Individual Net-Benefit Maximization: A Model for Understanding Breastfeeding Cessation among Low-Income Women

Prenatal perception of breastfeeding recommendations predicts early breastfeeding outcomes of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

BACKGROUND

Prenatal psychosocial factors predict breastfeeding practices but are not assessed in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVES

This study examined how prenatal perceptions of WIC's breastfeeding recommendations were associated with early breastfeeding outcomes.

METHODS

This study used longitudinal data from a national sample of 2053 pregnant participants in the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2) in 2013, the only national data assessing prenatal perceptions of WIC's breastfeeding recommendations. Early breastfeeding outcomes included breastfeeding initiation, breast milk first fed after birth, breastfeeding in the first hour, breast milk first fed after leaving the hospital, and breastfeeding status at the first and third months. The primary predictor was the participant's prenatal perception of whether WIC recommended breastfeeding only or not. Log-binomial regression was used with adjustment for socio-demographics, previous breastfeeding, WIC participation, breastfeeding support, and infant feeding intentions (IFI).

RESULTS

Without controlling for IFI, the perception of WIC recommending breastfeeding only predicted breastfeeding outcomes positively. The risk ratio (RR) associated with prenatal perceptions varied from 1.14 (95% CI: 1.03, 1.25; P = 0.008) for breastfeeding in the first hour, to 1.27 (95% CI: 1.12, 1.43; P < 0.001) for breast milk first fed after leaving hospital, to 1.66 (95% CI: 1.35, 2.04; P < 0.001) for 3-mo breastfeeding only. After controlling for IFI, the RRs were 1.13 (95% CI: 1.02, 1.24; P = 0.017) for breastfeeding in the first hour, 1.20 (95% CI: 1.06, 1.35; P = 0.004) for breast milk first fed after leaving hospital, and 1.49 (95% CI: 1.21, 1.84; P < 0.001) for 3-mo breastfeeding only, suggesting that prenatal perception was independently associated with breastfeeding outcomes.

CONCLUSIONS

Prenatal perception of WIC's breastfeeding recommendations can be regarded as a new psychosocial predictor of breastfeeding and a possible target for future intervention.

The Beliefs About Breastfeeding Questionnaire (BAB-Q): A psychometric validation study

Objectives

Questionnaires used to assess women’s beliefs as a predictor of breastfeeding behaviour are not theoretically informed or tested for psychometric validity and reliability. This study conducted a psychometric evaluation of the Beliefs About Breastfeeding Questionnaire (BAB‐Q).

Design

A two‐phase evaluation in an online cross‐sectional questionnaire study (N = 278) and cohort study sample (N = 264). A ten‐item questionnaire was proposed to assess women’s beliefs about the benefits and efforts of breastfeeding.

Methods

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) assessed construct validity and reliability. Multivariate regression analyses assessed validity in predicting breastfeeding behaviour and experiences.

Results

EFA found a shortened 8‐item, 2‐factor model had good fit (χ² = 23.3, df = 13, p < .040; CFI = .99, TLI = .99, RMSEA = .05), with significant factor loadings. Factor 1 (benefit beliefs) and factor 2 (effort beliefs) accounted for 47 and 19.4% of the explained variance and correlated moderately (r = −.40). CFA confirmed the solution in the cohort sample (χ² = 49.6 df = 19, p < .010; CFI = .97, TLI = .96, and RMSEA = .078). Adjusted regression analyses found beliefs did not reliably predict infant feeding practices. Women’s beliefs significantly predicted the likelihood that women experienced breastfeeding as ‘much more’ positive and negative than they expected.

Conclusions

The eight‐item questionnaire showed good model fit with acceptable loadings, and good reliability for all subscales. The utility of the BAB‐Q at predicting breastfeeding behaviour remains unclear and unsupported by empirical evidence. Further assessments of the predictive validity of the questionnaire in longitudinal studies with diverse beliefs and infant feeding practices are required.

Factors associated with cessation of exclusive breastfeeding at 1 and 2 months postpartum in Taiwan

Background

Breastfeeding benefits both mothers and infants. Even though Taiwan national policy promotes exclusive breastfeeding (EBF), the rates in Taiwan are below those in other developed countries. This study aimed to investigate factors associated with EBF cessation at 1 and 2 months postpartum.

Methods

This study was conducted in a community hospital in southern Taiwan between December 2016 and June 2017. Birth mothers (n = 1077) were interviewed by telephone at 1 and 2 months postpartum to collect information on infant feeding patterns (EBF since birth or not) and reasons for EBF cessation. Multivariate logistic regression models were used to determine risk factors associated with EBF cessation at 1 and 2 months.

Results

At 1 month, 432 participants (40.1%) maintained EBF. Factors associated with cessation were lack of tertiary education, primiparity, perceived low milk quantity, mother/infant separation, medical condition in mother, inconvenience/fatigue due to breastfeeding, and baby-centered factors. At 2 months, 316 participants (29.3%) maintained EBF. Factors associated with cessation were lack of tertiary education, primiparity, perceived low milk quantity, and return to work.

Conclusions

Education level, primiparity, perceived low milk quantity, and return to work are associated with premature cessation of EBF in Taiwan. Strategies about health education, family support, and baby-mother friendly environment can be used to achieve higher EBF rate.

Associations between perceived value of exclusive breastfeeding among pregnant women in the United States and exclusive breastfeeding to three and six months postpartum: a prospective study

BACKGROUND

Successful breastfeeding often starts with prenatally established intention. Yet, few mothers with the intention to exclusively breastfeed achieve their intended breastfeeding duration goal. This study examined the degree to which having a strong value of exclusive breastfeeding is associated with exclusive breastfeeding duration for at least 3 and 6 months postpartum among women who reported prenatal intention to exclusively breastfeed.

METHODS

Data were from the Infant Feeding Practices Study II, a longitudinal US national survey that followed maternal-infant dyads from pregnancy to 1 year postpartum. Bivariate and multivariate regression examined the degree to which strong maternal value of exclusive breastfeeding predicted exclusive breastfeeding duration.

RESULTS

Of the 1799 women who prenatally intended to exclusively breastfeed within the first few weeks postpartum, 34 and 9 % exclusively breastfed for at least 3 months and 6 months, respectively. Thirty-six percent of women reported strongly valuing exclusive breastfeeding out of which 46 % exclusively breastfeed to three months. In adjusted results, women who reported that they strongly value exclusive breastfeeding had more than twice the odds of exclusive breastfeeding for at least 3 months (Adjusted Odds Ratio [AOR] 2.29; 95 % confidence interval [CI] 1.84, 2.85) and for 6 months (AOR 2.49; 95 % CI 1.76, 3.53) compared to those who did not strongly value exclusive breastfeeding.

CONCLUSION

Valuing the benefits of exclusive breastfeeding during pregnancy is a strong independent predictor of actual exclusive breastfeeding duration. A minority of pregnant women strongly value exclusive breastfeeding and are able to exclusively breastfeed to 3 months even among women with established prenatal intention to exclusively breastfeed. Prenatal maternal education and environmental lactation support that extends into the postnatal period can promote longer duration of exclusive breastfeeding.

Aboriginal women in rural Australia; a small study of infant feeding behaviour

BACKGROUND

Aboriginal women in rural areas have lower rates of breastfeeding than Australian averages. The reasons for this are poorly understood. Aboriginal people experience higher morbidity and increased rates of chronic disease throughout the life cycle. The protective effects of sustained breastfeeding could benefit rural Aboriginal communities.

OBJECTIVE

To explore the factors impacting upon infant feeding choices in a rural Aboriginal Community.

METHODS

Semi-structured interviews were conducted with eight Aboriginal rural dwelling first time mothers. These women received a continuity of midwife and Aboriginal Health Worker model of care. Interviews were also undertaken with five Aboriginal Health Workers and two Aboriginal community breastfeeding champions. The analysis was integrated with a conventional literature review and was further developed and illustrated with historical literature. Indigenist methodology guided the study design, analysis and the dissemination of results.

RESULTS

Three key themes were identified. These were "I'm doing the best thing for..." which encompasses the motivations underpinning infant feeding decisions; "this is what I know..." which explores individual and community knowledge regarding infant feeding; and "a safe place to feed" identifying the barriers that negative societal messages pose for women as they make infant feeding decisions. It appears loss of family and community breastfeeding knowledge resulting from colonisation still influences the Aboriginal women of today.

DISCUSSION

Aboriginal women value and trust knowledge which is passed to them from extended family members and women within their Community. Cultural, historical and socioeconomic factors all strongly influence the infant feeding decisions of individuals in this study.

CONCLUSIONS

Efforts to normalise breastfeeding in the culture of rural dwelling Aboriginal women and their supporting community appear to be necessary and may promote breastfeeding more effectively than optimal professional care of individuals can do.

Food-package assignments and breastfeeding initiation before and after a change in the Special Supplemental Nutrition Program for Women, Infants, and Children

BACKGROUND

In 2009, the USDA implemented an interim rule that changed the prescribed foods in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Options for mother and infant dyads include a full breastfeeding package with no infant formula, a partial breastfeeding package with some infant formula, and a full formula package with a smaller postpartum food package for the mother. The changes were designed to encourage WIC mothers to choose breastfeeding for their infants.

OBJECTIVE

The purpose of this study was to measure changes in the following 3 outcomes: WIC food-package assignments, WIC infant formula amounts, and breastfeeding initiation.

DESIGN

We compared outcomes before and after implementation of the interim rule in a national random sample of 17 local WIC agencies (LWAs). The data source was administrative records for 206,092 dyads with an infant aged 0-5 mo in the sampled LWAs.

RESULTS

There were changes in WIC food-package assignments and infant formula amounts but no change in breastfeeding initiation. For dyads in whom the infant was in his or her birth month, the percentage of mothers who received the partial breastfeeding package fell from 24.7% (preimplementation) to 13.8% (postimplementation), the percentage of mothers who received the full breastfeeding package rose from 9.8% (preimplementation) to 17.1% (postimplementation), and the percentage of mothers who received the full formula package rose from 20.5% (preimplementation) to 28.5% (postimplementation).

CONCLUSIONS

After the change, fewer WIC mothers of new infants received the partial breastfeeding package. More WIC mothers received the full breastfeeding package, but more mothers also received the full formula package.

Participation in the Supplemental Nutrition Program for Women, Infants and Children (WIC) and breastfeeding: national, regional, and state level analyses

This research builds on literature that suggests a negative association between participation in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and breastfeeding. Variation in results at the national, regional, and state level has important policy implications for breastfeeding promotion through WIC. Using the 2007 National Immunization Survey dataset, Chi-square, ANOVA, and adjusted regression modeling techniques assess the relationship between WIC participation and breastfeeding initiation and duration. Adjusted regression models suggest a negative association between WIC participation and breastfeeding initiation rates (OR = 0.67, 95% CI: 0.61, 0.72). Of those who initiated breastfeeding, WIC participation was associated with a mean breastfeeding duration decrease of 0.63 months (95% CI: -0.86, -0.39). At the regional level, 3 of 7 regions showed a negative association between WIC participation and breastfeeding initiation. All of the regions indicated a negative association between WIC participation and breastfeeding duration. Out of 50 states, 13 had a statistically significant reduction in odds of initiation of breastfeeding and 10 had reduced duration of breastfeeding among participants of WIC when compared to non-participants. No state showed a positive association between WIC participation and breastfeeding. Regional and state differences in breastfeeding rates suggest that further research is needed to understand the role of national, regional, and state level policies which may undermine WIC's breastfeeding promotion efforts. Although WIC revised the food packages to create a stronger incentive for breastfeeding, a disincentive for breastfeeding may exist given the higher market value of the formula packages.

Unintended consequences of the WIC formula rebate program on infant feeding outcomes: will the new food packages be enough?

Approximately half of all mothers of infants born in the United States receive services through the Special Supplemental Nutrition Program for Woman, Infants and Children (WIC). Although WIC promotes breastfeeding, data suggest that, despite advances in the last 2 decades, WIC participants are less likely to initiate breastfeeding, and much less likely to continue, than non-WIC participants, including the non-WIC participants who are eligible for WIC. WIC recently revised their food packages and enhanced the monetary value of the breastfeeding packages. While these changes are an important step in supporting WIC's efforts to promote breastfeeding, other major factors, such as participants' perceptions of the value of the packages and WIC's dependency on rebates from formula companies to fund a portion of the program, may dampen WIC's breastfeeding promotion and support efforts. There is great need for additional research on these issues.

Racial/ethnic differences in breastfeeding duration among WIC-eligible families

PURPOSE

This research documented racial/ethnic differences in breastfeeding duration among mothers from seven diverse racial/ethnic groups in rural and urban areas of the United States that initiated breastfeeding among income and categorically eligible WIC participants.

METHODS

Using data from the Longitudinal 9-Month-Preschool Restricted-Use data file of the Early Childhood Longitudinal Study-Birth Cohort, this research first assessed racial/ethnic differences in breastfeeding initiation and duration, maternal and child health characteristics, social service usage, and sociodemographic characteristics. Next, breastfeeding survivorship and Cox proportional hazards models were estimated to assess potential racial/ethnic disparities in breastfeeding duration once these control variables were accounted for in multiple variable models.

FINDINGS

Breastfeeding initiation rates and breastfeeding durations of 6 months were lower among WIC-eligible mothers compared with all mothers. WIC-eligible, foreign-born Mexican-Origin Hispanic (FBMOH) mothers were most likely to breastfeed for 6 months. Breastfeeding duration rates dropped quickly after 4 months of duration among WIC-eligible mothers that initiated. Two crossover patterns in breastfeeding durations were noted among 1) FBMOH and non-Hispanic Black mothers and 2) Asian and Native American mothers. A FBMOH breastfeeding duration advantage was noted compared with non-Hispanic White mothers once all control variables were included in the Cox proportional hazard models. No other racial/ethnic disparities in breastfeeding duration were noted.

CONCLUSION

More attention to educational programs and broad forms of support as part of WIC are needed to help reach the breastfeeding duration goals of Healthy People 2010 and continued support of the Loving Support Peer Counseling Program may serve as an ideal policy for local WIC offices.

Predictors of breastfeeding exclusivity in a WIC sample

OBJECTIVE

To examine predictors of breastfeeding exclusivity in low-income women who received services from a Chicago area clinic of the Special Supplemental Nutrition Program for Women, Infants and Children Program (WIC).

DESIGN

A secondary data analysis of existing clinical and administrative data.

SETTING

An urban community health center serving low-income families.

PARTICIPANTS

Two hundred and thirty-five (235) low-income women who initiated breastfeeding and received WIC services.

METHODS

Logistic regression models were fit to existing prenatal and postpartum data to determine predictors of breastfeeding exclusivity during the immediate postpartum period.

RESULTS

Only 23% of the sample breastfed exclusively. Women who received first-trimester prenatal care were more likely to exclusively breastfeed than women who entered prenatal care in later trimesters (OR = 2.02, p ≤ 0.05). Women who declared intentions prenatally to exclusively breastfeed were more likely to exclusively breastfeed than women who did not intend to breastfeed (OR = 3.85, p ≤ 0.001). Overweight/obese women were less likely to exclusively breastfeed than normal/underweight women (OR = 0.50, p ≤ 0.05).

CONCLUSION

Findings from this study can be used to develop tailored interventions to promote breastfeeding exclusivity among low-income WIC recipients.

Food insecurity and weight status among U.S. children and families: a review of the literature

CONTEXT

Food insecurity disproportionately affects U.S. demographic groups of children and adult family members at the highest risk for obesity and may lead to weight gain through various pathways. This article reviews research regarding the relationship between food insecurity and weight status, and the potential role of federal food and nutrition assistance programs.

EVIDENCE ACQUISITION

A search for relevant peer-reviewed research studies among U.S. children and nonelderly adults, published between 2000 and March 2010, identified 42 studies regarding the relationship between food insecurity and weight status. There were 22 studies regarding the potential role of food and nutrition assistance programs.

EVIDENCE SYNTHESIS

Among children and men, support for an association between food insecurity and weight status has been mixed. Women who experience food insecurity are more likely to be overweight or obese compared to women with adequate household resources for food; however, there is little evidence that food insecurity promotes increased weight gain over time. Long-term participation in the Supplemental Nutrition Assistance Program may increase risk for excess weight gain.

CONCLUSIONS

Additional research addressing the limitations of current studies is needed to fully understand the observed linkages between food insecurity and risk for obesity. Nevertheless, there is substantial evidence these nutritional problems coexist, and it is critical that future efforts to eliminate hunger consider opportunities to promote healthy food choices and physical activity. Evaluations of policy changes and other intervention strategies are needed to determine the potential for food and nutrition assistance programs to more effectively reduce obesity among participants.