Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation





First Advisor

Dr. Kristin Ashford

Second Advisor

Dr. Ana Maria Linares


Maternal-child health authorities recommend that infants breastfeed exclusively for the first six months of life. Currently, 25% of infants in the United States do so. Breastfeeding specific care that mothers receive from their postpartum nurses and lactation specialists is integral to successfully initiating exclusive breastfeeding. Due to the time sensitive nature of establishing milk supply, interrupting the process of lactogenesis with supplementation puts infants at high risk for early termination of breastfeeding. The purpose of this dissertation is to examine the relationship of breastfeeding care received during the postpartum hospital stay, defined as the first 48-72 hours of life, and breastfeeding exclusivity among term, healthy infants.

First, an integrated review of the literature was performed to identify aspects of the postpartum hospital experience and behavior of nurses that mothers perceive as helpful or not toward establishing exclusive breastfeeding. Mothers reported they perceived nurses were too busy to help with breastfeeding. When nurses did offer help, their advice was inconsistent between providers and not evidence based. Mothers also noted that providers were hesitant to offer encouragement for a mother’s decision to breastfeed, for fear of causing guilt should the mother experience difficulty. Additionally, special consideration is needed for breastfeeding mothers after cesarean birth.

Next, a secondary analysis of data was performed to identify if maternal perception of the hospital experience is a predictor of exclusive breastfeeding during the postpartum hospital stay. Data was retrieved from the control group of a two-part randomized, controlled trial of a breastfeeding education intervention. Forty-five participants were included in this analysis. The outcome of interest was exclusive breastfeeding at hospital discharge and at four weeks after birth. The hospital experience was measured using a survey titled “Every Step Counts”. This 16-question survey measured hospital adherence to the Ten Steps to Successful Breastfeeding, guidelines that promote breastfeeding exclusivity and duration. Rating the hospital experience with a score of 13 or greater was associated with an increased likelihood of breastfeeding exclusively at the time of discharge. The influence of the hospital experience on breastfeeding exclusivity did not remain at four weeks after birth.

Finally, a primary investigation was conducted to further examine the relationship between hospital care and exclusive breastfeeding. In this study, a different tool was used to measure breastfeeding care in the hospital. The “Questionnaire for the Breastfeeding Mother” from the hospital self-appraisal and monitoring guide developed by the Baby Friendly Hospital Initiative was distributed on the day of discharge. This study revealed that a higher score on the questionnaire was associated with an increased likelihood of breastfeeding exclusively at discharge. Whether or not a participant’s own mother breastfed was also a predictor of breastfeeding exclusivity at discharge.

In summary, quality breastfeeding specific care from nurses and lactation specialists is critical to helping women to establish breastfeeding exclusivity in the immediate postpartum period. Close adherence to the Ten Steps yields positive outcomes of breastfeeding exclusivity. Thus, hospitals could benefit from following the Ten Steps in order to continue the national trend of increasing breastfeeding exclusivity and duration.

Digital Object Identifier (DOI)

Funding Information

Robert Wood Johnson Foundation, 2017-2020