Abstract
Introduction
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Background
Puerto Rico has been promoting breastfeeding actively by public policies and legislation drafted for more than 10 years. Impressive and comprehensive legislative projects defend the rights to breastfeed for mothers in every aspect of their daily lives. Major efforts culminated in 2004 with the enactment of Law 79, which regulates the use of artificial formulas in hospitals for normal newborns. In order to feed an infant formula, mothers must provide written consent for supplementation except in cases where it is medically indicated.
In 2006 two major legislative bills were signed by the governor. First, Law 156, “Ley de Acompañamiento durante el Trabajo de Parto, nacimiento y post-parto,” protects the rights of every woman in every health facility, whether it be private or public, on the island throughout her labor and postpartum period. Health practitioners are now required to fully inform as well as to allow the presence of the mother's trusted significant others, doulas, etc., and protect her right for rooming-in with her healthy uncomplicated newborn. Nevertheless, this new law permitted each institution to implement these changes depending on its individual regulations.
Finally, Law 239, enabling the mother's right to extract milk during her workday, was modified from Act 427 of December 16, 2000, and now allows an hour break for extraction during the workday for a mother who is in a full-time position. This break may be divided as needed (three periods of 20 minutes versus two periods of 30 minutes on-site), and she must be provided with an adequate clean space for such purposes. In the case of a workplace considered a small business in accordance with the size regulations of the Small Business Administration, these shall be bound to provide a period of half an hour (30 minutes) during each full-time working day to breastfeed or express breastmilk, which may be divided into two 15-minute periods.
Yet, in practice, enforcement of these measures by maternity hospitals and employers has been erratic and not uniform. Administrators and health professionals have not been consistent in the implementation of small changes in hospitals that could contribute to a successful initiation of breastfeeding, and employers have not been supportive enough, thus affecting the duration of breastfeeding for working mothers. Local and national statistics have consistently reflected this reality.
Baseline Comparative Results
The Centers for Disease Control and Prevention's (CDC's) 2011 National Survey of Maternity Practices in Infant Nutrition and Care 1 (mPINC) (the mPINC Survey is administered every 2 years to monitor and examine hospital routines that help or hinder breastfeeding) reported that only 39% of eligible maternity hospitals in Puerto Rico answered the mPINC survey, and these reported low rates of skin-to-skin contact and support for breastfeeding mothers after hospital discharge. Therefore, the Breastfeeding Promotion Committee of the Puerto Rico Health Department (Maternal, Child and Adolescent Health Division) with collaboration with the American Academy of Pediatrics (AAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Healthy Start planned the First Mother–Baby Summit Meeting, held on January 24, 2014, as a strategy to address these barriers.
Twenty eligible hospitals participated with an audience of 156 health professionals, including hospital administrators, pediatricians, neonatologists, pediatric residents, and nursing supervisors. One of the goals of the First Summit was to increase awareness of the disparities in labor room, nursery, and maternity practices among hospitals in the different health regions and to promote implementing changes toward optimal evidence-based practices that support the initiation of breastfeeding. There was ample discussion on the Healthy People 2020 Maternal and Child Health breastfeeding objectives, The Ten Steps, skin-to-skin measures, The Joint Commission perinatal core measures, and Puerto Rico's most recent breastfeeding statistics. A more humane and uniform approach in the delivery room as a tool to help increase breastfeeding rates in the island through the promotion of skin-to-skin measures, as well as the importance of collecting hospital statistics using the tools provided by The Joint Commission to help them complete finally the CDC's mPINC 2013 survey, was emphasized.
As part of this 2014 meeting all hospitals were encouraged to complete a self-assessment with the intention to highlight areas where modifications of hospital routines are necessary (i.e., rooming-in, skin-to-skin, etc.). The most significant findings from the initial self-assessment are that 66% of hospitals did not obtain any type of breastfeeding statistics, 45% still offered formula gift packs at discharge, and 50% didn't accept doulas or childbirth attendants. This trend of distribution of infant formula packs in hospitals is being reversed nationally as it is an evidence-based practice that decreases exclusive breastfeeding rates and leads to early weaning.2,3
Forty-five percent of hospitals recognized they lacked the resources to evaluate infant and mother breastfeeding problems such as latch and were unable to help these mothers after discharge, yet 100% indicated a willingness to start skin-to-skin practices. Seventy-five percent of participating hospitals expressed their interest in joining a Mother–Baby Coalition.
Our National Data
Local statistics based on the 2012 ESMI-Puerto Rico 4 (ESMI-PR) infant–maternal child health survey, which is obtained every 2 years from new mothers in Puerto Rico in hospital settings (sample size, n=1,728), suggested again poor compliance with the optimal care evidence-based strategies to promote optimal breastfeeding rates. Individual hospital breastfeeding rates vary greatly depending on the institution. However, overall, 72.3% of mothers reported breastfeeding at least once during their hospital stay, of which only 18.8% of infants were exclusively breastfed. This leads to a 6-month breastfeeding rate of 32.9%, with only 54.6% of these infants being exclusively breastfed. These statistics are way below the Healthy People 2020 goals. Twenty-six percent of mothers who did not breastfeed postpartum said they tried but that it was too painful to continue. Of all mothers surveyed, 21.7% breastfed and had contact skin-to-skin or early mother–infant contact in the hospital in the first hour postpartum, rooming-in was experienced by only 43.3%, and 17.3% were given infant formula at discharge.
The CDC mPINC 2013 results for Puerto Rico revealed that only 59% of the maternity hospitals offered 24-hour rooming-in versus 75% in the survey given to hospital staff in the 2014 Mother–Baby Summit, but many admitted it was rooming-in on a partial time schedule.
In 2014 formula discharge packs were distributed in 55% of participating hospitals (n=20) to the summit, whereas in 2015 only 43% of hospitals (n=23) did so. By comparison, national data in US hospitals reveal that in 2007 only one state, Rhode Island, had <25% of hospitals offering discharge packs, whereas in 2013 24% of states and territories had achieved that same 25% level. 2
The ESMI-PR revealed that the maternal group with significantly higher breastfeeding prevalence rates were high school graduates and women who started prenatal care in the first trimester, with infants born after 37 weeks of gestation and/or with a birth weight of >2,500 g, and with private health insurance. There was ample disparity among institutions and geographical areas. Breastfeeding rates decreased considerably, with 32.9% breastfeeding at 6 months (18% exclusively) and 16.5% at 12 months. The major reason for discontinuing breastfeeding before 6 months as reported by mothers was the perception of the baby not being satisfied or not getting enough milk (28%), latching difficulties (17.9%), and return to work or school (12.8%). Reasons for weaning before 12 months were again perception of the baby not being satisfied or not getting enough milk (25.6%) or latch problems (8%), and 7.3% declared that breastfeeding had become difficult, time consuming, and painful.
Analyzing these results, it becomes clear that one of the main reasons for early weaning in Puerto Rican mothers is the perception of insufficient milk. This seems to be a major cultural issue for all Latinos because the image of the healthy chubby baby is well ingrained in the Hispanic culture. An interesting theory was published in the First Breastfeeding Summit by Chin and Solomonik, 5 where the term “inadequate” was introduced at various levels making reference not only to the glandular tissue and breastmilk volume, but also as a reference to the woman's unique position in society.
So in our community, to address this situation the caregivers must include in all prenatal courses all the significant family members who will help the new mom feel adequate in her postpartum period with breastfeeding and her parenting skills. It has already been established that in order to promote health and succeed to change old traditions, close attention must be paid to families' cultural values in trying to understand their past behaviors. WIC peer counselors and home visiting nurses could follow this ideal model and offer priceless help to the mother–infant pair. 6 A better understanding of the familism versus the individualism in the Latino culture will help with the cultural empowerment in order to reduce the combined feeding approach used by Latino moms everywhere. Recognizing that the extended family will be involved in food preparation and grocery shopping, the issues of normal growth patterns for the breastfed child need to be reviewed in detail, as well as addressing the benefits of breastfeeding for mother, child, and community as contributing factors. The father also is important in major decisions for the family's well-being.
An orientation on the stomach's capacity of the infant and the suggested milk volumes that will ensure adequate growth and weight gain will also be helpful. Graphic descriptions of the newborns' stomach in pictures 7 or relative to objects such as marbles, ping pong balls, etc., will help all understand the real feeding requirement of the infant. This cultural difference is well explained by Cartagena et al., 8 who declared “Three major feeding practices and beliefs among Hispanic mothers potentially contribute to infant overfeeding. Hispanic mothers are more likely to practice nonexclusive breastfeeding, initiate early introduction of solid foods including ethnic foods, and perceive chubbier infants as healthy infants. Cultural norms driving family influences and socioeconomic factors play a role in the feeding tendencies of Hispanics.”
Reaching out to the new moms who are curious and enthusiastic and want what's best for their babies will help us impact better both the educated, acculturated, and informed, as well as the higher-risk groups. Traditionally the Puerto Rican mother is a spoiler and a nurturer but seeks approval from her relatives in this matriarchal society. Clinical psychology doctoral candidate Juliana Martinez has been exploring the concept of the Latina “dutiful daughter.” In her research (2015 unpublished thesis at City University of New York) she investigates cultural factors among Latina mother–daughter relationships that impact overall mental health and sense of self. For Latinas, the decision to breastfeed may be intrinsically connected to the dutiful daughter effect, meaning it will be influenced by intergenerational patterns of breastfeeding in the family. For example, a daughter would try to abide by her mother's own past experiences at motherhood, which had not included exclusive breastfeeding as an option.
We are therefore presented with multiple challenges and opportunities to improve exclusive breastfeeding rates in our island. Prenatal breastfeeding classes must be made available to all. ESMI-PR reflected that only 13.6% in this survey received some type of educational intervention during their pregnancy, and only 36% were instructed to breastfeed on-demand by the hospital staff. In comparison, the data from our 2015 Mother–Baby Summit show that 52% of the hospitals offered prenatal orientation. As a reality check, it is estimated that from 70% to 90% of our new moms are WIC recipients, so major efforts should be coordinated with the WIC peer counselors and nutritionists. As of Summer 2015, this WIC peer counselor workforce consists of around 90 individuals based in 94 clinics and will be extended to at least 10 hospitals island-wide. Following recommendations from the article by Chapman and Pérez-Escamilla, 9 where multiple interventions to promote successful breastfeeding are reviewed, the breastfeeding committee decided to pursue the multifaceted approach and convened all players in January 2015 for the Second–Mother Baby Summit. (Hospital administrators, medical directors, WIC, legislators, health insurance companies, and leaders of prenatal educators with experience in breastfeeding support groups were invited).
An overview of the results of the survey obtained in the First Mother–Baby Summit was introduced followed by a keynote speaker from the Pan American Health Organization (PAHO) describing the Latin American experience with the Baby Friendly Hospital Initiative, 10 who summarized the 2025 global goals for breastfeeding and nutrition. A review of the existing laws in Puerto Rico for breastfeeding mothers and the existing efforts and mechanisms for guaranteeing their rights were also presented. In the afternoon session, five diverse community efforts were described, highlighting the different approaches to prenatal education where various interventions ranging from doulas to breastfeeding clinics, lactation educators, midwives, psychologists, social workers, and volunteers have succeeded in improving rates of exclusive breastfeeding and redefined the cultural norm for the families they impact.
To spark community interest, a press conference was held 2 days prior to this meeting where the official results of mPINC 2013 for Puerto Rico were revealed. The composite quality score was 61.
Nationally this score was the second lowest in the nation ranked because Puerto Rico ranked 52 of 53, with a national median score of 75. Although the response rate from our hospitals was not ideal (42% of 31), there was improvement from the previous survey where 39% answered with the mPINC (and had a median score of 60). 11
Solutions
The reality behind this score raised concern among the respective health authorities. In response, as a direct consequence after re-evaluating the situation, the Secretary of Health signed Administrative Order 336 as part of hospital regulations requiring all hospitals to modify their maternity practices by establishing a Breastfeeding Support Program and to start implementing evidence-based changes such as the Ten Steps that could help reverse these circumstances.
The administrative order was officially signed in March 2015, and effective as of May 2015 all hospitals as part of their licensing requirement must comply with the Ten Steps and report annually their breastfeeding statistics in order to avoid monetary penalties. A complaint form was created for the patients so that they can report any unusual interference in the breastfeeding process such as inappropriate management or failure to comply with the designated steps. To help hospitals achieve these changes, a training workshop was offered to them last April in order to help them comply with the regulation. Basic to this movement is the establishment of a Breastfeeding Committee in each institution with a designated coordinator to help draft each hospital's policy. In all the activities developed in support of promoting breastfeeding, sample materials were distributed free of charge that included a list of local available resources and open access to a Web page 12 in Spanish with updated information. Tools for health professionals made available include examples from global alternatives to help train their house staff from various sources such as the CDC, the World Health Organization, the PAHO, and the AAP. All the keynote presentations from the Mother–Baby Summit of January 2015 were uploaded to this Web site for further review as needed.
Although this measure seemed drastic to many, it is a necessary step in order to break the status quo because there are no Baby Friendly Hospitals in Puerto Rico. It is the most logical alternative to help establish uniform hospital practices for all, eliminating unnecessary barriers for the uninsured and disadvantaged population. If we succeed in empowering women with culturally sensitive health promotion efforts, we must also strengthen the support mechanisms. Community programs for cultural empowerment as part of a breastfeeding coalition should also generate sufficient pressure to create these much-needed changes. A network of collaborators that initially educate our pregnant patients to make healthy lifestyle choices with active family participation is the first step. Politics, legislation, and new programs will then contribute for a positive change. Finally, establishing a monitoring system to document the results and the implementation of the improved maternity services as stipulated by Administrative Order 336 of the Health Department regulation should help us reach the goal of “Breastfeeding for All.” A more systematic approach by the Breastfeeding Promotion Committee should include opportunities for staff training, and regulatory visits could be the first step to pave the transformation toward a new norm for breastfeeding.
Footnotes
Acknowledgments
The author would like to thank Dr. Cindy Calderón (Maternal and Child Health Consultant, Puerto Rico Health Department) for her review of this manuscript and her leadership as the Chair of the Breastfeeding Committee, and also Gisela Castañer and Gathel Canino from Proyecto Lacta, who reviewed and collaborated in all activities related to the surveys.
Disclosure Statement
No competing financial interests exist.