Acculturation and the initiation of breastfeeding

Acculturation and Breastfeeding Among Hispanic American Women: A Systematic Review

Introduction Hispanic immigrants are more likely to breastfeed than are Hispanics born in the US, in part due to their acculturation. This paper aims to systematically review the existing literature on the association between acculturation and Hispanics' breastfeeding behaviors. Methods The systematic search used major databases such as Medline and PubMed, and it followed the PRISMA checklist. The scientific quality of the studies was rated using the Quality Assessment Tool for Quantitative Studies. Results We identified 1943 potential citations, of which 18 studies met the eligibility criteria. Overall, while 13 studies suggested that high-acculturated Hispanics were less likely to breastfeed compared with low-acculturated, five studies did not find significant evidence of such an association. Moreover, 12 studies used a static measure or a linear scale, which is not optimal; only three studies utilized bi/multidimensional scales to assess acculturation. Intention to breastfeed was examined in six studies, but the results were inconsistent. Breastfeeding initiation was examined in 11 studies, and two out of eight studies that examined breastfeeding duration, specifically analyzed exclusive breastfeeding at 6 months. Discussion Our results agree with the general hypothesis that higher acculturation is inversely related to breastfeeding rates, independently of income. Researchers used different methodologies to study acculturation and breastfeeding practices, limiting our ability to reach more detailed conclusions. Owing to the lack of a standard methodology for measuring acculturation, future studies should utilize bi/multidimensional scales when studying breastfeeding, in particular, in relation to breastfeeding intention and exclusive breastfeeding at 6 months; preferably according to Hispanic subgroups.

Interracial couples and breastfeeding initiation in the United States

In the past decade, the prevalence of interracial couples has steadily increased. Recent reports state that nearly one in five marriages are between spouses of different races. Interracial couples receive less social support and are more likely to separate. As a result, children born to these couples may be at an increased risk of poor health outcomes. This study aims to investigate the relationship between interracial couples and breastfeeding initiation. Data from the 2014 Vital Statistics Natality Birth database were analyzed. Data were restricted to singleton births and infants with no congenital malformations. Racial composition of parents was categorized as non-Hispanic (NH) white, NH black; Hispanic; NH white/NH black; NH white/Hispanic; and NH black/Hispanic. Breastfeeding initiation (yes; no) was categorized according to information from the child's birth certificate file. Multiple logistic regression was used to generate crude and adjusted odds ratios and 99% confidence intervals. After adjusting for confounders, all interracial couples with at least one Hispanic parent had increased odds of breastfeeding initiation. Interracial white and black parents had 18% lower odds of breastfeeding initiation. The lowest odds of breastfeeding initiation were observed among intraracial black parents, who had 43% lower odds of breastfeeding initiation compared to intraracial white parents. Breastfeeding non-initiation continues to pose the greatest risk for infants with at least one black parent. Nurses, midwives, physicians, and other medical staff should discuss potential barriers that may be unique to interracial couples and provide additional breastfeeding education and support.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Does the Degree of Acculturation Influence Breastfeeding Intention and Start or the Frequency of Early Weaning? Results of a Prospective Observational Study

Objectives

Recent breastfeeding studies from immigration countries have found that acculturation factors influence breastfeeding behaviour in women with a migration background. To date, there has been no systematic investigation for Germany. Therefore, we study whether and how the degree of acculturation within a population of migrant women influences the start, time and duration of breastfeeding.

Patient Population and Methodology

Pregnant women who were admitted to one of the three participating maternity clinics in Berlin for the birth of their child in the one-year study period were surveyed (including sociodemographic details, data on migration/acculturation). These women were interviewed again two or three days post partum (including start of breastfeeding, planned breastfeeding duration, reasons for not breastfeeding). In a subgroup, a telephone interview took place 6 months post partum about the actual breastfeeding duration, contraceptive behaviour post partum and availing of midwife services following delivery. Breastfeeding behaviour was analysed using multivariate regression models, among other things.

Results

The prepartum survey included 7100 women, 6884 women were contacted in the postnatal wards, and the subgroup six months after delivery comprised 605 women. No acculturation-related differences were found in the start of breastfeeding. In the adjusted model, a medium and higher degree of acculturation diminished the chance of planning a long breastfeeding period. More acculturated women show a greater risk of weaning within the first six months than less acculturated women.

Conclusion

The degree of acculturation has relevant significance for some aspects of breastfeeding behaviour in women with a migration background. This should be considered both in breastfeeding promotion programmes and in further national breastfeeding studies.

Randomized Controlled Trial to Prevent Infant Overweight in a High-Risk Population

OBJECTIVES

Infants are at risk of overweight. Infant overweight predisposes child, adolescent, and adult to obesity. We hypothesized that parent education, initiated prenatally and provided in the home, would reduce the incidence of infant overweight at age 12 months.

METHODS

Pregnant obese Latina women were recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and randomized to intervention versus control. Intervention subjects received home visits by trained Spanish-fluent community health workers who provided counseling on infant growth, breastfeeding, nutrition, child development, sleep, physical activity, and safety. Promotoras did not visit the control subjects. A research assistant collected outcome data on all subjects.

RESULTS

Compared to controls, parent education did not reduce infant overweight. Infant overweight developed rapidly and was present in 46% of infants by age 6 months. Infants overweight at 6 months were likely to be overweight at age 12 months (r = 0.60, P < .0001). Overweight was more common in formula-fed infants at ages 6 months (P < .06) and 12 months (P = .005). Breastfeeding was less common in families with employed mothers (P = .02) and unemployed fathers (P < .01), but the father living with the mother at the time of the prenatal visit predicted successful breastfeeding at infant age 2 months (P < .003). Compared to formula feeding, overweight at age 12 months was 2.7 times less likely for infants breastfed for ≥2 months (P = .01).

CONCLUSIONS

The lack of success of the intervention may be explained in part by a high cesarean section rate in the intervention group, food and employment insecurity, and confounding by WIC breastfeeding promotion, which was available to all mothers. Breastfeeding was the most important mediator of infant overweight. The study supports efforts by WIC to vigorously promote breastfeeding.

The impact of immigration on the breastfeeding practices of Mainland Chinese immigrants in Hong Kong

BACKGROUND

Researchers have found breastfeeding disparities between immigrant and native-born women in many countries. However, most studies on immigration and breastfeeding practices have been in Western countries. The aim of this study was to examine the effect of length of time since immigration on the breastfeeding practices of Mainland Chinese immigrants living in Hong Kong.

METHODS

We recruited 2704 mother-infant pairs from the postnatal wards of four public hospitals in Hong Kong. We examined the effect of migration status on the duration of any and exclusive breastfeeding.

RESULTS

Breastfeeding duration was progressively shorter as the time since immigration increased. When compared with mothers who had lived in Hong Kong for <5 years, Hong Kong-born participants had a 30% higher risk of stopping any breastfeeding (hazard ratio [HR] 1.34 [95% confidence interval {CI} 1.10-1.63]) and exclusive breastfeeding (HR 1.33 [95% CI 1.11-1.58]). In both Hong Kong-born and immigrant participants, breastfeeding cessation was associated with return to work postpartum and the husband's preference for infant formula or mixed feeding. Intention to exclusively breastfeed and to breastfeed for >6 months, and previous breastfeeding experience substantially reduced the risk of breastfeeding cessation for both Hong Kong-born and immigrant participants.

CONCLUSIONS

Health care professionals should consider immigration history in their assessment of pregnant women and provide culturally adapted breastfeeding support and encouragement to this population.

Nativity, Country of Education, and Mexican-Origin Women's Breastfeeding Behaviors in the First 10 Months Postpartum

BACKGROUND

Breastfeeding is associated with numerous health benefits for the infant and mother. Latina women in the United States have historically had high overall rates of initiation and duration of breastfeeding. However, these rates vary by nativity and time lived in the United States. Exclusive breastfeeding patterns among Latina women are unclear. In this study, we investigate the current and exclusive breastfeeding patterns of Mexican-origin women at four time points from delivery to 10 months postpartum to determine the combined association of nativity and country of education with breastfeeding duration and supplementation.

METHODS

Data are from the Postpartum Contraception Study, a prospective cohort study of postpartum women ages 18-44 recruited from three hospitals in Austin and El Paso, Texas. We included Mexican-origin women who were born in either the United States or Mexico in the analytic sample (n = 593).

RESULTS

Women completing schooling in Mexico had higher rates of overall breastfeeding throughout the study period than women educated in the United States, regardless of country of birth. This trend held in multivariate models while diminishing over time. Women born in Mexico who completed their schooling in the United States were least likely to exclusively breastfeed.

DISCUSSION

Country of education should also be considered when assessing Latina women's risk for breastfeeding discontinuation. Efforts should be made to identify the barriers and facilitators to breastfeeding among US-educated Mexican-origin women to enhance existing breastfeeding promotion efforts in the United States.

The Relationship Among Breastfeeding, Postpartum Depression, and Postpartum Weight in Mexican American Women

OBJECTIVE

To determine if symptoms of postpartum depression and postpartum weight varied according to the level of breastfeeding among women of Mexican origin at 1 month and 6 months postpartum.

DESIGN

Secondary quantitative analysis to study the differences in postpartum weight and depression among the mothers in the study who breastfed and those who did not.

SETTING

A heavily Hispanic community located in a major Southwestern U.S. city.

PARTICIPANTS

Women of Mexican origin (N = 150) who enrolled during their third trimesters in a local Special Supplemental Nutrition Program for Women, Infants, and Children clinic and were followed for 6 months.

METHODS

Weight was measured at 1 month and at 6 months postpartum at home visits with validated digital scales. Breastfeeding was measured according to World Health Organization criteria and recorded after monthly phone calls. Depression was measured at home visits at 1 month and 6 months with the Edinburgh Postnatal Depression Scale.

RESULTS

At 6 months postpartum, participants who did not breastfeed had the highest scores on the Edinburgh Postnatal Depression Scale; participants who breastfed nonexclusively had the lowest scores (p = .067). At both time points, there was a significant difference in weight (p = .017) between women who were doing any breastfeeding and women who were not breastfeeding.

CONCLUSION

Breastfeeding, even if not exclusive, contributed to lower depression scores and significantly lower postpartum weight among this sample of Mexican American women.

Effects of Support on the Initiation and Duration of Breastfeeding

Researchers attempted to increase the initiation of breastfeeding and its duration to 6 months among a group of low-income, Hispanic women through an intervention program which included prenatal education and home based postpartum support. All participants were telephoned after delivery to determine infant feeding method. Duration of breastfeeding was determined by counting the number of days from initiation to the last day the baby was put to the breast. The Bayesian approach was used for the statistical analyses. In the intervention group, the propensity to initiate breastfeeding exceeded that of the control group. Results indicate the intervention group had twice (2.31) the odds of starting breastfeeding, twice (1.84-3.15) the odds of continuing to breastfeed for 6 months, and only half (.50-.54) the tendency to quit at any one time than did the control group.

Prepregnancy Obesity Class Is a Risk Factor for Failure to Exclusively Breastfeed at Hospital Discharge among Latinas

BACKGROUND

Suboptimal infant feeding practices, including the failure to exclusively breastfeed, are modifiable risk factors that affect multiple maternal and child health outcomes. Women who are overweight or obese prenatally are more likely to fail to exclusively breastfeed. In the United States, Latinas represent a high-risk population with respect to overweight, obesity, and suboptimal infant feeding practices.

OBJECTIVES

Examine whether exclusive breastfeeding status at hospital discharge among overweight and obese Latinas was associated with (1) prepregnancy body mass index (BMI) and gestational weight gain and (2) sociodemographic, psychosocial, and maternal/infant biomedical factors.

METHODS

An electronic medical records review was conducted to determine exclusive breastfeeding status at hospital discharge among Latinas who gave birth at Hartford Hospital, Hartford, Connecticut, USA (N = 480). Eligible participants were ≥ 16 years, Latina, overweight or obese (BMI ≥ 25.0 kg/m(2)) and delivered a healthy full-term (≥ 37 weeks) singleton.

RESULTS

In the multivariable model, obese class II (BMI, 35.0-39.9 kg/m(2)) women had increased odds of failing to exclusively breastfeed at hospital discharge compared with overweight women. Planned formula use/partial breastfeeding was the single strongest predictor of nonexclusive breastfeeding status. Other risk factors included Puerto Rican ethnicity and parity.

CONCLUSION

Maternal prepregnancy obesity class is an important predictor of exclusive breastfeeding status at hospital discharge among overweight and obese Latinas. Future research should examine why in-hospital exclusive breastfeeding behaviors differ by obesity class to subsequently inform the design of breastfeeding promotion and support interventions tailored to the needs of Latinas by obesity class. Culturally appropriate prenatal breastfeeding promotion interventions emphasizing action and coping planning should be considered.

Acculturation and Intention to Breastfeed among a Population of Predominantly Puerto Rican Women

BACKGROUND

Latinas have high overall breastfeeding initiation rates, yet Puerto Ricans have among the lowest exclusive breastfeeding rates. This study sought to determine if acculturation was associated with intent to breastfeed in a predominantly Puerto Rican population.

METHODS

A cohort of Latina women were enrolled in Proyecto Buena Salud, and provided information on infant feeding intent (n = 1,323). Acculturation was assessed via the Psychological Acculturation Scale (PAS), language preference, and generation in the United States.

RESULTS

Increasing acculturation as measured by English language preference (aOR 0.61 [95% CI 0.42-0.88]) and second or third generation in the United States (aOR 0.70 [95% CI 0.52-0.95)] was inversely associated with odds of intending to exclusively breastfeed. Similarly, women with higher levels of acculturation as measured by the PAS (aOR 0.67 [95% CI 0.45-0.99]), English language preference (aOR 0.48 [95% CI 0.33-0.70]) and second or third generation in the United States (aOR 0.42 [95% CI 0.31-0.58]) were less likely to report intent to combination feed as compared with women with lower acculturation.

CONCLUSIONS

Acculturation was inversely associated with intent to exclusively breastfeed and intent to combination feed in this predominantly Puerto Rican sample.

Sleep Moderates and Mediates the Relationship Between Acculturation and Depressive Symptoms in Pregnant Mexican-American Women

OBJECTIVE

Greater acculturation is associated with adverse perinatal outcomes in Mexican-American women, but the mechanisms by which acculturation influences perinatal outcomes are unclear. Pregnant acculturated Mexican-American women are more likely to engage in unhealthy prenatal behaviors relative to those less acculturated, including poor sleep. As sleep disruptions are associated with acculturation and negative perinatal outcomes, particularly maternal depression, alterations in sleep may adversely affect pregnant Mexican-American women.

METHODS

Sixty pregnant women of Mexican descent completed surveys about sleep, acculturation, depressive symptoms and potential protective factor of social support.

RESULTS

Acculturation, but not social support, significantly predicted increased sleep disruptions as well as overall feeling less refreshed upon waking across pregnancy. Moderation analysis indicated that more acculturated women who took longer to fall asleep reported increased depressive symptoms. Feeling refreshed upon waking also mediated the relationship between increased acculturation and elevated maternal depressive symptoms.

CONCLUSIONS

Acculturation and altered sleep contribute to greater risk in Mexican-American women for maternal depressive symptoms in the perinatal period. These findings have implications for prevention and treatment of maternal mental health disorders, which may adversely affect perinatal outcomes in the vulnerable Mexican-American population.

Clinical Interventions to Promote Breastfeeding by Latinas: A Meta-analysis

CONTEXT

Breastfeeding duration and exclusivity among Latinas fall below recommended levels, indicating a need for targeted interventions. The effectiveness of clinical breastfeeding interventions for Latinas remains unclear.

OBJECTIVE

To systematically review the documented effectiveness of clinical breastfeeding interventions on any and exclusive breastfeeding among Latinas.

DATA SOURCES

English-language publications in Medline, CINAHL, and Embase were searched through May 28, 2015.

STUDY SELECTION

Fourteen prospective, controlled studies describing 17 interventions met inclusion criteria.

DATA EXTRACTION

Extracted study characteristics include study design, population characteristics, intervention components, timing and intensity of delivery, provider type, control procedures, and outcome measures.

RESULTS

Random-effects meta-analyses estimated risk differences (RDs) between breastfeeding mothers in intervention and control arms of each study and 95% prediction intervals (PIs) within which 95% of intervals cover the true value estimated by a future study. Interventions increased any breastfeeding at 1 to 3 and 4 to 6 months (RD 0.04 [95% PI -0.15 to 0.23] and 0.08 [-0.08 to 0.25], respectively) and exclusive breastfeeding at 1 to 3 and 4 to 6 months (0.04 [-0.09 to 0.18] and 0.01 [-0.01 to 0.02]). Funnel plot asymmetry suggested publication bias for initiation and 1- to 3-month any breastfeeding. Estimates were slightly larger among interventions with prenatal and postpartum components, 3 to 6 patient contacts, and delivery by an International Board Certified Lactation Consultant or lay provider.

LIMITATIONS

The published evidence for Latinas is limited, and studies have varying methodologic rigor.

CONCLUSIONS

Breastfeeding interventions targeting Latinas increased any and exclusive breastfeeding compared with usual care.

Acculturative stress negatively impacts maternal depressive symptoms in Mexican-American women during pregnancy

BACKGROUND

Mexican-American women exhibit high rates of prenatal maternal depressive symptoms relative to the general population. Though pregnant acculturated Mexican-American women experience cultural stressors such as acculturation, acculturative stress and discrimination that may contribute to elevated depressive symptoms, the contribution of these socio-cultural correlates to depressive symptomology is unknown.

METHOD

Ninety-eight pregnant women of Mexican descent were recruited from a community hospital clinic during their first trimester. Women completed surveys about acculturation, acculturative stress, perceived discrimination, general perceived stress, and maternal depressive symptoms as well as the potential protective factor of Mexican cultural values.

RESULTS

Women who experienced greater acculturative and perceived stress, but not perceived discrimination or acculturation, reported significantly elevated depressive symptoms during pregnancy. Also, women who experienced greater acculturative stress identified with a mixture of Mexican and American cultural values. However, only the Mexican cultural value of respect was protective against maternal depressive symptoms while adhering to the Anglo value of independence and self-reliance was a risk factor.

LIMITATIONS

A limitation in the study is the cross-sectional and descriptive self-report nature of the work, underscoring the need for additional research. Moreover, physiological measures of stress were not analyzed in the current study.

CONCLUSIONS

Results point to acculturative stress, above other cultural stressors, as a potential intervention target in culturally competent obstetric care. These findings have implications for maternal mental health treatment during pregnancy, which likely affects maternal-fetal programming and may favorably affect perinatal outcomes in the vulnerable Mexican-American population.

Racial and ethnic disparities in breastfeeding

This article's aim is to review the literature on racial and ethnic disparities in breastfeeding rates and practices, address barriers to breastfeeding among minority women, conduct a systematic review of breastfeeding interventions, and provide obstetrician-gynecologists with recommendations on how they can help increase rates among minority women. In order to do so, the literature of racial and ethnic disparities in breastfeeding rates and barriers among minority women was reviewed, and a systematic review of breastfeeding interventions among minority women on PubMed and MEDLINE was conducted. Racial and ethnic minority women continue to have lower breastfeeding rates than white women and are not close to meeting the Healthy People 2020 goals. Minority women report many barriers to breastfeeding. Major efforts are still needed to improve breastfeeding initiation and duration rates among minority women in the United States. Obstetrician-gynecologists have a unique opportunity to promote and support breastfeeding through their clinical practices and public policy, and their efforts can have a meaningful impact on the future health of the mother and child.

The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

Breastfeeding practices of ethnic Indian immigrant women in Melbourne, Australia

BACKGROUND

The health benefits of breastfeeding are well documented in public health and medical literature worldwide. Despite this, global rates of breastfeeding steadily decline during the first couple of months postpartum. Although immigrant women have higher initiation rates and a longer duration of breastfeeding overall, breastfeeding practices are compromised because of a myriad of socioeconomic and cultural factors, including the acculturation process. The objective of this study was to show how acculturation and cultural identity influenced breastfeeding practices among Indian immigrants in Melbourne, Australia.

METHODS

Twelve case studies were employed to gather narratives of women's lived experiences. Ethnographic field research methods were used to collect data, including participant observation, semi-structured interviews, case studies, and life histories. This provided in-depth information from women on various aspects of the immigrant experience of motherhood, including infant care and feeding. Participants were opportunistically recruited from Indian obstetricians and gynaecologists. Women identifying as ethnic Indian and in their third trimester of pregnancy were recruited. Interviews were conducted in women's homes in metropolitan Melbourne over a 12 month period between 2004 and 2005. Data were coded and analysed thematically.

RESULTS

All women identified as ethnic Indian and initiated breastfeeding in accordance with their cultural identity. Social support and cultural connectivity impacted positively on duration of breastfeeding. However, acculturation (adopting Australian cultural values and gender norms, including returning to paid employment) negatively influenced breastfeeding duration. In addition, the high reliance of recent immigrants on the advice of healthcare professionals who gave inconsistent advice negatively affected exclusive breastfeeding.

CONCLUSIONS

For ethnic Indian immigrant women breastfeeding practice is closely linked to acculturation and identity construction, both personal and communal. The lack of social and cultural networks for recent immigrants prevents their involvement in the cultural systems that traditionally support breastfeeding. With this in mind, healthcare professionals should deliver services in a culturally appropriate and sensitive manner where women feel supported as well as empowered.

The impact of transnational migration on intergenerational transmission of knowledge and practice related to breast feeding

OBJECTIVES

the aim of this study was to explore how migration from Bangladesh to the UK influenced the transmission of knowledge and practice related to breast feeding from one generation to the next.

METHODS

this qualitative study used an ethnographic approach and comprised two focus group discussions with 14 grandmothers who had migrated from Bangladesh to the UK and in-depth interviews with 23 mothers of Bangladeshi origin who had breast fed in the UK within the previous five years. The focus group discussions and 10 of the interviews with mothers were conducted in Sylheti by a bilingual researcher. The study took place in four localities in northern England in 2008.

FINDINGS

grandmothers and mothers of Bangladeshi origin emphasised the importance of intergenerational transmission of knowledge and practice related to breast feeding. However, migration disrupted this transmission through isolating women from their female kin, exposing them to a society in which breast feeding is mostly hidden and that privileges health professionals as an important source of information about breast feeding.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

understanding how migration influences the knowledge and advice that grandmothers pass on to younger mothers could help health professionals facilitate family support for breast feeding. Health professionals could start by asking grandmothers about their experiences of breast feeding in their countries of origin and the host country. Where relevant, previous poor professional support for breast feeding should be acknowledged. Health professionals should not underestimate their role in influencing breast feeding decisions of mothers of Bangladeshi origin.

Acculturation and celiac disease risk in second-generation immigrants: a nationwide cohort study in Sweden

OBJECTIVES

The burden of celiac disease (CD) is increasingly recognized as a global problem. However, whether this situation depends on genetics or environmental factors is uncertain. The authors examined these aspects in Sweden, a country in which the risk of CD is generally considered to be high. If environmental factors are relevant, CD risk in second-generation immigrant children should be related to maternal length of stay in Sweden before delivery.

MATERIAL AND METHODS

Linking the Swedish Medical Birth Registry to other national registries, the authors investigated all singleton children (n = 792,401) born in Sweden between 1987 and 1993. They studied the risk of CD in children before age 6 as a function of the mother's geographical region of birth and length of stay in Sweden before delivery using Cox regression models.

RESULTS

In children whose mothers immigrated to Sweden from a country outside of Europe, a maternal length of stay in Sweden of more than 5 years increased the hazard ratio (HR) of CD (1.73, 95% confidence interval (CI) 1.06-2.81). The authors observed a similar result among children born to mothers from a Nordic country outside of Sweden (HR 1.57, 95% CI 0.89-2.75), but a non-conclusive protective effect was observed in second-generation immigrant children from a non-Nordic European country (HR 0.65, 95% CI 0.39-1.09).

CONCLUSIONS

The risk of CD among second-generation immigrants seems to be conditioned by maternal length of stay in Sweden before delivery, suggesting that environmental factors contribute to the variation in CD risk observed across populations.

Assessing infant breastfeeding beliefs among low-income mexican americans

Focus groups were conducted with low-income, pregnant women and new mothers receiving services from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC program) along with their male partners and their mothers. All participants were Hispanics of Mexican American origin. The topics for the focus-group discussions were breastfeeding beliefs and perceptions. All participants were aware of the benefits of breastfeeding. Participants identified time, embarrassment, and pain as barriers to breastfeeding; discussed decision-making efforts regarding breastfeeding; identified cultural beliefs related to breastfeeding; and discussed the lack of care-provider support for breastfeeding.

Association between acculturation and breastfeeding among Hispanic women: data from the Pregnancy Risk Assessment and Monitoring System

BACKGROUND

Breastfeeding rates are typically higher among Hispanic women; however, they vary by acculturation status in that those more acculturated are less likely to breastfeed than those who are less acculturated. This study examined the association between acculturation and breastfeeding behaviors using population-based data.

METHODS

Data (N = 8942) from the Pregnancy Risk Assessment Monitoring System (PRAMS) were used for analysis. Acculturation status was determined using self-reported Hispanic ethnicity and the language in which the women responded to the PRAMS survey, either English or Spanish. Hispanic women who responded to the survey in Spanish were categorized as less acculturated than those who responded in English. Breastfeeding indicators used were: initiation, duration to ≥ 10 weeks, and exclusive breastfeeding to ≥ 10 weeks.

RESULTS

The prevalence rates of breastfeeding initiation, duration, and exclusive breastfeeding to ≥ 10 weeks were significantly higher among less acculturated than among highly acculturated. More acculturated were less likely to initiate breastfeeding (prevalence ratio [PR] = 0.88; 95% CI, 0.86-0.90), less likely to breastfeed ≥ 10 weeks (PR = 0.77; 95% CI, 0.72-0.82), and less likely to report exclusive breastfeeding to ≥ 10 weeks (PR =,0.70; 95% CI, 0.58-0.85). The relationship between breastfeeding continuation and acculturation persisted after adjusting for covariates in that more acculturated were less likely to breastfeed to ≥ 10 weeks (adjusted prevalence ratio [APR] = 0.81; 95% CI, 0.75-0.87), as did the relationship between exclusivity and acculturation; more acculturated were less likely to report exclusive breastfeeding (APR = 0.69; 95% CI, 0.55-0.87).

CONCLUSIONS

Breastfeeding promotion efforts must include culturally/linguistically supportive services to assure that women are able to make optimal infant feeding decisions.

Acculturative type is associated with breastfeeding duration among low-income Latinas

We sought to assess the relationship between acculturative type and breastfeeding outcomes among low-income Latinas, utilising a multidimensional assessment of acculturation. We analysed data derived from a breastfeeding peer counselling randomised trial. Acculturation was assessed during pregnancy using a modified Acculturation Rating Scale for Mexican Americans scale. Analyses were restricted to Latinas who completed the acculturation scale and had post-partum breastfeeding data (n = 114). Cox survival analyses were conducted to evaluate differences in breastfeeding continuation and exclusivity by acculturative type. Participants were classified as integrated-high (23.7%, n = 27), traditional Hispanic (36.8%, n = 42), integrated-low (12.3%, n = 14) and assimilated (27.2%, n = 31). The integrated-low group was significantly more likely to continue breastfeeding than the traditional Hispanic, assimilated, and integrated-high groups (P < 0.05, P < 0.05, and P < 0.01, respectively). The traditional Hispanic group was marginally more likely to continue breastfeeding than the integrated-high group (P = 0.06). Breastfeeding continuation rates vary significantly between acculturative types in this multinational, low-income Latina sample. Multidimensional assessments of acculturation may prove useful in better tailoring future breastfeeding promotion interventions.

Evaluation of a breastfeeding peer support program for fathers of Hispanic participants in a Texas special supplemental nutrition program for women, infants, and children

A mother's decision to breastfeed and the duration of breastfeeding depends on different factors; among them are the support of her husband or male partner and other social support. There have been different types of support programs for mothers and few have targeted fathers. In 2002, the Texas Special Supplemental Nutrition Program for Women, Infants, and Children introduced an innovative approach for encouraging breastfeeding among mothers and their spouses. The pilot Peer Dad Program targeted fathers to promote and support their spouse in breastfeeding. This cohort study evaluated duration of breastfeeding among Hispanic couples who enrolled in the pilot Peer Dad Program (n=101) and those who did not enroll (n=99). Structured interviews were conducted with Special Supplemental Nutrition Program for Women, Infants, and Children participants and their male partners. Unconditional logistic regression was used to estimate the likelihood of continuing breastfeeding past 6 months associated with participation in the Peer Dad Program and significant predictors. Mothers whose partner participated in the pilot Peer Dad Program were no more likely to continue breastfeeding past 6 months (odds ratio 1.44, 95% confidence interval 0.82 to 2.54) compared with mothers who received peer counseling only. The percentage of women in the intervention group (63.4%) who breastfed for 6 months or longer compared with women in the control group (54.6%) was not significant (P=0.20). Although other studies suggest that father's support lengthens breastfeeding duration, our study, which targeted Hispanic fathers, found no association due to its small sample size. Further research with larger studies is needed to establish this association.

Are 2 weeks of daily breastfeeding support insufficient to overcome the influences of formula?

OBJECTIVE

To evaluate the effectiveness of proactive telephone breastfeeding support in low-income, primiparous, primarily Latina women on 1) duration and exclusivity of breastfeeding, 2) satisfaction with feeding, 3) rationale for discontinuing breastfeeding and 4) health care utilization.

METHODS

Randomized controlled trial comparing usual care to 2 weeks of daily telephone calls by nurses by using culturally informed scripted protocols; and qualitative study of focused interviews on a sample of women in the intervention group (n = 40).

RESULTS

Breastfeeding duration and exclusivity rates, feeding method satisfaction, and reasons for stopping breastfeeding did not differ significantly between intervention (n = 161) and control (n = 180) groups, with 74% of both breastfeeding at 1 month and 28% and 37%, respectively, at 6 months. Insufficient milk supply was the main reason for stopping in both groups. Intervention infants were less likely to have a sick visit by 1 month (25%) than controls (35%, P = .05). Qualitative interviews revealed that the intervention was informative and helpful, with breastfeeding reported as healthier but harder; formula was a good alternative. Intervention mothers reporting < or =2 supplemental formula feedings on day 4 were more likely than mothers reporting > or =3 supplemental feedings to breastfeed at 1 month (odds ratio 7.7; 95% confidence interval 2.4-24.3).

CONCLUSIONS

Two weeks of daily telephone support did not increase breastfeeding duration but was associated with a decrease in sick visits in the first month. Early supplementation and the perception of formula as a good alternative to dealing with the breastfeeding difficulties appeared to be factors in failure of the intervention.

Effects of a prenatal intervention on breastfeeding initiation rates in a Latina immigrant sample

A randomized controlled trial study design was used to investigate the effectiveness of a Healthy Families America model prenatal intervention for increasing breastfeeding rates among Latina immigrants residing in an impoverished New York City community. Exposure to the intervention did not affect mother report of any breastfeeding (ABF) during the first week postpartum, but it did affect mother report of exclusive breastfeeding (EBF). Thirty-two percent (44/137) of mothers exposed to the intervention reported EBF during the first week postpartum compared to 20% (20/101) of mothers not exposed to the intervention (odds ratio 1.92; 95% confidence interval 1.05-3.52). This positive effect of the intervention on EBF remained statistically significant after controlling for the negative effect of household income on EBF (adjusted odds ratio, 1.89; 95% confidence interval, 1.02-3.50). Additional research is needed on the effectiveness of breastfeeding promotion programs targeting low-income Latinas.

Assignment to a hospital-based breastfeeding clinic and exclusive breastfeeding among immigrant Hispanic mothers: a randomized, controlled trial

A randomized controlled trial is used to determine whether assigning mixed feeders to a breastfeeding clinic within 1 week postpartum will increase exclusive breastfeeding at 1 month among Hispanic immigrants. Subjects are eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and 85% are monolingual Hispanic. Mothers (n = 522) of infants at low risk for hyperbilirubinemia are approached at bedside 20 to 48 hours after delivery and randomly assigned to treatment or control groups. Intent-to-treat analysis of feeding behavior at 4 weeks postpartum indicates that the intervention group is more likely to be exclusively breastfeeding (16.4% vs 10% in the control group, P = .03; adjusted odds ratio 1.87; 95% confidence interval, 1.07-3.26); that the incidence of formula supplementation does not differ between groups; and that the intervention group is less likely to supplement with water and tea (P < .002).

Health disparities among Mexican American women aged 15-44 years: National Health and Nutrition Examination Survey, 1999-2004

OBJECTIVES

We analyzed the health of Mexican American women aged 15 to 44 years, by generation and language preference, to guide planning for reproductive health services in this growing population.

METHODS

We used personal interview and medical examination data from the 1999 to 2004 National Health and Nutrition Examination Surveys. We used SUDAAN for calculating age-adjusted prevalence estimates of demographic and health characteristics. The Satterthwaite adjusted F test and Student t test were used for subgroup comparisons.

RESULTS

The women had different health profiles (P < .05) by generation and language preference. Second- and later-generation women and women who used more English were more likely to be sexually active, to have been younger at first intercourse, and to have had more male sexual partners than were first-generation women and women who used more Spanish. Compared with their first-generation counterparts, second- and later-generation women drank more alcohol, were better educated, had higher incomes, and were more likely to have health insurance. Third-generation women were more likely to have delivered a low-birthweight baby than were first-generation women.

CONCLUSIONS

Differences by generation and language preference suggest that acculturation should be considered when planning interventions to promote healthy reproductive behaviors among Mexican American women.

Health status of Mexican-origin persons: do proxy measures of acculturation advance our understanding of health disparities?

OBJECTIVES

This paper compares select health status indicators between the U.S. and Mexico, and within the Mexican-origin population using proxy measures of acculturation.

METHODS

Statistical data were abstracted and a Medline literature review conducted of English-language epidemiologic articles on Mexican-origin groups published during 1976-2005.

RESULTS

U.S.-born Mexican-Americans have higher morbidity and mortality compared to Mexico-born immigrants. Mexico has lower healthcare resources, life expectancy, and circulatory system and cancer mortality rates, but similar infant immunization rates compared to the U.S. Along the U.S.-Mexico border, the population on the U.S. side has better health status than the Mexican side. The longer in the U.S., the more likely Mexican-born immigrants engage in behaviors that are not health promoting. Conclusions Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups. It is not spending-time in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.

The influence of immigrant status and acculturation on the development of overweight in Latino families: a qualitative study

Exposure to obesogenic environments in the U.S. may foster development of overweight in immigrants with greater acculturation. Few studies document mechanisms of the acculturation process from immigrants' own perspectives or describe implications on the children of immigrants. Focus groups and in-depth interviews were conducted with immigrant Latina mothers (N = 51) examining mothers' beliefs, attitudes and practices related to early child feeding and weight. Focus group participants completing the Marin Acculturation Scale more closely identified with Latino culture, although the mean score (2.04, SD = 0.59) was close to "bicultural". Analysis revealed seven themes when mothers compared lifestyles between their native countries and the U.S., related to changes in (1) diet, perceived food quality and availability, (2) food and eating practices, (3) breastfeeding practices, (4) beliefs about food, child feeding and weight status, (5) weight status of mothers and children, (6) physical activity and sedentary lifestyles, and (7) social isolation and support.

A descriptive study of Cambodian refugee infant feeding practices in the United States

Background

The purpose of this exploratory study was to examine Cambodian refugee mothers' infant feeding beliefs, practices, and decision making regarding infant feeding in the U.S. and to explore if a culturally-specific breastfeeding program is appropriate for this community.

Methods

A self-administered questionnaire and a 30 minute in-person interview were used to collect information from nine women. The audio-taped interviews were transcribed, answers compiled, and themes from each question identified.

Results

All participants practiced either traditional Cambodian diet (pregnancy and postpartum diet including, tnam sraa, herbs mixed with either wine or tea), traditional Cambodian rituals (like spung, amodified sauna) or both, despite having lived in the U.S. for many years. All nine women initiated breastfeeding, however eight women introduced infant formula while in hospital. Perceived low milk supply and returning to work were the main reasons cited for partial breastfeeding and early cessation of breastfeeding.

Conclusion

While causes of initiation of other foods are similar to those found in the U.S. as a whole, a culturally-specific Cambodian breastfeeding support program may help overcome some breastfeeding problems reported by Cambodian refugee mothers who have immigrated to the United States.

Early postpartum breastfeeding and acculturation among Hispanic women

BACKGROUND

Exclusive breastfeeding in the hospital is predictive of postpartum breastfeeding patterns. Although breastfeeding rates are similar for Hispanic and white women in the United States, evidence shows that more acculturated Hispanic mothers have lower rates of breastfeeding than those less acculturated. To date, no studies have examined whether this pattern exists in the immediate postpartum period.

METHODS

We used medical record data from 1,635 participants in the San Diego Birth Center Study, a cohort study of low-income, low-risk pregnant women. We applied a proxy measure of acculturation to categorize participants into a low acculturation (Hispanic, Spanish speaking [n = 951]); high acculturation (Hispanic, English speaking [n = 408]); or white, English speaking (n = 276) group. Logistic regression was used to examine the relationship between acculturation and exclusive breastfeeding at the time of hospital discharge while controlling for potential confounders.

RESULTS

Exclusive breastfeeding rates were significantly different across acculturation groups (p < 0.01). After adjusting for available confounding variables, women in the low acculturation group were more likely to breastfeed exclusively at discharge than those in the high acculturation group (OR = 1.36, 95% CI = 1.01-1.84). Women in the white, English-speaking group also had greater odds of exclusive breastfeeding when compared with those in the high acculturation group (OR = 1.49, 95% CI = 1.02-2.19).

CONCLUSIONS

This cross-sectional study provides evidence of a correlation between acculturation and immediate postpartum breastfeeding, where higher acculturation is associated with lower odds of exclusive breastfeeding. Additional research is needed to understand how the process of acculturation may affect short- and long-term breastfeeding behavior.

The role of acculturation in nutrition, lifestyle, and incidence of type 2 diabetes among Latinos

Latinos have become the largest ethnic minority group in the U.S. and will become 25% of the population by 2050. The purpose of this critical review is to examine the influence of acculturation on type 2 diabetes and corresponding risk factors, including 1) dietary intake, 2) physical activity patterns, 3) smoking and alcohol consumption, and 4) obesity. Among Latinos, acculturation has been associated with obesity risk, suboptimal dietary choices including lack of breast-feeding, low intake of fruits and vegetables, a higher consumption of fats and artificial drinks containing high levels of refined sugar, smoking, and alcohol consumption. In contrast, acculturation has been positively associated with physical activity and a lower likelihood of type 2 diabetes among Latinos. However, findings have been inconsistent across acculturation indicators and appear to be strongly modified by Latino subethnicity and gender. It is important to improve existing acculturation measures available. Mexican Americans have been the target group in the majority of studies. Research in this group must continue but it is important to conduct additional research with other Latino subgroups that have been left out of most of the acculturation, lifestyles, and health outcomes research. Differences between acculturation and health-related outcomes may be confounded by socio-economic status, age, and movement from urban to rural areas. Longitudinal multivariate acculturation research is essential to disentangle these relations and to develop sound behavioral change theories that adequately predict behavioral change among Latinos.

The effect of time in the U.S. on the duration of breastfeeding in women of Mexican descent

OBJECTIVES

Although women of Mexican decent have high rates of breastfeeding, these rates may vary considerably by acculturation level. This study investigated whether increased years of residence in the U.S. is associated with poorer breastfeeding practices, including shorter duration of any and exclusive breastfeeding, in a population of low-income mothers of Mexican descent.

METHODS

Pregnant women (n = 490) were recruited from prenatal clinics serving a predominantly Mexican-origin population in an agricultural region of California. Women were interviewed during pregnancy, shortly postpartum, and when their child was 6 months, 1 year, 2 years, and 3.5 years of age.

RESULTS

Increased years of residence in the U.S. was associated with decreased likelihood of initiating breastfeeding and shorter duration of exclusive and any breastfeeding. Median duration of exclusive breastfeeding was 2 months for women living in the U.S. for 5 years or less, 1 month for women living in the U.S. for 6 to 10 years, and less than one week for women living in the U.S. for 11 years or more, or for their entire lives (lifetime residents). After controlling for maternal age, education, marital status and work status, lifetime residents of the U.S. were 2.4 times more likely to stop breastfeeding, and 1.5 times more likely to stop exclusive breastfeeding, than immigrants who had lived in the U.S. for 5 years or less.

CONCLUSIONS

Efforts are needed to encourage and support Mexican-origin women to maintain their cultural tradition of breastfeeding as they become more acculturated in the U.S.

Promoting exclusive breastfeeding for Hispanic women

This article focuses on assisting nurses with the promotion of exclusive breastfeeding in Hispanic women through the understanding of their heritage, cultural traditions, and acculturation. Nurses can incorporate these traditions into daily nursing practice in order to enhance the breastfeeding experience of Hispanic mothers. Because exclusive breastfeeding is low in minority groups in the United States, it is essential that nurses use the initial postpartum period to help educate women about exclusive breastfeeding. In order to accomplish this, nurses need culturally specific information, which promotes cultural traditions and also encourages breastfeeding.

Acculturation: implications for perinatal research

It is estimated that by 2009, Hispanics will have the highest birthrates for any minority group in the United States. Acculturation in Hispanic women of childbearing age is a critical aspect that researchers and clinicians need to consider with this population. Conceptualization and measurement issues of acculturation are addressed in this article. A framework for the complex task of acculturation research is presented. In the latter part of the article, a review of perinatal studies, in which measurement of acculturation in Hispanic women was included, is summarized for research on birthweight, breastfeeding, and postpartum depression. Implications for clinical practice with Hispanic women are hindered owing to methodological limitations of perinatal acculturation research identified in this article.

Infant feeding practices and maternal dietary intake among Latino immigrants in California

Mothers of 8-16-month-old infants were surveyed to examine infant feeding practices and maternal dietary intake associated with increased years of residency by Mexican immigrant families (n = 1093 mother-infant pairs). Mothers were recruited from San Diego and Contra Costa counties in California during 1992-93. Twenty-nine percent of Mexican mothers living in the United States for <6 years breastfed their infants exclusively for at least 16 weeks; only 20% of mothers living in the United States between 6 and 15 years and 17% of mothers residing in the United States for over 15 years engaged in exclusive breastfeeding. Neither breastfeeding duration nor the introduction of solids differed by years of residency. In contrast, maternal dietary intake varied markedly. Second generation mothers and those living in the United States the longest had significantly higher intakes of vegetables, low fat milk, salty snacks, animal protein, and cereals. Beyond early caregiving practices, the influence of years of residency on the diets of toddlers is less than that of the mothers.

Early infant feeding decisions in low-income Latinas

Breastfeeding rates remain low, especially among low-income minority women. The objective of this qualitative study was to assess barriers to breastfeeding and reasons for combination feeding among low-income Latina women and their families. Meetings were held with key informants to inform the sampling plan and develop questions for focus groups. Data were collected from eight qualitative focus groups with primiparous mothers postpartum, mothers breastfeeding at 4 to 6 months, mothers formula feeding at 4 to 6 months, grandmothers and fathers, and 29 individual interviews with formula- and combination-feeding mothers. Transcripts of focus groups and interviews were content coded and analyzed for thematic domains and then compared for concurrence and differences. Four main domains with 15 categories were identified: (a) Best of both: Mothers desire to ensure their babies get both the healthy aspects of breast milk and "vitamins" in formula. (b) Breastfeeding can be a struggle: Breastfeeding is natural but can be painful, embarrassing, and associated with breast changes and diet restrictions. (c) Not in Mother's Control: Mothers want to breastfeed, but things happen that cause them to discontinue breastfeeding. (d) Family and cultural beliefs: Relatives give messages about supplementation for babies who are crying or not chubby. Negative emotions are to be avoided so as to not affect mother's milk. Those counseling Latina mothers about infant feeding should discourage and/or limit early supplementation with formula, discuss the myth of "best of both," understand the fatalism involved in problem-solving breastfeeding issues, and enlist the altruism embedded in the family unit for support of the mother-infant pair.

Breastfeeding as health-promoting behaviour for Hispanic women: literature review

AIM

This paper reports a literature review to synthesize the evidence that breastfeeding is a health-promoting behaviour for Hispanic women and to demonstrate the usefulness of the Health Promotion Model in understanding and increasing breastfeeding behaviours in Hispanic women.

BACKGROUND

While breastfeeding has been shown to promote the health of both mother and infant, it has not been widely viewed from the perspective of the Health Promotion Model.

METHODS

The CINAHL and MEDLINE databases were searched using the terms 'Hispanic' or 'Latina', 'breastfeeding' and concepts specific to the Health Promotion Model (interpersonal relationships, social support, acculturation, self-efficacy, barriers, benefits, and commitment). Only papers in the English language from 1990 to 2003 (except for classic papers) that used research techniques were reviewed. Only those addressing breastfeeding intention, initiation or duration were included. The reference lists of each paper were examined for additional empirical papers that linked any of the determinants of the Health Promotion Model to breastfeeding among Hispanic women. Papers were organized using the ten determinants as headings: prior related behaviour, personal factors, perceived benefits, perceived barriers, perceived self-efficacy, activity-related affect, interpersonal influences, situational influences, immediate competing demands, and commitment to a plan of action. The review was conducted in 2003.

FINDINGS

The literature verifies that each of the 10 determinants of health-promoting behaviour also promotes breastfeeding for Hispanic women, particularly through the constructs of acculturation, interpersonal support, self-efficacy and immediate competing demands. Breastfeeding is not consistently defined in all studies, nor are Hispanic population groups uniformly classified according to country of origin. Specific interventions to promote breastfeeding have been implemented for women of Latin American origin, but randomized designs to measure outcomes have not been consistently employed with Hispanic women in the United States of America. Further intervention research is needed to confirm breastfeeding as a health-promoting behaviour and to inform breastfeeding education for this group.

Clinical lactation practice: 20 years of evidence

Lactation consultants depend on a vast multidisciplinary knowledge base to support their practices. To coincide with the 20-year anniversary of the International Lactation Consultant Association, the authors sought to highlight the knowledge base to demonstrate how practice has been affected. Using standard databases, they extracted English-language scientific literature related to breastfeeding and maternal and infant health outcomes; factors associated with breastfeeding initiation, exclusivity, and duration; lactation physiology; common breastfeeding challenges; breastfeeding practices within vulnerable populations; health professional support of breastfeeding; and breastfeeding practices in developing countries of Africa. Summaries of research are provided to demonstrate scientific method and knowledge evolution. As the knowledge of the biological, behavioral, and environmental factors that affect breastfeeding continues to grow, researchers and lactation consultants will identify additional research areas. Thus, the cycle of describing and explaining phenomena, testing interventions to improve practice, and ultimately improving breastfeeding outcomes worldwide will continue.

Prevalence of breastfeeding and acculturation in Hispanics: results from NHANES 1999-2000 study

BACKGROUND

A more current estimate to evaluate ethnic and acculturation differences in breastfeeding is warranted, given the rapid growth of the Hispanic population in the United States and the proliferation of breastfeeding promotion programs. The study objective was to describe current national estimates of the prevalence of breastfeeding and evaluate differences in reasons not to breastfeed by acculturation status.

METHODS

Secondary data analysis of the National Health and Nutrition Examination Survey (NHANES) 1999-2000 was performed on a nationally representative sample of non-Hispanic white women born in the U.S. and Hispanic women with at least one live birth. Acculturation status among Hispanics was assessed using a validated language scale, and prevalence of breastfeeding was based on maternal self-report.

RESULTS

Prevalence of breastfeeding was higher in less acculturated Hispanic women (59.2%) than high acculturated Hispanic women (33.1%) and white women (45.1%). Less acculturated Hispanic women were more likely to cite their child's physical/medical condition as a reason not to breastfeed (53.1%), whereas whites and more acculturated Hispanics were more likely to cite their child preferred the bottle (57.5% and 49.8%, respectively). A logistic regression analysis revealed no significant differences in likelihood to breastfeed between non-Hispanic whites and Hispanics after controlling for education, age, and income. Higher acculturated women were less likely to breastfeed their children than low acculturated women (95% CI: 0.14-0.40) even after education, age, and income were taken into account.

CONCLUSIONS

Acculturation differences in prevalence of breastfeeding and reasons not to breastfeed may be the result of attitudinal changes that occur due to acculturation. Further research into the acculturation process and its impact on breastfeeding may help to prevent the decline in breastfeeding that occurs as mothers become more acculturated. Meanwhile, patient education that addresses women's perceptions of the child's health condition and benefits of breastfeeding would be helpful.

Development and testing of a prenatal breastfeeding education intervention for Hispanic women

Many immigrant Hispanic women in the United States choose to bottle-feed rather than breastfeed. This article describes an intervention that was developed and tested in a two-step process. Two studies were undertaken. First, a qualitative inquiry explored the breastfeeding beliefs, attitudes, meanings, and practices of Hispanic women. Results informed the design of a culturally appropriate prenatal breastfeeding education intervention. Secondly, the researchers undertook a quantitative study of the intervention's success in increasing breastfeeding duration among Hispanic women. Methodology and findings of this study have implications for future interventions that promote breastfeeding.

Social capital, acculturation, and breastfeeding initiation among Puerto Rican women in the United States

To examine reasons for not breastfeeding, and to identify factors associated with ever breastfeeding among Puerto Rican women, a retrospective study was done using a convenience sample of 161 low-income Latino women with children younger than 6 years. Women were recruited from the Hispanic Health Council (43.5%), the Supplemental Nutrition Program for Women, Infants, and Children (29.8%), and other places (26.7%). Participants were interviewed using a pretested questionnaire specific to the target community. Most (73%) of the respondents chose to be interviewed in Spanish. Chi-square analyses were used to examine the bivariate association between ever breastfeeding and the independent variables. Multivariate logistic regression was conducted to estimate the independent association between acculturation, social capital, and breastfeeding. Women with more social capital were more likely (odds ratio = 2.25, 95% confidence interval, 1.02-4.95) to have breastfed the index child, suggesting that social capital is an important predictor of breastfeeding initiation in this community.

An evaluation of a breast-feeding education intervention among Spanish-speaking families

This study assessed the impact of an educational breast-feeding intervention on the knowledge, attitudes and perceived ability to access breast-feeding resources among Spanish-speaking Latino families making breast-feeding decisions. Conducted in cooperation with the local office of The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), this university-based, multidisciplinary outreach and research project was held in a semirural part of Utah, where Latinos constitute the fastest and largest growing group of the population and have the lowest breast-feeding duration rates. The results suggested that teaching a lactation class in Spanish to Latino women significantly increased their willingness to breast-feed and empowered them by increasing their belief that they could breast-feed even if they work or attend school, that they would not have a problem with insufficient milk, and that they would not need to limit their diet to breast-feed. Additionally, the study indicated that Latino women are more likely to access health care services from agencies providing services in Spanish, regardless of their secondary fluency in English.

Breastfeeding practices in a cohort of inner-city women: the role of contraindications

BACKGROUND

Little is known about the role of breastfeeding contraindications in breastfeeding practices. Our objectives were to 1) identify predictors of breastfeeding initiation and duration among a cohort of predominantly low-income, inner-city women, and 2) evaluate the contribution of breastfeeding contraindications to breastfeeding practices.

METHODS

Mother-infant dyads were systematically selected from 3 District of Columbia hospitals between 1995 and 1996. Breastfeeding contraindications and potential predictors of breastfeeding practices were identified through medical record reviews and interviews conducted after delivery (baseline). Interviews were conducted at 3-7 months postpartum and again at 7-12 months postpartum to determine breastfeeding initiation rates and duration. Multivariable logistic regression analysis was used to identify baseline factors associated with initiation of breastfeeding. Cox proportional hazards models were generated to identify baseline factors associated with duration of breastfeeding.

RESULTS

Of 393 study participants, 201 (51%) initiated breastfeeding. A total of 61 women (16%) had at lease one documented contraindication to breastfeeding; 94% of these had a history of HIV infection and/or cocaine use. Of the 332 women with no documented contraindications, 58% initiated breastfeeding, vs. 13% of women with a contraindication. In adjusted analysis, factors most strongly associated with breastfeeding initiation were presence of a contraindication (adjusted odds ratio [AOR], 0.19; 95% confidence interval [CI], 0.08-0.47), and mother foreign-born (AOR, 4.90; 95% CI, 2.38-10.10). Twenty-five percent of study participants who did not initiate breastfeeding cited concern about passing dangerous things to their infants through breast milk. Factors associated with discontinuation of breastfeeding (all protective) included mother foreign-born (hazard ratio [HR], 0.55; 95% CI 0.39-0.77) increasing maternal age (HR for 5-year increments, 0.80; 95% CI, 0.69-0.92), and infant birth weight > or = 2500 grams (HR, 0.45; 95% CI, 0.26-0.80).

CONCLUSIONS

Breastfeeding initiation rates and duration were suboptimal in this inner-city population. Many women who did not breastfeed had contraindications and/or were concerned about passing dangerous things to their infants through breast milk. It is important to consider the prevalence of contraindications to breastfeeding when evaluating breastfeeding practices in high-risk communities.

Breastfeeding initiation and duration: a 1990-2000 literature review

OBJECTIVE

To review the literature on breastfeeding initiation and duration and to delineate effective strategies for promoting positive breastfeeding behaviors.

DATA SOURCES

Computerized searches on MEDLINE, CINAHL, and the Cochrane Library.

STUDY SELECTION

Articles from indexed journals relevant to the objective and published after 1990 (except for classic findings) were reviewed. Although a myriad of pertinent articles was located, referenced citations were limited to three per point. When article selection was required for a specific point, preferences were given to (a) randomized controlled trials; (b) meta-analyses; (c) studies with the largest, most representative samples; and (d) investigations conducted in North America.

DATA EXTRACTION

Data were extracted and organized under the following headings: benefits of breastfeeding, breastfeeding initiation and duration, personal characteristics, attitudinal and intrapersonal characteristics, hospital policies and intrapartum experience, sources of support, breastfeeding interventions, and review implications.

DATA SYNTHESIS

Although the health benefits of breastfeeding are well documented and initiation rates have increased over the past 20 years, most mothers wean before the recommended 6-months postpartum because of perceived difficulties with breastfeeding rather than due to maternal choice. Women least likely to breastfeed are those who are young, have a low income, belong to an ethnic minority, are unsupported, are employed full-time, decided to breastfeed during or late in pregnancy, have negative attitudes toward breastfeeding, and have low confidence in their ability to breastfeed. Support from the mother's partner or a nonprofessional greatly increases the likelihood of positive breastfeeding behaviors. Health care professionals can be a negative source of support if their lack of knowledge results in inaccurate or inconsistent advice. Furthermore, a number of hospital routines are potentially detrimental to breastfeeding. Although professional interventions that enhance the usual care mothers receive increase breastfeeding duration to 2 months, these supportive strategies have limited long-term effects. Peer support interventions also promote positive breastfeeding behaviors and should be considered.

CONCLUSIONS

A promising intervention is the complementation of professional services with peer support from a mother experienced in breastfeeding. This lay support appears to be an effective intervention with socially disadvantaged women.