Overcoming Workplace Barriers: A Focus Group Study Exploring African American Mothers' Needs for Workplace Breastfeeding Support

In Support of Breast-/Chestfeeding by People With HIV in High-Income Settings

Given that HIV can be transmitted through breastfeeding, historically, breastfeeding among women with HIV in the US and other resource-rich settings was discouraged. Formula feeding was the mandated feeding option out of concern for breast-milk transmission of HIV, which occurred in 16-24% of cases pre-antiretroviral therapy (pre-ART) use. In January 2023, the US Department of Health and Human Services' Perinatal Guidelines were revised to support shared decision-making for infant feeding choices. Updated clinical trials' data from resource-limited settings suggest the actual breastmilk HIV transmission rate in the context of maternal ART or neonatal postexposure prophylaxis is 0.3-1%. High-income countries are reporting more people with HIV breastfeeding their infants without cases of HIV transmission. We present the reasons for fully embracing breast-/chestfeeding as a viable, safe infant feeding option for HIV-exposed infants in high-income settings, while acknowledging unanswered questions and the need to continually craft more nuanced clinical guidance.

Barriers and facilitators to expressing milk on campus as a breastfeeding student

Objective: Despite the growing student parent population, many postsecondary institutions in the United States (U.S.) lack sufficient lactation policies for students. The objective of this study was to explore breastfeeding students' perceived awareness and use of on-campus lactation rooms and identify barriers and facilitators to expressing milk on campus.Participants:A convenience sample of breastfeeding students enrolled in colleges/universities in the U.S.Methods:Information about students' experiences expressing milk on campus was collected via an online survey. Thematic analysis was used to qualitatively analyze self-reported barriers/facilitators to expressing.Results:Ninety-three participants representing 68 unique institutions completed the survey. Barriers to expressing on campus included inadequate lactation spaces, lack of storage for breast pump equipment/expressed milk, and lack of time to express. Conversely, access to adequate lactation spaces, having appropriate breast pump equipment, and on-campus social support, were important facilitators.Conclusion:Comprehensive lactation policies may improve on-campus breastfeeding experiences among students.

Breastfeeding Social Support Among African American Women in the United States: A Meta-Ethnography

BACKGROUND

In the United States, there are racial disparities in 6 months of exclusive breastfeeding. Only, 25.8% of American infants were breastfed for the first 180 days of life, with African American infants least (19.8%) exclusively breastfed in 2018.

PURPOSE

The meta-ethnography explored the breastfeeding support for African American women in the United States.

DATA SOURCES

The online databases of American Psychological Association, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Scopus were searched with key words, and the search was not limited by the year of publication.

STUDY SELECTION

The inclusion criteria for the study selection entailed all qualitative studies conducted on breastfeeding support among self-identified African American women in the United States, written in English language, peer reviewed, or dissertation. The initial search produced 905 articles of which 8 met the eligibility criteria.

DATA EXTRACTION

Data extraction and analysis were guided by Noblit and Hare's (1988) meta-ethnography approach. The analysis process was completed by a team of researchers, inclusive of breastfeeding experts.

RESULTS

Five overarching themes emerged including trustworthy information; early postpartum support by key influencers; maternal culture; tangible resources, and Black mothers' empowerment.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Social support is a major determinant for the initiation and continuation of breastfeeding among African American women in the United States. Future longitudinal studies are warranted to explore the social support of breastfeeding among African American women in the United States.

Racial Differences in Breastfeeding on the Mississippi Gulf Coast: Making Sense of a Promotion-Prevalence Paradox with Cross-Sectional Data

Breastfeeding is less prevalent among African American women than their white peers. Moreover, breastfeeding rates in the South lag behind those in other regions of the U.S. Consequently, various efforts have been undertaken to promote breastfeeding among groups for which this practice is less common. This study examines African American and white racial disparities concerning (1) exposure to breastfeeding promotional information and (2) reported prevalence of breastfeeding in primary social networks. The survey combines a randomly selected sample of adults representative of the population and a non-random oversample of African Americans in a predominantly rural tri-county area on the Mississippi Gulf Coast. An initial wave of 2019 Mississippi REACH Social Climate Survey data collected under the auspices of the CDC-funded REACH program (Mississippi's Healthy Families, Mothers, and Babies Initiative; 2018-2023) is used to examine racial disparities in these two key outcomes for Mississippians in Hancock, Harrison, and Jackson counties. The results show that African American respondents are more likely to be exposed to breastfeeding promotional messages than their white counterparts. However, the reported prevalence of breastfeeding in African American respondents' primary social networks is significantly lower than that indicated by their white peers. These paradoxical results underscore the limitations of promotional efforts alone to foster breastfeeding. While breastfeeding promotion is important, the reduction of racial disparities in this practice likely requires a multi-pronged effort that involves structural breastfeeding supports (e.g., lactation spaces, peer networking groups, and pro-breastfeeding employment policies and workplaces). This study provides a promising model of innovative methodological approaches to the study of breastfeeding while underscoring the complex nature of racial disparities in lactation prevalence.

Pandemic policies and breastfeeding: A cross-sectional study during the onset of COVID-19 in the United States

The United States is one of the few countries, and the only high-income country, that does not federally mandate protection of postpartum employment through paid postpartum maternity and family leave policies. At the onset of the COVID-19 pandemic in the U.S., stay-at-home orders were implemented nationally, creating a natural experiment in which to document the effects of de facto paid leave on infant feeding practices in the first postpartum year. The purpose of this cross-sectional, mixed-methods study was to describe infant and young child feeding intentions, practices, decision-making, and experiences during the first wave of the COVID-19 pandemic in the U.S. Quantitative and qualitative data were collected March 27-May 31, 2020 via online survey among a convenience sample of respondents, ages 18 years and older, who were currently feeding a child 2 years of age or younger, yielding 1,437 eligible responses. Nearly all (97%) respondents indicated an intention to feed their infant exclusively with human milk in the first 6 months. A majority of respondents who were breastfeeding (66%) reported no change in breastfeeding frequency after the implementation of COVID-19 stay-at-home orders. However, thirty-one percent indicated that they breastfed more frequently due to stay-at-home orders and delayed plans to wean their infant or young child. Key themes drawn from the qualitative data were: emerging knowledge and perceptions of the relationship between COVID-19 and breastfeeding, perceptions of immune factors in human milk, and the social construction of COVID-19 and infant and young child feeding perceptions and knowledge. There were immediate positive effects of stay-at-home policies on human milk feeding practices, even during a time of considerable uncertainty about the safety of breastfeeding and the transmissibility of SARS-CoV-2 via human milk, constrained access to health care services and COVID-19 testing, and no effective COVID-19 vaccines. Federally mandated paid postpartum and family leave are essential to achieving more equitable lactation outcomes.

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.

Returning to Work and Breastfeeding Duration at 12 Months, WIC Infant and Toddler Feeding Practices Study-2

Background: Returning to work can impact breastfeeding duration; limited data exist on how this may impact a lower income population. Methods: Data from U.S. Department of Agriculture's longitudinal study WIC Infant and Toddler Feeding Practices Study-2 were used to assess breastfeeding duration (<12 versus ≥12 months) by age of the baby when women first returned to work and work status (full time and part time). Multivariable logistic regression was used to determine the association of the timing of return to work, work status, and the combination (timing and work status) with breastfeeding duration. Results: Among women who had worked prenatally and initiated breastfeeding, 20.2% breastfed for ≥12 months. Compared to women who did not return to work, fewer women breastfed for ≥12 months if they returned full time or part time (34.1%, 12.0%, and 20.0%, respectively, p < 0.0001). Work status negatively impacted breastfeeding for ≥12 months (full-time adjusted odds ratio [aOR]: 0.24; 95% confidence interval [CI]: 0.13, 0.44 and part-time aOR: 0.51; 95% CI: 0.31, 0.83). Compared to women who did not return, those who returned full time within 3 months or returned part time >1 to 3 months after birth had lower odds of breastfeeding ≥12 months. Conclusions: Returning to work within 3 months after birth had a negative impact on breastfeeding for ≥12 months, particularly for those who returned full time. Efforts to support maternity leave and flexible work schedules could prolong breastfeeding durations among a low-income population. This study was a registered study at clinicaltrials.gov (NCT02031978).

Women's and Employers' Experiences and Views of Combining Breastfeeding with a Return to Paid Employment: A Systematic Review of Qualitative Studies

INTRODUCTION

Returning to paid employment is one of the reasons women stop breastfeeding earlier than they planned to. This systematic review aimed to provide insight into the experiences and views of women and employers on breastfeeding and returning to paid employment, with findings used to inform practice and policy.

METHODS

The review was guided by the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. Medline, CINAHL, PsycINFO, and Web of Science databases were searched for studies published in English. JBI's meta-aggregative approach informed data analysis. The studies in this analysis included women who stopped breastfeeding before, and those who continued breastfeeding after, returning to paid employment and the employers, work managers, or supervisors of women who continued breastfeeding after returning to paid employment.

RESULTS

Twenty-six articles presenting findings from 25 studies were included and critically appraised. Synthesized findings showed that women experienced physical and emotional difficulties and described gender and employment inequalities in accessing and receiving the support they needed. Women reported that the importance of their own motivation and having workplace legislation in place facilitated breastfeeding during employment. Support from employers, colleagues, and family members, as well as access to convenient child care, helped women continue breastfeeding on return to paid employment. Employers' personal experiences influenced their views on breastfeeding and working, and the need for more education and communication between employers and employers on breastfeeding in the workplace was recognized.

DISCUSSION

Support from family, work colleagues, and employers was important to reduce the physical and emotional challenges women experienced when combing breastfeeding with return to paid employment. Gender inequalities, especially in low- and middle-income countries, in accessing support exacerbated the difficulties women experienced. Limited data were identified regarding employers' experiences and views, suggesting an urgent need for further research to explore employers' and work colleagues' experiences and views.

The effect of vernix caseosa in preventing nipple problems among early postpartum women: A randomized-controlled single-blind clinical trial☆

BACKGROUND AND PURPOSE

Vernix caseosa, a natural substance similar to mother's milk with protective effects on the skin, might be effective in preventing nipple problems. The purpose of this study was to examine the potential efficacy of vernix caseosa compared to the conventional use of mother's milk in the prevention of postpartum nipple problems.

MATERIALS AND METHODS

This randomized, controlled, single-blind experimental study involved 64 primipara mothers who underwent cesarean section and were randomly and equally divided between the vernix caseosa group and the mother's milk group. All mothers received nipple care four times daily during the first postpartum week. Data were collected using personal information and nipple monitoring forms.

RESULTS

The incidence of nipple pain, rashes, and an abnormal appearance was similar in both groups on the first day postpartum (p = 0.132, p = 0.516, and p = 0.132, respectively), and none of the mothers had nipple cracks. On the seventh day, mothers in the vernix caseosa group had significantly less pain (p = 0.042), significantly reduced rash (p = 0.048), significantly higher satisfaction (p = 0.023), and no nipple cracks.

CONCLUSION

Nipple care with vernix caseosa is more effective than with mother's milk in preventing postpartum nipple pain, rashes, and cracks.

An Intergenerational Exploration of Breastfeeding Journeys Through the Lens of African American Mothers and Grandmothers

BACKGROUND

Many individuals comprise a nursing mother's social support network. Grandmothers within African American families, historically, have played a vital role in the transmission of culture. Understanding intergenerational perspectives within African American families related to infant feeding and scholarship about breastfeeding is critical, given the breastfeeding patterns among African American women.

RESEARCH AIM

To describe intergenerational perspectives within African American families, where the mother has successfully breastfed.

METHODS

A prospective, cross-sectional, qualitative design using semi-structured interviews was used. African American nursing mothers and maternal grandmothers (N = 14) residing in the Metro-St. Louis area, who reflected economic and educational diversity, were recruited. Inductive and iterative data analysis, framed by Black Feminist Theory allowed for emerging patterns reflecting the participants' voices.

RESULTS

Three of the six (50%) grandmother participants had breastfed. The majority of the mother participants were married (n = 5; 62.5%) and had a college degree (n = 4; 50.0%) or a high school diploma (n = 1; 12.5%); and four (50.0%) had received the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Three patterns emerged: (a) intergenerational connections; (b) changes in breastfeeding experiences over time; and (c) going with the flow (referring to the choice to work within the constraints of one's circumstances). Grandmothers supported mothers' breastfeeding decisions; grandmothers who had breastfed benefited from the updated information the mothers provided; and grandmothers who did not breastfeed acquired new breastfeeding knowledge, which informed the ways they supported the mothers.

CONCLUSION

The intergenerational perspectives surrounding breastfeeding within African American families participating in this study offer future research directions.

Communities and employers show a high level of preparedness in supporting working mothers to combine breastfeeding with work in rural Kenya

Community Readiness Model (CRM) through pragmatic mixed methods design, combining quantitative CRM survey with qualitative data, was used to assess the level of preparedness and readiness among local leaders, employers and community members in supporting working mothers to combine breastfeeding with work. The study was conducted in one of the tea state farms in Kericho County of Kenya. A total of 17 purposively selected men (fathers), lactating mothers, peer educators, health professionals (doctors, nurses and nutritionists), tea plantation managers and grandmothers were interviewed. The CRM that has six different dimensions was applied to determine the stage of readiness to support working mothers to combine breastfeeding with work. Community Readiness Score (CRS) was calculated descriptively as mean ± standard deviation (SD). Thematic analysis using NVIVO software was used to analyse qualitative data. We found that the mean (±SD) CRS was 7.3 (1.9), which corresponded to the third highest level of the nine stages or the ‘stabilization’ stage of community readiness. Dimensionally, the mean CRS was the highest (8.3 ± 1.9) for leadership followed by community efforts (7.5 ± 2.1), whereas the lowest CRS was observed for knowledge of efforts (6.6 ± 2.3) and availability of resources (6.6 ± 1.9). In conclusion, high level of readiness to support working women to combine work with breastfeeding with suboptimal knowledge of efforts and availability of resources was observed in the area. Future interventions should focus on enabling the community to feel more comfortable and creating detailed and refined knowledge on combining breastfeeding with work.

Racial Disparities in Sustaining Breastfeeding in a Baby-Friendly Designated Southeastern United States Hospital: An Opportunity to Investigate Systemic Racism

Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to many factors-historical roles, cultural norms, lack of social support, and systemic racism in the health care and lactation support system. The Baby-Friendly Hospital Initiative (BFHI) is an evidence-based program to increase breastfeeding through standardized protocols, and, in a Southeastern U.S. academic center, it was associated with increased breastfeeding, but the effect on racial disparities in breastfeeding was unknown. Methods: Through an institutional Perinatal Information Systems database, breastfeeding rates were compared before and after BFHI implementation. Breastfeeding initiation, sustained breastfeeding 24-hours before discharge, and patient demographics were assessed. Results: After BFHI implementation, mothers were overall 1.17 (95% confidence interval: 1.13-1.19) times more likely to initiate breastfeeding. For Black mothers, breastfeeding initiation increased significantly from 52% to 66%, but they were significantly less likely to sustain in-hospital breastfeeding compared to nonBlack mothers (69.4% versus 84.6%, p < 0.0001). Several demographic and medical comorbidities were significantly associated with failure to sustain breastfeeding to hospital discharge. When controlling for these factors, the racial disparity persisted. Conclusions: Since BFHI implementation, the racial gap in breastfeeding initiation decreased, but a significant disparity remained for sustained in-hospital breastfeeding. This study highlights the success of the BFHI program, but in the context of the current literature, also reveals the need for further work to ensure interventions are culturally competent and delivered equitably to support sustained breastfeeding for Black women.

Effectiveness of a breastfeeding program for mothers returning to work in Japan: a quasi-experimental study

BACKGROUND

Maternal employment has been described as a barrier to breastfeeding in many countries. In Japan, many mothers quit breastfeeding after returning to work because they do not know how to continue breastfeeding. The primary objective of this study was to investigate the effectiveness of a breastfeeding support program for mothers. The secondary objective was to explore the effectiveness of a pamphlet for mothers returning to work.

METHODS

This was a quasi-experimental design study with a program group (n = 48), pamphlet group (n = 46) and comparison group (n = 47) that took place from February 2017 to August 2018. Participants in the program and pamphlet groups were women who planned to return to work within 4-12 months after giving birth, while the comparison group included women who had been back at work for at least 3 months. The program involved a 90-min breastfeeding class, a pamphlet, a newsletter, and email consultation. The pamphlet group was sent only the pamphlet, while the comparison group received no intervention. The outcome was breastfeeding continuation rate at 3 months after returning to work.

RESULTS

The breastfeeding continuation rate 3 months after returning to work was significantly higher in the program group than in the comparison group (79.2% vs. 51.1%, p = 0.004). After adjusting for background factors, the program intervention had an effect on breastfeeding rates (adjusted odds ratio = 4.68, 95% confidence interval: 1.57, 13.96; p = 0.006). However, comparing the pamphlet and comparison groups revealed no significant differences in breastfeeding continuation rates at 3 months after returning to work (69.6% vs. 51.1%, p = 0.07).

CONCLUSIONS

Program intervention was associated with a significant increase in breastfeeding continuation rates 3 months after returning to work. Randomized controlled trials are needed to make this program applicable in practice. Pamphlet intervention resulted in no significant difference. Further study is necessary after examining the contents of the pamphlet.

Breastfeeding practices after a counselling intervention for factory workers in Bangladesh

Breastfeeding may be particularly challenging for female factory workers who have long working hours and inadequate access to health information and care. In Chattogram, Bangladesh, a peer counselling intervention was undertaken to improve infant feeding practices of factory workers. Counselling started during pregnancy and continued until children were 18 months old. This article presents the results of a cross‐sectional survey undertaken during 2 weeks in March–April 2017, after the project's conclusion. The aim was to compare breastfeeding practices, specifically early breastfeeding initiation and exclusive breastfeeding (EBF), among factory workers who had received peer counselling in the intervention areas (IA) with those of non‐counselled factory workers in the nearby comparison areas (CA). Six female interviewers, trained over 3 days, conducted interviews at the workers' homes. Data were analysed to assess the association of peer counselling with infant feeding practices. Factory workers (N = 382) with infants between 0 and 18 months of age participated in the survey, in IA (n = 188) and in CA (n = 194). Although there were more health facility deliveries among the CA workers, only 43 (22%) of those workers had initiated breastfeeding within 1 h of birth versus 166 (88%) of the IA workers (p < .001). EBF prevalence on 24‐h recall in infants aged 0–6 months was only 7/83 (8%) for the CA workers versus 73/75 (97%) for IA workers (p < .001). The survey showed that breastfeeding practices of factory workers in the IA after the intervention were significantly better than those of factory workers in the CA.

Prevalence of exclusive breastfeeding among mothers in the informal sector, Kampala Uganda

Exclusive breastfeeding (EBF) for the first six months of life is effective in preventing infant morbidity and mortality. However, 36% of Ugandan children below 6 months are not breastfed exclusively despite its active promotion. This study determined the prevalence and factors associated with exclusive breastfeeding among mothers working in the informal sector in Kampala district. A community based cross-sectional study targeting 428 interviews with mothers with children aged 0–5 months was conducted. Analysis was done using modified Poisson regression in Stata version 14. The prevalence of exclusive breastfeeding was 42.8%. The factors associated with exclusive breastfeeding included: attending antenatal care at least 4 times (APR = 1.24; 95% CI: 1.01–1.51), intention to exclusively breastfeed for 6 months (APR = 1.26; 95% CI: 1.01–1.57) or longer (APR = 1.38; 95% CI: 1.06–1.76), proper breastfeeding practices (APR = 4.12; 95% CI: 2.88–5.90), age of the infant (APR = 0.78; 95% CI: 0.65–0.94) and (APR = 0.48; 95% CI: 0.39–0.60) for children aged 2–3 and 4–5 months respectively and working in a lower position (APR = 0.68; 95% CI: 0.55–0.83). Mothers should be encouraged to attend antenatal care where they learn about the benefits of exclusive breastfeeding to children below 6 months hence enabling them to make informed decisions about exclusive breastfeeding. The government of Uganda should ensure maternity leave benefits of the employment act are enforced in the informal sector to allow women to practice EBF.

Supporting Exclusive Breastfeeding Among Factory Workers and Their Unemployed Neighbors: Peer Counseling in Bangladesh

BACKGROUND

Thirty-six percent of females are employed in Bangladesh, many in the readymade garments manufacturing industry. Inadequate access to health information, care, and long working hours makes exclusive breastfeeding particularly challenging for these employed mothers.

RESEARCH AIM

To describe the influence of a breastfeeding education and support program on breastfeeding patterns of mothers working in garment and other factories in Bangladesh.

METHODS

A descriptive two-group prospective, mixed methods, longitudinal prospective study was conducted from May 2015 to March 2017. Peer counselors were trained to provide home-based counseling from 6 months of pregnancy until infants completed 6 months for pregnant and lactating factory workers and neighboring unemployed women. The total evaluation sample (N = 304) consisted of participants still employed (n = 190) and unemployed (n = 144). Peer counselors recorded socioeconomic information, weights, and infant feeding patterns. Descriptive statistical analyses examined the peer counselors' influence on breastfeeding practices.

RESULTS

Initiation of breastfeeding within 1 hr was high in both groups, 173 (91%) among the employed, and 101 (89%) among the unemployed participants. Exclusive breastfeeding at 6 months was reported by 107 out of 125 (86%) of the employed participants versus 72 out of 76 (95%) of those unemployed.

CONCLUSIONS

Community-based peer counselors can help to inform, encourage, and support both factory workers and unemployed women with optimal breastfeeding patterns. Factories who have female workers should consider employing outreach peer counselors as part of their community social responsibility, and as a way to contribute to the sustainability of these programs.

The individual focus of nursing research in breastfeeding: Perpetuating a neoliberal perspective

In this paper, I argue for the need to shift the focus of nursing research regarding breastfeeding from that of individual responsibility to include a more system-focused, population health approach. In the 2011, "Call to Action to Support Breastfeeding," the U.S. Surgeon General called attention to the pervasive disparities in breastfeeding outcomes in the United States. A plethora of nursing research exists aimed at addressing these disparities; however, this research leans toward a neoliberal perspective, mainly focusing on individual factors and failing to address the systemic inequities contributing to these disparities. A shift in nursing science that focuses research at a population level would more effectively support addressing disparities in breastfeeding outcomes and embrace a commitment to social justice. In focusing at a population level, specific inequities that must be addressed include the negative history of breastfeeding in the Black population, systemic racism, and gender inequality. Critical research methodologies are proposed as useful approaches to address these inequities. By engaging in this level of research and using a critical lens, nurse scientists broaden their scope of care to include the entire population, motivate needed social and policy change, facilitate the choice to breastfeed, and ultimately eliminate breastfeeding disparities.

Integrative Review of Breastfeeding Support and Related Practices in Child Care Centers

OBJECTIVE

To synthesize the extant research on the support of breastfeeding and breast milk feeding and related practices in child care centers (i.e., daycare centers) in the United States and globally.

DATA SOURCES

We used key terms to search Ovid, CINAHL, and PubMed for articles that met eligibility criteria. When potentially relevant articles were identified in PubMed, we used the cited by and similar articles features to identify additional articles. We also examined the reference lists of reviewed studies.

STUDY SELECTION

We included original research articles on breastfeeding or breast milk feeding in child care centers published in 2000 or after and available in English. We reviewed titles and/or abstracts of 1,984 articles and abstracted 37 for full-text review. Of these, 16 studies met eligibility criteria and were included in the review.

DATA EXTRACTION

We abstracted data from the 16 articles to facilitate comparison and identification of patterns related to support of breastfeeding/breast milk feeding and related practices in child care centers. These data included year of publication, setting, design/methodology (and methodologic limitations), type of respondent/sampling unit (e.g., directors and staff members of child care centers, mothers), sample size, outcome measures, and pertinent study findings.

DATA SYNTHESIS

We categorized study findings into three themes: Knowledge, Attitudes, and Experiences of Staff Members in Child Care Centers; Implementation and Adherence to Policies, Practices, and Regulations in Child Care Centers; and Prevalence of Breastfeeding in Child Care Centers. Findings indicated staff members generally had positive attitudes toward breastfeeding but tended to remain neutral regarding encouragement and support of breastfeeding. Training and knowledge about breastfeeding among staff members in child care centers appears limited and focused mainly on the storage and preparation of breast milk; however, staff members indicated the desire to obtain additional education about breastfeeding. Few U.S. child care centers or states have comprehensive, evidence-based policies and regulations to address support for breast milk feeding and breastfeeding. The prevalence of breastfeeding in U.S. child care centers is less than that in other child care settings (home-based child care, etc.), child care centers in other developed countries, and national breastfeeding averages.

CONCLUSION

We found a general lack of policies and practices to support breastfeeding in child care centers, particularly in the United States. The degree to which this policy/practice deficit contributes to suboptimal breastfeeding rates among women who use child care centers requires further study.

Effectiveness of Workplace Lactation Interventions on Breastfeeding Outcomes in the United States: An Updated Systematic Review

BACKGROUND

Returning to work is one of the main barriers to breastfeeding duration among working mothers in the United States. However, the impact of workplace lactation programs is unclear.

RESEARCH AIM

The aim of this study was to evaluate the effectiveness of workplace lactation programs in the United States on breastfeeding practices.

METHODS

A systematic search was conducted of seven databases through September 2017. Articles ( N = 10) meeting the inclusion criteria of describing a workplace lactation intervention and evaluation in the United States and measuring initiation, exclusivity, or duration using an experimental or observational study design were critically evaluated. Two reviewers conducted quality assessments and reviewed the full-text articles during the analysis.

RESULTS

Common services provided were breast pumps, social support, lactation rooms, and breastfeeding classes. Breastfeeding initiation was very high, ranging from 87% to 98%. Several factors were significantly associated with duration of exclusive breastfeeding: (a) receiving a breast pump for one year (8.3 versus 4.7 months), (b) return-to-work consultations (40% versus 17% at 6 months), and (c) telephone support (42% versus 15% at 6 months). Each additional service (except prenatal education) dose-dependently increased exclusively breastfeeding at 6 months. Sociodemographic information including older maternal age, working part-time, longer maternity leave, and white ethnicity were associated with longer breastfeeding duration.

CONCLUSION

Workplace lactation interventions increased breastfeeding initiation, duration, and exclusive breastfeeding, with greater changes observed with more available services. More evidence is needed on the impact of workplace support in low-income populations, and the cost-effectiveness of these programs in reducing health care costs.

Reasons for Early Cessation of Breastfeeding Among Women with Low Income

Background: Most women in the United States do not meet their breastfeeding goals, and low-income women breastfeed at lower rates than the general population. While risk factors for early cessation have been documented, specific reasons for discontinuing among this population are less understood. We examined reasons for cessation among low-income mothers to inform the development of targeted strategies to address breastfeeding disparities. Materials and Methods: We performed a secondary data analysis using prospective data collected during a randomized intervention trial of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible women interviewed in the third trimester and at 1, 3, and 6 months postpartum. We included the 221 women who initiated breastfeeding and stopped by 6 months. Women's reasons for discontinuing breastfeeding were grouped by thematic category and compared by time of breastfeeding cessation. Results: The most common reasons reported overall for breastfeeding cessation were concerns about breast milk supply and latch difficulty. Some reasons differed significantly by time of cessation. Latch difficulty was reported most often by women who breastfed for 1 month or less; supply concerns increased with increasing breastfeeding duration. Returning to work/school was uncommonly reported for those who stopped by 1 month, but more frequently reported in those with later cessation. Conclusions: We found that low-income women reported similar reasons for early breastfeeding cessation as have been reported for other populations of women. These results underscore the need for appropriately timed, culturally sensitive interventions to reduce disparities in duration of breastfeeding, specifically to address latch difficulty in the first few weeks and supply concerns as infants grow.

Experiences of Racism and Breastfeeding Initiation and Duration Among First-Time Mothers of the Black Women's Health Study

BACKGROUND

Breastfeeding rates are lower for black women in the USA compared with other groups. Breastfeeding and lactation are sensitive time points in the life course, centering breastfeeding as a health equity issue. In the USA, experiences of racism have been linked to poor health outcomes but racism relative to breastfeeding has not been extensively investigated.

AIMS

This study aims to investigate the association between experiences of racism, neighborhood segregation, and nativity with breastfeeding initiation and duration.

METHODS

This is a prospective secondary analysis of the Black Women's Health Study, based on data collected from 1995 through 2005. Daily and institutional (job, housing, police) racism, nativity, and neighborhood segregation in relation to breastfeeding were examined. Odds ratios and 95% confidence intervals were calculated using binomial logistic regression for the initiation outcomes (N = 2705) and multinomial logistic regression for the duration outcomes (N = 2172).

RESULTS

Racism in the job setting was associated with lower odds of breastfeeding duration at 3-5 months. Racism with the police was associated with higher odds of breastfeeding initiation and duration at 3-5 and 6 months. Being born in the USA or having a parent born in the USA predicted lower odds of breastfeeding initiation and duration. Living in a segregated neighborhood (primarily black residents) as a child was associated with decreased breastfeeding initiation and duration relative to growing up in a predominantly white neighborhood.

CONCLUSION

Experiences of institutionalized racism influenced breastfeeding initiation and duration. Structural-level interventions are critical to close the gap of racial inequity in breastfeeding rates in the USA.

SEX DIFFERENCES IN THE SOCIAL ECOLOGY OF BREASTFEEDING: A MIXED METHODS ANALYSIS OF THE BREASTFEEDING VIEWS OF EXPECTANT MOTHERS AND FATHERS IN THE US EXPOSED TO ADVERSITY

Despite the significant health benefits of breastfeeding for the mother and the infant, economic class and race disparities in breastfeeding rates persist. Support for breastfeeding from the father of the infant is associated with higher rates of breastfeeding initiation. However, little is known about the factors that may promote or deter father support of breastfeeding, especially in fathers exposed to contextual adversity such as poverty and violence. Using a mixed methods approach, the primary aims of the current work were to (1) elicit, using qualitative methodology, the worries, barriers and promotive factors for breastfeeding that expectant mothers and fathers identify as they prepare to parent a new infant, and (2) to examine factors that influence the parental breastfeeding intentions of both mothers and fathers using quantitative methodology. A sample (N=95) of expectant, third trimester mothers and fathers living in a low-income, urban environment in Midwestern USA, were interviewed from October 2013 to February 2015 about their infant feeding intentions. Compared with fathers, mothers more often identified the benefits of breastfeeding for the infant's health and the economic advantage of breastfeeding. Mothers also identified more personal and community breastfeeding support resources. Fathers viewed their own support of breastfeeding as important but expressed a lack of knowledge about the breastfeeding process and often excluded themselves from discussions about infant feeding. The results point to important targets for interventions that aim to increase breastfeeding initiation rates in vulnerable populations in the US by increasing father support for breastfeeding.

Challenges and Supports of Breastfeeding at Workplace in Indonesia

Due to increased number of women workers in Indonesia in the last decade, numbers of women living as a worker and a housewife have increased. This also increases the potential risk of breastfeeding discontinuation. Three months of maternal leave policy and inadequate lactation promotion support in workplace have been identified as factors that hinder lactating practices. The World Health Organization recommendation of 6 months of exclusive breastfeeding and joined regulation of three Indonesia ministers (Ministry of Health, Ministry of Labour, and Ministry of Women Empower) have failed to improve the exclusive breastfeeding rate among female workers in Indonesia due to the lack of a standardized guideline on lactation promotion at workplace. In addition, very limited or no studies have been conducted to evaluate the impact of workplace-based lactation intervention programs on exclusive breastfeeding rate among female workers. This is because the relationship of lactation with working performance and productivity could not motivate employer to invest in workplace-based lactation promotion facility or program.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative

Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Enhancing Breastfeeding Through Healthcare Support: Results from a Focus Group Study of African American Mothers

Objectives To explore African American women's breastfeeding thoughts, attitudes, and experiences with healthcare professionals and subsequent influences on their breastfeeding interest and behavior. Insight was also sought about the most effective practices to provide breastfeeding support to African American women. Methods Thirty-eight pregnant or lactating African American women and racially diverse health professionals were recruited and participated in one of six membership specific focus groups in the metro Detroit area. An experienced focus group facilitator who was African American woman served as the primary group facilitator, using a semi-structured guide to discussions. Focus groups explored perceptions of personal and professional roles and behaviors that support African American women's breastfeeding behavior. Discussions were digitally recorded and audiotapes were transcribed. Thematic content analysis was conducted in combination with a review of field notes. Results Participants generally agreed that breastfeeding is the healthier feeding method but perceived that healthcare providers were not always fully supportive and sometimes discouraged breastfeeding. Non-breastfeeding mothers often expressed distrust of the information and recommendations given by healthcare providers and relied more on peers and relatives. Health professionals lacked information and skills to successfully engage African American women around breastfeeding. Conclusions for Practice Breastfeeding initiation and duration among African American mothers may increase when postpartum breastfeeding interventions address social and cultural challenges and when hospital breastfeeding support with the right professional lactation support, is void of unconscious bias and bridges hospital, community, peers, and family support. Professional lactation training for healthcare professionals who are in contact with expectant and new mothers and an increase in the number of IBCLC of color could help.

Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers

Breast cancer is the most commonly diagnosed cancer and a leading cause of death from cancer among U.S. women. Studies have suggested that breastfeeding reduces breast cancer risk among parous women, and there is mounting evidence that this association may differ by subtype such that breastfeeding may be more protective of some invasive breast cancer types. The purpose of this review is to discuss breast cancer disparities in the context of breastfeeding and the implications for black mothers. Black women in the U.S. have lower rates of breastfeeding and nearly twice the rates of triple-negative breast cancer (an aggressive subtype) compared with white women. In addition to individual challenges to breastfeeding, black women may also differentially face contextual barriers such as a lack of social and cultural acceptance in their communities, inadequate support from the healthcare community, and unsupportive work environments. More work is needed to improve the social factors and policies that influence breastfeeding rates at a population level. Such efforts should give special consideration to the needs of black mothers to adequately address disparities in breastfeeding among this group and possibly help reduce breast cancer risk. Interventions such as peer counseling, hospital policy changes, breastfeeding-specific clinic appointments, group prenatal education, and enhanced breastfeeding programs have been shown to be effective in communities of color. A comprehensive approach that integrates interventions across multiple levels and settings may be most successful in helping mothers reach their breastfeeding goals and reducing disparities in breastfeeding and potentially breast cancer incidence.

Breastfeeding is Natural but Not the Cultural Norm: A Mixed-Methods Study of First-Time Breastfeeding, African American Mothers Participating in WIC

OBJECTIVE

Identify facilitators, barriers, and needs to increase breastfeeding (BF) support.

DESIGN

Semistructured interviews based on the Theory of Planned Behavior, Iowa Infant Feeding Attitude Scale, and Breastfeeding Self-Efficacy Scale-Short Form to measure attitudes and self-efficacy, respectively.

SETTING

One WIC clinic in central Illinois.

PARTICIPANTS

First-time BF African American mothers enrolled in WIC (n = 15).

PHENOMENON OF INTEREST

BF facilitators and barriers in the African American community.

ANALYSIS

Descriptive coding and inductive thematic analysis.

RESULTS

Six themes emerged: normative infant feeding behavior within the sociocultural context; cultural beliefs about maternal nutrition and BF; time and costs associated with BF; managing and integrating BF while maintaining a social life; necessity of social support from significant others and female role models; and suboptimal support from institutions (hospitals, schools, workplace, and community). A novel finding was that participants believed that BF was expensive, because they believed that mothers must eat healthy to breastfeed. In addition, BF was considered natural but not the cultural norm. Mean Iowa Infant Feeding Attitude Scale score (n = 15) was 70 (SD = 7), indicating a positive attitude toward BF. Breastfeeding Self-Efficacy Scale-Short Form mean score of 62 indicated a relatively high level of self-efficacy.

CONCLUSIONS AND IMPLICATIONS

Interventions should focus on providing social support (emotional, tangible, informational, and encouragement) to African American mothers and their social networks to promote a BF-friendly environment.

Empowerment in breastfeeding as viewed by women: A qualitative study

BACKGROUND

The positive effect of breastfeeding on health is globally accepted. However, breastfeeding has not yet practiced at a favorite level. Empowerment of mothers is an important factor for continuing breastfeeding. This study was conducted to explore women's perception of empowerment in breastfeeding.

METHODS

The present qualitative study was conducted in conventional content analysis method. Thirty-four semi-structured deep interviews were conducted with 18 mothers, four key family members, and 12 other personnel involved in breastfeeding counseling services.

RESULTS

Analysis of participants' descriptions led to the emergence of five main categories: Enough knowledge and skill for breastfeeding, feeling adequacy in breastfeeding, overcoming breastfeeding problems, informed belief in the value of breastfeeding, and perceiving comprehensive support for breastfeeding.

CONCLUSION

In participants' point of view, empowerment in breastfeeding can be formed through an acquisition of "Enough knowledge and skill for breastfeeding" as well as assurance about the proper quality and quantity of mother's milk. As well as overcoming breastfeeding problems will lead to stabilization empowerment in breastfeeding. In addition, data analysis showed that informed belief in the value of breastfeeding strengthens the empowerment in breastfeeding and presence of perceived comprehensive support for breastfeeding facilitates empowerment in breastfeeding continuance. Thus, comprehensive plans should be designing for promoting breastfeeding.

Maternity Leave Length and Workplace Policies' Impact on the Sustainment of Breastfeeding: Global Perspectives

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.

Relationship between the Infant Feeding Preferences of Chinese Mothers' Immediate Social Network and Early Breastfeeding Cessation

BACKGROUND

The relationship between support from members of a mother's social network and breastfeeding continuation is receiving increased attention.

OBJECTIVES

The objectives of this study were to describe the infant feeding preferences of Chinese mothers' immediate social network and to examine the association between these preferences and early breastfeeding cessation.

METHODS

In total, 1172 mother-infant pairs were recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until breastfeeding stopped.

RESULTS

Over 40% of participants' partners preferred breastfeeding and half had no infant feeding preference. Only about 20% of participants' mothers or mothers-in-law preferred breastfeeding, and less than 10% reported that all of the 3 significant family members (partner, mother, and mother-in-law) preferred breastfeeding. The partner's preference for infant formula or mixed feeding (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.43-4.71) or having no preference (OR, 1.64; 95% CI, 1.16-2.30) was strongly associated with higher odds of stopping breastfeeding before 1 month. For every additional family member who preferred breastfeeding, the odds of stopping breastfeeding was reduced by almost 20% (OR, 0.81; 95% CI, 0.68-0.97). However, living with a parent-in-law (OR, 1.45; 95% CI, 1.02-2.07) was also a predictor of early breastfeeding cessation. Knowing someone who had breastfed for ≥ 1 month (OR, 0.64; 95% CI, 0.42-0.97) or having been breastfed as a child (OR, 0.67; 95% CI, 0.45-0.98) significantly lowered the odds of early breastfeeding cessation.

CONCLUSIONS

The infant feeding preferences of mothers' immediate social network are significantly associated with breastfeeding continuation. Prenatal breastfeeding education programs should involve significant family members to promote breastfeeding.

Benefits of a Dedicated Breastfeeding Facility and Support Program for Exclusive Breastfeeding among Workers in Indonesia

PURPOSE

A mother's working environment is believed to be a major determinant of exclusive breastfeeding (EBF) practice. We aimed to define the influence of a facility dedicated to breastfeeding and a breastfeeding support program at the workplace on breastfeeding practice.

METHODS

A cross-sectional study was performed in five workplaces. The inclusion criteria were female workers whose last child was between 6 and 36 months old. Observational data were obtained and a questionnaire was filled out. The World Health Organization definition for EBF was used.

RESULTS

Data from 186 subjects (74 office workers and 112 factory workers) were collected. Just over half (52%) of the mothers were between 20 and 46 years old, 75.3% had graduated from high school and university, 12.9% had more than two children and 36.0% owned a house. The prevalence of EBF during the last 6 months was 32.3%. A proper dedicated breastfeeding facility was available for 21.5% of the mothers, but only 7.5% had been in contact with a breastfeeding support program. The presence of a dedicated breastfeeding facility increased EBF practice almost threefold, by an odds ratio (OR) of 2.74 and a 95% confidence interval (CI) of 1.34-5.64 (p<0.05). Knowledge of the breastfeeding support program increased EBF practice by almost six times (OR, 5.93; 95% CI, 1.78-19.79) (p<0.05).

CONCLUSION

Our findings suggest that Governments should make it obligatory for employers to offer a breastfeeding support program and a dedicated breastfeeding facility at the workplace as these simple measures significantly increase EBF.