Breastfeeding outcomes after postpartum haemorrhage: a socio-ecological secondary analysis of the WOMAN trial

Breastfeeding has been recognised as a significant driver of neonatal and infant outcomes, particularly in Low- and Middle-income Country (LMIC) settings. Postpartum haemorrhage (PPH) is an increasingly common complication of childbirth, with multiple effects on mothers and their babies. This study aimed to explore the association between aspects of PPH care and outcomes, as they relate to the Socio-Ecological Model of Health for breastfeeding, and the rates of breastfeeding among this cohort of women. This was a secondary analysis of data from the WOMAN trial. The WOMAN trial was a randomised, controlled, pharmaceutical trial in 193 hospitals across 21 countries between 2010 and 2016. A binary logistic regression model was developed to examine the associations between the status of clinical and psycho-social factors from the individual and organisational levels of the Socio-Ecological Model of Health for breastfeeding and the rates of any breastfeeding during the study period. 16,285 mothers of healthy singleton babies were included in the current study. Factors that may result in maternal-infant separation in the immediate postpartum period were associated with lower rates of any breastfeeding in the study period. These included: the mother requiring transfer between hospitals following PPH (Odds Ratio 0.47 [95%CI 0.41–0.54]) and the mother being admitted to ICU postpartum (OR 0.65 [95%CI 0.54–0.78]). Maternal pain (OR 0.65 [95%CI 0.58–0.75]) and maternal anxiety or depression (OR 0.63 [95% CI 0.53–0.75]) were also associated with lower rates of breastfeeding. Some women who experience PPH are at increased risk of not initiating breastfeeding, particularly if there is maternal-infant separation. Organisational factors such as hospital transfer and ICU admission were strongly associated with reduced breastfeeding rates. Individual psycho-social and physical challenges, including pain and psychological distress, further compound these difficulties. Identifying women at higher risk of breastfeeding disruption following PPH could allow targeted support and interventions. Within emergency obstetric care there is a need for universal implementation of breastfeeding-friendly practices, informed by multi-disciplinary, evidence-informed guidelines.