Infant-Feeding Intentions and Behaviors of Physician Mothers

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Title:
Infant-Feeding Intentions and Behaviors of Physician Mothers
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1 online resource (60 p.)
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english
Creator:
Sattari, Maryam
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University of Florida
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Gainesville, Fla.
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Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Medical Sciences, Clinical Investigation (IDP)
Committee Chair:
Limacher, Marian
Committee Members:
Beyth, Rebecca J

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Subjects / Keywords:
breastfeeding -- physicians
Clinical Investigation (IDP) -- Dissertations, Academic -- UF
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Medical Sciences thesis, M.S.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
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Abstract:
Background: The strongest predictor of a physician advocating for breastfeeding is her personal breastfeeding experience. Previous literature has shown that physician mothers have excellent breastfeeding initiation rates, but very low breastfeeding continuation rates. However, these studies have not investigated breastfeeding intentions of physician mothers. We conducted 2 cross-sectional, institutional studies of physician mothers to determine their infant feeding intentions, behavior, clinical breastfeeding advocacy, and predictors of their personal infant-feeding behavior. Methods: Data on 238 children were obtained from 130 physician mothers, 50 whose main affiliation was with Johns Hopkins University (Baltimore, MD), and 80 whose main affiliation was with University of Florida (Gainesville, FL). The R statistical software package (V.2.15.0; R Foundation for Statistical Computing, Vienna, Austria, 2012) was used to generate means, standard deviations and frequencies of all demographic variables in the data set, and to conduct univariate tests. To account for the clustering of observations on mothers, we used generalized estimating equations to evaluate potential predictors of breastfeeding duration. 10 Results: While physician mothers intended to breastfeed 56% of the infants for at least 12 months, and while 97% of infants were breastfed at birth, only 34% continued to receive breastmilk at 12 months. Physician mothers who reported actively promoting breastfeeding among their female patients had significantly longer personal breastfeeding duration compared with physician mothers who denied actively promoting breastfeeding (10 months versus 6 months, p = 0.001). Similarly, reporting active breastfeeding promotion among female housestaff was associated with longer personal breastfeeding duration (10 months versus 3 months, p Conclusion: Our findings emphasize the discrepancy between physician mothers' breastfeeding duration goal and their actual breastfeeding duration and highlight the association between their personal breastfeeding success and their own active breastfeeding advocacy. Furthermore, our results support the importance of work-related factors in breastfeeding maintenance among physician mothers and suggest that a tailored intervention, providing time and institutional encouragement, might result in significant extension of the duration of breastfeeding.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Maryam Sattari.
Thesis:
Thesis (M.S.)--University of Florida, 2013.
Local:
Adviser: Limacher, Marian.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-05-31

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Applicable rights reserved.
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lcc - LD1780 2013
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UFE0045455:00001


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1 INFANT FEEDING INTENTIONS AND BEHAVIORS OF PHYSICIAN MOTHERS By MARYAM SATTARI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIEN CE UNIVERSITY OF FLORIDA 2013

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2 2013 M aryam Sattari

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3 To my father mother, husband, daughters, sisters, and brother, who have always inspire d by example

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4 ACKNOWLEDGMENTS I thank my mentors Doctors Dav id Levine, Janet Serwint, Maureen Novak, Becca Beyth, and Marian Limacher for their patient and continuous support I thank Mr. Dan Neal and Ms. Amanda Bertram for their invaluable assistance with the statistical analysis. I thank Mrs. Eve Johnson for inv aluable assistance with manuscript preparation and editi ng.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 LIST OF FIGURES ................................ ................................ ................................ .......... 8 ABSTRACT ................................ ................................ ................................ ..................... 9 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 11 Current Infant Feeding Recommendations ................................ ............................. 11 Current Breastfeeding Rates and Goals ................................ ................................ 11 ................................ ............................ 12 2 METHODS ................................ ................................ ................................ .............. 14 Survey Instrument Development ................................ ................................ ............. 14 First Survey Instrument ................................ ................................ .................... 14 Second Survey Instrument ................................ ................................ ............... 15 Eligibility Criteria ................................ ................................ ................................ ..... 15 Recruitment ................................ ................................ ................................ ............ 16 Johns Hopkins University School of Medicine Study ................................ ........ 16 University of Florida College of Medicine Study ................................ ............... 17 Analysis ................................ ................................ ................................ .................. 17 3 RESULTS ................................ ................................ ................................ ............... 19 Characteristics of Mothers and Children in the Overall Study ................................ 19 Work Place Characteristics ................................ ................................ ..................... 19 Infant Feeding Intentions and Behavior ................................ ................................ .. 20 Breastfeeding Promotion and Advocacy ................................ ................................ 22 Predictors of Breastfeeding Duration ................................ ................................ ...... 24 Qualitative Data ................................ ................................ ................................ ...... 26 4 DISCUS SION AND CONCLUSION ................................ ................................ ........ 34 Feeding Intentions and Behavior ................................ ... 34 Work Site Predictors of Breastfeeding Durati on ................................ ..................... 34 Physician Mothers' Breastfeeding Advocacy ................................ .......................... 36 Limitations ................................ ................................ ................................ ............... 37 Directions for the Future ................................ ................................ ......................... 38 Conclusion ................................ ................................ ................................ .............. 39

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6 APPENDIX A JOHNS HOPKINS UNIVERSITY SURVEY INSTRUMENT ................................ .... 41 B UNIVERSITY OF FLORIDA SURVEY INSTRUMENT ................................ ............ 47 LIST OF REFERENCES ................................ ................................ ............................... 55 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 60

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7 LIST OF TABLES Table page 3 1 Maternal demographics ................................ ................................ ...................... 28 3 2 Specialties of physician mothers included in the study ................................ ....... 29 3 3 Duration of personal breastfeeding and breastfeeding advocacy ....................... 30 3 4 Significant predictor s of breastfeeding duration ................................ .................. 31

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8 LIST OF FIGURES Figure page 3 1 Breastfeeding (BF) and exclusive breastfeeding (EBF) rates of physician mothers ................................ ................................ ................................ .............. 33

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science INFANT FEEDING INTENTIONS AND BEHAVIO RS OF PHYSICIAN MOTHERS By MARYAM SATTARI May 2013 Chair: Marian Limacher Major: Medical Science Clinical and Translational Science Background: The strongest predictor of a physician advocating for breastfeeding is her personal breastfeeding experien ce. Previous literature has shown that physician mothers have excellent breastfeeding initiation rates, but very low breastfeeding continuation rates. However, these studies have not investigated breastfeeding intentions of physician mothers. We conduct ed 2 cross sectional, institutional studies of physician mothers to determine their infant feeding intentions, behavior, clinical breastfeeding advocacy, and predictors of their personal infant feeding behavior. Methods: Data on 238 children were obtaine d from 130 physician mothers, 50 whose main affiliation was with Johns Hopkins University (Baltimore, MD), and 80 whose main affiliation was with University of Florida (Gainesville, FL). The R statistical software package (V.2.15.0 ; R Foundation for Statis tical Computing, Vienna, Austria, 2012 ) was used to generate means, standard deviations and frequencies of all demographic variables in the data set, and to conduct univariate tests. To account for the clustering of observations on mothers, we used general ized estimating equations to evaluate potential predictors of breastfeeding duration.

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10 Results: While physician mothers intended to breastfeed 56% of the infants for at least 12 months and while 97% of infants were breastfed at birth, only 34% continued to receive breastmilk at 12 months. Physician mothers who reported actively promoting breastfeeding among their female patients had significantly longer personal breastfeeding duration compared with physician mothers who denied actively promoting breastfe eding (10 months versus 6 months, p = 0.001) Similarly, reporting active breastfeeding promotion among female housestaff was associated with longer personal breas tfeeding duration (10 months versus 3 months, p < 0.00 1 ). Duration of lactation among physi cian mothers correlated with the following work site factors: 1) length of maternity leave 2) not having to make up missed call/work that occurred as result of pregnancy or maternity leave, 3) perceived level of support of breastfeeding efforts at work fr om colleagues, program directors, and chiefs, and 4) sufficient time at work for milk expression. Conclusion: Our findings emphasize the discrepancy between physician mothers' breastfeeding duration goal and their actual breastfeeding duration and highlig ht the association between their personal breastfeeding success and their own active breastfeeding advocacy. Furthermore, our results support the importance of work related factors in breastfeeding maintenance among physician mothers and suggest that a tai lored intervention, providing time and institutional encouragement, might result in significant extension of the duration of breastfeeding

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11 CHAPTER 1 INTRODUCTION Current Infant Feeding Recommendations Many health organizations recommend exclusive breastf eeding for the first 6 months of life, followed by continued breastfeeding for the first year and beyond 1,2 Exclusive breastfeeding is defined as infant not receiving any nutrition except breastmilk (with the exception of vitamins and medications). These recommendations are based on extensive evidence of health benefits for both breastfed infants and breastfeeding mothers. 3 Breastfeeding has been shown to protect infants against necrotizing enterocolitis, otitis media, gastroenteritis, hospitalization for lower respiratory tract infections, atopic dermatitis, sudden infant death syndrome, type 1 diabetes mellitus, and childhood asthma, leukemia, and obesity 4 8 Maternal benefits include reduced risk of diabetes mellitus and malignancy of breast and ovaries 3 In fact, with obesity and diabetes rates increasing more than ever in the United States, breastfeeding may be considered a cornerstone of preventive medicine. Furthermore, breastfeeding benefits extend beyond the mother and child dyad and include envir onmental, economic and health care cost savings. 9 1 1 For example, some estimate that the United States c ould save $13 billion and prevent 911 deaths ( 95% of which would be of infants ) in one year if 90% of families could comply with medical recommendations to breastfeed exclusively for 6 months 9 Current Breastfeeding Rates and Goals C urrent breastfeeding rates in the United States are 7 6 .9 % at birth, 4 7.2 % at 6 months, and 2 5.5 % at 12 months. 12 Exclusive breastfeeding rates are 36.0% at 3 months and 16 .3% at 6 months. 12 Although breastfeeding rates have been increasing

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12 in the United States, rates of continuation and exclusive breastfeeding are still below desired levels. 1 2 13 The Healthy People 2020 (HP2020) o bjectives released by the U.S. Department of Health and Human Services, contain aims to increase breastfee ding rates to 82% ever breast fed, 61% for 6 months, and 34% for 12 months. 1 3 Goals regarding exclusive breastfeeding include increasing rates to 46 % at 3 months and 26% at 6 months. 1 3 Interventions targeted at exclusive breastfeeding and breastfeeding duration are needed in order to achieve the HP2020 goals for breastfeeding. Physician breastfeeding counseling is one of the interventions that succes sfully increase breastfeeding initiation and duration. 14 18 A strong predictor of physicians' breastfeeding advocacy is their successful personal or spousal breastfeeding experience. 1 9 22 These observations are consistent of counseling patients about preventive issues. 2 3,24 As such, strategies to enhance breastfeedin g in physician families are important, not only for their own breastfeeding success and health of their child, but this behavior may also affect how well they can serve as role models and information sources of breastfeeding for their patients. To date, ou r understanding of breastfeeding among physicians in the United States has been based on cross sectional questionnaire surveys administered to residents and/or practicing physicians. 2 5 2 8 Results of these studies suggest that while female physicians have e xcellent breastfeeding initiation rates, their continuation rates are lower than the general population. 26 29 Previous studies identified return to work, work schedule, diminishing

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13 milk supp ly, and lack of adequate time for milk expression as reasons for breastfeeding cessation among this population. 2 5 28 In fact, Miller et al reported that 50% of resident mothers who had initiated breastfeeding weaned around the time of returning to work fr om maternity leave at a mean of 7 weeks postpartum 2 5 Physician mothers who continued to breastfeed after return to work identified insufficient time and lack of appropriate place at work for milk expression as obstacles to breastfeeding continuation. 2 5 2 7 However, because of lack of data about breastfeeding intentions of surveyed mothers, definitive conclusions could not be made regarding whether the drop in physician mothers' breastfeeding rates after return to work resulted from their decision to wean ea rlier than recommended or whether it reflected the influence of workplace related factors that discouraged breastfeeding maintenance despite maternal intention to continue. The purpose of this cross sectional survey study was to determine (1) personal infa nt feeding intentions and behavior (2) clinical breastfeeding advocacy, and (3) predictors of personal infant feeding behavior among a convenience sample of physician mothers Based on results of previous studies, we hypothesized that physician mothers wo uld have excellent breastfeeding initiation rates and that they would be at risk of not maintaining desired breastfeeding practices because of personal and institutional factors.

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14 CHAPTER 2 METHODS Survey Instrument Development First Survey I nstrument Prev ious studies published on breastfeeding among physicians in the United States were reviewed, and questionnaires utilized for these investigations were requested. After review of published data and questionnaires that were made available areas pertaining t o breastfeeding among physicians were identified. 17 19 20, 22 2 5 Survey items and response scales were developed to assess those areas, including breastfeeding intentions. The questionnaire was piloted in 2008 amon g 20 i nternal M edicine and p ediatric research fellows and faculty at Johns Hopkins University School of Medicine (Baltimore, MD) to ensure clarity. The criteria for participation in the pilot tended by faculty members and research fellows in General Internal Medicine and Pediatrics during which the survey was piloted and (2) volunteering to participate. The survey was administered in an interview setting to all volunteers, regardless of their g ender, stage of career, having had biologic children, and infant feeding method. We sought feedback to improve the survey instrument and considered all suggestions, including those to improve clarity and readability. The questionnaire was revised based on suggestions of participants. Pilot participants were not included in the subsequent studies. The final instrument contained 4 8 items and took approximately 15 30 minutes to complete ( Appendix A ) Questions included demographic information and previous brea stfeeding education. Participants were asked a series of questions for each of their children, including current age, infant feeding intention, breastfeeding duration goal, whether or

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15 not the infant was ever breastfed, age at which the infant first receive d any nutrition other than breastmilk age at which the infant was weaned from breastmilk completely, as well as work related factors and other enablers and obstacles of breastfeeding. Second Survey Instrument Further survey items and response scales wer e developed in 2009 and incorporated into the questionnaire mainly to assess breastfeeding advocacy of participants. A new yes/no question was added to assess if breastfeeding was d to inquire whether a participant reported actively promoting breastfeeding among their female patients. For the purp oses of this study we have defined this as clinical breastfeeding advocacy. Workplace breastfeeding advocacy was defined as active prom otion of breastfeeding among female housestaff. To assess workplace breastfeeding advocacy, all participants were asked about active breastfeeding promotion among female housestaff. Participants who reported not actively promoting breastfeeding among pat ients or housestaff were then asked the reason(s) for not doing so. While they were given a choice of possible reasons for not actively advocating breastfeeding, such as lack of time or expertise, they also had the option of choosing ng their reasons. This modified instrument contained 5 4 items and took approximately 20 30 minutes to complete (Appendix B) Eligibility Criteria Criteria for participation included being a female physician (MD or DO) and having at least one biological child. Eligible participants were included whether they were in training (e.g., resident or fellow) or had completed training (e.g., faculty at academic site or community practice). Participants were included regardless of their

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16 infant feeding methods (f ormula, breastmilk, or combination). While recruitment efforts only focused on physicians affiliated with Johns Hopkins University School of Medicine (JHU) and University of Florida College of Medicine (Gainesville, FL) we included physicians not affilia ted with either institution if they contacted us to express interest in the study and were otherwise eligible to participate. All such physicians had spouses or friends who were affiliated with one of the study institution s and had forwarded the recruitme nt e mail to them. Recruitment The institutional review boards at J HU and University of Florida College of Medicine ( UF ) approved the protocols for th is study At both ins titutions, Maryam Sattari, the p rincipal i nvestigator (PI) initiated recruitment thro ugh a recruitment e mail that contained information about the study and contact information for the PI. Johns Hopkins University School of Medicine Study We sent the recruitment e mail once to the head of the Institution's Women's Task Force as well as r esidency program dir ectors affiliated with JHU, with a request for dissemination to their respective programs P hysicians interested in participating in the study were instructed to contact the PI. We intended to interview as many participant s as possibl e with the goal of completing all interviews in August 2009 the latest date the PI would be able to conduct the interviews in person. The PI set up interviews with potential study participants as they responded via e mail or telephone to express interest in the study. Every attempt was made to conduct all the interviews in person. However, when not possible to meet in person part icipants were also interviewed by tele phone (n=10) Eleven participant s completed

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17 the paper questionnaire and were then inte rviewed in person or by telephone to confirm and verify answers. The PI conducted all of the by phone and in person interviews University of Florida College of Medicine Study At UF the recruitment e mail was sent once in 2009 to residency and fellowship program directors and once in 2010 to The PI set up interviews with potential study participants as they responded to express interest in the study. All participants were interviewed in person between October 2009 and July 2011 by the PI. Analysis Study data were collected and managed using REDCap electronic data capture tools hosted at UF. 30 The primary outcomes were (1) personal infant feeding intentions (2) breastfeeding initiation and continuati on behavior, ( 3 ) exclusive breastfeeding rates (4) c linica l breastfeed ing advocacy, and (5) predictors of breastfeeding duration in our study sample. We used the R statistical software package for descriptive statistics, including means, standard deviati ons and frequencies of all demographic variables in the data set, and to conduct univariate tests. We used the infant as the unit of analysis for calculation of rates because breastfeeding prac tices of some multiparous participant s varied with different of fspring. All comparisons were performed at a 95% confidence level. We created a series of models, each with age of complete weaning or breastfeeding duration as the outcome variable. We transformed maternal specialty to a dichotomous variable by assigni ng it as surgical if associated mainly with procedures and labeled all other specialties as non surgical. We included the following variables as primary predictors: maternal age at the time of study stage of career at the time of

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18 study, number of biologi cal children, study location (JHU or UF) specialty (surgical or n onsurgical), marital status, breastfeeding education in medical school and residency, and birth year of child partner work s tatus, maternal work environment, maternal stage of career at the time of childbirth, breastfeeding duration goal, maternal reasons for decision to breastfeed, duration of maternity leave, duration of paid leave, maternity leave makeup, return to work, and reasons for return to work. In subsequent multivariate analysis, w e used a mixed linear model to determine which survey responses were signif icant predictors of breastfeeding duration when controlling for maternal demographics and taking into account th e clustering of observations on study location and mothers. We controlled for the covariates that were not significant predictors of breastfeeding duration (i.e. number of biological children, specialty (surgical or nonsurgi cal), marital status, medical school breast feeding education, residency breast feeding education and birth year of child; all p values>0.25). S tudy location and mother were considered random factors. We modeled the mother as a repeated factor, used an e xchangeable working covariance structure, and excluded subjects still being breastfed at the time of the study. We considered any variable with a p value less than 0.05 a significant predictor of duration of breastfeeding/age of weaning.

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19 CHAPTER 3 RESUL TS Characteristics of Mothers and Children in the Overall Study One hundred and thirty interviews were included in this analysis. Eighty participants (61.5%) were re cruited at UF or affiliated institutions and 50 (38.5%) at JHU or affiliated institutions (Table 3 1) the time of the study, with a mean age of 37.6 years (Table 3 1 ). Thirty seven (28.5%) were still in training, and 93 (71.5%) had completed training. Additional demographics are characteri zed in Table 3 1 Participants' specialties are described in Table 3 2 Eighty f ive (6 5.4 %) participants we re in non surgical fields and 45 (34 .6 %) in surgical fields. Only 21.5% ( n = 28) of parti cipants reported receiving breastfeeding education in medical school and fewer still (19.2%; n =25) in residency. The 130 p hysicians included in the study had a total of 238 children, ranging in age from 6 weeks to 28 years old. One hundred and sixty nine (71%) of the children were born in or after 2003, the year that the 80 hour work week was implemented, and 69 (29%) were bo rn before 2003 (19). Six of the children (3%) were born prior to the mother entering medical school, 16 (5%) during medical school, 62 (29%) during residency, 41 (15%) during fellowship, 104 (43%) after maternal completion of medical training, and 9 (5%) in other stages of maternal career. Work Place Characteristics At the time of the study, two participant s had not returned to work (at 12 and 18 weeks postpartum ) While 15 (6.3%) participant s reported missing call as a result of pregnancy or maternity lea ve, 30 (12.6%) reported being required to make up missed call. Participant s reported returning to work as planned after 211 (88.7 %) births and

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20 returning full time in 194 (81.5%) cases Maternal full time return to employment postpartum occurred in 75 c ases ( 72% of faculty) while faculty, 40 ( 98% of fellow s ) during fellowship, 52 ( 84 % of residents) during residency, and 27 ( 87 %) in other stages of maternal career Participant s reported return to work was different than originally planned after 25 (10.5 %) childbirths. While r earlier than desired in 15 cases, one participant reported r eturn ing earlier due to maternal preference and two reported doing so secondary to financial reasons Seven participant s returned to wo rk later than expected four due to infant health and three due to maternal health. Participant s reported flexibility in their postpartum work schedule in 112 instances (47.1%), somewhat flexible schedules in 29 (12.2%) cases, and no flexibility in 94 (39 .5%) cases. Of the 62 participant s who experienced childbirth during residency, 18 (29%) reported flexibility in their work schedule postpartum, 11 (18%) reported some flexibility, and 33 (53%) no flexibility. Of 41 participant s who gave birth to a child during fellowship, 28 (68 .29 %) reported work schedule flexibility, 3 (7 .31 %) some flexibility, and 10 (24 .4%) no flexibility. Of 104 participant s who gave birth after completion of medical training, 56 ( 53.84 %) reported having flexibility in their postpa rtum schedule, 12 ( 11.54 %) some flexibility, and 36 ( 34.62 %) no flexibility. Infant Feeding Intentions and Behavior A ll 130 participant s reported planning to breastfeed after all 238 pregnancies. The two most frequent reasons cited for breastfeeding inten tion were infant health (98%; n= 226) and bonding (84%; n = 150). Other reasons for breastfeeding intention included maternal health, convenience and cost compared to formula, friends, family expectations (including spouse and mother), health care recomme ndations

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21 (pediatricians, obstetricians, official guidelines, and lactation consultants), breastfeeding being while working. In 215 pregnancies (90.3%), participant s expressed numerical goals for breastfeeding duration, ranging from one to 24 months, and in 134 cases (56.3%) planned to breastfeed for at least 12 mo nths. In 23 pregnancies, participant s either reported not having a goal regarding the length of breastfe eding or stated that they had hoped to breastfeed until return to work or as long as possible. Using the infants as the unit of analysis, breastfeeding initiation rate was 96.6%. Immediately after birth, 186 (78.2%) children were exclusively breastfed, 44 (18.5%) received a combination of breastmilk and formula, and eight (3.4%) received formula only. Participant s reported that three infants did not receive breastmilk secondary to maternal health another o ne with Group B strep infection and postpartum fever, and a third with Sheehan syndrome) two due to infant health reasons (jaundice and infant hyperbilirubinemia) and three because of lack of breastmilk. One hundred and forty two infants continued to rec eive breastmilk exclusively at 3 months and 59 at 6 months. Exclusive breastfeeding rates were 78.2%, 59.7%, and 24.8% at birth, 3 months, and 6 months ( Fig. 3 1 ). The mean duration of exclusive breastfeeding was 3.49 months (standard deviation of 2.43 a nd range of 0 13 months). The mean duration of breastfeeding was 9.91 months (standard deviation of 6.34 and range of 0 36). A total of 152 infants ( 63.9 %) continued to receive some breastmilk at 6 months, and 8 1 ( 34.0 %) at 12 months ( Fig. 3 1 ).

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22 Partici pant s continued to breastfeed 212 (89.1%) of the infants after return to work and reported expressing milk or breastfeeding at work in 2 02 (84.9%) cases. Thirty participant s were breastfeeding at the time of study. Breastfeeding Promotion and Advocacy Wo rk place breastfeeding advocacy was assessed at UF by a sking participant s whether they actively promoted breastfeeding among female houses taff. We considered a participant to demonstrate work place breastfeeding advocacy if they answered yes or provided e xampl es of their advocacy. Participant s who report ed advocating breastfeeding among housestaff had longer durations for personal breastfeeding ( 10.1 months vs 3.1 months) and exclusive breastfeeding ( 3.8 months vs. 1.7 ) compared to participant s who repor ted not advocating breastfeeding among housestaff (Table 3 3 ). Clinical breastfeeding advocacy was assessed by asking about breastfeeding promotion among pati ents. We considered a participant to have active clinical breastfeeding advocacy if she answere d yes or provided examples of breastfeeding advocacy among patients. Nine participant s reported that they did not have breastfeeding patients and were eliminated from this part of the analysis (Table 3 3 ). Participants who report ed clinical breastfeeding advocacy breastfed an average of 4 months longer than the participants who d id not actively promote breastfeeding among their patients (p<0.001). The main reasons for not wanting to advocate breastfeeding eing judgmental putting pressure on other mothers or participant s identified feeling pressure, guilt, or being judged when they had to start supplementation with formula or to completely terminate their brea stfeeding efforts.

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23 Using F maternal specialty (p=0.0154). Pediatricians, obstetricians, and family practitioners consistently reported active breastfeeding promotio n. Interestingly, parti cipant s in less obvious specialties, such as internal medicine, anesthesiology, psychiatry, and general surgery, reported actively promoting breastfeeding. For example, many internal medicine physicians reported discussing infant feeding choices with pati ents prior to pregnancy, in early pregnancy (before referral to obstetricians), and post partum, after female patients are released from their obstetricians. Anesthesiologists who report ed active promotion consider ed pharmacotherapy choices in their lactat ing patients and also educate d surgeon reported providing breast pumps for lactating patients admitted to her service. Psychiatrists reported discussing the safety of psychotropic agents wi th their lactating patients. Maternal goal for breastfeeding duration was also significantly associated with clinical (p<0.001) and work place (p<0.001) breastfe eding advocacy Participant s who reported that their breastfeeding cessation was work related were significantly less likely to report workplace breastfeeding advocacy (p=0.001), but not clinical breastfee ding advocacy (p=0.458). Participants who did not continue breastfeeding after return to work were significantly less likely to report clinical breastfeeding advocacy (p=0.031) and workplace breastfeeding advocacy (p<0.001). We did not find an association between participant maternal age at the time of study marital status, breastfeeding educa tion (medical school or residency), partner work status, perceived level of support at work

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24 environment during pregnancy, length of maternity leave, duration of paid leave, maternity leave type, work schedule flexibility, breastfeeding method at birth, mat ernal mental health postpartum, maternal energy level postpartum, maternal stress level postpartum, satisfaction with personal breastfeeding duration, availability of time or place at work for milk expression, or workplace support for breastfeeding efforts Predictors of Breastfeeding Duration None of the maternal demographic variables were significant predictors of breastfeeding duration. However, a number of factors were significantly associated with breastfeeding duration ( Table 3 4 ) Mothers were asked the reason for breastfeeding m other not interested in m other l ack of adequate milk t oo l ack m aternal i nfant i nfant not o ther breastfeeding cessation than those listed was associated with a 3.3 month increase in breastfeeding duration, four reasons for breastfeeding cessat ion had a negative associat ion with breastfeeding duration: infant health, lack of infant interest in breastfeeding, inadequate milk supply, and inadequate time for milk expression at work. Citing inadequate time as a reason for complete breastfeeding ces sation was associated with an average 2.9 month decrease in breastfeeding duration (p=0.013) Citing inadequate milk supply as reason for complete breastfeeding cessation was associated with an average 3.3 month decrease in breastfeeding duration (p=0.001 ). Participants who reported they encountered non support at work due to perceived special favors by their colleagues had an average 3.5 month decrease in breastfeeding

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25 duration compared to participants who did not report perception of perceived special fa v ors by their colleagues (p = 0.037). Potentially modifiable work site factors that were associated with breastfeeding duration consisted of (1) a requirement to make up missed work or call that occurred as a result of pregnancy or maternity leave, (2) d uration of maternity leave (3) availability of time at work to express milk or breastfeed and (4) support for her breastfeeding efforts at work from her colleagues and program director or chief. Not being required to make up work or call missed as a result of pregnancy or maternity leave was associated with a n average 3.6 month increase in breastfeeding duration (p = 0.016 ). Mean dura tion of breastfeeding for participant s who reported having to make up missed call or work was 8.0 months, compared to 10.1 months for participants who reported not having to make up missed call or work (p=0.043). A one week increase in total maternity leave (paid and unpaid) was associated with 0.14 month increase in breastfeeding duration ( r =0.16, p=0.022 ). To assess availability of time at work for milk expression, participant (e.g. occasionally compared to neve r) was associated with a 1.1 month increase in breastfeeding duratio n ( r=0.029, p <0.0001 ). Similarly, participant s were asked to rate the support that they felt they received for their breastfeeding efforts while working from colleagues, attending physic ians if appropriate, and pr ogram director or chief. Participant While attending support initial ly had a statistically significant association with

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26 breastfeeding duration (r = 0.17, p = 0.028), the correlation was no longer significant in the multivariate analysis. E ach unit increase in reported collegial support was associated with 1.3 month increa se in breastfeeding duration ( r = 0.19, p = 0.011 ) and each unit increase in reported support from chief or program director was associated with 1.1 month increase in breastfeeding duration (p=0.010) in the multivariate analysis Qualitative Data The one on one interaction with the survey participants allowed for collection of descriptive and qualitative data, even in response to forced response items in the questionn aire. Participant s in surgical specialties and procedure based subspecialties (e.g., gast roenterology ) reported one of their main challenges to be unavailability of lactation rooms close to operating or procedure rooms. Furthermore, participant s in surgical based fields universally reported less perceived support of their breastfeeding effort s at work as well as more employment related obstacles. One faculty physician expressed her opinion that it would be impossible for anesthesiology housestaff to continue breastfeeding after return to work due to logistics of patient flow and availability of coverage for operating rooms. Participan ts who were residents at the time of delivery provided many examples of the influence of specific r otations on their milk supply For example, one participant reported having no trouble maintaining breastfeeding different rotation that involved overnight call and was more stressful. The one to one interaction also revealed lingering ambival ence about childbearing and breastfeeding during training. For example, one faculty member reported being supportive of breastfeeding among both patients and housestaff, but

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27 ot be formal maternity leave. With the exception of the handful of participants who had experienced childbi rth while employed in New York or California, most participant s in this study reported using sick leave, vacation time, unpaid leave, or a combination thereof as their maternity leave. Participant s also volunteered information about lack of accommodations for breastfeeding mothers when taking medical boards for different specialties.

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28 Table 3 1 Maternal d emographics (n = 130) Category Number (%) Age (years) at time of study Mean +/ standard deviation 37.55 + 6.67 Range 26 60 Study locat ion Johns Hopkins University School of Medicine 50 (38.5%) University of Florida College of Medicine 80 (61.5%) Career s tage at time of s tudy In t raining (residency or fellowship) 37 (28.5%) Had c ompleted training 93 (71.5%) S pecialty ( s urgical or n on surgical) Surgical 46 (35.4%) Non surgical 84 (64.6%) Number of b iological c hildren 1 47 (36.2%) 2 63 (48.5%) 3 15 (11.5%) 4 5 (3.8%) Age of c hildren (months) Mean +/ standard dev iation 73.24 + 48.00 Range 1.5 336.0 Breastfeeding e ducation d uring m edical s chool Yes 28 (21.5%) No 102 (78.5%) Breastfeeding e ducation d uring r esidency Yes 25 (19.2%) No 105 (80.8%) Maternal s tage of c areer at c hildb irth Before medical school 6 (3%) During medical school 16 (5%) During residency 62 (29%) During fellowship 41 (15%) After completion of training 104 (43%) Other stages of medical training 9 (5%)

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29 Table 3 2 Sp ecialties of p hysician m others i ncluded in the s tudy Specialty Number Percentage (%) Surgical Anesthesiology 8 6.2 E ar, nose & throat 1 0.8 General s urgery and s ubspecialties 6 4.6 Medicine/ i nterventional c ardiology 8 6. 2 Medicine/ g astroenterology 7 5.4 Medicine/ p ulmonary and c ritical c are 1 0.8 Obstetrics g y necology 6 4.6 Ophthalmology 1 0.8 Pediatrics/ g astroenterology 1 0.8 Pediatrics/ p ulmonary 1 0.8 Radiology 4 3.1 Urology 1 0.8 Total surgical 4 5 3 4 .6 Non s urgical Dermatology 1 0.8 F amily m edicine 4 3.1 *General i nternal m edicine and s ubspecialties 5 5 42.3 Internal m edicine / p ediatrics 1 0.8 Neurology 4 3.1 Pathology 2 1.5 *Pediatrics and o ther p ediatric s ubspecialtie s 13 10.0 Physical m edicine and r ehab 1 0.8 Psychiatry 3 2.3 Radiation oncology 1 0.8 Total non surgical 8 5 6 5. 4 *Procedure based subspecialties, such as g astroenterology interventional c ardiology and p ulmonary in i nternal m edicine and p ediatrics s urgical other subspecialties (e.g. en n on s urgical

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30 Table 3 3 Duration of p ersonal b reastfeeding and b reastfeeding a dvocacy ( assessed only at UF) Workplace breastfeeding promotion (n=80) Clinical breastfeeding promotion (n=71 ) Yes No P value Yes No P value Mean duration of breastfeeding (months) 10.05 3.11 0.000 10.00 5.98 0.001 Standard deviation 6.26 2.31 6.34 4.29 Mean duration of exclusive breastfeeding (months) 3.77 1.66 0.002 3.70 2.80 0.069 Standard deviation 2.45 1.90 2.4 9 2.34 Nine participant s reported that they did not have breastfeeding patients and were eliminated from analysis as far as clinical breastfeeding promotion (n=71).

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31 Table 3 4 Significant predictors of breastfeeding duration (BF D ) ( controlling for mat ernal demographics ) Variable s Estimated e ffect on BFD in m onths (mo.) 95% CI for the effect P value General variables Maternal BFD g oal 0.86 increase in BFD for each 1 mo. increase in BFD goal (0.642, 1.08) <0.001 Infant f eeding m ethod at b irt h <0.001 Exclusive BF 8.2 increase in BFD compared to formula only (4.17, 12.10) <0.001 Combination (BF & formula) 3.0 increase in BFD compared to formula only (0.951, 4.95) 0.003 Infant feeding m ethod c onsistency 2.5 increase in BFD if reported cons istent infant feeding method during 30 days postpartum (0.589, 4.37) 0.011 Work related variables Maternity l eave 0.14 increase in BFD for each week increase in total maternity leave (paid and unpaid) (0.042, 0.233) 0.005 Maternity l eave m ake up 3.6 increase in BFD if mother did not report requirement to make up missed call or work (0.690, 6.54) 0.016 Collegial s upport of Milk Expression at Work ( MW ) 1.3 increase in BFD for each unit increase in score on this question (0.366, 2.25) 0 .007 P rogram d ir ector or c s upport of MW 1.1 increase in BFD for each unit increase in score on this question (0.263, 1.90) 0 .010 p erceived s pecial f i nfluenced c ollegial n on s upport of MW 3.5 decrease in BFD if ( 6.77, 0.145) 0.041

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32 Table 3 4. Continued Variables Estimated effect on BFD in months 95% CI for the effect Weaning related variables BF w eaning due to i nfant h ealth 6.6 increase in BFD if (1.57, 11.7) 0.011 BF w eaning due to i nfant l ack of i nterest in BF 2.17 decrease in BFD if ( 4.16, 0.200) 0.031 BF w eaning for i nadequate t ime 2.9 increase in BFD if (0.616, 5.12) 0.013 BF w eaning for i nadequate m ilk 3.3 increase in BFD if (1.32, 5.29) 0.001 BF w eaning du e to o ther r eason 3.4 increase in BFD if (1.70, 5.01) <0.001

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33 Figure 3 1. Breastfeeding (BF) and exclusive breastfeeding (EBF) rates of physician mothers

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34 CHAPTER 4 DISCUSSION AND CONCLUSION Physician Mothers Infant Feeding I ntentions a nd Behavior Our data demonstrate that despite high breastfeeding initiation rates among physician mothers in both institutions, there was a significant discrepancy between their breastfeeding duration goals and actual breastfeeding duration. This discrepa ncy and the reasons for cessation (lack of time and adequate milk supply) between 1 and 12 months suggest that work related factors not only influence physician mothers' breastfeeding behavior, but might have a larger impact on their breastfeeding behavior than their previous education and intentions on their breastfeeding duration. P hysician mothers in both our pilot stud ies universally reported their intention to breastfeed as well as awareness of benefits of breastfeeding and current recommendations. The ir intentions and knowledge correlated with their breastfeeding initiation practices. However, their breastfeeding maintenance was then determined by the interaction of personal factors, such as intent and knowledge, with work related issues Work Site Pr edictors of Breastfeeding Duration Previous studies have cited maternal postpartum employment as a major obstacle to exclusive breastfeeding and breastfeeding continuation. 15, 34 37 41 Availability of worksite lactation facilities, support from coworkers a nd supervisors, and length of maternity leave have been associated with breastfeeding success in working mothers, while inflexible work schedules have been associated with breastfeeding cessation 35,42 49 We expected similar associations among physician mo thers as they have reported lack of sufficient time and appropriate place for milk expression at work as well as inadequate milk supply as obstacles to breastfeeding continuation after return to work or

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35 as reasons for bre astfeeding cessation 25 28 Howeve r, we did not find a statistically significant correlation in our multivariate analysis between availability of worksite lactation facilities and breastfeeding duration of physician mothers. From our qualitative data, we believe that physician mothers oft en overcome the barrier of appropriate space at work for milk expression by creatively using unconventional locations, such as spaces in unused patient rooms, call rooms, or recovery rooms, to express milk. The work site variables that showed significant associations with breastfeeding level of overall support in her immediate work environment. Non clinical duties when physician mothers first return to work, protec ted time for milk expression during work hours, and work site support are modifiable factors that might influence physician T o date, randomized trials have not been conducted that evaluate the effectiv eness of workplace interventions in promoting breastfeeding among women returning to paid work after the birth of their child As women now make up almost half of the American workforce and more mothers of infants are par ticipating in the workforce scient ific evaluation of the effectiveness of workplace interventions in promoting breastfeeding among working mothers is an important next step in developing evidence based and cost effective health policy change to improve their breastfeeding continuation and exclusive breastfeeding rates. 52,53 Availability of time at workplace for milk expression/breastfeeding is a modifiable work site factor that might impact duration of breastfeeding among physician mothers. Interestingly, availability of time also

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36 correla ted with breastfeeding duration among lawyer mothers in one of our pilot studies 54 Protected time at work might be easier and more cost effective to modify than other potential work site factors, such as length of maternity leave O ur results support fur ther study to determine if protected time at workp lace for milk expression and breastfeeding as well as other programs to promote breastfeeding duration among physician mothers returning to work will increase the frequency and duration of their breastfeedi ng Physician Mothers Breastfeeding Advocacy Another interesting and perhaps even more important result of our study was the positive association between physician mother their self reported clinical breastfeeding a dvocacy. Frank et al. have reported a similar ive counseling practices 23, 24, 36 In 1995, Freed et al. found that among a large national sample of physicians in training and practice, previous personal or spousal breastfeeding experience was the greatest predictor of physician self confidence in effecti ve breastfeeding counseling 19 Our data expand on the results of Freed et al. and suggest that there might also be an associa tion between the quality of a physician mot and her breastfeeding advocacy. Our findings can be interpreted in several ways: If the association between personal breastfeeding experience and breastfeeding advocacy is causativ e, then interventions focused on promoting breastfeeding among physicians and enabling them to breastfeed successfully after return to work can potentially improve their attitudes toward advocating breastfeeding among their patients and society.

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37 Alternat ively, since we also found a correlation between maternal goal for breastfeeding duration with both actual personal breastfeeding duration and breastfeeding advocacy, the association between breastfeeding duration and advocacy might actually reflect the im breastfeeding behavior as well as advocacy, rather than any direct link between duration and advocacy. Another possibility is that there might be a stronger more primary factor, unidentified by our study, which independently affects maternal breastfeeding goals, actual duration and advocacy. The exact relationship between these factors would best be assessed by a prospective study of physician mothers. Limitations As this was a cross sectional stud y, our findings do not imply causality. To assess causality between maternal work site factors and breastfeeding behavior, prospective or interventional studies are needed Another potential limitation is institutional bias, as the individual studies wer e mainly conducted in two academic medical centers. A lthough this allowed for detailed, in depth analyses with extensive one on one interviews our findings might not be applicable to all physicians in the United States. The high percentage of participant s from i nternal m edicine or i nternal m edicine subspecialties suggests a potential recruitment bias that might be associated with the affiliation with the i nternal m edicine department. Uneven distribution of the recruitment e mail by program directors in different specialties might have also contributed to the recruitment bias. Although we attempted to recruit physician mothers who had not breastfed as well as those who had, it is possible that mothers who had chosen to breastfeed and had achieved their goal were more likely to volunteer to

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38 participate in the study. As such, another potential limitation of our study is selection bias resulting in over representation of actual breastfeeding rates among physician mothers. Ano ther potential limitation of our study is recall bias, as we memories of previous breastfeeding behavior. Retrospective infant feeding data based on maternal recall is a valid and reliable estimate of breastfeeding initiation and duration, especially when the dura tion of breastfeeding is recalled within 3 years. 50, 51 However, validity and reliability of maternal recall for age of introduction of food and liquids other than breastmilk (e.g., duration of exclusive breastfeeding) are less satisfactory, and validity a nd reliability of maternal recall for breastfeeding intention are not clear. 51 Directions for the Future Our findings ha ve important implications for future prospective research, involving a larger and more diverse sample from vari ou s healthcare settings to determine whether significant differences exist in infant feeding behavior and breastfeeding advocacy of physician mothers in different healthcare settings, specialties, and those in training versus physician mothers in practice. The results of such a study, with a larger sample size of physicians from different institutions, would also be more generalizable. Cause and effect relationships between personal infant feeding behavior of physician mothers and their breastfeeding advocacy would best be asses sed prospectively. Another area to further explore would be the relationship of

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39 Interventional studies to assess affect of interventions on breastfeeding success of working mothers are also important. Physician mothers would be an ideal group for further interventional stud ies for several reasons. In our studies, physician mothers consistently reported 100% breastfeeding intention and high breastfeeding initiat ion rates 55, 56 Since these mothers have uniquely uniform infant feeding intentions and behavior at birth, differences in their infant feeding behavior and breastfeeding dur ation after return to work are mostly determined by work site factors. Furthermore, impacts her own well being and the well being of her family, but also the health of her pa work place on breastfeeding behavior and breastfeeding advocacy of physician mothers, other variables such as infant outcomes and maternal utilization of sick days can be explored. Conclusion To our knowledge, this study is the second largest published multi specialty physician breastfeeding study in the United States. Our findings emphasize the discrepancy between physician mothers' breastfeeding duration goal and their a ctual breastfeeding duration and highligh t the association between their personal brea stfeeding success and their active breastfeeding advocacy. Furthermore, our results support the importance of work related factors in breastfeeding maintenance among phys ician mothers and suggest that a tailored intervention, providing time and institutional encouragement, might result in significant extension of the duration of breastfeeding We suggest that assigning non clinical duties when physician mothers first retu rn to work, offering collegial support for breastfeeding mothers, and providing

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40 protected time at work for milk expression or breastfeeding are factors that will influence

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41 APPENDIX A JOHNS H OPKINS UNIVERSITY SURVEY INSTRUMENT Section 1: Demographics 1.1 Age 1.2 Specialty: Anesthesiology Dermatology Emergency Medicine Family Medicine General Surgery Internal Medicine Ob gyn Orthopedic Surgery Pediatrics Psychiatry Radiology Other (P lease specify) 1.3 Current year in residency: PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY 6 PGY 7 Other (Please specify) 1.4 Are you Single, living without partner Single, living with domestic partner Married Separated Divorced Widowed 1.5 If you have a spouse/partner, what was his/her occupation at the time of birth of each child? Student Physician Other (Please specify)

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42 1.6 Did your spouse/partner work outside the home after your children were born? YES NO Section 2: Breastfeeding Educat ion 2.1 Do you recall formal education about breastfeeding in medical school? YES NO 2.2 Do you recall formal education about breastfeeding in residency? YES NO Section 3: Children 3.1 Do you have any biological children? YES please complete the fo llowing questions for each child: NO Thanks for completing the survey 3.2 Are you currently breastfeeding? 3.3 How many biologic children do you have? 3.4 What is the exact age of your child? 3.5 How would you describe your work environment during y our pregnancy? Extremely hostile Somewhat hostile Neutral Somewhat supportive Extremely supportive 3.6 Did you plan for your child to be breastfed? YES. Please specify reasons NO. Please specify reasons 3.7 If yes, what was your original goal f or length of breastfeeding? 3.8 In what stage of your career were you when your child was born? Before medical school During medical school During residency Other (Please specify)

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43 3.9 How many total weeks of maternal leave did you take? 3.10 Of that to tal, how many weeks were paid leave? 3.11 Were you required to make up any missed call your maternal leave incurred? YES NO 3.12 Did you return to work when you wanted to / had planned? YES NO. If no, please specify reason Residency required it Personal preference Financial need Infant health Other (Please describe) 3.13 What was your schedule on return to work? Full time Part time (Please describe) Did not return 3.14 What year did you return to work? 3.15 Did you have flexibility to schedule your rotations upon return to work? 3.16 What type of rotation did you do after returning to work? Inpatient wards Outpatient rotation Consult rotation Research Other (Please specify) 3.17 What was your second rotation a fter returning to work? Inpatient wards Outpatient rotation Consult rotation Research Other (Please specify) 4. Breastfeeding 4.1 How was your infant fed immediately after birth?

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44 Exclusively breastfed (with exception of medications and vitamins, inf ant only had breast milk) Combination of breast milk and formula Formula only Other (Please describe) 4.2 If infant was not breastfed at all, please describe why: Mother not interested in breastfeeding Mother not comfortable with breastfeeding Sche dule would not permit Maternal medical reasons Infant not interested in breastfeeding Infant medical reasons Other (please describe) 4.3 At what age was the child first fed something other than breast milk or medication (e.g. formula, juice, solids, etc.)? 4.4 Why was formula/other food introduced? 4.5 At what age was your infant weaned from breast milk completely? 4.6 How would you scale your mental health / emotional state during your breastfeeding period? Severely depressed Mildly depressed Not depressed at all 4.7 How would you rate your energy level while breastfeeding? Often tired Sometimes tired Seldom tired 4.8 Why did you choose to wean your infant at that time? Mother not interested in breastfeeding Mother not comfortable with b reastfeeding Lack of adequate milk supply Too stressful Lack of time Maternal health Infant health Infant not interested in breastfeeding Other (Please describe)

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45 4.9 Were you satisfied with the duration that you actually breastfed? YES Somewhat NO 4.10 How long did you plan to breastfeed? 4.11 What were factors that encouraged you as a parent to start breastfeeding? 4.12 What were factors that discouraged you from initiating breastfeeding? 4.13 What were factors that encouraged you to continu e breastfeeding? 4.14 What were factors that hindered breastfeeding continuation of your child? 4.15 Do you have any suggestions as to how a residency program can be supportive of breastfeeding efforts of new mothers upon returning to residency? 5. Brea stfeeding and Working 5.1 Did you continue breastfeeding after you returned to work? YES Please complete the following: NO Thanks for completing the survey. 5.2 Did you pump milk while working? YES Please complete the following: N0 Thanks for comp leting the survey. 5.3 Did you have sufficient time to express milk? Never Occasionally Sometimes Often Always 5.4 Did you have access to an appropriate place to express milk? Never Occasionally Sometimes Often Always 5.5 Name locations at wor k in which you have expressed milk in (check all that apply): Bathrooms Call room

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46 Private office space Shared office space Lactation rooms Cars Other specify 5.6 Did you hand over your pager while expressing milk? Never Occasionally Sometimes Often A lways 5.7 Please rate the support you felt from following people in your milk expression efforts while working: 1 2 3 4 5 Always usually neither usually always Opposed opposed supportive supportive supportive My efforts my efforts nor Oppositional Colleagues Attendings Program director 5.8 If your colleagues were other than supportive, please circle reasons you believe may have influenced this attitude (circle ALL that apply) 1. changes in the schedule 2. perceived special favors 3. lack of a ttending or residency director support 4. More work for others 5. Other (Please describe) Thank you for completing the survey!

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47 APPENDIX B U NIVERSITY OF FLORIDA SURVEY INSTRUMENT Section 1: Demographics 1.1 Age 1.2 Gender: Male Female 1.3 Specialty: Anesth esiology Dermatology Emergency Medicine Family Medicine General Surgery Internal Medicine Ob gyn Orthopedic Surgery Neurology Pediatrics Physical Medicine and Rehabilitation Psychiatry Radiology Internal Medicine/Pediatrics Other (Please spe cify) 1.4 Current year in residency: PGY 1 PGY 2 PGY 3 PGY 4 PGY 5 PGY 6 PGY 7 Other (Please specify) 1.5 Are you Single, living without partner Single, living with domestic partner Married Separated Divorced Widowed

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48 Other 1.6 Do you ha ve any biological children? YES NO Section 2: Breastfeeding Education 2.1 Do you recall formal education about breastfeeding in medical school? YES NO 2.2 Do you recall formal education about breastfeeding in residency? YES NO If you do not have biological children, this concludes the survey. Thanks for completing the survey. If you have biologic children, please complete the following: Section 3: Children 3.1 How many biologic children do you have? 3.2 What is the exact age of each child (if age less than 2 years, please state in months)? 3.3 Are you currently breastfeeding? YES NO 3.4 If you have a spouse/partner, what was his/her occupation at the time of birth of each child? 3.5 Did your spouse/partner work outside the home after you r child was born? YES NO 3.6 How would you describe your work environment during your pregnancy? Very unsupportive Somewhat unsupportive Neutral Somewhat supportive Very supportive

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49 3.7 Did you plan for your child to be breastfed? YES. Please ch eck all that apply Infant health Less infections/increased immunity Less allergies Increased IQ Decreased risk of obesity Decreased risk of diabetes Maternal health Postpartum weight loss More convenient than formula Cheaper than formula Bonding with infant Lactation consultant recommendations Ob/Gyn recommendations Pediatrician recommendations Breastfeeding class Own mother Friends/other mothers Other (please specify) NO. Please specify reasons 3.8 If yes, what was your original goal for length of breastfeeding? 3 months 6 months 12 months No goal Other (please specify) 3.9 In what stage of your career were you when your child was born? Prior to medical school During medical school During residency During fellowship Other (Please specify) 3.10 How many total weeks of maternity leave did you take? 3.11 Of that total, how many weeks were paid leave? 3.12 Were you required to make up any missed call your maternity leave incurred? YES NO

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50 3.13 Did you re turn to work when you had planned? YES NO. If no, please specify reason Residency required it Personal preference Financial need Infant health Other (Please describe) 3.14 What was your schedule on return to work/residency? Full time Part time (Please describe) Did not return 3.15 What year did you return to work? 3.16 Did you have flexibility to schedule your rotations upon return to work? YES NO Not Available Somewhat 3.17 What type of rotation did you do after re turning to work? Inpatient wards Outpatient rotation Consult rotation Research Other (Please specify) 3.18 What was your second rotation after returning to work? Inpatient wards Outpatient rotation Consult rotation Research Other (Please specify ) 4. Breastfeeding 4.1 How was your infant fed immediately after birth? Exclusively breastfed (with exception of medications and vitamins, infant only had breast milk) Combination of breast milk and formula Formula only

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51 Other (Please describe) 4.1a Yes No Please explain 4.2 If infant was not breastfed at all, please describe why: Mother not interested in breastfeeding Mother not comfortable with breastfeeding Schedule would not permit Maternal medical reasons Infant not interested in breastfeeding Infant medical reasons Other (please describe) 4.3 At what age was the child first fed something other than breast milk or medication (e.g. formula, juice, solids, etc.)? 4. 4 Why was formula/other food introduced? 4.5 At what age was your infant weaned from breast milk completely? 4.6 How would you scale your mental health / emotional state during your breastfeeding period? Severely depressed Mildly depressed Not depress ed at all 4.7 How would you rate your energy level while breastfeeding? Often tired Sometimes tired Seldom tired 4.7a How would you rate your stress level while breastfeeding? Very stressed Somewhat stressed Seldom Stressed 4.8 Why did you choose to wean your infant at that time? Mother not interested in breastfeeding Mother not comfortable with breastfeeding Lack of adequate milk supply Too stressful Lack of time

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52 Maternal health Infant health Infant not interested in breastfeeding Other ( Please describe) 4.8 a Was discontinuation of breastfeeding due to demands at work? YES NO 4.9 Were you satisfied with the duration that you actually breastfed? YES Somewhat NO 4.10 How long did you plan to breastfeed? 4.11 What were factors that encouraged you as a parent to start breastfeeding? 4.12 What were factors that discouraged you from initiating breastfeeding? 4.13 What were factors that encouraged you to continue breastfeeding? 4.14 What were factors that hindered breastfeeding conti nuation of your child? 5. Breastfeeding and Working 5.1 Did you continue breastfeeding after you returned to work? YES Please complete the following: NO Thanks for completing the survey. 5.2 Did you pump milk while working? YES Please complete th e following: N0 Thanks for completing the survey. 5.3 Did you have sufficient time to express milk? Never Occasionally Sometimes Often Always 5.4 Did you have access to an appropriate place to express milk?

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53 Never Occasionally Sometimes Often Always 5.5 Name locations at work where you have expressed milk (check all that apply; if more than one, please rank based on frequency of use with 1 being the most frequent): Lactation rooms Bathrooms Call rooms Private office spaces Shared office spaces Cars Other specify 5.6 Did you hand over your pager while expressing milk? Never Occasionally Sometimes Often Always 5.7 In general, please rate the support you felt from following people in your milk expression efforts while working: 1 2 3 4 5 6 Always usually neither usually always Opposed opposed supportive supportive supportive Know My efforts my efforts nor Oppositional Colleagues Attendings Program director 5.8 If you encountered colleagues who were not sup portive, please rank the reasons you believe may have influenced this attitude (1 most important) 6. changes in the schedule 7. perceived special favors 8. lack of attending or residency director support 9. More work for others 10. Other (Please describe)

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54 5.9 Which one of following would you suggest in a residency program as methods to effectively increase breastfeeding success of new mothers upon returning to residency? Check all that apply. Increased paid leave Formal maternity leave policy Non clinical rotations u pon return to work More lactation rooms Storage for breast milk Sinks inside/ close to lactation rooms Onsite daycare Shared /part time residency 5.10 Do you actively promote breastfeeding amongst your women patients? YES NO If No The major reason f or this is I don't think it is important I think this is my patient's decision and I should only respond if asked I don't have the time to address this with patients I don't feel I am expert enough Other 5.11 Do you actively promote breastfeeding amongst female housestaff? YES NO If No The major reason for this is I don't think it is important I think this is my patient's decision and I should only respond if asked I don't have the time to address this with patients I don't feel I am expert enough Other Thank you for completing the survey!

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55 LIST OF REFERENCES 1. American Academy of Pediatric s Breastfeeding and the use of human milk. Work Group on Breastfeeding. Pediatrics. 1997;100:1035 9. 2. World Health organization (WHO). Global strategy on infant and young child feeding. Geneva: WHO ; 2001. 3. Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep). 2007;153:1 186. 4. Eidelman AI; American Academy of P ediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496 506. 5. Grummer Shawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Contro l and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113(2): e81 6. 6. Scariati PD, Grummer Strawn LM, Fein SB. A longitudinal analysis of infant mortality and the extent of breastfeeding in the United States. Pediatrics. 1997;99(6):E5. 7. Bonati M, Campi R. Breastfeeding and infant illness. Am J Public Health. 2000;90:1478 9. 8. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeed Rev. 2001;9(2):11 18. 9. Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics. 2010;125(5):e1048 56. 10. Riordan JM The cost of not breastfeeding: a commentary. J Hum Lact 1997;13(2):93 7. 11. Wright AL. The rise of breastfeeding in the United St ates. Pediatr Clin North Am 2001;48(1):1 12. 12. C enter for D isease C ontrol and Prevention Breastfeeding Report Card United States, 2012 http://www.cdc.gov/breastfeeding/p df/2012BreastfeedingReportCard. pdf (accessed February 17, 2013). 13. U.S. Department of Health and Human Services. www.healthypeople.gov/ hp2020/Objectives.htm (accessed November 9, 201 2 ).

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56 14. Lawrence RA. Practices a nd attitudes toward breast feeding among medical professionals. Pediatrics 1982;70:912 920. 15. Taveras EM, Li R, Grummer Strawn L, Richardson M, Marshall R, Rego VH, Miroshnik I, Lieu TA. Opinions and practices of clinicians associated with continuation of ex clusive breastfeeding. Pediatrics. 2004;113(4):e283 90. 16. Sikorski J, Renfrew MJ, Pindoria S, et al. Support for breastfeeding mothers. Cochrane Database Syst Rev 2002;(1):CD001141. 17. Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of Breastfeeding Interve ntion Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA 2001;285:413 420. 18. Labarere J, Gelbert Baudino N, Ayral DS, et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prosp ective, randomized, open trial of 226 mother infant pairs. Pediatrics 2005;115:e139 e146. 19. Freed GL, Clark SJ, Sorenson J, et al. National assessment of physicians' breastfeeding knowledge, attitudes, training, and experience. JAMA 1995;273:472 476. 20. Schanle r RJ, O'Connor KG, Lawrence RA. Pediatricians' practices and attitudes regarding breastfeeding promotion. Pediatrics 1999;103:E35. 21. Freed GL, Clark SJ, Lohr J, Sorenson JR. Pediatrician involvement in breast feeding promotion: A national study of residents and practitioners. Pediatrics 1995;96:490 494. 22. Freed GL, Clark SJ, Cefalo R, et al. Breastfeeding education of obstetrics gynecology residents and practitioners. Am J Obstet Gynecol 1995;173:1607 1613. 23. Frank E. STUDENTJAMA. Physician health and patient car e. JAMA. 2004; 291(5) :637. 24. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians' prevention related practices. Arch Fam Med. 2000; 9(4) :359 67. 25. Miller N, Miller D, Chism M. Breastfeeding practices among resident physicians. Pediatrics 1996; 98(3):434 7. 26. Arthur CR, Saenz RB, Replogle WH. The employment related breastfeeding decisions of physician mothers. J Miss State Med Assoc 2003;44(12):383 7. 27. Arthur CR, Saenz RB, Replogle WH. Personal breast feeding behaviors of female physicians in Miss issippi. South Med J 2003;96(2):130 5.

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57 28. Kacmar JE, Taylor JS, Nothnagle M, Stumpff J. Breastfeeding practices of resident physicians in Rhode Island. Med Health R I 2006;89(7):230 1. 29. Sattari M, Levine D, Serwint JR. Physician mothers: an unlikely high risk group call for action. Breastfeed Med 2010;5(1):35 9. 30. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) A metadata driven methodology and workflow process for pr oviding translational research informatics support. J Biomed Inform 2009;42:377 381. 31. Karinu K, Sorino PH, Ezrine SF, et al. Does maternal employment affect breastfeeding? Am J Public Health 1989;79:1246 1250. 32. Gielen AC, Faden RR, O'Campo P, et al. Maternal employment during the early postpartum period: Effects on initiation and continuation of breastfeeding. Pediatrics 1991;87:298 305. 33. Calnen G. Paid maternity leave and its impact on breastfeeding in the United States: An historic, economic, political, and social perspective. Breastfeed Med 2007;2:34 44. 34. Ryan AS, Zhou W, Arensberg MB. The effect of employment status on breastfeeding in the United States. Womens Health Issues 2006;16:243 251. 35. Visness CM, Kennedy KI. Maternal employment and breastfeeding: Find ings from the 1988 National Maternal and Infant Health Survey. Am J Public Health 1997;87:945 950. 36. Frank E, Breyan J, Elon L. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med. 2000; 9(3) :287 90. 37. P hilibert I, Friedman P, Williams WT. New requirements for resident duty hours. JAMA 2002; 288(9):1112 4. 38. Hawkin SS, Griffiths LJ, Dezateux C, Law C; The Millennium Cohort Study Child Health Group. The Impact of maternal employment on breast feeding durati on in the UK Millennium cohort study. Public Health Nutr. 2007;10(9):891 6. 39. McKinley NM, Hyde JS. Personal Attitudes or Structural Factors? A Contextual Analysis of Breastfeeding Duration. Psycho Women Quart. 2004;28:388 399. 40. Cooking AR, Donath SM, Amir LH. Maternal employment and breastfeeding: results from the longitudinal study of Australian children. Acta Paediatr. 2008;97(5):620 3. 41. Meek JY. Breastfeeding in the workplace. Pediatr Clin North Am 2001;48(2):461 74.

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60 BIOGRAPHICAL SKETCH Maryam Sattari is an assistant professor in College of Med ici ne, Department of Medicine She graduated from Berry College in 1995 with a B.S in mathematics and biochemistry She received her M.D. in 1999 and completed her residency training in internal medicine in 2002, all at Emory University School of Medicine This thesis completes the requirements for a Master of Science in Medical Science with a concentration in c linical and t ranslational s cience supported in part by the NIH/NCRR Clinical and Translation al Science Award to the University of Florida, UL1 TR000064