BREASTFEEDING MEDICINE

Volume 12, Number 4, 2017 Clinical Research

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2016.0205

Breastfeeding Initiation in Mothers

with Repeat Cesarean Section:
The Impact of Marital Status

Jordyn T. Wallenborn, Whitney C. Graves, and Saba W. Masho

Abstract

Background: Approximately 90% of mothers with a primary C-section have a subsequent C-section. To date,
research has demonstrated that primary C-sections are associated with breastfeeding noninitiation. However,
it is unknown if this association persists after the primary C-section. Furthermore, literature has shown a
differing relationship between breastfeeding initiations by marital status. Due to the high proportion of women
who give birth while unmarried, investigating differences by marital status will add a significant contribution
to breastfeeding literature. This study investigates the association between repeat C-section and breastfeeding
initiation within marital status groups using a nationally representative cross-sectional survey.
Materials and Methods: Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System were
analyzed. The sample was restricted to women with a previous singleton live birth who had C-section and
whose infant was alive at the time of interview (N = 34,854). Multiple logistic regression analyses were con-
ducted to obtain crude and adjusted odds ratio (AOR) and 95% confidence intervals (CIs).
Results: After adjusting for potential confounders, married women who had a repeat C-section were 2.2 times
(AOR = 2.16, 95% CI = 1.69–2.77) more likely to never breastfeed compared to women with vaginal birth after
caesarean section (VBAC). Similarly, the odds of breastfeeding noninitiation were 76% (AOR = 1.76, 95%
CI = 1.47–2.12) higher among women with a repeat C-section compared to women with VBAC. No significant
associations were exhibited among nonmarried women.
Conclusions: Enhanced educational programs and counseling support may be needed to help families cope with
delivery challenges and resulting stressors that may reduce their desire to initiate breastfeeding in the post-
partum period.

Keywords: cesarean section, VBAC, breastfeeding initiation, marital status

Introduction delivery room resuscitation, and less oxygen requirement in

the NICU compared to elective repeat C-sections.4

I n recent years, efforts were made to encourage women

to have vaginal birth after cesarean section (VBAC). In
2012, the United States (US) National Center for Health
Statistics reported a VBAC rate of 10.2 percent in the United
States, which is the highest percentage since 2005.1 Despite
this increase, *9 out of 10 women with a primary cesarean
section (C-section) have a subsequent birth by C-section.
This high proportion can be attributed to the lack of knowl-
edge surrounding VBAC outcomes2 and/or the poor im-
plementation of VBAC initiatives.3 Nevertheless, VBAC has
been associated with lower neonatal intensive care unit
(NICU) rates, lower rates of oxygen for infants during
Research has also shown that women who have VBAC
initiate breastfeeding more quickly compared to women who
gave birth by C-section.5 Even for women who attempt
VBAC (trial of labor), initiation of breastfeeding was higher
than women with a scheduled C-section (61.3 percent and
58.9 percent, respectively).6 This suggests that C-sections
are a potential barrier to breastfeeding initiation.7 This bar-
rier could be caused by a delayed onset of milk production,
which has been shown to be significantly associated with
C-sections.8
In addition to C-section, marital status has been shown
to impact breastfeeding practices.9,10 For example, a United

Division of Epidemiology, Department of Family Medicine and Population Health, School of Medicine, Virginia Commonwealth
University, Richmond, Virginia.

1
2 WALLENBORN ET AL.
Kingdom cohort study reported that unmarried mothers had a
higher risk for not breastfeeding their infant.9 Conversely, a
nationally representative U.S. cross-sectional study found
married women were at an increased risk for never breast-
feeding and breastfeeding a shorter duration for overweight
and obese women compared to nonmarried normal weight
women.10 Although this relationship could be more related to
obesity, marital status is an important factor to consider when
examining breastfeeding practices due to recent trends and
inconsistencies in previous literature.
According to the national KIDS Count Data Center, the
prevalence of births to unmarried women have stayed con-
stant at *41% from 2010 to 2014.11 Because of the proven
benefits of VBAC, the importance of breastfeeding initiation,
and large proportion of births to unmarried women,12 un-
derstanding how these health behaviors differ among groups
of married and unmarried women would provide novel in-
sights into maternal and child health. Even though research
has clearly demonstrated a link between mode of delivery and
success of breastfeeding initiation, literature is limited when
considering differences between groups of married and un-
married women. Furthermore, additional research is needed
to corroborate and expand Regan et al.’s findings—the only
known study to investigate this relationship in the United
States. Therefore, this study aims to investigate whether the
association between repeat C-section and breastfeeding ini-
tiation differs by marital status groups.
Materials and Methods
Data from Phase 5 (2004–2008) and Phase 6 (2009–2011)
of the Pregnancy Risk Assessment Monitoring System
(PRAMS) were analyzed. PRAMS is a population-based
survey used to identify maternal experiences and behaviors
before and during pregnancy, and during early months after
birth. The sample includes women who recently had a live
birth and are identified through state birth certificate records.
Each participating state samples between 1,300 and 3,400
women per year with a minimum overall response rate of
65%. To ensure a representative sample population, higher
risk groups are sampled at a higher rate. More information on
PRAMS can be found elsewhere.13
The dataset used in this study included 319,689 women
who had live births. Women who did not have a previous live
birth, who had a multiparous birth whose infant was not
alive at the time of interview, who did not have a prior C-
section, or who had missing information for reported mode of
delivery or breastfeeding initiation were excluded. This
yielded a total of 34,854 women for analysis. This study was
approved as exempt by the [anonymous for review] institu-
tional review board.
Birthing method for the current delivery was defined using
the survey item, ‘‘How was your new baby delivered, vagi-
nally or by Cesarean delivery?’’ Based on this question, a
dichotomous variable (VBAC; repeat C-section) was created.
Breastfeeding initiation, the outcome variable, was based on
the survey item, ‘‘Did you ever breastfeed or pump breast
milk to feed your new baby after delivery?’’ and was di-
chotomized as yes or no.
To identify potential confounding variables, a variety of
covariates were considered. These covariates were based on
previous research and literature reviews6,10,14,15 and included
maternal race (Non-Hispanic Black, Non-Hispanic White,
Hispanic, Non-Hispanic other), maternal age (<20; 20–24;
25–29; 30–34; 35+ years), maternal education (<12 years;
12 years/H.S. diploma; >12 years), maternal morbidity (yes;
no), number of stressors (1; 2; 3; 4+), prepregnancy body
mass index (BMI) (underweight [<18.5 kg/m2]; normal [18.5–
24.9 kg/m2]; overweight [25–29.9 kg/m2]; obese [>30 kg/m2]),
income (less than $20,000; $20,000–$34,999; $35,000–
$49,999; $50,000+), marital status (married, other), WIC
during pregnancy (yes; no), insurance (private; Medicaid;
none; other; multiple), adequacy of prenatal care (inade-
quate; intermediate; adequate; adequate plus), and low birth
weight of infant (normal weight; low birth weight; very low
birth weight).
Maternal morbidity was defined by 12 different ailments,
including diabetes before pregnancy, diabetes during preg-
nancy, vaginal bleeding, kidney/bladder infection, severe
nausea, incompetent cervix, hypertension, placenta problems,
preterm labor, premature rupture of membranes, blood trans-
fusion, and injury from a car accident. Prepregnancy BMI was
based on two survey items, weight before pregnancy and
height without shoes. BMI groups were based on Centers for
Disease Control and Prevention (CDCs) standard BMI cate-
gories. Due to the high number of missing values for smoking
status during the last three months of pregnancy (36.9%), the
variable was not considered for analysis.
Descriptive analysis was conducted to examine the dis-
tribution of the study population. Chi-square test was used
to make bivariate group comparisons between women who
initiated breastfeeding and those who did not. Odds ratios
(OR) and 95% confidence intervals (CIs) were calculated to
examine the association between never breastfeeding and
potential confounders. Race, prepregnancy BMI, age, marital
status, and insurance were tested as effect modifier; however,
marital status was the only significant effect modifier at
p = 0.005. Due to the significant interaction, two separate
models were considered. The first model did not stratify by
marital status. Because marital status was a statistically sig-
nificant effect modifier, it was not included in the first model.
The second model utilizes a stratified analysis. Data were
stratified by marital status to provide further insight into the
association. Multiple logistic regression analyses were con-
ducted to examine the associations after controlling for
confounders. All potential confounders that resulted in at
least a 10% change in the crude OR were included in the final
models.16 If no potential confounders met this rule, a fully
adjusted model was used. Data were analyzed using SAS
version 9.4 statistical software and accounted for multistage
complex sampling.
Results
Among the study population, the prevalence of breast-
feeding initiation was 75.2%. One in ten (10.0%) women
gave birth by VBAC. The majority of the women in this study
sample were Non-Hispanic White (59.7%), married (70.3%),
had at least some college education (56.6%), and had re-
peat C-section (90.0%). Breastfeeding initiation was highest
among women aged 30–34 years (32.6%), who had private
insurance (48.4%), and had an income of at least $50,000. In
contrast, never breastfeeding was highest among women with
Medicaid (47.8%), received WIC services (54.3%), and had
BREASTFEEDING INITIATION AND REPEAT C-SECTION 3

an income less than $20,000. All potential confounders
showed significant differences between women who never
breastfed and initiated breastfeeding (Table 1).
Bivariate analyses revealed that all variables among mar-
ried women were significantly associated with never breast-
feeding. Among women who were not married, statistically
significant associations were found among age, education,
race/ethnicity, income, insurance, adequacy of prenatal care
utilization, and breastfeeding noninitiation (Table 2).
Table 3 shows the logistic regression analysis before strati-
fication. Compared to women who gave birth by VBAC, the
odds of never breastfeeding were 1.9 times (COR = 1.89, 95%
CI = 1.61–2.21) higher among women who gave birth by repeat
C-section. After fully adjusting for all covariates, the estima-
tes were slightly attenuated but remained significant. The odds
of never breastfeeding were nearly 1.8 times (adjusted odds
ratio [AOR] = 1.76, 95% CI = 1.47–2.12) higher among women
with a repeat C-section compared to women with VBAC.

Table 1. Distribution of Maternal Characteristics by Breastfeeding Initiation

Total Never breastfed Breastfed Chi square
Potential confounders n = 34,854 n = 8,302 n = 26,552 p
Age (years) <0.0001
£19 2.0 3.6 1.4
20–24 16.1 23.8 13.6
25–29 27.1 27.4 27.0
30–34 31.3 27.3 32.6
‡35 23.5 17.9 25.4
Education (years) <0.0001
Did not finish high school (<12 years) 16.5 22.1 14.7
High school diploma (12 years) 26.9 36.6 23.7
College or higher (>12 years) 56.6 41.3 61.6
Race/ethnicity <0.0001
White, Non-Hispanic 59.7 63.6 58.4
Black, Non-Hispanic 14.9 22.4 12.5
Other, Non-Hispanic 6.6 3.4 7.6
Hispanic 18.8 10.6 21.5
Not married 29.7 44.8 24.8 <0.0001
Income <0.0001
<$20,000 32.5 44.7 28.5
$20,000–$34,999 17.1 18.0 16.8
$35,000–$49,000 10.5 9.1 10.9
‡$50,000 39.9 28.1 43.8
Insurance <0.0001
Private 45.3 35.8 48.4
Medicaid 34.1 47.8 29.6
None 3.3 1.5 3.9
Other 2.0 1.5 2.2
Multiplea 15.4 13.4 16.0
Adequacy of prenatal care utilization <0.0001
Inadequate 11.6 15.9 10.2
Intermediate 12.4 11.3 12.7
Adequate 45.3 40.3 46.9
Adequate plus 30.7 32.5 30.1
VBAC 10.0 6.3 11.2 <0.0001
WIC recipient 42.9 54.3 39.2 <0.0001
Prepregnancy BMI <0.0001
Underweight 2.6 2.9 2.6
Normal 40.4 33.4 42.8
Overweight 27.0 27.8 26.7
Obese 29.9 35.9 27.9
Number of stressors <0.0001
None 31.0 27.0 32.3
1 24.3 21.2 25.3
2 16.6 17.2 16.4
3 or more 28.1 34.7 26.0
Number of morbidities <0.0001
None 36.6 31.8 38.1
1–2 48.7 50.8 48.0
3+ 14.8 17.4 13.9
All analyses were performed on weighted data.
a
Multiple indicates two or more of the following insurances (private, Medicaid, or other).
BMI, body mass index; VBAC, vaginal birth after cesarean Section; WIC, women, infants, and children.
4 WALLENBORN ET AL.

Table 2. Factors Associated with Not Initiating Table 3. Association Between Mode
Breastfeeding by Marital Status of Delivery and Breastfeeding Initiation
Odds ratio Odds ratio Never breastfed Never breastfeda
Potential (95% CI) (95% CI) Mode of delivery COR (95% CI) AOR (95% CI)
confounders Married Not married
Repeat C-Section 1.89 (1.61–2.21) 1.76 (1.47–2.12)
Age (years) VBAC 1.00 1.00
£19 2.69 (1.50–4.82) 1.69 (1.22–2.36) a
20–24 1.51 (1.25–1.81) 1.44 (1.21–1.71) Adjusted for race, age, income, education, insurance, WIC
25–29 Ref. Ref. participation during pregnancy, adequacy of prenatal care, maternal
30–34 0.92 (0.81–1.05) 0.99 (0.81–1.21) morbidity, prepregnancy BMI, and stress.
COR, crude odds ratio; AOR, adjusted odds ratio.
‡35 0.84 (0.73–0.97) 0.72 (0.58–0.91)
Education (years)
Did not finish 1.76 (1.49–2.09) 1.57 (1.31–1.88)
high school
(<12 years) Table 4 shows the logistic regression analysis stratified
High school 2.01 (1.79–2.26) 1.66 (1.40–1.97) by marital status. Although the unadjusted analysis showed
diploma higher odds of never breastfeeding among unmarried
(12 years) women who had a repeat C-section (COR = 1.38, 95%
College or higher Ref. Ref. CI = 1.08–1.75), the estimate lost significance after adjust-
(>12 years) ing for all covariates. Among married women who had a
Race/ethnicity repeat C-section, the odds of never breastfeeding were 2.5
White, Ref. Ref. times (COR = 2.48, 95% CI = 1.99–3.09) higher compared
non-Hispanic to women with VBAC. The fully adjusted model demon-
Black, 0.90 (0.78–1.07) 1.15 (0.98–1.34) strated a significant yet attenuated estimate for married
non-Hispanic women. Women who had a repeat C-section were 2.2 times
Other, 0.30 (0.24–0.38) 0.58 (0.43–0.78)
non-Hispanic (AOR = 2.16, 95% CI = 1.69–2.77) more likely to never
Hispanic 0.43 (0.35–0.52) 0.28 (0.22–0.35) breastfeed compared to women with VBAC.
Income
<$20,000 1.68 (1.46–1.92) 1.79 (1.29–2.50) Discussion
$20,000–$34,999 1.35 (1.17–1.56) 1.55 (1.08–2.22) Breastfeeding initiation was prevalent among the major-
$35,000–$49,000 1.19 (1.02–1.40) 1.31 (0.84–2.04)
ity of study participants (75%). Our results also demonstrate
‡$50,000 Ref. Ref.
that repeat C-sections are associated with breastfeeding
Insurance noninitiation. Furthermore, the current study revealed that
Private Ref. Ref.
this relationship differs by marital status. These results add
Medicaid 1.53 (1.35–1.73) 1.48 (1.22–1.80)
None 0.51 (0.35–0.74) 0.31 (0.18–0.52) to the growing evidence that C-sections negatively affect
Other 0.65 (0.37–1.13) 0.72 (0.44–1.18) breastfeeding practices.
Multiplea 1.05 (0.92–1.20) 0.95 (0.72–1.24) In the current study, women with a repeat C-section were
Adequacy of prenatal care utilization more likely to never breastfeed compared to women with
Inadequate 0.95 (0.78–1.18) 1.38 (1.13–1.70) VBAC. This finding is consistent with previous research
Intermediate 0.69 (0.58–0.82) 0.98 (0.78–1.24) that demonstrated a negative association between having
Adequate 0.77 (0.69–0.86) 0.90 (0.76–1.07) a C-section delivery and breastfeeding initiation.5,6,17 This
Adequate plus Ref. Ref. relationship could be explained by breastfeeding intention—
WIC recipient 1.43 (1.29–1.60) 1.23 (1.04–1.44)
Prepregnancy BMI
Underweight 1.43 (1.02–1.99) 1.08 (0.71–1.62)
Normal Ref. Ref. Table 4. Association Between Repeat Cesarean
Overweight 1.40 (1.22–1.60) 1.10 (0.91–1.32) Section and Breastfeeding Initiation
Obese 1.79 (1.58–2.02) 1.19 (1.00–1.41) Stratified by Marital Status
Number of stressors Never breastfed Never breastfeda
None Ref. Ref. Mode of delivery COR (95% CI) AOR (95% CI)
1 0.96 (0.84–1.10) 0.92 (0.73–1.18)
2 1.10 (0.95–1.27) 1.11 (0.88–1.40) Not married
3 or more 1.34 (1.20–1.58) 1.05 (0.86–1.28) Repeat C-section 1.38 (1.08–1.75) 1.35 (1.00–1.83)
Number of morbidities VBAC 1.00 1.00
None Ref. Ref. Married
1–2 1.28 (1.15–1.43) 1.06 (0.90–1.25) Repeat C-section 2.48 (1.99–3.09) 2.16 (1.69–2.77)
3+ 1.43 (1.22–1.67) 1.14 (0.94–1.37) VBAC 1.00 1.00
Bold estimates are significant. Bold estimates are significant.
a a
Multiple indicates two or more of the following insurances Adjusted for maternal age, education, insurance, income, WIC
(private, Medicaid, or other). participation, maternal morbidities, prenatal care adequacy, stress,
CI, confidence interval. race, and prepregnancy BMI.
BREASTFEEDING INITIATION AND REPEAT C-SECTION
a strong predictor of breastfeeding outcomes.18 Specifically,
a prospective cohort study reported that women with a planned
C-section are more likely to not intend to breastfeed.19
This finding could also be explained by the physiological
differences effect resulting from a C-section. Lactogenesis
has been shown to be significantly lower in the first 5 days
postpartum in women with C-sections compared to women
with a vaginal delivery.20 Lactogenesis is defined as, ‘‘the
onset of milk secretion and includes all of the changes in the
mammary epithelium necessary to go from the undifferenti-
ated mammary gland in early pregnancy to full lactation
sometime after parturition.’’21 In addition to the physiologi-
cal effects, previous studies have hypothesized that pain after
a C-section may make spending time with the newborn dif-
ficult or causes a lack of infant to breast contact, which is
associated with never breastfeeding and a shorter duration of
breastfeeding.7,22
The current study also found that married women with
a repeat C-section were more likely to never breastfeed,
whereas unmarried women did not show an association. This
finding is supported by Masho et al. (2016), a study that
reported married women, who were overweight or obese, to
be more at risk to never breastfeed or have a shorter breast-
feeding duration. Despite previous evidence demonstrating
that obesity results in delayed breastfeeding initiation, the
current study controlled for prepregnancy BMI; as a result,
influences from this factor are limited. Therefore, examining
the association between VBAC and breastfeeding initiation
among married women supports the need for practitioners
to consider how interpersonal relationships may increase
the risk of poor maternal health behaviors.
However, it is important to note that these findings conflict
with other previous studies that demonstrated higher rates of
breastfeeding initiation among married women than their
nonmarried counterparts.9,23,24 These inconsistencies may be
the result of differences among each study’s sample popu-
lations. For example, Chin et al. (2008) examined the asso-
ciation between race and education on breastfeeding among
women in Louisiana and found that married Black women
were more than twice as likely to breastfeed compared to
nonmarried Black women. Another study that utilized data
from parents with babies between 9 and 11 months old in
the United Kingdom found that unmarried or cohabitating
women were at a higher risk of not breastfeeding than mar-
ried women.9 While these studies utilized state specific or
international populations, the current study and Masho et al.
(2016) both analyzed samples that were nationally represen-
tative of women in the United States, which may have con-
tributed to the inconsistencies exhibited among these studies.
Furthermore, the difference between married and unmar-
ried women may be explained by the lack of spousal support
among the two groups. The 2011 U.S. Surgeon General’s
report on breastfeeding stated that some fathers may have
concerns about being excluded from bonding and caring for
their child if breastfeeding is practiced. In addition, some
spouses may perceive breastfeeding as a barrier that may
prevent mothers from maintaining other responsibilities,
such as household chores.25 Consequently, this negative in-
fluence may inherently decrease the mothers’ willingness to
breastfeed.
The current study not only contributes to the limited lit-
erature on repeat C-section and breastfeeding initiation but
5
further also explored the importance of marital status on
maternal health behaviors and outcomes. To the authors’
knowledge, this is the first study to examine the association
between repeat C-section and breastfeeding initiation by
marital status. Furthermore, this study used a large, nation-
ally- representative sample of women in the United States.
Despite its strengths, this study is not without limitations.
Because of the cross-sectional nature of the study, causality
cannot be inferred. The use of self-reported data may have
resulted in recall bias among the survey respondents or the
potential for under/overreporting of breastfeeding initiation;
however, previous research has stated that maternal recall of
breastfeeding initiation is reliable.26 Furthermore, a variety
of potential confounders such as breastfeeding intention, self-
efficacy, and perceived milk supply were not available in the
dataset and could not be assessed. Nonetheless, this study
provides evidence that may help to improve public health
practice and policy to increase breastfeeding initiation.
Conclusion
A woman’s mode of delivery and marital status were
both found to be significantly associated with breastfeeding
initiation. Despite the potential for improved maternal and
child health outcomes and the quality of nutrition provided
from breastfeeding, maternal and familial perceptions com-
pounded by potential adverse birth experiences may alter a
mother’s intention and willingness to breastfeed. Enhanced
educational programs and counseling support may be needed
to help families cope with delivery challenges and resulting
stressors that may reduce their desire to initiate breastfeeding
in the postpartum period. Using similar practices during the
prenatal period may also prepare women and their families on
how to successfully overcome any medical challenges that
may hinder their potential to breastfeed. Moreover, providers
should be aware of the effect of marital status when educating
pregnant and postpartum women. Future research should
examine alternative breastfeeding interventions for women
with a repeat C-section delivery to promote the initiation and
continuation of breastfeeding during the postnatal period.
Mixed method analyses and qualitative studies that further
explore the role of marital status on breastfeeding practices
and the variation in factors identified to influence breast-
feeding by marital status may also be beneficial. Findings
from these additional research efforts may help develop en-
hanced interventions to increase breastfeeding initiation rates
among women.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Jordyn T. Wallenborn, MPH
Division of Epidemiology
Department of Family Medicine
and Population Health
School of Medicine
Virginia Commonwealth University
830 East Main Street, Suite 821
P.O. Box 980212,
Richmond, VA 23298-0212
E-mail: wallenbornjt@vcu.edu