THE ASSOCIATION OF MATERNAL OVERWEIGHT AND OBESITY WITH

BREASTFEEDING DURATION

WENDY HAZEL ODDY, PHD, MPH, BAPPSCI, JIANGHONG LI, PHD, MSC, BA,
LINDA LANDSBOROUGH, BSC (NURSING), RN, RM, IBCLC, GARTH EDWARD KENDALL, PHD, MPH, RN,
SARAS HENDERSON, PHD, MED, RN, AND JILL DOWNIE, PHD, MSC, RN

Objective To determine whether maternal prepregnancy overweight or obesity has an independent effect on breastfeeding
duration.
Study design A prospective birth cohort study of 1803 live-born children and their mothers ascertained through antenatal
clinics at the major tertiary obstetric hospital in Perth, Australia, were followed until 3 years of age. Unconditional logistic, Cox
regression, and Kaplan Meier analyses were used to model the association between
maternal prepregnancy overweight and obesity and the duration of predominant or any
breastfeeding allowing for adjustment of confounders (infant factors: gender, birth
weight, gestational age, age solids introduced, and older siblings; maternal factors:
smoking, education, age, race, marital status, pregnancy and birth complications, cesar- From the Telethon Institute for Child
Health Research, Centre for Child Health
ean section, and socioeconomic status). Research, University of Western Australia,
Results Overweight and obese women were more likely to have discontinued breast- PO Box 855, West Perth, Perth, Western
Australia 6872, Australia, School of Public
feeding at any time before 6 months than normal weight women (P < .0005) following Health, Curtin University of Technology,
adjustment for potential confounders. GPO Box U1987, Perth, Western Australia
6845, Australia, South West Health Service,
Conclusion We have shown that prepregnancy body mass index is associated with Health, Department of Western Australia,
reduced breastfeeding duration, and that mothers who are overweight or obese before 4 Royal Street, East Perth, Western Aus-
tralia, Australia, School of Nursing and Mid-
pregnancy tend to breastfeed their infants for a shorter duration than normal weight wifery, Curtin University of Technology,
mothers independent of maternal socioeconomic and demographic characteristics. GPO Box U1987, Perth, Western Australia
(J Pediatr 2006;149:185-91) 6845, Australia.
W.H. Oddy is supported by a Population
Health Research Fellowship from the Na-
tional Health & Medical Research Council
besity is increasing worldwide among women in the reproductive ages.1-3

O Women who are obese have higher rates of amenorrhoea and infertility,4
higher risk of complications during pregnancy such as hypertension and
gestational diabetes, and delivery complications such as higher rates of cesarean
of Australia. The Raine Study is funded by
the National Health & Medical Research
Council of Australia, the Western Austra-
lian Health Promotion Foundation and the
Raine Study Foundation.
sections and prolonged delivery.3 In addition, their obesity may adversely affect the W.H. Oddy developed the hypothesis, un-
dertook statistical analyses, wrote the main
health of their child.5,6 Children of obese mothers have a higher risk for intrauterine drafts of the paper and is correspondent
fetal death, congenital abnormalities, head trauma, shoulder dystocia, fractures of the for this manuscript and requests for re-
clavicle,7 brachial plexus lesions, and increased risk of death within the first year of prints. J. Li contributed to writing of the
main draft, statistical analysis and result in-
life.8 Further, obese and overweight mothers breastfeed their infants less than normal terpretation. L. Landsborough was respon-
weight mothers.9 sible for the literature review and contrib-
uted to interpretation of the results. S.
Research on the determinants of breastfeeding demonstrates a negative association Henderson, G.E. Kendall, and J. Downie
between obesity and, to a lesser extent, overweight on the initiation and continuation of assisted with drafts of the manuscript and
breastfeeding.9-11 Three hypotheses have been proposed to explain this association. First, interpretation of the results.
Received for publication Sep 19, 2005; re-
obese women may have difficulties in initiating and maintaining breastfeeding because of turned for revision Feb 14, 2006; accepted
a different pattern of hormones compared with that of normal weight women.12,13 for publication Apr 4, 2006.
Second, the infants of obese and overweight women may have physical difficulty latching Reprint requests: Wendy Hazel Oddy,
PhD, MPH, BappSci, Telethon Institute for
on to the breast tissue.12 Third, the association between obesity, overweight, and breast- Child Health Research, PO Box 855, West
feeding is confounded by other factors that negatively affect the initiation and duration of Perth, Western Australia 6872, Australia.
E-mail: wendyo@ichr.uwa.edu.au.
breastfeeding, such as pregnancy and birth complications, cesarean section, poor self-
0022-3476/$ - see front matter
esteem and depression, and low socioeconomic status.14 Three major weaknesses of the
Copyright 2006 Mosby Inc. All rights
majority of previous studies include insufficient sample size, nonrandom sampling, and reserved.
lack of adjustment for a range of important covariates likely to confound the observed 10.1016/j.jpeds.2006.04.005

185
association between maternal obesity and duration of breastfeed-
ing.12,15 Also, the point at which maternal body mass index
(BMI) affects breastfeeding duration was not established.2
Our study aims to overcome these limitations by using
data from the Western Australian Pregnancy Cohort Study,16,17
which provides a sufficient sample size for analysis and data on a
wide range of potential confounding factors. Our primary hy-
pothesis was that maternal prepregnancy overweight and obesity
has independent effects on breastfeeding duration.
METHODS
Study Population
The Western Australian Pregnancy Cohort Study com-
menced in 198916 in which 2968 women were serially re-
cruited at or before the 18th week of gestation from the public
antenatal clinic at King Edward Memorial Hospital (KEMH)
and nearby private antenatal clinics in Perth, Western Aus-
tralia. Approximately 100 women per month were enrolled
for a total of 30 months commencing in May 1989 and
finishing in November 1991. The criteria for enrollment were
gestational age between 16 and 20 weeks, sufficient profi-
ciency in English to understand the implications of partici-
pation, an expectation to deliver at KEMH, and an intention
to remain in Western Australia so that follow-up of their
child through childhood would be possible. At the time of
enrollment, data were collected from mothers about their
general health, including prepregnancy weight, height, and
socioeconomic situation. By the end of the pregnancy phase,
2868 (97%) children remained available for follow-up at birth.
Data were collected on the infant birth and included gender,
gestational age, birth weight, and physiological and clinical
indicators of ill health.
Infant Feeding
Breastfeeding information was collected on the first,
second, and third year questionnaires regarding the duration
of breastfeeding in months. Mothers were asked Did you
breastfeed your baby? If they said no this was recorded as
never breastfed. If they said yes they were asked At what lege diploma/other types, professional and university degrees),
age did you stop breastfeeding? If the response was less than
1 month this was recorded as breastfed for more than never,
but less than 1 month. If the response was less than 2 months,
for example, these babies were considered breastfed for less
than 2 months.
Parents kept a diary card of their childs feeding history
prior to the year 1 and year 3 interviews. Duration of any
breastfeeding was defined as the age at which breastfeeding
stopped and was expressed as a continuous variable (in
months) and as binary variables (having breastfed for less than
2 months compared to having breastfed for 2 or more months,
less than 4 months compared to breastfed for 4 months or
more, less than 6 months compared to breastfed for 6 months
or more). Previous analyses show that these dichotomous
cut-points were the most statistically appropriate.17 Addition-
ally, duration of predominant breastfeeding was defined as the
186 Oddy et al
age at which other milk was introduced. The infants pre-
dominant source of nourishment was breast milk but the
infant may also have received water and water-based drinks,
fruit juice, vitamin drops, and medicines. Predominant
breastfeeding was expressed as a continuous variable (in
months) and as binary variables described above. The mean
age of introduction to solid foods was 4.35 months with a
standard deviation of 1.39 months. The age of solid food
introduction ( 4 months) was included in all analyses.
Body Mass Index
Information collected by 1 of 3 research midwives in-
cluded mothers height and prepregnancy weight.16 Height
was measured at the initial antenatal assessment before re-
cruitment and enrollment into the study and recorded in the
study antenatal notes. Height was confirmed by the midwives
who had standardized procedures for height measurement in
pregnant women, at the first study follow-up between 16 and
20 weeks gestation to the nearest 0.1 cm with a Harpenden
Stadiometer (Holtain Ltd, Crymych, Wales, UK), and re-
corded in the questionnaire. Prepregnancy weight of mothers
was reported at the first follow-up and was self-reported.
Prepregnancy BMI was calculated as weight (kg)/height (m)2.
In accordance with international definitions of over-
weight and obesity, overweight was operationally defined as a
BMI of at least 25 kg/m2 and obesity as a BMI of at least 30
kg/m2.18 Normal weight was defined as less than 25 kg/m2.
As a method of validation, prepregnancy BMI (mean 22.37
[SD 4.25]) was tested against BMI measured when the child
was 8 years of age (mean 25.95 [SD 5.75]) using Pearsons
correlations and both measures were highly correlated (R
0.806; P .0005; n 1338).
Measures of Potential Confounders
The potential confounders for the effect of maternal
prepregnancy overweight or obesity on the duration of pre-
dominant or any breastfeeding included the following mater-
nal factors: smoking in pregnancy (yes versus no), education
(did not complete secondary education, trade certificate/col-
age at time of the infant birth ( 20, 20-24, 25-29, 30-34,
and 35 and older), race (Aboriginal, Caucasian, and other),
marital status (married, never married/de facto, separated/
divorced/widowed), parity, pregnancy and birth complica-
tions (pregnancy problems: antepartum haemorrhage, diabe-
tes, preeclampsia, threatened abortion, and urinary tract
infection; birth problems: threatened preterm labor, fetal dis-
tress, traumatic delivery) as well as cesarean section (elective
or assisted). Pregnancy and birth complications were consid-
ered separately in analysis. A measure of the socioeconomic
status of the residential area where the family resided at the
time of data collection,19 analyzed as quantiles, was included
as a binary variable (Socioeconomic Index for Areas (SEIFA)
- postcode 25th centile compared to 25th centile). Infant
characteristics that were considered in analysis included ges-
tational age; birth weight and age solids were introduced.
The Journal of Pediatrics August 2006
 In addition, a measure of postpartum emotional distur-
bance, the baby blues, was included in the analysis.20 The
index of baby blues is a scale of postnatal feelings reported by
mothers while in hospital ranging from 0 to 16 and provides
a categorical variable (less than 3 baby blues responses com-
pared to 3 or more responses).
Statistical Analysis
Unconditional stepwise logistic regression analyses were
used to examine the independent impact of maternal over-
weight, obesity, and a combination of both on the binary
outcomes of breastfeeding, with adjustment for the infant and
maternal characteristics described above. Cox regression
modeling was used to establish the relative risk (hazard ratio)
of prepregnancy overweight and obesity on the age at which
breastfeeding ceased following adjustment for all confound-
ers. In addition, the duration of any breastfeeding was ana-
lyzed with prepregnancy overweight and obesity using Kaplan
Meier survival functions and the log rank statistic. Statistical
significance was defined at the 2-sided P .05 level. The final
data-set generated 99% power to detect an odds ratio of 2.0
and 95% power to detect an odds ratio of 1.5 for most
analyses. All analyses were undertaken using SPSS-PC v13
software (SPSS Inc., Chicago, IL).
Ethics Approval
Informed consent was obtained for follow-up of the
cohort from enrollment. The ethics committees of King Ed-
ward and Princess Margaret Hospitals approved the protocol
for the study.
RESULTS
Of 2868 live births, 2611 (91%) children were available
for follow-up at 3 years (13 children had since died, 124
children had been withdrawn, and 120 children [predomi-
nantly living overseas] were lost to follow-up). Complete data
for all analyses were available for 1803 (69% [1803/2611])
children. Selected sociodemographic, prenatal, and perinatal
characteristics of the Raine Study cohort at birth were com-
pared with those in our study children. Between nonpartici-
pants and participants the proportion of low birth weight
children differed significantly (13.8% versus 5.2%) as did the
proportion of children born before 37 weeks gestation (16.1%
versus 7.5%). There were more boys (52.5% versus 48.3%)
and mothers were more likely to be unmarried (87.6% versus
76.3%; P .0005), to have smoked in pregnancy (52.1%
versus 35.3%; P .0005), and to be in the lower socioeco-
nomic group (26.9% versus 19.6%; P .0005) but the pro-
portion born by cesarean section delivery did not differ (22.2
% versus 20.1%). While there is some evidence of differential
loss to follow-up, the 2 groups were very similar with regard
to most prenatal and perinatal characteristics.
Table I outlines the maternal and infant characteristics
of the 1803 participants in our study for whom complete data
were available. Of the mothers in the study, 9% never breast-
The Association Of Maternal Overweight And Obesity With Breastfeeding Duration
fed their infants, 26% stopped any breastfeeding by 2 months,
41% discontinued by 4 months, and 51% did so by 6 months.
Prior to pregnancy 18% of mothers were overweight or obese.
Overweight and obese mothers were more likely to stop
breastfeeding earlier than normal weight mothers. The study
population included 8% of mothers who gave birth at a
gestational age of less than 37 weeks (preterm), and 6% of
mothers were younger than 20 years of age at the time of their
infants birth. At some time during pregnancy 35% of mothers
smoked, 35% had pregnancy complications, 45% had birth
problems, and 20% of mothers had an elective (11.0%) or
assisted (9.0%) cesarean section. Pregnancy complication
prevalences included antepartum hemorrhage (7.7%) (pla-
centa previa [0.2%]; abruption [0.5%]; marginal bleed, lower
genital tract bleed, unclassified, postcoital [7.0%]), diabetes
(maybe [1.7%], yes [3.6%], gestational diabetes [1.9%]),
threatened abortion (6.4%), preeclampsia (23.0%), and uri-
nary tract infection (3.9%). Birth problem prevalences in-
cluded threatened preterm labor (2.7%), fetal distress (6.9%),
and birth trauma (37.0%).
Mothers who were overweight or obese compared to
normal weight women had significantly more pregnancy
problems (P .002), and cesarean sections (P .0005).
Obese women had more assisted and elective cesareans than
normal or overweight mothers (assisted 14.2% versus 8.7%; P
.061: elective 18.6% versus 10.5%; P .012). Overweight
or obese mothers compared with normal weight mothers were
more likely to be of lower socioeconomic status (P .002),
have fewer years of education (P .0005) and more older
children (P .0005), and have significantly more diabetes
and preeclampsia (diabetes 8.1% versus 2.6%; P .0005:
preeclampsia 33.7% versus 20.5%; P .0005) and less birth
trauma (32.2% versus 38.1%; P .044).
There was a higher incidence of the baby blues in
mothers who were overweight or obese before pregnancy,
which approached statistical significance (40% in the prepreg-
nancy overweight/ obese group versus 35% in the normal
weight group; P .136). Further, mothers with a baby
blues score compared to no blues were more likely to never
breastfeed (11.8% versus 6.8%; P .001) or stop breastfeed-
ing before 2 months (31% versus 23%; P .0005) or 4
months (44% versus 38%; P .037). Mothers with urinary
tract infections (P .001) and preeclampsia (P .033)
breastfed for a shorter duration at all time points. Mothers
with large for gestational age (LGA) or macrosomic babies
at birth (4000 g) initiated breastfeeding slightly less than
mothers with babies with a birthweight of 4000 g or under
(90.2% versus 91.2%; P .585). At 6 months the macrosomic
babies were breastfed for a shorter time than smaller babies
but this was not significant (47% versus 49.1%; P .640).
There was a reduced incidence of breastfeeding initia-
tion in the overweight and obese groups, which approached
statistical significance in unadjusted analysis (P .057). Ma-
ternal prepregnancy overweight or obesity was a significant
predictor of the duration of predominant or any breastfeeding
(P .0005) and women with obesity were more likely to have
187
Table I. Characteristics of the cohort*
Normal Pearson chi-square
Maternal weight category Total weight Overweight Obese (P value)
% (N)
100.0 (1803) 82.0 (1479) 11.7 (211) 6.3 (113)
Outcome variables
Never Breastfed 8.9 (160) 8.2 (122) 11.4 (24) 12.4 (14) ns
Breastfeeding 2 mo 26.2 (473) 24.0 (355) 33.6 (71) 41.6 (47) .0005
Breastfeeding 4 mo 40.5 (731) 37.9 (560) 50.2 (106) 57.5 (65) .0005
Breastfeeding 6 mo 51.1 (922) 49.0 (725) 59.7 (126) 62.8 (71) .001
Potential confounders
Gender (male) 52.5 (947) 52.5 (776) 54.0 (114) 50.4 (57) ns
Gestational age (37 wks) 7.5 (135) 7.0 (103) 12.3 (26) 5.3 (6) .014
Birth-weight 2500 g 94.8 (1709) 94.9 (1403) 93.4 (197) 96.5 (109) ns
2500 g 5.2 (94) 5.2 (76) 6.7 (14) 3.5 (4) ns
Any older siblings at birth 50.0 (901) 47.8 (707) 58.8 (124) 61.9 (70) .0005
Solids introduced before 4 mo 21.2 (378) 21.0 (307) 21.4 (45) 23.4 (26) ns
Lowest 25th centile SEIFA 19.6 (354) 18.3 (271) 22.7 (48) 31.0 (35) .002
Birth problems 44.5 (802) 45.0 (666) 39.8 (84) 46.0 (52) ns
Pregnancy problems 35.1 (633) 33.5 (495) 43.1 (91) 41.6 (47) .007
Elective or emergency caesarean 20.1 (362) 18.5 (273) 24.6 (52) 32.7 (37) .0005
Maternal age at birth (20 y) 6.2 (111) 6.3 (93) 4.7 (10) 7.1 (8) ns
Maternal race
Caucasian 85.9 (1549) 85.4 (1263) 86.7 (183) 91.2 (103) ns
Aboriginal 2.1 (38) 2.0 (30) 1.9 (4) 3.5 (4) ns
Other (usually Asian) 11.4 (216) 12.6 (186) 11.4 (24) 5.3 (6) ns
Maternal education ( year 12) 39.8 (717) 41.6 (616) 35.1 (74) 23.9 (27) .0005
Maternal marital status
Never married 9.5 (171) 9.3 (137) 7.6 (16) 15.9 (18) .035
Married 71.9 (1297) 71.3 (1055) 76.8 (162) 70.8 (80) ns
De facto 15.7 (283) 16.6 (245) 11.4 (24) 12.4 (14) ns
Separated/divorced/widowed 2.9 (52) 2.8 (42) 4.3 (9) 0.9 (1) ns
Maternal smoking in pregnancy 35.3 (637) 35.6 (527) 34.6 (73) 32.7 (37) ns
*Available for follow-up from birth N 2868 - N Given 1803 where all variables in all multivariate analyses are available
Body mass index (BMI) kg/m2; 25 normal weight; 2529.9 overweight; 30 obese.
The question asked was At what age did you stop breastfeeding? (months) and the results given are cumulative. Each level of breastfeeding is compared with all later times.
Socio-Economic Index for Area.

discontinued any breastfeeding at any time before 6 months
following birth compared with normal weight women (Table
II). The same pattern held true for overweight women, al-
though to a lesser degree. When combined, both overweight
and obese mothers were more likely to have stopped breast-
feeding at any time before 6 months than normal weight
women. The results for predominant breastfeeding were not
different compared to any breastfeeding; therefore, the results
for the association of maternal overweight and obesity with
any breastfeeding are given.
Table II also presents the results from stepwise logistic
analysis that adjusted for all possible confounding factors. The
association between prepregnancy overweight and obesity
with breastfeeding duration was strengthened following ad-
justment for these factors, although the association with ini-
tiation (never breastfed) was weakened. Overweight mothers
were more likely to discontinue breastfeeding before 2 months
than normal weight mothers, as were obese women. Overall,
the results suggest that women with overweight and obesity as
a group were more likely to discontinue breastfeeding at any
time before 6 months following birth than women of normal
weight, following adjustment for confounders. Several of
these confounding variables were significantly associated with
an earlier cessation of breastfeeding. These included maternal
smoking during pregnancy (P .0005), maternal education
(P .0005), maternal age (P .001), and age solids were
introduced (P .0005). Less strongly associated with the
duration of breastfeeding was the protective association with
presence of older siblings (P .001).
In a Cox regression model (Table III), adjusting for the
identified confounding variables (maternal education, mater-
nal age, pregnancy problems, older siblings at birth, smoking
during pregnancy, and solids introduced before 4 months),
maternal overweight and obesity (as a dichotomous variable
compared with normal weight mothers) remained a signifi-
cant risk factor for the cessation of any breastfeeding (odds
ratio [OR] 1.18; 95% confidence interval [CI] 1.05, 1.34; P
.007). The interpretation of this finding is that those women
who were overweight or obese compared with normal weight
women had an 18% increased risk of stopping breastfeeding

188 Oddy et al The Journal of Pediatrics August 2006

Table II. The association of breastfeeding duration and prepregnancy maternal overweight and obesity in
unadjusted and adjusted analyses
Unadjusted
Never breastfed* Breastfed <2 mo Breastfed <4 months Breastfed <6 months
Odds Ratio 95% Confidence Limits P value
Overweight 1.19 1.37 1.37 1.31
0.811.74 1.061.78 1.071.75 1.021.69
.366 .017 .012 .033
Obese 1.56 1.98 1.97 1.68
0.971.50 1.412.78 1.402.77 1.182.38
.068 .0005 .0005 .004
Overweight or obese 1.36 1.65 1.63 1.48
0.001.86 1.322.05 1.322.01 1.201.83
.057 .0005 .0005 .0005
Adjusted
Overweight 1.30 1.52 1.62 1.53
0.822.07 1.11, 2.09 1.20, 2.18 1.13, 2.07
.270 .009 .001 .005
Obese 1.28 2.08 1.98 1.54
0.702.34 1.39, 3.12 1.32, 2.95 1.02, 2.32
.423 .0005 .001 .038
Overweight or obese 1.34 1.89 1.95 1.76
0.901.99 1.45, 2.47 1.51, 2.51 1.35, 2.28
.147 .0005 .0005 .0005
*For each level of breastfeeding outcome, the stated odds ratio contrasts the odds of being breastfed in infants exposed to maternal overweight or obesity compared with normal weight
mothers. 95% confidence limits and P values are beneath.
BMI weight/(kg)/(m); Overweight BMI 2529.9: Obese 30.
Adjusted for gender, gestational age birth weight of baby, and age solids introduced and maternal factors: smoking in pregnancy, education, age, parity, race, marital status, pregnancy
problems, birth problems, elective or emergency cesarean section, and SEIFA Index.

Table III. Relation between breastfeeding and prepregnancy overweight or obesity in a multivariate Cox
proportional hazards regression model
Outcome Breastfeeding per Reference Hazard ratio* 95% confidence P
month (n 1803) category (adjusted) limits value
Exposure
Prepregnancy overweight or obese Yes 1.18 1.05, 1.34 .007
Maternal education 12 y 0.77 0.69, 0.85 .0005
Maternal age 20 y 1.27 1.03, 1.56 .023
Pregnancy problems Yes 1.09 0.99, 1.20 .082
Older siblings at birth Yes 0.86 0.78, 0.95 .003
Smoking in pregnancy Yes 1.26 1.13, 1.39 .0005
Solids before 4 mo Yes 1.53 1.36, 1.72 .0005
*Each hazard ratio adjusted for the effect of all other exposures in the table.

with each additional month of breastfeeding duration. A
Kaplan Meier survival analysis (Figure 1) demonstrates that
mothers who were overweight or obese were more likely to
stop breastfeeding earlier than mothers who were of normal
weight (P .021).
DISCUSSION
We have shown that independent of maternal socio-
economic, demographic, and biomedical characteristics, ma-
ternal prepregnancy overweight and obesity reduces breast-
feeding duration at all time points up to 6 months following
birth.
The findings from our study agree with those of a
prospective Australian study that examined the perinatal ef-
fects of maternal BMI.21 Despite adjusting for the effects of
mothers age, occupation, and time of first breastfeed, the
findings from their study showed that higher maternal BMI
had a significant independent impact on breastfeeding cessa-
tion.
Dewey15 found that emergency cesarean section and

The Association Of Maternal Overweight And Obesity With Breastfeeding Duration 189

Figure. Kaplan Meier survival analysis for age when breastfeeding
stopped, stratified by prepregnancy weight group (overweight and obese
versus normal weight) (log rank statistic 5.37; df 1; P .021).
prolonged duration of labor were significantly associated with
delayed initiation of lactation with both factors more common
in overweight and obese women.14 In agreement with
Deweys study, we showed that overweight or obese mothers
were more likely to have emergency cesarean (elective and
assisted) than normal weight mothers (P .0005) and these
were more common in obese mothers.
In our study, we observed a reduced incidence of breast-
feeding initiation in overweight and obese women compared
with normal weight women, which approached statistical
significance (P .057). Overweight and obese mothers at-
tempted to breastfeed but were less successful in continuing
beyond the first weeks after birth. There is the possibility that
some overweight mothers made an effort to initiate breast-
feeding but were unsuccessful in the milk coming in. In fact,
there may be biological mechanisms that link maternal body
weight to breastfeeding duration. For example, a difference in
steroid hormones connected to lactation has been observed,12
and infants of women with a high BMI may have a high
demand for energy intake, are less satisfied with breast milk,
which in turn may lead to an early introduction of formula
milk. Further, babies of obese women may have physical
difficulty in latching on to the breast tissue or they may not be
able to grasp a large breast.12 One prospective study used the
mother-baby assessment tool developed by Mulford22 to as-
sess the babys sucking ability and attachment. This study
showed that sucking ability was not associated with breast-
feeding but that women who were obese had an increased
relative risk of discontinuing breastfeeding.
190 Oddy et al
Rasmussen and Kjolhede13 provided some insights into
possible biological mechanisms. They hypothesized that a
reduced prolactin response to suckling and a higher-than-
normal level of progesterone concentration in the first week
after delivery might compromise early lactation. These au-
thors showed that overweight and obese women had a lower
prolactin response to suckling at day 7, but the concentration
of progesterone did not differ between normal weight and
overweight or obese women at either time point. The finding
that overweight or obese mothers have a lower prolactin
response to suckling suggests a biological basis for the asso-
ciation between prepregnant overweight and obesity and
breastfeeding duration. Because this study was based on just
40 mothers of term infants, larger studies are required to
establish the evidence for biological mechanisms that link
maternal BMI and breastfeeding duration.
A strength of our study was the ability to systematically
adjust for the possible confounding factors identified in the
literature, which included parity, maternal race, marital status,
maternal education, maternal age, the socioeconomic status of
the area (where the mother lived when the baby was born),
obstetric and pregnancy complications, smoking during preg-
nancy, age solids were introduced, a measure of baby blues,
birth weight, and gestational age. By such detailed adjust-
ment, we have established the point at which the negative
impact of obesity and overweight on breastfeeding duration
occurs and further established the independent link between
maternal body weight and breastfeeding duration.
A limitation of our study was that approximately 19% of
women did not answer the questionnaires in relation to
breastfeeding and therefore these missing cases were excluded
from analysis. The nonresponse was significantly correlated
with maternal socioeconomic factors, such as no secondary
education and teenage or single motherhood (P .001).
These factors may have biased our estimated effects in either
direction. Since obesity is prevalent in low socioeconomic
groups, the nonresponse to the breastfeeding questions may
also be significantly correlated to maternal overweight and
obesity. In fact, more mothers in our study who were over-
weight or obese with education less than 12 years did stop
breastfeeding earlier at each time point (for example, by 2
months 27% of overweight or obese mothers had stopped
breastfeeding compared with 18% of normal weight mothers;
P .001). This result suggests a downward bias in the
unadjusted results. The association between maternal over-
weight and obesity and breastfeeding duration would have
been stronger if missing cases could be included but would
not have significantly affected the independent association
where maternal socioeconomic factors were taken into ac-
count.
Several factors strengthen the confidence in our find-
ings. First, this is a prospective birth cohort study thus pro-
viding precise data on antenatal factors such as smoking,
delivery mode, and birth and pregnancy complications. These
factors have been suggested as potential confounders that may
account for the association between prepregnancy overweight
The Journal of Pediatrics August 2006
and obesity and breastfeeding, but have not been comprehen-
sively examined in previous research. Second, our analysis was
based on data collected from a sufficiently large cohort of
women, and the response rate has been high in all subsequent
follow-ups. Thus even with nonresponse from years 1 to 3,
the sample size was sufficiently large and provided adequate
statistical power. Third, the breastfeeding data obtained from
the questionnaire were validated with the child health study
nurse by diary card and face-to-face interview. Finally, ma-
ternal BMI measured before birth was highly correlated with
a later measure of maternal BMI taken when the child was 8
years old thus confirming the consistency and accuracy of this
measure.18
Full acknowledgement is extended to all chief investigators and
staff of the West Australian Pregnancy Cohort Study and the
families who participated in the research project. The authors
gratefully acknowledge Professor Nicholas de Klerk for his statis-
tical advice.
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