Abstract
Post-hospitalization lactation support is traditionally done by private lactation consultants and by mother-to-mother support groups such as La Leche League. Those models play an important role, but more is needed to deal with the inner-city community who cannot identify or afford private lactation consultants. Additionally, there is also a lack of peer support groups in inner-city or immigrant communities, which may be due to concerns of safety or fears of disclosing immigration status or may be a reflection of the lack of support groups in their country of origin. Many immigrants come from communities with abundant extended family and community supports, which provide role models for breastfeeding, yet lose those supports once they immigrate.
There is a need to develop new models and interventions for inner-city communities. To assure that these models are culturally relevant and appropriate, it is important to engage the communities in developing these models. One method of doing this is to utilize community-based participatory research (CBPR) in the model development. The W.K. Kellogg Foundation's Community Health Scholars Program defines CBPR as “a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings.” 2 CBPR promotes building partnerships between research institutions and local communities to facilitate the translation of research into practice. This is particularly important when studies are conducted with racial/ethnic minority communities. An underlying premise of the approach is that including community members as partners in the research process increases the capacity of researchers to identify, understand, and effectively address key public health issues.
In the inner city community of Elmhurst, N.Y., nearly 90% of live births are to foreign-born mothers, particularly from Mexico, Ecuador, and Bangladesh (unpublished data). Although we are fortunate in our patient population to have an initiation of breastfeeding rate of 82%, in 2009 the exclusive breastfeeding rate was only 15% (unpublished data). The beliefs that artificial milk has “extra vitamins” and that doing “los dos” is healthier for a baby are not only widespread in our Latina community, but are being heard in the Bengali community as well. Although Bengali women overwhelmingly exclusively breastfeed in Bangladesh, they rarely exclusively breastfeed in the United States. As in most immigrant populations, acculturation and length of time in the United States decrease breastfeeding and exclusive breastfeeding. This translates into a need for more breastfeeding interventions as our populations become more acculturated.
The catch-all labels of “Hispanic” or “South-Asian” do not adequately describe the diverse cultures represented in our service community. It has become clear through research and observation that breastfeeding initiatives need to be tailored to the specific cultural and linguistic needs of each community. The format of large support groups might be an appropriate and comfortable format for lactation support for many of the Latinas and Indo-Mexicanas. However, this format does not engage the more private and reserved Bengali women, who are more frequently Muslim, with a culture of heightened modesty. The husbands of the Bengali women tend to be more involved and need to be engaged prior to any intervention. Bengali women also do not generally seek out “breastfeeding support” unless the problem, pain, or infant weight gain is so severe as to require a doctor's referral. However, Bengali women will engage in learning about infant feeding and development.
In order to address these issues, we conducted focus groups with these communities and have adopted three interventions. These interventions resulted in the hospital assuming a more traditional community role. The first intervention, a grant-funded Lactation Clinic, aims to improve post-hospital discharge professional lactation support. The clinic is primarily staffed by a community person who was originally trained as a peer counselor and then trained as a lactation consultant. Physicians attend the clinic and consult for all medical problems. The clinic meets twice a week and evaluates an average of 10 mother–infant pairs each session.
Our second intervention was the development of a Visiting Nurse Home Lactation Support Program. A visiting nurse pays home visits to new mothers who are either exclusively breastfeeding or who are mixed breastfeeding and bottle feeding but with a stated desire to become exclusive. This intervention includes three home visits by the nurse within the first 2 weeks after discharge. At each visit, the nurse assesses the mother's knowledge level skill and comfort with breastfeeding. The nurses respond to common breastfeeding problems and concerns and provide lactation support.
The third intervention was the development of a monthly New Mother's Group. The hospital setting was chosen because it addressed the issue of safety concerns and was a well-known entity to our population. Interestingly, the New Mother's Group was originally called “Lactation Support Group.” We found that this did not work, particularly for our Bengali mothers, who shared that breastfeeding is “natural” and were embarrassed to seek help for something “they should know how to do.”
These interventions are a first step. We are currently developing a more formal CBPR study that will adhere to fundamental principals of qualitative research and more carefully stratify participants to represent key communities. We will conduct formal coding of transcripts and construct themes. It is anticipated that based on the barriers and challenges identified through this focus group/structured interview process that a more culturally relevant and respectful intervention will be developed. We realize this study may reveal the need for multiple interventions that not only reflect the different ethnic communities, but also address the community of care providers.
Footnotes
Disclosure Statement
No competing financial interests exist.