Why did women stop breastfeeding

CLINICAL RESEARCH Breastfeeding Support and Early Cessation Lynne Porter Lewallen, Margaret J. Dick, Janet Flowers, Wanda Powell, Kimberly Taylor Zickefoose, Yolanda G. Wall, and Zula M. Price Objective: To examine the types of help women received with breastfeeding both in the hospital and at home and the reasons why women stopped breastfeeding earlier than intended. Design: A descriptive design with open-ended questions. Setting: After participant recruitment in the postpartum hospital room, data were collected by phone 8 weeks after delivery. Patients/Participants: Three hundred seventynine women planning to breastfeed for at least 8 weeks after uncomplicated delivery. Main Outcome Measures: Breastfeeding status at 8 weeks postpartum; report of help with breastfeeding in the hospital and at home. Results: Sixty-eight percent of women were still breastfeeding at 8 weeks, although 37% of those reported supplementing with formula. Of those who had stopped, the most common reason was insufficient milk supply. Other reasons included painful nipples and latch problems, personal reasons, returning to work or school, and drugs/illness of the mother or baby. Most women received help with breastfeeding in the hospital, but only 55% received help with breastfeeding after hospital discharge. Conclusions: The primary reasons for early cessation of breastfeeding are amenable to nursing intervention. Every opportunity should be taken to address these issues both in the hospital and through follow-up calls. JOGNN, 35, 166-172; 2006. DOI: 10.1111/J. 1552-6909.2006.00031.x. Keywords: Breastfeeding Breastfeeding information Breastfeeding support Duration Early cessation Accepted: May 2005 It is well known that breastfeeding is more beneficial than formula feeding for both infants and mothers ( Dennis, 2002 ). Many influential health organizations recommend breastfeeding for at least the first 6 months of an infant s life ( Child and Adolescent Health and Development, 2000-2002; Work Group on Breastfeeding, American Academy of Pediatrics, 1997 ), and the Healthy People 2010 goal is for 75% of American women to initiate breastfeeding and 50% to continue until 6 months ( Department of Health and Human Services, 2000 ). Why did women stop breastfeeding earlier than intended, and what types of help did they receive in the hospital and at home? Although we are approaching the initiation goal, with 71% of women initiating breastfeeding, the 6-month rate is far short of the goal. Only 36% of women continue breastfeeding until 6 months (Centers for Disease Control and Prevention, Department of Health and Human Services, 2003). The purpose of this study was to examine the types of help women received with breastfeeding both in the hospital and at home and the reasons why women stopped breastfeeding earlier than intended. The literature on early weaning has focused on reasons for stopping breastfeeding and barriers to continued breastfeeding. Return to work, perception 166 JOGNN 2006, AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses

of inadequate milk supply, and lack of support by medical professionals are among the reasons given for early breastfeeding cessation ( Blyth et al., 2002; Ertem, Votto, & Leventhal, 2001; Hill, 1991; Isabella & Isabella, 1994; Kirkland & Fein, 2003; Lawson & Tulloch, 1995; Lowe, 1994; Matthews, Webber, McKim, Banoub-Baddour, & Laryea, 1998; Quinn, Koepsell, & Haller, 1997 ). However, studies that documented these reasons frequently did not report the intended length of breastfeeding of their subjects (Blyth et al.; Ertem et al., 2001 ; Kirkland & Fein; Lowe; Quinn et al., 1997 ); so it is difficult to tell whether subjects intended prenatally to breastfeed longer than they actually did. Additionally, some of the studies asked women to choose from a predetermined list of rea sons for breastfeeding cessation (Isabella & Isabella; Kirkland & Fein; McLeod, Pullon, & Cookson, 2002 ), and women s real reasons for stopping may not have been represented. In her study of barriers to continuing breastfeeding for 6 months, Hogan (2001) found that lack of knowledge about breastfeeding management skills and support for breastfeeding were the main barriers to long-term breastfeeding in her sample of 70 randomly selected subjects in Nova Scotia. Once discharged, the mothers in this study desired more support from family members, hospital professionals, and community-based professionals. McKeever et al. (2002) demonstrated that 101 mothers of term newborns in Canada who had in-home visits by lactation consultants after discharge had longer breastfeeding duration rates than those who had usual care. Lactation consultant support postpartum positively influenced breastfeeding duration in this sample. In a prospective study of 490 women in New Zealand, women who felt a need for more information about breastfeeding when interviewed prior to delivery and who reported experiencing breastfeeding problems postpartum breastfed for a shorter period than women who reported having adequate information prior to delivery ( McLeod et al., 2002 ). Some women use written materials for information about breastfeeding both during pregnancy and after hospital discharge, but many health-related written materials are at a high-grade level ( Bastable, 2003 ), though women at low literacy levels tend to breastfeed less than women at higher literacy levels ( Kaufman, Skipper, Small, Terry, & Mcgrew, 2001 ). Other ways women get breastfeeding information after hospital discharge have not been well documented. The purpose of this study, then, was to add to the information available in the literature by following women who had expressed an intention to breastfeed for at least 8 weeks, to see how much and what kind of help they received with breastfeeding, and to compare the reasons for failing to meet their breastfeeding goals to those already documented in the literature. Methods The data reported here were collected as part of three studies conducted in the Southeastern United States to examine the ability to predict early breastfeeding attrition. The quantitative data have been reported elsewhere ( Evans, Dick, Lewallen, & Jeffrey, 2004 ). This article reports the primary analysis of the qualitative data from all three studies. All the studies were approved by the University Institutional Review Board (IRB) as well as IRBs of all hospitals involved. Inclusion criteria for the study were age 18 years or older, able to speak and understand English, delivering a term neonate requiring only routine newborn care and being discharged with the mother, breastfeeding for the 1st time, access to a telephone, and intending to breastfeed for at least 8 weeks. If women intended to breastfeed for less than 8 weeks, they were excluded from the study. Women were recruited into the study by registered nurse research assistants in their postpartum rooms. All women who met study criteria were approached in their rooms, told about the study, and invited to participate. The hospitals in which the women delivered were community and specialty women s hospitals, and all had lactation consultants on staff. Data were collected by these research assistants by phone at 8 weeks postpartum. This time frame for the phone calls was consistent with the inclusion criteria for the study, in which women were asked if they planned to breastfeed for at least 8 weeks. Three hundred ninety-nine women intending to breastfeed for at least 8 weeks were interviewed in their postpartum hospital rooms after healthy term deliveries. During telephone calls to breastfeeding women at 8 weeks postpartum, all were asked three open-ended questions: Did you receive help with breastfeeding in the hospital, and, if so, who helped you? Did you receive help with breastfeeding after you got home, and, if so, who helped you? If you had questions about breastfeeding your baby, how did you get them answered? The questions were chosen based on literature review of important factors in breastfeeding duration. The last question was asked to identify any other sources of information, not previously mentioned, that the women used to find out more about breastfeeding. Those women who had stopped breastfeeding were asked an additional question: Why did you stop breastfeeding? Answers were recorded verbatim in writing during the phone call. Responses were transcribed by the principal investigator. All responses were read to get a sense of the data and then were put into categories using qualitative content analysis ( Leedy & Ormrod, 2005; Morgan, 1993 ). Categories were determined by using actual participant responses, rather than a priori from the literature. Each response was placed into only one category. The category assignment of the data was examined by a 2nd investigator, and March/April 2006 JOGNN 167

agreement was reached on both the types of categories and the placement of individual responses within those categories. Results The sample consisted of 399 women with a modal age category of 27 to 30 (range 18-44) years. Occasionally, a woman omitted a response to the demographic questions, so some percentages are based on slightly fewer than 399. Nearly three quarters (74.1%, n = 292) of the sample were white, 20.3% ( n = 80) African American, and 5.5% ( n = 22) some other minority. Sixteen percent ( n = 63) of the sample had high school or less as their highest level of education, 32.6% ( n = 128) had some college, and 51.4% ( n = 202) were college graduates. Nearly three quarters (71.8%; n = 283) of the women delivered vaginally, 28.2% ( n = 111) by cesarean. Although all were 1st-time breastfeeders, 12.4% were not 1st-time mothers (para II = 49; para III = 11; para IV = 5; para V = 1). Slightly less than half of the women (48.1%; n = 179) 1st fed their newborns within 1 hour after delivery, and 51.8% ( n = 193) later. We were able to reach 379 breastfeeding women at 8 weeks postpartum (95%) to assess breastfeeding status. These 379 women will be the focus of the remainder of the results. Of those, 256 (67.5%) were still breastfeeding, though 93 of those still breastfeeding (36.3%) were supplementing the breastfeeding with formula. Ninety-two percent ( n = 350) of the women reported having help with breastfeeding in the hospital. Many women reported more than one source of help in the hospital. The great majority of those receiving help in the hospital (79.4%; n = 278) reported being helped by lactation consultants, and 58.2% ( n = 204) reported receiving help from nurses or nursing students. A small number (0.02%; n = 7) reported receiving help in the hospital from family members. This situation changed once the women returned home with their infants. Only 54.8% ( n = 208) of the women reported receiving help with breastfeeding once discharged from the hospital. Of the women identifying the source of their help at home, the majority ( n = 167; 80.2%) reported receiving the help from lactation consultants either via phone calls (initiated by the woman or the lactation consultant) or via visits (hospital visits or home visits). Family and home-care nurses were the next most frequent sources of home help ( n = 21 and 20, respectively). Also cited as sources of breastfeeding help at home were physicians ( n = 13), hospital classes and Special Supplemental Nutrition Program for Women, Infants & Children ( n = 5 for each), calls back to the hospital ( n = 3), and La Leche League ( n = 2). When the women were asked how they got answers to their questions about breastfeeding after returning home, many reported multiple sources of information. Sources of information were sometimes, but not always, those the women reported as being sources of help in the earlier question. The most commonly reported source of information was books and other written materials ( n = 95). Family and friends were frequently consulted with breastfeeding questions ( n = 76), as were lactation consultants ( n = 33) and nurses who were in clinics or physician s offices or who visited the home ( n = 30). Other sources of information mentioned included classes ( n = 18), physicians ( n = 16), the hospital where delivery occurred ( n = 16), La Leche League ( n = 4), and online resources ( n = 3). Almost all women received help with breastfeeding in the hospital, but only slightly more than half received help after returning home. Of the 121 women who had stopped breastfeeding by 8 weeks postpartum (31.9% of those who had initiated breastfeeding), 20 (16.5%) had stopped by the end of the 1st week postpartum, and another 22 (18.1%) had stopped by the end of the 2nd week postpartum ( Figure 1 ). Women who had stopped breastfeeding by the time of the 8-week postpartum call were asked why did they stop ( Table 1 ). The largest number ( n = 42) cited insufficient milk supply as the reason. They said things like, I wasn t making enough milk and I couldn t satisfy him. The 2nd most common reason for early weaning ( n = 30) was painful nipples or latch problems. These two issues were combined into one category because poor latch is a common cause of sore nipples, and many of the women combined them into one reason when describing why they stopped breastfeeding early. Some of the women reporting this said that the baby never really latched on well from the time of birth. Number of Women 25 20 15 10 5 0 1 2 3 4 Stopped 5 FIGURE 1 Pattern of Breastfeeding Cessation ( n = 121) 6 7 168 JOGNN Volume 35, Number 2

TABLE 1 Reasons for Stopping Breastfeeding Before 8 s Postpartum ( N = 121) Reason Number of Women (%) Insufficient milk supply 42 (34.7) Painful nipples/latch problems 30 (24.7) Personal reasons 19 (15.7) Returning to work/school 16 (13.2) Drugs/illness of mom or baby 15 (12.3) Note. Percentages do not add up to 100 because one woman cited more than one reason for stopping. In 19 women, personal reasons precipitated breastfeeding cessation. They said things like, I didn t like being wet all the time I was self-conscious, People gave me too much advice; I didn t feel comfortable, and It was too much trouble I couldn t go anywhere. Medications taken by the mother or illnesses of self or infant were cited as the reason for weaning by 15 women. It was not clear if the women decided themselves to wean due to the medications or illnesses, or if they were advised to wean by someone else. Medications mentioned included antibiotics and oral contraceptives; illnesses ranged from reflux in the infant to hospitalization for surgery or postpartum complications for the mother. Four of these women specified that they stopped breastfeeding due to mastitis. Sixteen women reported weaning earlier than they had expected to because they returned to work or school. Some of these women reported that they had no place to pump; others reported difficulty maintaining an adequate milk supply. Discussion The vast majority of this sample (92%) received assistance with breastfeeding in the hospital. Most other studies have not specifically asked about quantity and type of help with breastfeeding in the hospital. Most women received help from lactation consultants and nurses, which illustrates the tremendous importance of these key personnel in getting breastfeeding off to a good start, particularly with 1st-time breastfeeders, who have no personal experience on which to rely. Only 54.8% of women in this sample reported help of any kind while at home. Since the early postpartum period has been documented as one of the peak times for breastfeeding cessation ( Ertem et al., 2001; Matthews et al., 1998 ), this may be the time when help is most needed. In this study, 16.5% of the women stopped during the 1st week postpartum, and even more women stopped during the 2nd week ( Figure 1 ). Typically, pediatricians see their breastfeeding newborns for the 1st checkup at 1 week of life, and the timing of breastfeeding cessation seen in this and other studies suggests that a 1-week postpartum visit for well-child care is too late to intervene for many breastfeeding mothers (Ertem et al., p. 546). Of the women who reported receiving help while at home, most (80.2%) received it from lactation consultants, which illustrates the importance of having these resources available to mothers after discharge. Family was reported as a very small source of help in the hospital (0.02% of women), but this changed after hospital discharge, when 9% of women reported receiving help from family. In some studies, family members have been found to be supportive ( Evans et al., 2004 ) and in other studies found to be discouraging of breastfeeding, particularly if breastfeeding problems arise or the baby seems hungry ( Bentley, Dee, & Jensen, 2003 ). Family members were also cited by women in this study as sources of information about breastfeeding. When asked about other ways they got information about breastfeeding, written materials was the most common response. Often, women are aware of the benefits of breastfeeding prior to delivery but are not as aware of correct practices of breastfeeding, and written materials can be helpful in this way to provide correct information ( Ertem et al., 2001 ) that is easily accessible. Interestingly, very few women reported the Internet as a source of information about breastfeeding. Given the prevalence of websites offering good information about breastfeeding (e.g., www. breastfeeding.com, www.lalecheleague.org ), this is surprising. Reasons these women reported stopping breastfeeding prior to 8 weeks were similar to those found in other studies. Perception of insufficient milk supply was the most common reason and has been cited elsewhere as a major reason for premature weaning ( Ertem et al., 2001; Hill, 1991; Isabella & Isabella, 1994; Kirkland & Fein, 2003; Lawson & Tulloch, 1995; Lowe, 1994; Matthews et al., 1998; Quinn et al., 1997 ). Formula supplementation is often begun prior to breastfeeding cessation if inadequate milk supply is a concern, and 37% of the women who were still breastfeeding at 8 weeks reported supplementing. Formula supplementation has been shown to decrease breastfeeding duration (Lawson & Tulloch; Vallenas & Savage, 1998 ). Nearly 25% of women in this study reported painful nipples and latch problems as the primary reason for early weaning. Painful nipples are reported in other studies as a reason why women stop breastfeeding ( Kirkland & Fein, 2003; Lawson & Tulloch, 1995 ) but usually are not the most important reason. Especially with 1st-time breastfeeders, as all the women in this study were, it is important for nurses to assist mothers in achieving good latch-on. An ideal time for this to occur is at the 1st feeding immediately after birth, when newborns are usually awake and alert. In this study, more than half of the women (51.8%) reported that the 1st feeding occurred more than 1 hour after birth, which may have meant the newborns were less alert and able to latch optimally. March/April 2006 JOGNN 169

Returning to work is a common reason women give for stopping breastfeeding ( Hauck, 2000; Kirkland & Fein, 2003; Quinn et al., 1997 ), and in this study, this was the case for 13.2% of the women. These women had all intended to breastfeed for 8 weeks, so it is unclear that if their plans for breastfeeding once back at work were not successful or if they had to return to work earlier than planned. Drugs prescribed for the mother and illness of the mother or the baby was a reason for early weaning in 12.3% of this sample. This is infrequently mentioned in other studies as a reason for stopping breastfeeding. Sometimes drugs are prescribed for the mother for reasons unrelated to reproduction, such as for acute or chronic illnesses or diagnostic tests, and health care personnel caring for the women may not have current informa - tion about which drugs are compatible with lactation ( Crenshaw, 2005 ) and may recommend stopping lactation or supplementing with formula, which may contribute to decreased milk supply. Nursing Implications The most common reason for early weaning reported in this study, perception of insufficient milk supply, is clearly amenable to nursing intervention. Breastfeeding classes prior to delivery often focus on the benefits of breastfeeding and getting started, but many women need additional information after delivery in order to tell if their babies are getting enough milk from the breast. In Western culture, we often are accustomed to relying on numbers (as in ounces gone from a bottle) rather than physical signs that our babies are receiving enough nutrition. Nurses could provide information about physical signs that the baby is receiving enough milk during the inpatient stay, as part of discharge teaching (orally and using literature) and in follow-up calls, which are common in many hospitals. Literature supplementing oral teaching should be given, so women have something to which to refer when concerns arise. When providing information in writing, care must be taken that the information is simple to read and understand ( Kaufman et al., 2001 ). The primary reasons for early cessation of breastfeeding are amenable to nursing intervention and should be addressed in the hospital and during postdischarge follow-up. Nurses and lactation consultants should take the opportunity to observe feedings while the woman is hospitalized rather than waiting for the woman to ask for help. This can be a challenge with short staffing, but it is essential to identify ineffective breastfeeding patterns prior to the woman s discharge from the hospital. Painful nipples can develop for the 1st time after hospital discharge, and follow-up phone calls, which are routinely made by many hospitals, should specifically assess for this and provide information about ways to relieve pain and assess for the cause of the pain. A key intervention to decrease sore nipples is assuring proper infant latch-on at the breast ( Tait, 2000 ). Additionally, a variety of therapies are used for sore nipples, including air drying, breast shells, application of compresses using warm, wet tea bags or simple water compresses ( Lavergne, 1997 ), application of expressed breast milk to the nipples, or various creams such as lanolin or A & D ointment ( Bell & Rawlings, 1998 ). Returning to work or school is a reality for many women today. Nurses can help breastfeeding women become aware of how to pump, maintain a milk supply, and make plans for infant feedings while they are at work. For some women, working and breastfeeding may be too stressful, but many women can maintain lactation even while working, if given sufficient information and support. Specific interventions such as nursing more frequently while at home, maintaining good hydration status, proper methods for storing breast milk, and suggested pumping frequency are all important to discuss with the woman before she returns to work. Helping women obtain breast pumps and learn to use them effectively can also increase breastfeeding duration after returning to work. Support from the workplace, including private, clean pumping locations, and regular breaks during which pumping can occur are essential to encourage long-term breastfeeding ( Hauck, 2000 ). Medications and illness may be unavoidable reasons for stopping breastfeeding prematurely, but with pumping, breastfeeding may be maintained even in these situations. Additionally, if consultation about drugs that are compatible with breastfeeding is readily available to women and their health care providers, therapy that does not interrupt breastfeeding could be provided ( Crenshaw, 2005 ). This information could be obtained from health care professionals, books, or online resources. There will always be women who decide to stop breastfeeding for personal reasons, and those decisions must be respected. However, if all women had a resource to which they could turn if breastfeeding was not going well, perhaps even some of these reasons could be overcome and breastfeeding continued. There is a great need for nursing research in the area of breastfeeding duration. Studies have consistently shown that insufficient milk supply, difficulties with the mechanics of breastfeeding such as latch, and the need to return to work are barriers to continued breastfeeding. Future 170 JOGNN Volume 35, Number 2

research should focus on cost-effective interventions to assist women with common breastfeeding problems that can lead to early weaning. These interventions could be individual-based focusing on how to assess and increase milk supply and achieve a proper latch, institution-based focusing on professional or peer support offered to patients after discharge, or policy-based focusing on improving pumping and storage facilities at workplaces in the community. Limitations of the Study Since this study used a convenience sample, generalizations to other populations cannot be made. The study population was mostly well educated, so the results may not reflect the experiences of women who are not as well educated. Although all women were breastfeeding for the 1st time, 66 were not 1st-time mothers. Experience caring for a previous child may have influenced how these women reacted to breastfeeding. Additionally, the hospitals in which women for this study were recruited had strong lactation consultant support, and this may have affected the results. Conclusion Nurses and lactation consultants are seen by women as major sources of support and information both in the hospital and at home. We need to take this role very seriously and use every opportunity to assess women s breastfeeding progress and provide information about successful breastfeeding techniques. Additionally, staff nurses and lactation consultants in the same facility should work together to make sure that consistent messages are being delivered to breastfeeding women. Since women also look to written resources for information, nurses and lactation consultants should become aware of resources available at bookstores as well as in the hospital, so that the best sources can be recommended to women. Additionally, the role of family in home breastfeeding support cannot be overlooked. Family members should be included in prenatal and postnatal education, and the family members whom nurses and lactation consultants encounter in patient care should be encouraged to ask questions, so that they can have correct and current information to offer to the breastfeeding woman. Acknowledgment Partially funded by a Ruth P. Council grant from Gamma Zeta chapter, Sigma Theta Tau International. REFERENCES Bastable, S. B. ( 2003 ). Literacy in the adult patient population. In S. B. Bastable ( Ed.), Nurse as educator: Principles of teaching and learning for nursing practice ( 2nd ed., pp. 189-231 ). Boston : Jones & Bartlett. Bell, K. K., & Rawlings, N. L. ( 1998 ). Promoting breast-feeding by managing common lactation problems. Nurse Practitioner, 23, 102-123. Bentley, M. E., Dee, D. L., & Jensen, J. L. ( 2003 ). Breastfeeding among low income, African-American women: Power, beliefs and decision making. Journal of Nutrition, 133, 305S - 309S. Blyth, R., Creedy, D. K., Dennis, C.- L., Moyle, W., Pratt, J., & DeVries, S. M. ( 2002 ). Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory. Birth, 29, 278-284. Centers for Disease Control and Prevention, Department of Health and Human Services. ( 2003 ). 2003 National Immunization Survey. Retrieved March 18, 2005, from http://www.cdc.gov/breastfeeding/nis_data/index.htm Child and Adolescent Health and Development. ( 2000-2002 ). Nutrition: Infant and young child. World Health Organization. Retrieved June 9, 2004, from http://www.who.int/ child-adolescent-health/nutrition/infant_exclusive.htm Crenshaw, J. ( 2005 ). Breastfeeding in nonmaternity settings. American Journal of Nursing, 105, 40-51. Dennis, C. L. ( 2002 ). Breastfeeding initiation and duration: A 1990-2000 literature review. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 31, 12-32. Department of Health and Human Services. ( 2000 ). Healthy people 2010: Conference edition. Washington, DC : Author. Ertem, I. O., Votto, N., & Leventhal, J. M. ( 2001 ). The timing and predictors of the early termination of breastfeeding. Pediatrics, 107, 543-548. Evans, M. L., Dick, M. J., Lewallen, L. P., & Jeffrey, C. ( 2004 ). Modified breastfeeding attrition prediction tool: Prenatal and postpartum tests. Journal of Perinatal Education, 13, 1-8. Hauck, C. L. ( 2000 ). Breastfeeding and the workplace: A review of the literature. Mother Baby Journal, 5, 45-51. Hogan, S. E. ( 2001 ). Overcoming barriers to breastfeeding: Suggested breastfeeding promotion programs for communities in eastern Nova Scotia. Canadian Journal of Public Health, 92, 105-108. Hill, P. D. ( 1991 ). The enigma of insufficient milk supply. MCN. American Journal of Maternal Child Nursing, 16, 312-316. Isabella, P. H., & Isabella, R. A. ( 1994 ). Correlates of successful breastfeeding: A study of social and personal factors. Journal of Human Lactation, 10, 257-264. Kaufman, H., Skipper, B., Small, L., Terry, T., & Mcgrew, M. ( 2001 ). Effect of literacy on breast-feeding outcomes. Southern Medical Journal, 94, 293-296. Kirkland, V. L., & Fein, S. B. ( 2003 ). Characterizing reasons for breastfeeding cessation throughout the first year postpartum using the construct of thriving. Journal of Human Lactation, 19, 278-285. Lavergne, N. A. ( 1997 ). Does application of tea bags to sore nipples while breastfeeding provide effective relief? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26, 53-58. Lawson, K., & Tulloch, M. I. ( 1995 ). Breastfeeding duration: Prenatal intentions and postnatal practices. Journal of Advanced Nursing, 22, 841-849. March/April 2006 JOGNN 171

Leedy, P. D., & Ormrod, J. E. ( 2005 ). Practical research: Planning and design ( 8th ed.). Upper Saddle River, NJ : Pearson, Merrill, Prentice Hall. Lowe, T. ( 1994 ). Breastfeeding: What happens during the first 12 months? Australian Family Physician, 23, 204-208. Matthews, K., Webber, K., McKim, E., Banoub-Baddour, S., & Laryea, M. ( 1998 ). Maternal infant-feeding decisions: Reasons and influences. Canadian Journal of Nursing Research, 30, 177-198. McKeever, P., Stevens, B., Miller, K.- L., MacDonell, J. W., Gibbins, S., Guerriere, D., et al. ( 2002 ). Home versus hospital breastfeeding support for newborns: A randomized controlled trial. Birth, 29, 258-265. McLeod, D., Pullon, S., & Cookson, T. ( 2002 ). Factors influencing continuation of breastfeeding in a cohort of women. Journal of Human Lactation, 18, 335-343. Morgan, D. L. ( 1993 ). Qualitative content analysis: A guide to paths not taken. Qualitative Health Research, 3, 112-121. Quinn, A. O., Koepsell, D., & Haller, S. ( 1997 ). Breastfeeding incidence after early discharge and factors influencing breastfeeding cessation. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 26, 289-294. Tait, P. ( 2000 ). Nipple pain in breastfeeding women: Causes, treatment, and prevention strategies. Journal of Midwifery & Women s Health, 45, 212-215. Vallenas, C., & Savage, F. ( 1998 ). Evidence for the ten steps to Successful breastfeeding. Geneva, Switzerland : Division of Child Health and Development, World Health Organization. Retrieved September 6, 2004, from http://www. who.int/child-adolescent-health/new_publications/ NUTRITION/WHO_CHD_98.9.pdf Work Group on Breastfeeding, American Academy of Pediatrics. ( 1997 ). Breastfeeding and the use of human milk (RE9729). Pediatrics, 100, 1035-1039. Lynne Porter Lewallen, PhD, RN, is an assistant professor at School of Nursing in The University of North Carolina at Greensboro, NC. Margaret J. Dick, PhD, RN, is an associate professor at School of Nursing in The University of North Carolina at Greensboro, NC. Janet Flowers, MSN, RN, is a registered nurse at Catawba Valley Medical Center, Hickory, NC. Wanda Powell, MSN, RN, NNP, is a registered nurse at Frye Regional Medical Center, Hickory, NC. Kimberly Taylor Zickefoose, MSN, RN, is a registered nurse at North Lincoln High School and Carolinas Medical Center, Charlotte, NC. Yolanda G. Wall, MSN, RN, is a clinical instructor at School of Nursing in The University of North Carolina at Greensboro, NC. Zula M. Price, MSN, RN, is a clinical instructor at North Carolina A&T State University, Greensboro, NC. Address for Correspondence: Lynne Porter Lewallen, PhD, RN, Assistant Professor, School of Nursing, The University of North Carolina at Greensboro, Greensboro, NC 27402-6170. E-mail: lynne_lewallen@uncg.edu. 172 JOGNN Volume 35, Number 2