Acculturation and breastfeeding on the United States-Mexico border

Acculturation and Breastfeeding Among Hispanic American Women: A Systematic Review

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

Breast-Feeding in Immigrant Women: The Role of Social Support and Acculturation

This study assessed the influence of social support and acculturation on breast-feeding in 962 low-income immigrant women in New York Women completed a questionnaire during their postpartum visit. Logistic regression analyses revealed that more acculturated women were 2 times less likely to decide to breast-feed than less acculturated women. The influence of acculturation decreased, however, when controlling for other predictor variables. Predictor variables of breast-feeding (p < .OS) were intent, being a nonsmoker, breast-feeding role modeling, and a negative response to the item "A modern woman breast-feeds her baby." Acculturation did not influence breast-feeding. More acculturated women reported more social support. The results indicate a need to target breast-feeding promotion to the most vulnerable group of young mothers (i.e., recent arrivals and women who are undecided about their infantfeeding method).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

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

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

Sociocultural influences on the determinants of breast-feeding by Latina mothers in the Cincinnati area

While breast-feeding initiation and duration among US Latina women appear to decrease with acculturation, health care providers in the Greater Cincinnati area have noted lower rates of breast-feeding among even first-generation Latina immigrants. This study's purpose was to identify determinants of breast-feeding for Latina mothers in Cincinnati through qualitative interviews and Spanish Breastfeeding Self-Efficacy Scale ratings. Our findings suggest that, along with similar levels of breast-feeding self-confidence, foreign-born Latina women in the Greater Cincinnati area share similar breast-feeding determinants with the general population. However, characteristics of these determinants and their impact vary because of unique pressures experienced by this community.

'Breast is not always best': South Asian women's experiences of infant feeding in the UK within an acculturation framework

Acculturating to a host country has a negative impact on immigrant women's breastfeeding practices, particularly when coming from countries where breastfeeding rates are higher than Western countries. Whether this is true of those immigrating to the UK remains to be investigated. The study aimed to explore whether acculturating to the UK had detrimental effects on breastfeeding practices of South Asian women, and to provide explanations as to how acculturation may have exerted its influence. Twenty South Asian women completed semi-structured interviews exploring infant feeding experiences. Data were thematically analysed. A bidimensional measure assessed women's acculturation status. Women displaying low acculturation levels were aware of living in a formula-feeding culture but this had little influence on breastfeeding intentions/behaviours; drawing upon South Asian cultural teachings of the psychological benefits of breast milk. These women opted to formula-feed in response to their child's perceived demands or in a bid to resolve conflict; either when receiving information about the best feeding method or between their roles as a mother and daughter-in-law. Highly acculturated women also experienced such conflict; their awareness of the formula-feeding culture governed feeding choice. The findings provide a picture of how acculturation may affect South Asian women's breastfeeding intentions and behaviours; encouraging health service providers to meet the varying needs of an acculturating population. If breastfeeding is to be encouraged, it is necessary to understand factors influencing feeding choice; with particular attention to the acculturation pathways that may govern such decisions. This paper highlights ways to tailor information for South Asian women depending on levels of acculturation.

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

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

Predicting breast-feeding attrition: adapting the breast-feeding attrition prediction tool

CONTEXT

Current breast-feeding rates fall short of the recommendations set forth in Health People 2010. The Breast-feeding Attrition Prediction Tool (BAPT), administered in the postpartum period, has been useful in predicting breast-feeding attrition. However, assessing a woman's intention to breast-feed prior to birth would identify women at risk for breast-feeding attrition.

PURPOSE

The purpose of this study was to describe a revised BAPT, administered antepartally that measures intention to breast-feed.

METHODS

The BAPT, comprising 94 items on a 6-point Likert-type scale, was translated into Spanish and back-translated for accuracy. The BAPT was then revised by reducing the number of items to 35 (32 were used for analysis) and contracting the 6-point scale to 3 categories. A Bayesian item response model provided the psychometric properties of the revised BAPT.

RESULTS

The revised BAPT was completed by 143 Mexican American pregnant women. Items, some reverse scored, were recoded as "agree" versus "disagree." Item analyses indicated a wide range of item discriminabilities, with most items being useful measures of intention to breast-feed. Person analyses provided scores for intention to breast-feed. A simpler scoring system was devised for applications.

CONCLUSIONS

The revised BAPT shows promise as a measure of intention to breast-feed. The scoring system also indicates which women may need additional interventions to promote breast-feeding.

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

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

Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003

OBJECTIVES

Previous research has shown substantial racial/ethnic and socioeconomic disparities in US breastfeeding initiation and duration rates. However, the role of immigrant status in understanding such disparities has not been well studied. In this study we examined the extent to which breastfeeding initiation and duration varied by immigrant status overall and in conjunction with race/ethnicity and socioeconomic status after controlling for other relevant social and behavioral covariates.

METHODS

The cross-sectional data for 33121 children aged 0 to 5 years from the 2003 National Survey of Children's Health were used to calculate ever-breastfeeding rates and duration rates at 3, 6, and 12 months by social factors. Multivariate logistic regression was used to estimate relative odds of never breastfeeding and not breastfeeding at 6 and 12 months.

RESULTS

More than 72% of mothers reported ever breastfeeding their infants, with the duration rate declining to 52%, 38%, and 16% at 3, 6, and 12 months, respectively. Ever-breastfeeding rates varied greatly among the 12 ethnic-immigrant groups included in this analysis, from a low of 48% for native black children with native parents to a high of 88% among immigrant black and white children. Compared with immigrant Hispanic children with foreign-born parents (the least acculturated group), the odds of never breastfeeding were respectively 2.4, 2.9, 6.5, and 2.4 times higher for native children with native parents (the most acculturated group) of Hispanic, white, black, and other ethnicities. Socioeconomic patterns also varied by immigrant status, and differentials were greater in breastfeeding at 6 months.

CONCLUSIONS

Immigrant women in each racial/ethnic group had higher breastfeeding initiation and longer duration rates than native women. Acculturation was associated with lower breastfeeding rates among both Hispanic and non-Hispanic women. Ethnic-immigrant and social groups with lower breastfeeding rates identified herein could be targeted for breastfeeding promotion programs.

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

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

International migration and infant health in Mexico

This paper examines the flip side of the epidemiological paradox, namely the relationship between international migration experience and positive infant health outcomes in Mexico. Building upon past research that has explored the role of economic remittances in contributing to the positive relationship between international migration and birth outcomes in sending country communities, the present analysis focuses on the noneconomic effects of paternal migration experience on infant health. The data come from a hospital-based postpartum survey (HPS 2001) recently completed in two high-migrant sending states of Western Mexico. The findings demonstrate that the positive effect of international migration on infant health occurs in the context of considerable loss of social support and high stress levels. Socioeconomic improvements facilitated by the receipt of remittances, coupled with positive health behaviors, are two factors that contribute to this protective effect.

Maternal obesity is negatively associated with breastfeeding success among Hispanic but not Black women

Prepregnant overweight and obesity have been associated with failure to initiate and to sustain breastfeeding (BF) among Caucasian women; however, this relationship has not been studied among either Black or Hispanic women. Information extracted from medical records was used to examine the relationship between prepregnant overweight (BMI = 26.1-29.0 kg/m(2)) and obesity (BMI > 29.0 kg/m(2)) and the initiation and duration of BF among Black and Hispanic women living in an urban area. Among 587 Hispanic women, those who were obese were more likely than normal-weight women to feed formula and breast milk rather than to feed breast milk alone before discharge [odds ratio (OR): 1.9; 95% CI: 1.2-3.1]. Obese Hispanic women also had higher rates of discontinuation of exclusive BF [relative risk (RR): 1.5; 95% CI: 1.1-2.0]) and higher rates of discontinuation of BF to any extent (RR: 1.5; 95% CI: 1.1-2.1) during the first 6 mo postpartum. Among 640 Black women, prepregnant BMI was neither associated with differences in feeding pattern before discharge nor with differences in rates of discontinuation of exclusive or any BF. We concluded that among healthy women who attempt to breastfeed in the hospital, maternal prepregnant obesity was negatively associated with initiation and duration of BF in Hispanic women. In contrast, prepregnant BMI did not have the same association among Black women who attempted to breastfeed. We speculate that obesity may have a different biological meaning for BF success in Black women than it does in those who are Caucasian or Hispanic.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Breastfeeding attitudes in a sample of Spanish-speaking Hispanic American women

This descriptive, cross-sectional study examined attitudes toward breastfeeding in 57 Spanish-speaking Hispanic American women. Participants were asked to complete a Spanish version of the Breastfeeding Behavior Questionnaire (Cuestionario de Comportamiento Amamantar). The instrument is composed of 12 vignettes to which women agreed or disagreed using a Likert-type scale. Content validity was ascertained by a group of Spanish-speaking health professionals, and a Pearson correlation coefficient of .96 was calculated for test-retest reliability. Women were also interviewed for demographic data, reproductive history, and experience with breastfeeding. Mean scores on the instrument revealed generally positive attitudes toward breastfeeding. Although recent evidence suggests that breastfeeding initiation has been decreasing in Hispanic women, more than 90% of the women in this sample stated that their intention was to breastfeed and felt that they were supported in their decision by significant others.

Adapting a measure of acculturation for cross-cultural research

Although Filipino Americans are projected to become the largest Asian American ethnic group in this millennium, no acculturation measure existed for this group. This article describes a systematic and replicable process used in adapting and modifying A Short Acculturation Scale for Hispanics (ASASH) for use with Filipino Americans. It depicts the multiple and iterative steps of translation and backtranslation to produce A Short Acculturation Scale for Filipino Americans (ASASFA) in English and in Tagalog--the Philippine national language. Also, it describes the methods undertaken for the measures to achieve linguistic and cross-cultural validity through content, technical, experiential, semantic, and conceptual equivalence. With the dearth of linguistically and culturally valid measures for immigrant populations, the adaptation of valid measures developed for other cultures remains a viable option.

Acculturation and the initiation of breastfeeding

Despite the fact that breastfeeding is the most appropriate form of nutrition for the healthy term infant, the rate of initiation in the U.S. is declining. One demographic factor associated with this low rate is ethnicity and so in this study we measured acculturation (one aspect of ethnicity) into the U.S. and its relationship to the successful initiation of breastfeeding in a sample of women recruited approximately 2 months prenatally in a U.S.-Mexico border city. Interviews were administered in English or Spanish by bilingual interviewers prenatally (n = 906), natally (n = 788), and postnatally (n = 715). Acculturation (measured with a 20 item instrument) was strongly related to the intent to (p < 0.001) or the successful initiation of breastfeeding (p < 0.001). Marital status (p = 0.014) and education (p = 0.002) were related to breastfeeding prenatally and natally. Initiation of breastfeeding was highest among those women least acculturated (52.9%) and lowest in those most acculturated (36.1%) indicating an inhibiting effect of acculturation. To improve the rate of initiation of breastfeeding in the U.S. (a national health goal) intervention programs must consider cultural factors.