Breastfeeding and smoking among low-income women: results of a longitudinal qualitative study

Mediation of the effect of prenatal maternal smoking on time to natural menopause in daughters by birthweight-for-gestational-age z-score and breastfeeding duration: analysis of two UK birth cohorts born in 1958 and 1970

BACKGROUND

Prenatal maternal smoking, lower birthweight, and shorter breastfeeding duration have all been associated with an earlier age at menopause in daughters. We estimated the extent to which birthweight-for-gestational-age z-score and breastfeeding duration mediate the effect of prenatal maternal smoking on time to natural menopause in daughters.

METHODS

Using pooled data from two prospective birth cohort studies - the 1970 British Cohort Study (n = 3,878) followed-up to age 46 years and the 1958 National Child Development Study (n = 4,822) followed-up to age 50 years - we perform mediation analysis with inverse odds weighting implemented in Cox proportional-hazards models.

RESULTS

Prenatal maternal smoking was associated with lower birthweight z-scores [β: -0.29; 95% CI -0.34, -0.24] and reduced breastfeeding duration [RRR< 1month: 0.90; 95% CI 0.79, 1.02; RRR≥ 1 month: 0.66; 95% CI 0.59, 0.73 relative to women who were never breastfed]. Greater z-score for birthweight [HR: 0.96; 95% CI 0.91, 1.01] and longer breastfeeding duration [HR≥ 1 month: 0.84; 95% CI 0.74, 0.96] were associated with lower hazards for earlier age at natural menopause. The total effect of prenatal maternal smoking on the time to natural menopause in daughters was estimated as a HR of 1.13 [95% CI 1.02, 1.24]. Birthweight z-score and breastfeeding duration jointly explained an estimated 14% of the total effect [HRNIE: 1.02; 95% CI 0.99, 1.05].

CONCLUSIONS

The consequences of smoking during pregnancy on the earlier experience of natural menopause in daughters may partly be offset by intrauterine growth and longer breastfeeding duration to the extent that they mediate the risk of earlier menopause. However, since the extent of mediation by birthweight z-score and breastfeeding duration is small, other factors, including the direct effect of maternal smoking in utero, may play a more important role.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review

OBJECTIVE

The objective of this review was twofold: (i) to comprehensively identify the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning health care providers' interactions with them about their smoking, when such interactions occurred during contact for prenatal or postnatal health care in any health care setting; and (ii) to synthesize the research findings for recommendations to strengthen health care providers' interventions regarding smoking during pregnancy and smoking during the postnatal period.

INTRODUCTION

Maternal tobacco smoking during pregnancy and maternal tobacco smoking postnatally pose serious health risks for the woman, fetus, and offspring, whereas maternal smoking cessation has beneficial health effects. Given the importance of health care providers' interactions with pregnant and postnatal women for smoking cessation care, it is essential to understand women's experiences of such interactions.

INCLUSION CRITERIA

Studies considered for this review had qualitative research findings about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) in relation to health care providers' interactions with them about their smoking.

METHODS

The review was conducted using the JBI approach to qualitative systematic reviews. Published studies were sought through 6 academic databases (eg, CINAHL, MEDLINE). Unpublished studies were searched in 6 gray literature sources (eg, ProQuest Dissertations and Theses, Google Scholar). Reference lists of retrieved records were also searched. The searches occurred in October and November 2020; no country, language, or date limits were applied. Study selection involved title and abstract screening, full-text examination, and critical appraisal of all studies that met the inclusion criteria for the review. Study characteristics and research findings were extracted from the included studies. Study selection and extraction of findings were conducted by two reviewers independently; differences between reviewers were resolved through consensus. The research findings were categorized, and the categories were aggregated into a set of synthesized findings. The synthesized finding were assigned confidence scores. The categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 57 included studies varied in qualitative research designs and in methodological quality (from mostly low to high). There were approximately 1092 eligible participants, and 250 credible and unequivocal research findings. The research findings yielded 14 categories and 6 synthesized findings with low to very low confidence scores. Some women who smoked tobacco during pregnancy and some women who smoked tobacco postnatally lacked supportive interactions by health care providers regarding their smoking; other women experienced supportive interactions by health care providers. Women were adversely impacted when health care providers' interactions lacked supportiveness, and were beneficially impacted when interactions were supportive. Women varied in openness to health care providers' interactions regarding their smoking, from not being receptive to being accepting, and some women wanted meaningful health care provider interactions.

CONCLUSIONS

Although confidence in the synthesized findings is low to very low, the evidence indicates that supportive health care provider interactions may facilitate positive smoking behavior change in pregnancy and postnatally. It is recommended that health care providers implement accepted clinical practice guidelines with women who smoke prenatally or postnatally, using an approach that is person-centered, emotionally supportive, engaging (eg, understanding), and non-authoritarian.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

Cigarette smoking during breastfeeding in Papua New Guinea: Prevalence and demographic and socio-economic predictors

BACKGROUND

Cigarette smoking during breastfeeding is reported to contribute to significant changes in the composition of breast milk not only by reducing its protective features but also affecting infants' response to breastfeeding and breast milk. However, studies on the prevalence of cigarette smoking and associated factors during breastfeeding are limited in Papua New Guinea (PNG). This study estimates the prevalence of cigarette smoking and its association with demographic and economic factors among breastfeeding women in PNG.

METHODS

We used weighted survey data from the 2016-2018 PNG Demographic and Health Survey (PNGDHS). A weighted sample of 3,822 women who were breastfeeding during the survey were included in the study. The outcome variable in the present study is current cigarette smoking. A multiple logistic regression analysis was used to estimate the association between current cigarette smoking status and socio-demographic and economic variables of breastfeeding women. The regression analysis results were reported using adjusted odds ratios (aOR) with their respective 95% confidence intervals (CIs).

RESULTS

From the weighted sample, the prevalence of cigarette smoking among breastfeeding women was 21.9%; of which 60.8% smoked daily. The mean number of cigarettes smoked in the last 24 hours preceding the survey was 6.05(SD = 5.99). Multiple logistic regression analysis revealed that breastfeeding women who were from the Momase (aOR: 2.337, CI: 1.786-3.058, p<0.001) and Highlands (AOR: 1.589, CI: 1.213-2.082, p = 0.001), had no religious affiliation (aOR: 3.665, CI: 1.235-10.877, p = 0.019), and households with daughters as household heads (aOR: 1.901, CI: 1.231-2.935, p = 0.004) and being in more than one union (aOR: 2.374, CI: 1.805-3.123, p<0.001) were significantly more likely to smoke cigarette compared to women from southern region, those affiliated to Anglican church, those with husband as household heads, and being in one union respectively.

CONCLUSION

Cigarette smoking among breastfeeding women in PNG is relatively high, and region of residence, religion, relationship to household head, and the number of unions remain independent predictors. Interventions should target the individual socio-economic and cultural contexts within which breastfeeding occurs.

Intention to Breastfeed and Paternal Influence on Pregnant Mothers Exclusively Using Marijuana Compared with Other Substances

Objective: To determine intention to breastfeed (ITBF) rates among mothers exclusively using marijuana (eMJ) compared with electronic cigarettes (eEcig), tobacco products (eTob), or multisubstances (MS), nonusers (NU), and the influence of paternal presence and paternal substance use. Study Design: Cross-sectional study of parental survey responses merged with electronic birth certificates. Accounting for clinical and social determinants of health, analyses of ITBF included (1) all mothers, (2) single mothers, and (3) mothers with fathers. Results: Among all mothers (n = 1,073), eMJ, eTob, and MS users had lower odds of ITBF compared with NU. Only eMJ users had lower odds of ITBF for those without paternal presence. However, in those mothers with a paternal presence, odds of ITBF were similar to NU for eMJ, eTob, and MS users when accounting for paternal factors, including paternal substance use. Conclusion: Women exclusively using MJ have lower ITBF compared with NU. However, paternal presence mitigated this effect, independent of parental MJ use. The presence of fathers may represent a unique predictor for increased ITBF in MJ using mothers.

Reciprocal Associations Between Maternal Smoking Cessation and Breastfeeding

Background: Pregnancy is a motivating factor to quit smoking, but many women relapse postpartum. The underlying mechanisms and the necessary duration of breastfeeding that provide long-term protection against postpartum smoking relapse are unknown. Aims: We aimed to examine (1) associations of smoking cessation with breastfeeding initiation and duration; (2) necessary breastfeeding duration to reduce or prevent risk of postpartum smoking relapse. Methods: In this cohort study, we recruited 55 mothers, either smoking or have quit smoking, who recently delivered their baby from the Greater Buffalo area, NY, USA. Results: Quitters had a higher breastfeeding initiation rate (73.7% versus 30.8%; p = 0.029) and breastfed longer (p < 0.024) than nonquitters. Mothers who never breastfed relapsed quicker than mothers who did (p = 0.039). There was a 28% reduction in smoking relapse at 12 months postpartum for every month longer of breastfeeding duration (confounder-adjusted hazard ratio, 0.72 [95% confidence interval, 0.55-0.94]; p = 0.014). The estimated smoking relapse risk was 60.0% for nonbreastfeeding, 22.4% for 3 months of breastfeeding, 8.4% for 6 months of breastfeeding, and 1.2% for 12 months of breastfeeding. Conclusion: Smoking cessation was associated with increased breastfeeding initiation and duration. Smoking relapse risk decreased with longer breastfeeding duration, and 12 months of breastfeeding may help to prevent smoking relapse. An integrated intervention of maternal smoking cessation and breastfeeding promotion is promising to enhance both behaviors.

Perceived Sleep Quality and Fatigue in a Population of New Mothers: A Cross-Sectional Study Comparing Relationships with Breastfeeding and Bottle Feeding

Introduction: This study, which used a cross-sectional design, was carried out to examine the factors associated with the way mothers fed their infants such as breastfeeding or bottle feeding, and to compare perceived sleep quality and fatigue levels. Method: The study sample consisted of a total of 100 women in the 4th to 16th week postpartum, including 50 women breastfeeding and 50 women bottle feeding their infants. The data of the study were collected in Family Health Centers (FHC) through the face-to-face interview technique using "a Personal Information Form," "the Pittsburgh Sleep Quality Index-PSQI," and "the Checklist Individual Strength-CIS." Results: The mothers' total sleep quality (PSQI) score was found to not differ significantly according to the type of infant feeding. Similarly, total scores for fatigue assessment obtained from the CIS did not differ according to the infant feeding type variable. A significant positive correlation was found between total sleep quality and total fatigue level, and subjective fatigue level. Discussion: The sleep quality and fatigue levels of mothers are independent of the method of feeding their infants. Midwives should plan initiatives with parents to improve maternal sleep quality and reduce fatigue levels and inform parents that breastfeeding is not a factor that reduces sleep quality or increases fatigue. Clinical Trials.gov ID: 1129/5463.

Association of prenatal medical risk with breastfeeding outcomes up to 12 months in the All Our Families community-based birth cohort

Background

Prenatal medical risk describes physical health issues or biological factors that predate or arise during pregnancy which heighten the risk of adverse outcomes, and often warrant specialized obstetric care. The influence of the nature and magnitude of prenatal risk on breastfeeding outcomes remains poorly understood. The objective of this study was to determine the association between prenatal medical risk and breastfeeding initiation and duration up to 1 year postpartum.

Methods

We analysed a subset of data from the All Our Families longitudinal cohort (n = 2706) of women in Calgary, Canada who delivered a liveborn infant between 2008 and 2010. Data were collected from self-report questionnaires and medical records. Women with complete data on prenatal medical risk factors and breastfeeding outcomes were included in this analysis. Prenatal medical risk was operationalized as one integer score of risk severity and four binary risk types capturing pre-pregnancy characteristics, past obstetric problems, current obstetric problems, and substance use. Outcomes were breastfeeding initiation defined as the infant ever receiving breast milk, and duration operationalized as still breastfeeding at 4 months, at 12 months, and time to breastfeeding cessation in weeks. We used logistic regression and Cox regression with right censoring at 52 weeks or attrition to calculate odds ratios (OR) and hazard ratios (HR), respectively, adjusting for sociodemographic vulnerability, parity, mode of delivery, and gestational age.

Results

Prenatal medical risk severity and type were not significantly associated with breastfeeding initiation, with the exception of pre-pregnancy risk type (OR 0.45; 95% CI 0.26, 0.77). Risk severity was associated with lower odds of breastfeeding to 4 months (OR 0.94; 95% CI 0.90, 0.99), 12 months (OR 0.93; 95% CI 0.87, 0.98), and earlier breastfeeding cessation (HR 1.05; 95% CI 1.02, 1.08). Associations with shorter breastfeeding length across the first postpartum year were observed for pre-pregnancy, current obstetric, and substance use risk types, but not past obstetric problems.

Conclusion

Prenatal medical risk is associated with shortened duration of breastfeeding. Women with prenatal medical risk may benefit from the proactive arrangement of lactation support before and following delivery to promote continued breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00413-0.

Smoking Cessation among Pregnant and Postpartum Women from Low-Income Groups in the United States

INTRODUCTION

Pregnancy creates a unique window of opportunity for smoking cessation. However, pregnant women from underserved groups can face personal, social, and environmental challenges that impede quitting. This study draws upon the socioecological framework to explore perspectives on smoking cessation among pregnant and postpartum women from low-income groups in the mid-South of the United States.

METHODS

Semistructured interviews were conducted with 60 women who were pregnant or postpartum. Data were analyzed in Dedoose qualitative software using the directed content analysis approach.

RESULTS

Findings reveal that at the individual level, motivations for smoking cessation included the fact of being pregnant, risks associated with the infant's health, and desire to breastfeed. However, some pregnant women perceived that slowing down on smoking during pregnancy was adequate to prevent harm to their fetuses. Individual-level factors that made smoking cessation difficult included nicotine addiction and habit, boredom, stressful life circumstances, fear of weight gain, and perceived lack of willpower. At the interpersonal level, living in a smoke-free environment where loved ones do not smoke and emotional and practical support from social network members including partners and family members were thought to facilitate smoking cessation. At the organizational level, access to nicotine replacement therapies and counseling aided in their abilities to quit smoking. At the policy level, pregnant women viewed increase in cigarette prices, warning labels on the cigarette pack, and the potential for a ban on cigarette sales as having some effect in helping them quit smoking.

DISCUSSION

This study offers theoretical insights into factors that function as barriers or facilitators of smoking cessation among pregnant and postpartum women from low-income groups in the United States. Designing multilevel smoking cessation interventions while considering the interplay of individual, interpersonal, organizational, and policy level factors may lead to better cessation outcomes.

Challenges Experienced by Women Who Smoke During Pregnancy or Postnatally

Maternal smoking during pregnancy and maternal smoking postnatally are important public health concerns worldwide. Smoking adversely affects the woman's general health and is causally related to pregnancy complications and serious health outcomes for the child, such as stillbirth, preterm delivery, low birth weight, and sudden infant death. The purpose of this research was to examine maternal smoking through a quantitative descriptive survey of 164 women, 120 who were pregnant and 44 who were postnatal. Women experienced barriers to quitting smoking, including dealing with stress, being exposed to smokers, not being ready to quit, not knowing how to quit, not looking for or not being able to find information about smoking or quitting smoking, and lacking adequate social and healthcare provider support. On the other hand, women revealed characteristics that suggest they might have had improved potential for quitting smoking, including having negative feelings about smoking, having cut down on smoking, smoking at a low level, having made quit attempts, thinking it would not be hard to quit smoking, being in the preparation stage of behavioral change, and thinking their healthcare providers (HCPs) would help them if they decided to quit. Taken together, those findings suggest that HCPs could offer important assistance to help women achieve smoking cessation. However, more research needs to be conducted to clarify the role and effectiveness of various HCPs in smoking cessation interventions and to identify measures to strengthen their provision of such interventions.

A longitudinal, observational study of women who persisted in smoking in successive pregnancies

BACKGROUND

This longitudinal study examined the profile and pregnancy-related behaviours of women who reported smoking in two successive pregnancies when they presented for prenatal care in a large maternity hospital.

METHODS

Using the hospital electronic medical records, women who delivered two successive singleton pregnancies during the years 2011-15 were analyzed. Standardized data were computerized by a midwife at the first prenatal visit, following delivery and before discharge.

RESULTS

Over the 5 years, 6647 women delivered twice. Overall 5754 (86.6%) were persistent non-smokers in both pregnancies, 609 (9.2%) were persistent smokers in both pregnancies and between pregnancies 202 (3.0%) quit and 82 (1.2%) started smoking. Compared with persistent non-smokers, persistent smokers had higher rates of reported illicit drug use, alcohol consumption and psychological problems and lower rates of planned pregnancy, folic acid supplementation and breastfeeding in both pregnancies (all P < 0.001). In persistent smokers, folic acid supplementation practices deteriorated and illicit drug use increased in the subsequent pregnancy.

CONCLUSIONS

We found that approximately one in 10 women smoked in two consecutive pregnancies. Furthermore, compared with non-smokers, persistent smokers were more likely to report other health behaviours associated with adverse pregnancy outcomes and may require additional multidisciplinary support.

Experiences and cessation needs of Indigenous women who smoke during pregnancy: a systematic review of qualitative evidence

OBJECTIVES

The aim of this review was to identify and synthesize the best available evidence to address two questions: i) what is the experience of smoking during pregnancy for Indigenous women? and ii) what are the smoking cessation needs of Indigenous women who smoke during pregnancy?

INTRODUCTION

Smoking during pregnancy not only affects pregnant women's general health but also causes such serious problems as pre-term delivery, low birth weight, and sudden infant death. Rates of smoking during pregnancy are particularly high among Indigenous women. Learning about Indigenous women's experiences of smoking during pregnancy and associated smoking cessation needs is important to providing informed health care to them.

INCLUSION CRITERIA

The participants of interest were Indigenous women who smoked during a current or past pregnancy. The phenomena of interest were the experiences of smoking during pregnancy for Indigenous women and the smoking cessation needs of Indigenous women during pregnancy. The context was any community worldwide where pregnant Indigenous women live. Studies considered for this review were those in which qualitative data were gathered and analysed on the phenomena of interest, including mixed methods research.

METHODS

A comprehensive search was conducted for published studies in academic databases (i.e. PubMed, CINAHL, PsycINFO, Embase, Sociological Abstracts, SocINDEX, and Web of Science), unpublished studies in sources of gray literature (i.e. ProQuest Dissertations and Theses, OAIster, LILACS, MedNar, Google, Google Scholar, OpenGrey and relevant websites), and any additional studies in reference lists. Language and date limiters were not applied. The searches included all studies globally and were carried out on October 31, 2016. Studies that met the inclusion criteria were assessed for methodological quality by two reviewers independently, using the criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Descriptive details of each study accepted for this review were extracted in accordance with the elements of the JBI Data Extraction Form for Qualitative Research. The research findings that were relevant to the phenomena of interest and had participant voice were extracted from each included study and synthesized using the JBI meta-aggregative approach. The synthesized findings were assigned confidence scores in accordance with the JBI ConQual approach.

RESULTS

Thirteen studies were included in this review following careful consideration of the methodological quality of each study. The studies yielded a total of 116 research findings, which were grouped into 19 categories and then aggregated to form five synthesized findings. Confidence in the findings was determined to be low to very low (see ConQual Summary of Findings).

CONCLUSION

There is a small body of research evidence on Indigenous women's experiences of smoking during pregnancy and their smoking cessation needs. Confidence in the synthesized findings is constrained due to methodological limitations in many of the primary studies included in this review, along with mixed credibility of the research findings from across primary studies.

Safety of Electronic Cigarette Use During Breastfeeding: Qualitative Study Using Online Forum Discussions

BACKGROUND

Electronic cigarettes (e-cigs) are an increasingly popular alternative to smoking, helping to prevent relapse in those trying to quit and with the potential to reduce harm as they are likely to be safer than standard cigarettes. Many women return to smoking in the postpartum period having stopped during pregnancy, and while this can affect their decisions about breastfeeding, little is known about women's opinions on using e-cigs during this period.

OBJECTIVE

The aim of this study is to explore online forum users' current attitudes, motivations, and barriers to postpartum e-cig use, particularly as a breastfeeding mother.

METHODS

Data were collected via publicly accessible (identified by Google search) online forum discussions, and a priori codes identified. All transcripts were entered into NVivo for analysis, with a template approach to thematic analysis being used to code all transcripts from which themes were derived.

RESULTS

Four themes were identified: use, perceived risk, social support and evidence, with a number of subthemes identified within these. Women were using e-cigs to prevent postpartum return to smoking, but opinions on their safety were conflicting. They were concerned about possible transfer of harmful products from e-cigs via breastmilk and secondhand exposure, so they were actively seeking and sharing information on e-cigs from a variety of sources. Although some women were supportive of e-cig use, others provided harsh judgement for mothers who used them.

CONCLUSIONS

E-cigs have the potential to reduce the number of women who return to smoking in the postpartum period and potentially improve breastfeeding rates, if breastfeeding mothers have access to relevant and reliable information. Health care providers should consider discussing e-cigs with mothers at risk of returning to smoking in the postpartum period.

Perceptions and Practices of Infant Feeding among African American Women

A large urban hospital in Florida implemented changes to achieve the Baby-Friendly Hospital Initiative (BFHI) designation in 2015 resulting in an increase of exclusive breastfeeding rates at hospital discharge; however, African American women continue to have the lowest rates overall. Qualitative interviews were conducted with 20 African American women who received prenatal care at a low-income women's clinic and gave birth at an affiliated BFHI hospital. Using a medical anthropology analytical framework to examine predisposing, enabling, and service-related factors that affect breastfeeding, this study investigated interpersonal, sociocultural, and institutional barriers to breastfeeding. Common challenges experienced by participants included lack of maternity leave from work, lack of access to electric pumps, social pressures to initiate formula supplementation, fears that breastfeeding renders infants overly dependent on their mother's care, and a lack of breastfeeding role models and/or support networks to normalize longer-term breastfeeding. We conclude that efforts to increase breastfeeding rates for African American women and promote culturally sensitive interventions must address underlying socioeconomic and structural barriers, women's perceptions of breastfeeding benefits and difficulties, and the need for improvements in postnatal lactation and doula support to foster a more inclusive culture of breastfeeding.

Comparison of national cross-sectional breast-feeding surveys by maternal education in Europe (2006-2016)

OBJECTIVE

Breast-feeding is an important determinant of health of mothers and their offspring. The present study aimed to compare breast-feeding rates across Europe disaggregated by maternal education and establish what proportion achieves at least 50 % exclusive breast-feeding (EBF) at 6 months.Design/SettingSecondary analysis of national or sub-national studies' breast-feeding data for EU Member States plus Norway and Iceland, published in 2006-2016. Nineteen EU Member States plus Norway reported rates of EBF and any breast-feeding disaggregated by maternal education, of which only thirteen could be matched to the International Standard Classification of Education.ParticipantsMothers and their infants aged 0-12 months.

RESULTS

Data on EBF rates at 6 and 4 months were found in only four and six countries, respectively. At 6 months, EBF rates of 49 % in Slovakia and 44 % in Hungary were closest to WHO's target of at least 50 % EBF. At 4 months, mothers with high education level in Denmark, the Netherlands and Germany had the highest EBF rates (71, 52 and 50 %, respectively). Mothers with low education level were less likely to initiate breast-feeding and cessation occurred early. The inequality gap ranged from 63 % in Irish mothers to no gap or very low levels of inequality in Poland, Sweden and Norway.

CONCLUSIONS

More mothers with high, compared with low, education initiate breast-feeding and practise EBF for longer. More European policies should be targeted to protect, support and promote breast-feeding, especially among mothers with only mandatory education.

Determinants of Exclusive and Mixed Breastfeeding Durations and Risk of Recurrent Illnesses in Toddlers Attending Day Care Programs Across Lebanon

PURPOSE

Breastfeeding rates continue to decrease in Lebanon. Studies addressing the relationship between breastfeeding duration and health outcomes in Middle Eastern countries are scarce. This study is the first in Lebanon to have investigated the determinants of both exclusive and mixed breastfeeding durations and the relationship with health in infants and toddlers.

DESIGN AND METHODS

Our sample of 1051 toddlers is nationwide and representative of all toddlers enrolled in daycare centers, and aged between 12 and 36 months.

RESULTS

Median of exclusive breastfeeding duration was 15 days and mean age of formula introduction was 2.03 (±3.22) months. Exclusive breastfeeding was initiated at a mean age of 10.56 (±27.12) hours and half of the toddlers (51.6%) were exposed to formula milk since day one following birth. Determinants of both exclusive and total breastfeeding durations were related to several parents' socio-demographic and behavioral factors. A longer duration of exclusive breastfeeding was associated with a lower frequency of pediatrician visits, antibiotic prescriptions, absence from daycare, and a lower risk of otitis, colic and UTI occurrence, after adjusting for cofounders. Similarly, a longer duration of total breastfeeding was associated with less antibiotic prescriptions and a lower risk of otitis.

CONCLUSIONS

Our study highlights the health benefits of extending exclusive breastfeeding duration. It is urgent to address alarmingly low breastfeeding rates in Lebanon. Policy implementation and enforcement along with raising awareness and creating a supportive environment for breastfeeding mothers should involve the various stakeholders in order to succeed in increasing breastfeeding rates and duration.

Determinants of dietary practices during pregnancy: A longitudinal qualitative study in Niger

Undernutrition is associated with maternal morbidity and poor pregnancy outcomes. This qualitative study seeks to understand the multilevel factors influencing maternal dietary practices in Niger, including the impact of pregnancy illnesses on diet. Criterion-based, purposive sampling was used to select pregnant women and household members from 24 villages in a rural district of the Maradi Region in south-central Niger. Semistructured interviews (n = 153) and focus group discussions (n = 38) explored 4 primary themes: (a) perceptions of ideal diet during pregnancy, (b) barriers to consuming the ideal diet, (c) coping strategies including dietary responses related to pregnancy illnesses, and (d) changes in perceptions from early to late pregnancy. Longitudinal data collection allowed for repeated interviews of pregnant women to document changes in dietary practices throughout pregnancy. Transcripts were coded using an inductive approach informed by grounded theory methodology. Participants categorized foods into 4 primary dietary taxonomies when discussing ideal maternal diets but cited constraints related to accessibility and availability impeding routine consumption of these foods. Perceptions of "modern," urban foods as healthy, coupled with key structural barriers such as food costs, were identified. Maternal morbidity influenced food consumption, as women reported reducing food intake early in pregnancy in response to illness episodes. Although awareness of optimal foods for supporting healthy pregnancies was moderately high, some misconceptions were observed and multilevel barriers to food security restricted opportunities for consuming these foods. Nutrition-specific and nutrition-sensitive interventions could improve access and availability of acceptable foods for supporting increased dietary intake during pregnancy.

Prospective associations of breastfeeding and smoking cessation among low-income pregnant women

Although low-income pregnant women have high rates of smoking and low rates of breastfeeding, few studies have examined prospective associations between these risk factors in community samples. Doing so may help improve breast-feeding support programs in this population. We used a secondary analysis of 247 low-income pregnant smokers in Memphis, Tennessee, who were interviewed up to 4 times (twice during pregnancy and twice through 6 months postpartum). Smoking cessation during prepartum and postpartum was defined as a self-report of not smoking for ≥1 week and an expired carbon monoxide level of <10 ppm. Multivariable logistic regression analyses were used to determine whether intent to breastfeed was associated with smoking cessation and whether smoking cessation was associated with actual breastfeeding. Models were adjusted for sociodemographic, pregnancy-related, and smoking-related confounders. Thirty-nine percent of participants intended to breastfeed, and 38% did so. Women who intended to breastfeed were 2 times more likely to quit smoking prepartum (adjusted OR = 1.99, 95% CI [1.06, 3.74]), but not postpartum (adjusted OR = 1.27, 95% CI [0.57, 2.84]). Quitting smoking at baseline and during pregnancy was associated with subsequent breastfeeding (adjusted OR 2.27, 95% CI [1.05, 4.94] and adjusted OR = 2.49, 95% CI [1.21, 5.11]). Low-income women who intended to breastfeed were more likely to quit smoking during pregnancy and those who quit smoking at baseline and prepartum were more likely to breastfeed. Simultaneously supporting breastfeeding and smoking cessation may be very useful to change these important health behaviours among this high-risk population.

Predictors of breastfeeding duration in a predominantly Māori population in New Zealand

BACKGROUND

Although breastfeeding duration in New Zealand's indigenous Māori is shorter than in non-Māori, we know little about barriers or motivators of breastfeeding in this community. The aim of this analysis was to identify predictors for extended duration of breastfeeding amongst participants drawn from predominantly Māori communities in regional Hawke's Bay.

METHODS

Mother/baby dyads were recruited from two midwifery practices serving predominantly Māori women in mostly deprived areas, for a randomised controlled trial comparing the risks and benefits of an indigenous sleeping device (wahakura) and a bassinet. Questionnaires were administered at baseline (pregnancy) and at one, three and six months postnatal. Several questions relating to breastfeeding and factors associated with breastfeeding were included. The data from both groups were pooled to examine predictors of breastfeeding duration.

RESULTS

Māori comprised 70.5% of the 197 participants recruited. The median time infants were fully breastfed was eight weeks and Māori women were more likely to breastfeed for a shorter duration than New Zealand European women with an odds-ratio (OR) of 0.45 (95% CI 0.24, 0.85). The key predictors for extended duration of breastfeeding were the strong support of the mother's partner (OR = 3.64, 95% CI 1.76, 7.55) or her mother for breastfeeding (OR = 2.47, 95% CI 1.27, 4.82), longer intended duration of maternal breastfeeding (OR = 1.02, 95% CI 1.00, 1.03) and being an older mother (OR = 1.07, 95% CI 1.02, 1.12). The key predictors for shorter duration of breastfeeding were pacifier use (OR = 0.28, 95% CI 0.17, 0.46), daily cigarette smoking (OR = 0.51, 95% CI 0.37, 0.69), alcohol use (OR = 0.54, 95% CI 0.31, 0.93) and living in a more deprived area (OR 0.40, 95% CI 0.22, 0.72).

CONCLUSIONS

Breastfeeding duration in this group of mainly Māori women was shorter than the national average. Increasing the duration of breastfeeding by these mothers could be further facilitated by ante and postnatal education involving their own mothers and their partners in the support of breastfeeding and by addressing pacifier use, smoking and alcohol use.

Drinking or Smoking While Breastfeeding and Later Cognition in Children

BACKGROUND AND OBJECTIVES

Although prenatal alcohol and nicotine exposure are associated with reduced cognition in children, associations between consumption of alcohol during lactation and cognition have not been examined. We aimed to examine whether drinking or smoking while breastfeeding lowers children's cognitive scores. We hypothesized that increased drinking or smoking would be associated with dose-dependent cognitive reductions.

METHODS

Data were sourced from Growing Up in Australia: The Longitudinal Study of Australian Children. Participants were 5107 Australian infants recruited in 2004 and assessed every 2 years. Multivariable linear regression analyses assessed relationships between drinking and smoking habits of breastfeeding mothers and children's Matrix Reasoning, Peabody Picture Vocabulary Test-Third Edition and Who Am I? scores at later waves.

RESULTS

Increased or riskier wave 1 maternal alcohol consumption was associated with reductions in Matrix Reasoning scores at age 6 to 7 years in children who had been breastfed (B = -0.11; SE = 0.03; 95% confidence interval: -0.18 to -0.04; P = .01). This relationship was not evident in infants who had never breastfed (B = -0.02; SE = 0.10; 95% confidence interval = -0.20 to 0.17; P = .87). Smoking during lactation was not associated with any outcome variable.

CONCLUSIONS

Exposing infants to alcohol through breastmilk may cause dose-dependent reductions in their cognitive abilities. This reduction was observed at age 6 to 7 years but was not sustained at age 10 to 11 years. Although the relationship is small, it may be clinically significant when mothers consume alcohol regularly or binge drink. Further analyses will assess relationships between alcohol consumption or tobacco smoking during lactation and academic, developmental, physical, and behavioral outcomes in children.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Infant feeding decisions and behaviours among low-income smoke-exposed women: timing and change during pregnancy

Objective

The present study aimed to describe change in feeding intentions and predictors of breast-feeding intentions during the course of pregnancy.

Design

Analysis of prospectively collected data from a larger randomized controlled trial of a health education intervention to reduce environmental smoke exposure among women during and after pregnancy.

Setting

Participants were recruited from prenatal clinics, but all further communication occurred with participating women living in the community.

Subjects

Low-income, adult women (n399) were interviewed during the 16th and 32nd week of pregnancy to ascertain prenatal feeding intentions and breast-feeding knowledge, attitudes and self-efficacy. Characteristics of women by infant feeding intention were assessed along with differences in intention from 16 to 32 weeks of pregnancy and feeding behaviours after delivery. Differences in psychosocial variables between women of different intention for infant feeding were measured. Women in each category of feeding intention were assessed for changes in psychosocial factors by eventual infant feeding behaviour.

Results

Feeding intention early in pregnancy was strongly, but not consistently, associated with feeding intention late in pregnancy, feeding initiation and later feeding patterns. Over one-third of women who were undecided at 16 weeks’ gestation or earlier initiated breast-feeding. Increases in knowledge and improvement in time, social factors and social support barriers were found among those who exclusively breast-fed.

Conclusions

Results indicate that feeding decisions may change during pregnancy. Determining when women make feeding decisions during their pregnancy warrants more research. Interventions to increase breast-feeding intentions should target knowledge, self-efficacy and barriers.

The Influence of Smoking on Breast feeding Among Women Who Quit Smoking During Pregnancy

INTRODUCTION

Understanding factors related to breast-feeding intention, initiation, duration, and weaning among women who quit smoking as a result of pregnancy may inform interventions to increase breast-feeding rates among women who smoke.

METHODS

Women (N = 300) who quit smoking as a result of pregnancy and enrolled in a postpartum relapse prevention trial were interviewed about breast-feeding intention prior to delivery. Breast-feeding initiation, duration, reasons for weaning, and relapse to smoking were assessed at 12-weeks postpartum.

RESULTS

The majority of pregnant former smokers intended to breastfeed (68%), and actual rates of breast feeding were higher (74%). Among women who initiated breast feeding, weaning before 2 months was common (41%). For most women (69%), smoking had no effect on breast-feeding decisions. Among the 31% of women who reported that smoking influenced their feeding decisions, 83% indicated that they did not smoke or decreased smoking frequency in order to breastfeed while 17% did not breastfeed or quit breast feeding in order to smoke. Women who decided to forgo breast feeding to smoke were significantly more likely to have a high school education or less (p < .001) and to be African American (p < .0001) than those who had other reasons not to breastfeed.

CONCLUSIONS

Most women who quit smoking during pregnancy initiate breast feeding, and the majority report smoking did not influence feeding decisions. Importantly, among women for whom smoking did influence feeding decisions, most reported changing smoking behavior to enable breast feeding. Interventions to increase breast-feeding initiation and duration may decrease postpartum relapse and improve maternal and infant health.

IMPLICATIONS

This study extends the literature on women's perception of the influence of smoking on breast feeding by assessing breast-feeding intent, initiation, duration, and reasons for weaning longitudinally among women who quit smoking as a result of pregnancy. The results support a need for additional research to determine the effectiveness of breast feeding supports as a component of interventions to reduce postpartum smoking relapse.

Postpartum smoking relapse--a thematic synthesis of qualitative studies

BACKGROUND AND AIMS

Many women quit smoking during pregnancy, but relapse after the baby is born. To understand why and identify ways of preventing this, this study reviewed the qualitative literature on women's experience of postpartum smoking relapse.

METHODS

A systematic review of qualitative studies and process evaluations of trials. We undertook a thematic synthesis of published qualitative data.

RESULTS

We screened 1336 papers. Twenty-two papers reporting on 16 studies were included, reporting on the views of 1031 postpartum women. Factors affecting relapse and barriers and facilitators to relapse prevention were identified around the key themes of beliefs, social influences, motivation, physiological factors and identity. Women's beliefs about smoking as a means of coping with stress and the need for social support, especially from a partner, emerged as important. Extrinsic motivation to quit during the pregnancy (for the health of the fetus) appeared to be a factor in prompting relapse after the baby was born. During the immediate postpartum period women believed that physiological changes influence cigarette cravings. The stress of caring for a newborn, sleeplessness and adjusting to a new mothering identity were also reported to be important.

CONCLUSIONS

Among women who quit smoking during pregnancy, those who relapse postpartum talk commonly about no longer needing to protect the baby and the effects of stress. Partner support and a sense of changed identity are cited as factors preventing relapse.

Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth

AIM

To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies.

BACKGROUND

The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed.

DESIGN

A synthesis of qualitative research using meta-ethnography.

DATA SOURCES

Five electronic databases (January 1990-May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the review's aims.

REVIEW METHODS

Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups.

RESULTS

Four factors were identified that acted both as barriers and facilitators to women's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking.

CONCLUSION

The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting.

Outcomes and factors associated with breastfeeding for <8 weeks among preterm infants: findings from 6 states and NYC, 2004-2007

To examine breastfeeding outcomes and factors associated with breastfeeding <8 weeks among preterm infants. Pregnancy Risk Assessment Monitoring System (PRAMS) data for seven sites from 2004 to 2007 were used. Logistic regression was used to identify correlates of short breastfeeding duration among preterm infants. Among preterm infants, short breastfeeding duration (<8 weeks) was associated with maternal age ≤19 years (OR 1.75; 95 % CI: 1.22, 2.50), infant birth weight between 1,500 and 2,499 g (OR 1.29; 95 % CI: 1.01, 1.65), maternal obesity (OR 1.52; 95 % CI: 1.17, 1.98), smoking (OR 2.61; 95 % CI: 1.87, 3.63), and hypertension (OR 1.34; 95 % CI: 1.06, 1.69). Receiving a phone number for breastfeeding help (OR 0.59; 95 % CI: 0.44, 0.78) and not receiving a gift pack with formula (OR 0.64; 95 % CI: 0.47, 0.87) were associated with decreased odds of short duration. Speaking with a provider about breastfeeding prenatally was associated with increased odds of short duration (OR 1.75; 95 % CI: 1.33, 2.30). These findings strengthen the hypothesis that infant and maternal health are determinants of breastfeeding preterm infants and suggest a need to provide additional support to smokers, obese and hypertensive women, and mothers of infants with birth weights between 1,500 and 2,499 g, to help them sustain breastfeeding. Support from hospitals, such as providing a telephone number for breastfeeding help, and not providing a gift pack with formula, can also make a difference. These practices should be adopted by hospitals.

Breastfeeding and Methadone Therapy: The Maternal Experience

BACKGROUND

Despite evidence of low transfer of methadone into breast milk and the potential physical and psychological benefits that breastfeeding offers for methadone-exposed mothers and infants, the rate of breastfeeding initiation in this population is about half that reported nationally. This study describes the perceptions surrounding breastfeeding decisions and management among pregnant and postpartum women taking methadone.

METHODS

Seven pregnant women and 4 postpartum women enrolled in methadone maintenance programs participated in semistructured, audiotaped interviews and focus groups, respectively, about their breastfeeding experiences. Transcripts were analyzed and coded using qualitative content analysis.

RESULTS

Three major content categories were identified: (1) fears, barriers, and misconceptions about breastfeeding while taking methadone; (2) motivation and perceived benefits of breastfeeding; and (3) sources of information, support, and anxiety about general breastfeeding management and breastfeeding while taking methadone. Lack of support from the health care community and misinformation about the dangers of combining breastfeeding and methadone therapy represented significant, yet modifiable, barriers to breastfeeding success in methadone-exposed women.

CONCLUSIONS

Interventions to increase the prevalence of breastfeeding among women taking methadone should address identified logistical, educational, and psychological barriers and consider inclusion of women themselves, partners, peers, and clinicians. In particular, clinicians who care for methadone-exposed mothers and infants should be educated on therapeutic communication, up-to-date breastfeeding contraindications, and the health benefits of breastfeeding in this population.

Challenges and enablers to smoking cessation for young pregnant Australian women: a qualitative study

BACKGROUND

Western Australian (WA) perinatal statistics indicate an 8 percent decrease in smoking by pregnant women from 1999 to 2009. Despite the success of cessation interventions, the incidence of tobacco smokers among young pregnant women remains a cause for concern. To inform development of an appropriate suite of interventions, a qualitative study was undertaken to gain insight into the perceived challenges and enablers young pregnant women encounter when attempting to modify their smoking.

METHOD

A hypothetical scenario and interview questions were used: if a young pregnant woman decided to decrease or stop her smoking 1) what could assist her, and 2) what are the challenges that she would need to overcome? Thematic analysis was conducted. Our sample included English-speaking pregnant women recorded as a smoker, 16 to 24 years of age, and attending antenatal services at a public maternity hospital.

RESULTS

Thirty-six women participated in an interview. "Habit" was noted as the key theme under perceived challenges and incorporated three subthemes: learn to deal with stress; the urge for a smoke; and not being left out. Concern over the health of their baby emerged as the main theme and enabler to change behavior. Four subthemes were extracted around keeping their baby healthy: getting the facts; you need someone; something you can take to help; and keeping your mind off it.

CONCLUSIONS

Our findings highlight the complex issues around smoking for young pregnant WA women. Insight into these challenges and enablers may inform development of more suitable interventions to address the unique needs of this group of pregnant women.

Prevalence and predictors of early breastfeeding among late preterm mother-infant dyads

BACKGROUND

Although late preterm infants (LPIs), at 34(0/7)-36(6/7) weeks of gestation, are reported to have suboptimal rates of breastfeeding, there is a lack of quantitative evidence describing this trend. This study examined the prevalence of breastfeeding initiation and factors associated with breastfeeding non-initiation within a Pennsylvania population-based cohort of late preterm mother-infant dyads.

SUBJECTS AND METHODS

Descriptive statistics and odds ratios were used to assess and compare breastfeeding initiation rates in 2003-2009 among LPI mothers (n=62,451) and their infants (n=68,886) with moderately preterm (n=17,325) and term (n=870,034) infants. Binary logistic regression was used to determine the association of system/provider, sociodemographic, and medical factors with breastfeeding non-initiation in late preterm mother-infant dyads for the year 2009 (n=7,012).

RESULTS

Although LPI breastfeeding initiation in Pennsylvania increased significantly from 2003 (54%) to 2009 (61.8%) (p<0.001), the 2009 prevalence remained well below rates in term infant populations and national standards. The regression model indicated that interactions involving sociodemographic variables, including marital status, age, race/ethnicity, education, parity, Women, Infants and Children Program participation, and smoking status were among the most significant factors associated with LPI breastfeeding non-initiation (p<0.05). The univariate results were similar to those reported in preterm and term populations.

CONCLUSIONS

Our data suggest that certain, unexpected demographic groups in the late preterm population be prioritized for further analysis and possibly greater breastfeeding support. More research is indicated to understand the effect of modifiable psychosocial factors on LPI breastfeeding initiation.

Longer previous smoking abstinence relates to successful breastfeeding initiation among underserved smokers

OBJECTIVES

The purpose of this study was to examine sociodemographic and behavioral factors related to successful breastfeeding initiation among medically underserved maternal smokers-a population with persistently low rates of initiation.

SUBJECTS AND METHODS

Pretreatment data from a larger randomized behavioral counseling, secondhand smoke reduction trial was examined for this study. Maternal smokers with babies younger than 4 years old reported breastfeeding behaviors. Mothers who breastfed for >4 weeks (n = 50) were matched with mothers who never initiated breastfeeding based on infant age, gender, and maternal race. Multinomial logistic regression analysis tested the hypothesis that a greater duration of mothers' longest previous smoking abstinence would predict successful breastfeeding initiation in the context of other sociodemographic and behavioral factors known to relate to breastfeeding (e.g., education level, income, and maternal age).

RESULTS

The sample consisted of current maternal smokers with a mean age of 28.8 ± 7.1 years. Among participants, 94% were African American, 81% were single, 63% reported an annual family income less than $15,000, and 76% had completed a high school education or less. Logistic regression demonstrated that a longer duration of previous smoking abstinence and education beyond high school predicted breastfeeding initiation.

CONCLUSIONS

Maternal smokers' previous success at smoking abstinence may increase the likelihood of successful breastfeeding initiation. To improve prenatal health education for maternal smokers with low education levels, researchers should explore the utility of merging smoking cessation and postpartum relapse prevention advice within the context of lactation counseling to maximize success of smokers' efforts to initiate breastfeeding.

Tobacco

Anthropologists have long studied tobacco, what is today the world's greatest cause of preventable death. Their publications have garnered modest attention, however, even as the academy is increasingly interested in global health, transnational commoditization, pharmaceuticals, and the politics of life and death. We take stock of anthropology's tobacco literature and our discipline's broader appetites. We review how colleagues have studied health issues related to tobacco and engaged with theory and policy pertaining to the production, consumption, and regulation of drugs. We assess ways scholars working at the interface of anthropology and cigarettes have analyzed gender and ethnicity, corporate predation and industry-related harm, governmental management of disease, and the semiotics of misinformation. We discuss why anthropology has not more broadly and ardently engaged the study of tobacco. And we identify areas for further research capable of illuminating more fully tobacco's analytical potential and toxic effects.

Breastfeeding initiation in a rural sample: predictive factors and the role of smoking

The study objective was to identify demographic, medical, and health behavior factors that predict breastfeeding initiation in a rural population with low breastfeeding rates. Participants were 2323 women who experienced consecutive deliveries at 2 hospitals, with data obtained through detailed chart review. Only half the women initiated breastfeeding, which was significantly associated with higher levels of education, private insurance, nonsmoking and non-drug-using status, and primiparity, after controlling for confounders. Follow-up analyses revealed that smoking status was the strongest predictor of failure to breastfeed, with nonsmokers nearly twice as likely to breastfeed as smokers and with those who had smoked a pack per day or more the least likely to breastfeed. Findings reveal many factors placing women at risk for not breastfeeding and suggest that intervention efforts should encourage a combination of smoking cessation and breastfeeding while emphasizing that breastfeeding is not contraindicated even if the mother continues to smoke.

Nutritional requirements during lactation. Towards European alignment of reference values: the EURRECA network

There is considerable variation in reference values for micronutrient intake during lactation across Europe. The European Micronutrients Recommendations Aligned project aims to harmonize dietary recommendations throughout Europe. Recommended nutrient intakes during lactation are based on limited data and are often extrapolated from known secretion of the nutrient in milk with adjustments for bioavailability, so that differences between values can be partly ascribed to differences in methodological approaches and how these approaches were applied. Few studies have considered the impact of lactation on the mother's nutritional status. Rather, focus has been placed on the influence of maternal nutritional status on the composition of her breast milk. Most common nutritional deficits in breast milk are the result of maternal deficiencies of the water-soluble vitamins, thiamine, riboflavin and vitamins B6 and B12. Other than maternal vitamin A status, which to some extent is reflected in breast milk, concentrations of fat-soluble vitamins and most minerals in breast milk are less affected by maternal status. Factors relating to suboptimal maternal nutritional status during lactation include maternal age, diet and lifestyle factors and spacing of consecutive births. Recent research is providing new knowledge on the micronutrient requirements of lactating women. Identifying needs for research and improving understanding of the differences in values that have been derived by various committees and groups across Europe will enhance transparency and facilitate the application of dietary recommendations in policy-making decision and their translation into recommendations for lactating women. Given the wide variation in breastfeeding practices across Europe, making nutritional recommendations for lactating women is complex and challenging. Thus, it is crucial to first examine the cultural practices within and across European populations and to assess its relevance before making recommendations.

Factors associated with successful establishment of breastfeeding in very preterm infants

AIM

To describe feeding practices at hospital discharge in relation to characteristics of the very preterm infants (VPI) and their mothers.

METHODS

Design. Prospective hospital-based registration of very preterm infants born with a gestational age < or =32 weeks in Denmark during 2004-2008. Subjects. Healthy mothers and VPI without diseases causing eating disabilities at discharge.

RESULTS

A total of 478 VPI were registered. At discharge, 60% were exclusively breastfed, 35% were exclusively bottlefed, and 5% were both breast- and bottle-fed. Mothers of high social class (p = 0.000) and 'not smoking' (p = 0.003) were significantly more often breastfeeding their preterm infant(s) at discharge. Single births infants tended more often to be breastfed (p = 0.09). Infant age at discharge and duration of hospitalization did not influence breastfeeding at discharge. Increase in weight z-score from birth to discharge was largest in the bottlefeeding-group compared with the breastfeeding-group (p = 0.000) probably as a result of feeding practice the last week(s) of hospitalization.

CONCLUSION

Breastfeeding can successfully be established in very preterm infants. Mothers of low social classes, smokers, multiple birth and very preterm infants with low weight for age may need extra attention in breastfeeding establishing policies.

Are starting and continuing breastfeeding related to educational background? The generation R study

OBJECTIVE

To assess the effect of a woman's educational level on starting and continuing breastfeeding and to assess the role of sociodemographic, lifestyle-related, psychosocial, and birth characteristics in this association.

METHODS

We used the data of 2914 participants in a population-based prospective cohort study. Information on educational level, breastfeeding, sociodemographic (maternal age, single parenthood, parity, job status), lifestyle-related (BMI, smoking, alcohol use), psychosocial (whether the pregnancy was planned, stress), and birth (gestational age, birth weight, cesarean delivery, place and type of delivery) characteristics were obtained between pregnancy and 12 months postpartum. Odds ratios and 95% confidence intervals of starting and continuing breastfeeding for educational level were obtained by logistic regression, adjusted for each group of covariates and for all covariates simultaneously.

RESULTS

Of 1031 highest-educated mothers, 985 (95.5%) started breastfeeding; the percentage was 73.1% (255 of 349) in the lowest-educated mothers. At 6 months, 39.3% (405 of 1031) of highest-educated mothers and 15.2% (53 of 349) of lowest-educated mothers were still breastfeeding. Educationally related differences were present in starting breastfeeding and the continuation of breastfeeding until 2 months but not in breastfeeding continuation between 2 and 6 months. Lifestyle-related and birth characteristics attenuated the association between educational level and breastfeeding, but the association was hardly affected by sociodemographic and psychosocial characteristics.

CONCLUSIONS

Decisions to breastfeed were underlain by differences in educational background. The underlying pathways require further research. For the time being, interventions on promoting breastfeeding should start early in pregnancy and should increase their focus on low-educated women.