Using the Socio-ecological Framework to Determine Breastfeeding Obstacles in a Low-Income Population in Tijuana,Mexico: Healthcare Services

Abstract

Background:

In Mexico, breastfeeding rates are one of the lowest of Latin America, with 14.4% of infants under 6 months being exclusively breastfed. Previous studies indicate that lack of support from healthcare services is a serious obstacle to breastfeeding mothers in Mexico. Our objective was to identify the main obstacles to breastfeeding presented by the healthcare services in a low-income population in Tijuana, Mexico.

Materials and Methods:

We used a socio-ecological framework to determine factors affecting breastfeeding practices. In four low-income communities in Tijuana we conducted focus groups and interviews with mothers, fathers, grandparents, and key informants. Interview notes and focus group transcripts were then studied in-depth independently by three researchers. The primary analytic technique was constant comparison.

Results:

One hundred twenty-nine subjects participated in this study: six focus groups (n=53) and 51 interviews among mothers, fathers, and grandparents, as well as 25 interviews among key informants. Main healthcare service obstacles to breastfeeding were erroneous information, lack of training and supervision, negative attitudes, miscommunication between healthcare providers (HCPs) and patients, detrimental medical practices such as giving free formula at hospitals, and the conflict of interest between the infant food industry and the HCPs.

Conclusions:

This study showed that women in low-income communities in Tijuana face multiple obstacles to breastfeeding presented by healthcare services. In order to increase breastfeeding rates, institutional and structural changes are required.

Introduction

Breastfeeding is the single most cost-effective intervention to prevent child mortality.^1,2 The benefits of breastfeeding are beyond child survival and include better child development and improved maternal health.^3–5 In Mexico, breastfeeding rates are one of the lowest of Latin America, with 14.4% of infants under 6 months being exclusively breastfed.⁶ Particularly in North Mexico, where Tijuana is located, there is a lower prevalence than the national average, with 10.6% of infants under 6 months being exclusively breastfed.

Women approach breastfeeding within a specific institutional, social, and cultural context.^7,8 However, traditionally most studies are designed based on limited maternal data, focusing blame on the mother as the only person responsible for any infant feeding decision⁹ without awareness of the many environmental factors that can impact breastfeeding.

The socio-ecological framework for breastfeeding shows that group-level factors are the attributes of the environments that enable or disable mothers to breastfeed, such as the hospital and health facilities and the home and work environments.^10,11 Many women have reported receiving minimal advice about breastfeeding from a physician, or finding the information confusing.^12,13 Taveras et al.¹⁴ found that women whose physicians recommended supplementing with formula or who did not consider their advice to mothers on breastfeeding duration to be very important were more likely to have discontinued exclusive breastfeeding by 12 weeks postpartum.

The purpose of this study was to identify the main obstacles to breastfeeding created by healthcare services in a low-income population in Tijuana, Mexico, in order to develop specific, culturally appropriate educational material for breastfeeding promotion. We selected the socio-ecological framework adapted for breastfeeding by Hector et al.¹⁰ and Tiedje et al.¹¹ This model shows an integrated view of breastfeeding practices and identifies factors that may be modifiable for intervention planning. These actions target both modification of individual behaviors and environments in which individuals live and breastfeed. The model includes three levels: (1) individual-level factors are those associated directly with the mother, infant, and the “mother–infant dyad”; (2) group-level factors are attributes of the environments (in this case, hospitals and health facilities) that enable or disable mothers to breastfeed; and (3) societal-level factors influence the acceptability and expectations about breastfeeding and provide context in which mothers' feeding practices occur.

Materials and Methods

We used a variety of qualitative methods to assess individual, group, and societal determinants of breastfeeding (Table 1). We took elements from phenomenology and feminism theory to collect and analyze data and focus on the meaning women give to the breastfeeding experience as well as the social contexts that inform and structure personal experience.

Table 1.

Qualitative Methods Used to Assess Breastfeeding Determinants According to the Socio-ecological Framework

Breastfeeding determinants	Target population	Qualitative method
Individual level
Attributes of the mother	Mothers	FG, interviews
Attributes of the infant
Group level
Home/family environment	FathersGrandparents	FG, interviews
Hospital/health services/schools	Healthcare providers, promotoras, school coordinators	IKI, document analysis, observations
Work environment/day care	Daycare coordinator	IKI, document analysis
Social level
Cultural norms: child feeding, parenting, sexuality, gender roles	PsychologistSociologist	IKI, document analysis
Food system: formula industry	Food industry representative	IKI, document analysis
Laws: maternity/paternity leave		Document analysis

FG, focus groups; IKI, interviews with key informants; promotoras, community healthcare workers.

Focus groups and interviews

We recruited low-income mothers, fathers, and grandparents for a series of focus groups and interviews at four communities in East Tijuana (Florido, Mariano Matamoros, Terrazas del Valle, and El Niño). Community health workers (promotoras) recruited participants for focus groups that complied with inclusion criteria: mothers, fathers, and grandparents of children <5 years of age living in one of the four selected areas. As compensation for participation, each promotora was given a $15 store gift card at the end of the focus group discussions. To encourage free expression by participants, the focus groups facilitator was a nongovernmental healthcare provider (HCP) (D.B.-G.). Focus groups lasted between 50 and 120 minutes.

For interviews, participants were approached at waiting areas of healthcare clinics belonging to the Minister of Health. The interviewers approached participants appearing to meet study criteria. They conducted a semistructured interview whenever study participants indicated the willingness to do so. Interviews lasted between 20 and 40 minutes.

At the start of each focus group or interview we obtained verbal consent from all participants, and then they were asked to complete a short, demographic questionnaire. Focus groups and interviews continued to be conducted until no new information was obtained from mothers. Before this study was initiated, approval by protocol exemption was obtained from the human subject committees of the University of California Davis and from the State Department of Health. Only the Principal Investigator and two research assistants had access to the full tapes. Pseudonyms were used, and further minor modifications were made in order to ensure anonymity.

Script guide

Based on the socio-ecological framework, we created a script guide for focus groups and interviews. Focus group questions were reviewed by three members of the University of California Davis research staff and three promotoras working in these communities. The following areas were explored in the script for mothers:

1. Infant feeding practices used by participants

2. Reasons mothers generally choose to breastfeed or formula feed their infants

3. Their own infant feeding intentions before the birth of their babies, and their actual practices after their babies were born

4. Factors that influenced their actual infant feeding practices, including influential beliefs, persons, and events

5. Suggested strategies/ interventions to promote breastfeeding at the community level

We modified the script for each group of key informants. Specifically, for HCPs we queried perceptions of the most common infant feeding recommendations from other HCPs, lactation training received, obstacles for HCPs to counsel about breastfeeding at the doctors' office (e.g., time constraints), main factors women take into account when deciding about breastfeeding, the influence of infant feeding industry, and what are the lactation resources for mothers in their communities.

Interviews with key informants

Twenty-five key informants were approached by D.B.-G. to participate in the study. Most of them were HCPs (seven nurses, five physicians, three community health workers, and one doula), three academicians from health schools and two from psychosocial areas, two representatives of nongovernmental organizations providing maternal/infant health and nutrition education, one food industry representative, and one daycare center director. They were interviewed in a private room at their office, with only the researcher present. Interviews lasted between 30 and 90 minutes. Notes were taken during the interview.

Data analysis

Focus groups were tape-recorded and transcribed verbatim. Interview notes and focus group transcripts were then studied in-depth as a whole independently by three researchers. One of these researchers (D.B.-G.) was the facilitator of the focus groups. Thematic analysis followed the approach specified by Pollio et al.¹⁵ Each of the three researchers extracted the main themes, phrases, and meanings of the participants' words as they related to mothers and breastfeeding within the sociocultural context of the mothers' lives. The primary analytic technique was constant comparison.^16,17 Maternal focus group data were the first analyzed. We selected the main themes and subthemes and labeled them with a code. Then we analyzed data from fathers, grandparents, and other key informants. Most of the meaningful comments could be categorized within the previous themes and subthemes; if they could not, we added additional themes/subthemes. We also used classical content analysis in which the researcher counts the number of times each code was used. The factors taken into account to classify themes were the frequency, extensiveness (how many different people say something as opposed to how many times by the same person), and emotion. Other analytic techniques used only with mothers were word count, key words in context, and connecting networks.

We used the following strategies to increase validity^18,19:

1. Intensive, long-term involvement. We attended over the course of a year to the general hospital and the four community settings at clinics and community centers.

2. Rich data. We had verbatim transcripts from focus groups and detailed, descriptive note-taking from interviews and observations.

3. Respondent validation. We returned to the communities to conduct one focus group and 23 interviews to communicate our findings and ask for feedback.

4. Triangulation. We collected information from a diverse range of individuals and settings, using a variety of methods to reduce the risk of systematic biases.

Results

In total, 129 participants were part of this study: 104 parents (mothers, n=66; fathers, n=11) and grandparents (n=27) and 25 key informants in health services, daycare, the infant food industry (IFI), and psychosocial areas. There were six focus groups (three with mothers, one with fathers, one with grandparents, and one with mothers and fathers) that varied in size from five to 12 participants. A summary of the parents' and grandparents' sociodemographic characteristics obtained using the pre-interview questionnaire is given in Table 2.

Table 2.

Sociodemographic Characteristics of Participants from Low-Income Communities

	Mothers	Fathers	Grandparents
Age (years)	27.9±7.6	41±9.2	65.4±11.0
Education (years)	8.9±2.9	8.9±3.0	3.9±3.6
Child's age (years)	2.4±1.3	4.1±1.8
Number of children	2.4±2.8	2.5±3.8
Parity
Primiparous	30 (17)
Multiparous	70 (40)
No information	(9)
Marital status
Single/widow	13 (7)	0	48 (10)
Married	40 (23)	64 (7)	48 (10)
Living with partner	47 (27)	36 (4)	1 (1)
No information	(9)	0	(6)
Residence status
Migrants	74 (43)	70 (8)	91 (21)
Non-migrants	26 (15)	30 (3)	9 (2)
No information	(8)	0	6
Migrants' percentage lifetime living in Tijuana	46±25	44±27	29±19
Occupation
Employed	21 (12)	82 (9)	28 (5)
[% at maquiladoras]^a	[58 (7)]	[44 (4)]	0
Students	2 (1)	0	0
Homemaker	77 (43)
Unemployed		18 (2)	72 (13)
No information	(10)	0	(9)

Data are mean±SD values or percentage (n), for subjects with known information, as indicated.

A maquiladora is an assembly factory.

Themes

In total, 22 major themes/obstacles were identified among comments of all participants. Major themes were further classified as individual, group, societal, or intervention factors. Here we discuss the group theme of Health Services. In a continuing phase of this study we returned to the study communities to validate data and asked mothers to rank the main 10 obstacles to breastfeeding. The group factor of lack of support from family, health services, and work environment was ranked as sixth.

Subthemes and representative quotes supporting each theme are summarized in Table 3.

Table 3.

Subthemes, Quotes, and Words Related to Healthcare Service Determinants of Breastfeeding in Our Study Population

Category	Quotes ^a
Erroneous information	“I asked the pediatrician and he said: ‘It is because she's no longer full with your milk.’ ‘Then we go backwards.' ‘No, what you can do is to give her breastmilk in the morning and when it is time to go to bed you give her formula so she doesn't wake up at night.' I did so and my daughter does not wake up at night.” (Mother)
Lack of training	“During the formative years it is never covered, which means, it is not in the curriculum. Sometimes we focus on a high-level pediatrician attention, with the most sophisticated devices; however, breastfeeding that doesn't cost anything, just a matter of talking to the mother, it is still not taking into account” (Nurse)“And they could teach it to me, but many times it is about one's attitude. I have the knowledge but I don't have the attitude. This also including nurses, the ones that are dedicated to infant–maternal care, the attitude is lost, it gets lost.” (Pediatrician)
Lack of supervision	“When the people who are in a higher position aren't convinced about what they are doing, they don't transmit it.” (Pediatrician)
Negative attitudes	“I think the HCP [healthcare provider] is not sensitive to it. In theory they are, and everyone is going to say you should breastfeed, but at a moment notice they ask to suspend it. Then you see that doctors are only covering the breastfeeding requirement because the institution supposedly supports it, but they aren't convinced that is important, that's the point.” (Pediatrician/lactation consultant)“The HCP looks for comfort. The truth, for me it is easier, which means working with less stress…Honestly, I prefer that he eats one ounce, two ounces of formula as opposed to fall in a period of hypoglycemia. Well if you know the physiological process and so, it is not like that, but the fear is always there.” (Pediatrician)“The experience of the HCP with breastfeeding influences a lot. They also lack the support and there isn't any nursery near the hospital. There are some HCPs who think: ‘Breastfeeding is very difficult, the babies end up biting you,’ which means, themselves complaining, and as a result they tell that to the patients, ‘don't breastfeed, there are several good formulas.’” (Pediatrician/lactation consultant)“The obstetricians think the baby is like a pimple that it is going to burst.” (Pediatrician)“Well, there is lots of mistrust. Well, they know the subject, but if they have here a lady who needs something, they don't do anything. More than anything, the attitude to make it possible for the woman to breastfeed. If one asks how do I feed the baby? They said ‘ask the pediatrician’; come on, they should tell them to breastfeed.” (Pediatrician)
Poor communication	“Some of them are despots. Or you call them and they won't even look at you. They pretend to not listen to you. Once I didn't stay quiet and the doctor wanted to scold me and I said no, you won't scold me, I came here for you to guide me because you are the one who knows…and if you are going to scold me, you know what, just stay here with your little white doctor robe…you are not going to scold me.” (Mother)“With doctors you feel like you don't know anything and you are useless.” (Mother)“What do I do? Should they die of starvation? It is easy since the doctor isn't with them [twins] all day. You should also take into account the mothers' point of view.” (Mother)
Detrimental practices	“My daughter said to them [doctors] ‘I will keep breastfeeding’ and they told her ‘yes, it doesn't matter, but he is not going to be full with your milk.’” (Grandmother)“He [doctor] said: ‘Furthermore it is a right as a mother that you receive your milk.’” (Mother)“They [nurses] can wake you up at 3 a.m. to ask you, ‘Hey doctor I don't have your indications for formula.’ Once they told me, ‘The baby is crying and you didn't indicate any formula,' 'and what's going on?,’ ‘it is because he is hungry,’ ‘well, put some compresses on her, give him a massage, etc.’ ‘What? You are not going to give him formula?’ ‘No.’ ‘Ah! And she hung up.’ And the other day I got there with the father, ‘hey, is there something wrong?’ No. This means, it was only the initiative of the nurse.” (Pediatrician/lactation consultant/referring to private practice)
Relation with infant food industry	“Even when it is a Baby-Friendly hospital they always seem to find a way to get in, especially when a new formula just comes out and supposedly has new attributes. In case they let in the representatives, nobody says anything, only the ones from the breastfeeding program. Supposedly the security personnel should be informed about not letting in bottles or cans of milk in the diaper bag. You can make a lot of enemies because you don't know who actually let them through.” (Nurse)“And you know what practices I see the pediatricians recommend? Mixed [feeding]. It is not something imposed by the culture, it is something imposed by the market. Because you know the doctors benefit from the laboratories. To start with, the pediatrician always recommends a particular formula.” (Psychologist)

Words in English	Words in Spanish
Help	Ayuda
Frustration	Frustración
Weak/tired	Debilidad/cansancio
Complain	Queja
Scold/reprimand	Regaños
Listen	Escuchar
Quiet	Callados
Anger	Coraje

To achieve semantic equivalence, quotes were translated to English by a professional translator and back-translated to Spanish by another professional translator.

Healthcare services subthemes

Erroneous information

Participants mentioned that HCPs offered as information what we understood to be myths surrounding breastfeeding (e.g., the belief that the mothers' milk didn't sit well with the baby, that the baby isn't satisfied with just breastmilk, or after 6 months the milk is like water and useless to the baby).

Lack of training

HCPs noted that in nursing and medical schools there are no courses on maternal lactation and many times the subject is superficially taught. Residents do receive education on the subject, but only in a theoretical way. Responsibility for maternal education and clinical care is delegated to nurses who receive no training in lactation; most learning is “on the job” without formal supervision.

HCPs agreed that effective training is needed, where both theoretical and practical aspects are covered, and the objective must be improvements in both knowledge and attitudes. HCPs have to be aware of the importance of breastfeeding in order to transmit it to their patients.

Lack of supervision

Some of the health workers said that a supervisor for the breastfeeding program is needed. These programs generally are managed by doctors or nurses in addition to other responsibilities. Even if it is their primary responsibility, they do not have support staff to help them provide an effective service. Health workers perceive that there is no interest from higher authorities to increase breastfeeding rates.

Negative attitudes

Participants using health services expressed feelings of frustration, dissatisfaction, and rejection of some of the HCP's attitudes as lack of interest and arrogance. Some of the comments were that doctors, instead of providing information or assistance, scold the mother. Other participants said that the attitudes toward breastfeeding rely on the HCP's own breastfeeding experience.

From the HCP's perspective, there is the notion that other HCPs are not sensitive in regard to breastfeeding. The pediatric chief of a hospital estimated that only 20% of the HCPs are truly interested in promoting and supporting breastfeeding in this hospital, and the other 80% recommend breastfeeding cessation as soon as the mother or infant presents with a problem, despite being aware of the benefits of breastfeeding. One nurse said this type of attitude usually happened with HCPs with higher education and that it was very difficult to communicate with them. Other HCPs interviewed mentioned that these attitudes could result in part because they look for the easiest solution owing to the heavy workload.

The HCPs interviewed think that beside pediatricians, other physicians attending to the mother–infant dyad have even less interest in lactation, especially obstetricians. Mothers commented that the majority of obstetricians don't talk about breastfeeding in their practices. Nurses mentioned that pediatricians are more interested in the health of the baby and as a result they want the baby to be well nourished.

Poor communication

There is a perception that physicians have a disconnection to reality and that the information and advice they give to mothers is not practical or clear. As a result, the mother experiences frustration, confusion, and finally mistrust in what doctors tell her.

Detrimental practices

Some of the practices in the healthcare services that can negatively impact breastfeeding that were mentioned by participants include:

• Infant feeding recommendations. The main recommendation in the medical plan notes for newborn feeding is “mixed feeding,” which means breastfeeding and/or supplementing with formula. It is confusing and sends the message that formula can be needed for no apparent reason.

• Free formula at the Instituto Mexicano del Seguro Social (IMSS) (Social Security Mexican Institute). The IMSS is a social security institution for formal workers; thus it is perceived as a right or benefit for mothers to receive formula. In addition, many times formula is offered before breastfeeding is promoted. Even if the mother says that she does not want formula, the HCP insists that it is her right and/or that maybe with only breastfeeding the baby would not be satisfied.

• Private hospital practices. HCPs interviewed considered that private hospitals have even more practices promoting formula, including a higher prevalence of cesarean deliveries, mother and child separation, formula supplementation, free formula, and lack of information about breastfeeding for mothers.

• IFI practices. Physicians have various incentives to prescribe formula. The practices that the IFI representatives use include giving doctors who take care of the mother–infant dyad free formula and other items they can use in their practice, always with the brand of the formula visible. In addition, doctors who prescribe formula receive economic benefits such as free dinners and travels to medical meetings. As an interesting note, while the author was interviewing an HCP in one of the public institutions about the influence of IFI, the interview was interrupted by an IFI representative who wanted to speak with the HCP.

At the hospital level, the IFI representatives visit the doctors and mothers to promote their products, even though such visits are prohibited by the International Code of Marketing of Breast milk Substitutes, signed by Mexico. Many times the IFI representatives take advantage of the evening or weekend shifts, knowing there will be less supervision. In some private hospitals, IFI representatives give out free formula. Also, the IFI exercises its influence through direct advertising in magazines for parents.

Discussion

We found various healthcare factors negatively affecting breastfeeding in this border population. Unfortunately, mothers are still being given erroneous information about breastfeeding from HCPs. Previous studies in the 1990s conducted in Mexico reported also that one of the main obstacles to breastfeeding was the lack of proper knowledge, as well as negative attitudes and practices detrimental to lactation coming from HCPs.^20–23 In the study of Guerrero et al.,²⁰ 42% of mothers in periurban Mexico indicated that at some time a physician advised them to cease breastfeeding, with half of those mothers reporting complying with the advice. Rodriguez-Garcia et al.²³ found that many general medical practitioners counsel women to wean by 2 months or to wean for minor infant illnesses such as cold or diarrhea.

One of the reasons mentioned in this and previous studies^24–26 about why HCPs don't have current information on breastfeeding is due to the lack of training. In a U.S. national assessment of physicians' breastfeeding knowledge, attitudes, training, and experience,²⁴ residents cited inadequate training, consisting mainly of didactic lectures, and no preparation for clinical encounters. A meta-analysis of controlled trials of formal continuing medical education concluded that knowledge is necessary but not itself sufficient to lead to changes in professionals' behavior and in patient outcomes.²⁵ There is a need for training in skilled support, not only based on lectures about the benefits and biological properties of breastmilk.^25–28 When well-designed educational training interventions for HCPs are offered, there is evidence of a favorable effect on breastfeeding rates.^29,30

A physician's attitudes and personal beliefs about breastfeeding influence the advice given to mothers.²⁴ There are physicians who still think that breastfeeding and formula feeding are equally acceptable forms of nutrition.³¹ This lack of basic knowledge affects the way they provide breastfeeding support for women.

Our results are in accordance with previous studies³² that have found poor communication skills from HCPs at providing breastfeeding advice to women. Communication problems can be reduced by using a patient-centered approach, in which the mother feels comfortable in sharing her feelings.¹⁴ There are several positive verbal and nonverbal behaviors, such as encouragement, motivational interviewing, and positive reinforcement, that HCPs can learn to influence mothers to continue breastfeeding.^14,33,34

There are some healthcare practices particularly detrimental to breastfeeding found in this study. The access to free formula was observed also in a previous study in Tijuana.¹⁴ This sends the message that mothers are going to need it at some point. It is unacceptable that public institutions certified as Baby-Friendly continue to have this practice. Not only is free formula a reality, but it is promoted. There is even less regulation at private hospitals. Not one of them is certified as Baby-Friendly in Tijuana; thus they are open to formula industry marketing.

The relationship between physicians and commercial IFI manufacturers has been discussed in the literature.^35,36 One of the practices found in this study was the IFI promotion of its products by giving free formula to HCPs and other gifts with the formula brand visible, including infant feeding information for mothers. In a study conducted at an obstetric outpatient setting in Rochester, NY,³⁷ women receiving formula promotions had significantly higher rates of weaning within the first 2 weeks compared with women who received only breastfeeding-supportive materials.

HCPs in this study noted that some IFI manufacturers promote physicians prescribing formula by taking them to medical conferences. Many companies still provide free meals, research grants, and financial support for conferences to doctors.³⁸ This creates a conflict of interest in which the physician feels obligated to return the favor.³⁹

Limitations

The findings from this study do not necessarily apply to a larger population of mothers, even those meeting the eligibility criteria for our study. Mothers from this convenience sample were recruited by promotoras; they were mostly migrant, multiparous, and low-income homemakers. Our findings were based on self-reported behavior. They are dependent upon the subject's recollections of breastfeeding events, associated feelings, and socially acceptable behaviors.

Strengths

We collected information from a diverse range of individuals (mothers, fathers, grandparents, HCPs, daycare personnel, experts on sociology and psychology, and IFI personnel) and settings (community centers, clinics, hospitals, and academic institutions), using a variety of methods (focus groups, interviews, and observations) and data analysis (organizational and theoretical categories, connecting networks) by different people to reduce the risk of chance associations and systematic biases due to a specific method. We also returned to the communities to conduct one focus group and 23 interviews to communicate our findings and ask them for feedback. They validated our findings and help us ranked the 10 main obstacles to breastfeeding to be used for educational message design (manuscript in preparation).

Recommendations for interventions

We propose the following recommendations for this community, based on our findings and analysis of other studies conducted in Mexican populations:

1. Baby-Friendly Hospital Initiative (BFHI) implementation and evaluation. Even though all the public hospitals in Tijuana were once certified as Baby-Friendly, they have not been recertified and lack a regulatory committee that ensures the steps are followed. A supervisor is needed to coordinate this initiative.

2. Private hospitals must modify those practices that are detrimental to breastfeeding. These changes need to be demanded by mothers and civil organizations that work for the health and well-being of mothers and babies. They must ask for Baby-Friendly hospitals, which also mandate training for nurses and physicians.

3. The environment provided for the new mother and infant should be characterized by collaboration among nurses, physicians, and organized peer support groups. Multidisciplinary training could help in ensuring that women receive consistent messages from all health professionals.

4. The IMSS needs to review its policy about free formula. It can train HCPs attending mothers and babies to make sure they first promote breastfeeding and address breastfeeding obstacles, including skilled assessment and management to resolve breastfeeding inadequacy, before discussing formula feeding. Non–medically indicated formula supplementation should only be provided to mothers requesting it after education on the risks of its use.

5. HCPs need to be trained on basic breastfeeding knowledge, skills, and sensitive communication. Training objectives must include changes in breastfeeding knowledge, attitudes, practices, and communication skills. Our data indicate an urgent need to require appropriate and comprehensive training of all HCPs caring for mothers and/or infants and young children in Mexico.

6. HCPs and hospitals must stop sponsorship from IFI in any form.

7. HCPs should follow evidence-based care for outpatient support of breastfeeding, such as outlined in the Academy of Breastfeeding Medicine Clinical Protocol #14: Breastfeeding-Friendly Physician's Office: Optimizing Care for Infants and Children.⁴⁰

Conclusions

This study revealed fragmented healthcare support for breastfeeding in a low-income population in Tijuana, Mexico. Knowledge and attitudes of HCPs and communication between HCPs and patients, as well as medical practices such as giving free formula at hospitals, need to be considered when planning interventions to promote, support, and protect breastfeeding in this population. Given the vast evidence on effectiveness of the BFHI,⁴¹ rigorous re-institution of these guidelines would be an important step toward increasing breastfeeding exclusivity and duration.

The socio-ecological framework helps us to think in more integral and sustainable ways to create a breastfeeding culture. Emphasis on changing individual maternal behaviors must be changed. HCPs and administrators must recognize that they are key elements to increase breastfeeding rates.

Footnotes

Acknowledgments

Thanks to Lucia Kaiser and Yvette Flores for helpful suggestions after manuscript review; Teresa Ewell for translation support; Iliana Castañeda from the Minister of Health in Tijuana, Fronteras Unidas Pro-Salud, and UABC for logistical and data collection support. This work was supported by: Centro Nacional de Ciencia y Tecnologia, from México (CONACYT) and by the Inter-American Fellowship (IAF) Grassroots Development, Institute of International Education from the USA.

Disclosure Statement

No competing financial interests exist.

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