A total of 187 mothers consented to participate, of which 88 (47%) chose to stay in a CC. Of the 99 (53%) participants who chose to go home during their confinement period, a third of them employed confinement ladies to provide them confinement care at home while the remainder received their care from family members.
We were able to interview 77 (88%) participants from the CC group and 96 (97%) from the home group at one month post-partum. At 6 months, 68 (77%) from the CC group and 86 (87%) from the home group completed the interview. (See Figure 1)
Baseline characteristics
The maternal and infant baseline characteristics are presented in Table 1. The overall mean maternal age was 32.3 (SD 4.0) years with 54% having previous experience with breastfeeding and 57% delivering in a Baby Friendly Hospital Initiative (BFHI) accredited hospital. Most mothers had tertiary education and all had at least secondary school education, which reflects what is expected in Penang. The overall mean infant gestational age was 38.7 (SD 1) weeks and mean birth weight of 3149 (SD 322) g. There were no differences in the age, education background, delivery at a BFHI accredited hospital, mode of delivery; infant gestation and birth weight between the two groups. However, we found that significantly more primigravidas (53% CC vs 34% H, p = 0.01) and fewer mothers with prior breastfeeding experience going to CCs (44% CC vs 62% H, p = 0.01).
Table 1: Baseline characteristics of the mothers and infants (n = 187)
Characteristics
|
Place of confinement, n (%)
|
Confinement centre
(n = 88)
|
Home
(n = 99)
|
Age of mothers (years), mean (SD)
|
32 (4.3)
|
32 (3.3)
|
Received tertiary Education
|
70 (79.6)
|
80 (80.8)
|
Delivery in BFHI hospital
|
49 (55.7)
|
57 (57.6)
|
Primigravida*
|
47 (53.4)
|
34 (34.3)
|
Had previous breastfeeding experience*
|
39 (44.3)
|
62 (62.6)
|
Mode of delivery
Vaginal
Instrumental
Caesarean
|
41 (46.6)
15 (17.1)
32 (36.4)
|
51 (51.5)
16 (16.2)
32 (32.3)
|
Male infant
|
45 (51.1)
|
56 (56.6)
|
Gestational age at birth (weeks), mean (SD)
|
38.72 (1)
|
38.67 (1)
|
Infant’s birth weight (g), mean (SD)
|
3141.25 (303.6)
|
3156.07 (339.2)
|
* p value < 0.05
Breastfeeding practices at 1 month and 6 months
At 1-month post-partum, all the interviewed participants were still breastfeeding, except 2 mothers from the home group. There was no difference in the exclusive breastfeeding rates between the two groups (62% for CC and 56% for home, p = 0.36). Similarly, at 6 months, there was no difference in the exclusive breastfeeding rates between the two groups (37% for CC and 42% for home, p = 0.70). Simple logistic regression showed no association between exclusive breastfeeding rates and place of confinement at 1 month, OR 1.3 (95% CI 0.7, 2.4) or at 6 months, OR 0.8 (95% CI 0.4, 1.6). Multiple logistic regression adjusted for known clinically important confounders (education level, past breastfeeding experience, place of delivery, mode of delivery, spent more than 6 hours a day with baby, sleeping with baby at night, employment status at 6 months) also did not show that the CC or home was a factor affecting exclusive breastfeeding rates at 1 month (aOR 1.7 (95% CI 0.9, 3.3) and at 6 months (aOR 0.9 (95% CI 0.4, 1.7) or ‘any breastfeeding rates’ at 6 months (aOR 1.1 (95% CI 0.5, 2.2). We were unable to estimate the odd’s ratio for ‘any breastfeeding rates’ at 1 month because all except 2 participants from the home group were breastfeeding (see Table 2).
Table 2: Crude and adjusted ORs for breastfeeding at 1 and 6 months defined by place of confinement
|
Odd’s Ratio, OR (95% CI)
|
p value
|
Adjusted Odd’s Ratio, aOR (95% CI) a
|
p value
|
At 1 month
|
Exclusive breastfeeding
|
1.3 (0.7 - 2.4)
|
0.42
|
1.7 (0.9 - 3.3)
|
0.14
|
Any breastfeeding b
|
Not estimable
|
Not estimable
|
At 6 months
|
Exclusive breastfeeding
|
0.8 (0.4 - 1.6)
|
0.52
|
0.9 (0.4 - 1.7)
|
0.67
|
Any breastfeeding
|
1.0 (0.5 - 1.9)
|
0.99
|
1.1 (0.5 - 2.2)
|
0.82
|
a Adjusted for maternal education level, past breastfeeding experience, place of delivery, mode of delivery, spent more than 6 hours a day with baby, rooming-in at night, employment status at 6 months
b All mothers except 2 from the home group were practicing some form of breastfeeding
Among all participants who were still breastfeeding at 1 month (n = 171), 29% were breastfeeding directly from the breast, 49% only fed their infants with expressed breast milk (baby was never latched to breast) and 21% used a combination of both. Significantly more participants from CCs were only feeding expressed breast milk compared to those from home (62% vs 39%, p < 0.001) at 1 month (See Table 3).
Table 3: Methods of breastfeeding by place of confinement at 1 month
|
Confinement centre
n (%)
|
Home
n (%)
|
Expressed milk feeding only
|
48 (62)
|
37 (39)
|
Direct latch feeding only
|
9 (12)
|
41 (43)
|
Direct latch and expressed milk feeding
|
20 (26)
|
16 (17)
|
Stopped breastfeeding
|
0
|
2 (2)
|
Among participants who only fed expressed breast milk at 1 month, 41% of them stopped breastfeeding by 6 months compared with 35% of those who had included direct latching to their breastfeeding routine (p = 0.64). We explored reasons for not directly breastfeeding at 1 month. The main reason was the perception that direct breastfeeding was very time consuming and prevented them from resting properly (n = 28). Other reasons included having problems associated with latching (n = 22), the need to monitor baby’s milk intake (n = 14), and difficulty accessing their baby in the nursery or discouraged from directly latching their infants (n = 8). One mother did not want to place the baby near her breasts saying “I feel dirty because I haven’t had a shower for so long.”
Breastfeeding experience
Overall, 66% of the participants in the CC group reported that their centre was supportive of breastfeeding. When asked reasons for saying so, they cited one or more reasons which we categorised into the following: staff helped them overcome breastfeeding problems, mental support from staff, breastfeeding education given by staff (especially for mothers with no prior breastfeeding experience), availability of peer support from other mothers in the same centre. Of note, none of the participants stated that they perceived their centre to be supportive of breastfeeding because they had received encouragement to spend time with their infant or to breastfeed at night.
For both groups, we asked if they faced any hindrance to breastfeeding. Ten participants from the CC group reported that they did encounter one or more forms of hindrance which we categorized into the following: staff were not helpful with breastfeeding problems; staff encouraged formula feeding; mother was asked to pump less breast-milk because there was inadequate refrigerator storage space; family members against breastfeeding; inappropriate information given regarding breastfeeding such as the need to stop breastfeeding in a jaundiced baby or for diarrhea or skin rashes; or misconceptions such as “baby would be hungry without formula”, “breast milk will cause indigestion”, “breastfeeding was troublesome and would result in a clingy baby”. However, not being allowed to breastfeed at night was not cited as a perceived hinderance to breastfeeding. Interestingly, three of the participants who said they had some hindrance to breastfeeding had earlier considered their centres to be supportive of breastfeeding. On the other hand, 8 participants from the home group indicated that they had faced breastfeeding hindrance either because their family members or hired confinement lady did not support breastfeeding.
Sleeping arrangements during the confinement period
Despite 66% of CC participants reporting that their centre supported breastfeeding, only 57% reported that their CC allowed mothers to sleep with their babies. However, even among the 43 participants whose CCs allowed them to sleep with their babies, 38 participants said they chose not to do so. They would sleep in their own room (sometimes with a few other mothers in the same room) while their babies slept in a nursery. When we compared CC participants with participants at home, only 8% of CC participants actually slept with their babies while 69% of those from home did so (p < 0.001).
Only 73% of CC participants reported that they could access their babies at any time of the day or night, while the remaining 27% had some restrictions. In particular, 17 participants reported that their CC discouraged or disallowed breastfeeding at night. Other restrictions included designated times to be with or see their baby through a window in the nursery. We illustrated how much access a mother has to her baby if they did not room-in together in Table 4.
Table 4: Mother’s access to baby in the nursery (for participants who did not sleep with their babies, n = 71)
Description
|
n (%)
|
Baby could be brought out of the nursery at any time to be with mother. In addition, mothers could see their babies from outside of the nursery through a window, any time of the day or night.
|
51 (66)
|
Baby could be brought out of the nursery at any time to be with mother. Window for mothers to see their babies in the nursery only open for certain hours of the day.
|
8 (10)
|
Baby could be brought out of the nursery at any time to be with mother but unable to see baby while in the nursery.
|
2 (3)
|
Baby allowed out of the nursery during the day. No physical access to baby at night. However, mothers can see their babies through a window from outside of the nursery any time of the day or night.
|
5 (6)
|
Baby only allowed out of the nursery during the day. No physical access to baby at night. Window for mothers to see their babies in the nursery only open certain hours of the day.
|
3 (4)
|
Baby only allowed out of the nursery during the day. No physical access to baby at night. Unable to see baby from outside of the nursery.
|
2 (3)
|
Breastfeeding problems encountered and sources of help
Breastfeeding problems were experienced by 81% in the CC group and 76% in the home group. Among those with breastfeeding problems, significantly more participants in CCs (79%) compared with those at home (59%) encountered latching difficulties, breast engorgement, blocked ducts, mastitis, abscess and sore nipples (p = 0.03). However, there was no significant difference in the number of participants experiencing inadequate milk (n= 40 vs 33, p = 0.06). The number of participants who perceived that family members were the main source of hindrance to breastfeeding was also similar in both groups (n = 9 vs 8, p = 0.64).
Sources of help for breastfeeding problems were different for participants in CCs and home. Participants in CCs mainly sought help from centre staff (39%) and breastfeeding support groups (19%) while most home participants obtained help either from friends (17%) or healthcare professionals (20%). Only 7% of participants staying at home obtained help from family members. Of the 32 participants who hired a ‘confinement lady’, eight sought their assistance. For both groups, only 4% sought help from lactation consultants.