Reframing the Context of the Breastfeeding Narrative: A Critical Opportunity for Health Equity Through Evidence-Based Advocacy

Ethical Issues in Breastfeeding and Lactation Interventions: A Scoping Review

BACKGROUND

Infant feeding interventions that promote and support breastfeeding are considered important contributions to global public health. As these interventions often target private settings (e.g., individuals' homes) and involve vulnerable populations (e.g., pregnant women, infants, and underprivileged families), a keen awareness of ethical issues is crucial.

RESEARCH AIM

The purpose of this scoping review was to capture the key elements of the current ethical discourse regarding breastfeeding and lactation interventions.

METHOD

A scoping review was conducted using Arksey and O'Malley's (2005) methodology to identify the ethical issues of breastfeeding and lactation interventions as they are reflected in the scholarly literature published between January 1990 and October 2022. Abstracts (N = 3715) from PubMed, ScienceDirect, JSTOR and the Cochrane Database of Systematic Reviews were screened. The final sample consisted of 26 publications.

RESULTS

The recurring ethical issues identified in these studies were: the normative assumptions of motherhood; maternal autonomy and informed choice; information disclosure, balancing risks and benefits, and counseling practices; stigma and social context; ethics of health communication in breastfeeding campaigns; and the ethical acceptability of financial incentives in breastfeeding interventions.

CONCLUSION

This review illustrated that, while a wide range of ethical arguments were examined, the emphasis has been primarily on accounting for mothers' experiences and lactating persons' choices, as well as achieving public health objectives relating to infant nutrition in breastfeeding interventions. To effectively and ethically implement breastfeeding and lactation interventions, we must consider the social, economic, and cultural contexts in which they occur. One key learning identified was that women's experiences were missing in these interventions and, in response, we suggest moving beyond the dichotomous approach of individual health versus population health.

Research on Health Disparities: Strategies and Findings From the Black Women's Health Study

The American Journal of Epidemiology has been a platform for findings from the Black Women's Health Study (BWHS) that are relevant to health disparities. Topics addressed have included methods of follow-up of a large cohort of Black women, disparities in health-care delivery, modifiable risk factors for health conditions that disproportionately affect Black women, associations with exposures that are highly prevalent in Black women, and methods for genetic research. BWHS papers have also highlighted the importance of considering social context, including perceived experiences of racism, in understanding health disparities. In the future, BWHS investigators will contribute to documentation of the role that structural racism plays in health disparities.

Breastfeeding in Incarcerated Settings in the United States: A National Survey of Frequency and Policies

Objectives: To assess the existence of prison and jail policies and practices that allow incarcerated women to breastfeed while in custody, and prevalence of women in custody who pumped human milk for their infants. Methods: We surveyed 22 state prison systems and 6 county jails from 2016 to 2017 about policies related to breastfeeding and other programs for pregnant and parenting women in custody. In addition, 11 prisons and 5 jails reported 6 months of monthly, prospective data on the number of women pumping human milk, as well as information on placement of infants born to women in custody. Results: Eleven prisons and five jails had policies that supported the practice of expressed milk, either through pumping or breastfeeding. Over 6 months at these sites that allowed lactation, there were 207 women who gave birth in the prisons and an average of 8 women/month who pumped human milk; at the jails, there were 67 women who gave birth and an average of 6 women/month who pumped human milk. Most infants born to women in custody were placed in the care of a family member. Conclusions: Breastfeeding and the provision of human milk are critical public health issues. Our data show inconsistent implementation of policies and practices supportive of breastfeeding in prisons and jails. However, there are institutions in the United States that are supportive of incarcerated women's breastfeeding and lactation needs. Further research is needed to identify the barriers and facilitators associated with implementing supportive breastfeeding policies and practices in the carceral system.

Geodemographies of Breastfeeding Support

BACKGROUND

Mother-to-mother breastfeeding support organizations provide important information and guidance for helping mothers initiate and maintain breastfeeding, postpartum. However, the availability of this support is limited by a constellation of barriers, including race, culture, socioeconomic status, and geography.

RESEARCH AIMS

To identify the geodemographic composition of communities where breastfeeding support was available from the mother-to-mother support organizations Breastfeeding USA and La Leche League, identify underlying issues of equity, and highlight locations where more support resources may be needed.

METHODS

The locations of mother-to-mother support meetings were collected by ZIP code (N = 180) and were combined with a geodemographic database and exploratory spatial data analysis to explore the compositional characteristics of communities served (N = 1,173).

RESULTS

Significant gaps in the geographic distribution of breastfeeding support existed. While many metropolitan areas benefited from numerous mother-to-mother support groups and peer counselors, the geographic footprint of this support favored communities that were white, affluent, and suburban.

CONCLUSION

Spatial analytics combined with geodemographic analysis provide a unique perspective into the diverse landscape of mother-to-mother breastfeeding support groups at a local level. Our results highlighted inequities in the distribution of support provided and prescriptive guidance regarding where more resources may be needed.

The CRIAA Program complex intervention in primary care to support women and their families in breastfeeding: Study protocol for a pilot trial

AIM

To report a pilot study protocol to assess the feasibility of a complex intervention, in the primary healthcare context, to support women and their families in breastfeeding.

DESIGN

A pilot/feasibility trial with control and intervention groups.

METHODS

The study will be conducted in two primary healthcare centres with 40 childbearing women (20 control group; 20 intervention group), with their partner/meaningful person and their respective healthcare professionals. Intervention group participants will receive the intervention: (a) in a breastfeeding workshop during their third trimester of pregnancy; and (b) via virtual breastfeeding support for six months postpartum. Health professionals will be trained to deliver the intervention. The control group will receive standard care in the outpatient clinic. The pilot will help determine the intervention's feasibility. Data collected pre-intervention, 10-days postpartum and two-, four-, and six-months postpartum will provide estimates of the intervention's preliminary effects on self-efficacy and main outcomes. Research Ethics Committee approval was obtained in April 2019.

DISCUSSION

Breastfeeding support is a complex reality influenced by multiple factors. Therefore, approaches to breastfeeding are also, requiring interventions that address its multidimensional nature, including all actors involved. The proposed intervention will be applied by an interdisciplinary professional health team, allowing for its incorporation into standard practice and its perpetual maintenance.

IMPACT

The study will produce an original, comprehensive, complex intervention addressing contextual, and organizational factors to promote breastfeeding support using an interdisciplinary and family-based approach; breastfeeding self-efficacy is the core concept. The program evaluation and feasibility study will permit exploration of the integration of the intervention's novel aspects into the daily work of professionals and reveal how to better use existing resources in a full-scale clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03944642.

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.

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.