DISCUSSIONBreastfeeding practices in women with type 1 diabetes: A discussion of the psychosocial factors and policies in Sweden and Australia
Introduction
Breastfeeding has well recognised maternal, infant and public health benefits.1 The World Health Organization (WHO) recommends exclusive breastfeeding (only breast milk and medicines) for babies to 6 months of age, and the continuation of breastfeeding for at least 2 years, together with complementary foods.2 Breastfed infants have a lower risk of developing gastroenteritis, respiratory illnesses, otitis media and Sudden Infant Death Syndrome than infants who are not breastfed.3 Infants who are not breastfed are at a higher risk of developing type 1 diabetes mellitus (T1DM) and of developing obesity in later life.4 Despite strong evidence underpinning the WHO recommendations there are marked regional variations in breastfeeding rates. In women with T1DM, breastfeeding rates are suboptimal.
In Australia, initiation rates of breastfeeding have been reported to be between 92% and 96%5; however there is a sharp decline in the rates of ‘exclusive’ and ‘any’ breastfeeding in each month following birth.6 While Australian rates of breastfeeding initiation and breastfeeding at 3 months are comparable to many OECD (Organization for Economic Co-operation and Development) countries including Sweden, by 6 months they are significantly lower.7 In the Australian general population in 2011–12, nearly three-quarters (73.9%) of children aged 4 months or less were still receiving breast milk, however by the ages of 6–9 months this figure had decreased to 60%.8 Less than one-third (29.7%) of children aged 9–12 months were still receiving breast milk (Australian Bureau of Statistics (ABS), 2014).9 Exclusive breastfeeding to 2 months of age occurred in over half (57.8%) of all children, while 38.6% of children had been exclusively breastfed to at least 4 months or age. Exclusive breastfeeding to at least 6 months occurred in 15–17.6% of children (ABS, 2014)9, 8 with regional variation.8
Two Australian national surveys8, 10 have investigated the relationship between socio-economic status and women's attitudes, infant feeding practices and breastfeeding initiation and duration to 3, 6 and 12 months. They found that the gap has widened between the most and least disadvantaged,8 with higher levels of education and income associated positively with rates of initiation, intensity and duration of breastfeeding.10 These findings are echoed in a Victorian study11 that found breastfeeding rates were lowest among women from lower socio-economic groups, those with lower education and incomes, and those from specific cultural groups. Research on the influence of psychosocial factors on breastfeeding initiation and duration specifically among women in Australia with T1DM is lacking.
A recent Swedish and Australian comparative study of breastfeeding in rural areas highlighted that Swedish women without diabetes were more likely to breastfeed 2 months after birth than the Australian women.12 However, primiparous women in Sweden were significantly less likely than Australian women to be satisfied with the available resources to support breastfeeding, such as the practical help with breastfeeding, information about breastfeeding and formulas as well as breastfeeding support after 2 months.12 Australian women who were identified as having received optimal assistance the first time they breastfed were more likely to continue breastfeeding 2 months after birth.12 Moreover, the study highlighted several other factors that possibly influenced breastfeeding outcomes; these included the attitudes of women, their partners and health professionals, as well as socio-economic factors.12
The Swedish general population has one of the highest rates of breastfeeding at 6 months in the world, with 65% of infants breastfed (any breast milk) and 10% breastfed (exclusively).13 This difference between Swedish and Australian breastfeeding continuation is despite many demographic similarities between the two countries; both are high income countries with similar birth rates and total health expenditure. This suggests differences in attitudes and policies impact on practice. Understanding differences might provide critical insights into factors which will positively influence continuation of breastfeeding and might be of particular benefit to ‘at risk’ populations such as mother and infant affected by T1DM.
The psychosocial and economic predictors of breastfeeding initiation and duration among women with T1DM may identify protective factors for breastfeeding and inform intervention strategies. The aim of this paper is to discuss psychosocial factors, policies and practices that impact on the breastfeeding practices of women with T1DM.
Section snippets
Breastfeeding in women with type 1 diabetes
The prevalence of T1DM in pregnancy is approximately 0.3% in Australia14 and 0.5% in Sweden.15 The condition is associated with increased maternal morbidity, longer periods of hospitalisation, impairment of quality of life (QoL) and higher rates of medical intervention.16, 17, 18 In addition, there is a greater risk of adverse perinatal outcomes,19 increased perinatal mortality and morbidity, congenital anomalies, prematurity, macrosomia, neonatal hypoglycaemia, respiratory distress syndrome,
The impact of psychosocial factors on breastfeeding and well-being in transition to motherhood
Our appraisal of the literature relating to pregnancy in women with T1DM indicates that while numerous studies31, 32 have focused on the physical and medical aspects of the condition, fewer have been concerned with psychosocial impacts. This gap in evidence has been addressed in part by a recent emerging body of research in Sweden that has addressed the emotional and social issues during transition to motherhood among women with T1DM.28, 33, 34 The findings suggest that women with T1DM diabetes
Health services and policies impacting breastfeeding and the transition to motherhood
In Australia, the average length of stay in a public hospital is 2 days after a spontaneous vaginal birth and 4 days for a lower uterine segment caesarean delivery.37 In Victoria, women are offered one publicly funded home visit by a domiciliary midwife and further support is dependent on clinical or psychosocial needs.37 In a local Swedish study, women with diabetes stayed in hospital maternity care for 3.5 days compared to a reference group without diabetes who stayed 2.2 days.23 Australian
Conclusion
Supportive and targeted care that encourages initiation and continuation of breastfeeding among women with T1DM is vital to achieving optimal physical, emotional and social well-being for the mother and her baby. Swedish research highlights the impact of socio-economic conditions and psychosocial variables that impact on the initiation and continuation of breastfeeding in women with T1DM. Key factors that emerged from Swedish research are that social support from both health professionals and
Conflict of interest
The authors have no conflict of interest to disclose.
Acknowledgment
There has been no financial assistance relevant to the preparation of this manuscript.
Bodil Rasmussen is Course Director for Graduate Certificate in Diabetes Education and has a strong research track record in psychosocial aspects of living with diabetes, particular life transitions.
References (45)
- et al.
Comparison of breastfeeding in rural areas of Sweden and Australia – a cohort study
Women Birth
(2013) - et al.
Psychosocial correlates of exclusive breastfeeding: a systematic review
Midwifery
(2013) - et al.
Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial
Midwifery
(2011) The optimal duration of exclusive breastfeeding: report of an expert consultation
(2002)- et al.
Breastfeeding and maternal and infant health outcomes in developed countries
Evid Rep Technol Assess (Full Rep)
(2007) - et al.
Evidence on the long-term effects of breastfeeding: systematic review and meta-analyses
(2007) Growing up in Australia: the Longitudinal Study of Australian Children: 2010–11 annual report
(2012)The Australian National Breastfeeding Strategy 2010–2015
(2009)Health at a glance 2011: OECD indicators
(2011)
Australian national infant feeding survey: indicator results. Authoritative information and statistics to promote better health and well-being
Australian Health Survey: Health Service Usage and Health Related Actions 2011–2012, Publication No. 4364.0.55.002. 26/03/2013
Socioeconomic status and rates of breastfeeding in Australia: evidence from three recent national health surveys
Med J Aust
Hyperglycemia and adverse pregnancy outcomes
N Engl J Med
Quality of life in pregnancy and post-partum: a study in diabetic patients
Qual Life Res
Hypoglycaemia during pregnancy in women with Type 1 diabetes
Diabet Med
Peri-conceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes
Diabetes Care
Breastfeeding duration in families with type 1 diabetes compared to non-affected families: results from BABYDIAB and DONALD studies in Germany
Breastfeed Med
Cited by (6)
Indicators of ‘good’ feeding, breastfeeding latch, and feeding experiences among healthy women with healthy infants: A qualitative pathway analysis using Grounded Theory
2021, Women and BirthCitation Excerpt :Recognising pathways to successful breastfeeding amongst cohorts of healthy women who give birth to healthy, term infants, could guide future research in identifying whether barriers and facilitators of breastfeeding are comparable across different cohorts of women. For example, women with obesity during pregnancy [8] or women with diabetes [9] are less likely to initiate and continue breastfeeding than women without health complications, despite strong intentions for breastfeeding [14]. Evidence suggests that support strategies are more effective when tailored to women and their experiences [5,11], with the World Health Organisation [12] (WHO) identifying tailored breastfeeding counselling as a priority for future research.
Psychosocial wellbeing among new mothers with diabetes: Exploratory analysis of the postnatal wellbeing in transition questionnaire
2019, Sexual and Reproductive HealthcareCitation Excerpt :While everyday life does not have to be highly organised and structured for most people, for mothers with diabetes new daily patterns may need to be established [11,12,27], in addition to adjusting to bodily changes [22]. The additional demands of meeting the needs of an infant require even more organisation, and often a woman with diabetes perceives that the infant’s needs come before her own [15]. This has been referred to as a constant “balancing act” [28]; in these circumstances, women may find it difficult to prioritise self-care.
Development of a breastfeeding website for women with pre-pregnancy diabetes: A mixed method study
2023, Breastfeeding ReviewDevelopment of Website For Breastfeeding Women With Type 1 or Type 2 Diabetes
2021, Research SquareInitial validation of the diabetes and breastfeeding management questionnaire (DBM-Q)
2020, International Journal of Environmental Research and Public Health
Bodil Rasmussen is Course Director for Graduate Certificate in Diabetes Education and has a strong research track record in psychosocial aspects of living with diabetes, particular life transitions.
Helen Skouteris is Associate Head of School and her research relates to psychological well-being and health promotion in regard to infant, children's and mothers’ health, particular focusing on women's breastfeeding practices.
Marie Berg is a midwife and has a long research track record related to women's health and pregnancy.
Cate Nagle is a midwife and researches in women health and risk pregnancies including obesity and risks related to clinical deterioration and intervention.
Heather Morris is a psychologist and facilitated the literature review as a research assistant in the School of Psychology, Deakin University.
Alison Nankervis is an endocrinologist working with women with diabetes and the President of the Australasian Diabetes in Pregnancy Society (ADIPS).
Carina Sparud-Lundin is Head of Department, a paediatric nurse and diabetes educator with long research track record related to psychosocial aspects to women living with diabetes.