A qualitative study to understand cultural factors affecting a mother's decision to breast or formula feed

Why do mothers mix milk feed their infants? Results from a systematic review

CONTEXT

Combining or supplementing breastfeeding with formula feeding, also called mixed milk feeding (MMF), is a common infant feeding practice. However, there is no well-established MMF evidence-base for informing and guiding parents. A better understanding of the reasons why mothers practice MMF may facilitate identification of efficient strategies for supporting exclusive breastfeeding, and/or opportunities to prolong breastfeeding, at least partially.

OBJECTIVE

An updated systematic literature review was undertaken with the primary aim of gaining a deeper understanding of the reasons why mothers choose MMF.

DATA SOURCES

Six databases were searched for relevant articles published in English from January 2012 to January 2022.

DATA EXTRACTION

Two reviewers independently performed the screenings and data extraction, and any differences were resolved by a third reviewer. Data from 138 articles were included, 90 of which contained data on MMF reasons/drivers, and 60 contained data on infant age and/or maternal demographic factors associated with MMF.

DATA ANALYSIS

A total of 13 different unique MMF drivers/reasons were identified and categorized according to whether the drivers/reasons related to perceived choice, necessity, or pressure. Risk of bias was evaluated using the Quality Assessment Tool of Diverse Studies and the JBI Systematic Reviews tool. Several different terms were used to describe and classify MMF across the studies. The most commonly reported reasons for MMF were related to a perception of necessity (39% of drivers, eg, concerns about infant's hunger/perceived breast milk insufficiency or breastfeeding difficulties), followed by drivers associated with perceived choice (34%; eg, having more flexibility) and perceived pressure (25%; eg, returning to work or healthcare professionals' advice). This was particularly true for infants aged 3 months or younger.

CONCLUSION

The key global drivers for MMF and their distribution across infant age and regions were identified and described, providing opportunities for the provision of optimal breastfeeding support. A unified definition of MMF is needed in order to enable more comparable and standardized research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022304253.

Attitudes on breast feeding among persons with HIV who have given birth and their perceptions of coercion during counseling on safe infant feeding practices

Persons with HIV can receive mixed messages about the safety of breastfeeding. We sought to assess if they felt coerced to formula feed when counseled about practices to reduce HIV transmission. Persons with HIV who had given birth were eligible to complete a survey to describe their experiences with infant feeding counseling and if they felt coerced to formula feed. An Iowa Infant Feeding Attitude Scale (IIFAS) assessed attitudes towards breastfeeding. Qualitative analyses were performed on narrative responses. One hundred surveys were collected from sites in Georgia, North Carolina, Pennsylvania, and South Carolina. The mean IIFAS score (n, 85) was 47 (SD 9.2), suggesting relatively favorable attitudes toward breastfeeding. Thirteen persons reported feeling coerced to formula feed. When controlling for choosing to give any breast milk, persons with any college education were more likely to report feeling coerced (aOR 9.8 [95% CI 1.8-52.5]). Qualitative analyses revealed three themes: perceiving breastfeeding as unsafe, engaging in shared decision-making, and resisting advice to formula feed. Persons with HIV desire to be counseled about safe infant feeding practices and have their questions answered without judgement. We highlight experiences of persons with HIV that reflect a need for a nuanced approach to infant feeding counseling.

Role of Health Care Providers in Encouraging Formula Feeding in Mosul City

Unacceptable advertisements and deceptive promotion of formula feeding undermine breastfeeding and threaten infant and maternal health worldwide. The purpose of this study was to estimate the role of healthcare providers and other sources in promoting the use of formula feeding among attendants at healthcare facilities in Mosul, Iraq. This one-year cross-sectional study was conducted at three healthcare facilities in Mosul, Iraq. Mothers of formula-fed infants under the age of one year were surveyed with a prepared questionnaire. Data analysis was performed using descriptive and inferential statistics. Of the 400 women who participated, 73% stated that healthcare professionals encouraged the use of formula feeding without a convenient reason, of which more than 80% were pediatricians and nursery nurses. Only 27% percent of the women chose to formula-feed their infants based on other factors. An extensive analysis of this attitude is warranted.

Factors influencing Aboriginal and Torres Strait Islander women's breastfeeding practice: A scoping narrative review

BACKGROUND

The nutritional and health benefits of breastfeeding for infants and young children are well-established however rates of breastfeeding initiation and duration for Aboriginal and Torres Strait Islander children are lower than non-Indigenous children.

AIM

To describe factors influencing breastfeeding practice amongst Aboriginal and Torres Strait Islander women.

METHODS

A scoping narrative review was conducted using the Joanna Briggs Institute framework. A search was conducted in four online databases (PubMed, Scopus, ANU SuperSearch, and Science Direct). Findings were analysed using [30] narrative synthesis.

FINDINGS

This review included 9 journal articles, a conference summary and a book. This review identified four factors influencing women's breastfeeding practice; sources of support, culturally appropriate care, intention to breastfeed and social determinants.

CONCLUSION

Multiple social determinants resulting from colonization have interrupted traditional infant feeding practices and women's sources of support. Although Aboriginal and Torres Strait Islander women have strong intention to breastfeed, their breastfeeding outcomes are impacted by lack of pro-breastfeeding support when encountering breastfeeding challenges as well as norms surrounding the use of infant formula milk. Culturally appropriate care is essential for identifying women's needs and avoiding stereotyping. Further research is needed to investigate the effectiveness of breastfeeding interventions for this group of women.

Forming the Perception of WIC Infant Feeding Recommendations: A Qualitative Study

Nearly half of newborns in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Promoting breastfeeding is a programmatic priority, although formula vouchers are provided for those who do not exclusively breastfeed. Previous literature suggests that participant perception of WIC's breastfeeding recommendations is a significant factor predicting breastfeeding initiation, duration, and exclusivity outcomes. However, little is known about how participants' perceptions of WIC's breastfeeding recommendations are formed. To address this knowledge gap, we conducted a qualitative pilot study in Nevada, interviewing 10 postpartum WIC mothers and 12 WIC staff who had interacted with participants regarding infant feeding. Results showed participants and staff reported various perceptions of what WIC recommends, the factors that contribute to these perceptions, and how these perceptions affect breastfeeding practices. Respondents also described that WIC has a negative legacy as the "free formula program," and that environmental factors, such as the recent formula recall, have had an impact on participants' infant feeding practices. More effective public campaigns and programmatic strategies are needed to target participants' prenatal self-efficacy and to communicate the availability of skilled lactation support in the early postpartum period to improve participants' perceptions of WIC's position on breastfeeding.

Lactation Outcomes After Participation in a Tailored Prenatal Nutrition Consultation Among Women With Infants With Congenital Anomalies

OBJECTIVE

To describe lactation outcomes among of a cohort of mother-infant dyads in which the women had an individualized prenatal nutrition consultation intervention.

DESIGN

Descriptive cohort study.

SETTING

A free-standing children's hospital with a center for fetal diagnosis and treatment and a specialized maternity unit.

PARTICIPANTS

A total of 160 women who had prenatal nutrition consultations in 2014 to 2017 and gave birth to infants with known congenital anomalies and required intensive care after birth.

METHODS

We surveyed women regarding their lactation outcomes after the Breastfeeding Report Card metrics of the Centers for Disease Control and Prevention and obtained permission to abstract demographic and clinical information from the setting's electronic health record. We analyzed data with standard descriptive statistics.

RESULTS

Among the cohort, 86.9% (n = 139) of participants intended to provide human milk or combination feeding in the prenatal period. A total of 128 (92.1%) infants were first exposed to human milk enterally. At the time of discharge, 92.1% (n = 128) of the infants received human milk. The breastfeeding outcomes of the cohort significantly surpassed national data: initiation (98.1% vs. 84.1% national), breastfeeding at 3 months (89.4%), exclusive breastfeeding at 3 months (60% vs. 46.9% national), breastfeeding at 6 months (76.9% vs. 58.3% national), exclusive breastfeeding at 6 months (45% vs. 25.6% national), breastfeeding at 12 months (50.6% vs. 35.3% national), and breastfeeding beyond 12 months (34.4%).

CONCLUSIONS

Lactation outcomes among women who had prenatal nutrition consultations far surpassed national data, and this intervention has implications for family-centered prenatal care, informed decision making, and improved breastfeeding outcomes in the hospital setting and postdischarge.

Breastfeeding Awareness and Empowerment (BAE): A Black Women-Led Approach to Promoting a Multigenerational Culture of Health

1 Background

Critical gaps in the U.S. healthcare system perpetuate adverse reproductive health outcomes for Black people. Grounded in reproductive justice and trauma-informed care, Breastfeeding Awareness and Empowerment (BAE) has developed a program titled BAE Cafe to directly address these gaps by providing community-based lactation and perinatal mental health support. A literature review identified key programmatic gaps, namely, access to knowledge relevant to troubleshooting breastfeeding, peer support, community support and healthcare system support, and system-level factors that impede families and communities from accessing lactation support.

2 Methods

This paper describes BAE Cafe through a group process observation and participant survey.

3 Results

The observation of groups highlighted the core elements of the BAE Cafe model: knowledge, support and mental health support in a peer driven format. Participant survey feedback was overwhelmingly positive and highlighted the critical importance of lactation support for Black women by Black women and BAE's role in participants' decisions to continue breastfeeding.

4 Conclusions

BAE Cafe is a replicable, scalable, peer-driven and low-barrier intervention that has the potential to improve outcomes for Black families. Additional research and investment are now needed to assess large-scale implementation to reduce disparities and address health inequity across different contexts and settings.

Fathers' role in sustainability of exclusive breastfeeding practice in post-cesarean-section mothers

Background: The success of breastfeeding among post-cesarean- section mothers requires strong willingness and commitment, self-confidence, support from various professionals, and internal support (especially from their husband) and the belief and value of their family. Exclusive breastfeeding remains low in some cities such as in West Java, especially in post-cesarean-section mothers, who are influenced by certain factors. The purpose of this study is to identify husbands’ role and their support for post-cesarean-section mothers in exclusive breastfeeding.

Design and Methods: This study used a qualitative phenomenological approach. with a combination of different data collection techniques: focus group discussion and in-depth interviews. Twelve husbands of post-cesarean-section mothers participated in this study. Data were analyzed by thematic content analysis.

Results: Four themes were identified namely knowledge about exclusive breastfeeding, the role of the father during breastfeeding, the experience of the husband and the family in supporting breastfeeding, and Women’s lack of knowledge, inconvenience due to pain as the most impending factors of exclusive breastfeeding.

Conclusion: Most fathers seem eager to be involved and assist their partners to give breastfeeding to their baby. Furthermore, adequate support from family members, health care professionals, and employers can enable fathers to encourage and help their partners initiate and maintain exclusive breastfeeding. Fathers’ emotional, practical, and physical supports are also important factors that promote successful breastfeeding and enrich the experience of mothers.

Perspectives on Breastfeeding from Mothers with Postpartum Depression Symptoms: A Qualitative Assessment of Antecedents, Barriers, Facilitators, and Intervention Suggestions

Background: Postpartum depression (PPD) is one of the most common birthing complications, and studies negatively associate PPD with breastfeeding initiation and continuation. However, little is known about either the breastfeeding experience of mothers with PPD or what resources mothers need for sustained breastfeeding from their perspectives. This study aimed to identify the antecedents, barriers, and facilitators to breastfeeding for mothers with PPD, understand the relationship between self-efficacy and emergent themes, and generate suggestions to inform supportive interventions. Materials and Methods: Birth mothers who screened positive for PPD and reported breastfeeding were recruited to participate in semistructured interviews. Interviews were transcribed verbatim, and inter-coder discrepancies from double coding were resolved through consensus. Thematic analysis was facilitated using immersion-crystallization methods. Results: Participants identified five antecedent themes that encourage initiation (professional support, infant health, mother's health, cost-effectiveness, and faith), four facilitator themes for sustained breastfeeding (infant connection, decreased stress, personal attributes, and logistical strategies), and seven barrier themes (physical pain, infant nutrition, negative feelings, latching difficulties, medical conditions, public breastfeeding, and sleep). Participants' suggestions fell into three primary themes: supportive services, managing expectations, and respecting self-determination. Conclusion: Antecedent and facilitator themes did not overlap, indicating that factors encouraging breastfeeding initiation differ from sustaining factors. Participant suggestions, barriers, and facilitators did not largely differ from mothers without PPD in other qualitative studies. Therefore, interventions should tailor support to specific breastfeeding phase and may not need to be markedly different for mothers with PPD, in addition to depression management.

Influencers of women's choice and experience of exclusive formula feeding in hospital

OBJECTIVES

Explore what influenced women's decision to exclusively formula feed, and their experiences with formula feeding within a maternity hospital environment.

DESIGN

This mixed methods study used a cross-sectional exploratory survey design. Short surveys were administered by telephone in the postpartum period. Content analysis revealed common themes for responses to open-ended questions on what influenced women's choice and experience with formula feeding. Descriptive statistics were used for demographic characteristics, and frequencies conducted on some themes.

PARTICIPANTS AND SETTING

English-speaking women who chose to exclusively formula feed, and attended a tertiary maternity hospital in Australia were invited to participate; 102 women were interviewed.

FINDINGS

Themes that influenced women to choose exclusive formula feeding were: 'Previous breastfeeding challenges', 'social and societal issues' including convenience, comfort, and trust in formula, and 'maternal health' including medical issues and medications, breast physiology and mental health. Themes from the formula feeding experience in hospital were: 'Supportive' elements such as midwifery care, convenience, and resources, and 'hindering' elements such as a perceived breastfeeding agenda and systemic barriers.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Previous breastfeeding difficulties were a common influence on exclusive formula feeding in subsequent pregnancies, highlighting the importance of adequate support during the primary lactation/infant feeding experience. Greater comfort and confidence levels with formula feeding and a sense of trust in formula were also influential. Some maternal medications, conditions, or physiological circumstances were perceived by women as impacting breastfeeding or breastmilk, signposting the importance of antenatal screening and assessment to support women's options and decisions regarding infant feeding. A perception of professional and organisational preferences for breastfeeding over formula feeding contributed to some women feeling judged for their choice. This reminds midwives to consider the complex intersection of factors that influence infant feeding decisions and ensure all mothers are respected and fully supported.

Subject Matter Experts Identify Health Equity Concerns in Breastfeeding for African American Women

Although the rate of breastfeeding initiation in the United States has continued to rise since 1972, African American mothers continue to experience a significant disparity in initiation. The aim of this study was to explore the perceptions of the facilitators and barriers of breastfeeding initiation among African American mothers from the perspective of subject matter experts (SMEs). This study was part of a larger study that also involved focus group methodology with African American women. The purpose of this article is to describe the opinions, knowledge, and perceptions of SMEs who work with African American mothers. A semistructured interview guide was used to interview 7 SMEs at which point no new themes emerged from the data. SMEs highlighted the significance of modifiable factors in breastfeeding initiation decisions and validated many perceptions of African American mothers. SMEs identified many critical issues foundational to community perspective and shaping future success in raising breastfeeding initiation rates. To increase breastfeeding initiation rates among African American mothers, strategies beyond the individual level are necessary. SMEs recognize the importance of addressing fundamental issues related to historical perspectives, normalization, education, and disparities in breastfeeding as critical.

Pregnant Women's Reports of the Impact of COVID-19 on Pregnancy, Prenatal Care, and Infant Feeding Plans

PURPOSE

The aim of this study is to describe how the COVID-19 (coronavirus) pandemic has affected pregnancy, prenatal maternity care practices, and infant feeding plans among pregnant persons in the United States.

STUDY DESIGN

Cross-sectional descriptive study using an app-based survey.

METHODS

A link to the survey was sent via email to users of the Ovia Pregnancy app on May 20, 2020 and was open for 1 week. Participants were asked to complete the survey as it applied to their pregnancy, breastfeeding, and maternity care received during the COVID-19 pandemic, beginning approximately February 2020 through the time of the survey. There were 258 respondents who completed the survey.

RESULTS

The majority (96.4%; n = 251) of pregnant women felt they received safe prenatal care during this time period. Slightly less 86.3% (n = 215) felt they received adequate prenatal care during this time period. 14.2% (n = 33) reported changing or considering changing the location where they planned to give birth due to COVID-19. Of those who reported they had begun purchasing items for their baby, 52.7% reported that the COVID-19 pandemic has affected their ability to get items they need for their baby.

CLINICAL IMPLICATIONS

Although it is imperative to implement policies that reduce risk of transmission of COVID-19 to pregnant women and health care providers, it is necessary for health care providers and policy makers to listen to the collective voices of women during pregnancy about how COVID-19 has affected their birth and infant feeding plans and their perception of changes in prenatal care.

Women's Perceptions about Breastfeeding: A Preliminary Study

Background: Breastfeeding rates are low in many communities in the United States and require attention to come up with ideas that will help increase breastfeeding. This study investigated the effects of income, age, race and education on mothers’ perceptions about breastfeeding and whose needs and views should be considered in a women’s breastfeeding journey. Methods: A survey was distributed via email and Facebook to 525 participants; 453 participants (86.3%) responded to the survey. Results: Younger adults were more likely to agree that fathers should have some say about breastfeeding. Those earning USD 0–USD 50,000 were more likely to agree relative to those with higher incomes on children being entitled to mother’s milk, and children’s needs over-riding those of others. There was a statistically significant difference by education about women's wishes about breastfeeding being considered more important than those of their spouses. However, there was no statistically significant difference for any demographic group for breastfeeding decisions coming from women only. On women’s breasts being primarily for infant's nutrition, people who earned USD 0–USD 50,000 were more likely to agree relative to those who earned more than USD 50,000; younger adults were significantly more likely to agree. Those who earned USD 0–USD 50,000 were more likely to agree relative to those in other income brackets that extended family members should have input regarding babies being breastfed; minority participants were significantly more likely to agree relative to white participants; those with less than 4-year college education were more likely to agree relative to those with a minimum of four-year college education. Younger adults were more likely to agree that employers must provide extended maternity leave to make it easier for mothers to breastfeed. On women having the right to breastfeed in public places, younger adults were significantly more likely to agree compared to older adults. Conclusion: Women have favorable views about breastfeeding and prefer being in charge about decisions to breastfeed.

Understanding the factors influencing low-income caregivers' perceived value of a federal nutrition programme, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

OBJECTIVE

Retention of participants has been an issue in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). It has been suggested that the perceived value of WIC may affect whether participants remain in the programme. The present study aimed to explore this phenomenon.

DESIGN

Using a constructivist approach, thirty-one individual in-depth interviews were conducted. Transcripts were analysed using constant comparative analysis. Social, cultural and environmental factors that contribute to the value of WIC were explored as the phenomenon of interest.

SETTING

Eight WIC clinics across the State of Illinois, USA.ParticipantsThirty-one caregivers of children enrolled in WIC for at least 6 months.

RESULTS

Several factors influenced perceived value of WIC at the interpersonal (level of social support), clinic (value of WIC services v. programme administration issues), vendor (shopping difficulties), community and systems levels (other programme use, stigma and restrictions on food choice). Other themes existed along continua, which overlapped several levels (continuum of perceived need and perceived value of infant formula).

CONCLUSIONS

Many caregivers value WIC, especially before their child turns 1 year old. Improvements are needed at the clinic, during shopping and within the food packages themselves in order to increase perceived value of WIC.

Factors That Influence Breastfeeding Initiation Among African American Women

OBJECTIVE

To examine cultural and socioenvironmental factors that affect breastfeeding initiation among African American women.

DESIGN

Qualitative descriptive design and conventional content analysis.

SETTING

A large, inner-city, primary care center affiliated with a 500-bed children's hospital within a large, Northeastern U.S. city.

PARTICIPANTS

Participants were 34 U.S.-born African American mothers of healthy term infants 0 to 3 months of age.

METHODS

Six focus groups were conducted using a 16-question, scripted interview guide.

RESULTS

A number of complex factors that influenced breastfeeding initiation included certain cultural beliefs about sexuality, the influence of family and peer networks, information sources, intentions, and a variety of other barriers and facilitators.

CONCLUSION

Our findings suggest that the decision to initiate breastfeeding is not solely determined by the woman within the African American community. Because this decision is contingent on multiple factors external to the woman, it is important to recognize the role that partners, grandmothers, communities, information sources, and health care providers/organizations play in women's decisions. Implementation of multilevel strategies is critical to increase breastfeeding initiation among African American mothers.

A Qualitative Study of Social, Cultural, and Historical Influences on African American Women's Infant-Feeding Practices

The purpose of this study was to describe cultural factors influencing African American mothers' perceptions about infant feeding. Analysis of six focus group discussions of diverse African American mothers yielded sociohistorical factors that are rarely explored in the breastfeeding literature. These factors are events, experiences, and other phenomena that have been culturally, socially, and generationally passed down and integrated into families, potentially influencing breastfeeding beliefs and behaviors. The results from this study illuminate fascinating aspects of African American history and the complex context that frames some African American women's choice about breastfeeding versus artificial supplementation feeding. This study also demonstrates the need for developing family centered and culturally relevant strategies to increase the African American breastfeeding rate.

A multisite audit to assess how women with complex social factors access and engage with maternity services

OBJECTIVE

to audit women with socially complex lives' documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.

BACKGROUND

women living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.

METHOD

data was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.

FINDINGS

non-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.

CONCLUSION

this data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.

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.

Integrative Literature Review of Factors Related to Breastfeeding in African American Women: Evidence for a Potential Paradigm Shift

BACKGROUND

Human milk has widespread health benefits for infants, mothers, and society. However, not all populations of women, particularly African American women, engage in human milk feeding at high rates. Research aim: The purpose of this integrative literature review is twofold: (a) to examine factors that influence low rates of human milk feeding among African American women and (b) to introduce a need for a methodological paradigm shift to develop culturally relevant and effective interventions.

METHODS

The authors searched four electronic social science databases for peer-reviewed journal articles pertaining to human milk among African American women published from 1990 to 2015. Both coauthors independently assessed these articles using thematic analysis and validation. The database search yielded 47 peer-reviewed articles.

RESULTS

Three main themes emerged explaining the human milk feeding disparity: (a) the social characteristics of women likely not to feed human milk (e.g., low socioeconomic status, single); (b) women's perceptions of human milk feeding; and (c) the quality of human milk feeding information provided by health care providers (i.e., limited human milk information).

CONCLUSION

Current literature does include sociohistorical factors that have shaped current norms. Adding sociohistorical frameworks, paying particular attention to the embodied experience of historical trauma, could lead to the development of new evidence-based, culturally sensitive interventions to enhance human milk feeding in the African American community.

Long-Term Breastfeeding in African American Mothers

BACKGROUND

According to the Centers for Disease Control and Prevention, 39.1% of African American infants are breastfed at 6 months. However, few studies have explored the breastfeeding experiences of African American women who successfully breastfeed to 6 months or longer durations. Research aim: The goal of this qualitative study was to explore the long-term breastfeeding experiences of low-income African American women using the positive deviance approach.

METHODS

African American women with breastfeeding experience were recruited through Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) breastfeeding peer counselors. Eligibility criteria included being age 18 or older, currently participating in WIC, and having breastfed one child for at least 6 months in the past 2 years. Semistructured, in-depth interviews were conducted with 11 participants. Interviews were audio-recorded and professionally transcribed. Transcripts were then analyzed for emerging themes using thematic analysis in NVivo software.

RESULTS

Participants had on average three children each, with an average length of breastfeeding of 10.5 months per child. Four main themes developed: (a) deciding to breastfeed, (b) initiating breastfeeding, (c) breastfeeding long-term, and (d) expanding breastfeeding support. Participants offered culturally tailored suggestions to improve breastfeeding support for other African American women: prenatal discussions of breastfeeding with health care providers, African American lactation support personnel and breastfeeding support groups, and African American breastfeeding promotion in print and digital media.

CONCLUSION

Women who participated in this study breastfed for longer durations than the national average for African Americans. Findings can inform practice and research efforts to improve breastfeeding rates in this population using lessons learned from successful women.

Contested moral landscapes: Negotiating breastfeeding stigma in breastmilk sharing, nighttime breastfeeding, and long-term breastfeeding in the U.S. and the U.K

Recent public health breastfeeding promotion efforts have galvanized media debates about breastfeeding in wealthy, Euro-American settings. A growing body of research demonstrates that while breastfeeding is increasingly viewed as important for health, mothers continue to face significant structural and cultural barriers. Concerns have been raised about the moralizing aspects of breastfeeding promotion and its detrimental effects on those who do not breastfeed. Far less, however, is known about the moral experiences of those who pursue breastfeeding. This study draws together research on breastmilk sharing (2012-2016) and nighttime breastfeeding from the U.S. (2006-2009), and long-term breastfeeding from the U.K. (2008-2009) from three ethnographic projects to address this gap. Comparative analysis of these cases reveals that while breastfeeding is considered ideal infant nutrition, aspects of its practice continue to evoke physical and moral danger, even when these practices are implemented to facilitate breastfeeding. Breastmilk sharing to maintain exclusive breastmilk feeding, nighttime breastfeeding and bedsharing to facilitate breastfeeding, and breastfeeding beyond the accepted duration are considered unnecessary, unhealthy, harmful or even deadly. The sexual connotations of breastfeeding enhance the morally threatening qualities of these practices. The cessation of these "problematic" breastfeeding practices and their replacement with formula-feeding or other foods is viewed as a way to restore the normative social and moral order. Mothers manage the stigmatization of these breastfeeding practices through secrecy and avoidance of health professionals and others who might judge them, often leading to social isolation. Our findings highlight the divide between perceptions of the ideal of breastfeeding and its actual practice and point to the contested moral status of breastfeeding in the U.S. and the U.K. Further comparative ethnographic research is needed to illuminate the lived social and moral experiences of breastfeeding, and inform initiatives to normalize and support its practice without stigmatizing parents who do not breastfeed.

Mother's Beliefs, Attitudes, and Decision Making Related to Infant Feeding Choices

All mothers at some point make a decision about whether to breast- or formula feed their infant. Marital status, education, age, culture, and confidence have all been identified as variables affecting this decision. Previous research has concentrated on the decision-making process in breastfeeding mothers. This qualitative descriptive study investigated the beliefs, attitudes, and decisions of both breast- and formula-feeding mothers. Four categories were identified influencing maternal decision making: (a) infant nutritional benefits, (b) maternal benefits, (c) knowledge about infant feeding, and (d) personal and professional support. Analysis of the data indicated that mothers differed in their choice depending on whether they were infant- or maternal-centered and that most women combine both methods of feeding.

Barriers and Contributors to Breastfeeding in WIC Mothers: A Social Ecological Perspective

BACKGROUND

In response to the Surgeon General's Call to Action to Support Breastfeeding, the goal of this research was to assess the barriers and positive contributors to breastfeeding initiation and duration in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants using the social ecological model (SEM).

MATERIALS AND METHODS

A cross-sectional design was used to survey WIC mothers (n = 283) in southern New Hampshire. Analysis of breastfeeding initiation and duration revealed statistically significant results primarily at the individual level of the SEM. Findings also showed influences at the interpersonal, community, and organizational levels. There were significant differences in beliefs toward breastfeeding between women who ever breastfed and women who never breastfed. Women who ever breastfed were more likely to agree that breastfeeding assists with losing baby weight (89% versus 77%; p = 0.03), babies fed breastmilk are less likely to get sick (86% versus 74%; p = 0.04), and breastfeeding helps mothers bond with their babies more quickly than formula feeding (88% versus 72%; p < 0.01). Breastfeeding duration was significantly related to employment status; among women who breastfed for 6 months or longer, 15% were employed full-time, 30% worked part-time, and 55% indicated "other" such as unemployed or stay-at-home mother (p = 0.01). Logistic regression revealed that maternal age was the most significant predictor of breastfeeding duration (odds ratio = 1.11; 95% confidence interval, 1.03, 1.19; p < 0.004).

CONCLUSIONS

Results indicate opportunities to inform and support women in the prenatal and postpartum period, improve the social and built environment, and develop and advocate for policies in an effort to support breastfeeding.

WIC peer counselors' perceptions of breastfeeding in African American women with lower incomes

BACKGROUND

African American women have the lowest breastfeeding rates among all racial/ethnic groups in the United States. Peer counseling is an effective intervention in improving breastfeeding in this population. However, little is known on peer counselors' perceptions of breastfeeding in African American women.

OBJECTIVE

As part of a larger qualitative study, the goal of this study was to understand the contextual factors influencing breastfeeding decisions of low-income African American women from the perspective of breastfeeding peer counselors (PCs).

METHODS

Three focus groups were conducted with 23 PCs from the Women, Infants, and Children program in a southeastern state. All focus group discussions were audio-recorded, professionally transcribed, and analyzed using thematic analysis. Bronfenbrenner's socioecological model was used to group categories into themes.

RESULTS

Of the sample, 47.8% were African American, 78.2% were married, and 56.5% had some college education. Five main themes emerged to describe factors at multiple levels influencing breastfeeding in PCs' low-income African American clients: individual, microsystem, exosystem, macrosystem, and chronosystem. Novel findings included (1) having breast pumps may give African American women a "sense of security," (2) cultural pressures to be a "strong black woman" can impede breastfeeding support, and (3) breastfeeding "generational gaps" have resulted from American "slavery" and when formula was "a sign of wealth."

CONCLUSION

As PCs described, low-income African American women's breastfeeding decisions are affected by numerous contextual factors. Findings from this study suggest a need to broaden the public health approach to breastfeeding promotion in this population by moving beyond individual characteristics to examining historical and sociocultural factors underlying breastfeeding practices in African American women.

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.