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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 12  |  Page : 1662-1668

The effect of maternal fatigue on breastfeeding


1 Department of Nursing, Faculty of Health Sciences, Çankırı Karatekin University, Cankiri, Turkey
2 Departmant of School of Health Midwifery, Mersin University, Mersin, Turkey
3 Departmant of School of Health Midwifery, Adıyaman University, Adıyaman, Turkey

Date of Submission14-Nov-2018
Date of Acceptance19-Jun-2019
Date of Web Publication3-Dec-2019

Correspondence Address:
Dr. D K Senol
Department of Nursing, Faculty of Health Sciences, Cankırı Karatekin University, 18000 Cankiri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_576_18

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   Abstract 


Background: Postpartum fatigue means tiredness, sense of suffocation, and decreased physical and mental capacity. Fatigue reduces postpartum women's ability of concentrate, which may increase the frequency of postpartum depression, and their babies and cause babies' weaning off breastmilk earlier. Aim: Postpartum fatigue reduces the ability of mothers to concentrate and has a negative effect on communication between mothers and their babies. This study was performed to determine the effect of fatigue on breastfeeding and breastfeeding behaviors in postpartum women. Subjects and Methods: The study had a descriptive desing and was carreid out in a postpartum clinic of a maternal, obstetric, and pediatric diseases hospital. It included 374 women giving normal vaginal birth. Data were gathered with a socio-demographic features form and Visual Analogue Scale for Fatigue. Results: The mean score was 6,91 ± 2,25 for the subscale fatigue and 2,38 ± 0,91 for the subscale energy. The women reporting that it was not difficult to give birth and that they had little or some fatigue had significantly higher scores for energy (P = 0.001). The women starting to breastfeed in the hour of giving birth (P = 0.003) and the women breastfeeding at 1-hour intervals (P = 0.100) had a lower score for fatigue. The women not needing help while breastfeeding had a significantly lower score for fatigue (P = 0.001), while those reporting to give additional food had a significantly higher score for fatigue (P = 0.014). Conclusion: Women feel tired in the early postpartum period due to giving birth and their tiredness is increased by breastfeeding and infant care.

Keywords: Breastfeeding, early postpartum period, postpartum fatigue


How to cite this article:
Senol D K, Yurdakul M, Ozkan S A. The effect of maternal fatigue on breastfeeding. Niger J Clin Pract 2019;22:1662-8

How to cite this URL:
Senol D K, Yurdakul M, Ozkan S A. The effect of maternal fatigue on breastfeeding. Niger J Clin Pract [serial online] 2019 [cited 2019 Dec 10];22:1662-8. Available from: http://www.njcponline.com/text.asp?2019/22/12/1662/272210




   Background Top


Fatigue is defined as imbalance between activity and rest which may not occur at the end of a sleeping period.[1] Postpartum fatigue means tiredness, sense of suffocation, and decreased physical and mental capacity which may affect maternal and child health.[2] About 60% of the postpartum women experience fatigue, which affects their health.[3] Fatigue reduces postpartum women's ability of concentrate, which may increase the frequency of postpartum depression, anxiety, and risk of postpartum women's sleepiness, their babies, create a negative impact on interactions between women and their babies and cause babies' weaning off breastmilk earlier.[1],[3] In addition, fatigue has such negative effects as impairment of maternal health, women's delayed return to daily life activities, babies' early weaning off breastmilk and delayed development of babies.[4],[5],[6] It is a commonly reported problem.[7] Women feel tired in the early postpartum period due to giving birth and their tiredness is increased by breastfeeding and infant care.[8],[9]

Postpartum fatigue is affected by many factors like maternal age, education, prior depression, increased metabolic needs, hormones, anemia, thyroid dysfunction, cardiomyopathy, nutrition, nausea, vomiting, alcohol intake, smoking, and type of delivery.[5],[10] Furthermore, breastfeeding duration, type of delivery, wound/episiotomy healing and physical factors like pain and breastfeeding can lead to postpartum fatigue.[11]

The above-mentioned problems experienced in the postpartum period can make relaxation in these women difficult and increase their anxiety. While most of the postpartum women can naturally cope with these problems, others experience severe anxiety, which has a negative effect on oxytocin secretion and creates breastfeeding problems.[12] They can pose the risk of discouraging postpartum women from breastfeeding. Health professionals, especially nurses and midwives, who work with postpartum women, can help mothers and their babies to experience a healthier postpartum period. It is important that nurses and midwives should be aware of factors increasing postpartum fatigue and how it affects breastfeeding. This study was performed to determine the effect of postpartum fatigue on breastfeeding.


   Materials and Methods Top


Study design, setting, and participants

The study population included postpartum women admitted to the postpartum clinic of a maternal, obstetric and pediatric hospital in Mersin, south-east Turkey, between August and December in 2017 and having a normal delivery. Sample size was calculated using the Free Statistics Calculators website (https://www.danielsoper.com/statcalc/calculator.aspx?id = 47). Confidence interval was taken as 95%, effect size as 0.258 (Cohen d < 0.5)[12] and the power as 80%. The sample size was determined 374 postpartum women. The study inclusion criteria was women having a single, live baby, having no chronic diseases, experiencing the 24 hours of the postpartum period and accepting to participate in the study.

Data collection and tools

Data were gathered with a socio-demographic features form and Visual Analogue Scale for Fatigue (VAS-F). The demographic features form, prepared by the researchers in light of the literature, is composed of 15 questions about demographic and obstetric features such as age, education, type of family, employment, health insurance, number of pregnancy, number of deliveries, smoking status, frequency of receiving prenatal care, hemoglobin levels at the time of presenting to hospital and breastfeeding behavior such as the time to start breastfeeding, the frequency of breastfeeding, the duration of breastfeeding, the status of receiving additional food and breastfeeding education of the women included into the study. It was piloted on 30 postpartum women to determine its understandability. Since no problems were reported by the women, the form was used as it was. VAS-F is utilized to measure energy and fatigue levels. It was developed by Lee et al.[13] (1990) and adapted into Turkish and its validity and reliability were tested by Yurtsever in 1999. VAS-F is composed of 18 items, of which 13 (1, 2, 3, 4, 5, 11, 12, 13, 14, 15, 16, 17, 18) were loaded on its subscale fatigue and five (6, 7, 8, 9, 10) were loaded on the subscale energy.[14] There are positive expressions at one end of VAS-F while there are negative expressions at the other end and 10 cm-lines between these expressions. The items loaded on fatigue are in an order from the most positive to the most negative ones while the items loaded on energy are in an order from the most negative to the most positive ones. Higher scores for fatigue and lower scores for energy indicate more severe fatigue.[14] In the Turkish version, the numbers zero and ten were put at the ends of 10 cm-lines between the items since it was thought to help the participants to mark the most appropriate fatigue and energy levels. The participants were asked to mark by putting a vertical line on the 10 cm-lines which corresponds best to their feeling of fatigue and degree of energy. Later, a ruler was used to determine how tired or energetic the participants were. VAS-F has been used to determine postpartum fatigue in studies in the country and abroad. The score range for VAS-F has not been reported clearly by Lee et al. The lowest and the highest scores for the subscale fatigue were zero and 130 respectively, and the lowest and the highest scores for the subscale energy were zero and 50, respectively. Zero points in fatigue sub-dimension are not tired at all and 130 points represent the most tired score. In the evaluation of the energy sub-dimension, 0 means the highest energy and 50 points the lowest energy score.[13] The Cronbach α coefficient of the subscale fatigue was found to be 0.909 and subscale energy was found 0.824 in the present study.

It took 20 minutes for each participant to complete the data collection tools.

Ethical aspects of the research

Written permission was taken from the administration of the hospital where the study was conducted, and ethical approval was obtained from the ethical committee of Çankırı Karatekin University (approval date: 13.10.2016 and approval number: 2016/03). After the aim of the study was explained to all the women participating in the study, they were assured that obtained results would not be used for any purposes except research. As stated in the ethics committee permission Informed consent was orally obtained. The aim of the study and publication of the data collected exclusively for scientific purposes without using participants' names, were explained to the participants and their verbal consent was taken in accordance with the Declaration of Helsinki.

Data analyses

The statistical analyses were performed by using the SPSS 21.0 (IBM Corp., Armonk, NY, USA). P < 0.05 was considered as significant. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to describe the main variables of the study. Since Kolmogorov-Smirnov and Shapiro-Wilk tests showed that the data had a normal distribution, t test was utilized to compare two groups and one-way ANOVA to compare three groups. LSD and Tukey tests were employed to determine the group causing a difference.


   Results Top


Of all women included in the study (n = 374), 67.1% (n = 250) were aged 20–35 years, 50.5% (n = 189) were secondary school graduates, 69.3% (n = 259) had a nuclear family, 78,9% (n = 295) were housewives and 80.5% (n = 301) had a health insurance. Forty-eight-point seven percent (n = 182) of the women had three or more pregnancies, 38.8% (n = 145) of the women gave birth to three or more children and 72,5% (n = 271) received prenatal care on at least four occasions. The percentage of smokers was 21.1% (n = 79). Sixty-four percent (n = 239) of the women had less than 11 gr/dl hemoglobin when they presented to hospital for birth.

On the average, women aged 19 years or younger scored higher for fatigue 7.24 (0.3) (95% CI 6,8–8,0) and women aged 20–35 years got the highest score for energy. The distribution of the mean scores for fatigue (P = 0.434) and energy (P = 0.215) by age groups was similar. Whether the women were primipara or multipara did not affect the mean scores for fatigue and energy (P = 0.589, P = 0.275). The women reporting to have a difficult childbirth got a significantly higher mean score for fatigue (P = 0.001), whereas the women reporting to have no difficulty in giving birth got a significantly higher mean score for energy (P = 0.001).

The women having hemoglobin in the normal range had a lower mean score for fatigue and a higher mean score for energy and the mean scores had a similar distribution (P = 0.492, P = 0.783). The women feeling very tired 7.79 (2) (95% CI 7,9-8,8) and tired 7,17 (2) (95% CI 7,3-7,9) had significantly higher scores for fatigue (P = 0.001). The women having very little tiredness 2.90 (1) (95% CI 2,5-3,2) and the women having a little tiredness 2.68 (1) (95% CI 2,6-3,2) had significantly higher scores for energy (P = 0.001). There was no significant difference in the mean scores for fatigue and energy, but the smokers got higher scores for fatigue [Table 1].
Table 1: The Distribution of the scores for fatigue and energy by their several characteristics (n:374)

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The women starting to breastfeed their babies within 1 hour of their childbirth got a significantly lower mean score for fatigue (P = 0.003), but there was no significant difference in scores for energy between the women breastfeeding and those not breastfeeding within 1 hour of their childbirth (P = 0.351). The women breastfeeding their babies at 1-hour or less than 1-hour intervals got a significantly lower mean score for fatigue (P = 0.001); however, no significant difference was found in scores for energy between the women (P = 0.100). The women not needing help to breastfeed their babies got a significantly lower mean score for fatigue (P = 0.001) and significantly higher mean score for energy (P = 0.014).

The women giving additional food to their babies had a significantly higher mean score for fatigue (P = 0.001), but the mean scores for energy did not differ significantly (P = 0.072). The women giving water containing sugar to their babies after giving birth got a significantly higher mean score for fatigue (P = 0.001). However, the mean scores for energy were not significantly differ in terms of giving water containing sugar (P = 0.203) [Table 2].
Table 2: Comparison of mean scores for fatigue and energy between mothers women with different features of breastfeeding (n:374)

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   Discussion Top


The aim of the present study was to determine the effect of fatigue experienced by the women in their early postpartum period on breastfeeding and breastfeeding behaviors.

Postpartum fatigue is affected by many factors, i.e. physiological, psychological, situational. Fatigue cannot be only caused by prolonged labor, type of delivery, perceived pain, wound healing, and involution, but is also influenced by individual factors, such as race, employment status, number of childbirths and age.[15],[16] In the current study, women 19 years old or younger and women aged more than 35 years experienced more severe fatigue; however, women aged 20–35 years had the highest scores for energy. Consistent with this finding, Bakker et al. reported a relation between older ages (>34) and postpartum fatigue.[17]

Postpartum fatigue commonly appears in primipara and this is considered normal.[18] In the current study, although there was no significant difference in the mean scores for energy between the primipara and the multipara, primiparae were found to have a higher mean score for fatigue. Similar to the results of the present study, Lai et al. found in their study that primiparae having vaginal delivery were more tired than multiparae.[5] Troy et al. also observed that primiparae experienced more severe postpartum fatigue.[11] These findings can be attributed to positive effects of multipara's previous infant care experiences on their coping with fatigue and preserving their energy.

A higher proportion of women having prolonged duration of the phase of labor and difficulty in delivery followed by perinatal trauma, experienced postpartum fatigue.[18],[19],[20] In the present study, women reporting to have a prolonged labor were found to feel more tired, whereas those reporting to have no difficulty were found to be more energetic. Hsieh et al. also reported that prolonged and difficult labor caused higher levels of fatigue.[21]

Postpartum anemia, which has a prevalence of 22%–50% in developed countries and 50%–80% in developing countries, is a health problem worldwide. The main causes of postpartum anemia are prior iron deficiency and iron deficiency due to intrapartum excess loss of blood.[22],[23] Ferritin measurement in the early postpartum period is not useful for the diagnosis of iron deficiency anemia since an acute response during delivery does not yield accurate results. Therefore, diagnosis of postpartum anemia should be based on hemoglobin measurement. Fatigue is considered as the main symptom of anemia.[24]

In the present study, women having normal ranges of hemoglobin when they were presented to hospital for birth felt less tired and more energetic than those having lower levels of hemoglobin. However, there have been studies showing no relation between fatigue and anemia. Van Der Woudea et al. reported no significant difference in postpartum fatigue between women with anemia and those without anemia.[24] Postpartum iron-deficiency anemia is associated with clinical symptoms, most prominently maternal fatigue.[25],[26] It is known that anemia presenting before pregnancy persists during pregnancy and that women with chronic anemia experience lower levels of energy and may recognize their decreased energy in the postpartum period.[24] This can explain the lack of a difference in fatigue and energy between women with anemia and those without anemia.

In the present study, women feeling tired and very tired during their pregnancy to the point of being unable to perform their activities, were found to be significantly more tired in the postpartum period. Bakker et al. also reported a significant relation between severe fatigue in the thirtieth gestational week and postpartum fatigue.[10]

Peripheral chemoreflex is the most important reflex necessary for rapid cardiovascular adaptation in hypoxia. When hypoxia occurs, it triggers some factors for example, hb is low. They cause vasodilatation and increase ATP production through blood glucose value used by cells for energy. Smokers feel tired due to factors triggered by peripheral chemoreflex and hypoxia.[27] In the present study, smoking women were found to feel more tired.

Postpartum fatigue affects physical activities and infant care in mothers. It is one of the most common causes of early cessation of breastfeeding. It has been reported that fatigue is frequently associated with insufficient breastmilk production.[17] The women starting to breastfeed their babies within one hour of delivery and at intervals of one hour or less, felt significantly less tired. In a study mothers partly breastfeeding were found to feel more tired than those fully breastfeeding their babies.[28] In another similar study, the level of fatigue experienced in the days and weeks after birth reduced the self-efficacy of breastfeeding.[29]

Although newborn care is a satisfying process for some mothers, it can be problematic and tiring for others. These problems include difficulties in care, nutrition and safety of newborns.[5] In the current study, the women reporting not to need assistance were found to be less tired and more energetic. Consistent with this finding, it has been reported in the literature that there is a relation between fatigue and infant care. Taylor and Johnson noted that fatigue affected infant care and that the mothers feeling tired had difficulty in caring for their babies.[15] In addition, a study reported a moderate correlation between postpartum fatigue and infant care.[5]

In the current study, women who reported to give their babies water containing sugar before breastfeeding after giving birth and additional food felt more tired. In addition, several studies have revealed that postpartum fatigue has a negative effect on wound healing, motherhood behaviors, infant care activities, relationships with family members, work performance, self-care power, and the quality of life.[30] It has also been reported that postpartum fatigue has a negative impact on the relationship between mothers and their babies and growth and development of babies.[31],[32] Both the results of this study and the findings reported in the literature concur that early postpartum fatigue creates a negative influence on breastfeeding and leads mothers to feed their babies with additional food earlier.


   Conclusions Top


In the present study, the younger, older and primipara mothers, as well as those having a difficult delivery were shown to feel more tired. Furthermore, the mothers experiencing postpartum fatigue started breastfeeding late, breastfed their babies less frequently and started earlier to give their babies additional food. The women not needing help while breastfeeding had a significantly lower score for fatigue. It is therefore recommended that midwives and nurses be equipped with appropriate knowledge and skills to detect factors affecting postpartum fatigue and provide women experiencing this condition with support for breastfeeding.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study has not been financially supported by any commercial organization.

Conflicts of interest

There are no conflicts of interest.



 
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