Associations between adverse childhood experiences and breastfeeding initiation and duration: a longitudinal birth cohort study in Pakistan

Rationale: Prior studies have found that a history of adverse childhood experiences (ACEs) is associated with breastfeeding initiation and duration, but the evidence is inconsistent. Despite low- and middle-income countries (LMICs) carrying a disproportionate amount of poor maternal and infant health outcomes, and despite evidence that breastfeeding could alleviate some of these outcomes, little research has assessed the relative impact of ACEs on breastfeeding initiation and duration of exclusive breastfeeding in LMICs. Objective: The study investigates whether maternal ACEs are associated with breastfeeding initiation and exclusive breastfeeding at 3 and 6 months postpartum among a cohort of women from rural Pakistan. Methods: The cross-sectional analysis included 869 women 18-45 years of age from the Bachpan Cohort Study. Multivariable modified log-Poisson regression models were used to assess the relationship between any ACE exposure with breastfeeding initiation (n=755) and exclusive breastfeeding at 3 (n=758) and 6 months (n=809). Models were adjusted for known confounders. Results: 55.2% of participants reported experiencing at least 1 ACE. 17.6% of women with a history of at least one ACE reported initiating breastfeeding within an hour of childbirth. 43.8% of women with at least one ACE reported exclusively breastfeeding at 3 months postpartum and 7.6% of women with at least one ACE reported exclusively breastfeeding within the last 24 hours at 6 months postpartum. There was no significant difference between groups for initiating breastfeeding. However, women who had experienced ACEs were less likely to recall exclusively breastfeeding at 3 (RR=0.8; 95 CI=0.7, 0.9) and 6 months (RR=0.8; 95% CI=0.5, 1.2) postpartum compared to women with no self-reported history of ACEs. Conclusion: Our findings indicate that ACEs may contribute to differences in exclusive breastfeeding. Understanding the long-term effects of ACEs on breastfeeding is important to help inform the design of intervention programs to prevent or mediate the negative repercussions of ACEs.