The joys and challenges of promoting breastfeeding in south central Los Angeles

Georgia's breastfeeding promotion program for low-income women

OBJECTIVE

Beginning in 1990, Georgia's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) initiated 5 new strategies to promote breastfeeding among its pregnant and postpartum clients. These strategies were implemented in 1991, each to be provided as an addition to its standard program of counseling on breastfeeding and distributing appropriate literature: 1) enhanced breastfeeding education, 2) breast pump loans, 3) hospital-based programs, 4) peer counseling, and 5) community coalitions. The enhanced breastfeeding education strategy provides access to a hotline as well as periodic training of staff, and the breast pump loan provides free breast pumps to mothers who want to use them. The hospital-based strategy provides bedside support and counseling to women who have just given birth and includes staff training, as well as a hotline number for women to call after they leave the hospital. The peer-counseling strategy focuses on identifying former WIC participants who have successfully breastfed their infants; these women are recruited to provide support and encouragement to current WIC participants. Finally, the community coalitions approach is designed to identify existing community attitudes about breastfeeding, establish plans to address gaps in breastfeeding services, to develop resource guides on breastfeeding for the community, and to advocate at the community level to support breastfeeding women. The objective of our research was to evaluate the impact of breastfeeding promotion strategies on breastfeeding initiation among WIC participants in Georgia.

METHODS

Using data from the Pregnancy Nutrition Surveillance System (PNSS) for 1992-1996, we examined breastfeeding initiation rate during this period and compared rates among 6 different intervention strategies. Also, we used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to assess breastfeeding initiation and duration among WIC enrollees. We conducted 13 focus groups to understand the experiences of program participants. Ten focus groups were conducted with women who were breastfeeding their infants, 3 each with women from the community coalitions, hospital-based programs, and standard education programs, and 1 with women from the breast pump loan program. Three focus groups were conducted with women who were feeding their infants formula.

RESULTS

PNSS data show that breastfeeding initiation increased in the Georgia WIC program from 31.6% in 1992 to 39.5% in 1996. PRAMS data confirmed the increase in breastfeeding initiation from 33.6% (standard error [SE]: 2.2) in 1993 to 42.1% (SE: 2.4) in 1996 among WIC participants. Both datasets (PRAMS and PNSS) showed breastfeeding initiation to be well below the year 2000 goal of 75%. Overall, PRAMS data show a high breastfeeding initiation among non-WIC participants (range: 64.7% [SE: 2.2]) for 1994 to 70.1% (SE: 2.2) in 1996. The percent change between 1993 and 1996 was 8% for non-WIC participants, and it was 25% for the WIC participants among those responding to the PRAMS questionnaire. Data from PRAMS indicated no statistical change in the percentage of WIC enrollees who breastfed their infants for 8 weeks or more; this estimate was 18.3% (95% confidence interval (CI): 14.9-21.8) in 1993 and 19.4% (95% CI: 15.7-23.2) in 1996, well below the Healthy People 2000 objective of 50% at 6 months. According to PNSS data, the largest increases in breastfeeding initiation for 1992 to 1996 were among younger women (</=19 and 20-24 years old), those with no college (less than high school and high school only), unmarried, and black women (see Table 1). The smallest increases during this period were among older women (30+), those with more than a high school education, and women who were white, Hispanic, or from other ethnic or racial groups. The PRAMS data (1993-1996) generally display similar results, but the pattern by marital status demonstrated larger increases for married women than for unmarried women.

A comparison of two methods of antenatal breast-feeding education

OBJECTIVE

To compare a woman-centered antenatal breast-feeding programme based on concepts of peer and husband/partner support with a control group, who received antenatal breast-feeding education led by a midwife childbirth educator.

DESIGN

Longitudinal, quasi-experimental study.

SETTING

A large private hospital in Sydney.

PARTICIPANTS

A convenience sample of 179 primiparous women who attended childbirth education classes were recruited. One hundred and fifty-four participants remained following attrition and the application of selection criteria. There were 86 participants in the control group and 68 in the experimental group. The study population had a mean age of 30.4 years, were all married or living with a partner, were predominantly Australian born citizens (84%), and recorded a higher than average level of education than the population in general (Australian Bureau of Statistics 1997).

INTERVENTION

Nursing Mothers Association Australia (NMAA) representatives, their male partners and a mother who was willing to demonstrate breast-feeding, facilitated the experimental group.

MEASUREMENTS AND FINDINGS

Maternal perceptions of success using the Maternal Breastfeeding Evaluation Scale (MBFES) (Leff et al. 1994) and breast-feeding duration rates up to 25 weeks after birth were the outcome measures. No differences were found between groups in relation to maternal perceptions of success or duration rates. A difference was, however, detected in the qualitative data used to explore questions related to breast-feeding support and are to be reported elsewhere. Overall, breast-feeding duration rates were very high when compared to previously reported breast-feeding duration rates in Australia. There were no differences in breast-feeding duration rates or in maternal perceptions of success between those babies given supplementary feeds in hospital and those who were not, although early supplementation at home appeared to reduce breast-feeding duration.

IMPLICATIONS FOR PRACTICE

While no differences were found between groups in relation to breast-feeding duration and maternal perceptions of success, the homogeneity of the sample limits its extrapolation. The extraordinary rates of breast-feeding and the lack of research into antenatal breast-feeding education, warrants further investigation of these teaching styles across other populations. Importantly, this research found that a peer-led model of breast-feeding education was as effective as a midwife-led group in producing breast-feeding initiation and duration rates higher than other previously reported breast-feeding rates with the potential to enhance social support networks.

Using cultural knowledge in health promotion: breastfeeding among the Navajo

Although many attempts have been made to promote breastfeeding in a variety of contexts, few programs have explicitly incorporated cultural beliefs in these efforts. This article describes a breastfeeding promotion program conducted on the Navajo reservation. This program was designed to be culturally appropriate. Background information regarding beliefs and factors affecting infant feeding practices in this setting is provided, followed by a description of the intervention. The intervention, which incorporated both social marketing and community participation techniques, consisted of three components: an intervention in the health care system, a community intervention, and an individual intervention. Based on medical records review of feeding practices of all the infants born the year before (n = 988) and the year after (n = 870) the intervention, the program was extremely successful. This combination of techniques, including qualitative and quantitative research into local definitions of the problem, collaboration with local institutions and individuals, reinforcement of traditional understandings about infant feeding, and institutional change in the health care system, is an effective way of facilitating behavioral change.

Swimming upstream: breastfeeding care in a nonbreastfeeding culture

Women once gave birth and began breastfeeding within the cultural context of a traditional system of care; now they begin breastfeeding in a hospital. Historically, hospital care was arranged to fit artificial feeding. Little was known about the science of breastfeeding until recently. Basing our breastfeeding care on the cultural norm of bottle feeding has led to the development of many unfavorable attitudes and practices. Given an opportunity to learn how breastfeeding works and to improve our breastfeeding care skills, hospital nurses can play an important part in current efforts to make breastfeeding the community norm.