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Yu PJ, Wu WR, Liu CY. Public policy on breastfeeding among working mothers in Taiwan: comparison between two national surveys. BMC Pregnancy Childbirth 2023; 23:768. [PMID: 37924019 PMCID: PMC10623794 DOI: 10.1186/s12884-023-06069-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/15/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Creating a supportive breastfeeding environment after childbirth and enabling women to work with reassurance are essential in maternal care services. The study aimed to explore the effectiveness of the utilization rate of public and workplace lactation rooms in relation to the breastfeeding rate among postpartum women returning to work in Taiwan. METHODS The study involved a secondary data analysis on 6,992 and 7,350 postpartum women surveyed in 2011 and 2016, respectively. Interviews were conducted with women six months postpartum. Logistic regression analysis was employed to calculate the odds ratio and investigate the differences in the utilization rates of public lactation rooms (PLR) and workplace lactation rooms (WLR) among working mothers over a five-year period, to confirm the effectiveness of public strategies. RESULTS Comparing the years 2011 and 2016, significant differences in the rates of exclusive breastfeeding (EBF) and any breastfeeding (ABF) among working mothers returning to work after an 8-week maternity leave, depending on whether they used PLR or WLR. The rates were higher in 2016 than in 2011. For mothers who used PLR, the breastfeeding rates for EBF at the second, fourth, and sixth months (2011 vs. 2016: 67.6% vs. 81.1%, 75.0% vs. 86.4%, 77.5% vs. 86.2%) and ABF at the second, fourth, and sixth months (2011 vs. 2016: 60.3% vs. 73.9%, 68.8% vs. 81.3%, 73.7% vs. 85.6%). For mothers who used WLR, the breastfeeding rates for EBF at the second, fourth, and sixth months (2011 vs. 2016: 51.3% vs. 58.7%, 54.7% vs. 61.4%, 57.5% vs. 59.3%) and ABF at the second, fourth, and sixth months (2011 vs. 2016: 48.4% vs. 57.0%, 52.3% vs. 60.5%, 54.1% vs. 62.4%). When comparing 2011 to 2016 from the second to the sixth month postpartum, adjusted odds ratios for EBF (PLR: 4.17-5.23 vs. 4.06-6.22, WLR: 1.71-1.83 vs. 1.30-1.61) and ABF (PLR: 6.44-7.02 vs. 9.27-9.90, WLR: 1.91-1.98 vs. 1.97-1.99) showed differences. CONCLUSION Lactation support rooms play a vital role in motivating working mothers to sustain breastfeeding upon their return to work. Incentivizing businesses to build additional lactation rooms and offering breastfeeding resources is essential in striving to enhance the global breastfeeding rate.
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Affiliation(s)
- Pei-Jung Yu
- Mackay Medical College, New Taipei City, Taiwan, R.O.C
| | - Wan-Ru Wu
- Tzu Chi University, Hualien City, Taiwan R.O.C
| | - Chieh-Yu Liu
- National Taipei University of Nursing and Health Science, Taipei City, Taiwan R.O.C..
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Barasinski C, Stankovic M, Debost-Legrand A, Delabaere A, Vendittelli F, Dutheil F. Workplace Lactation Support: A Cross-Sectional Study in a University Hospital and a Perinatal Network. Nutrients 2022; 14:nu14173463. [PMID: 36079721 PMCID: PMC9460242 DOI: 10.3390/nu14173463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022] Open
Abstract
Return to work negatively affects the initiation and duration of breastfeeding. Our study’s objective was to assess the percentage of departments in Auvergne with an appropriate space for pumping milk at work. Our cross-sectional survey investigated the arrangements for facilitating the continuation of breastfeeding on return to work at all departments at the Clermont-Ferrand University Hospital Center and perinatal (obstetric and pediatric) departments in this region. Our principal endpoint was the percentage of departments reporting that they had a lactation room—a room where nursing mothers can express milk—and whether it met the criteria defined by the French Labor Code. Among 98 respondents, 44 departments (44.9%) did not offer lactation rooms; of the remaining 54 departments, only 11 rooms met the legal requirements. All perinatal departments offered lactation rooms. The availability of a lactation room was associated with other breastfeeding support, such as a break period for expressing milk (p < 0.0001) and the availability of a refrigerator to store it (p = 0.01). Almost half the responding departments did not offer a lactation room where mothers could breastfeed or pump their milk. Measures must be envisioned to facilitate the pumping of breast milk by French women returning to work.
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Affiliation(s)
- Chloé Barasinski
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Centre National de la Recherche Scientifique (CNRS), Institut Pascal, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
- Correspondence: ; Tel.: +33-0-473755089
| | - Marina Stankovic
- School of Midwifery, University of Clermont-Auvergne, F-63000 Clermont-Ferrand, France
| | - Anne Debost-Legrand
- CHU Clermont-Ferrand, CNRS, Institut Pascal, Réseau de Santé en Périnatalité d’Auvergne, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Amélie Delabaere
- Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Centre National de la Recherche Scientifique (CNRS), Institut Pascal, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Françoise Vendittelli
- CHU Clermont-Ferrand, CNRS, Institut Pascal, Réseau de Santé en Périnatalité d’Auvergne, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Frédéric Dutheil
- CNRS, Laboratoire de Psychologie Sociale et Cognitive (LaPSCo), Physiological and Psychosocial Stress, CHU Clermont-Ferrand, Occupational and Environmental Medicine, Université Clermont Auvergne, WittyFit, F-63000 Clermont-Ferrand, France
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What support is needed prior to the designation as baby-friendly hospital? CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2022. [DOI: 10.1016/j.cegh.2022.101045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Using a lactation room at the workplace is associated with longer breastfeeding duration in working mothers. NUTR HOSP 2021; 37:918-925. [PMID: 32960635 DOI: 10.20960/nh.03242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction IIntroduction: maternal employment after childbirth is associated with abandonment of breastfeeding; however, lactation rooms in the workplace increase the practice of breastfeeding. Objective: to compare the frequency and duration of breastfeeding among working mothers based on the presence of lactation rooms in their workplaces. Methods: we included mothers from different institutions whose infants were between 6 and 35 months (n = 158), and an ad hoc questionnaire was applied to assess breastfeeding, exclusive breastfeeding (EBF), partial breastfeeding (PBF), and use of human milk substitutes (HMS). Two groups were compared: working mothers with a lactation room at their workplace (n = 76) versus working mothers without this resource (n = 82). Results: breastfeeding duration (7.5 vs. 5.0 months, p < 0.001) and EBF (3.0 vs. 1.2 months, p = 0.005) were higher in mothers who had a lactation room. HMS use was shorter in mothers who had a lactation room (2.5 vs. 10.0 months, p = 0.001). There were more working mothers who breastfed for more than six months (75.0 % vs. 48.8 %) [OR = 3.15 (95 % CI, 1.60-6.19), p = 0.001] and 12 months (31.6 % vs. 14.6 %) [OR = 2.69 (95 % CI, 1.23-5.87), p = 0.014] when lactation rooms were available in their workplaces. Conclusion: the presence of a lactation room in the workplace was associated with a higher frequency and duration of breastfeeding.
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Romijn M, van Tilburg LJL, Hollanders JJ, van der Voorn B, de Goede P, Dolman KM, Heijboer AC, Broekman BFP, Rotteveel J, Finken MJJ. The Association between Maternal Stress and Glucocorticoid Rhythmicity in Human Milk. Nutrients 2021; 13:nu13051608. [PMID: 34064929 PMCID: PMC8151700 DOI: 10.3390/nu13051608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/02/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic stress is often accompanied by alterations in the diurnal rhythm of hypothalamus–pituitary–adrenal activity. However, there are limited data on the diurnal rhythmicity of breast milk glucocorticoids (GCs) among women with psychological distress. We compared mothers who sought consultation at an expertise center for pregnant women with an increased risk of psychological distress with control mothers for GC diurnal rhythmicity in milk and saliva obtained at the same time. Methods: We included 19 mothers who sought consultation at the psychiatry–obstetric–pediatric (POP) outpatient clinic and 44 control mothers. One month postpartum, mothers collected on average eight paired milk and saliva samples during a 24 h period. GC levels were measured using liquid chromatography–tandem mass spectrometry. GC rhythmicity parameters were determined with specialized software. Results: For both milk and saliva, no group differences regarding GC rhythms were found. Milk cortisol area under the curve with respect to the ground was lower in the POP group than in the control group (p = 0.02). GC levels in human milk and saliva were highly correlated within each group (p < 0.001). Conclusion: Although there were no differences between groups in GC rhythmicity, the total amount of milk cortisol was lower in the POP group. Long-term follow-up is needed to address the impact of vertical transmission of breast milk GCs.
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Affiliation(s)
- Michelle Romijn
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location VUmc, 1081 HV Amsterdam, The Netherlands; (L.J.L.v.T.); (J.J.H.); (J.R.); (M.J.J.F.)
- Department of Pediatrics, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-(0)20-444-3137
| | - Luca J. L. van Tilburg
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location VUmc, 1081 HV Amsterdam, The Netherlands; (L.J.L.v.T.); (J.J.H.); (J.R.); (M.J.J.F.)
| | - Jonneke J. Hollanders
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location VUmc, 1081 HV Amsterdam, The Netherlands; (L.J.L.v.T.); (J.J.H.); (J.R.); (M.J.J.F.)
| | - Bibian van der Voorn
- Department of Pediatrics, Division of Endocrinology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Paul de Goede
- Laboratory of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, 1105 AZ Amsterdam, The Netherlands;
| | - Koert M. Dolman
- Department of Pediatrics, Onze Lieve Vrouwe Gasthuis (OLVG), 1006 AE Amsterdam, The Netherlands;
| | - Annemieke C. Heijboer
- Department of Clinical Chemistry, Endocrine Laboratory, Vrije Universiteit Amsterdam, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands;
| | - Birit F. P. Broekman
- Department of Psychiatry, VU University Medical Centre, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands;
| | - Joost Rotteveel
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location VUmc, 1081 HV Amsterdam, The Netherlands; (L.J.L.v.T.); (J.J.H.); (J.R.); (M.J.J.F.)
| | - Martijn J. J. Finken
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Centers, location VUmc, 1081 HV Amsterdam, The Netherlands; (L.J.L.v.T.); (J.J.H.); (J.R.); (M.J.J.F.)
- Department of Pediatrics, Amsterdam Reproduction & Development Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, 1081 HV Amsterdam, The Netherlands
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Female Employees' Perception of Breastfeeding Support in the Workplace, Public Universities in Spain: A Multicentric Comparative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176402. [PMID: 32887489 PMCID: PMC7504108 DOI: 10.3390/ijerph17176402] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite scientific recommendations for exclusive breastfeeding until 6 months of age and complementary breastfeeding to 2 years of age, breastfeeding abandonment rates increase with time, and one of the main reasons is that women go back to work. AIM To analyze the perception of support of breastfeeding workers to continue breastfeeding at two Spanish universities, and associated factors. METHODS A multicenter retrospective cross-sectional comparative study conducted in a population of 777 female workers at the Universidad de Sevilla (US) and the Universitat Jaume I (UJI) in Spain using an online questionnaire. RESULTS The response rate was 38.74% (n = 301). Of all the participants, 57.8% continued breastfeeding after returning to work. The factors associated with continuing breastfeeding for longer were the university having a breastfeeding support policy and special accommodation (p < 0.001); participating in breastfeeding support groups (p < 0.001); intending to continue breastfeeding after returning to work (p < 0.001); knowing the occupational legislation in force (p = 0.009); having a female supervisor (p = 0.04). CONCLUSION Breastfeeding support initiatives and having special accommodation to pump and preserve breast milk after returning to work are associated with a longer duration of female workers' breastfeeding.
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Leon-Larios F, Pinero-Pinto E, Arnedillo-Sanchez S, Ruiz-Ferron C, Casado-Mejia R, Benitez-Lugo M. Female employees' perception of breastfeeding-friendly support in a public university in Spain. Public Health Nurs 2019; 36:370-378. [PMID: 30740776 DOI: 10.1111/phn.12590] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 01/03/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To explore women's experience with continuing breastfeeding when they returned to work. DESIGN AND SAMPLE A cross-sectional study was conducted. Participants were female employees at the University of Seville who gave birth in the last 10 years while working at University. MEASURES A questionnaire in Spanish was used to collect information on sociodemographic variables, employment characteristics, continued breastfeeding behavior after returning to work and the dimensions of the validated scale the Workplace Breastfeeding Support Scale (WBSS). RESULTS A total of 197 women responded, consisting of 53.8% faculty and 46.2% administrative staff. Almost all the women had breastfed their children (92.9%). The proportion of women who continued to breastfeed after they returned to work was 51.3%. The main reason given for interrupting lactation was the challenge of reconciling family and work (53.1%). Faculty members took more breaks for breastfeeding (p = 0.002) and were able to arrange their breaks more easily (p < 0.001). Since it was easier for them to find a quiet place to pump breast milk (p = 0.025), they were more likely to continue breastfeeding after returning to work than were administrative staff (59.8% vs. 41.1%, p < 0.009). CONCLUSION A designated lactation space and amenities should be provided in order to extend the duration of breastfeeding.
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Affiliation(s)
- Fatima Leon-Larios
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
| | - Elena Pinero-Pinto
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
| | | | - Cecilia Ruiz-Ferron
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
| | - Rosa Casado-Mejia
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
| | - Marisa Benitez-Lugo
- Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, Seville, Spain
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Steurer LM. Maternity Leave Length and Workplace Policies' Impact on the Sustainment of Breastfeeding: Global Perspectives. Public Health Nurs 2017; 34:286-294. [PMID: 28295576 DOI: 10.1111/phn.12321] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Breastfeeding is a global initiative of the World Health Organization and the U.S. domestic health agenda, Healthy People 2020; both recommend exclusive breastfeeding, defined as providing breast milk only via breast or bottle, through the first 6 months of an infant's life. Previous literature has shown the correlation between socioeconomic status and breastfeeding, with higher maternal education and income as predictors of sustained breastfeeding. This same population of women is more likely to be employed outside the home. METHODS PubMed and the Cochrane Database of Systematic Reviews were searched using inclusion and exclusion criteria to identify the effect of maternity leave length and workplace policies on the sustainment of breastfeeding for employed mothers. RESULTS Common facilitators to sustainment of breastfeeding included longer length of maternity leave as well as adequate time and space for the pumping of breast milk once the mother returned to the workplace. Barriers included inconsistency in policy and the lack of enforcement of policies in different countries. CONCLUSIONS There is a lack of consistency globally on maternity leave length and workplace policy as determinants of sustained breastfeeding for employed mothers. A consistent approach is needed to achieve the goal of exclusive breastfeeding for infants.
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Affiliation(s)
- Lisa M Steurer
- School of Nursing and Health Studies, University of Missouri-Kansas City, St. Louis, Missouri
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EFFECT OF ANTENATAL LACTATION COUNSELLING AND POSTNATAL LACTATION SUPPORT IN IMPROVING BREASTFEEDING INITIATION RATES AND EXCLUSIVE BREASTFEEDING IN LESS EDUCATED MOTHERS OF RURAL AREA OF CHANDU- BUDHERA. ACTA ACUST UNITED AC 2017. [DOI: 10.14260/jemds/2017/219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Dun-Dery EJ, Laar AK. Exclusive breastfeeding among city-dwelling professional working mothers in Ghana. Int Breastfeed J 2016; 11:23. [PMID: 27602050 PMCID: PMC5012076 DOI: 10.1186/s13006-016-0083-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 08/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background In Ghana, periodic national surveys report the practice of exclusive breastfeeding (EBF) in the general population to be over 50 %. However, little is known about EBF among professional working mothers, particularly its duration after maternity leave. Female workers are entitled to 12 weeks (84 days) of maternity leave with full pay in Ghana, and this can be extended by two additional weeks in case of a caesarean or abnormal delivery. This study assessed the prevalence of EBF, as well as factors associated with the practice among professional working mothers in one of the ten regional capitals of Ghana. Methods The study was descriptive cross-sectional in design and employed a multi-stage sampling technique to sample 369 professional working mothers. The study was planned and implemented between January to July 2015. Study-specific structured questionnaires were used in the data collection over a period of one month. Some factors including demographic characteristics, types of facilities available at workplace to support breastfeeding, challenges to exclusive breastfeeding at the workplace and mother’s knowledge base on EBF, were assessed. Exclusive breastfeeding is defined as feeding infants with only breast milk, without supplemental liquids or solids except for liquid medicine and vitamin or mineral supplements. Results There was a near universal awareness of exclusive breastfeeding among respondents (99 %). Even though most mothers initiated breastfeeding within an hour of delivery (91 %), the EBF rate at six months was low (10.3 %). The study identified three elements as determinants of EBF; Those who did not receive infant feeding recommendation from health workers were less likely to practice exclusive breastfeeding (Adjusted Odds Ratio [AOR] 0.45; 95 % Confidence Interval [CI] 0.27, 0.77), mothers who had shorter duration of maternity leave were less likely to practice exclusive breastfeeding (AOR 0.09; 95 % CI 0.02, 0.45), and those who had a normal delivery were almost 10 times as likely to practice exclusive breastfeeding (AOR 9.02; 95 % CI 2.85, 28.53). Conclusion Given the high breastfeeding initiation, but low EBF continuation rate among professional working mothers, improved policies around maternity leave and breastfeeding friendly work environments are needed.
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Affiliation(s)
- Elvis J Dun-Dery
- Department of Population, Family and Reproductive Health, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Amos K Laar
- Department of Population, Family and Reproductive Health, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
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Breast-feeding perceptions, beliefs and experiences of Marshallese migrants: an exploratory study. Public Health Nutr 2016; 19:3007-3016. [PMID: 27230629 DOI: 10.1017/s1368980016001221] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine perceptions, beliefs and experiences affecting breast-feeding in Marshallese mothers residing in Northwest Arkansas, USA. DESIGN A qualitative, exploratory study using a brief survey and focus groups. Marshallese women, 18 years or older who had a child under 7 years of age, were included in the study. SETTING Community-based organization in Northwest Arkansas. RESULTS The majority of mothers viewed breast milk as superior to formula, but had concerns about adequate milk supply and the nutritional value of their milk. The primary barriers to exclusive breast-feeding in the USA included public shaming (both verbal and non-verbal), perceived milk production and quality, and maternal employment. These barriers are not reported in the Marshall Islands and are encountered only after moving to the USA. Breast-feeding mothers rely heavily on familial support, especially the eldest female, who may not reside in the USA. The influence of institutions, including the Special Supplemental Nutrition Program for Women, Infants, and Children, is strong and may negatively affect breast-feeding. CONCLUSIONS Despite the belief that breast milk is the healthiest option, breast-feeding among Marshallese mothers is challenged by numerous barriers they encounter as they assimilate to US cultural norms. The barriers and challenges, along with the strong desire to assimilate to US culture, impact Marshallese mothers' perceptions, beliefs and experiences with breast-feeding.
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Affiliation(s)
- Rafael Pérez-Escamilla
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Dan Sellen
- University of Toronto, Dalla Lana School of Public Health, Toronto, Canada
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