Infant Feeding Beliefs, Attitudes, Knowledge and Practices of Chinese Immigrant Mothers: An Integrative Review of the Literature

Infant Feeding Outcomes From a Culturally-Adapted Early Obesity Prevention Program for Immigrant Chinese American Parents

OBJECTIVE

To examine whether a cultural adaptation of an early childhood obesity prevention program promotes healthy infant feeding practices.

METHODS

Prospective quasi-experimental study of a community-engaged multiphasic cultural adaptation of an obesity prevention program set at a federally qualified health center serving immigrant Chinese American parent-child dyads (N = 298). In a group of historical controls, we assessed early infant feeding practices (breastfeeding, sugar-sweetened beverage intake) in 6-month-olds and then the same practices alongside early solid food feeding practices (bottle weaning, fruit, vegetable, sugary or salty snack consumption) in 12-month-olds. After implementation, we assessed these practices in an intervention cohort group at 6 and 12 months. We used cross-sectional groupwise comparisons and adjusted regression analyses to evaluate group differences.

RESULTS

At 6 months, the intervention group had increased odds of no sugar-sweetened beverage intake (aOR: 5.69 [95% confidence interval (CI): 1.65, 19.63], P = .006). At 12 months, the intervention group also had increased odds of no sugar-sweetened beverage intake (aOR: 15.22 [95% CI: 6.33, 36.62], P < .001), increased odds of bottle weaning (aOR: 2.34 [95% CI: 1.05, 5.23], P = .03), and decreased odds of sugary snack consumption (aOR: 0.36 [0.18, 0.70], P = .003). We did not detect improvements in breastfeeding, fruit, vegetable, or salty snack consumption.

CONCLUSIONS

A cultural adaptation of a primary care-based educational obesity prevention program for immigrant Chinese American families with low income is associated with certain healthy infant feeding practices. Future studies should evaluate cultural adaptations of more intensive interventions that better address complex feeding practices, such as breastfeeding, and evaluate long-term weight outcomes.

The role of breastfeeding support in racial/ethnic disparities in breastfeeding practices

BACKGROUND

Persistent racial/ethnic disparities in breastfeeding practices in the United States are well documented but the underlying causes remain unclear. While racial/ethnic disparities are often intertwined with socioeconomic disparities in breastfeeding, studies suggest that lack of breastfeeding support from family, health care organizations and workplaces may contribute to racial/ethnic disparities in breastfeeding rates. No studies have investigated the extent to which racial/ethnic disparities in breastfeeding practices can be explained by breastfeeding support.

METHODS

We used survey data from participants of a federal nutrition assistance program in Los Angeles County, the most populous county in the United States, to examine causal mechanisms underlying racial/ethnic disparities in breastfeeding in five groups: Spanish-speaking Latina, English-speaking Latina, Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and Non-Hispanic Asian (NHA). Applying causal mediation analysis, this study estimated the proportion of racial/ethnic differences in breastfeeding ('any' breastfeeding, i.e., partial or exclusive) rates at 6 months that could be explained by differential access to breastfeeding support from family, birth hospitals and workplaces.

RESULTS

NHB and English-speaking Latina mothers were less likely, and Spanish-speaking Latina mothers more likely to breastfeed through 6 months than NHW mothers. Lack of breastfeeding support from family, hospitals and workplaces accounted for approximately 68% of the difference in any breastfeeding rates at 6 months between NHW and NHB mothers and 36% of the difference between NHW and English-speaking Latina mothers.

CONCLUSION

These findings highlight the importance of improving support from family, hospitals and workplaces for breastfeeding mothers to reduce racial/ethnic disparities in breastfeeding.

Infant Feeding Practices and Social Support Networks Among Immigrant Chinese American Mothers With Economic Disadvantage in New York City

BACKGROUND

Maternal social support promotes healthy infant feeding practices, which influence healthy growth and development. Less is known about how the interplay of social support networks and multicultural health beliefs may influence infant feeding practices, particularly among immigrant Chinese American mothers with economic disadvantage and low breastfeeding rates.

RESEARCH AIM

To explore the role of social support networks in the development of infant feeding practices in immigrant Chinese American mothers with infants.

METHODS

This was a prospective, cross-sectional qualitative study where we conducted semi-structured interviews in Mandarin, Cantonese, or English with Chinese American mothers of infants (N = 25) at a federally qualified health center in the Sunset Park neighborhood of Brooklyn, New York. Data were analyzed by a multicultural, multidisciplinary team using qualitative thematic analysis and the constant comparative method to identify and iteratively refine emerging codes.

RESULTS

Three themes emerged describing how broad transnational communities and close family and friends influence maternal-infant feeding practices: (1) Gathering and processing infant feeding information from broad transnational resources (i.e., from both the mother's country of residence and the mother's country of origin); (2) aligning maternal feeding attitudes with cultural health beliefs of local social networks; and (3) gaining confidence with transactional maternal-infant feeding interactions.

CONCLUSIONS

Strategies to promote healthy infant feeding should consider how family supports and culturally-relevant coaching can help align multilevel transnational social networks with healthy infant feeding practices.

Saudi Women's Breastfeeding Knowledge, Attitude, and Practices: A Systematic Review and Meta-analysis

INTRODUCTION

Despite the health benefits of breastfeeding, Saudi women do not exclusively breastfeed their babies. The purpose of this article was to synthesize Saudi women's breastfeeding knowledge, attitude, and practices and identify the factors that women reported for their breastfeeding cessation.

METHODOLOGY

A systematic review and meta-analysis of randomized clinical trials and cross-sectional studies was undertaken.

RESULTS

Saudi women reported poor knowledge in managing breastfeeding challenges and had a positive attitude toward formula feeding. Giving premade formula and sugar water was a common practice. The breastfeeding initiation rate (31.5%, 95% confidence interval [CI]: [22%, 41.8%]) and exclusive breastfeeding at 6 months were low (15.15, 95% CI: [8%, 24%]). Perceived low milk supply, returning to work, and using contraception were the main reasons for early breastfeeding cessation.

DISCUSSION

The integration of Islamic, political, and economic cultures in Saudi Arabia can influence women's breastfeeding practices. There is a need for culturally appropriate breastfeeding educational programs for Saudi women.

[Perinatal beliefs: Neurocognitive mechanisms and cultural specificities]

Perinatal beliefs contribute to the experience of pregnancy and the process of parenthood. Many of these perinatal beliefs have been perpetuated and evolved over time and throughout the world, exerting their influence on the behavior of pregnant women in interaction with medical recommendations. These beliefs generally offer explanations for gravidic and puerperal phenomena, helping to reduce the uncertainty of parents faced with the biological, psychological and social transitions of pregnancy. But certain beliefs can also be harmful, and alter the maternal experience of pregnancy and postpartum. In this paper, we provide an overview of the beliefs associated with the perinatal period. We successively detail the beliefs concerning fertility, pregnancy, childbirth, and postpartum, specifying the cultural beliefs from other cultures interacting with medical recommendations. Finally, we propose a neurocognitive model of perinatal beliefs generation, and we show the need to know these beliefs to improve care in midwifery, obstetrics, and fetal medicine.

Children's longitudinal bodyweight in Australia: Influence of migrant mothers' long-term residency, attachment to, and level of childhood overweight in country-of-birth

Immigration creates opportunities and imposes constraints associated with acculturation. We used the Australian national longitudinal survey of children aged 2 to 17 to evaluate the influence of mothers' long-term residency in Australia, mothers' attachment to country-of-birth, and macro indicators of childhood overweight environment at mothers' country-of-birth on children's longitudinal bodyweight. Both mothers' long-term exposure to the Australian environment and attachment to country-of-birth were associated with increased children's bodyweight z-scores. The childhood overweight environment in mothers' country-of-birth continued to influence their children's bodyweight after immigration. A better understanding of factors related to mothers' migration and children's bodyweight status is necessary to identify risk factors and migrant sub-groups needing extra support.

Complementary feeding practices and the associated risk of childhood obesity among ethnic minority groups living in high-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Complementary feeding (CF) is defined as the period from when exclusive breast milk and formula are no longer sufficient for meeting the infant's nutritional needs. The CF period occurs from birth to 23 months of age. Though the recommended guidelines for introducing CF is from around 6 months of age, data indicates that some infants are introduced to food earlier than 6 months which can predispose children to obesity and overweight. Obesity in ethnic minority groups (EMG) is higher than their native counterparts and often tracks into adulthood. Hence, our aim was to conduct a systematic review and meta-analysis on the available literature to identify the risk of childhood overweight/obesity associated with CF practices concerning their timing, as well as the frequency and type of CF food introduced. We focused specifically on EMG children living in high-income countries.

METHODS AND ANALYSIS

A methodological literature search surrounding childhood obesity and overweight (COO) risk associated with CF practices will be conducted in May 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. The following academic databases will be methodologically searched: PubMed, EMBASE, PsycINFO, CINAHL, SCOPUS, Cochrane Library and the WHO Global Index Medicus. Three independent researchers will be involved in independent screening and review the included articles based on the predefined inclusion and exclusion criteria. Where conflicts arise during the screening process, it will be resolved through discourse until a consensus is reached. Information on CF practices and anthropometric measurements will be extracted to ascertain the risk of COO. For this study, WHO body mass index for age and sex percentiles, Centers for Disease Control and Prevention classification and other recognised country-specific classifications will be utilised for the outcome.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed as the results will be drawn from currently available published literature. Outcomes of the review will be shared through peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CRD42021246029.

Breastfeeding experiences of Latina migrants living in Spain: a qualitative descriptive study

Background

The migratory flows in Spain have changed due to the arrival of a diverse migrant population. Among the new migrants the Latino collective predominate with more than half being women of childbearing age. There are no previous studies exploring breastfeeding experiences of migrants in a country where their mother tongue is spoken. This study aimed to explore Latina migrants’ breastfeeding experiences in a Spanish-speaking country.

Methods

A descriptive qualitative study was carried out in the main province in southern Andalusia between November 2019 and June 2020. The study used intentional sampling. The study participants were contacted by video calls and data were collected through a semi-structured in-depth interview (n = 19). The interviews were transcribed and analysed by thematic analysis.

Results

The nineteen participants were aged between 22 and 43 years old and came from six different countries in Latin America. The two main categories that emerged were breastfeeding facilitators and barriers, divided into ten interrelated sub-categories: working conditions; precarious socioeconomic conditions; lack of support (health professionals, family and society); physiological changes, pain and fatigue; ignorance and wrong beliefs; support networks (partner, health professionals and family); host country versus home country; religious practices/worship; appropriate attitude, knowledge and experience; and breastfeeding support groups. Most of the study participants stated that their breastfeeding experiences were influenced by barriers such as work and by facilitators such as peer support.

Conclusions

More support from caregivers and more sensitivity to cultural diversity were demanded by the women and well-trained professionals are needed to enable breastfeeding for a longer time. This paper provides caregivers, such as nurses, more knowledge about the care demanded by migrant women to ensure a longer breastfeeding experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00423-y.

Combined effects of weight change trajectories and eating behaviors on childhood adiposity status: A birth cohort study

Previous studies have suggested that infant rapid weight change can be associated with an increased weight later in life. However, the weight change trajectory in early life over time and which childhood lifestyle behaviors may modify the risk of rapid weight change have not been characterized. Using our ongoing birth cohort study, we have addressed these issues. Nine follow-up time points (birth, 3, 6, 9, 12, 18, 24, 36, and 48 months) were used to calculate the change between two adjacent weight-for-age z-scores (WAZ-change), and then WAZ-change trajectories were defined via group-based trajectory modeling. The solitary, independent and combined effects of WAZ-change trajectories and each lifestyle factor (eating behaviors, physical activity, media exposure time and total sleep duration) on childhood adiposity measures at age 4 years were determined using multivariate regression analysis. Overall, 84 (38%) children had a steady growth trajectory from birth to 4 years, while the other 137 (62%) children had an early infancy rapid growth trajectory, particularly in the first three months. Compared to children with steady growth, children with early infancy rapid growth had a significantly higher body mass index, waist circumference, and subcutaneous fat. Moreover, weight change trajectory and three eating behaviors (i.e. food responsiveness, satiety responsiveness and food fussiness), not only had independent effects, but also combined (synergistic) effects on the majority of adiposity measures. Our results extend the current literature and provide a potentially valuable model to aid clinicians and health professionals in designing early-life interventions targeting specific populations, specific ages and specific lifestyle behaviors to prevent childhood overweight/obesity.

The process of culturally adapting the Healthy Beginnings early obesity prevention program for Arabic and Chinese mothers in Australia

Background

Behavioural interventions for the early prevention of childhood obesity mostly focus on English-speaking populations in high-income countries. Cultural adaptation is an emerging strategy for implementing evidence-based interventions among different populations and regions. This paper describes the initial process of culturally adapting Healthy Beginnings, an evidence-based early childhood obesity prevention program, for Arabic and Chinese speaking migrant mothers and infants in Sydney, Australia.

Methods

The cultural adaptation process followed the Stages of Cultural Adaptation theoretical model and is reported using the Framework for Reporting Adaptations and Modifications-Enhanced. We first established the adaptation rationale, then considered program underpinnings and the core components for effectiveness. To inform adaptations, we reviewed the scientific literature and engaged stakeholders. Consultations included focus groups with 24 Arabic and 22 Chinese speaking migrant mothers and interviews with 20 health professionals. With input from project partners, bi-cultural staff and community organisations, findings informed cultural adaptations to the content and delivery features of the Healthy Beginnings program.

Results

Program structure and delivery mode were retained to preserve fidelity (i.e. staged nurse calls with key program messages addressing modifiable obesity-related behaviours: infant feeding, active play, sedentary behaviours and sleep). Qualitative analysis of focus group and interview data resulted in descriptive themes concerning cultural practices and beliefs related to infant obesity-related behaviours and perceptions of child weight among Arabic and Chinese speaking mothers. Based on the literature and local study findings, cultural adaptations were made to recruitment approaches, staffing (bi-cultural nurses and project staff) and program content (modified call scripts and culturally adapted written health promotion materials).

Conclusions

This cultural adaptation of Healthy Beginnings followed an established process model and resulted in a program with enhanced relevance and accessibility among Arabic and Chinese speaking migrant mothers. This work will inform the future cultural adaptation stages: testing, refining, and trialling the culturally adapted Healthy Beginnings program to assess acceptability, feasibility and effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10270-5.

Women's Empowerment and Determinants of Early Initiation of Breastfeeding: A Scoping Review

INTRODUCTION

Early initiation of breastfeeding (EIBF), the immediate provision of mothers' breast milk to infants within the first hour of life, has been recommended by the WHO. However, EIBF is not widely practiced, thereby increasing infant mortality risk. This review explored the available and published studies that identified interventions that empower mothers to practice EIBF.

METHOD

We conducted a scoping review to answer the aforementioned aims. Empowerment, Women, Breastfeed, and Initiation were used as initial keywords, which were further developed using Medical Subject Headings by the National Center for Biotechnology Information. Five databases, namely: Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature via EBSCO, ProQuest, and MedLine via PubMed, were searched for potential articles. We also searched the references in addition to the main search.

FINDINGS

We included 28 articles in this review. Education was mostly used as women's empowerment indicator in EIBF intervention. Additionally, we identified barriers (C-section and postoperative pain, lactation problems and pregnancy complications, mothers' social and demographic factors, mothers' lack of professional support, babies' condition preventing EIBF) and facilitators (mothers' positive behavior in relation to educational level, completion of antenatal care, poor economic situations of mothers, babies' size at birth) of EIBF.

DISCUSSION

Education is the widely used intervention to promote mothers' participation in improving EIBF rate. Furthermore, mothers' and babies' deferring conditions and traditional practices are barriers for EIBF. This review recommends future research and empowerment efforts that sensitively address the identified barriers.

Patterns and predictors of exclusive breastfeeding in Chinese Australian mothers: a cross sectional study

BACKGROUND

While exclusive breastfeeding is recommended to 6 months of age, just 15% of mothers in Australia achieve this. The rate appears to be even lower among mothers born in China, where 90% have introduced infant formula by this time. This study aimed to examine infant feeding patterns in the first 12 months of life and the factors associated with exclusive breastfeeding at 4 months of age and infant formula introduction by 1 month of age among Chinese Australian mothers.

METHODS

Chinese Australian women with a child aged 1 to 4 years born in Australia were recruited through social media and asked to complete an online survey. Chinese ethnicity was defined as the mother or her parents having been born in mainland China, Taiwan or Hong Kong. Infant feeding practices since birth and a range of psychosocial and cultural factors were assessed. A total of 289 Chinese Australian mothers completed the survey. The relationships between exposure variables and exclusive breastfeeding at 4 months or infant formula use by 1 month were examined using multivariable logistic regression.

RESULTS

Almost all (93%) mothers initiated breastfeeding, however by 1 month of age exclusive breastfeeding rates reduced to 44%, with a further decline to 33 and 18% at 4 and 6 months respectively. Concurrently, 7% of parents reported infant formula feeding at birth increasing to 55 and 63% at 1 and 6 months of age respectively. The rates of any breastfeeding were 81% at 6 months and 50% at 12 months of age. Breastfeeding intention, self-efficacy and awareness of the infant feeding guidelines were key factors associated with sustained exclusive breastfeeding to 4 months.

CONCLUSIONS

While Chinese Australian mothers had comparable exclusive breastfeeding rates at 6 months to the general Australian population, twice as many had introduced infant formula by 1 month of age. There is an urgent need to support Chinese Australian mothers in the perinatal period to strengthen their knowledge, intention and confidence to delay early introduction of infant formula and promote exclusive breastfeeding in the early postpartum period.

Breastfeeding and emerging motherhood identity: An interpretative phenomenological analysis of first time Chinese Australian mothers' breastfeeding experiences

BACKGROUND

Chinese Australian mothers are more likely than the general Australian mothers to introduce formula in the first month of age. A better understanding of the context of formula introduction in the early weeks of birth can provide a deeper insight into how Chinese Australian mothers can be supported to continue exclusive breastfeeding.

METHODS

An interpretative phenomenological analysis approach was used to examine the lived breastfeeding experiences of 11 first time Chinese mothers in Australia. The experiences of those who breastfed exclusively were compared to those who introduced formula in the first month after birth.

FINDINGS

An overarching theme across all participants' narratives was the meaning ascribed to breastfeeding in their emerging motherhood identity. Breastfeeding could be a pragmatic and a socially desirable method to nourish an infant but lacking personal identification to the mother. These mothers were more vulnerable to the early introduction of formula, especially when the support environment was lacking. Maternal identity conflict was common and negatively impacted exclusive breastfeeding and mothers' mental health. In contrast, mothers who identified closely with breastfeeding showed greater persistence and enjoyment in breastfeeding and were more likely to continue breastfeeding exclusively. Health professionals were perceived to have an important influence in strengthening maternal breastfeeding motivation and self-efficacy.

CONCLUSION

Breastfeeding support to Chinese Australian mothers needs to consider how breastfeeding can be better integrated with their motherhood identity. Health professionals are well-positioned to facilitate this process through a better understanding of mothers' cultural and social contexts around breastfeeding.

Breastfeeding beliefs and experiences of African immigrant mothers in high-income countries: A systematic review

Breastfeeding provides optimal nutrition for the healthy growth of infants and is associated with reduced risks of infectious diseases, child and adult obesity, type 2 diabetes, and other chronic diseases. Migration has been shown to influence breastfeeding especially among migrants from low-and-middle-income countries. This mixed-methods systematic review aimed to identify, synthesise, and appraise the international literature on the breastfeeding knowledge and experiences of African immigrant mothers residing in high-income countries. MEDLINE, CINAHL, Embase, PsychINFO, Scopus, and Web of Knowledge databases were searched from their inception to February 2019. Grey literature, reference, and citation searches were carried out and relevant journals hand-searched. Data extraction and quality assessment were independently carried out by two reviewers. An integrated mixed-methods approach adopting elements of framework synthesis was used to synthesise findings. The initial searches recovered 8,841 papers, and 35 studies were included in the review. Five concepts emerged from the data: (a) breastfeeding practices, showing that 90% of African mothers initiated breastfeeding; (b) knowledge, beliefs, and attitudes, which were mostly positive but included a desire for bigger babies; (c) influence of socio-demographic, economic, and cultural factors, leading to early supplementation; (d) support system influencing breastfeeding rates and duration; and (e) perception of health professionals who struggled to offer support due to culture and language barriers. African immigrant mothers were positive about breastfeeding and willing to adopt best practice but faced challenges with cultural beliefs and lifestyle changes after migration. African mothers may benefit from more tailored support and information to improve exclusive breastfeeding rates.

The Association of Acculturation and Complementary Infant and Young Child Feeding Practices Among New Chinese Immigrant Mothers in England: A Mixed Methods Study

Acculturation has an influence on mothers' beliefs and the perceived behaviours of different ethnicities. Few studies have been conducted on complementary infant and young child feeding practices (CIYCFP) in minorities in England, particularly in Chinese immigrants. This mixed study aims to explore the association of acculturation and IYCF among new Chinese immigrant mothers using purposive snowball sampling from an informal Chinese community. The participants' responses to the Infant Feeding Style Questionnaire (IFSQ) and Mutual Intercultural Relations in Plural Societies (MIRIPS), questionnaire (n = 32) were collected. A sub-set of 15 also participated in semi-structured interviews. Pearson's correlation coefficient analysis and thematic analysis were performed to analyse the survey and semi-structured interview data, and triangulation was employed to integrate quantitative and qualitative findings. This study indicated that Chinese mothers who scored high in integration were more likely to respond to satiety and attention; those inclined to be marginalised were more likely to indulge their children. Those who were more culturally separated were more likely to restrict the food quality offered to their children. This study also indicated that Chinese immigrants balanced western and Chinese feeding practices to combat feeding and culture conflict. This study presents preliminary findings of the association between acculturation and CIYCFP, which can improve culturally appropriate CIYCFP in minorities. Further studies are needed to explore intervention programs to tailor CIYCFP with consideration for acculturation in the minority.

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.

Prepregnancy obesity as a risk factor for exclusive breastfeeding initiation in Japanese women

OBJECTIVES

Breastfeeding rates in many countries fall short of the World Health Organization's recommendations. It has been reported that exclusive breastfeeding (EBF) is negatively associated with obesity; however, the association varies with ethnicity, and little information is available from Asia. We explored whether prepregnancy body mass index (BMI) and gestational weight gain (GWG) were associated with initiation of EBF.

METHODS

We investigated 6125 Japanese women with full-term (37-42 wk of gestation) singleton babies between January 2010 and June 2013, in a hospital with the largest annual number of deliveries in Tokyo, Japan.

RESULTS

Successful EBF initiation was observed in 72% of women 1 mo after delivery. The average GWG was 10 kg in underweight (BMI < 18.5 kg/m²) and normal weight (BMI 18.5-24.9 kg/m²) women; 7 kg in overweight (BMI 25-29.9 kg/m²) women, and 4 kg in obese (BMI ≥ 30 kg/m²) women. After adjusting for covariates, stepwise modeling revealed that compared with women of normal weight, obesity (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.16-0.53), and a single-unit increase in the GWG (OR, 0.98; 95% CI, 0.96-1.00) were significantly associated with unsuccessful EBF initiation. No statistical interaction was evident between prepregnancy BMI and GWG. Other significant risk factors for unsuccessful EBF initiation included older maternal age (P < 0.001), nulliparity (P < 0.001), cesarean delivery (P < 0.001), an earlier gestational week (P < 0.001), a light-for-date infant (P < 0.05), and mother-child separation for clinical reasons (P < 0.001).

CONCLUSIONS

This study suggested that prepregnancy obesity is a risk factor for EBF initiation among Japanese women.