternal return to work after
maternity leave and breastfeeding, including initiation,
type and duration of breastfeeding, were collected at both
the 6 and 18 months interviews. We dened return to work
as starting work again after maternity leave or after giving
birth. Breastfeeding was dened as only breastfeeding or
mixed breastfeeding with milk.
The population was grouped by age: 19 and below; 20
34; and 35 or above. The educational levels were stratied
into three groups: university and college or above; senior
high school; and junior high school and below. Family
income per month was dened as the total parental
income per month within four categories expressed in new
Taiwandollars (NT$, newTaiwan dollars, 1 US$ 34 NT$ in
2009): 30,000 or lower, 30,001100,000, 100,001200,000,
and over 200,000.
Details of maternal chronic diseases, body mass index
(BMI) before giving birth and types of birth were obtained
from the interview questionnaire. Maternal chronic dis-
eases included hypertension, heart disease, diabetes
mellitus, asthma, and allergies. There were four groups
for maternal body mass index before birth: 25, 30, 35
or above 35. Types of birth were normal spontaneous
delivery or cesarean section. In addition, neonatal jaundice
(infants with photo therapy or blood replacement), childs
allergic dermatitis before the age of 6 months by doctors
diagnosis, and nursery patterns (including supplemental
baby-food feeding before the age of 6 months), and the
days per week the mother was living with the baby around
the ages of 6 and 18 months were also collected.
Information related to the infants, such as gender, birth
order, birth weight, and gestational weeks, was obtained
from the National Taiwan Birth Register. Low birth weight
refers to babies with birth weight below 2500 g, and
preterm birth to babies born before 37 completed weeks
(259 days) of gestation.
2.4. Statistical analysis
A Chi-square test was performed to examine the
differences withregard tobasic characteristics andpotential
risk factors. Multiple logistic regressions were performed to
estimate odds ratios (ORs) and the 95% condence intervals
(CIs) of the dichotomous initial breastfeedingoutcomes after
adjusting for the potentially confounding factors of demo-
graphics (maternal age, education, and birth order of infant)
andother items (maternal chronic diseases, bodymass index
(BMI) before giving birth, type of birth, neonatal jaundice,
Fig. 1. Process of data collection.
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 463
pretermbirth, mother living withthe babyaroundthe age of
6 months). Finally, to predict continuation of breastfeeding,
Cox regression analysis was used to estimate hazard ratios
(HRs) andtheir 95%condence intervals (CIs) after adjusting
for the potentially confounding factors of maternal age,
education, BMI before giving birth, type of birth, gender of
infant, preterm birth, neonatal jaundice, allergy dermatitis
before 6 months by doctors diagnosis, supplemental baby-
food feeding before 6 months, mother living with the baby
around 6 and 18 months. This statistical analysis was
performed using SPSS for Windows, Release 11.0.
3. Results
3.1. Comparing non-responders and responders
Aowchart of data collection and reasons for the loss to
follow-up is shown in Fig. 1. 2952 and 1076 women were
lost to follow-up in the two home interviews, respectively.
Over 50% of the loss to follow-up in the two visits was due
to refusal to participate.
The information from the 4028 non-responders and
20,172 responders is compared in Table 1. The character-
istics of parents age, gender and singleton status of infants
betweenthenon-responders andtheresponders aresimilar,
while the prevalence rates of low birth weight and preterm
babies were slightly higher for the former group.
3.2. Characteristics of the study subjects
The characteristics of the subjects and factors examined
in the interviews are summarized in Tables 2 and 3,
respectively. Most of the participating women were 2034
years old (85.5%). The majority had a senior high school
education (40.1%) or university and higher (45.5%), and
77.3% of the families had a monthly income of 30,001
100,000 NT$. About half of the infants were rst born
(50.4%) and 52.4% were male.
Most of the womenlackedchronic diseases (80.5%), hada
BMI of lessthanor equal to30beforegivingbirth(84.7%), and
had a normal spontaneous delivery (66.7%). Most of the
infants were not pretermbabies (91.7%), and had no allergy
dermatitis before the age of 6 months by doctors diagnosis
(93.1%), but 34.1% had neonatal jaundice. 89.6% babies had
been fed supplemental baby-food before 6 months old, and
over 87.0% mothers lived with their babies 7 days per week.
3.3. Prevalence of initiation and duration of breastfeeding
Prevalence rates of breastfeeding are shown in Table 4.
The overall prevalence rate of initial breastfeeding was
83.7%. Postpartum women returning to work less than or
equal to 1 month had the lowest initiation of breastfeeding
(77.5%), but had a higher prevalence of breastfeeding
duration less than or equal to 1 month (34.9%) than the
overall population (26.8%). This highlights the relationship
between short maternal leave and the initiation and
duration of breastfeeding.
Overall, 67.9%, 25.4%, and 12.7% mothers having initial
breastfeeding still breastfed their infants at the age of 1, 6
and 12 months, respectively. There existed a signicant
difference of continued breastfeeding among different
groups of maternal return to work. Women with maternal
leave less than or equal to 6 months ceased breastfeeding
earlier than those with maternal leave beyond 6 months,
and those who did not return to work up to 18 months after
birth. The cumulated prevalence of continued breastfeeding
for mothers having initial breastfeeding is shown in Fig. 2.
Reasons for not initiating and quitting breastfeeding at
the 6 months interview are shown in Table 5. The major
reasons for most mothers who never breastfed or quit were
insufcient breast milk (57.6% and 43.3%, respectively),
and the inconvenience with regard to returning to work
(12.7%) or with breast milking in the workplace (20.5%).
3.4. Factors related to initiation and continuation of
breastfeeding
Factors related to breastfeeding initiation are shown in
Table 6. After adjustment for maternal age, education,
chronic diseases, BMI before giving birth, type of birth, birth
order, preterm birth, neonatal jaundice, and mother living
with the baby around the age of 6 months, the odds ratios of
initial breastfeeding seemed no different, except for post-
partumwomen who returnedtowork less thanor equal to 1
monthandthosewhodidnot returntowork[odds ratio(OR)
0.71; 95% condence interval (CI) 0.62, 0.80].
Table 1
Comparison of characteristics between lost to the follow-up (n = 4,028)
and follow-up groups (n = 20,172).
Characteristics Lost to
follow-up (non-
responders)
Follow-up
(responders)
P value
Parents
Mean of maternal
age (years)
28.93 28.85 <0.001
Mean of paternal
age (years)
33.48 32.77 <0.001
Infants
Mean of infant birth
weight (grams)
3059.05 3105.65 <0.001
Mean of gestational
weeks
38.13 38.41 <0.001
Male gender of
infants (%)
52.6 52.4 0.868
Singleton (%) 51.2 50.4 0.289
Low birth weight (%) 9.2 6.8 <0.001
Preterm birth (%) 10.8 8.3 <0.001
Fig. 2. Cumulative prevalence of continued breastfeeding by different
times of maternal return to work.
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 464
Table 2
Characteristics of study subjects.
Characteristics Total No return to work Return to work status up to 18 months (months) P value
1 2 3 6 12 >12
Total 20,172 6,994 2,033 8,228 629 913 829 546
Maternal age (years) <0.001
19 397 (2.0) 217 (3.1) 34 (1.7) 48 (0.6) 14 (2.2) 27 (3.0) 38 (4.6) 19 (3.5)
2034 17,251 (85.5) 5,921 (84.7) 1,723 (84.8) 7,065 (85.9) 534 (84.9) 817 (89.5) 713 (86.0) 478 (87.5)
35 2,524 (12.5) 856 (12.2) 276 (13.6) 1,115 (13.6) 81 (12.9) 69 (7.6) 78 (9.4) 49 (9.0)
Maternal education <0.001
Junior high school 2,910 (14.4) 1,711 (24.5) 249 (12.2) 397 (4.8) 87 (13.8) 158 (17.3) 179 (21.6) 129 (23.6)
Senior high school 8,090 (40.1) 3,279 (46.9) 1,025 (50.4) 2,467 (30.0) 247 (39.3) 423 (46.3) 376 (45.4) 273 (50.0)
University + 9,172 (45.5) 2,004 (28.7) 759 (37.3) 5,364 (65.2) 295 (46.9) 332 (36.4) 274 (33.1) 144 (26.4)
Family income per month (NT$) <0.001
30,000 2,332 (11.6) 1,390 (19.9) 194 (9.5) 225 (2.7) 69 (11.0) 136 (14.9) 185 (22.3) 133 (24.4)
30,001100,000 15,595 (77.3) 5,211 (74.5) 1,594 (78.4) 6,623 (80.5) 462 (73.5) 703 (77.0) 613 (73.9) 389 (71.2)
100,001200,000 1,977 (9.8) 316 (4.5) 197 (9.7) 1,260 (15.3) 89 (14.1) 65 (7.1) 29 (3.5) 21 (3.8)
>200,000 268 (1.3) 77 (1.1) 48 (2.4) 120 (1.5) 9 (1.4) 9 (1.0) 2 (0.2) 3 (0.5)
Birth order <0.001
1 10,162 (50.4) 3,228 (46.2) 891 (43.8) 4,422 (53.7) 350 (55.6) 554 (60.7) 455 (54.9) 262 (48.0)
2 7,773 (38.5) 2,797 (40.0) 804 (39.5) 3,164 (38.5) 219 (34.8) 283 (31.0) 294 (35.5) 212 (38.8)
3 2,237 (11.1) 969 (13.9) 338 (16.6) 642 (7.8) 60 (9.5) 76 (8.3) 80 (9.7) 72 (13.2)
Gender of infant 0.974
Male 10,578 (52.4) 3,680 (52.6) 1,059 (52.1) 4,328 (52.6) 326 (51.8) 471 (51.6) 428 (51.6) 286 (52.4)
Female 9,594 (47.6) 3,314 (47.4) 974 (47.9) 3,900 (47.4) 303 (48.2) 442 (48.4) 401 (48.4) 260 (47.6)
Values in parentheses are percentages.
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Table 3
Factors related to breastfeeding.
Factors Total No return to work Return to work status up to 18 months (months) P value
1 2 3 6 12 >12
Total 20,172 6,994 2,033 8,228 629 913 829 546
Maternal factors
Chronic diseases 0.079
Yes 3,935 (19.5) 1,290 (18.4) 382 (18.8) 1,686 (20.5) 119 (18.9) 183 (20.0) 167 (20.1) 108 (19.8)
Body mass index (BMI) before giving birth <0.001
25 7,205 (35.7) 2,660 (38.0) 687 (33.8) 2,803 (34.1) 235 (37.4) 322 (25.3) 301 (36.3) 197 (36.1)
30 9,892 (49.0) 3,290 (47.0) 975 (48.0) 4,216 (51.2) 307 (48.8) 437 (47.9) 404 (48.7) 263 (48.2)
35 2,559 (12.7) 854 (12.2) 312 (15.3) 1,025 (12.5) 72 (11.4) 128 (14.0) 100 (12.1) 68 (12.5)
>35 516 (2.6) 190 (2.7) 59 (2.9) 184 (2.2) 15 (2.4) 26 (2.8) 24 (2.9) 18 (3.3)
Type of birth 0.086
Normal spontaneous delivery 13,455 (66.7) 4,702 (67.2) 1,337 (65.8) 5,441 (66.1) 402 (63.9) 634 (69.4) 576 (69.5) 363 (66.5)
Caesarean section 6,717 (33.3) 2,292 (32.8) 696 (34.2) 2,787 (33.9) 227 (36.1) 279 (30.6) 253 (30.5) 183 (33.5)
Infant factors
Preterm birth <0.001
Yes 1,674 (8.3) 658 (9.4) 164 (8.1) 588 (7.1) 64 (10.2) 79 (8.7) 67 (8.1) 54 (9.9)
Neonatal jaundice 0.036
Yes 6,875 (34.1) 2,441 (34.9) 670 (33.0) 2,720 (33.1) 219 (34.8) 332 (36.4) 310 (37.4) 183 (33.5)
Allergic dermatitis before 6 months of
age by doctors diagnosis
<0.001
Yes 1,399 (6.9) 421 (6.0) 123 (6.1) 640 (7.8) 54 (8.6) 55 (6.0) 64 (7.7) 42 (7.7)
Nursery patterns
Supplemental baby-food feeding before
6 months of age
0.109
Yes 18,081 (89.6) 6,254 (89.4) 1,818 (89.4) 7,372 (89.6) 560 (89.0) 813 (89.0) 769 (92.8) 495 (90.7)
Mother living with the baby around
6 months of age (days per week)
<0.001
2 1,869 (9.3) 129 (1.8) 244 (12.1) 1,296 (15.9) 83 (13.3) 89 (9.9) 20 (2.4) 8 (1.5)
36 564 (2.8) 36 (0.5) 68 (3.4) 391 (4.8) 34 (5.4) 22 (2.5) 8 (1.0) 5 (0.9)
7 17,593 (87.9) 6,811 (97.6) 1,699 (84.5) 6,458 (79.3) 507 (81.3) 786 (87.6) 799 (96.6) 533 (97.6)
Mother living with the baby around
18 months of age (days per week)
<0.001
2 1,807 (9.0) 183 (2.6) 233 (11.6) 1,101 (13.5) 80 (12.9) 91 (10.2) 72 (8.8) 47 (8.7)
36 508 (2.5) 31 (0.4) 71 (3.5) 328 (4.0) 22 (3.5) 26 (2.9) 23 (2.8) 7 (1.3)
7 17,675 (88.4) 6,760 (96.9) 1,705 (84.9) 6,704 (82.4) 518 (83.5) 777 (86.9) 723 (88.4) 488 (90.0)
Values in parentheses are percentages.
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Factors affecting the continuation of breastfeeding are
shown in Table 7. After adjustment for maternal age,
education, BMI before giving birth, type of birth, preterm
birth, gender, birthorder of infant, neonatal jaundice, allergic
dermatitis before the age of 6 months by doctors diagnosis,
supplemental baby-food feeding before 6 months and the
mother living with the baby around the age of 6 and 18
months(days per week), mothersreturningtoworklessthan
or equal to12 months after birthwere signicantlyearlier in
weaning than those that did not return to work [maternal
leave 1 month: hazard ratio (HR) 1.49; 95% condence
interval (CI) 1.41, 1.57; maternal leave 2 months: HR1.41;
95%CI 1.35, 1.50; maternal leave 3months: HR1.18; 95%CI
1.08, 1.29; maternal leave 6 months: HR1.26; 95%CI 1.17,
1.36; maternal leave 12 months: HR 1.10; 95% CI 1.02,
1.19].
4. Discussion
Our study showed that the timing and length of
maternity leave and return to work patterns were
signicantly associated with breastfeeding initiation and
continuation. Overall, the initiation of breastfeeding was
common, but the continuation rate was low. Women who
commenced work less than or equal to 1 month after
giving birth were signicantly less likely to initiate
breastfeeding, and those who returned to work within
12 months after giving birth ceased breastfeeding sig-
nicantly earlier than those who did not. The timing of
maternal return to work, especially within 6 months, is
thus shown to be an important factor for working women
with regard to breastfeeding. As it is very rare to still have
maternity leave at 12 months or later after giving birth,
breastfeeding cessation is less dependent on factors
external to the mothers or childs preferences.
As the number of women with young children in the
workforce has increased (Directorate-General of Budget,
2008; Noble, 2001; Leibowitz and Klerman, 1995), more
mothers have had to consider the conicts between
breastfeeding and employment (Kimbro, 2006; Noble,
2001). However, little research on maternity leave and
breastfeeding in Asia has been published, especially using
population-basedcohort statistics, andthus our population-
based survey might provide some information about other
developing countries in Asia. Although, this study was T
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Table 5
The major reasons for not initiating and quitting breastfeeding at the 6
months interview.
Reasons Total
Reasons for not initiating breastfeeding 3,295
Insufcient milk 1,897 (57.6)
Inconvenience with regard to returning to work 418 (12.7)
Baby refusing the breast 415 (12.6)
Maternal physical or psychological problems 241 (7.3)
Infant jaundice 141 (4.3)
Reasons for quitting breastfeeding 16,877
Did not quit breastfeeding 4,402 (26.1)
Insufcient milk 7,305 (43.3)
Inconvenience of breast milking in the workplace 3,466 (20.5)
Baby refusing the breast 837 (5.0)
Values in parentheses are percentages.
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 467
designed to obtain samples that could be representative of
all pregnant women in Taiwan, further investigation using
the 2005 Taiwan National Birth Registration database is
warranted to obtain a more comprehensive sample. Despite
incomplete data from 16% of the subjects and signicant
differences with regard to low birth weight and preterm
deliveries, the basic characteristics between the responder
and the non-responder groups were similar, although there
arestatisticallysignicant differences duetotheeffect of the
large sample sizes. The reason for no response appeared to
be unrelated to our measurement outcomes. In order to
reduce the recall bias, we only recruited subjects with
completed interviews within 6 and 18 months after giving
birth. We measured whether or not they had ever breastfed,
and if so, for how long. In addition, the home interviews
using a structured questionnaire by well-trained inter-
viewers were also effective in minimizing the recall bias.
Our study results show that the overall prevalence rate
of breastfeeding initiation was 83.7%, ranging from 77.5%
to 86.3% for different groups according to the timing of
maternal return to work. Compared with other countries,
these are moderate gures (World Health Organization,
2009), and consistent with another study conducted in
Taiwan (Huang et al., 2004), which found that pregnant
women had a high tendency to choose breastfeeding
(88.7% including mixed feeding). Between most of the
groups, the prevalence rate of the initiation of breastfeed-
ing showed no signicant differences. However, women
Table 6
Factors related to the initiation of breastfeeding in logistic regression models.
Factors Crude odds ratio
(95% CI)
P value Adjusted odds
ratio
a
(95% CI)
P value
Return to work status up to 18 months (months) <0.001 <0.001
No return to work
b
1.00 (reference) 1.00 (reference)
1 0.74 (0.65,0.84) <0.001 0.71 (0.62,0.80) <0.001
2 1.36 (1.24,1.48) <0.001 0.96 (0.87,1.06) 0.420
3 1.28 (1.01,1.61) 0.039 1.12 (0.89,1.43) 0.338
6 1.14 (0.95,1.38) 0.164 1.04 (0.86,1.28) 0.671
12 1.13 (0.93,1.37) 0.224 1.07 (0.87,1.30) 0.526
>12 0.97 (0.78,1.22) 0.819 0.98 (0.78,1.23) 0.846
Maternal age (years) <0.001 0.010
19
b
1.00 (reference) 1.00 (reference)
2034 1.87 (1.49,2.35) <0.001 1.42 (1.12,1.80) 0.004
35 1.70 (1.33,2.17) <0.001 1.35 (1.04,1.75) 0.026
Maternal education <0.001 <0.001
Junior high school
b
1.00 (reference) 1.00 (reference)
Senior high school 1.22 (1.11,1.35) <0.001 1.28 (1.15,1.42) <0.001
University + 3.37 (3.02,3.76) <0.001 3.43 (3.04,3.88) <0.001
Maternal chronic diseases
Yes 1.22 (1.11,1.35) <0.001 1.14 (1.03,1.26) 0.012
Maternal body mass index (BMI) before giving birth <0.001 <0.001
25
b
1.00 (reference) 1.00 (reference)
30 1.05 (0.97,1.14) 0.267 1.05 (0.96,1.14) 0.311
35 0.86 (0.76, 0.97) 0.011 0.97 (0.85,1.09) 0.581
>35 0.50 (0.41,0.62) <0.001 0.65 (0.52,0.80) <0.001
Type of birth
Normal spontaneous delivery
b
1.00 (reference) 1.00 (reference)
Caesarean section 0.73 (0.68,0.79) <0.001 0.74 (0.68,0.81) <0.001
Birth order <0.001 <0.001
1
b
1.00 (reference) 1.00 (reference)
2 0.80 (0.74,0.87) <0.001 0.84 (0.77,0.91) <0.001
3 0.54 (0.49,0.61) <0.001 0.70 (0.62,0.79) <0.001
Gender of infant
Male
b
1.00 (reference) 1.00 (reference)
Female 1.05 (0.98,1.13) 0.184 1.05 (0.97,1.14) 0.194
Preterm birth
Yes 0.79 (0.69,0.89) <0.001 0.90 (0.79,1.03) 0.122
Neonatal jaundice
Yes 0.97 (0.90,1.05) 0.466 1.00 (0.92,1.08) 0.948
Mother living with the baby around 6 months of age (days per week) <0.001 <0.001
2
b
1.00 (reference) 1.00 (reference)
36 1.12 (0.88,1.43) 0.370 1.10 (0.86,1.42) 0.447
7 1.37 (1.13,1.44) <0.001 1.57 (1.37,1.78) <0.001
Abbreviations: CI, condence interval.
a
Model was adjusted for maternal age, education, chronic disease, maternal BMI before giving birth, type of birth, birth order, gender of infant, preterm
birth, neonatal jaundice and mother living with the baby around age of 6 months (days per week).
b
Reference category.
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 468
with an early return to work, less than or equal to 1 month
after giving birth, were signicantly less likely to initiate
breastfeeding, at a rate of only 77.5%. From the interviews,
in addition to the reason of insufcient breast milk,
inconvenience with regard to returning to work was the
major reason given by 12.7% of the mothers who never
breastfed. The results thus show that an early return to
work is a signicant factor in the decision whether or not to
breastfeed (Arora et al., 2000).
According to World Health Organization guidelines, the
recommended feeding practices for infants are exclusive
breastfeeding for the rst 6 months (World Health
Organization, 2008). In contrast, the overall rate for
Taiwanese mother breastfeeding for at least 6 months was
only 25.4% (including exclusive or mixed breastfeeding). In
addition, thedurationof breastfeedingfor mothersinTaiwan
was lower than that in most Western countries (World
Health Organization, 2009) and Thailand (Yimyam et al.,
Table 7
Factors related to the continuation of breastfeeding in multiple Cox regression models.
Factors Crude hazard ratio
(95% CI)
P value Adjusted hazard
ratio
a
(95% CI)
P value
Return to work status up to 18 months (months) <0.001 <0.001
No return to work
b
1.00 (reference) 1.00 (reference)
1 1.53 (1.45,1.62) <0.001 1.49 (1.41,1.57) <0.001
2 1.39 (1.34,1.44) <0.001 1.41 (1.35,1.50) <0.001
3 1.22 (1.11,1.34) <0.001 1.18 (1.08,1.29) <0.001
6 1.37 (1.27,1.49) <0.001 1.26 (1.17,1.36) <0.001
12 1.15 (1.06,1.25) 0.001 1.10 (1.02,1.19) 0.011
>12 1.06 (0.96,1.17) 0.225 1.03 (0.94,1.13) 0.563
Maternal age (years) <0.001 <0.001
19
b
1.00 (reference) 1.00 (reference)
2034 0.78 (0.69,0.87) <0.001 0.77 (0.69,0.86) <0.001
35 0.62 (0.55,0.70) <0.001 0.66 (0.59,0.74) <0.001
Maternal education <0.001 <0.001
Junior high school
b
1.00 (reference) 1.00 (reference)
Senior high school 1.17 (1.11,1.23) <0.001 1.00 (0.95,1.04) 0.904
University + 0.91 (0.87,0.96) <0.001 0.66 (0.63,0.69) <0.001
Maternal body mass index (BMI) before giving birth 0.014 0.014
25
b
1.00 (reference) 1.00 (reference)
30 0.98 (0.94,1.01) 0.153 0.97 (0.94,0.99) 0.034
35 1.05 (0.99,1.01) 0.078 1.02 (0.97,1.07) 0.500
>35 1.08 (0.97,1.20) 0.176 1.08 (0.99,1.19) 0.095
Type of birth
Normal spontaneous delivery
b
1.00 (reference) 1.00 (reference)
Caesarean section 1.10 (1.06,1.14) <0.001 1.14 (1.10,1.17) <0.001
Gender of infant
Female 0.94 (0.91,0.97) <0.001 0.96 (0.93,0.99) 0.003
Birth of order 0.703
1
b
1.00 (reference) 0.998 1.00 (reference)
2 1.00 (0.89,1.12) 0.997 1.01 (0.98,1.05) 0.416
3 1.00 (0.85,1.17) 0.999 1.01 (0.96,1.06) 0.654
Preterm birth
Yes 1.05 (0.99,1.11) 0.086 1.08 (1.02,1.14) 0.003
Neonatal jaundice
Yes 1.01 (0.98,1.04) 0.639 1.00 (0.97,1.03) 0.958
Allergic dermatitis before 6 months of age by doctors diagnosis
Yes 0.90 (0.85,0.96) 0.001 0.93 (0.88,0.99) 0.019
Supplemental baby-food feeding before 6 months of age
Yes 1.34 (1.27,1.41) <0.001 1.26 (1.20,1.32) <0.001
Mother living with the baby around 6 months of age (days per week) <0.001 <0.001
2
b
1.00 (reference) 1.00 (reference)
36 0.94 (0.85,1.05) 0.267 0.98 (0.88,1.08) 0.647
7 0.64 (0.60,0.67) <0.001 0.79 (0.74,0.84) <0.001
Mother living with the baby around 18 months of age (days per week) <0.001 <0.001
2
b
1.00 (reference) 1.00 (reference)
36 0.98 (0.88,1.10) 0.774 0.99 (0.89,1.10) 0.825
7 0.66 (0.62,0.70) <0.001 0.84 (0.78,0.89) <0.001
Abbreviations: CI, condence interval.
a
Model was adjusted for maternal age, education, BMI before giving birth, type of birth, preterm birth, gender, birth order of infant, neonatal jaundice,
allergic dermatitis before 6 months of age by doctors diagnosis, supplemental baby-food feeding before 6 months and mother living with the baby around
the age of 6 and 18 months (days per week).
b
Reference category.
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 469
1999), but higher thanthat inHongKong(Leunget al., 2002).
The results showed a high rate of breastfeeding initiation,
andthena dramatic decreaseafter the postpartumperiod. In
the current study, 20.5% of mothers quit breastfeeding
because of the inconvenience of breast milking in the
workplace, and thus a friendlier work environment with
regard to breastfeeding might encourage the practice.
Our results show that breastfeeding levels fell dramati-
cally 1 month after birth, with a probable reason being
Taiwanesetraditional beliefsandpracticesinthepostpartum
period (Racen et al., 2007). In traditional Taiwanese culture,
women must have 1 month of complete rest for postpartum
recuperation, and this might enable and encourage women
to practice breastfeeding during this time. Furthermore,
women typically quit breastfeeding before returning to
work, often after the 8-week period that is the standard
length of maternity leave in Taiwan (Chen et al., 2006).
Our results showthat therates of breastfeedingcessation
differed signicantly, especially for those women who
returned to work within 1 or 2 months. These ndings are
similar to those of an earlier study showing that the rate of
quitting breastfeeding is highest in the rst month (Kimbro,
2006). The relationship between the return to work and the
timing of quitting breastfeeding uncovered in this work
shows that conicts between womens productive and
reproductive roles have been intensied by the rapid
economic development and social changes in Taiwan.
Inour study, about 58.5%(47.5%returnedtothe samejob
as duringpregnancy, and11.0%returnedtothe different job,
data not shown) and 65.3% of the women returned to work
at 6 and 18 months after giving birth, respectively. About
70.7%, 3.8%, 8.2%and17.2%of the womenworkedinthe day,
night, shift time, andthe dayandnight, respectively, at the 6
months survey. Furthermore, around 20% and 12% of the
working women thought that their current jobs usually or
always inuencedhowtheycouldtake care of their children
at the 6 and 18 months surveys, respectively. Our results
show that about 12% of the mothers lived apart from their
child before it was 18 months old. In Taiwan, it is common
that grandparents help to take care of their grandchildrento
let childs parents return to work. Hence, if a couple lives
apart fromtheir parents, they may also live apart fromtheir
children. It might explain that a part of mothers lived apart
from their children.
In Taiwan the mandated maternity leave is 8 weeks
(Council of Labor Affairs, 2008), shorter than in Ireland (18
weeks), Sweden (14 weeks), and the USA(12 weeks) (Galtry,
2003; Berger et al., 2005). If the twin aims of encouraging
womentojointhe workforce andcontinue breastfeeding are
tobemet, itwill benecessarytondwaystoreducetocurrent
conictsbetweenthetwo. It isimportant tonot onlyconsider
howstatutory provisions might best be reformed to address
the needs of breastfeedingworkers, but alsotofocus onways
in which workplaces can become more breastfeeding-
friendly. These include part-time work, job-sharing, phase-
back, exitime, on-site and near-site day care, breastfeeding
breaks andprovisionfor freezingor storingbreast milkinthe
workplace. Suchmeasuresmightencourageworkingwomen
to initiate and continue breastfeeding.
Successful breastfeeding depends on multiple factors
relating to the parents, infants, and wider environment. In
addition, all health encounters during a womens repro-
ductive years should include counselling on appropriate
medical care and behaviour to optimize pregnancy out-
comes (American Academy of Pediatrics and American
College of Obstetricians and Gynecologists, 2002). Nurses
play an important role in this because they are the rst line
of contact with pregnant women. In the current study,
16.3% of the women did not breastfeed their children at all.
To address this, early intervention to initiate breastfeeding
is possible for nurses providing obstetric care during the
perinatal period. Furthermore, research has shown that the
baby-friendly hospital environments that have been
developed in recent years can contribute to breastfeeding
initiation in the early postpartum period (Bartington et al.,
2006). To prevent the ending of breastfeeding before
return to work, community health nurses should under-
take home visits to postpartum women and/or nurses
should provide adequate information about breastfeeding
during the well-baby examination visits. On the mothers
return to work, occupational health nurses can provide
useful information and strategies to help them to continue
breastfeeding.
There are several limitations in our study. First, though
the birth registration includes data on birth weight,
gestation duration, and characteristics of live born infants
and their mothers, it has no information with regard to
spontaneous abortions or stillborn infants. Furthermore, it
is difcult to collect detailed information of working title
by using the questionnaires in this study, thus we cannot
adequately explore the deeper relationships between work
environments, work patterns and breastfeeding. Another
limitation is that the practice of breastfeeding in Taiwan
rarely follows the WHO denition of exclusive breastfeed-
ing, which refers to the practice of feeding only breast milk,
without other liquids or any solids (WHO, 2004). Hence,
we did not analyze exclusive breastfeeding and mixed
feeding separately. The further investigation of work
patterns and breastfeeding is warranted.
5. Conclusions
Breastfeeding is common in Taiwan, but usually takes
place for a relatively short time. In the current study,
maternityleave was animportant factor inthe initiationand
continuationof breastfeedingforemployedwomen. Employ-
ment seems to be a persistent barrier to continued breast-
feeding, and thus a comprehensive strategy is required to
encourage the practice in working women. Frompregnancy,
through the early postpartum period, and to the return to
work, educational and promotional strategies to encourage
andsupport breastfeeding should be undertaken, withthese
making particular use of nurses, who are in frequent contact
with women, both before and after they give birth.
Acknowledgements
We are very grateful for the enduring support and
assistance of Professor Tung-Liang Chiang, Institute of
HealthPolicy and Management, National Taiwan University
College of Public Health, Taipei, Taiwan; Professor Yueliang
Leon Guo, Department of Environmental and Occupational
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 470
Medicine, National TaiwanUniversityHospital andNational
Taiwan University College of Medicine; Professor Meng-
Chin Lee, Institute of Medicine, Professor Hui-Sheng Lin,
School of Public Health, Chung Shan Medical University.
Taichung, Taiwan; and Professor Bih-Ching Shu, Institute of
Allied Health Sciences, College of Medicine, National Cheng
Kung University, Tainan, Taiwan.
Conicts of interest: None.
Funding: This study was based on the data from the
Taiwan Birth Cohort Study Database and supported by
grants BHP-PHRC-92-4, DOH93-HP-1702 and DOH94-HP-
1702 from the Bureau of Health Promotion, Department of
Health, Taiwan.
Ethical approval: All study participants provided
informed consent as approved by the Ethics Review Board
of the National Taiwan College of Public Health.
Appendix A
Questions for collecting the information of breastfeeding and maternal return to work
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 471
Appendix A (Continued )
C.H. Chuang et al. / International Journal of Nursing Studies 47 (2010) 461474 472
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