Low rate of initiation and short duration of breastfeeding in a maternal and infant home visiting project targeting rural, Southern, African American women

A systematic literature review of breastfeeding interventions among Black populations using the RE-AIM framework

BACKGROUND

Lactation support resources are less likely to be located in close proximity to where Black families live and there is a systemic racist health care belief that Black women prefer bottle feeding (with infant formula) over breastfeeding. Together, these lead to lower reported breastfeeding rates of Black babies compared to other racial / ethnic groups. It is imperative to have a deeper understanding of the cultural aspects as well as the underlying limitations that prevent Black women / persons from being supported to breastfeed. There is a need to know how effective breastfeeding interventions are in reaching the intended population; how well they work in promoting breastfeeding initiation and continuation; and how successful they are when implemented at the setting and staff level. The purpose of this investigation was to establish the level of internal and external validity that was reported by breastfeeding intervention studies among Black communities.

METHODS

Studies on breastfeeding interventions on Black people that were published between the years 1990 and 2019 were carefully examined through PubMed, EBSCOhost, Web of Science, and OneSearch. A total of 31 studies fulfilled the requirements to be included for this evaluation. In order to extract the information from the articles, the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework extraction tool was utilized.

RESULTS

On average, the proportion of studies that reported across reach, effectiveness, adoption, implementation, and maintenance indicators was 54, 35, 19, 48, and 9%, respectively. Across core RE-AIM indicators only sample size (100%) and breastfeeding outcomes (90%) were reported consistently. External validity indicators related to representativeness of participants (16%) and sites (3%) were rarely reported. Similarly, adherence to intervention protocol, and indicator of internal validity, was reported in a small proportion of articles (19%).

CONCLUSION

This body of literature under-reported on aspects associated to both internal and external validity across all RE-AIM domains. The reporting of the individual level of representativeness; the setting level of representativeness; the intervention's adherence to the protocol; the expenses; and the factors of sustainability would benefit from improvement in future research.

Feeding practices and micronutrient status of children aged 0-36 months in Thulamela Municipality, Limpopo province

BACKGROUND

Micronutrient deficiency continues to be a major public health problem affecting infants and young children under 5 years of age worldwide.

AIM

The study aims to investigate feeding practices and micronutrient status of children aged 0-36 months.

SETTING

The study was conducted at government clinics located in Thulamela Municipality, which is one of the local municipalities in Vhembe District, Limpopo province.

METHODS

A cross-sectional survey was conducted. A total of 250 mothers with children aged 0-36 months were enrolled. A structured questionnaire was used to interview the mothers. Biochemical measurements of children were assessed using standard procedures.

RESULTS

Only 7.6% of children were exclusively breastfed for 6 months. Majority (87.5%) of the children were introduced to complementary foods before 6 months and 98.8% of the children had a low dietary diversity score of less than four, while 9.2% had a dietary diversity score of more than four. The prevalence of vitamin A deficiency, anaemia and iron deficiency was 21.7%, 53.6% and 13.1%, respectively. For mothers who initiated breastfeeding immediately after delivery, the odds of children having low ferritin were 0.11 times, as compared to children who were initiated breastfeeding a day after delivery (odds ratio = 0.11; 95% confidence interval = 0.015-0.812).

CONCLUSION

Most of the children were introduced to complementary foods earlier than 6 months of age. Infant feeding practices were associated with micronutrients status.

CONTRIBUTION

The study contributes to the body of literature on feeding practices and the micronutrient status of children.

Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review

BACKGROUND

In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates?

METHODS

The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies.

RESULTS

We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and  interpersonal level (n = 3).

CONCLUSIONS

Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended  to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes.

Black/African American Breastfeeding Experience: Cultural, Sociological, and Health Dimensions Through an Equity Lens

Background: Disparities in breastfeeding (BF) continue to be a public health challenge, as currently only 42% of infants in the world and 25.6% of infants in the United States are exclusively breastfed for the first 6 months of life. In 2019, the infants least likely to be exclusively breastfed at 6 months are African Americans (AA) (17.2%). Materials and Methods: A scoping review of the literature was undertaken by using Arksey and O'Malley's six-stage framework to determine key themes of AA women's experience BF through an equity lens. Electronic databases of CINAHL and PubMed were searched for peer-reviewed, full-text articles written in the English language within the past 5 years by using the terms BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators. Results: Initially, 497 articles were identified, and 26 peer-reviewed articles met the eligibility criteria. Through an equity lens, three main themes emerged, which summarized AA women's BF experience: cultural (family, peers and community support; misconceptions; personal factors), sociological (prejudices, racism, home environment; financial status; sexuality issues; BF role models; employment policies), and health dimensions (family involvement; timely and honest information from staff; baby-friendly hospital initiatives; postnatal follow-up; special supplemental nutrition program for women, infants, and children). Conclusion: For AA women, exclusively BF is beset with diverse cultural, health, and sociological challenges. Multifaceted approaches are needed for successful resolution of BF challenges to bridge the racial gap in BF in the United States. Future studies may explore interventions targeted to modifiable barriers to improve BF outcomes.

Path Model Validation of Breastfeeding Intention Among Pregnant Women

OBJECTIVE

To validate a blended health belief model and integrated behavioral model of selected modifiable psychosocial constructs during pregnancy to seek the best-fit path model for breastfeeding intention.

DESIGN

A nonexperimental, cross-sectional study.

SETTING

A virtual online market research sample aggregator.

PARTICIPANTS

Women (N = 300) between 18 and 45 years of age in their second or third trimesters of pregnancy participated in the study in February 2018.

METHODS

Based on the health belief model and the integrated behavioral model, we proposed a theoretical framework, including self-efficacy for breastfeeding, knowledge, perceived benefits, perceived barriers, attitude toward breastfeeding, patient-provider interaction, and motivation to breastfeed, to predict breastfeeding intention. We administered a 98-item questionnaire modified from preexisting instruments. We conducted descriptive, bivariate, and regression analyses to help with the formation of the path model.

RESULTS

The best-fit path model with all significant paths and effect directions showed that intention to breastfeed is directly influenced by motivation to breastfeed, attitudes toward breastfeeding, and self-efficacy for breastfeeding, which together accounted for 56% (R²) of the variance in intention. We also identified indirect effects from knowledge about breastfeeding, patient-provider interaction, perceived benefits, and perceived barriers and their interrelationships with effect directions.

CONCLUSION

Through our findings, we contribute to the emerging body of evidence that shows the significant variables and their effect directions for breastfeeding intention. Incorporating these findings may provide support and evidence for clinical and community interventions focusing on modifiable psychosocial constructs during pregnancy to promote breastfeeding and further investigations using health behavior theories.

Engaging African American Parents to Develop a Mobile Health Technology for Breastfeeding: KULEA-NET

BACKGROUND

African Americans breastfeed less than other groups, which has implications for health throughout the life course. Little is known about mobile health technologies to support breastfeeding.

RESEARCH AIMS

This study proceeded in two phases. The aim of Phase 1 was to identify ideal technological components and content of a mobile health intervention. The aim of Phase 2 was to determine the usability of a prototype, KULEA-NET, based on the Phase 1 findings.

METHODS

For this mixed-methods study, we used community-based participatory research methods and user-centered technology design methods. We used open coding in NVivo 11 to organize data from focus groups and in-depth interviews, then we analyzed the data. We then developed a prototype and tested the prototype's usability with the System Usability Scale. Fifty pregnant and postpartum African Americans from the District of Columbia participated.

RESULTS

Participants preferred an app with text messaging technology and identified areas for intervention: self-efficacy, parent-child attachment beliefs, social support, public breastfeeding and social desirability, and returning to work. Desired features included local resources, support person access, baby care logs, identification of public breastfeeding venues, and peer discussions. The System Usability Scale score was 73.8, which indicates above average usability.

CONCLUSIONS

A mobile health technology like KULEA-NET can be used to meet the breastfeeding needs of African Americans, build social desirability, and complement traditional health care. The appeal of an African American-specific intervention is unclear. Responding to mixed feeding practices is challenging. KULEA-NET is a mobile breastfeeding intervention guided by the preferences of African American parents and offers promising usability metrics.

Enhanced vs Standard Parents as Teacher Curriculum on Factors Related to Infant Feeding among African American Women

OBJECTIVES

To determine the comparative impact of the standard Parents as Teachers (PAT) to the nutrition and physical activity enhanced version (PATE) of the perinatal educational curriculum on compliance with infant feeding recommendations and changes in maternal infant feeding knowledge and beliefs.

METHODS

Women at least 18 years of age, <19 weeks pregnant, and residing in three Mississippi counties were randomized to the standard PAT or the PATE version of the perinatal educational curriculum. Infant diets were assessed via 24-hour diet recall at postnatal months 1 to 12. Maternal knowledge and beliefs about infant feeding were assessed via survey at baseline and postnatal month 12. Compliance with infant feeding recommendations and differences in compliance between treatment arms were assessed using Kaplan-Meier survival curves. Longitudinal changes in maternal knowledge and beliefs were assessed with McNemar tests of symmetry.

RESULTS

Postnatal retention for the PAT and PATE arms were 83% (25/30) and 88% (21/24). Compliance with feeding recommendations for PAT and PATE participants, respectively, was 40% and 63% for no solid food before 6 months; 23% and 21% for no sugar-sweetened beverages before 12 months; 100% (both) for no fruit juice before 6 months; and 43% and 46% for no snack chips, French fries, and other fried food and candy before 12 months. Median times to feeding sugar-sweetened beverages were 10.1 and 9.6 months in PAT and PATE arms. Significant differences in compliance between arms were not found (P > 0.05). Participants' knowledge and beliefs about infant feeding were generally in agreement with expert recommendations at baseline, with few changes over time or between arms.

CONCLUSIONS

Findings suggest the need for further intervention focused on translating knowledge into action to improve diets of weaning infants in this region of the United States.

Preventive Health Application to Increase Breastfeeding

Background: Mother-infant dyads are not meeting recommended breastfeeding goals. There is lack of consensus regarding any program's ability to increase breastfeeding duration to meet the recommended guidelines, and effective strategies are needed moving forward to help families meet those goals. Primary prevention utilizing consistent visits with lactation professionals with a group of new mothers may efficiently address this care gap. Methods: Mother-infant dyads attending a newborn care clinic for 6 weeks received feeding assessment and standard-of-care guidance from an Internationally Board-Certified Lactation Consultant (IBCLC). Regression analysis was completed with outcome variables "exclusive direct breastfeeding" (EDB) and "any breastfeeding" (AB) at 6 weeks postpartum (PP) and odds ratios were calculated. Results: The number and timing of IBCLC visits was correlated with EDB at 6 weeks PP. Maternal/infant dyads seen at day 3 had 2.5 times higher odds of EDB at 6 weeks than those not receiving IBCLC standard-of-care feeding assessment. Dyads seen at days 3 and 14 had 3.4 times higher odds of EDB than those with less follow-up. Bottle use correlated with decreased odds of AB at 6 weeks PP; similarly, dyads seen only at day 14 PP had decreased odds of EDB. When looking at timing of the first involvement, dyads seen at 3 days had higher odds of EDB than dyads first seen at day 14 PP. Conclusions: This primary prevention strategy of early minimal intervention using an IBCLC increased the odds of EDB and AB at 6 weeks PP. These data support the conclusion that early feeding assessment the first 2 weeks PP with an IBCLC may increase breastfeeding at 6 weeks PP.

Factors Influencing Southeastern U.S. Mothers' Participation in Baby-Friendly Practices: A Mixed-Methods Study

BACKGROUND

Mothers in the southeastern United States, including rural-dwelling and African American mothers, have historically had low rates of breastfeeding; however, no studies have investigated these mothers' experiences of breastfeeding support processes associated with the Baby-Friendly Hospital Initiative. Research aim: This study aimed to determine factors influencing southeastern U.S. mothers' participation in Baby-Friendly practices and breastfeeding decisions.

METHODS

Using a convergent parallel mixed-methods design, medical record review of mother-infant dyads ( n = 234) provided data to determine if those who participated in more than half of the Ten Steps to Successful Breastfeeding had improved breastfeeding outcomes. Logistic regression was conducted to determine whether maternal demographic/clinical characteristics were predictive of Baby-Friendly practice participation. Qualitative methods included in-depth interviews ( n = 16). Directed content analysis was conducted to identify themes. Results of the analysis of the two data sets were triangulated to enhance understanding of mothers' barriers to and facilitators of participation in Baby-Friendly practices.

RESULTS

Rural-dwelling and African American mothers had greater odds of nonparticipation in Baby-Friendly practices relative to other groups (odds ratios = 5 and 10, respectively; p ≤ .01). Mothers who received lactation consultation and had moderate (15-44 min) or completed (≥ 45 min) skin-to-skin contact had greater odds of participation in Baby-Friendly practices (both odds ratios ≥ 17.5; p < .05). Directed content analysis revealed six themes: maternal desire to breastfeed, infant state, maternal state, milk supply concerns, provider support, and access to breastfeeding equipment and support services.

CONCLUSION

Rural-dwelling African American mothers had limited knowledge of Baby-Friendly practices; however, culturally tailored services could improve Baby-Friendly practice participation and breastfeeding success.

Infant growth outcomes from birth to 12 months of age: findings from the Delta Healthy Sprouts randomized comparative impact trial

OBJECTIVE

Multicomponent lifestyle modification interventions designed for gestational and early postnatal periods may be key to preventing obesity in children. The primary objective of the study was to determine if infant growth outcomes differed between treatment arms of an 18-month, maternal, infant and early childhood home visiting project.

METHODS

Pregnant women at least 18 years of age, less than 19 weeks pregnant and residing in a lower Mississippi Delta county were recruited between March 2013 and December 2014. Postnatal data were collected from 24 experimental and 30 control participants between September 2013 and May 2016. Infant growth outcomes were modelled as time-to-event data using Kaplan-Meier survival curves with log-rank tests to determine if survival curves differed between treatment arms.

RESULTS

Retention rates for the experimental and control arms were 88% (21/24) and 83% (25/30), respectively. Approximately three-fourths of infants in both treatment arms were classified as overweight and experienced rapid weight gain during the first 12 months of life. No differences between median times neither to classification as overweight (3-4 months) nor to experiencing rapid weight gain (6-7 months) were observed between treatment arms.

CONCLUSIONS

As compared with a standard educational (control) curriculum, an educational curriculum enhanced with diet and physical activity components was not effective at improving infant growth outcomes.