Back to nature? Historical and cross-cultural perspectives on barriers to optimal breastfeeding

Maternal perceptions of human milk expression output: An experimental design using photographs of milk

BACKGROUND

The widespread use of breast pumps in the United States is a recent phenomenon that is reshaping how individuals understand and perceive lactation. In the 1990s, adequacy of milk supply was primarily measured indirectly by infant weight gain and/or diapers; now >95% of all lactating persons in the United States use breast pumps and are seeing their milk regularly. How seeing milk impacts the perception of lactation sufficiency is an important area of research. Research aim/question: To understand personal and intersubjective influences of seeing expressed human milk on perceptions of milk supply among participants who express milk for their infants.

METHODS

We surveyed 805 lactating participants from the United States about their pumping practices using an online survey. Participants described pumping practices, milk output, and beliefs. They were then randomized to view one of three photographs of expressed milk (<2 oz, 4 oz, >6oz) and asked to imagine they had just pumped that amount and provide a written response; this created 4 exposure groups (2 increase and 2 decrease) and a control group (no difference).

RESULTS

Participants randomized to a higher volume reported more positive feelings and used the terms "good", "great", and "accomplished" to describe emotional responses to output. Participants randomized to lower milk volumes reported more feelings of "bad" or "depressed." A subset of participants reported feeling "annoyed" about small volumes of milk.

CONCLUSIONS

Participants in this study were very conscious of the volume of milk pumped each session; both increases and decreases were associated with emotional responses that could contribute to decisions about pumping practices, perceived milk supply, and lactation duration.

Evolutionary biological perspectives on current social issues of breastfeeding and weaning

Breastfeeding and weaning are actively studied from evolutionary, medical, and social research perspectives because of their close association with infant mortality, lifetime health, and human population dynamics. Each discipline benefits from an interdisciplinary exchange of knowledge regarding the bases, processes, and consequences of these phenomena. However, current social issues related to breastfeeding and weaning have received little attention from an evolutionary biology perspective. We address this gap by reviewing current social issues related to human breastfeeding and weaning in an evolutionary framework. This approach helps build a conceptual framework with the goal of better understanding ultimate causes of or influences on these current social issues. The six social issues reviewed here fall into three categories: the spatiotemporal constraints of breastfeeding, abuse of breast milk as valuable material, and mismatch in breastfeeding practices. Some of these issues have an evolutionary basis. We analyze the structure of these social issues and discuss their possible solutions in terms of extension of the trade-off theory in evolutionary biology. Our discussion on the current social issues in breastfeeding and weaning highlights the effectiveness of an approach rooted in evolutionary theory and biological anthropology.

Greater male vulnerability to stunting? Evaluating sex differences in growth, pathways and biocultural mechanisms

CONTEXT

Child stunting has increasingly become the focus of large-scale global health efforts with the inclusion of stunting eradication as one of the Sustainable Development Goals of the United Nations. Child sex has been identified as a biological risk factor for stunting, and sex-specific approaches to stunting prevention have been proposed.

OBJECTIVE

This paper examines four pathways, developmental sensitivity, energetics, caretaking and measurement, proposed to contribute to sex differences in linear growth faltering and stunting risk.

METHODS

Anthropological, public health and clinical literature on sex differences in stunting and the mechanisms contributing to variability across contexts are reviewed.

RESULTS

The direction of sex differences in stunting prevalence varies across countries and between households. Sex differences in growth trajectories and immune function beginning prenatally place boys at greater risk of infection and undernutrition, but these biological differences are interpreted by parents and within household contexts that are shaped by social and cultural norms which, in turn, influence care and feeding practices.

CONCLUSION

A perspective that incorporates an examination of the social and environmental factors shaping child growth in specific contexts is needed to understand sex-based vulnerability to stunting and to develop context-appropriate interventions.

Determinants of optimum exclusive breastfeeding duration in rural India: a mixed method approach using cohort and content analysis design

BACKGROUND

Despite established benefits, exclusive breastfeeding (EBF) rate remains poor in India. This study measured the rate of early initiation of breastfeeding and EBF up to 42 days postpartum period and the reasons associated with early interruption of it.

METHODS

In this study we followed a cohort 319 mother-newborn dyads, on a scheduled day of each week for six postpartum weeks (42 postpartum days), during May 2017 - March 2019. We used standard maternal 24 h recall method to collect data on newborn feeding practices. Additionally, using content the analysis method, we analysed the data captured through open ended question on current breastfeeding practice and reasons to identify the sociocultural facilitators/barriers of exclusive breastfeeding .

RESULTS

Of the retained 306 newborns, early initiation of breastfeeding rate was 60% (184/306), whereas, EBF rate was 47% (143/306). Mothers' educational level did not emerge as a risk for unsuccessful breastfeeding practices, whereas, father being not the major earner of the family (Relative risk [RR] 2.4; 95% Confidence interval [CI] 1.7,3.3), mothers who did not believe that effect of breastfeeding is longstanding (RR 1.8; 95% CI 1.3, 2.1) emerged as a risk for unsuccessful EBF practices. Lack of self-conviction about EBF among mothers; significant family members' influence; cultural beliefs; emerged as major socio-environmental barriers of early interruption of exclusive breastfeeding. Repeated counselling by the healthcare provider particularly focusing on exclusive breastfeeding, supportive family environment in terms of the elders being aware of the positive health outcomes of it, and prior positive experience emerged as the socio-environmental facilitators for successful EBF until 42 postpartum days.

CONCLUSIONS

We conclude that the socio-environmental causes need to be addressed through the present healthcare delivery system for ensuring better infant feeding outcome.

Violent conflict and breastfeeding: the case of Iraq

BACKGROUND

This study explores the relationship between armed conflict and breastfeeding practices of Iraqi mothers. To date, the relationship between violent conflict and breastfeeding is surprisingly understudied. Especially in the Middle East, which is conflict-prone and has a young population, research on war and household behavior is critical for promoting recovery and sustainable development.

METHODS

This study employs a unique pairing of the Iraq Body Count Database and the 2006 and 2011 Multiple Indicator Cluster Surveys for Iraq. We use probit models to explore the association between armed conflict and several breastfeeding outcomes - whether a child was ever breastfed, whether a child was breastfed within 1 h after birth, whether a child is currently breastfed, and whether an infant under 6 months of age is exclusively breastfed. Our proxies for conflict intensity are the average rate of conflict-related casualties across the 3 years prior to survey administration and the rate of casualties averaged across the 2 years prior to the birth of the child, in the governorate in which the family resides. We employ a number of other independent variables important for breastfeeding status, including health controls and characteristics of the household, child and mother. We also use a Cox proportional hazards model to study the association between conflict and breastfeeding duration. We complement this analysis with various robustness checks, including disaggregation by year, controls for household wealth and an analysis of breastmilk substitutes and their potential for an interaction with household wealth.

RESULTS

We find in our main results that increases in conflict-related casualties are associated with a significant decline in the probability that a child was ever breastfed and a decline in the probability that a child is currently breastfeeding. There is no significant association with exclusive breastfeeding or with initiation of breastfeeding within 1 h after birth. This result is robust to alternative measures of conflict, although some coefficients from estimation based on the 2006 subsample are positive and not significant, and reverse causation is a potential source of bias in interpreting cross-sectional feeding patterns. Results on breastfeeding duration are mixed. Our results also suggest an increase in the use of breastfeeding substitutes like formula concurrent to higher levels of conflict among wealthier households.

CONCLUSION

The results are informative in the context of designing policy aimed at stabilizing the long-term health and productivity of populations in conflict areas. Infant formula provided with the objective of offering temporary relief creates risks, including reducing the probability and duration of breastfeeding. Attention to the supply of health care and to support systems for women, especially skilled breastfeeding support and targeted support to infants dependent on formula, are matters of the utmost urgency during and after conflict periods.

BREASTFEEDING INTENTION AND KNOWLEDGE IN SECONDARY-SCHOOL STUDENTS

SUMMARY – Breast milk makes the world healthier and better. Deaths and suffering of thousands of children and mothers each year could be prevented through universal breastfeeding, along with enormous economic savings. The aim of this study was to examine the knowledge of breastfeeding and intention to breastfeed in third-year secondary school students from various high schools and to make a conclusion on the unique and structured education program on breastfeeding in secondary schools. A total of 252 third-year secondary school students from 4 high schools in Bjelovar, Kutina and Pakrac completed an online questionnaire on the knowledge and intention to breastfeed. The results were presented by descriptive statistics methods. Kruskal-Wallis test was conducted for intention scale and χ²-test for questions about knowledge. Logistic regression was used to predict probabilities of a response. The results showed the responses of students from individual schools to be statistically significantly different in some questions of knowledge and some items of intention of breastfeeding. Insufficient breastfeeding information in schools does not provide a basis to third-year secondary school students to make an informed decision about breastfeeding in adulthood. We propose development and use of a unique structured educational program on breastfeeding for secondary school students.

Effect of Breastfeeding in Early Life on Cardiorespiratory and Physical Fitness: A Systematic Review and Meta-Analysis

BACKGROUND

Numerous studies have reported the associations between the type of feeding during infancy and subsequent chronic diseases.

OBJECTIVE

The objective of this systematic review is to synthesize the available literature concerning the effect of breastfeeding in infancy on physical and cardiorespiratory fitness in children and adolescents.

MATERIALS AND METHODS

We performed a comprehensive search of medical bibliographic databases to identify observational studies reporting the association between breastfeeding and cardiorespiratory or physical fitness. Random effects model was used for calculating the pooled estimates.

RESULTS

Three studies with 2,792 children were included in the meta-analysis. The mean value of VO₂max was similar between formula-fed and 1-3 months breastfed participants (standardized mean difference [SMD]: 0.1, 95% confidence intervals [CI]: -0.09 to 0.29, p = 0.31). There was no difference between 3 and 6 months breastfed (SMD: 0.17, 95% CI: -0.01 to 0.35, p = 0.06), >6 months breastfed (SMD: 0.37, 95% CI: -0.03 to 0.78, p = 0.07), and formula-fed children. The pooled SMD in handgrip strength was 0.09 (95% CI: -0.04 to 0.23; p = 0.17) between 1 and 3 months breastfed and formula-fed children .Nevertheless, 3-6 months (SMD: 0.13; 95% CI: 0.03-0.24) and >6 months (SMD: 0.19; 95% CI: 0.01-0.37) breastfeeding was associated with higher handgrip strength compared with formula-fed children. Breastfeeding for 1-3 (SMD: 0.20; 95% CI: 0.12-0.28), 3-6 (SMD: 0.27; 95% CI: 0.18-0.37), and >6 months (SMD: 0.34; 95% CI: 0.11-0.58) led to a significantly higher standing long-jump performance compared with formula feeding.

CONCLUSIONS

Breastfeeding shows beneficial effects on physical fitness, but further well-designed studies need to clarify effects of breastfeeding on cardiorespiratory fitness.

Infant feeding pattern in the first six months of age in USA: a follow-up study

Background

Infant feeding may consist of direct breastfeeding (DBF), pumping and bottle feeding (P&F), formula feeding (FF), solid food feeding (SFF), and any combination. An accurate evaluation of infant feeding requires descriptions of different patterns, consistency, and transition over time.

Methods

In United States of America, the Infant Feeding Practice Study II collected information on the mode of feeding on nine occasions in 12 months. We focused on the first 6 months with six feeding occasions. To determine the longitudinal patterns of feeding the latent class transition analyses was applied and assessed the transition probabilities between these classes over time.

Results

Over 6 months, 1899 mothers provided feeding information. In month 1 the largest latent class is FF (32.9%) followed by DBF (23.8%). In month 2, a substantial proportion of the FF class included SFF; which increases over time. A not allocated class, due to missing information was identified in months 1-3, transitions to SFF starting in month 4 (8.9%). In month 1, two mixed patterns exist: DBF and P&F combined with FF (13.9%) and DBF combined with P&F (18.7%). The triple combination of DBF, P&F, and FF (13.9%) became FF in month 2 (transition probability: 24.8%), and DBF in combination with P&F (transition probability: 49.1%). The pattern of DBF combined with P&F is relatively stable until month 4, when at least 50% of these infants receive solid food. Only 23-26% of the infants receive direct breastfeeding (DBF) in months 1-4, in month 5-6 SFF is added. Mothers who used FF were less educated and employed fulltime. Mothers who smoke and not residing in the west of the United States were also more likely to practice formula feeding.

Conclusion

Infant feeding is complex. Breastfeeding is not predominant and we additionally considered the mixed patterns of feeding. To facilitate direct breastfeeding, a substantial increase in the duration of maternal leave is necessary in the United States.

Economic determinants of breastfeeding in Haiti: The effects of poverty, food insecurity, and employment on exclusive breastfeeding in an urban population

There is limited and inconsistent empirical evidence regarding the role of economic factors in breastfeeding practices, globally. Studies have found both negative and positive associations between low income and exclusive breastfeeding (EBF). Employment, which should improve household income, may reduce EBF due to separation of mother and infant. In the context of a randomized controlled study of lipid-based complementary feeding in an urban slum in Cap Haitien, Haiti, we examined the economic factors influencing breastfeeding practices using mixed methods. Findings demonstrate relationships between urban context, economic factors, and breastfeeding practices. Poverty, food insecurity, time constraints, and limited social support create challenges for EBF. Maternal employment is associated with lower rates of EBF and less frequent breastfeeding. Extreme food insecurity sometimes leads to increased exclusive breastfeeding among Haitian mothers, what we call "last resort EBF." In this case, women practice EBF because they have no alternative food source for the infant. Suggested policies and programs to address economic constraints and promote EBF in this population include maternal and child allowances, quality child care options, and small-scale household urban food production.

Using group model building to develop a culturally grounded model of breastfeeding for low-income African American women in the USA

AIMS AND OBJECTIVES

To identify barriers and supporting factors for breastfeeding, and the dynamic interactions between them, as identified by low-income African American women and lactation peer helpers.

BACKGROUND

Stark breastfeeding disparities exist between African American mothers and their White counterparts in the USA. This pattern is often replicated across the globe, with marginalised populations demonstrating decreased breastfeeding rates. While breastfeeding research focused on sociocultural factors for different populations has been conducted, a more dynamic model of the factors impacting breastfeeding may help identify effective leverage points for change.

DESIGN

Group model building was used as a grounded theoretical approach, to build and validate a model representing factors impacting breastfeeding and the relationships between them.

METHODS

Low-income African American women (n = 21) and lactation peer helpers (n = 3) were engaged in model building sessions to identify factors impacting breastfeeding. A two-cycle process was used for analysis, in vivo and axial coding. The final factors and model were validated with a subgroup of participants.

RESULTS

The participants generated 82 factors that make breastfeeding easier, and 86 factors that make breastfeeding more challenging. These were grouped into 10 and 14 themes, respectively. A final model was constructed identifying three domains impacting breastfeeding: a mother's return to work or school, her knowledge, support and persistence, and the social acceptance of breastfeeding.

CONCLUSIONS

This study documented the sociocultural context within which low-income African American women are situated by identifying factors impacting breastfeeding, and the dynamic interactions between them. The model also provided various leverage points from which breastfeeding women can be supported.

RELEVANCE TO CLINICAL PRACTICE

Postpartum nurses are critical in supporting breastfeeding practices. To be most effective, they must be aware of the factors impacting breastfeeding, some of which may be unique to women based on their culture.

Preventative lipid-based nutrient supplements (LNS) and young child feeding practices: findings from qualitative research in Haiti

To prevent undernutrition in an urban slum in Haiti, a lipid-based nutrient supplement (LNS) was introduced through a randomised control trial. Food supplementation for young child nutrition has a long history in Haiti, but there is little empirical information regarding the effects of supplementation on young child feeding practices. One of the concerns raised by supplementation is that it may disrupt other positive feeding practices such as breastfeeding and use of other complementary foods, with negative consequences for child nutrition. We conducted 29 in-depth interviews with mother-baby pairs from the three comparison groups: control, 3-month LNS supplementation and 6-month LNS supplementation. Findings from those in the LNS groups indicated high acceptance and satisfaction with LNS and perceptions that it positively affects child health and development. LNS was integrated into and enhanced ongoing complementary feeding practices. The effects of LNS use on duration and perceived quantity of breastfeeding were variable, but generally, breastfeeding was maintained during and after the intervention. Interviews generated insights into beliefs regarding infant and young child feeding practices such as introduction and use of complementary foods, and breastfeeding duration, exclusivity and cessation. Implications for the use of LNS in public health nutrition programmes are discussed.

Breast-feeding Duration: Early Weaning-Do We Sufficiently Consider the Risk Factors?

OBJECTIVES

Breast-feeding is the recommended form of nutrition for the first 6 months. This target is unmet, however, in most industrialized regions. We evaluated aspects of breast-feeding in a cohort of mother-baby dyads.

METHODS

Breast-feeding practices in 555 mother-baby dyads were prospectively studied for 24 months (personal interview at birth and 7 structured telephone interviews).

RESULTS

Of the babies, 71.3% were fully breast-fed on discharge from maternity hospitals and 11.9% were partially breast-feed. Median breast-feeding duration was 6.93 (interquartile range 2.57-11.00) months; for full (exclusive) breast-feeding 5.62 (interquartile range 3.12-7.77) months; 61.7% received supplemental feedings during the first days of life. Breast-feeding duration in babies receiving supplemental feedings was significantly shorter (median 5.06 months versus 8.21 months, P < 0.001). At 6 months, 9.4% of the mothers were exclusively and 39.5% partially breast-feeding. Risk factors for early weaning were early supplemental feedings (odds ratio [OR] 2.87, 95% CI 1.65-4.98), perceived milk insufficiency (OR 7.35, 95% CI 3.59-15.07), low breast-feeding self-efficacy (a mother's self-confidence in her ability to adequately feed her baby) (OR 3.42, 95% CI 1.48-7.94), lower maternal age (OR 3.89, 95% CI 1.45-10.46), and lower education level of the mother (OR 7.30, 95% CI 2.93-18.20).

CONCLUSIONS

The recommended full breast-feeding duration of the first 6 months of life was not reached. Sociodemographic variables and factors directly related to breast-feeding practices play an important role on breast-feeding duration/weaning in our region. Understanding risk factors will provide insights to give better support to mothers and prevent short- and long-term morbidity following early weaning.

Breastfeeding and childhood asthma: systematic review and meta-analysis

Asthma and wheezing disorders are common chronic health problems in childhood. Breastfeeding provides health benefits, but it is not known whether or how breastfeeding decreases the risk of developing asthma. We performed a systematic review and meta-analysis of studies published between 1983 and 2012 on breastfeeding and asthma in children from the general population. We searched the PubMed and Embase databases for cohort, cross-sectional, and case-control studies. We grouped the outcomes into asthma ever, recent asthma, or recent wheezing illness (recent asthma or recent wheeze). Using random-effects meta-analyses, we estimated pooled odds ratios of the association of breastfeeding with the risk for each of these outcomes. We performed meta-regression and stratified meta-analyses. We included 117 of 1,464 titles identified by our search. The pooled odds ratios were 0.78 (95% confidence interval: 0.74, 0.84) for 75 studies analyzing "asthma ever," 0.76 (95% confidence interval: 0.67, 0.86) for 46 studies analyzing "recent asthma," and 0.81 (95% confidence interval: 0.76, 0.87) for 94 studies analyzing recent wheezing illness. After stratification by age, the strong protective association found at ages 0-2 years diminished over time. We found no evidence for differences by study design or study quality or between studies in Western and non-Western countries. A positive association of breastfeeding with reduced asthma/wheezing is supported by the combined evidence of existing studies.

HIV serostatus and disclosure: implications for infant feeding practice in rural south Nyanza, Kenya

BACKGROUND

The World Health Organization (WHO) recommends that HIV-infected women practice exclusive breastfeeding (EBF) for the first 6 months postpartum to reduce HIV transmission. The aim of this study was to determine the effects of HIV/AIDS knowledge and other psychosocial factors on EBF practice among pregnant and postpartum women in rural Nyanza, Kenya, an area with a high prevalence of HIV.

METHODS

Data on baseline characteristics and knowledge during pregnancy, as well as infant feeding practices 4-8 weeks after the birth were obtained from 281 pregnant women recruited from nine antenatal clinics. Factors examined included: fear of HIV/AIDS stigma, male partner reactions, lack of disclosure to family members, knowledge of prevention of mother-to-child transmission (PMTCT) and mental health. In the analysis, comparisons were made using chi-squared and t-test methods as well as logistic multivariate regression models.

RESULTS

There were high levels of anticipated stigma 171(61.2%), intimate partner violence 57(20.4%) and postpartum depression 29(10.1%) and low levels of disclosure among HIV positive women 30(31.3%). The most significant factors determining EBF practice were hospital delivery (aOR = 2.1 95% CI 1.14-3.95) HIV positive serostatus (aOR 2.5 95% CI 1.23-5.27), and disclosure of HIV-positive serostatus (aOR 2.9 95% CI 1.31-6.79). Postpartum depression and PMTCT knowledge were not associated with EBF (aOR 1.1 95% CI 0.47-2.62 and aOR 1.2 95% CI 0.64-2.24) respectively.

CONCLUSIONS

Health care workers and counselors need to receive support in order to improve skills required for diagnosing, monitoring and managing psychosocial aspects of the care of pregnant and HIV positive women including facilitating disclosure to male partners in order to improve both maternal and child health outcomes.

Predictors of breastfeeding duration among women in Kuwait: results of a prospective cohort study

The purposes of this paper are to report the prevalence of breastfeeding to six months among women in Kuwait and to determine the factors that are associated with the duration of breastfeeding. A cohort of 373 women recruited from maternity wards in four hospitals in Kuwait city were followed from birth to 26 weeks postpartum. The association of any and full breastfeeding duration and predictor variables were explored using multivariate Cox's proportional hazards models. At six months, 39% of all infants were receiving some breast milk and only 2% of infants had been fully breastfed to 26 weeks. Women born in other Arab countries were less likely to discontinue breastfeeding than women born in Kuwait. Other factors positively associated with breastfeeding duration were level of maternal education, higher parity, infant being demand fed in hospital and a preference for breastfeeding on the part of the infant's father and maternal grandmother. The introduction of a pacifier before four weeks of age and the mother intending to return to work by six months were negatively associated with duration. These findings present a number of opportunities for prolonging breastfeeding duration in Kuwait.

Predictors of breastfeeding duration among women in Kuwait: results of a prospective cohort study

The purposes of this paper are to report the prevalence of breastfeeding to six months among women in Kuwait and to determine the factors that are associated with the duration of breastfeeding. A cohort of 373 women recruited from maternity wards in four hospitals in Kuwait city were followed from birth to 26 weeks postpartum. The association of any and full breastfeeding duration and predictor variables were explored using multivariate Cox's proportional hazards models. At six months, 39% of all infants were receiving some breast milk and only 2% of infants had been fully breastfed to 26 weeks. Women born in other Arab countries were less likely to discontinue breastfeeding than women born in Kuwait. Other factors positively associated with breastfeeding duration were level of maternal education, higher parity, infant being demand fed in hospital and a preference for breastfeeding on the part of the infant's father and maternal grandmother. The introduction of a pacifier before four weeks of age and the mother intending to return to work by six months were negatively associated with duration. These findings present a number of opportunities for prolonging breastfeeding duration in Kuwait.

Perceptions of caregivers about health and nutritional problems and feeding practices of infants: a qualitative study on exclusive breast-feeding in Kwale, Kenya

Background

Despite the significant positive effect of exclusive breast-feeding on child health, only 32% of children under 6 months old were exclusively breast-fed in Kenya in 2008. The aim of this study was to explore perceptions and feeding practices of caregivers of children under 6 months old with special attention to the caregivers’ indigenous knowledge, perceptions about the health and nutritional problems of their infants, and care-seeking behaviors that affect feeding practices.

Methods

The study was exploratory and used an inductive approach. In all, 32 key informants, including mothers, mothers-in-law, and traditional healers, were interviewed in-depth. The number of participants in free-listing of perceived health problems of babies, in ranking of the perceived severity of these health problems, and in free-listing of food and drink given to children under 6 months old were 29, 28, and 32, respectively. Additionally, 28 babies under 6 months old were observed at home with regard to feeding practices. Data obtained using these methods were triangulated to formulate an ethnomedical explanatory model for mothers who do not practice exclusive breast-feeding.

Results

The informants stated that various types of food, drink, and medicine were given to infants under 6 months old. Direct observation also confirmed that 2- to 3-month-old babies were given porridge, water, juice, herbal medicine, and over-the-counter medicine. Mothers’ perceptions of insufficient breast milk production and a lack of proper knowledge about the value of breast milk were identified in key informant interviews, free-listing, and ranking as important factors associating with the use of food and drink other than breast milk; in addition, perceived ill health of babies appears to be associated with suboptimal practice of exclusive breast-feeding. Caregivers used various folk and popular medicines from the drugstore, their own backyard or garden, and traditional healers so that the mother or child would not be exposed to perceived risks during the vulnerable period after birth.

Conclusions

Mothers should be advised during their antenatal and postnatal care about exclusive breast-feeding. This should be done not as a single vertical message, but in relation to their concerns about the health and nutritional problems of their babies.

Current knowledge and future research on infant feeding in the context of HIV: basic, clinical, behavioral, and programmatic perspectives

In 2008, between 129,000 and 194,000 of the 430,000 pediatric HIV infections worldwide were attributable to breastfeeding. Yet in many settings, the health, economic, and social consequences of not breastfeeding would have dire consequences for many more children. In the first part of this review we provide an overview of current knowledge about infant feeding in the context of HIV. Namely, we describe the benefits and risks of breastmilk, the evolution of recommended infant feeding modalities in high-income and low-income countries in the last two decades, and contextualize the recently revised guidelines for infant feeding in the context of HIV current knowledge. In the second section, we suggest areas for future research on the postnatal prevention of mother-to-child transmission of HIV (PMTCT) in developing and industrialized countries. We suggest two shifts in perspective. The first is to evaluate PMTCT interventions more holistically, to include the psychosocial and economic consequences as well as the biomedical ones. The second shift in perspective should be one that contextualizes postnatal PMTCT efforts in the cascade of maternal health services. We conclude by discussing basic, clinical, behavioral, and programmatic research questions pertaining to a number of PMTCT efforts, including extended postnatal ARV prophylaxis, exclusive breastfeeding promotion, counseling, breast milk pasteurization, breast milk banking, novel techniques for making breast milk safer, and optimal breastfeeding practices. We believe the research efforts outlined here will maximize the number of healthy, thriving, HIV-free children around the world.

Breastfeeding and the introduction of solids in Australian infants: data from the 2001 National Health Survey

OBJECTIVE

To present estimates on rates of breastfeeding and timing of introduction of solid foods to Australian children, 1998-2001.

METHODS

Analysis of data from the 2001 Australian National Health Survey (NHS) using lifetable methods. Infant feeding questions were asked by personal interview in respect to 1,883 children aged under three years of age.

RESULTS

At discharge from hospital, 83.3% of infants were breastfeeding, which is similar to estimates from the 1995 NHS. At 13 weeks postpartum, 64.3% were breastfeeding, 49.0% at 25 weeks and 24.9% were continuing to breastfeed at one year. At 25 weeks, 18.4% of infants were fully breastfed. Solid food was being offered regularly to 15.2% of infants at 13 weeks and 88.0% by 26 weeks.

CONCLUSION

Fewer than 50% of infants are receiving breast milk at six months, which is considerably lower than the 80% figure recommended by the latest Dietary Guidelines for Children and Adolescents. Very few Australian infants are being exclusively breastfed for the recommended six months. Infant feeding practices in Australia appear to have remained unchanged between 1995 and 2001.

Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts

BACKGROUND

Weighing breastfed babies has been the subject of some controversy as the previous international growth chart was largely based on data from infants fed infant formula. The concern that professionals may be misled by the charts into suggesting to mothers that they supplement unnecessarily was a major impetus for the World Health Organization's investment in a new growth chart. Evidence of interpretation in practice has been scant.

METHODS

An ethnographic study was conducted in a town in the Northwest of England to investigate this issue. In the first phase, women and health visitors were observed in the well-child clinic during clinic sessions and breastfeeding group meetings. In the second phase, longitudinal interviews with 14 women were conducted. Each woman was interviewed up to three times in the first six months after the birth of her baby, with a total of 35 interviews.

RESULTS

Mothers and health visitors focussed on weight gain with frequent weighing and attention to even minor fluctuations of the plotted line being evident. Women felt it important to ensure their baby's weight followed a centile, and preferred for this to be the fiftieth centile. Interventions included giving infant formula and solids as well as changing what the mother ate and drank. Women also described how they worried about their baby's weight. Little effective support by health professionals with breastfeeding technique was observed.

CONCLUSION

Babies were weighed more often than officially recommended, with weighing and plotting being at the core of each clinic visit. The plotted weight chart exerted a powerful influence on both women's and health visitors' understanding of the adequacy of breastfeeding. They appeared to rate the regular progression of weight gains along the chart centiles more highly than continued or exclusive breastfeeding. Thus weighing and visual charting of weight constituted a form of surveillance under the medical gaze, with mothers actively participating in self monitoring of their babies. Interventions, by mothers and health visitors, were targeted towards increasing weight gain rather than improving breastfeeding effectiveness. Improvements in training are needed for health visitors in weighing techniques, assessing growth patterns--particularly of breastfed babies--and in giving information to women, if the practice of routine weight monitoring is to support rather than undermine breastfeeding.

In practice, the theory is different: a processual analysis of breastfeeding in northeast Brazil

'Na prática, a teoria è outra' (in practice, the theory is different) is an old Brazilian saying. This phrase summarizes well the general practice of breastfeeding in Brazil: 'Breast is best' is central in the pregnant women's future oriented 'theory' of how their infant should be fed. In the subsequent weeks after delivery, however, in the daily practicalities of feeding their infant, this theory is, to a large extent, abandoned. The present study is based on a sample of 300 mothers in the city of Aracaju in the Northeast of Brazil. Through interviews, the differences and similarities between knowledge and practice with respect to infant feeding were established. An explanation of these differences is developed on the basis of a processual analysis of the qualitative and quantitative results of the interview data. Nearly all mothers were knowledgeable of the need to breastfeed, and nearly all mothers had initiated breastfeeding. However, only a minority was exclusively breastfeeding at the time of the interview. A distinction is made between a breastfeeding process and a de-breastfeeding process. The data suggest that mothers, in general, start the de-breastfeeding process with the positive intention of ameliorating the infant's situation without realizing the negative processual consequences that most likely ends in a cessation of breastfeeding. The study supports the view that health policy should underline the processual character of both breastfeeding and de-breastfeeding when promoting the importance of exclusive breastfeeding.

The conceptualization of perceived insufficient milk among Mexican mothers

This study sought to provide a comprehensive picture of maternal conceptualization of Perceived Insufficient Milk (PIM) using qualitative methods (semistructured interviews, free lists, and rankings) in Mexico. Two hundred and seven first-time mothers of infants younger than 6 months and mothers-to-be who were (or intended to be) breastfeeding were interviewed in waiting areas at a hospital and a health clinic in Mexico City, Mexico, from September 2000 to January 2001. Pattern searching and triangulation of the 3 qualitative methods indicated that women viewed crying as the chief symptom of PIM. Maternal diet and liquid intake were cited as both the most salient causes and treatments for PIM. The main coping strategy in the event of PIM was formula feeding. These findings highlight the need for addressing maternal concerns in relation to PIM, especially regarding the role of crying as the initiator of the PIM cycle.

Mortality among HIV-1-infected women according to children's feeding modality: an individual patient data meta-analysis

BACKGROUND

Two recent analyses of HIV-1-infected mothers' mortality according to their children's feeding modality have produced conflicting results.

METHODS

An individual patient data meta-analysis was conducted using data regarding HIV-1-infected women from eligible clinical trials. Analyses included Cox proportional hazards regression modeling, with children's feeding modality treated as a time-dependent covariate.

RESULTS

Of 4237 HIV-1-infected women, 162 (3.8%) died within 18 months after delivery. The risk of mortality during the 18-month period after delivery did not differ significantly by children's feeding modality (ever vs. never breast-fed), with or without adjustment for maternal CD4(+) count. Treating children's feeding modality as a time-dependent covariate, the risk of mortality was lower among women still breast-feeding (hazard ratio = 0.05, 95% confidence interval: 0.03, 0.09; P < 0.0001) than among those who had ceased, with similar results observed with adjustment for maternal CD4(+) count.

CONCLUSIONS

HIV-1-infected women with lower CD4(+) counts were less likely to initiate breast-feeding. Mothers' mortality during the 18-month period after delivery did not differ significantly according to children's feeding modality (ever vs. never breast-fed). Of those women who initiated breast-feeding, the lower mortality risk among those still breast-feeding compared with those not breast-feeding likely represents better overall maternal health (with healthier women being able to breast-feed longer).

Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National Immunization Survey

OBJECTIVE

In the third quarter of 2001, the National Immunization Survey (NIS) began collecting data on the initiation and duration of breastfeeding and whether it was the exclusive method of infant feeding. Using the data from the 2002 NIS, this study estimates breastfeeding rates in the United States by characteristics of the child, mother, or family.

METHODS

The NIS uses random-digit dialing to survey households nationwide with children 19 to 35 months old about vaccinations and then validates the information through a mail survey of the health care providers who gave the vaccinations. In 2002, approximately 3500 households from the NIS were randomized to 1 of the 3 rotating topical modules that covered breastfeeding.

RESULTS

More than two thirds (71.4%) of the children had ever been breastfed. At 3 months, 42.5% of infants were exclusively breastfed, and 51.5% were breastfed to some extent. At 6 months, these rates dropped to 13.3% and 35.1%, respectively. At 1 year, 16.1% of infants were receiving some breast milk. Non-Hispanic black children had the lowest breastfeeding rates. Breastfeeding rates also varied by participation in day care or the Women, Infants, and Children program, socioeconomic status, and geographic area of residence.

CONCLUSIONS

Although the rate of breastfeeding initiation in the United States is near the national goal of 75%, at 6 and 12 months postpartum the rates of breastfeeding duration are still considerably below the national goals of 50% and 25%, respectively. In addition, rates of exclusive breastfeeding are low. Strenuous public health efforts are needed to improve breastfeeding behaviors, particularly among non-Hispanic black women and socioeconomically disadvantaged groups.

Development and testing of a prenatal breastfeeding education intervention for Hispanic women

Many immigrant Hispanic women in the United States choose to bottle-feed rather than breastfeed. This article describes an intervention that was developed and tested in a two-step process. Two studies were undertaken. First, a qualitative inquiry explored the breastfeeding beliefs, attitudes, meanings, and practices of Hispanic women. Results informed the design of a culturally appropriate prenatal breastfeeding education intervention. Secondly, the researchers undertook a quantitative study of the intervention's success in increasing breastfeeding duration among Hispanic women. Methodology and findings of this study have implications for future interventions that promote breastfeeding.

Breastfeeding advice given to African American and white women by physicians and WIC counselors

OBJECTIVE

This study determined rates of breastfeeding advice given to African American and white women by medical providers and WIC nutrition counselors, and sought to determine whether racial differences in advice contributed to racial differences in rates of breastfeeding.

METHODS

The study used data from the 1988 National Maternal and Infant Health Survey, a cross-sectional survey of a nationally representative sample of mothers with a live birth, infant death, or fetal death in 1988. The authors compared white women (n=3,966) and African American women (n=4,791) with a live birth in 1988 on self-reported rates of medical provider and WIC advice to breastfeed, WIC advice to bottlefeed, and breastfeeding.

RESULTS

Self-reported racial identification did not predict medical provider advice. However, being African American was associated with less likelihood of breastfeeding advice and greater likelihood of bottlefeeding advice from WIC nutrition counselors. In multivariate analyses controlling for differences in advice, being African American was independently associated with lower breastfeeding rates (odds ratio [OR] = 0.41, 95% CI 0.32, 0.52).

CONCLUSIONS

African American women were less likely than white women to report having received breastfeeding advice from WIC counselors and more likely to report having received bottlefeeding advice from WIC counselors. However, African American and white women were equally likely to report having received breastfeeding advice from medical providers. Lower rates of breastfeeding advice from medical or nutritional professionals do not account for lower rates of breastfeeding among African American women.

Breastfeeding advice given to African American and white women by physicians and WIC counselors

OBJECTIVE

This study determined rates of breastfeeding advice given to African American and white women by medical providers and WIC nutrition counselors, and sought to determine whether racial differences in advice contributed to racial differences in rates of breastfeeding.

METHODS

The study used data from the 1988 National Maternal and Infant Health Survey, a cross-sectional survey of a nationally representative sample of mothers with a live birth, infant death, or fetal death in 1988. The authors compared white women (n=3,966) and African American women (n=4,791) with a live birth in 1988 on self-reported rates of medical provider and WIC advice to breastfeed, WIC advice to bottlefeed, and breastfeeding.

RESULTS

Self-reported racial identification did not predict medical provider advice. However, being African American was associated with less likelihood of breastfeeding advice and greater likelihood of bottlefeeding advice from WIC nutrition counselors. In multivariate analyses controlling for differences in advice, being African American was independently associated with lower breastfeeding rates (odds ratio [OR] = 0.41, 95% CI 0.32, 0.52).

CONCLUSIONS

African American women were less likely than white women to report having received breastfeeding advice from WIC counselors and more likely to report having received bottlefeeding advice from WIC counselors. However, African American and white women were equally likely to report having received breastfeeding advice from medical providers. Lower rates of breastfeeding advice from medical or nutritional professionals do not account for lower rates of breastfeeding among African American women.

Contemporary Trends in Infant Feeding Research

▪ Abstract  This review examines current research in the subfields of anthropology and related disciplines on the biocultural process of breastfeeding and broader questions of infant and young-child feeding. The themes of sexuality, reproduction, embodiment, and subjective experience are then linked to the problems women who breastfeed face in bottle-feeding cultures. Anthropologists have contributed to policy-relevant debates concerning women's work and scheduling in relation to infant care and exclusive breastfeeding. The extensive ethnographic work on children's transition to consuming household foods demonstrates the need to integrate research on breastfeeding with research on complementary feeding. Current debates around HIV and chemical residues in breastmilk call for a critical examination of the effects of globalization and corporate control on infant feeding practices. The literature shows how the narrow specialty of infant feeding has broad implications for the discipline.

Public perceptions on breastfeeding constraints

To describe public perceptions on breastfeeding constraints, the authors studied the responses of 2369 US adults who participated in the Healthstyles 2000 national mail survey (response rate = 75%). Among them, 2351 answered at least 1 of the 12 breastfeeding items. Public perceptions were positive for 8 of the 12 items. Among the other 4, however, almost half of US adults (45%) agreed that a breastfeeding mother has to give up too many lifestyle habits, 31% thought that babies ought to be fed cereal or baby food by age 3 months, 31% said that 1-year-olds should not be breastfed, and 27% considered breastfeeding in public embarrassing. The results revealed more negative perceptions among non-whites, people under 30 or above 65 years, and those who had low income and less education. To promote and support breastfeeding in society as a whole, these messages need to be considered in planning and implementing breastfeeding interventions.

Liminality and breastfeeding: women negotiating space and two bodies

It is almost universally accepted that breastfeeding infants is nutritionally superior to bottle-feeding. However, despite this medical advice, in many countries breastfeeding rates remain low and in the UK, rates are relatively static. The literature on breastfeeding has discussed international rates and the broad socio-economic factors influencing these rates. Through an observational study of a group of breastfeeding and non-breastfeeding women in the United Kingdom, this research utilises contemporary theoretical perspectives on the body, space and rites of passage, and investigates the reasons why some breastfeeding mothers may be in a liminal period, and the breastfeeding event itself, at times, a liminal and marginalised act. The paper argues that, for the group studied, breastfeeding is sometimes discouraged by its medicalisation, and that breastmilk and breastfeeding are often considered by mothers to be embarrassing. Many of the women studied regarded certain public and private places to be unacceptable places to breastfeed and claimed to modify their behaviour accordingly. The paper demonstrates the value of conducting locally based qualitative research into breastfeeding experiences, and of using theoretical perspectives from post-medical geography to interpret women's experiences.

Breastfeeding, wage labor, and insufficient milk in peri-urban Kathmandu, Nepal

This article presents a case study of breastfeeding mothers who are working as carpet-makers in peri-urban Kathmandu, Nepal. A sample of women surveyed about their current infant feeding practices revealed that half of the infants aged three to four months had been introduced to non-breast milk foods and liquids. During in-depth interviews some mothers explained that they supplemented breastfeeding with either milk or solids if they felt that they did not have enough breast milk for their infants. Reports of insufficient milk (IM) among these Nepali women is discussed within the larger context of IM as a worldwide phenomenon that is often associated with the cessation of breastfeeding and the switch to bottle-feeding based on commercial milk products. On average, the women in this study breastfed their infants until the latter were approximately three years of age. A status quo method for determining median duration of breastfeeding indicates that there is no significant difference in the duration of breastfeeding between mothers who work in carpet-making factories and those who spin wool at home. It is argued that reports of IM in this setting are not associated with the abandonment of breastfeeding, for a number of reasons including: the cultural approbation of breastfeeding; the low usage of baby bottles among peri-urban mothers, and the flexible labor practices of the carpet-making industry.

Comparison of infant feeding patterns reported for nonindustrial populations with current recommendations

The observation that young child-feeding practices rarely conform to current global recommendations is of major public health nutrition policy concern and raises questions about whether near-universal compliance with recommendations is feasible in any population. This analysis uses indicators of age at introduction of complementary foods and termination of breastfeeding available from ethnographic and demographic reports published between 1873 and 1998 to test the hypothesis that recent and contemporary nonindustrial societies practice patterns of infant feeding concordant with current global recommendations. Results suggest that ethnographically reported average ages at introduction of nonbreast milk liquids (4.5 +/- 6.0 mo) and solids (5.0 +/- 4.0 mo) and the duration of breastfeeding (29.0 +/- 10.0 mo) among a sample of 113 such populations concord with those at which key weaning transitions are biologically optimal for most normal healthy children. However, wide variation in estimates across populations remains unexplained and serious limitations in the available data preclude proper assessment of the underlying distribution of the timing of weaning transitions within populations.

The rise of breastfeeding in the United States

What factors influenced the resurgence of breastfeeding in the last decades of the twentieth century? This article has considered several explanations. Demographic trends, particularly the increased birth rate among black and Hispanic women, coupled with the resurgence of breastfeeding in these groups, may have contributed to the increase in the breastfeeding rate during the 1990s but likely played a minimal role in the earlier, more dramatic increase. The decrease in breastfeeding in the earlier part of the twentieth century may be partly attributable to increased maternal employment, but the resurgence of breastfeeding occurred during the late twentieth century--a period of unprecedented influx of new mothers into the workforce. There is no evidence that health care practitioners are providing more support for breastfeeding, and most international and US policies postdated the resurgence of breastfeeding, although they may have influenced the increase in the 1990s. A more plausible explanation of the resurgence of breastfeeding in all major segments of society is the pervasive influence of the natural-childbirth movement of the 1960s and 1970s, with its effects on the standard management of childbirth. Also, the increase in breastfeeding among low-income women may be attributable partly to programmatic changes in the provision of supplemental food through the WIC program and the targeting of breastfeeding-promotion efforts to the specific concerns of these women. Although breastfeeding increased at the end of the twentieth century relative to earlier decades, the disparity between the recommended rates and those achieved by US women is great. Thus, efforts to increase breastfeeding initiation and duration should continue, particularly for the groups that are at greatest risk for illness, such as minority and low-income infants. This article suggests that the strategies likely to have a lasting effect on future breastfeeding rates will be social pressures that affect existing barriers to breastfeeding. Such pressures may come from health maintenance organizations, insurance companies, and the US government, which are likely to increasingly recognize the costs of not breastfeeding to their institutions. The provision of flexible work hours and paid maternity leave, either by the US government or family-friendly workplaces, could increase the ability of employed women to optimally feed their infants. As Retsinas noted in an article on the cultural context of breastfeeding, "While it is 'known' that breastfeeding is better, our society is not structured to facilitate that choice." Efforts to improve breastfeeding rates need to make visible the wider cultural context in which infant-feeding choices are made and alter components that make it difficult for US women to feed their infants optimally.

Risk, uncertainty, and agency: culture and safe motherhood in Morocco

This article critically examines the notion that Moroccan women's infrequent use of health facilities during pregnancy and birth results from their lack of awareness of the risks of childbirth. It argues that while ethnographic data appear at first to lend support to this hypothesis, a closer examination of the customs surrounding birth shows that ideas about risk are found in local constructions of childbirth. The choices women make regarding birth and the flexibility that characterizes their decisions reflect the uncertain circumstances of labor and problems in the accessibility and quality of health services. Differences in the notions of risk that women hold and express are a function, not of an inability to conceive of risks, but rather of the real alternatives they have for controlling these risks.