Breastfeeding and its impact on daily life in women with type 1 diabetes during the first six months after childbirth: A prospective cohort study
Background For mothers with diabetes, breastfeeding is a great challenge due to their struggle with potentially unstable blood glucose levels. This paper explores breastfeeding attitudes and impact of breastfeeding on the daily life of mothers with type 1 diabetes compared with non-diabetic mothers. Methods We performed a prospective cohort study of 108 mothers with type 1 diabetes and a reference group of 104 mothers in the west of Sweden. Data were collected through medical records and structured telephone interviews at 2 and 6 months after childbirth. Results Women in both the diabetes group and the reference group had high levels of confidence (84% and 93% respectively) in their breastfeeding capacity before childbirth, and 90% assessed breastfeeding as a positive and an important experience during the six months of follow-up. About 80% assessed breastfeeding as influencing daily life ‘very much’ or ‘quite a lot’ at 2 months as did 60% at 6 months, with no difference between the groups. In mothers with diabetes, the impact of breastfeeding on the priority of other duties decreased over time, as did feelings of time pressure and negative effects on patterns of sleep. Compared to the reference group, mothers with diabetes at 6 months remained more affected by disruptions in daily life and they felt more worried about their health both at 2 and 6 months after childbirth. For the reference group mothers’ sensitivity to unexpected disruptions in daily routines decreased between 2 and 6 months after childbirth, and they expressed a greater need to organize their time than mothers with diabetes. Conclusion Mothers with diabetes type 1 express more worry for own health and are more sensitive to distruptions. To balance their everyday life and to reduce the risk of stress and illhealth they are therefor, compared to other mothers, likely to need additional professional and peer support.
RES E AR C H Open Access
Breastfeeding and its impact on daily life in
women with type 1 diabetes during the first
six months after childbirth: a prospective
, Lena-Karin Erlandsson
and Carina Sparud-Lundin
Background: For mothers with diabetes, breastfeeding is a great challenge due to their struggle with potentially
unstable blood glucose levels. This paper explores breastfeeding attitudes and impact of breastfeeding on the daily
life of mothers with type 1 diabetes compared with non-diabetic mothers.
Methods: We performed a prospective cohort study of 108 mothers with type 1 diabetes and a reference group of
104 mothers in the west of Sweden. Data were collected through medical records and structured telephone
interviews at 2 and 6 months after childbirth.
Results: Womeninboththediabetesgroupandthereferencegroup had high levels of confidence (84% and 93%
respectively) in their breastfeeding capacity before childbirth, and 90% assessed breastfeeding as a positive and an
important experience during the six months of follow-up. About 80% assessed breastfeeding as influencing daily life ‘very
much’ or ‘quite a lot’ at 2 months as did 60% at 6 months, with no differencebetweenthegroups.Inmotherswith
diabetes, the impact of breastfeeding on the priority of other duties decreased over time, as did feelings of time pressure
and negative effects on patterns of sleep. Compared to the reference group, mothers with diabetes at 6 months remained
more affected by disruptions in daily life and they felt more worried about their health both at 2 and 6 months after
childbirth. For the reference group mothers’ sensitivi ty to unexpected disruptions in daily routines decreased between 2
and 6 months after childbirth, and they expressed a greater need to organize their time than mothers with diabetes.
Conclusion: Mothers with diabetes type 1 express more worry for own health and are more sensitive to distruptions. To
balance their everyday life and to reduce the risk of stress and illhealth they are therefor, compared to other mothers,
likely to need additional professional and peer support.
It is recommended that mothers should exclusively
breastfeed their infants for the first 6 months because of
the many benefits of breastfeedin g . For mothers,
breastfeedin g is a deeply personal and embodie d expe-
rience which requires maternal commitment, adaption
and support . For some mothers, breastfeeding leads
to feelings of connectedness including harmony, one-
ness, and completeness, while for others it can lead to
disconnectedness and dissatisfaction  and be seen as a
moral imperative . Breastfeeding influences self-
esteem  but for many women it is connected with
shame and guilt related to a feeling of failure to live up
to ideals of good motherhood . Mothers who exclu-
sively breastfeed report higher levels of self-e fficacy than
mothers who exclusively formula feed their infants .
Several studies report high maternal breastfeeding self-
efficacy being associated with prolonged breastfeeding
, and women’s intention to breastfeed to be a strong
predictor for breastfeeding initiation and duration .
For mothers with diabetes, breastfeeding may be more
challenging than for mothers without diabetes. The ini-
tiation and establishment is often affected by birth
related complications [10,11]; their newborns often show
* Correspondence: email@example.com
Institute of Health and Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden
Full list of author information is available at the end of the article
© 2012 Berg et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Berg et al. International Breastfeeding Journal 2012, 7:20
a premature sucking pattern  and often need early
feeding because of a high risk of hypoglycae mia [13,14].
Early initiation of breastfeeding is shown to be a strong
predictive factor for long-term breastfeeding of infants
whose mothers have type 1 diabetes [10,11].
Mothers with type 1 diabetes have a different point
of entry into the breastfeeding situation than non-diabetic
mothers. Their situation includes a struggle in daily life
with breastfeeding, albeit with a strong motivation to suc-
ceed, simultaneously filled with uncertainty and unpre-
dictability related to their own unstable glycemic control
[15,16]. This instability results from a decreased need for
insulin related to increased glucose consumption during
the first few weeks of breastfeeding [17,18]. Mothers with
diabetes experience daily life as unpredictable and related
to problems with recognising their signs and symptoms of
bodily reactions related to diabetes during breastfeeding
Activities in daily life have been described as forming a
pattern . Some activities dominate in terms of time
and awareness, such as working or watching a movie,
while others are performed with less attention, such as
driving to work or having a cup of coffee. Daily life also
includes a varied number of unexpected activities which
interrupt and change the rhythm in the pattern of daily
activities. Whilst most adults organize their daily life
around stable weekly rhythms of activities, they are to
some extent open to changes of plans and routines. Thus,
people can generally manage with having a daily life and
patterns of daily activities that are only partly predictable
. However, having diabetes implies a tension between
balancing self-management of diabetes with engagement
in valued activities, and predictability and stable routines
are beneficial for self-management of the disease . For
mothers with diabetes, greater effort and flexibility is
required when they become a mother in order to balance
glycemic control because breastfeeding impacts on the
patterns of daily activities and often requires establishing
new daily patterns of activities [15,21]. With the aim
of identifying needs to develop supportive activities, this
paper explores breastfeeding attitudes and the impact of
breastfeeding on the daily life of mothers with type 1
diabetes compared with non-diabetic mothers.
As part of a research project investigating breastfeeding
in mothers with type 1 diabetes (MODIAB-breastfeeding)
a prospective cohort study comparing diabetes group with
a reference group was performed. Findings have been
reported in two publications [11,22].
Participants and setting
Mothers with type 1 diabetes who had given birth during
2007–2009 at four hospitals in the western region of
Sweden were invited to participate in the study by a cli-
nical midwife assisting the research project. The women
were invited during their stay at the maternity ward. For
every included mothe r with type 1 diabetes, the next
mother giving birth at the same hospital was invited as a
reference if she did not have any form of diabetes or
other long-term illness, and if she fulfille d the matching
criteria: gestational week and same parity (primipara or
multipara). Due to their short stay at the maternity ward,
these referen ce mothers were contacted by the clinical
research midwife by telephone within two weeks after
childbirth. Exclusion criteria for both groups were inabi-
lity to understand and speak Swedish. Verbal and writ-
ten information about the study was given and informed
consent was obtained from each participa nt. The study
was approved by the Regional Ethical Review Board
In Sweden, a team of midwives, obstetricians and
pediatricians manages the care of mother and child du-
ring the first week after childbirth. Thereafter the pri-
mary health care organization is responsible for the
health care of children aged 0–6 years. This child health
care service is free of charge and almost all parents visit
the pediatric/district nurse/physician regularly during
this time, with high frequency in the first few months
and with longer intervals thereafter.
Data on mode of delivery, gestational week and parity were
collected from medical records. In addition, data were
collected from telephone interviews with the mothers at 2
and 6 months after childbirth. The interviews followed a
structured questionnaire developed by the research group
and based on earlier studies [15,23,24]. The questionnaire
had been tested for face validity including comprehensibi-
lity and meaningfulness in a pilot group of 10 women with
type 1 diabetes and 10 matched controls. Included were
questions on socio-demographic factors, confidence about
breastfeeding capacity (‘very high’/‘high ’/‘low’), overall ex-
perience of breastfeeding (positive/negative), attitude to the
importance of breastfeeding (‘very important’/‘important’/
‘quite important’/‘unimportant’); occurrence of complica-
tions such as milk supply, occurrence of blocked ducts,
cracked nipples or painful breastfeeding (yes/no). Agree-
ment with a series of statements on how breastfeeding
had impacted on daily structure (yes/no) between 0–2
months and between 2–6 months were also included, as
previous qualitative studies had identified that mothers
with diab etes struggle to get structure in daily life with
simultaneous demands of diabetes management and breast-
feeding . An example of such statement is “breastfeed-
ing has decreased the priority of other duties” (see all
statements in Table 1).
Berg et al. International Breastfeeding Journal 2012, 7:20 Page 2 of 6
In this project, exclusive breastfeeding was defined as
no supplementation of formula milk, and partial breast-
feeding as a combination of breastfeeding and formula
feeding. To distinguish between the occurrence of exclu-
sive and partial breastfeeding, the women were asked at
time for telephone interview (at 2 and 6 months postpar-
tum), how many weeks (or months) after breastfeeding
initiation they had breastfed exclusively and partially re-
spectively (data not reported here).
Statistical power calculations were calculated on the vari-
ables, breastfeeding rates  and psychological well-being
 and not the variables central in this study. Analyses
of study variables were conducted using the software
SPSS 18.0 (Chicago, IL). Tests were two-tailed and con-
ducted at 5% significance level. Mean (standard deviation/
SD), median, and range (min-max) was used for descrip-
tive data; n (%) was used for categorical and dichotomous
variables. Pearson’s Chi-Square test and Fisher’s Exact test
were used for dichotomous variables to analyse differences
between the diabetic group (DG) and the reference group
(RG). Wilcoxon Signed Rank test was used to evaluate dif-
ferences over time within the groups, e.g. between mea-
surements at 2 and 6 months after childbirth.
Study group characteristics
Included at 2 months were 108 mothers in the diabetic
group and 104 in the reference group: at 6 months these
were 108 and 99 respectively. The number of potential
participants in the diabetic group was 128. Those who
declined to participate or missed inclusion (n = 20) did
not differ in any of the following aspects: age, gestational
week, mode of delivery, and birth weight. It was not
possible to conduct attrition analysis on the reference
group due to logistical obstacles. Study group character-
istics have been presented elsewhere . In brief, mean
age did not differ between the two groups (31.2 vs. 31.1,
p = 0.88) and neither did marital status: 97.2% vs. 98.1%
were co-habiting (p = 0.37). Moreover, educational level
did not differ between the groups (p = 0.93). The major-
ity had completed university degrees (diabetes group
56.1% and reference group 58.3%). Mean gestational
week at childbirth in the total group (diabetes and refer-
ence group) wa s 37.9 (SD 1.8) and 53% were primipa-
rous with no differences between the groups in line with
the matching criteria. Vaginal delivery was less common
among mothers with diabetes than in the refer ence
group (43.1 vs. 74.3%) .
The frequency of breastfeeding at discharge from hos-
pital was 55% in the diabetic group compared to 76.2%
in the reference group (p < 0.01). Breastfeeding rates at
2 and 6 months after childbirth are presented in Table 2,
and originally in Sparud-Lundin et al. .
Breastfeeding attitudes and complication rates
Of the women with diabetes, 84.1% (n = 90/108) had ‘very
high’ or ‘high’ confidence in their breastfeeding capacity
before childbirth compared to 92.3% (n = 96/104) women
Table 1 Comparison of breastfeeding impact on daily structure in mothers with and without type 1 diabetes 0–2 and
2–6 months postpartum
Mothers in Diabetes Group (DG) Mothers in Reference Group (RG) DG versus RG
Agreement with statements on whether
breastfeeding had impacted on daily
n = 105
n = 101
It has decreased the priority of n (%)
87 (71.4) 52 (53.6) 71 (70.3) 64 (68.5) 0.879 0.076
I sleep better than before n (%) 7 (6.7) 5 (8.2) 9 (8.9) 6 (6.8) 0.609 0.783
I sleep worse than before n (%) 81 (77.1) 62 (63.9) 83 (82.2) 70 (74.2) 0.392 0.165
I need to organize my time more
than before n (%)
87 (82.9) 71 (73.2) 94 (93.1) 82 (87.6) 0.032 0.051
I have become more sensitive to
unexpected disruptions in my daily
routine n (%)
57 (54.3) 49 (50.5) 48 (47.5) 31 (33.0) 0.403 0.041
I feel more worried about my
health n (%)
36 (34.3) 31 (32.0) 10 (10.9) 14 (14.8) <0.001 0.012
I feel less worried about my
health n (%)
27 (25.7) 19 (19.6) 28 (27.7) 24 (25.0) 0.755 0.598
I feel time pressure in my daily
life n (%)
78 (74.3) 58 (59.8) 62 (61.4) 55 (58.4) 0.053 1.000
I feel more calm and harmonious
than before n (%)
46 (43.8) 40 (41.7) 44 (44.0) 42 (44.3) 1.000 1.000
Wilcoxon Signed Rank Test
Fisher’s exact test
only ‘yes’ answers are reported ** experiences concerned breastfeeding impact during the period.
Berg et al. International Breastfeeding Journal 2012, 7:20 Page 3 of 6
in the reference group; this difference was not significant
(p = 0.19). Moreover, there were no differences in attitude
regarding the importance of breastfeeding at 2 months or
6 months; a few (3 to 7%) assessed it as ‘unimportant’
(Table 2). Women in the reference group were more likely
to have experienced cracked nipples and consequently
painful breastfeeding initially (Table 2). Use of pacifiers
was more frequent in the diabetes group than in the refer-
ence group at 2 months (85.2 vs. 71.2%, p = 0.02) but not
at 6 months (77.6 vs. 73.1%, p = 0.51).
Breastfeeding impact on daily life
The overall experience of breastfeeding was positive for
almost all women in both groups (Table 2). Breastfeeding
was assessed as influencing daily life ‘very much’ or ‘quite
alot’ during 0 to 2 months by 76.9% of mothers in the
diabetes group (n = 83/108) and by 82% of mothers in the
reference group (n = 84/104) (p = 0.62). At 6 months its
influence had dropped; the same assessment being given
by 63.1% of mothers with diabetes (n = 65/103) and 58.2%
(n = 57/98) of the mothers in the reference group
(p = 0.56). This influence significantly dropped over time
in both groups (diabetes group: p < 0.01 and reference
group: p < 0.01).
Detailed descriptions and a comparison of the impact
of breastfeeding on daily structure for mot hers in dia-
betes and reference groups are presented in Table 1.
Within the diabetes group, the impact of breastfeeding
on the priority of other duties (p < 0.01) and feelings
of time pressu re decreased between 2 and 6 months
(p = 0.02). Negative effects on patterns of sleep also
decreased during this time (p = 0.01). Within the refer-
ence group, the only difference between 2 and 6 months
after childbirth was being less sensitive to unexpected
disruptions in daily routines (p = 0.02). Mothers with
diabetes remained more affected by disruptions in daily
life 2 to 6 months postpa rtum. At 2 months, mothers in
the reference group expressed a greater need to organize
their time than mothers in the diabetes group (p = 0.03).
Women with diabetes felt more worried about their
health during the entire period (p < 0.01 and p = 0.01
respectively) (Table 1).
A high proportion of the women in both groups had felt
confident during pregnancy in their capacity to breastfeed.
Perhaps this explains, why the mothers with diabetes des-
pite the daily diabetes related pressures, did breastfeed to
such a high extent at both 2 and 6 months after childbirth.
A high degree of self-efficacy has been found elsewhere to
positively influence women’s decision to breastfeed .
Another encouraging result in our study is that the overall
experience of breastfeeding was positive for almost all
women in both groups, and especially for the mothers
Table 2 Comparison of breastfeeding rates, complications and experience in mothers with type 1 diabetes (DG) and
the reference group (RG)
Diabetes group Reference group DG versus RG Diabetes group Reference group DG versus RG
n = 108
n = 104
n = 108
Breastfeeding rate * n (%) 88 (80.7) 95 (91.3) 0.045
67 (61.5) 79 (76.7) 0.023
Exclusive 72 (80.0) 82 (86.3) 0.325
28 (44.4) 30 (40.5) 0.729
Insufficient milk supply 35 (36.1) 28 (29.5) 0.359
31 (35.2) 31 (28.6) 0.553
Oversupply of breast milk 36 (37.1) 33 (34.7) 0.847
20 (22.7) 17 (16.2) 0.651
Once 10 (10.3) 12 (12.6) 0.656
9 (10.2) 7 (6.7) 0.636
Twice or more 4 (4.1) 11 (11.6) 0.063
4 (4.5) 5 (4.8) 0.553
Cracked nipples 29 (29.9) 52 (54.7) 0.001
10 (11.4) 6 (5.7) 0.494
Painful breastfeeding 34 (35.4) 54 (56.8) 0.009
8 (9.1) 8 (7.6) 0.543
Positive 97 (94.2) 98 (95.1) 1.00
90 (92.8) 89 (90.8) 0.542
Importance of breastfeeding
n = 101 n = 104 0.204
n = 105 n = 99 0.724
Very important /important 77 (76.2) 78 (74.3) 83 (79.8) 74 (74.7)
Quite important 21 (20.8) 19 (18.1) 21 (20.2) 20 (20.2)
Not important/ not relevant 3 (3.0) 8 (7.6) 0 (0.0) 5 (5.1)
Fisher’s Exact test * The numbers report on occurrence of breastfeeding at 2 and 6 months interviews. Data reported elsewhere .
Berg et al. International Breastfeeding Journal 2012, 7:20 Page 4 of 6
with diabetes. We have previously reported that these
women experience a demanding time during the first few
months with their newborn . It would be reasonable
to believe that other aggravating circumstances, such as
the high frequency of caesarean sections, maternal com-
plications etc., among women with diabetes can have an
impact on health outcomes postpartum. However, these
variables were not shown to explain the shorter duration
of breastfeeding but are likely to explain why initiation
and establishment were more delayed in the diabetic
At both 2 and 6 months after childbirth, mothers with
diabetes reported less need to organize their time than
before compared to the reference mothers. This may
indicate that the mothers with diabetes already had dis-
tinct daily structures in place. While everyday life does
not have to be highly organized and structured for most
people, it often is for mothers with diabetes. As has been
described previously [15,22,23,25], for them organizing
and predicting everyday life means balancing activities
with managing blood glucose levels. This daily challenge
might be, at the same time, the explanation for the
somewhat inconsistent result that although the mothers
with diabetes reported less need to organize their time,
they remained more affected by disruptions in daily
life at 6 months postpartum than the reference group
mothers. Being accustomed to structure as mothers
managing their diabetes may have made them more
sensitive to changes and disruptions even before they
entered motherhood and began breastfeeding. This sug-
gested explanation has to be scientifically proven in
The study also focused on women’s concerns about
their own health, and we found that the mothers with
diabetes reported being more worrie d about their health
during the entire study period compared to the reference
group. The reason for this was not studied. One expla-
nation might be that their need for insulin, which had
increased 2 to 3 times during pregnancy, suddenly de-
creased afterwards and was frequently less than it was
before pregnancy . Hypoglycemic episodes in rela-
tion to breastfeeding have also been reported to be more
frequent , sometimes even dramatic episodes were
experienced . Another explanation might be that the
increased daily interruptions related to care for the new-
born or increased sensitivity to disruptions affected the
mothers’ level of concern. This suggested explan ation
also needs to be further explored.
Another study of a general population of women in
Sweden (aged 38 and 50) showed that perceived high
frequency of interruptions was related to poor subjective
health among the younger women, and to low satisfac-
tion with life as a whole in both groups. Women with
children living at home and/or who lived with a partner
experienced disturbing interruptions more frequently
than those without children living at home or those who
lived alone . Because frequent interruptions and
changes in daily activities may constitute a risk for a re-
duction in subjective health, it might be beneficial to
advise women with diabetes to minimize the risk for
interruptions and changes in routines after childbirth.
Our previou s findings showed a negative effect on psy-
chological well-being the more breastfeeding affected
diabetes management . Since one of the most com-
mon sources of interruptions and daily minor hassles in
women’s daily life are family members , it might be
important to inform those living with new mothers with
diabetes about their increased sensitivity to interruptions
in daily life and an extended need for support to reduce
such daily minor hassles to reduce risk of stress and ill
health. Previous studies have shown that peer supporters
are more likely than health care professionals to provide
an authentic presence related to sharing experiences
. Mothers with diabetes often lack access to support-
ive persons with common experiences of diabetes and
childbearing [16,28]. Sharing experiences about con-
structive ways of balancing everyday life and of ma-
naging unpredictable blood glucose levels while dealing
with daily activities during breastfeeding and childcare
might reduce their extraordinary challenges .
There are several limitations to be aware of in this study.
The relatively small sample size might have implications
for the power of the study as statistical power calcula-
tions were calculated on variables not central in this
study. Another limitation is that due to logistical obsta-
cles we have no information on the drop-out rate in the
The use of a questionnaire which has not been psycho-
metrically evaluated is a further limitation. We did not
find any psych ometrically evaluated instrument covering
the broad aspects of interest in this study. Unfortunately,
the Breastfeeding Self-Efficacy Scale  had not yet
been translated and validated to a Swedish population.
We did, however, test our questionnaire for face validity
in both groups of women. Similar statements about daily
structure and interruptions have been used in other stu-
dies with women [26,30] which may thereby increase the
applicability of these statements in the questionnaire. A
factor that supports the use of a specifically designed
questionnaire is the need to use contextual questions in
specific and unique situations. Detailed validation might
be needed in some areas. When exploring new areas, a
creative and pragmatic approach has to be used, and
there are many examples of useful data being derived
from simple tools in different studies . Nevertheless,
Berg et al. International Breastfeeding Journal 2012, 7:20 Page 5 of 6
these preliminary findings require replication and further
investigation in order to draw conclusions.
The strength of our study is the use of matched con-
trols with same parity and childbirth in the same gesta-
tional week, as it allows comparison between two groups
with a crucial difference such as living with or without a
demanding chronic illness – diabetes, for example.
The results indicate that mothers with diabetes might be
more sensitive to changes and disruptions because of
their increased need for daily structure related to ma-
naging diabetes particularly in relation to breastfeeding.
Based on this and findings from previous studies, one
can conclude that they are likely to need additional pro-
fessional and peer support after childbirth to balance
their everyday life to reduce the risk of stress and ill
health. Both health profess ionals and relatives need to be
informed of the unique prerequisites of entering mother-
hood when having diabetes.
The authors declare that they have no competing interests.
CS-L collected and analysed data and wrote the manuscript. L-KE wrote the
manuscript. MB analysed data and wrote the manuscript. All authors read
and approved the final manuscript.
The study was funded by the Swedish Diabetes Association (DIA2007-016),
Capio Research Foundation (2007–1405), and The Goljes Foundation. The
authors are grateful to Annelen Dahlgren, Annlis Fröjd, Ingrid Krus, Maria
Hassel Salén and Monica Ellkvist for their assistance in identifying
participants, and to all the women who participated in the study.
Institute of Health and Care Sciences, Sahlgrenska Academy, University of
Gothenburg, Gothenburg, Sweden.
Department of Health Sciences, Faculty
of Medicine, Lund University, Lund, Sweden.
Received: 10 April 2012 Accepted: 16 December 2012
Published: 21 December 2012
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Cite this article as: Berg et al.: Breastfeeding and its impact on daily life
in w omen with type 1 diabetes during the first six months after
childbirth: a prospective cohort study. International Breastfeeding Journal
Berg et al. International Breastfeeding Journal 2012, 7:20 Page 6 of 6