'Life does not make it easy to breast-feed': using the socio-ecological framework to determine social breast-feeding obstacles in a low-income population in Tijuana, Mexico

Healthcare professionals and commercial milk formula recommendations in the urban Mexican context

Introduction

Breastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions.

Methods

The study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months (n = 74) on FGDs and IDIs.

Results

Through a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF.

Discussion

This study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions.

The Ethics of Ancient Lactation and the Cult of the Perfect Breastfeeding Mother

Breastfeeding is a key issue found in ancient sources that resonates with public debates today, affecting women in different parts of the world and of all social classes. The aim of this research was to identify breastfeeding narratives in ancient medical and philosophical texts from the 1st to the 6th century CE that address ethical issues in the medical management and social perception of new mothers. We examined 15 literary sources and one funerary inscription on lactation and critically evaluated the ancient idea of the perfect breastfeeding mother versus the non-breastfeeding mother. We then discussed our historical data in terms of objectivity and significance in relation to contemporary attitudes towards motherhood and lactation, e.g., (1) the cult of the perfect, breastfeeding mother in contemporary lactation education and (2) the onset of conditions which may affect normal breastfeeding, such as dysphoric milk ejection reflex (D-MER), breastfeeding aversion response (BAR) or post-partum depression. The analysis of the results showed that in both ancient and contemporary postnatal health care: (1) good mothering is associated with breastfeeding and (2) alternative feeding methods are acknowledged, but never as the best, natural option. Finally, our analysis shows that public health policies on breastfeeding and mothers' own knowledge of their bodies are contested between nursing theories, social expectations and economic factors.

Infant feeding choices among Panamanian mothers: A qualitative study

Infant and child nutrition practices are among the most critical determinants of infant health and breastfeeding is considered the gold standard of infant feeding. Despite extensive public health interventions to promote breastfeeding, its prevalence has decreased in recent years in Panama, particularly in urban settings. There has been a nearly 20% drop in breastfeeding in the 10 years leading to 2020. Current literature often fails to elucidate the factors underpinning Panamanian mothers' decision making in relation to breastfeeding. This article explores the experiences, views, and decision making related to infant feeding choices of mothers in Panama City. The study used a qualitative approach, involving online semistructured interviews with seven participants. Utilizing the socioecological model enabled an understanding of the influence of the various, nested levels of a mother's social environment on behaviors and practices. Five themes were developed following analysis: "practical, bodily, and emotional challenges"; "workplace influences"; "family and friends' support"; "the role of health care and healthcare professionals"; "the influence of social and cultural norms on decisions and practices." The main barrier to breastfeeding was the lack of family support, especially from grandmothers. In contrast, private lactation consultation and partners' support were perceived as the best approaches for breastfeeding success, suggesting an urgent need for publicly available lactation support. This study demonstrates the importance of understanding the complexity of the social norms surrounding infant feeding, showing the challenges that mothers face in this process, and sheds light on the (public) interventions necessary to improve breastfeeding initiation and continuation.

A Systematic Review of Research on Non-Maternal Caregivers' Feeding of Children 0-3 Years

Although people other than mothers participate in feeding, few interventions include non-maternal caregivers, especially those promoting healthy development among children aged 0-3 years. Understanding the role and influence of non-maternal caregivers is essential for the development and effectiveness of early childhood feeding interventions; yet, no reviews have examined non-maternal caregivers of children aged 0-3 years. This study assessed what is known about non-maternal caregivers' feeding of children aged 0-3. We systematically reviewed 38 empirical quantitative, qualitative, and mixed methods studies, cataloged in PubMed and Web of Science and published between 1/2000-6/2021. The studies showed that non-maternal caregivers engage in child feeding and their attitudes and behaviors affect child outcomes. Like mothers, non-maternal caregivers vary in the extent to which their knowledge and attitudes support recommended feeding practices and the extent to which they exhibit responsive feeding styles and practices. Children of broad ages were included in the studies; future research should include infant/toddler-only samples to allow for better assessment of age-specific feeding constructs. The studies also revealed issues specific to non-maternal caregivers that are unlikely to be addressed in interventions developed for mothers. Thus, the review highlighted features of non-maternal caregiving of children 0-3 years that could be addressed to support feeding and child outcomes.

Views and experience of breastfeeding in public: A qualitative systematic review

Breastfeeding rates in many Global North countries are low. Qualitative research highlights that breastfeeding in public is a particular challenge, despite mothers often having the legal right to do so. To identify barriers and facilitators, we systematically searched the qualitative research from Organisation for Economic Co-operation and Development countries relating to breastfeeding in public spaces from 2007 to 2021. Data were analysed using the Thematic Synthesis technique. The review was registered with PROSPERO (registration number: CRD42017081504). Database searching identified 3570 unique records. In total, 74 papers, theses, or book chapters, relating to 71 studies, were included, accounting for over 17,000 mothers. Overall, data quality was high. Our analysis identified that five core factors influenced mothers' thought processes and their breastfeeding in public behaviour: legal system; structural (in)equality; knowledge; beliefs and the social environment. Macro-level factors relating to legislation and inequality urgently require redress if breastfeeding rates are to be increased. Widespread culture change is also required to enhance knowledge, change hostile beliefs and thus the social environment in which mother/infant dyads exist. In particular, the sexualisation of breasts, disgust narratives and lack of exposure among observers to baby-led infant feeding patterns resulted in beliefs which created a stigmatising environment. In this context, many mothers felt unable to breastfeed in public; those who breastfed outside the home were usually highly self-aware, attempting to reduce their exposure to conflict. Evidence-based theoretically informed interventions to remove barriers to breastfeeding in public are urgently required.

Factors influencing breastfeeding practices in China: A meta-aggregation of qualitative studies

The World Health Organization recommends that women exclusively breastfeed until their babies are 6 months old and continue to breastfeed while introducing complementary foods. A meta‐aggregation methodology was used to systematically review and synthesise the qualitative studies on factors influencing breastfeeding practices of healthy Chinese women in Greater China. English and Chinese databases were searched to identify peer‐reviewed qualitative studies (published 2008–2019). Relevant data were extracted, and key themes related to factors influencing breastfeeding practices were identified. Of 7587 articles identified, 22 qualitative studies met inclusion criteria for the review, 10 of which were published in Chinese. A total of 87 themes were extracted from all included studies and classified into 9 subcategories: government enactment of policies, implementation of policies in workplaces, social expectations, social support, medical and health services, services with Chinese characteristics, breastfeeding and pumping facilities, maternal perceptions of breastfeeding and self‐efficacy to breastfeed. The nine subcategories were then grouped into four categories. Potential effect associations among these influence factors of breastfeeding practices emerged from categories and subcategories. Family members' influence on breastfeeding motivation and self‐efficacy suggest a potential benefit of breastfeeding promotion interventions targeting the whole family. The role of primary care should be fully exploited in breastfeeding promotion, including both prenatal education and post‐partum visits. Standardising the training and qualifications of maternity matrons (yuesao) and folk breastfeeding specialists (cuirushi) can promote evidence‐based approaches to facilitating breastfeeding during the confinement period. Increased availability of breastfeeding and pumping facilities in the workplace would facilitate continuing breastfeeding after returning to work.

'[The pediatrician] said that maybe my milk, instead of doing good, no longer helped': the ecology of infant formula in rural communities in Central Mexico

OBJECTIVE

As Mexico continues to develop, an epidemiological and nutritional transition has led to an increase in infant formula use in its rural and indigenous communities. Our objective was to determine the social and cultural factors that influence the use of formula in such populations in Central Mexico.

DESIGN

Qualitative study using a data collection instrument based on the socio-ecological framework.

SETTING

Two rural and indigenous communities in Central Mexico.

PARTICIPANTS

Mothers, fathers, grandparents and healthcare providers.

RESULTS

Breast-feeding was favoured in both communities; however, several cultural traditions hindered exclusive breast-feeding. As these communities became more developed, emerging ideas of modernity led to negative connotations about breast-feeding and many mothers began to view formula as a complement for breast-feeding. Formula was seen as a convenient solution for breast pain, insufficient milk and body image. Healthcare providers promoted the use of formula through their own beliefs, information, communication and conflicts of interest with formula industry representatives. The recent social and economic changes in these communities combined with the increased advertising and availability of breast milk substitutes have facilitated the preference for formula.

CONCLUSIONS

Women in rural, indigenous communities in Central Mexico are increasingly using formula. Efforts at the policy and institutional levels are needed to protect mothers and their children from the detrimental consequences of unregulated formula promotion and the formula culture that it brings with it.

Factors associated with abandoning exclusive breastfeeding in Mexican mothers at two private hospitals

BACKGROUND

Exclusive breastfeeding (EBF) has multiple benefits for both the child and the mother; however, there is little data regarding the reason why Mexican mothers with a high socio-economic level abandon EBF before 6 months, and there is limited information about the practice of breastfeeding in private hospitals. The objective was to identify the factors associated with the cessation of exclusive breastfeeding in Mexican mothers at two private hospitals.

METHODS

A cross-sectional study was conducted with 218 upper-class mothers selected according to their place of residence by geographic location, socio-economic level, and pediatric consultations cost. They were over 18 years old and with children aged 6 to 24 months. Data were collected between July and November 2016 by face to face interview using a structured questionnaire while the mothers waited for the pediatric postnatal care consultation in two private hospitals in northeastern Mexico. Exclusive breastfeeding was measured according to World Health Organization (WHO) recommendations, which consist of providing only breast milk for the first 6 months of life. Chi-squared tests and multivariate logistic regression were performed.

RESULTS

Mean maternal age was 31.4 years (SD of 4.4) and most of the participants had an undergraduate education, were married, and worked outside the home. The prevalence of exclusive breastfeeding at 6 months was 28%. Upper-class working mothers are less likely to continue breastfeeding. There was a negative association with employment (AOR 13.69; 95% CI 1.59, 111.11), bottle use in the first 6 months (AOR 7.93; 95% CI 3.07, 20.48), and a low level of knowledge (AOR 2.18; 95% CI 1.04, 4.56). After 6 months, only 61 mothers (28%) maintained exclusive breastfeeding.

CONCLUSIONS

Knowledge level, bottle use, and employment are associated with premature cessation of EBF in Mexican upper-class mothers, attending two private hospitals. There was a high percentage of breastfeeding cessation in the sample. It is necessary to reinforce a strategy that coordinates the action of the different laws, regulations and programs affecting the exclusive breastfeeding practice, in order to adequately promote breastfeeding and support mothers in both public and private sectors.

Examining working mothers' experience of exclusive breastfeeding in Ghana

BACKGROUND

Although substantial evidence exists on factors that influence exclusive breastfeeding, there is a general lack of qualitative studies that examine how specific workplace factors constrain or promote exclusive breastfeeding among working mothers. The current study therefore examines working mothers' experience of exclusive breastfeeding, laying emphasis on the influence of workplace factors on working mothers' decision to exclusively breastfeed their babies.

METHODS

The study uses a qualitative research approach and a three-stage purposive sampling procedure to select 20 mothers from 10 organizations in five industries for in-depth interviews on their exclusive breastfeeding experience. Data collected from the interviews were analysed using content analysis, with two major themes emerging for discussion.

RESULTS

The results suggest that two major factors influence exclusive breastfeeding among working mothers: practice of exclusive breast feeding (knowledge and understanding of exclusive breastfeeding, and experience in exclusive breastfeeding) and workplace factors (length of maternity leave, closing time, absence of maternity policy in organizations, inadequate institutional support and family work-life balance).

CONCLUSION

The results of the study suggest that workplace factors play an equally crucial role in the decision by mothers to exclusively breastfeed their babies. Thus, in the special case of working mothers where breastfeeding prevalence is low, the findings of this study can be crucial in evolving appropriate policies to support working mothers in their effort to exclusively breastfeed their babies.

A Qualitative Exploration of the Determinants of Exclusive Breastfeeding (EBF) Practices in Wajir County, Kenya

Background

The World Health Organization recommends exclusive breastfeeding for the first six months of life. A qualitative study was conducted to assess the factors that influence the practice of exclusive breastfeeding amongst mothers attending Wajir County Hospital, Kenya.

Method

This study was part of a cross-sectional study to compare the exclusive breastfeeding rates amongst primiparous and multiparous mothers with infants under 6 months old attending Wajir County Hospital. Focus group discussions and key informant interviews were conducted to collect information on exclusive breastfeeding and related factors. Four focus group discussions were conducted with mothers who exclusively breastfed and the same number with mothers who did not exclusively breastfeed their babies. Key informant interviews were conducted with nine healthcare providers. The data were transcribed, and a content analysis identified common themes and inferences.

Results

The exclusive breastfeeding rate among the mothers in the larger study was 45.5%. There was no disparity between the practice of exclusive breastfeeding between primiparous and multiparous mothers. Despite the high knowledge and positive attitudes towards exclusive breastfeeding of most mothers, the practice of exclusive breastfeeding was unsatisfactory. The major hindrances identified were cultural barriers propagated by mothers-in-law and traditional birth attendants; the belief that babies cannot live without water; and a few unsupportive health workers. The uptake of exclusive breastfeeding was enhanced by Islamic teaching on breastfeeding, education from a few supportive healthcare providers; support from husbands; and positive deviance among some lactating mothers who practiced exclusive breastfeeding.

Conclusions

Deeply rooted cultural factors were the major hindrance to the practice of exclusive breastfeeding. Most of the mothers did not practice exclusive breastfeeding, despite the majority being knowledgeable and having positive attitudes towards the practice. The influence of mother-in-law’s and traditional birth assistants were major barriers. Strengthening the Community Health Strategy through training traditional birth attendants on Infant Young Child Nutrition practices, designing mechanisms linking traditional birth assistants to existing health facilities for support, and capacity building and monitoring is critical in promoting exclusive breastfeeding. Behavior change and communication through multiple channels within the community should be utilized to maximize promotion of exclusive breastfeeding among all stakeholders.

Hidden Realities of Infant Feeding: Systematic Review of Qualitative Findings from Parents

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent's attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent's expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.

The Associations Between Breastfeeding Duration and Body Dissatisfaction, Ethnicity, and Obesity Among Mexican Women, a Cross-Sectional Study, ENSANUT 2012

Introduction: Body image dissatisfaction (BID) has been inversely associated with breastfeeding initiation particularly among women with obesity. However, less is known on BID and the association with maintaining breastfeeding in Mexico, where breastfeeding rate is decreasing across ethnic subgroups. Therefore, we explore this gap of knowledge in diverse ethnic subgroups across levels of maternal weight status. Methods: Data were derived from the Mexican National Health and Nutrition Survey (Encuesta Nacional de Salud y Nutrición [ENSANUT] 2012), and 10,466 women aged 20-49 years were included. Breastfeeding (<6 months versus ≥6 months) of the last child, BID (Stunkard Figure Rating Scale), anthropometric (body mass index, BMI), sociodemographics, and biological variables were collected. Crude and adjusted target associations and effect modifiers were assessed using weighted-logistic regression models. Results: Overall, 72.4% of ever breastfeeding mothers breastfed a minimum of 6 months, 22% were indigenous, 74% were dissatisfied with their body image (BID >0), and 37% had obesity (BMI ≥30 kg/m²). In the multivariable analysis, for each one-unit increase in the BID score, the adjusted odds of breastfeeding (≥6 months) decreased by 6% (odds ratio [OR] = 0.94, 95% confidence interval [CI]: 0.89-0.99). After stratifications, only among women with obesity, a greater BID score was associated with lower odds of breastfeeding duration by 24% (OR = 0.76, 95% CI: 0.64-0.89) in indigenous and by 10% (OR = 0.90, 95% CI: 0.82-0.98) in non-indigenous women. Conclusions: Mexican women with a higher BID score reported lower odds of breastfeeding duration (≥6 months). Body image concerns should be integrated into a health promotion curriculum to mitigate their negative effect particularly in certain segments of the populations, such as women with obesity and among indigenous women.

Breastfeeding practices, beliefs, and social norms in low-resource communities in Mexico: Insights for how to improve future promotion strategies

INTRODUCTION

Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.

OBJECTIVE

Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.

METHODS

We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).

RESULTS

Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.

CONCLUSIONS

Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.