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Mothers’ attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa
Women and Birth 28 (2015) e80–e86
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUALITATIVE
Mothers’ attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa Nicola L. Hawley a,*, Rochelle K. Rosen b,c, E. Ashton Strait d, Gabriela Raffucci c, Inga Holmdahl d, Joshua R. Freeman d, Bethel T. Muasau-Howard e, Stephen T. McGarvey d a
Department of Chronic Disease Epidemiology, School of Public Health, Yale University, United States Centers for Behavioral and Preventative Medicine, The Miriam Hospital, United States Department of Behavioral and Social Sciences, Warren Alpert Medical School, Brown University, United States d International Health Institute, School of Public Health, Brown University, United States e Lyndon B Johnson Tropical Medical Center, American Samoa b c
A R T I C L E I N F O
Article history: Received 24 February 2015 Received in revised form 15 April 2015 Accepted 15 April 2015 Keywords: Breastfeeding Formula Infant feeding Mothers American Samoa
A B S T R A C T
Background: In American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration. Aims: (1) To examine American Samoan mothers’ feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding. Methods: Eighteen semi-structured interviews were conducted with American Samoan mothers at 16– 32 days postpartum. Interviews focused on mother’s knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data. Findings: Intention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous ‘‘back-up option’’ where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design. Conclusion: This study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Adequate nutrition during infancy and early childhood is essential for growth, health, and development. The World Health Organization (WHO)/UNICEF guidelines for infant feeding recommend exclusive breastfeeding for the first six months, followed by nutritionally adequate and safe complementary feeding with
* Corresponding author at: Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT 06520-8034, United States. Tel.: +1 203 737 7176. E-mail address: [email protected] (N.L. Hawley).
continued breastfeeding to two years or beyond.1 Adherence to these guidelines varies widely within and across populations; worldwide it is estimated that fewer than 38% of infants are exclusively breastfed for the first six months of life2 despite numerous benefits for mother and infant.3–9 In American Samoa, initiation of breastfeeding is almost universal but the duration of exclusivity is short, with only 28% of infants exclusively breastfeeding at four months of age.10 This early decline in exclusive breastfeeding is of particular concern in this setting based on evidence that exclusive breastfeeding to four months post-partum is protective against obesity in American Samoan infants.10 With the population heavily burdened by obesity (35% of infants are overweight/obese by 15 months; 65.6%
http://dx.doi.org/10.1016/j.wombi.2015.04.002
1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
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of adults 18–74 years are obese)10,11 identifying and implementing strategies to prevent obesity-related disease is imperative and promoting exclusive breastfeeding to the recommended six months may be a promising strategy. To develop culturally appropriate interventions targeting extended exclusive breastfeeding, an understanding of the existing structural and social barriers to exclusive breastfeeding is needed. This paper contributes to this understanding by examining American Samoan mother’s experiences, as well as their knowledge, attitudes, and beliefs, about infant feeding. 2. Methods 2.1. Study design A longitudinal, mixed-methods study was designed to document and understand determinants of infant feeding practices in American Samoa. Data collection took place between April and September 2013. The study protocol consisted of quantitative questionnaire data collection at three time points: pre-delivery (average 37 weeks gestation), and at approximately 3- and 8-weeks postpartum. A subset of participants also completed semi-structured interviews at the same time points. This paper presents data from those qualitative interviews. Individual interviews were chosen for this study based on knowledge and prior experience that the Samoan culture may promote conformity to a group norm.12 We hoped that more variation in personal opinion about infant feeding would be achieved through individual interviews than in a focus group setting. 2.2. Sample A convenience sample of 46 pregnant women (Samoan ethnicity, 18 years old, with uncomplicated singleton pregnancies), due to deliver between May and July 2013, were recruited into the study from prenatal clinics at the Lyndon B Johnson Tropical Medical Center (LBJTMC) in Pago Pago, the capital city, and the Tafuna Family Health Center, Tafuna before being followed up postnatally in their homes. Both prenatal clinics provide care to low risk pregnancies, while LBJTMC also serves women with high risk pregnancies (as the only full service hospital on the island). Participants were approached in person, in the clinic waiting room, by study research assistants, and invited to participate. Of 69 potential participants approached, 61 met eligibility criteria and received a description of the study purpose and procedures. This explanation took place in a private area outside of the clinic. Research staff described clearly the longitudinal nature of the study and the time commitment associated with it. We were also cognizant of the fact that, due to our recruiting in the prenatal clinic, women may have had concerns about declining participation affecting their care. We were careful to explain that the research was independent of the prenatal care clinic and their providers, that declining participation would not affect their care, and that we would not be sharing with the providers the identities of those participants who accepted or declined participation. Of the n = 46 women recruited, all completed a quantitative questionnaire (the pre-delivery questionnaire) at the time of recruitment. Twenty-one of the 46 were then asked to participate in a semi-structured qualitative interview (which was completed immediately following the quantitative questionnaire). These 21 participants were purposively sampled to equally represent women planning to exclusively breastfeed, mixed- and formula feed, and participants were identified based on the intentions for feeding they expressed in the pre-delivery questionnaire. At 3- and 8-weeks postpartum, we were able to recontact 12 of these 21 to
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complete a follow up interview (n = 6 at both time points, n = 6 at week 3 only; 18 interviews total), with the remainder lost to follow up from both the wider study and this qualitative sub-study. 2.3. Semi-structured interview procedures All interviews were conducted in English by a female Brown University undergraduate student researcher (EAS), trained in facilitation of interviews by RKR, with minimal interpretation by a Samoan research assistant as needed. One participant required extensive use of a translator. The Samoan interviewer transcribed and translated all Samoan portions of that interview. Prior to the pre-delivery interview, the interviewer (EAS), introduced herself and explained to participants that her interest was in their personal experiences and invited participants to use their own words to describe their own experiences and opinions. She shared with participants that she herself had no experience of infant feeding, and therefore she was interested to learn from them, and that there were no right or wrong, or more or less relevant responses. The pre-delivery interviews, conducted in a private space at the prenatal clinic, were short, three-question interviews, designed to explore intentions for infant feeding and identify sources of social support (Table 1). Responses to the pre-delivery questions were used to inform the post-partum qualitative interview agendas which focused on mothers’ knowledge and beliefs about infant feeding, details of how their infants were actually being fed, why the mother had chosen this feeding method, and how decisions about infant feeding were made within her social surroundings. For example, if a woman expressed pre-delivery that her main sources of support in making decisions about infant feeding were likely to be her partner/husband and her mother, the interviewer
Table 1 Semi-structured interview guide: topics and example sub-questions.. Pre-Delivery You mentioned in the questionnaire that you plan to feed your baby [survey response: breast milk, formula etc.] why do you think the baby should be fed this way? Who was important in helping you make the decision about how you would like to feed your baby? Do you think anyone else will be sharing responsibility for feeding the baby with you? Post-Partum Interviews (3- and 8-weeks) 1. Feeding Your Baby Can you tell me about the way you planned to feed your baby before he/ she was born? How are you feeding the baby now? (If the mother reported something different than planned: can you tell me how you feel about doing _____ when originally you planned to ____?) Why did you decide to breastfeed/formula feed/feed a combination? Where did you get information to help you make that decision? 2. Family’s Role in Feeding Does anyone besides you/your partner feed the baby? Who takes care of the baby most of the time? Do any of your family buy food for the baby? Who decides what the baby is fed? Whose opinions about feeding the baby are most important to you? 3. Public Experiences Do you breastfeed your baby in public? What is that experience like? If not, would you feel comfortable breastfeeding in public? 4. Feeding and Infant Health Can you describe some of the things that you think of a healthy baby – how do they act? What do they do? How do babies tell you when they are hungry? Have you ever had trouble recognizing your baby’s hunger? How do you know when to feed the baby? How do you know when they are full? 5. Feeding Education Do you feel that you know what the best way to feed a baby is? Has anyone educated you about infant feeding? Is there anything you don’t know about infant feeding that you would like to learn? 6. General Question: Is there anything else about feeding babies in American Samoa that you would like us to know?
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would ask specifically about those supporters in the post-partum interviews. Similarly, if a woman intended to formula feed pre-delivery, but at the 3-week postpartum interview she was breastfeeding, the interviewer would ask about what motivated her to change her plans. The two post-partum interviews (at 3- and 8-weeks) were conducted in women’s homes (occasionally with other children present, but away from any other adults in the household) and took approximately 30–45 min each. This paper describes findings from a thematic analysis of the postpartum interviews (the interview guide is provided in Table 1, and the same general guide used for both interviews). Knowledge and attitudes about infant feeding did not change appreciably between the 3- and 8-week interviews, therefore the results are combined here. Informed consent was obtained from all participants and the protocol was granted ethical clearance by the Brown University Institutional Review Board (IRB), the American Samoan Department of Health, and the LBJTMC Privacy Office. The funding organization had no role in the collection of data, its analysis or interpretation.
3. Results 3.1. Participant characteristics Participants ranged in age from 22 to 36 years (Table 2). Four women were primiparous; among the eight multiparous women, all reported having breastfed an older child. All of the infants were healthy, term deliveries. In the pre-delivery interview, 11 of the 12 participants expressed intentions to exclusively breastfeed for the first few weeks (Q: ‘‘What method do you plan to use to feed your baby in the first few weeks?’’). By the three week interview, 9 of the 12 women were supplementing their breastfeeding with formula. 3.2. Themes Four salient themes emerged: attitudes and beliefs about infant feeding; breastfeeding problems; convenience; and family involvement. 3.3. Attitudes and beliefs about infant feeding
2.4. Data analysis Audio tapes of the interviews were transcribed and comments made in Samoan translated into English. Transcripts were checked against the audio recordings for accuracy and cleaned to remove identifying information. Codes for the analysis were developed after an initial reading of all the transcripts and field notes and were based on the main interview questions, prior research, and emergent concepts from the current data. To develop the codes, three reviewers (NH, GR, RKR) each independently reviewed three transcripts and constructed a draft coding structure. Those drafted codes were discussed and clarified, and an initial codebook agreed upon. The codes were further refined during coding of subsequent transcripts; where this occurred, changes were applied to all of the transcripts. All transcripts were reviewed by at least two coders (GR, NLH and RKR) who coded each transcript individually before meeting to compare and agree on final codes. All interviews were entered into NVivo software (QSR) to facilitate data management and subsequent analyses. A thematic analysis13 was conducted in which individual codes were read in aggregate and a written summary of the code was created. Thirty-seven codes were identified and these were merged into four themes. The analysis attempted to achieve a fair representation of the opinions and perceptions of the study participants. Quotes were selected to illustrate the results and participants’ colloquial language was retained.
3.3.1. Breastfeeding Most discussions of breastfeeding focused on perceived benefits for the infant. Breastfeeding seemed to be the cultural norm in American Samoa and knowledge about its benefits was widespread. By breastfeeding, mothers believed that their children would be strong, healthy, and avoid illness. When you give birth it’s better for the baby to feed for breast milk before formula. We all know that. It’s very important to breastfeed baby because, you know, in Samoa we have that thinking and saying that when you breastfeed, baby will be healthy, won’t get sick as easily. (Participant 5, age 22, first child). All participants agreed that breastfeeding was the best way to feed infants. In addition to improving their sleep and making them less constipated, many mothers indicated that breast milk provided all the nutrients and vitamins an infant needs. A number of participants also discussed breastfeeding as a way of bonding and establishing a close relationship with their babies. Some mothers claimed that they knew breastfeeding was better for their infant’s health because of their own prior experience with infant feeding. This participant had formula fed her first child: I always look back during the time [older child] was a baby. . . she always was sick, but right now, her? My newborn baby? She never has been sick. So I know the difference. That’s why I woke
Table 2 Characteristics of the study sample. Participant
Age
Number of childrena
Marital Status
Educationb
Employed
Feeding mode at interview
1
36 27 36 27 22 29 30 24 25 27 35 25
7 3 2 4 1 1 5 1 4 2 1 3
m m m m s m s c m m m m
col col pg hs col hs hs col hs hs pg hs
Yes No Yes No No No No No No No Yes Yes
Mixed feeding Mixed feeding Mixed feeding Exclusive breastfeeding Mixed feeding Mixed feeding Mixed feeding Exclusive breastfeeding Mixed feeding Exclusive breastfeeding Mixed feeding Mixed feeding
2 3 4 5 6 7 8 9 10 11 12
Abbreviations: marital status: c = cohabiting, m = married, s = single; education: col = college, hs = high school, pg = postgraduate a Number of children includes the newly born infant being discussed. b Highest level of education completed.
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up, that’s why I say I don’t want any more formulas. (Participant 10, age 27, second child). Some mothers also mentioned benefits for them, including post-partum weight loss, although these mothers were quick to explain that these motivations were secondary to the perceived benefits for the baby. 3.3.2. Formula It’s [formula] just something that substitutes my breast milk for him, but I have nothing against formula milk. (Participant 3, age 36, first child). This statement encompasses the participants’ general attitude towards formula. Although a few mothers expressed a strong negative view of formula, the majority were unable to describe any negative consequences of formula feeding. Most women saw formula purely as a supplement to breastfeeding; breastfeeding was preferred but formula a suitable alternative when breast milk was not an option. Mothers reported using formula to supplement breastfeeding when they felt the infant was not satiated after an attempt to breastfeed or when formula was a more convenient option for them. A small number of participants thought that ‘other women’ may prefer to use formula because of concerns about changes in the shape of their breasts or discomfort breastfeeding in public. Concerns about public breastfeeding were not common among the study participants but some women did describe choosing to be discrete about their breastfeeding in public (i.e. finding a private space) out of respect for the comfort of others. 3.4. Breastfeeding problems Almost all participants reported problems with breastfeeding. Pain while nursing was frequently reported but, in general, mothers agreed that their breasts became less sensitive with continued breastfeeding. Some mothers also revealed that they had inverted or cracked nipples which prevented their infant latching properly and resulted in a painful and frustrating breastfeeding experience and the need to use formula or a breast pump. Many mothers felt they were not producing enough milk to meet their child’s demands. This usually resulted in mothers supplementing their breastfeeding with formula, for example: I was first thinking of just breastfeeding him but then when he was born, I guess my breast milk didn’t supply enough for him, and then he demanded more, so I have to, my second option is the formula. (Participant 3, age 36, first child). Some mothers struggled with feelings of inadequacy and frustration when they felt they were unable to successfully breastfeed their children. Infant crying was commonly identified as a key indicator of hunger, and discussions of child hunger and satiety cues and insufficient milk supply were closely linked. For me, I don’t want to – you know it’s my first baby and it’s hard for me and I don’t want her to cry, so it’s better formula is there when I have problems for breast milk. (Participant 5, age 22, first child). Finally, some mothers expressed concerns that their own diets being high in fat and fried food might cause the baby discomfort if they breastfed. After expressing these concerns to their doctors, mothers were advised to use gripe water to soothe their babies’ stomachs after breastfeeding if they had eaten fried foods. They appeared to take this advice rather than choosing to formula feed instead.
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3.5. Convenience The convenience of breast- versus formula feeding was widely discussed, but was dependent on how convenience was defined. For breastfeeding mothers, convenience was closely linked to the high cost of formula and the fact that breastfeeding required less work (i.e. it was faster than preparing formula). When breastfeeding, I don’t have to get up and boil the bottles. . .. And it saves me a lot ‘cause the powder is like twenty, twenty two dollars a can (Participant 1, age 36, seventh child). In contrast, formula-feeding mothers described formula’s convenience either in when they felt they were not producing enough milk and formula was a convenient alternative, or when it was necessary for other people to feed their child. I want to introduce her to formula ‘cause, you know, I’m. . . I gotta lot of work to do in the household and sometimes I need my older kids to, to help me out with my child. (Participant 1, age 36, seventh child). 3.6. Family involvement Almost all participants described their mothers and experienced older sisters as being important caregivers to their infant and being sources of advice for feeding decisions. In general, husbands were described as being involved in conversations about infant feeding but ultimately deferring to the participant’s decisions. While health care providers were noted as providing invaluable support early on (during the hospital stay), women described relying on their family to guide them postpartum. One participant suggested that family support was particularly important in the American Samoan culture. She felt healthcare providers did not provide her with enough information and support before the baby was born because: I think they just assume that everybody knows. . . I don’t have sisters, and my mother passed away when I was nineteen. Living here everybody just kind of thinks that you have a family member that’s gonna explain all of that to you. (Participant 11, age 35, first child). 4. Discussion Prior to this study, very little contemporary research has been conducted on the infant feeding practices of Pacific Island populations. Our discussions with American Samoan mothers elucidated their attitudes and beliefs about infant feeding and in the process identified both potential barriers to exclusive breastfeeding and opportunities for those attempting to promote exclusive breastfeeding to capitalize on participant’s strong sense of family and belonging to the American Samoan culture. In other settings, intention to breastfeed is consistently one of the strongest predictors of breastfeeding initiation and duration.14–16 Here, however, pre-delivery intentions were not consistent with postpartum practice. Though most mothers intended to exclusively breastfeed and all women initiated breastfeeding, many began formula supplementation shortly after birth. It appeared that mothers recognized the benefits of breastfeeding, but missed the importance of exclusively breastfeeding in early infancy. Rather than supplementing because of a preference for formula, its use was described universally as a ‘‘back-up option’’ when breastfeeding was not possible or not sufficient. This is in contrast to several studies in low/middle income populations which have suggested that formula may be preferred as a symbol of status or
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wealth, or because of beliefs about its health benefits. While partial breastfeeding is better than none, particularly for infant immunity,17–19 there are many reasons, including our specific interests in promoting healthy infant weight gain in this setting, to encourage women to make their breastfeeding exclusive for the first six months. Three potential barriers to exclusive breastfeeding emerged: (1) the convenience of formula (or inconvenience of breastfeeding), (2) the common perception among mothers that they were not producing enough breast milk and (3) the pain experienced while breastfeeding. Mothers also expressed concerns about how their own diet while breastfeeding might cause the infant discomfort, but rather than this prompting formula introduction, these particular mothers took steps to minimize the exposure of their infants to their high fat/fried diet; although the action of using of gripe water as a prophylactic in this situation inherently nullified exclusive breastfeeding. Definitions of convenience varied by current feeding practices; formula-feeding mothers thought formula was convenient in times where they needed others to feed the baby, while exclusively breastfeeding mothers thought breastfeeding was more convenient both in terms of time and cost. Although, for most mothers, convenience of breastfeeding was more closely related to the relative inconvenience of the alternative (formula) than to some intrinsic value in breastfeeding. In qualitative studies in other settings formula-feeding mothers have consistently highlighted the practical benefits of bottle-feeding and tended to focus on ‘mother-centered’ issues such as bottle-feeding allowing them greater freedom.20,21 While some participants in this study did acknowledge that formula allowed others to feed the baby, their decisions to supplement with formula were far more frequently ‘child-centric’ with formula-feeding mothers declaring that it was in the best interests of their child. Importantly, convenience was closely related to women’s perceptions of infant satiety and the adequacy of her milk supply. Most participants felt they were not producing enough milk to meet their child’s demands and this usually led to formula supplementation. These findings are consistent with other studies among Samoans in New Zealand22–24 and reflect the most commonly cited reason given around the world for the early termination of breastfeeding.25–27 It is estimated that only 5–10% of women are unable to lactate because of physiological conditions,27 however, some studies do point to greater difficulties among women who are overweight/ obese or gain weight excessively during pregnancy,28–30 both of which are prevalent issues in American Samoa.31 It is more common for women to experience physiological impairment of lactation caused by either stress or the introduction of formula supplementation to the infant. Other explanations proposed include maternal misperceptions of hunger and satiety cues26,32,33 and the fact that an insufficient milk supply may be viewed as a more socially acceptable reason for weaning compared to the inconvenience of breastfeeding.27 Given how commonly insufficient milk was cited as the reason for formula supplementation, further exploration of this phenomenon among American Samoan mothers is warranted. As we seek greater understanding of insufficient milk, efforts to promote breastfeeding could begin by ensuring mothers recognize infant hunger cues and understand the demand-supply dynamics of breast milk production; a strategy that has been effective in other populations.34 As mothers often reported feelings of inadequacy and frustration with their milk supply, postpartum support should focus on reducing these feelings which could be perpetuating stress-related milk supply issues.35 Equally, efforts should focus on allaying women’s fears that their breast milk supply is inadequate to support healthy infant growth.
Most participants in this study reported pain and other difficulties while breastfeeding, which is in line with the welldocumented physical challenges of breastfeeding.36 Many mothers seemed not to have anticipated the intensity or the range of challenges that they faced while breastfeeding. One explanation for this may be that, in existing efforts to promote breastfeeding by highlighting the positive aspects, the negative aspects of breastfeeding are not being addressed. Since maternal self-efficacy is highly correlated with the duration of breastfeeding,37,38 preparing women prenatally for the challenges they are likely to face may increase maternal self-efficacy in problem-solving and in turn prolong exclusive breastfeeding.39–41 The positive influence of social support for breastfeeding initiation and duration is extremely well established42–44; both lay and professional support is effective in increasing the duration of breastfeeding.45 The importance of family members to these American Samoan mothers, particularly older, female family members, was extremely clear. Underlying American Samoan culture is the fa’a Samoa (literally, ‘‘the Samoan way’’), which distinguishes the Samoan community from the rest of their Pacific Island counterparts.46 The foundation of Fa’a Samoa is family. As such, healthcare decisions are often a family affair47,48 and this also seems to be the case for infant feeding. A caveat of fa’a Samoa in this context may be alofa, respect for older generations,46 which may make it hard for mothers to counter the recommendations of older family members about infant care and feeding. Several recent interventions, however, have shown positive outcomes for breastfeeding initiation when partners and other family members are included in breastfeeding interventions.49,50 Interventions targeting the infants’ grandmothers, a strategy which would be extremely relevant to the American Samoan population, appear to be promising.51,52 The importance of social interactions in this setting may be amenable to group interventions which have also proved to be efficacious and acceptable in other settings.50,53 4.1. Strengths and limitations This is the first study to use qualitative methods to explore infant feeding practices among American Samoan mothers. While the study sample size was small, it represented a wide range of maternal age, parity, and education. Findings may not be generalizable outside of the American Samoan population but may provide an educated starting point for discussions about breastfeeding with other Pacific Island groups. Issues with sample retention among the wider study sample impacted the qualitative study. Qualitative participants were identified based on predelivery intentions for feeding and were selected to represent women planning to exclusively breastfeed, mixed- and formula feed. Unfortunately, loss to follow up disproportionally impacted those planning to mixed- and formula feed. Those women may have had different experiences of feeding, potentially facing additional challenges which prevented their continued participation in the study or they were unwilling to discuss. Despite the limited sample size, saturation was reached on a number of the key topics. The perceived health benefits of breastfeeding, for example, were fully explored, as were the relative convenience of breast- versus formula feeding and the importance of family. Since this was an exploratory study there were both semi-structured questions, asked in all interviews, as well as emergent topics raised in only a few interviews. Some topics were therefore less fully explored. We were unable to triangulate our findings with other data collection methods, however key findings were shared with experts from the American Samoan Department of Health and WIC and their feedback supported the face validity of our findings. Transcripts were not returned to participants for comment or correction. This type of
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research is useful for documenting how women explain their decisions, but there may have been other unexpressed factors surrounding formula use that were not given for reasons of social acceptability or because they were mother- rather than child-centric. 5. Conclusion With an understanding of the barriers to exclusive breastfeeding in this setting, interventions may now be developed and existing practices strengthened. Promotion of breastfeeding is a priority for the local Department of Health and the Women, Infants, and Children (WIC) organization, who both provide prenatal and postpartum breastfeeding support services. Our findings identified a number of strategies which could be used by these organizations: making a clear distinction in the benefits of exclusive breastfeeding vs. any breastfeeding at all, preparing women for the physical challenges of breastfeeding, and involving close female family members in breastfeeding education. Providers should be particularly sensitive to educating and empowering women without family support. By implementing these practices, rates of exclusive breastfeeding in the first six months may improve and, as such, contribute to better infant health outcomes. Acknowledgements The authors would like to acknowledge the efforts of Cathy Paopao and Lucille Leota-Ngiraiwet for their assistance in facilitating the data collection in American Samoa. We would also like to acknowledge LBJTMC, the American Samoa Department of Health, and WIC American Samoa for their support of this research. EAS, IH and JF were supported by Brown University Undergraduate Teaching and Research Awards and the Framework in Global Health scholarship. References 1. World Health Organization. The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva, Switzerland: World Health Organization; 2001. 2. World Health Organization Infant and young child feeding: fact sheet N8 342. http://www.who.int/mediacentre/factsheets/fs342/en/ [accessed 07.01.15]. 3. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeeding Rev 2001;9:11–8. 4. Duijts L, Jaddoe VWV, Hofman A, Moll HA. Prolonged and exclusive breastfeeding reduces the risk of infectious disease in infancy. Pediatrics 2010;126:e18–25. 5. Galton Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy. JAMA Pediatr 2003;157: 237–43. 6. Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol 2005;161:15–26. 7. Owen CG, Whincup PH, Kaye SJ, Martin RM, Davey Smith G, Cook DG, et al. Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence. Am J Clin Nutr 2008;88:305–14. 8. Rosenblatt KA, Thomas DB. Lactation and the risk of epithelial ovarian cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiol 1993;22:192–7. 9. Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Br J Obstet Gynaecol 1994;101:804–5. 10. Hawley NL, Johnson WJ, Nu’usolia O, McGarvey ST. The contribution of feeding mode to obesogenic growth trajectories in American Samoan infants. Pediatr Obes 2014;9:e1–3. 11. Keighley ED, McGarvey ST, Quested C, McCuddin C, Viali S, Maga UA. Nutrition and health in modernizing Samoans: temporal trends and adaptive perspectives. In: Ohtsuka R, Ulijaszek SJ, editors. Health change in the Asia-Pacific region: biocultural and epidemiological approaches. Cambridge, UK: Cambridge University Press; 2007. p. 147–91. 12. Macpherson C, Macpherson LA. Samoan medical belief and practice. Auckland, NZ: Auckland University Press; 1990. 13. Guest G, McQueen KM, Namey EE. Applied thematic analysis. Thousand Oaks, CA: Sage; 2011. 14. Forster DA, McLachlan HL, Lumley J. Factors associated with breastfeeding at six months postpartum in a group of Australian women. Int Breastfeed J 2006;1:18–29.
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15. Blyth RJ, Creedy DK, Dennis CL, Moyle W, Pratt J, De Vries SM, et al. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors. J Hum Lact 2004;20:30–8. 16. Swanson V, Power KG. Initiation and continuation of breastfeeding: theory of planned behaviour. J Adv Nurs 2005;50:272–82. 17. Pabst HF, Spady DW, Pilarski LM, Carson MM, Beeler JA, Krezolek MP. Differential modulation of the immune response by breast- or formula-feeding of infants. Acta Paediatr 1997;86:1291–7. 18. Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics 2007;119:e837–42. 19. Bilenko N, Ghosh R, Levy A, Deckelbaum RJ, Fraser D. Partial breastfeeding protects Bedouin infants from infection and morbidity: prospective cohort study. Asia Pac J Clin Nutr 2008;17:243–9. 20. Shepherd CK, Power KG, Carter H. 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Gussler JD, Briesmeister LH. The insufficient milk syndrome: a biocultural explanation. Med Anthropol 1980;4:145–74. 27. Tully J, Dewey KG. Private fears, global loss: a cross-cultural study of the insufficient milk syndrome. Med Anthropol 1985;9:225–43. 28. Rasmussen KM. Association of maternal obesity before conception with poor lactation performance. Annu Rev Nutr 2007;27:103–21. 29. Li R, Jewell Grummer-Strawn L. Maternal obesity and breast-feeding practices. Am J Clin Nutr 2003;77:931–6. 30. Hilson JA, Rasmussen KM, Kjolhede CL. Excessive weight gain during pregnancy is associated with earlier termination of breast-feeding among white women. J Nutr 2006;136:140–6. 31. Hawley NL, Johnson W, Hart CN, Triche EW, Ching JA, Muasau-Howard B, et al. Gestational weight gain among American Samoan women and its impact on delivery and infant outcomes. BMC Pregnancy Childbirth 2015;15:10–7. 32. Greiner T, van Esterik P, Latham MC. The insufficient milk syndrome: an alternative explanation. Med Anthropol 1981;5:233–47. 33. Segura-Millan S, Dewey KG, Perez-Escamilla R. Factors associated with perceived insufficient milk in a low-income urban population in Mexico. J Nutr 1994;124:202–12. 34. Kandiah J, Burian C, Amend V. Teaching new mothers about infant feeding cues may increase breastfeeding duration. Food Nutr Sci 2011;2:259–64. 35. Dewey KG. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr 2001;131:3012–5. 36. Kelleher CM. The physical challenges of early breastfeeding. Soc Sci Med 2006;63:2727–38. 37. Denis C-L. Theoretical underpinning of breastfeeding confidence: a self-efficacy framework. J Hum Lact 1999;17:183–200. 38. Blyth R, Creedy D, Dennis CL, Moyle W, Pratt J, De Vries SM. Effect of maternal confidence on breastfeeding duration: an application of breastfeeding selfefficacy theory. Birth 2002;29:278–84. 39. Nichols J, Schutte NS, Brown RF, Dennis C-L, Price I. The impact of a self-efficacy intervention on short-term breast-feeding outcomes. Health Educ Behav 2009;36:250–9. 40. Noel-Weiss J, Rupp A, Cragg B, Bassett V, Woodend AK. Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding self-efficacy and breastfeeding duration. J Obstet Gynecol Neonatal Nurs 2006;35:616–24. 41. McQueen KA, Dennis C-L, Stremler R, Norman CD. A pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. J Obstet Gynecol Neonatal Nurs 2001;40:35–46. 42. Dennis CL. Breastfeeding peer support: maternal and volunteer perceptions from a randomized controlled trial. Birth 2002;29:169–76. 43. Sikorski J, Renfrew MJ, Pindoria S, Wade A. Support for breastfeeding mothers: a systematic review. Paediatr Perinat Epidemiol 2003;17:407–17. 44. Falceto OG, Giugliani ER, Fernandes CL. Couples’ relationships and breastfeeding: is there an association. J Hum Lact 2004;20:46–55. 45. Britton C, McCormick FM, Renfrew MJ, Wade A, King SE. Support for breastfeeding mothers. Cochrane Database Syst Rev 2007;1. 46. Baker PT, Hanna JM, Baker TS. The changing Samoans: behavior and health in transition. New York, NY: Oxford University Press; 1986. 47. Capstick S, Norris P, Sopoaga F, Tobata W. Relationships between health and culture in Polynesia – a review. Soc Sci Med 2009;68:1341–8. 48. Norris P, Fa’alau F, Va’ai C, Churchward M, Arroll B. Navigating between illness paradigms: treatment seeking by Samoan people in Samoa and New Zealand. Qual Health Res 2009;19:1466–75. 49. Susin LRO, Giugliani ERJ. Inclusion of fathers in an intervention to promote breastfeeding: impact on breastfeeding rates. J Hum Lact 2008;24:386–92.
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50. Dyson L, McCormick FM, Renfrew MJ. Interventions for promoting the initiation of breastfeeding. Cochrane Database Syst Rev 2005;2. 51. Aubel J, Toure I, Diagne M. Senegalese grandmothers promote improved maternal and child nutrition practices: the guardians of tradition are not adverse to change. Soc Sci Med 2004;59:945–59.
52. Ingram J, Johnson D, Hamid N. South Asian grandmothers’ influence on breast feeding in Bristol. Midwifery 2003;19:318–27. 53. Hoddinott P, Chalmers M, Pill R. One-on-one or group-based peer support for breastfeeding? Women’s perceptions of a breastfeeding peer coaching intervention. Birth 2006;33:139–46.
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Women and Birth journal homepage: www.elsevier.com/locate/wombi
ORIGINAL RESEARCH – QUALITATIVE
Mothers’ attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa Nicola L. Hawley a,*, Rochelle K. Rosen b,c, E. Ashton Strait d, Gabriela Raffucci c, Inga Holmdahl d, Joshua R. Freeman d, Bethel T. Muasau-Howard e, Stephen T. McGarvey d a
Department of Chronic Disease Epidemiology, School of Public Health, Yale University, United States Centers for Behavioral and Preventative Medicine, The Miriam Hospital, United States Department of Behavioral and Social Sciences, Warren Alpert Medical School, Brown University, United States d International Health Institute, School of Public Health, Brown University, United States e Lyndon B Johnson Tropical Medical Center, American Samoa b c
A R T I C L E I N F O
Article history: Received 24 February 2015 Received in revised form 15 April 2015 Accepted 15 April 2015 Keywords: Breastfeeding Formula Infant feeding Mothers American Samoa
A B S T R A C T
Background: In American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration. Aims: (1) To examine American Samoan mothers’ feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding. Methods: Eighteen semi-structured interviews were conducted with American Samoan mothers at 16– 32 days postpartum. Interviews focused on mother’s knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data. Findings: Intention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous ‘‘back-up option’’ where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design. Conclusion: This study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting. ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction Adequate nutrition during infancy and early childhood is essential for growth, health, and development. The World Health Organization (WHO)/UNICEF guidelines for infant feeding recommend exclusive breastfeeding for the first six months, followed by nutritionally adequate and safe complementary feeding with
* Corresponding author at: Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT 06520-8034, United States. Tel.: +1 203 737 7176. E-mail address: [email protected] (N.L. Hawley).
continued breastfeeding to two years or beyond.1 Adherence to these guidelines varies widely within and across populations; worldwide it is estimated that fewer than 38% of infants are exclusively breastfed for the first six months of life2 despite numerous benefits for mother and infant.3–9 In American Samoa, initiation of breastfeeding is almost universal but the duration of exclusivity is short, with only 28% of infants exclusively breastfeeding at four months of age.10 This early decline in exclusive breastfeeding is of particular concern in this setting based on evidence that exclusive breastfeeding to four months post-partum is protective against obesity in American Samoan infants.10 With the population heavily burdened by obesity (35% of infants are overweight/obese by 15 months; 65.6%
http://dx.doi.org/10.1016/j.wombi.2015.04.002
1871-5192/ß 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
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of adults 18–74 years are obese)10,11 identifying and implementing strategies to prevent obesity-related disease is imperative and promoting exclusive breastfeeding to the recommended six months may be a promising strategy. To develop culturally appropriate interventions targeting extended exclusive breastfeeding, an understanding of the existing structural and social barriers to exclusive breastfeeding is needed. This paper contributes to this understanding by examining American Samoan mother’s experiences, as well as their knowledge, attitudes, and beliefs, about infant feeding. 2. Methods 2.1. Study design A longitudinal, mixed-methods study was designed to document and understand determinants of infant feeding practices in American Samoa. Data collection took place between April and September 2013. The study protocol consisted of quantitative questionnaire data collection at three time points: pre-delivery (average 37 weeks gestation), and at approximately 3- and 8-weeks postpartum. A subset of participants also completed semi-structured interviews at the same time points. This paper presents data from those qualitative interviews. Individual interviews were chosen for this study based on knowledge and prior experience that the Samoan culture may promote conformity to a group norm.12 We hoped that more variation in personal opinion about infant feeding would be achieved through individual interviews than in a focus group setting. 2.2. Sample A convenience sample of 46 pregnant women (Samoan ethnicity, 18 years old, with uncomplicated singleton pregnancies), due to deliver between May and July 2013, were recruited into the study from prenatal clinics at the Lyndon B Johnson Tropical Medical Center (LBJTMC) in Pago Pago, the capital city, and the Tafuna Family Health Center, Tafuna before being followed up postnatally in their homes. Both prenatal clinics provide care to low risk pregnancies, while LBJTMC also serves women with high risk pregnancies (as the only full service hospital on the island). Participants were approached in person, in the clinic waiting room, by study research assistants, and invited to participate. Of 69 potential participants approached, 61 met eligibility criteria and received a description of the study purpose and procedures. This explanation took place in a private area outside of the clinic. Research staff described clearly the longitudinal nature of the study and the time commitment associated with it. We were also cognizant of the fact that, due to our recruiting in the prenatal clinic, women may have had concerns about declining participation affecting their care. We were careful to explain that the research was independent of the prenatal care clinic and their providers, that declining participation would not affect their care, and that we would not be sharing with the providers the identities of those participants who accepted or declined participation. Of the n = 46 women recruited, all completed a quantitative questionnaire (the pre-delivery questionnaire) at the time of recruitment. Twenty-one of the 46 were then asked to participate in a semi-structured qualitative interview (which was completed immediately following the quantitative questionnaire). These 21 participants were purposively sampled to equally represent women planning to exclusively breastfeed, mixed- and formula feed, and participants were identified based on the intentions for feeding they expressed in the pre-delivery questionnaire. At 3- and 8-weeks postpartum, we were able to recontact 12 of these 21 to
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complete a follow up interview (n = 6 at both time points, n = 6 at week 3 only; 18 interviews total), with the remainder lost to follow up from both the wider study and this qualitative sub-study. 2.3. Semi-structured interview procedures All interviews were conducted in English by a female Brown University undergraduate student researcher (EAS), trained in facilitation of interviews by RKR, with minimal interpretation by a Samoan research assistant as needed. One participant required extensive use of a translator. The Samoan interviewer transcribed and translated all Samoan portions of that interview. Prior to the pre-delivery interview, the interviewer (EAS), introduced herself and explained to participants that her interest was in their personal experiences and invited participants to use their own words to describe their own experiences and opinions. She shared with participants that she herself had no experience of infant feeding, and therefore she was interested to learn from them, and that there were no right or wrong, or more or less relevant responses. The pre-delivery interviews, conducted in a private space at the prenatal clinic, were short, three-question interviews, designed to explore intentions for infant feeding and identify sources of social support (Table 1). Responses to the pre-delivery questions were used to inform the post-partum qualitative interview agendas which focused on mothers’ knowledge and beliefs about infant feeding, details of how their infants were actually being fed, why the mother had chosen this feeding method, and how decisions about infant feeding were made within her social surroundings. For example, if a woman expressed pre-delivery that her main sources of support in making decisions about infant feeding were likely to be her partner/husband and her mother, the interviewer
Table 1 Semi-structured interview guide: topics and example sub-questions.. Pre-Delivery You mentioned in the questionnaire that you plan to feed your baby [survey response: breast milk, formula etc.] why do you think the baby should be fed this way? Who was important in helping you make the decision about how you would like to feed your baby? Do you think anyone else will be sharing responsibility for feeding the baby with you? Post-Partum Interviews (3- and 8-weeks) 1. Feeding Your Baby Can you tell me about the way you planned to feed your baby before he/ she was born? How are you feeding the baby now? (If the mother reported something different than planned: can you tell me how you feel about doing _____ when originally you planned to ____?) Why did you decide to breastfeed/formula feed/feed a combination? Where did you get information to help you make that decision? 2. Family’s Role in Feeding Does anyone besides you/your partner feed the baby? Who takes care of the baby most of the time? Do any of your family buy food for the baby? Who decides what the baby is fed? Whose opinions about feeding the baby are most important to you? 3. Public Experiences Do you breastfeed your baby in public? What is that experience like? If not, would you feel comfortable breastfeeding in public? 4. Feeding and Infant Health Can you describe some of the things that you think of a healthy baby – how do they act? What do they do? How do babies tell you when they are hungry? Have you ever had trouble recognizing your baby’s hunger? How do you know when to feed the baby? How do you know when they are full? 5. Feeding Education Do you feel that you know what the best way to feed a baby is? Has anyone educated you about infant feeding? Is there anything you don’t know about infant feeding that you would like to learn? 6. General Question: Is there anything else about feeding babies in American Samoa that you would like us to know?
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would ask specifically about those supporters in the post-partum interviews. Similarly, if a woman intended to formula feed pre-delivery, but at the 3-week postpartum interview she was breastfeeding, the interviewer would ask about what motivated her to change her plans. The two post-partum interviews (at 3- and 8-weeks) were conducted in women’s homes (occasionally with other children present, but away from any other adults in the household) and took approximately 30–45 min each. This paper describes findings from a thematic analysis of the postpartum interviews (the interview guide is provided in Table 1, and the same general guide used for both interviews). Knowledge and attitudes about infant feeding did not change appreciably between the 3- and 8-week interviews, therefore the results are combined here. Informed consent was obtained from all participants and the protocol was granted ethical clearance by the Brown University Institutional Review Board (IRB), the American Samoan Department of Health, and the LBJTMC Privacy Office. The funding organization had no role in the collection of data, its analysis or interpretation.
3. Results 3.1. Participant characteristics Participants ranged in age from 22 to 36 years (Table 2). Four women were primiparous; among the eight multiparous women, all reported having breastfed an older child. All of the infants were healthy, term deliveries. In the pre-delivery interview, 11 of the 12 participants expressed intentions to exclusively breastfeed for the first few weeks (Q: ‘‘What method do you plan to use to feed your baby in the first few weeks?’’). By the three week interview, 9 of the 12 women were supplementing their breastfeeding with formula. 3.2. Themes Four salient themes emerged: attitudes and beliefs about infant feeding; breastfeeding problems; convenience; and family involvement. 3.3. Attitudes and beliefs about infant feeding
2.4. Data analysis Audio tapes of the interviews were transcribed and comments made in Samoan translated into English. Transcripts were checked against the audio recordings for accuracy and cleaned to remove identifying information. Codes for the analysis were developed after an initial reading of all the transcripts and field notes and were based on the main interview questions, prior research, and emergent concepts from the current data. To develop the codes, three reviewers (NH, GR, RKR) each independently reviewed three transcripts and constructed a draft coding structure. Those drafted codes were discussed and clarified, and an initial codebook agreed upon. The codes were further refined during coding of subsequent transcripts; where this occurred, changes were applied to all of the transcripts. All transcripts were reviewed by at least two coders (GR, NLH and RKR) who coded each transcript individually before meeting to compare and agree on final codes. All interviews were entered into NVivo software (QSR) to facilitate data management and subsequent analyses. A thematic analysis13 was conducted in which individual codes were read in aggregate and a written summary of the code was created. Thirty-seven codes were identified and these were merged into four themes. The analysis attempted to achieve a fair representation of the opinions and perceptions of the study participants. Quotes were selected to illustrate the results and participants’ colloquial language was retained.
3.3.1. Breastfeeding Most discussions of breastfeeding focused on perceived benefits for the infant. Breastfeeding seemed to be the cultural norm in American Samoa and knowledge about its benefits was widespread. By breastfeeding, mothers believed that their children would be strong, healthy, and avoid illness. When you give birth it’s better for the baby to feed for breast milk before formula. We all know that. It’s very important to breastfeed baby because, you know, in Samoa we have that thinking and saying that when you breastfeed, baby will be healthy, won’t get sick as easily. (Participant 5, age 22, first child). All participants agreed that breastfeeding was the best way to feed infants. In addition to improving their sleep and making them less constipated, many mothers indicated that breast milk provided all the nutrients and vitamins an infant needs. A number of participants also discussed breastfeeding as a way of bonding and establishing a close relationship with their babies. Some mothers claimed that they knew breastfeeding was better for their infant’s health because of their own prior experience with infant feeding. This participant had formula fed her first child: I always look back during the time [older child] was a baby. . . she always was sick, but right now, her? My newborn baby? She never has been sick. So I know the difference. That’s why I woke
Table 2 Characteristics of the study sample. Participant
Age
Number of childrena
Marital Status
Educationb
Employed
Feeding mode at interview
1
36 27 36 27 22 29 30 24 25 27 35 25
7 3 2 4 1 1 5 1 4 2 1 3
m m m m s m s c m m m m
col col pg hs col hs hs col hs hs pg hs
Yes No Yes No No No No No No No Yes Yes
Mixed feeding Mixed feeding Mixed feeding Exclusive breastfeeding Mixed feeding Mixed feeding Mixed feeding Exclusive breastfeeding Mixed feeding Exclusive breastfeeding Mixed feeding Mixed feeding
2 3 4 5 6 7 8 9 10 11 12
Abbreviations: marital status: c = cohabiting, m = married, s = single; education: col = college, hs = high school, pg = postgraduate a Number of children includes the newly born infant being discussed. b Highest level of education completed.
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up, that’s why I say I don’t want any more formulas. (Participant 10, age 27, second child). Some mothers also mentioned benefits for them, including post-partum weight loss, although these mothers were quick to explain that these motivations were secondary to the perceived benefits for the baby. 3.3.2. Formula It’s [formula] just something that substitutes my breast milk for him, but I have nothing against formula milk. (Participant 3, age 36, first child). This statement encompasses the participants’ general attitude towards formula. Although a few mothers expressed a strong negative view of formula, the majority were unable to describe any negative consequences of formula feeding. Most women saw formula purely as a supplement to breastfeeding; breastfeeding was preferred but formula a suitable alternative when breast milk was not an option. Mothers reported using formula to supplement breastfeeding when they felt the infant was not satiated after an attempt to breastfeed or when formula was a more convenient option for them. A small number of participants thought that ‘other women’ may prefer to use formula because of concerns about changes in the shape of their breasts or discomfort breastfeeding in public. Concerns about public breastfeeding were not common among the study participants but some women did describe choosing to be discrete about their breastfeeding in public (i.e. finding a private space) out of respect for the comfort of others. 3.4. Breastfeeding problems Almost all participants reported problems with breastfeeding. Pain while nursing was frequently reported but, in general, mothers agreed that their breasts became less sensitive with continued breastfeeding. Some mothers also revealed that they had inverted or cracked nipples which prevented their infant latching properly and resulted in a painful and frustrating breastfeeding experience and the need to use formula or a breast pump. Many mothers felt they were not producing enough milk to meet their child’s demands. This usually resulted in mothers supplementing their breastfeeding with formula, for example: I was first thinking of just breastfeeding him but then when he was born, I guess my breast milk didn’t supply enough for him, and then he demanded more, so I have to, my second option is the formula. (Participant 3, age 36, first child). Some mothers struggled with feelings of inadequacy and frustration when they felt they were unable to successfully breastfeed their children. Infant crying was commonly identified as a key indicator of hunger, and discussions of child hunger and satiety cues and insufficient milk supply were closely linked. For me, I don’t want to – you know it’s my first baby and it’s hard for me and I don’t want her to cry, so it’s better formula is there when I have problems for breast milk. (Participant 5, age 22, first child). Finally, some mothers expressed concerns that their own diets being high in fat and fried food might cause the baby discomfort if they breastfed. After expressing these concerns to their doctors, mothers were advised to use gripe water to soothe their babies’ stomachs after breastfeeding if they had eaten fried foods. They appeared to take this advice rather than choosing to formula feed instead.
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3.5. Convenience The convenience of breast- versus formula feeding was widely discussed, but was dependent on how convenience was defined. For breastfeeding mothers, convenience was closely linked to the high cost of formula and the fact that breastfeeding required less work (i.e. it was faster than preparing formula). When breastfeeding, I don’t have to get up and boil the bottles. . .. And it saves me a lot ‘cause the powder is like twenty, twenty two dollars a can (Participant 1, age 36, seventh child). In contrast, formula-feeding mothers described formula’s convenience either in when they felt they were not producing enough milk and formula was a convenient alternative, or when it was necessary for other people to feed their child. I want to introduce her to formula ‘cause, you know, I’m. . . I gotta lot of work to do in the household and sometimes I need my older kids to, to help me out with my child. (Participant 1, age 36, seventh child). 3.6. Family involvement Almost all participants described their mothers and experienced older sisters as being important caregivers to their infant and being sources of advice for feeding decisions. In general, husbands were described as being involved in conversations about infant feeding but ultimately deferring to the participant’s decisions. While health care providers were noted as providing invaluable support early on (during the hospital stay), women described relying on their family to guide them postpartum. One participant suggested that family support was particularly important in the American Samoan culture. She felt healthcare providers did not provide her with enough information and support before the baby was born because: I think they just assume that everybody knows. . . I don’t have sisters, and my mother passed away when I was nineteen. Living here everybody just kind of thinks that you have a family member that’s gonna explain all of that to you. (Participant 11, age 35, first child). 4. Discussion Prior to this study, very little contemporary research has been conducted on the infant feeding practices of Pacific Island populations. Our discussions with American Samoan mothers elucidated their attitudes and beliefs about infant feeding and in the process identified both potential barriers to exclusive breastfeeding and opportunities for those attempting to promote exclusive breastfeeding to capitalize on participant’s strong sense of family and belonging to the American Samoan culture. In other settings, intention to breastfeed is consistently one of the strongest predictors of breastfeeding initiation and duration.14–16 Here, however, pre-delivery intentions were not consistent with postpartum practice. Though most mothers intended to exclusively breastfeed and all women initiated breastfeeding, many began formula supplementation shortly after birth. It appeared that mothers recognized the benefits of breastfeeding, but missed the importance of exclusively breastfeeding in early infancy. Rather than supplementing because of a preference for formula, its use was described universally as a ‘‘back-up option’’ when breastfeeding was not possible or not sufficient. This is in contrast to several studies in low/middle income populations which have suggested that formula may be preferred as a symbol of status or
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wealth, or because of beliefs about its health benefits. While partial breastfeeding is better than none, particularly for infant immunity,17–19 there are many reasons, including our specific interests in promoting healthy infant weight gain in this setting, to encourage women to make their breastfeeding exclusive for the first six months. Three potential barriers to exclusive breastfeeding emerged: (1) the convenience of formula (or inconvenience of breastfeeding), (2) the common perception among mothers that they were not producing enough breast milk and (3) the pain experienced while breastfeeding. Mothers also expressed concerns about how their own diet while breastfeeding might cause the infant discomfort, but rather than this prompting formula introduction, these particular mothers took steps to minimize the exposure of their infants to their high fat/fried diet; although the action of using of gripe water as a prophylactic in this situation inherently nullified exclusive breastfeeding. Definitions of convenience varied by current feeding practices; formula-feeding mothers thought formula was convenient in times where they needed others to feed the baby, while exclusively breastfeeding mothers thought breastfeeding was more convenient both in terms of time and cost. Although, for most mothers, convenience of breastfeeding was more closely related to the relative inconvenience of the alternative (formula) than to some intrinsic value in breastfeeding. In qualitative studies in other settings formula-feeding mothers have consistently highlighted the practical benefits of bottle-feeding and tended to focus on ‘mother-centered’ issues such as bottle-feeding allowing them greater freedom.20,21 While some participants in this study did acknowledge that formula allowed others to feed the baby, their decisions to supplement with formula were far more frequently ‘child-centric’ with formula-feeding mothers declaring that it was in the best interests of their child. Importantly, convenience was closely related to women’s perceptions of infant satiety and the adequacy of her milk supply. Most participants felt they were not producing enough milk to meet their child’s demands and this usually led to formula supplementation. These findings are consistent with other studies among Samoans in New Zealand22–24 and reflect the most commonly cited reason given around the world for the early termination of breastfeeding.25–27 It is estimated that only 5–10% of women are unable to lactate because of physiological conditions,27 however, some studies do point to greater difficulties among women who are overweight/ obese or gain weight excessively during pregnancy,28–30 both of which are prevalent issues in American Samoa.31 It is more common for women to experience physiological impairment of lactation caused by either stress or the introduction of formula supplementation to the infant. Other explanations proposed include maternal misperceptions of hunger and satiety cues26,32,33 and the fact that an insufficient milk supply may be viewed as a more socially acceptable reason for weaning compared to the inconvenience of breastfeeding.27 Given how commonly insufficient milk was cited as the reason for formula supplementation, further exploration of this phenomenon among American Samoan mothers is warranted. As we seek greater understanding of insufficient milk, efforts to promote breastfeeding could begin by ensuring mothers recognize infant hunger cues and understand the demand-supply dynamics of breast milk production; a strategy that has been effective in other populations.34 As mothers often reported feelings of inadequacy and frustration with their milk supply, postpartum support should focus on reducing these feelings which could be perpetuating stress-related milk supply issues.35 Equally, efforts should focus on allaying women’s fears that their breast milk supply is inadequate to support healthy infant growth.
Most participants in this study reported pain and other difficulties while breastfeeding, which is in line with the welldocumented physical challenges of breastfeeding.36 Many mothers seemed not to have anticipated the intensity or the range of challenges that they faced while breastfeeding. One explanation for this may be that, in existing efforts to promote breastfeeding by highlighting the positive aspects, the negative aspects of breastfeeding are not being addressed. Since maternal self-efficacy is highly correlated with the duration of breastfeeding,37,38 preparing women prenatally for the challenges they are likely to face may increase maternal self-efficacy in problem-solving and in turn prolong exclusive breastfeeding.39–41 The positive influence of social support for breastfeeding initiation and duration is extremely well established42–44; both lay and professional support is effective in increasing the duration of breastfeeding.45 The importance of family members to these American Samoan mothers, particularly older, female family members, was extremely clear. Underlying American Samoan culture is the fa’a Samoa (literally, ‘‘the Samoan way’’), which distinguishes the Samoan community from the rest of their Pacific Island counterparts.46 The foundation of Fa’a Samoa is family. As such, healthcare decisions are often a family affair47,48 and this also seems to be the case for infant feeding. A caveat of fa’a Samoa in this context may be alofa, respect for older generations,46 which may make it hard for mothers to counter the recommendations of older family members about infant care and feeding. Several recent interventions, however, have shown positive outcomes for breastfeeding initiation when partners and other family members are included in breastfeeding interventions.49,50 Interventions targeting the infants’ grandmothers, a strategy which would be extremely relevant to the American Samoan population, appear to be promising.51,52 The importance of social interactions in this setting may be amenable to group interventions which have also proved to be efficacious and acceptable in other settings.50,53 4.1. Strengths and limitations This is the first study to use qualitative methods to explore infant feeding practices among American Samoan mothers. While the study sample size was small, it represented a wide range of maternal age, parity, and education. Findings may not be generalizable outside of the American Samoan population but may provide an educated starting point for discussions about breastfeeding with other Pacific Island groups. Issues with sample retention among the wider study sample impacted the qualitative study. Qualitative participants were identified based on predelivery intentions for feeding and were selected to represent women planning to exclusively breastfeed, mixed- and formula feed. Unfortunately, loss to follow up disproportionally impacted those planning to mixed- and formula feed. Those women may have had different experiences of feeding, potentially facing additional challenges which prevented their continued participation in the study or they were unwilling to discuss. Despite the limited sample size, saturation was reached on a number of the key topics. The perceived health benefits of breastfeeding, for example, were fully explored, as were the relative convenience of breast- versus formula feeding and the importance of family. Since this was an exploratory study there were both semi-structured questions, asked in all interviews, as well as emergent topics raised in only a few interviews. Some topics were therefore less fully explored. We were unable to triangulate our findings with other data collection methods, however key findings were shared with experts from the American Samoan Department of Health and WIC and their feedback supported the face validity of our findings. Transcripts were not returned to participants for comment or correction. This type of
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research is useful for documenting how women explain their decisions, but there may have been other unexpressed factors surrounding formula use that were not given for reasons of social acceptability or because they were mother- rather than child-centric. 5. Conclusion With an understanding of the barriers to exclusive breastfeeding in this setting, interventions may now be developed and existing practices strengthened. Promotion of breastfeeding is a priority for the local Department of Health and the Women, Infants, and Children (WIC) organization, who both provide prenatal and postpartum breastfeeding support services. Our findings identified a number of strategies which could be used by these organizations: making a clear distinction in the benefits of exclusive breastfeeding vs. any breastfeeding at all, preparing women for the physical challenges of breastfeeding, and involving close female family members in breastfeeding education. Providers should be particularly sensitive to educating and empowering women without family support. By implementing these practices, rates of exclusive breastfeeding in the first six months may improve and, as such, contribute to better infant health outcomes. Acknowledgements The authors would like to acknowledge the efforts of Cathy Paopao and Lucille Leota-Ngiraiwet for their assistance in facilitating the data collection in American Samoa. We would also like to acknowledge LBJTMC, the American Samoa Department of Health, and WIC American Samoa for their support of this research. EAS, IH and JF were supported by Brown University Undergraduate Teaching and Research Awards and the Framework in Global Health scholarship. References 1. World Health Organization. The optimal duration of exclusive breastfeeding: report of an expert consultation. Geneva, Switzerland: World Health Organization; 2001. 2. World Health Organization Infant and young child feeding: fact sheet N8 342. http://www.who.int/mediacentre/factsheets/fs342/en/ [accessed 07.01.15]. 3. Oddy WH. Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeeding Rev 2001;9:11–8. 4. Duijts L, Jaddoe VWV, Hofman A, Moll HA. Prolonged and exclusive breastfeeding reduces the risk of infectious disease in infancy. Pediatrics 2010;126:e18–25. 5. Galton Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy. JAMA Pediatr 2003;157: 237–43. 6. Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol 2005;161:15–26. 7. Owen CG, Whincup PH, Kaye SJ, Martin RM, Davey Smith G, Cook DG, et al. Does initial breastfeeding lead to lower blood cholesterol in adult life? A quantitative review of the evidence. Am J Clin Nutr 2008;88:305–14. 8. Rosenblatt KA, Thomas DB. Lactation and the risk of epithelial ovarian cancer. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Int J Epidemiol 1993;22:192–7. 9. Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Br J Obstet Gynaecol 1994;101:804–5. 10. Hawley NL, Johnson WJ, Nu’usolia O, McGarvey ST. The contribution of feeding mode to obesogenic growth trajectories in American Samoan infants. Pediatr Obes 2014;9:e1–3. 11. Keighley ED, McGarvey ST, Quested C, McCuddin C, Viali S, Maga UA. Nutrition and health in modernizing Samoans: temporal trends and adaptive perspectives. In: Ohtsuka R, Ulijaszek SJ, editors. Health change in the Asia-Pacific region: biocultural and epidemiological approaches. Cambridge, UK: Cambridge University Press; 2007. p. 147–91. 12. Macpherson C, Macpherson LA. Samoan medical belief and practice. Auckland, NZ: Auckland University Press; 1990. 13. Guest G, McQueen KM, Namey EE. Applied thematic analysis. Thousand Oaks, CA: Sage; 2011. 14. Forster DA, McLachlan HL, Lumley J. Factors associated with breastfeeding at six months postpartum in a group of Australian women. Int Breastfeed J 2006;1:18–29.
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