Abstract
Abstract
Background:
Non-exclusive breastfeeding among Latina women is commonly seen in the newborn period. The reasons behind las dos cosas (“both things”) are not well understood but have included the beliefs that formula has vitamins and that adding formula will result in a chubbier baby, which is desirable. Many previous studies involved Mexican and Puerto Rican women living in the mainland United States.
Methods:
We performed detailed semistructured interviews with 17 Latina mothers in late pregnancy or the newborn period at a community hospital and an affiliated clinic in Massachusetts, serving a large Dominican population. Women were asked about their beliefs about breastfeeding, colostrum, and infant formula. Transcripts were analyzed using Nvivo 9 software (QSR International Pty. Ltd., Melbourne, Australia) to identify the frequencies of common trends.
Results:
The most common reasons for introducing formula were treatment for insufficient milk, to keep the baby fuller longer, and planning for return to work. None of the women understood the potential risks of introducing formula on the establishment of breastfeeding, particularly on milk supply. Many thought that even limited amounts of breastfeeding were sufficient to produce a healthier child, failing to understand a negative dose–response effect of formula on health and milk production. While every woman saw breastfeeding as healthier, only one saw formula as unhealthy, an important distinction. None of the women expressed familiarity with medical recommendations around breastfeeding duration or exclusivity, with many believing that breastmilk alone would be insufficient to satisfy the hunger or nutritional needs of a growing child after as little as 3 months. Women consistently demonstrated a willingness to learn from health professionals.
Conclusions:
In counseling Latina women, it may be important to discuss the risks of formula to infant health, breastfeeding, and milk supply and to include the medical recommendations for breastfeeding exclusivity. Educational opportunities exist in the prenatal setting and when postpartum women request formula.
Introduction
Low-income Latinas have been found to have the lowest rates of in-hospital exclusivity of all other low-income ethnic groups. 4 Bunik et al. 2 described multiple factors influencing “Las Dos” in Mexican women living in Denver, CO: the desire for a chubby baby, which is best achieved by adding formula, and the perception that a crying baby would be best soothed by formula—both are factors sometimes driven by pressure from family members. In addition, they described maternal consumption of specific foods and staying inside during La Cuarentena (40 days postpartum) as important determinants of maintaining sufficient milk. Negative emotions could spoil mother's milk, and mothers often have a fatalistic attitude about breastfeeding, where factors beyond a mother's control determine her ability to breastfeed. Like other studies, 5 the importance of vitamins in formula was also stressed, with women desiring “the best of both.”
Previous studies on Latinas living in the mainland United States focused mostly on Mexican2,6–8 and Puerto Rican9,10 women with some data on Dominican women.11,12 Differences in breastfeeding rates have been described among Latinas from different countries, generally mirroring the breastfeeding rates in their home countries. 12 Historically Puerto Rico has had much lower breastfeeding initiation rates than other Latin American countries, although their rates are now rising. 13 It has been described that Puerto Rican women commonly view “big is healthy.” 14 A study of largely low-income Dominican women in New York found mothers reporting that no one contributing to their household income was the biggest factor negatively influencing any and exclusive breastfeeding. 11
Nearly all research shows breastfeeding rates are higher in less acculturated Latina women,11,12,15,16 but one study showed higher exclusivity rates in U.S.-born Latinas at a U.S. Baby-Friendly hospital, compared with foreign-born Latinas, 5 which suggests that Baby-Friendly status may be responsible for reversing this trend in that one hospital.
In meetings with the Massachusetts Baby-Friendly Collaborative, 17 staff from one hospital had reported persistent use of mixed feeding among its postpartum Latinas, despite their efforts to reverse this trend, which prompted this study. The objective of the study was to describe qualitatively the factors that led mixed feeding in this population, so that appropriate interventions could be designed.
Subjects and Methods
This qualitative study took place in the postpartum unit and nursery of an urban community hospital in Eastern Massachusetts, which was not Baby-Friendly, and its affiliated clinic. Subjects were chosen on a convenience sample of women self-identified as Latina and breastfeeding, or with the intention to breastfeed, based on availability and consent to participate on interview days. Recruitment flyers were posted in English and Spanish. All interviews were conducted by one of the authors (C.R.), who is bilingual and a native Spanish speaker, and were audiotaped with the mother's permission and then transcribed. The semistructured interviews consisted of 16 series of questions about attitudes on breastfeeding, colostrum, formula, expressing milk, and sources of influence. The interview tool was developed expressly for this study (Fig. 1). We also collected information on subjects' demographics and social background. All women gave informed consent, and each was compensated for her time with a $5 gift card. Interviews were conducted in either Spanish (seven interviews) or English (10 interviews) and occurred in July and August 2009. Telephone follow-up interviews were conducted 7 months later and included questions about why one's milk dries up, but only five women could be reached. The Institutional Review Board of Harvard Medical School (Boston, MA) approved the study.
Interview tool of Latina mothers (English version).
Study population
Sixty-five percent of respondents identified themselves as Dominican in ethnicity, 18% as Puerto Rican, 6% as Mexican, 6% as Ecuadoran, and 6% only as “Hispanic.” Their average age was 24.3 years, average education was 11.9 years, and they spent an average of 13.8 years in the U.S. mainland. Some were born here and moved abroad as infants, others experienced the reverse, and some subjects went back and forth between the United States and abroad. Eighty-eight percent were postpartum, and 13% were pregnant. Thirty-five percent were multiparas. Eighty-two percent indicated that at least one person in the household was contributing to household income, and in 6% this was clearly not the case; we had insufficient information for the remaining 12%. Table 1 summarizes additional characteristics of the subjects.
Analysis of transcripts
Transcripts were analyzed using a grounded theory approach, 18 facilitated by Nvivo 9 software (QSR International Pty. Ltd., Melbourne, Australia). Each transcript was coded according to 38 different themes that were identified, all by one author (M.B.) who also speaks Spanish, with additional translation support from a native speaker (C.R.). Spanish transcripts were analyzed in Spanish to preserve their linguistic authenticity. Eleven themes specifically centered on attitudes on formula.
Results
Our analysis revealed several different themes, which are highlighted below:
Breastfeeding as healthy and natural
Every woman in our sample knew that breastfeeding was “healthier” for the baby, although one woman also said she was convinced formula was equally healthy. Seven also noted it was good for the mother, mostly in terms of weight loss. Their favorable views of breastfeeding included the importance of bonding (41%) and that breastfeeding was “natural” (29%). Fifty-nine percent also said that they knew colostrum was “good,” although one woman explained that in the Dominican Republic, her mother told her colostrum is the “old milk” that should be discarded. Because many women were unfamiliar with colostrum until they gave birth, they likely learned about colostrum from healthcare professionals.
Concerns about milk supply
A majority of women (59%) stated that formula should be useful when a mother is not producing enough milk, with the implication that insufficient milk production is quite common and formula is the remedy. Several women commented on the importance of eating certain foods in order to produce enough milk (such as drinking milk or eating chocolate). Another mother, who had given five bottles in her 3 days postpartum because of visitors, seemed to ascribe her previous problem with low milk supply to circumstances beyond her control: “I wanna try [to breastfeed] as long as I can, but I unfortunately have the problem that my milk dries up quickly so I have to switch to the formula.” Fifty-three percent of women spoke almost two dozen times about concerns about milk supply, and half of these women believed that, inevitably, milk dries up, seemingly without explanation or reason. One woman says she knows it is best to give one or the other so the child will not be confused by the bottle, but for her, she will give both “because I don't know if can produce enough milk and manage work and school.”
Only one woman said anything about the physiology of supply and demand around milk supply, stating, “I heard that the more milk you give, the more you produce.” However, she clearly did not understand the corollary: That the more formula one gives, the less milk one produces. Like many others, she planned to give formula as a remedy for insufficient milk supply. Her comments embodied the lack of confidence many women had in their ability to make enough milk and their lack of understanding on the effect of formula on milk production. Another woman said she was advised to pump “constantly” to get her body to make more milk and that she was successful in now making enough. However, it is unclear if she understood the physiologic reasons why this technique worked.
Comfort around formula feeding
Formula was not generally seen as harmful, and most women reported they felt comfortable giving formula in addition to breastfeeding. The parents of an infant born at 28 weeks of gestation both favored breastfeeding over formula, but both felt “fine” with giving both at that time, not realizing that formula can be particularly harmful to their preterm infant. Another woman had looked forward to bottle feeding her child in the United States, because formula is rarely used in the Dominican Republic, but she was ultimately convinced that breastfeeding would still be healthier here. Women heard positive things about formula: “Like they say, nowadays they put everything that the child needs on the formula, the minerals, vitamins, whatever,” or “It's the same thing as breastfeed, it has vitamins and minerals.” Many women commented how formula keeps the baby fuller longer, which allows women to “get more done” or “get more sleep.”
While women often described breastfeeding as “natural,” formula by contrast, was described as “chemical” or “processed” (41%). Only one woman noted that formula-fed infants are “always more sick” than breastfed ones.
Fifty-nine percent commented that formula may not be tolerated well, specifically causing gastrointestinal upset such as gas, although at least to some extent, they thought this was due to air in the bottles. It is notable that gastrointestinal intolerance from formula might be distinguished from other statements about breastfed babies having fewer colds and infections.
Lack of knowledge about a dose–response effect
Many women mentioned that breastfeeding is important for the first few weeks, “especially for the antibodies,” with the implication that just a few weeks of breastfeeding is sufficient to produce a healthier baby. One woman will start “Las Dos” because “3 weeks is more or less favorable to see the results.” Another woman said, “Most relatives and friends they start breastfeeding for a short time and end up with the formula very quickly within a week or two, or start with both. They use the first week or 2 to feed the baby, again for the antibodies everybody recommends that they have.” Still another said, “I think people who don't wanna breastfeed, I think they should for at least the first couple of weeks, just to give them all the good stuff you have built up in you.”
Lack of familiarity with medical recommendations
No women expressed awareness of the medical recommendations around duration and exclusivity of breastfeeding. Several said that after a few months, breastmilk is not sufficient for a growing child's needs and will not keep him or her full.
Disconnect between willingness to pump and desire to use formula
Mothers mentioned anxieties about returning to work and school as a reason to give formula early on, to make sure the infant will take formula. Every woman said she was comfortable with pumping milk, and most reported no barriers to pumping at work, and, yet, when they spoke of being separated from their child for work, school, or other reasons, they spoke mostly of giving formula, not expressed milk: “So when I'm not around who is gonna breastfeed the baby, nobody else has milk. So having formula will help them out for when I'm not there.” In our follow-up interviews, a couple of the women had tried to pump when they returned to work or school but were discouraged by inability to express much milk or by having to pump in a bathroom.
Negative views about the mother's body and/or milk
Several women demonstrated negative feelings about their bodies in relation to breastfeeding. Some women thought formula was more enjoyable to the baby than breastmilk (12%) or that the baby “didn't like the breast” (12%). One said, “it grossed [the baby] out.” Eighteen percent were embarrassed about breastfeeding in front of others, and others mentioned concern about excess attachment (12%), excess time (18%), or breasts “falling” (sagging) (12%).
Lack of supportive hospital practices
There were dozens of references across 65% of subjects that reflected some lack of evidence-based hospital practices that adequately support the nursing dyad. The women mostly did not recognize any problems with hospital practices; on the contrary, most women reported satisfaction with the care and breastfeeding assistance they received. Postpartum women gave bottles of formula for non-medical reasons such as visitors and feeling tired. On that unit, only staff could provide mothers with formula; thus it appears they did so without effective education about the risks. No mothers mentioned using alternative feeding methods to give formula such as cup feeding. In a couple of instances, women described how the nurse could get the infant to latch but did not show the mother how to do this by herself, and the mother failed to get her infant to latch when she was alone. Another child was sent to the nursery at birth for hypothermia and given a bottle; yet hypothermia is usually preventable when World Health Organization guidelines 19 are used. Both mothers of Special Care Nursery infants were separated from their infants and were given inadequate support in establishing and maintaining lactation, yet neither recognized this is as a problem that could have been addressed better.
Concerns about pain
Some women also complained of significant pain with latch, although for most, pain was a problem that was minor, bearable, or less than expected. One woman said, “everybody is like ‘it's gonna be painful,’ but it's not.”
Reasons for introducing formula
The biggest reason to use formula was to treat insufficient milk production (59%). Aside from the general belief that formula is not harmful, women introduced formula for various other reasons: In anticipation of going back to work or school (41%), for embarrassment about nursing in front of others (12%), and because formula keeps the baby fuller for longer (29%) and thus can allow the mother to get more sleep (24%). Formula was generally seen as more convenient compared with breastfeeding (41%), an “easy way out” for those who “get lazy.”
Peers and mothers as important influences
Women were primarily influenced by their peers, including sisters and cousins, as well as by their mothers. Although their partners were supportive of breastfeeding, they generally deferred to the woman's judgment in such matters, rarely influencing their behavior overtly (6%).
Health professionals as influences
Women often described how staff helped them in the postpartum period. When asked if they would have taken a breastfeeding class, 47% were willing (and 12% took one), 35% were not willing only because it was inconvenient, and only 18% thought a class was unnecessary.
Discussion
The richness and consistency of our interviews confirm and expand the existing descriptions of Latina attitudes on exclusive breastfeeding, adding perspectives not previously described. The view that a few weeks of breastfeeding is sufficient to have a healthier baby allows the mother to introduce formula early in order to meet her other perceived needs and may explain why women feel little angst at stopping breastfeeding, as described elsewhere. 7 Mixed feeding is thus considered acceptable and desirable and not viewed as harmful. There were a surprising lack of comments indicating an understanding of a dose–response effect of breastfeeding on infant health, nor was there an understanding that the more formula one gives, the greater the negative impact on the establishment of breastfeeding, milk supply, and infant health. Although breastfeeding is “healthier,” formula is not generally viewed as unhealthy, even if it is seen as unnatural or causing gastrointestinal upset, likely because formula feeding is normative in the United States. Comfort with formula feeding has been described elsewhere as an important component explaining mixed feeding in the general U.S. population. 20
Our observations also fit with prior research of attitudes in the general U.S. population, in which “breastfeeding was healthier and better than formula,” but formula was “good enough” and “not bad” for the baby. 21 One study showed that 25.7% of U.S. adults from the 2003 HealthStyles survey agreed with the statement, “infant formula was as good as breastmilk,” but 76.9% did not agree with the statement, “feeding a baby formula instead of breastmilk will increase the chances the baby will get sick.” 22
Our data suggest that clear use of language around the risks of formula feeding may be the most effective way to educate women, including clear descriptions of negative dose–response effects. This may be especially important when postpartum women are requesting formula, but may be useful in the preconception and prenatal periods, as well in follow-up visits.
The widespread perception that formula is a remedy for insufficient milk underscores the failure of these women to understand that in the vast majority of cases, formula may be the cause of insufficient milk, not its remedy. Consideration may be given to requiring labeling on infant formula advising women of the risks to the establishment of breastfeeding in the early postpartum period.
Concern with actual pain seems to be less of an issue in these women than it has been with anticipation of pain seen in pregnant low-income women. 23
Our interviews also demonstrate that some women have a fatalistic attitude toward some aspects of breastfeeding, especially toward milk supply, which is consistent with previous literature in Mexicans in the Denver area. 2 Of those that did not, they thought the main determinant of sufficient milk was a mother's diet. Despite some comments that eating properly is important for adequate milk production, that factor alone does not appear to suffice. Women's beliefs about milk supply were also influenced by difficulties of close family members in maintaining breastfeeding. It is interesting that although negative experiences from relatives who breastfed seemed to add to women's fears about milk supply, the opposite was not true. The experiences of their mothers in particular, some of whom breastfed multiple children exclusively for a prolonged period of time, did not add to their confidence in their ability to make enough milk; none of the women described any inherent ability to produce milk thta they might have inherited from their mothers. The absence of successful peer role models was evident here and has been described elsewhere in Latinas. 7
Thus, education around the physiology of milk production may be important in this population, especially if done using language emphasizing “risks” to breastfeeding and health. Messages that “any breastfeeding is better than none” may be misinterpreted to mean that any breastfeeding is sufficient. Education using risk-based language should be done in a way where a woman can explain it back to the health professional to ensure that she understands. Inquiring about sources of information on breastfeeding and the breastfeeding experiences of peers may provide a foundation to discussing these principles with mothers.
The complete lack of awareness of medical recommendations around breastfeeding exclusivity and duration is significant. Women consistently demonstrated that healthcare professionals often influenced them; thus it seems likely that education from healthcare professionals around these topics may be effective, particularly in the prenatal setting and postpartum hospitalization. Prenatal education should take place at scheduled prenatal obstetric and Special Supplemental Nutrition Program for Women, Infants and Children appointments and be incorporated into prenatal classes because many women would not or could not take a separate breastfeeding class. This need has been identified elsewhere. 7
In addition, full implementation of evidence-based practices around infant feeding would have reduced the use of mixed feeding in these women. The issues seen at this hospital were typical for the average U.S. hospital. 24 Familiarizing women with relevant aspects of the Ten Steps to Successful Breastfeeding may be expected to influence their behavior and help them more accurately assess the quality of their care. The one study of Latinas at a Baby-Friendly hospital 5 supports that such practices may reverse Latina mixed-feeding trends described elsewhere.
Research on Mexican and Puerto Rican women has shown that women give formula in part because chubbier babies are valued.2,14 None of our subjects reported this view, but instead focused on the infant being too old to be “filled” by breastfeeding alone. In other words, they were focusing on perceived hunger and satiation, rather than infant body habitus.
Our findings also suggest that Latina women may benefit from education on the use of expressed milk, rather than formula, when mothers are separated from their infants for work, school, or other reasons. The passage of the worksite protection for lactating employees as part of the 2010 Patient Protection and Affordable Care Act provides an additional impetus to educate women about revising their expectations to express their milk, rather than use formula, when returning to work.
Our small sample size meant that the study was not powered to draw comparative conclusions among different ethnic subgroups. However, we did achieve data saturation in several of the themes such as healthiness of breastfeeding. It is unclear if these results are generalizable to other Latina populations or the population at large. Future research would benefit from larger study populations, comparing attitudes among Latina subgroups, and further exploring the attitudes surrounding milk production.
Conclusions
Using risk-based language by healthcare professionals around introduction of formula would appear to be important in reducing the rate of mixed feeding in this Latina population. Explanation of the dose–response effect of breastfeeding on health and the negative dose–response effect of formula would appear to be important. Other areas that need to be addressed include finding other ways to meet mothers' need for rest, for recognizing appropriate signs of satiation, and providing support for working women and education around use of expressed milk. Outreach to patients' mothers, peers, and partners may also be helpful. Finally, implementation of evidence-based maternity practices around infant feeding remains critically important.
Since our interviews were completed, our study hospital has made significant strides in implementing evidence-based practices.
Footnotes
Acknowledgments
The authors would like to thank Gail Walker, Amy Winship, Cherryl Gordon, and Tanya Lieberman for their help and support in this project. Funding for this study was provided by the Harvard Medical School Office of Enrichment Programs.
Disclosure Statement
No competing financial interests exist.