- Email: [email protected]
Neonatal Feeding Practices of Anglo American Mothers and Asian Indian Mothers Living in the United States and India
R E S E A R CBHR I E F .
.
.
.
I
.................................................................
.......
Neonatal Feeding Practices of Anglo American Mothers and Asian Indian Mothers Living in the United States and India S R I M A T H IK A N N A N ,PHD’; B E T T YRUTHC A R R U T HPHD, , R D 2 ; J E A NS K I N N E R ,PHD, R D 2 ‘Human Nutrition Program, Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan; 2Department of Nutrition, University of Tennessee, Knoxville, Tennessee
professionals. Nutritionists are encouraged to understand t h e maternal reasons for withholding colostrum and prelacteal f e e k n g and to give compatible messages targeted at women OfAsian Indian origin about breast-feeding.
ABSTRACT
Objective: TOcompare the colostrum and prelacteal feeding practices of Anglo American mothers and Asian Indian mothers living in the United States and India.
KEY WORDS: neonatal feeds, Anglo Americans, Asian Indians, nutrition education
Design: Data were collected by interviews in the mother’s home.
(I Nutr Educ Behav. 2004;36:315-319.)
Setting:. Southeastern United States and India. Participants: Participants included 75 mother-infant pairs (n = 25 per ethnic group).
INTRODUCTION The neonatal stage of the life cycle is the first 28 days following birth.This is considered the critical stage of life, when the foundation for nutritional adequacy for future life is laid. International and national organizations recommend that mothers initiate breast-feeding within a half hour of birth.’-j Despite the maternal and infant health benefits of colostrum, mothers in many cultures across the globe are known to withhold colostrum from the n e ~ n a t e . As ~ . ~Soranus, a Roman physician of the second century, wrote: “Colostrum feeding is especially hazardous for the first few days.”h In the Indian subcontinent, there has been a historical taboo associated with feeding colostrum.’ Mothers sometimes replace colostrum with prelacteal feeds. Any food or drink other than breast milk offered to the neonate during the first 3 days of life before the mother starts breast-feeding is considered to be a prelacteal feed. To our knowledge, this is the first reported descriptive study that compares the cross-cultural neonatal feeding practices of Asian Indian mothers residing in the United States versus those living in India and Anglo American women.This investigation examines whether Asian Indian mothers living in the southeastern United States retained and continued cultural practices from their country of origin.The objectives of the study were 2-fold: to compare neonatal feeding practices, specifically the colostrum and prelacteal feeding practices ofAnglo American mothers,Asian Indian American mothers living in the United States, and Asian Indian mothers residing in India, and to deter-
Kirariables Measured: Demographic characteristics, length of US residence, mother’s colostrum and prelacteal feeding practices, and associated reasons. Analysis: Descriptive statistics. Results: All Anglo American mothers initiated breastfeeding immediately after the infant’s birth, and none gave prelacteal feeds. Asian Indian mothers living in the United States and India initiated breast-feeding postpartum at means of 12 and 30 hours, respectively. Six of the Asian Indian women living in the United States and 17 Asian Indian mothers living in India delayed introducing colostrum and fed prelacteal feeds. Conclusions and Implications: Asian Indian women who come to live in the United States demonstrate different feeding practices than their Indian counterparts. In India, women may receive guidance regarding breast-feeding primarily from relatives and friends, whereas in the United States, breast-feeding counseling may be provided by health ...................................................... Research was conducted at the Department of Nutrition, University ofTennessee. Address for correspondence: Srimathi Kannan, PhD, Human Nutrition Program. Department of Environmental Health Sciences. R o o m 6224, SPH-II. 1420 Washington Heights, School of Pubhc Health, University of Michigan, Ann Arbor, MI 48109-202Y;Tel: (734) 936-1629; Fax: (734) 763-8095; E-mail: kannans@ umich.edu. 02004 SOCIETY FOR N U T R I T I O N EDUCATION
315
316
Kannan et al/NEONATAL FEEDING PRACTICES O F ASIAN INDIAN M O T H E R S I N INDIA AND T H E US
mine the reasons for neonatal feeding practices in these 3 groups of women.
SAMPLE DESCRIPTION Recruitment of Participants Seventy-five mother-infant pairs were drawn from a population of Anglo American (n = 25) and Asian Indian mothers (n = 25) residing in the southeastern United States and a comparison group of Asian Indian mothers (n = 25) living in southeastern India. Subjects were recruited fiom university and community populations through personal and community networks, clinics and health departments, churches, and newspaper announcements of births. In addition, a recruitment poster and postage-paid, self-addressed cards were posted at community centers, clinics, and local stores that served these particular ethnic groups.
Selection Criteria and Description of Participants Potential participants from all 3 ethnic groups had to be primiparous, of middle and upper socioeconomic status, and older than 19 years; mothers on public assistance were excluded. Their infants had to be full term and healthy and weigh > 2500 g at birth. Ethnicity was based on the mother’s self-reported country of birth and the national language spoken in the home. For the Asian Indian American mothers, the infants’ parents had to be born in India, to have lived in the United States for more than 1 year and less than 8 years, and to have demonstrated fluency in spoken and written English. Similar language skills were required of the Asian Indian mothers living in India. Based on the data obtained for parental education and employment, socioeconomic status was calculated.*The study was approved by the University of Tennessee’s Knoxville Institutional Review Board for Human Subjects.
and father’s occupation, annual household income, number and age of children, and country of birth of the children. The Infant Feeding Practice Questionnaire was pilot-tested with 10 mothers in each ethnic group during personal interviews conducted in the mothers’ homes. Based on the feedback received from the mothers, a question investigating the method of preparation of prelacteal feeds was added.
Descriptive Analysis Means and frequencies were calculated for sociodemographic characteristics and for the colostrum j p d / o r prelacteal feeding practices.” Responses to open-ended questions about feeding practices and the reasons associated with these practices were tabulated.
Description of the Sociodemographic and Ethnic Characteristics The mean ages ofAsian Indian mothers living in the United States andAsian Indian mothers in India were not significantly different; however, the mothers in India were significantly younger than the mothers residing in the United States. Fourteen Anglo American versus 8 Asian Indian mothers in the United States and 8 Asian Indian mothers living in India had baccalaureate degrees. More Anglo American mothers than Asian Indian mothers living in India were employed full time and in part-time work, respectively. Over 50% of the fathers in the 3 groups held baccalaureate degrees.The fathers as primary wage earners held professional and technical jobs. Asian Indian mothers had resided in the United States for 4.7 ? 2.2 years (range 2-7 years).At the time of the interview, 14 of 25 and 20 of 25 infants of Indian origin, respectively, had a maternal grandmother living in the home. None of the Anglo American mothers had a maternal grandmother living with them at the time of the study.
LESSONS LEARNED Description of the Questionnaire Items Time When Colostrum Was Introduced The questionnaire for this study was a modified form of existing questionnaires previously used for infants in the first year of life.9*10 The Infant Feeding Practice Questionnaire included ethnicity-specific items for cultural information needed in this study and incorporated open- and closedended questions about colostrum and prelacteal feeds. Mothers gave information about the timing for initiating breastfeeding and reasons, if any, for not initiating breast-feeding. Specific questions involved whether mothers fed colostrum and/or prelacteal feeds and their reasons associated with these practices. If prelacteal feeds were given, the kinds of prelacteal feeds and methods of preparation were recorded. During the household interviews conducted with the feeding practice questionnaire, mothers provided demographic information about their marital status, age, number of years of residence in the United States, mother’s and father’s education, mother’s
All Anglo American mothers (n = 25) in this study initiated breast-feeding within the first hour postpartum, as did 19Asian Indian mothers living in the United States and 8 Asian Indlan mothers residing in India. S i x of the 25 Asian Indian infants living in the United States and 17 of the 25 infants residing in India received colostrum at a later time (mean = 12 and 30 hours following birth, respectively). Reasons for Delaying the Feeding of Colostrum Reasons associated with delaying feeding of colostrum are shown in the Table.The most common reasons cited by Asian Indian mothers in the United States related to a traditional practice to wait before introducing colostrum and the idea that friends and relatives in India were doing the same. Similarly, a
November
Journal of Nutrition Education and Behavior Volume 36 Number 6
majority of the Asian Indian mothers in India delayed the feeding of colostrum because they were following the advice dispensed by their mother or mother-in-law. Asian Indian mothers in the United States and Asian India mothers living in India, 32% and 12%, respectively, believed that colostrum causes indigestion.
Time When Prelacteal Feeds Were Introduced
All of the mothers (6 Asian Indian American mothers in the United States and 17 Asian Indian mothers living in India) Table. Summary of Reasons Reported by Asian Indian American Mothers in the United States and India for Not Feeding Colostrum" and for Offering Prelacteal Feedst
Reason
Number of Responses
For Not Feeding Colostrum (n = 6 Asian Indian Mothers in the US) It is traditional not to feed colostrum. Friends and relatives in India are not feeding colostrum. Colostrum causes diarrhea. Colostrum causes indigestion. Colostrum is not good for the infant's health. Reasons for Preiacteal Feeding (n = 6 Asian Indian Mothers in the US) Prelacteal feeds help in the flow of urine. Prelacteal feeds make the infant strona. Motherhother-in-lawkister-in-law advises prelacteal feeds. Friends and relatives in India offer prelacteal feeds. Prelacteal feeds make the infant healthy. Prelacteal feeds Drevent colds in the infant. Prelacteal feeds are a substitute for breast milk. Reasons for Not Feeding Colostrum (n = 17 Asian Indian Mothers in India) Motherhother-in-law/sister-in-law advises not feedina colostrum. Colostrum is bad for the baby. Colostrum causes indigestion. The color of the milk does not look good. The babv is too weak to suck. The baby is not able to suck. Reasons for Preiacteal Feeding (n = 17 Asian Indian Mothers in India) It is traditional to give prelacteal feeds. Motherhother-in-lawkister-in-law advises prelacteal feeds. Prelacteal feeds helD redace water. Prelacteal feeds help in the flow of urine. Physicians advise prelacteal feeds. Prelacteal feeds helD the babv sleeD better. The babv is too weak to suck. The baby needs energy. Prelacteal feeds flush out the meconium.
6
5 4 3
3
6 6 6 6 5
December 2004
317
who delayed providing colostrum used prelacteal feeds for their infants. Three of the Asian Indian mothers living in the United States and 14 of the Asian Indian mothers residing in India introduced prelacteal feeds within the first 4 hours postpartum.The 3 Asian Indian mothers living in the United States who gave prelacteal feeds did so every 6 hours for the first 24 hours compared with mothers in India who gave feedings every 4 hours for the first 24 hours postpartum and every 8 hours thereafter for the next 30 hours. The other 3 Asian Indian mothers in the United States and 3 mothers living in India who did not feed colostrum gave prelacteal feeds between 4.5 and 6 hours postpartum and offered prelacteal foods every 6 hours during the first 48 hours posdartum.
Reasons Related to Maternal Feeding of Prelacteal Foods The Table presents a summary of the reasons reported by both groups of Asian Indian mothers for offering prelacteal feeds.The most common reasons given by Indian mothers living in the United States were the following: prelacteal feeds prevent colds in the baby; they help urine flow in the baby and/or make the baby strong; such advice was given by a mother or mother-in-law; and this mimicks the feeding practices of family and friends in India. Similar to the Asian Indian mothers residing in the United States, Asian Indian mothers in India gave a repertoire of reasons for offering prelacteal feeds to the infant. Over one third of the mothers said that they were following family traditions and complying with the advice of in-laws.
Kinds of Prelacteal Feeds Offered
4 4
16 10 8 8 6
Both groups of Asian Indian mothers who delayed feeding colostrum fed a variety of prelacteal feeds to their infants. One or more of the following feeds were reported: honey, water sweetened with sugar, glucose, or jaggery (crude sugar from sugar cane). Feeds were prepared as local concoctions flavored with the following herbs in varying proportions: cumin and/or cardamom, nutmeg, asafetida, caraway, cinnamon, and aniseed. A few mothers offered castor oil.
5
DISCUSSION 10 9 8 8 7
7 5
4 4
'All mothers gave at least one reason for not feeding colostrum. tMost mothers gave at least one reason for offering prelacteal feeds.
This study attempted to understand the neonatal feeding practices of Asian Indian women living in India and Asian Indian American and Anglo American mothers residing in the southeastern region of the United States.The central research question addresses whether Asian Indian women immigrating to America adapt to the norms and infant feeding practice of the country they reside in or whether they retain the cultural norms and practices from India, their country of birth. The findings fiom this study indicate that the recommended practice of initiating breast-feeding within the first few hours of birth was more common among Anglo American
318
Kannan
et
al/NEONATAL FEEDING PRACTICES OF ASIAN INDIAN MOTHERS I N INDIA AND THE US
participants than among mothers ofAsian Indian origin. Compared with Anglo American mothers, a majority of the Asian Indian mothers living in the United States and Asian Indian mothers residing in India delayed initiation of breast-feeding and used prelacteal feeds in place of colostrum. According to the World Health Organization/UNICEF recommendations, initiating breast-feeding within 12 to 30 hours after childbirth ensures adequate amounts of colostrum intake for the infants.’ As previously stated, mothers in this study were not discarding colostrum; instead, they were delaying their initiation of the feeding of colostrum. A similar postpartum delay in the initiation of breast-feeding was seen among Hmong mothers living in Northern California.” In contrast to the feeding practices of the mothers in our study, whereby the Asian Indian American and Asian Indian mothers delayed the introduction of colostrum, mothers in some cultures expel and throw away the colostrum because they believe that “the colostrum is dirty.”13 The strong influence of family advice and cultural tradition on postpartum feeds is evident in the reasons given by both groups of Asian Indian mothers, although the degree of this influence may vary for these 2 groups. That is, 64% of Asian Indian mothers living in India compared with 20% ofAsian Indian mothers in the United States cited the influence of relatives and friends as a reason for not feeding colostrum immediately after birth. We speculate that because Asian Indian mothers living in India who participated in this investigation were younger than the Asian Indian mothers in the United States and also had greater access to family members, the magnitude of the combined influence of network members on the feeding decisions of the young Asian Indian mother living in India would be a greater proportion than of the Asian Indian mother residing in the United States. For both groups of Asian Indian mothers, the family’s influence is accompanied by cultural traditions that impact colostrum feeding decisions.This finding is partly based on our previous report that both groups ofAsian Indian mothers initiated breast-feeding at an auspicious time of the day called Mahurat. For the first year of an Indian infant’s life, the timing of major infant feeding milestones is determined by the mother and her family members based on an annual solarlunar astrological calendar that gives the auspicious times of each day for 365 days of the year.’” It is interesting to note that for both groups of mothers of Asian Indian origin, health-related reasons for neonatal feeding decisions were more numerous than other reasons reported (see Table). The mothers of Indian origin believed in the infant-centered fbnctional health benefits of prelacteal feeds, such as gastrointestinal, purgative, medicinal, physiological, developmental, and more specific nutritional benefits.This is a significant finding because neonatal prelacteal feeding practices are not in compliance with “Guidelines h m the Baby Friendly Hospital Initiative” and “Recommendations from the Expert Meeting on Optimal Feeding Practices.”’ From a cultural perspective,Asian Indian scriptures recommend feeding honey to the neonate with the objective of expelling meconium.’ Based
on our previously published results,’” neonatal feeding behaviors have a basis in the mother’s belief system about promoting wellness in the first days of an infant’s life. The introduction of prelacteal feeds may present a cultural challenge to health professionals. Rural low-income mothers in India are known to give prelacteal feeds of plain water, diluted animal milk, or milk sweetened with sugar, honey, glucose, or jaggery and an herbal concoction,Janam Ghutti.14O f 152 Egyptian neonates studied by Hossain et al, 60% were offered prelacteal feeds in the form of sugar water and regular and/or herbal teas.4 Similarly,Mexican American mothers fed herbal tea or glucose water immediately following birth.l5ll6 The current study has several 1imitations.The sample size was too small to analyze the responses for significant differences between groups. Furthermore, the overlapping nature of the categories of self-reported responses associated with the maternal reasons for colostrum and prelacteal feeding practices reported precludes the evaluation of betweengroup differences. Another important limitation is that only women residing in the southeastern United States and India were sampled.These findings may not be applicable to other Anglo American or Asian Indian mothers in the United States or Asian Indian mothers living in India. We also caution against extrapolation of findings to other ethnic groups residing in the United States. T h e results presented here are best viewed as a preliminary step toward exploring the differences between the neonatal feeding practices of mothers belonging to these 3 ethnic groups. T h e findings of this research contribute to the existing literature on cross-cultural infant feeding practices. We concluded that those Asian Indian women living in the United States who participated in our study are, in fact, adopting recommended neonatal feeding practices.Accu1turation is a slow process, one that involves several stages.We have previously shown that the longerAsian Indian mothers lived in the United States, the more similar their feeding beliefs are to that of the host culture.I0 As a function of their time of residence in the United States,Asian Indian mothers may seek and obtain increased access to feeding information that may substitute for and/or displace the family-centered resources that were reported by mothers living in 1ndia.This study adds to the literature in describing some Asian Indian primiparous mothers who are culturally changing with their current environment, whereas other primiparous mothers are not.
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study have major implications for the design of nutrition education programs for Asian Indian mothers immigrating to the United States.The study findings further support the fact that health organizations and the people served may perceive a guideline or recommendation differently. Assessing the cultural viewpoints of the population served will meet a dual purpose: it will enhance the cultural
Journal of Nutrition Education and BehaviorVolume 36 Number 6
competencies of health professionals and the effectiveness of the nutrition education programs. We can anticipate initial resistance to recommended changes in infant feeding practices from the primiparous mothers and from their supporting social network. Because time plays an important role in the acculturation process for immigrant^,'^^'^*'* the question remains as to how to accelerate positive changes in neonatal feeding practices through education and health services. The health-related reasons cited by the Asian Indian mothers living in the United States and Asian Indian mothers living in India and participating in this study reflect a universal concern about infants’ health. Focus on these health concerns may offer an opportunity to counsel Asian Indian mothers about nonrecommended prelacteal feedings.
REFERENCES 1. World Health Organization/UNICEEThe ten steps to successful breastfeeding. In: Baumslag N, ed. Breastfeeding: The Pussport to L$. New York, Ny: Sage Publishers; 1989:15-20. 2. American Dietetic Association. Position of the American Dietetic Association. Promotion and support of breast-feeding. J Am Diet Assoc. 1997;97:662-666. 3. American Academy of Pediatrics Committee on Nutrition. On the feeding of solid foods to infants. Pediatrics. 1980;65:1178-1181. 4. Hossain MM, Reves RR,Radwan MM, Habib M, Dupont HL.The timing ofbreastfeedmg initiation and its correlates in a cohort ofrural Egyptian infants.J?iop Pediatr. 1995;41:354-359. 5. Ibrahim MM, Penson LA, Omar MM, Wall S. Breast feeding and the dietary habits ofchildren in rural Somalia. Acta Pediatr. 1992;81:480-483. 6. Levin SS.A Philosophy ofInfanf Feeding. Springfield,Ill: Charles C.Thomas Publishing; 1963.
November
December 2004
319
7. Singhal GD, Guru LVAnatomical and obstetrical considerations in ancient surgery based on Susruta Samhita.Varanasi, India: B.H.U. Press; 1971. 8. Hollingshead AB. Four Factor Index o/Social Status.New Haven, Conn:Yale University Press; 1975. 9. Fomon SJ. Nutritional Disorders of Children-Prevention, Screening, Followup. Bethesda, M d US Dept of Health Education and Welfare, U S Government Printing Office; 1977. 10. Kannan S, Carruth BR, Skinner JD. Cultural influences on infant feeding beliefs of mothers.JAm Diet Assoc. 1999;99:88-90. 11. On L. An Introducfion f o Statistical Methods and Data Analysis. 3rd ed. Boston, Mass: PWS-Kent Publishing Co.; 1988. 12. Tuttle C R , Dewey KG. Impact of a breastfeeding promotion program for Hmong women at selectedWIC sites in northern California.JNutr Educ. 1995;27:69-74. 13. Gittelsohn J, ShankarAVWest KP Jr, Ram R,Dhungel C, Dahal B. Infant feeding practices reflect antecedent risk of xerophthalmia in Nepah children. EurJ Clin Nutr. 1997;51:484-490. 14. Bhandara S, Tak SK, Goyal S. Breast-feeding vs top feeding: impact on growth, morbidity, and mortality in neonatal period. Indian] Nutr Diet. 1983;20:255-258. 15. Kokmos M, Dewey KG. Infant feeding practices of migrant Mexican American families in northern California. Ecol Food Nutr. 1986;18:209-220. 16. Zive MM, McKay H, Spohner GC, Boyles SL. Nelson JA, Nader PR. Infant feeding practices and adiposity in four year old Anglo- and Mexican-Americans. AmJ Clin Nufr. 1992;55:1104-1108. 17. Dixon LB, Sundquist J,Winkleby M. Differences in energy, nutrient and food intakes in a US sample of Mexican-American women and men: findings from theThird National Health and Nutrition Examination Survey, 1988-1994. AmJ Epidemiol. 2000;152:548-557. 18. Suarez L, Hendricks KA, Cooper SP, Sweeney AM, Hardy RJ, Larsen RD. Neural tube defects among Mexican Americans living on the US-Mexico border: effects of folic acid and dietary folate. Am J Epidemiol. 2000; 152:1017-1023.
.
.
.
I
.................................................................
.......
Neonatal Feeding Practices of Anglo American Mothers and Asian Indian Mothers Living in the United States and India S R I M A T H IK A N N A N ,PHD’; B E T T YRUTHC A R R U T HPHD, , R D 2 ; J E A NS K I N N E R ,PHD, R D 2 ‘Human Nutrition Program, Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan; 2Department of Nutrition, University of Tennessee, Knoxville, Tennessee
professionals. Nutritionists are encouraged to understand t h e maternal reasons for withholding colostrum and prelacteal f e e k n g and to give compatible messages targeted at women OfAsian Indian origin about breast-feeding.
ABSTRACT
Objective: TOcompare the colostrum and prelacteal feeding practices of Anglo American mothers and Asian Indian mothers living in the United States and India.
KEY WORDS: neonatal feeds, Anglo Americans, Asian Indians, nutrition education
Design: Data were collected by interviews in the mother’s home.
(I Nutr Educ Behav. 2004;36:315-319.)
Setting:. Southeastern United States and India. Participants: Participants included 75 mother-infant pairs (n = 25 per ethnic group).
INTRODUCTION The neonatal stage of the life cycle is the first 28 days following birth.This is considered the critical stage of life, when the foundation for nutritional adequacy for future life is laid. International and national organizations recommend that mothers initiate breast-feeding within a half hour of birth.’-j Despite the maternal and infant health benefits of colostrum, mothers in many cultures across the globe are known to withhold colostrum from the n e ~ n a t e . As ~ . ~Soranus, a Roman physician of the second century, wrote: “Colostrum feeding is especially hazardous for the first few days.”h In the Indian subcontinent, there has been a historical taboo associated with feeding colostrum.’ Mothers sometimes replace colostrum with prelacteal feeds. Any food or drink other than breast milk offered to the neonate during the first 3 days of life before the mother starts breast-feeding is considered to be a prelacteal feed. To our knowledge, this is the first reported descriptive study that compares the cross-cultural neonatal feeding practices of Asian Indian mothers residing in the United States versus those living in India and Anglo American women.This investigation examines whether Asian Indian mothers living in the southeastern United States retained and continued cultural practices from their country of origin.The objectives of the study were 2-fold: to compare neonatal feeding practices, specifically the colostrum and prelacteal feeding practices ofAnglo American mothers,Asian Indian American mothers living in the United States, and Asian Indian mothers residing in India, and to deter-
Kirariables Measured: Demographic characteristics, length of US residence, mother’s colostrum and prelacteal feeding practices, and associated reasons. Analysis: Descriptive statistics. Results: All Anglo American mothers initiated breastfeeding immediately after the infant’s birth, and none gave prelacteal feeds. Asian Indian mothers living in the United States and India initiated breast-feeding postpartum at means of 12 and 30 hours, respectively. Six of the Asian Indian women living in the United States and 17 Asian Indian mothers living in India delayed introducing colostrum and fed prelacteal feeds. Conclusions and Implications: Asian Indian women who come to live in the United States demonstrate different feeding practices than their Indian counterparts. In India, women may receive guidance regarding breast-feeding primarily from relatives and friends, whereas in the United States, breast-feeding counseling may be provided by health ...................................................... Research was conducted at the Department of Nutrition, University ofTennessee. Address for correspondence: Srimathi Kannan, PhD, Human Nutrition Program. Department of Environmental Health Sciences. R o o m 6224, SPH-II. 1420 Washington Heights, School of Pubhc Health, University of Michigan, Ann Arbor, MI 48109-202Y;Tel: (734) 936-1629; Fax: (734) 763-8095; E-mail: kannans@ umich.edu. 02004 SOCIETY FOR N U T R I T I O N EDUCATION
315
316
Kannan et al/NEONATAL FEEDING PRACTICES O F ASIAN INDIAN M O T H E R S I N INDIA AND T H E US
mine the reasons for neonatal feeding practices in these 3 groups of women.
SAMPLE DESCRIPTION Recruitment of Participants Seventy-five mother-infant pairs were drawn from a population of Anglo American (n = 25) and Asian Indian mothers (n = 25) residing in the southeastern United States and a comparison group of Asian Indian mothers (n = 25) living in southeastern India. Subjects were recruited fiom university and community populations through personal and community networks, clinics and health departments, churches, and newspaper announcements of births. In addition, a recruitment poster and postage-paid, self-addressed cards were posted at community centers, clinics, and local stores that served these particular ethnic groups.
Selection Criteria and Description of Participants Potential participants from all 3 ethnic groups had to be primiparous, of middle and upper socioeconomic status, and older than 19 years; mothers on public assistance were excluded. Their infants had to be full term and healthy and weigh > 2500 g at birth. Ethnicity was based on the mother’s self-reported country of birth and the national language spoken in the home. For the Asian Indian American mothers, the infants’ parents had to be born in India, to have lived in the United States for more than 1 year and less than 8 years, and to have demonstrated fluency in spoken and written English. Similar language skills were required of the Asian Indian mothers living in India. Based on the data obtained for parental education and employment, socioeconomic status was calculated.*The study was approved by the University of Tennessee’s Knoxville Institutional Review Board for Human Subjects.
and father’s occupation, annual household income, number and age of children, and country of birth of the children. The Infant Feeding Practice Questionnaire was pilot-tested with 10 mothers in each ethnic group during personal interviews conducted in the mothers’ homes. Based on the feedback received from the mothers, a question investigating the method of preparation of prelacteal feeds was added.
Descriptive Analysis Means and frequencies were calculated for sociodemographic characteristics and for the colostrum j p d / o r prelacteal feeding practices.” Responses to open-ended questions about feeding practices and the reasons associated with these practices were tabulated.
Description of the Sociodemographic and Ethnic Characteristics The mean ages ofAsian Indian mothers living in the United States andAsian Indian mothers in India were not significantly different; however, the mothers in India were significantly younger than the mothers residing in the United States. Fourteen Anglo American versus 8 Asian Indian mothers in the United States and 8 Asian Indian mothers living in India had baccalaureate degrees. More Anglo American mothers than Asian Indian mothers living in India were employed full time and in part-time work, respectively. Over 50% of the fathers in the 3 groups held baccalaureate degrees.The fathers as primary wage earners held professional and technical jobs. Asian Indian mothers had resided in the United States for 4.7 ? 2.2 years (range 2-7 years).At the time of the interview, 14 of 25 and 20 of 25 infants of Indian origin, respectively, had a maternal grandmother living in the home. None of the Anglo American mothers had a maternal grandmother living with them at the time of the study.
LESSONS LEARNED Description of the Questionnaire Items Time When Colostrum Was Introduced The questionnaire for this study was a modified form of existing questionnaires previously used for infants in the first year of life.9*10 The Infant Feeding Practice Questionnaire included ethnicity-specific items for cultural information needed in this study and incorporated open- and closedended questions about colostrum and prelacteal feeds. Mothers gave information about the timing for initiating breastfeeding and reasons, if any, for not initiating breast-feeding. Specific questions involved whether mothers fed colostrum and/or prelacteal feeds and their reasons associated with these practices. If prelacteal feeds were given, the kinds of prelacteal feeds and methods of preparation were recorded. During the household interviews conducted with the feeding practice questionnaire, mothers provided demographic information about their marital status, age, number of years of residence in the United States, mother’s and father’s education, mother’s
All Anglo American mothers (n = 25) in this study initiated breast-feeding within the first hour postpartum, as did 19Asian Indian mothers living in the United States and 8 Asian Indlan mothers residing in India. S i x of the 25 Asian Indian infants living in the United States and 17 of the 25 infants residing in India received colostrum at a later time (mean = 12 and 30 hours following birth, respectively). Reasons for Delaying the Feeding of Colostrum Reasons associated with delaying feeding of colostrum are shown in the Table.The most common reasons cited by Asian Indian mothers in the United States related to a traditional practice to wait before introducing colostrum and the idea that friends and relatives in India were doing the same. Similarly, a
November
Journal of Nutrition Education and Behavior Volume 36 Number 6
majority of the Asian Indian mothers in India delayed the feeding of colostrum because they were following the advice dispensed by their mother or mother-in-law. Asian Indian mothers in the United States and Asian India mothers living in India, 32% and 12%, respectively, believed that colostrum causes indigestion.
Time When Prelacteal Feeds Were Introduced
All of the mothers (6 Asian Indian American mothers in the United States and 17 Asian Indian mothers living in India) Table. Summary of Reasons Reported by Asian Indian American Mothers in the United States and India for Not Feeding Colostrum" and for Offering Prelacteal Feedst
Reason
Number of Responses
For Not Feeding Colostrum (n = 6 Asian Indian Mothers in the US) It is traditional not to feed colostrum. Friends and relatives in India are not feeding colostrum. Colostrum causes diarrhea. Colostrum causes indigestion. Colostrum is not good for the infant's health. Reasons for Preiacteal Feeding (n = 6 Asian Indian Mothers in the US) Prelacteal feeds help in the flow of urine. Prelacteal feeds make the infant strona. Motherhother-in-lawkister-in-law advises prelacteal feeds. Friends and relatives in India offer prelacteal feeds. Prelacteal feeds make the infant healthy. Prelacteal feeds Drevent colds in the infant. Prelacteal feeds are a substitute for breast milk. Reasons for Not Feeding Colostrum (n = 17 Asian Indian Mothers in India) Motherhother-in-law/sister-in-law advises not feedina colostrum. Colostrum is bad for the baby. Colostrum causes indigestion. The color of the milk does not look good. The babv is too weak to suck. The baby is not able to suck. Reasons for Preiacteal Feeding (n = 17 Asian Indian Mothers in India) It is traditional to give prelacteal feeds. Motherhother-in-lawkister-in-law advises prelacteal feeds. Prelacteal feeds helD redace water. Prelacteal feeds help in the flow of urine. Physicians advise prelacteal feeds. Prelacteal feeds helD the babv sleeD better. The babv is too weak to suck. The baby needs energy. Prelacteal feeds flush out the meconium.
6
5 4 3
3
6 6 6 6 5
December 2004
317
who delayed providing colostrum used prelacteal feeds for their infants. Three of the Asian Indian mothers living in the United States and 14 of the Asian Indian mothers residing in India introduced prelacteal feeds within the first 4 hours postpartum.The 3 Asian Indian mothers living in the United States who gave prelacteal feeds did so every 6 hours for the first 24 hours compared with mothers in India who gave feedings every 4 hours for the first 24 hours postpartum and every 8 hours thereafter for the next 30 hours. The other 3 Asian Indian mothers in the United States and 3 mothers living in India who did not feed colostrum gave prelacteal feeds between 4.5 and 6 hours postpartum and offered prelacteal foods every 6 hours during the first 48 hours posdartum.
Reasons Related to Maternal Feeding of Prelacteal Foods The Table presents a summary of the reasons reported by both groups of Asian Indian mothers for offering prelacteal feeds.The most common reasons given by Indian mothers living in the United States were the following: prelacteal feeds prevent colds in the baby; they help urine flow in the baby and/or make the baby strong; such advice was given by a mother or mother-in-law; and this mimicks the feeding practices of family and friends in India. Similar to the Asian Indian mothers residing in the United States, Asian Indian mothers in India gave a repertoire of reasons for offering prelacteal feeds to the infant. Over one third of the mothers said that they were following family traditions and complying with the advice of in-laws.
Kinds of Prelacteal Feeds Offered
4 4
16 10 8 8 6
Both groups of Asian Indian mothers who delayed feeding colostrum fed a variety of prelacteal feeds to their infants. One or more of the following feeds were reported: honey, water sweetened with sugar, glucose, or jaggery (crude sugar from sugar cane). Feeds were prepared as local concoctions flavored with the following herbs in varying proportions: cumin and/or cardamom, nutmeg, asafetida, caraway, cinnamon, and aniseed. A few mothers offered castor oil.
5
DISCUSSION 10 9 8 8 7
7 5
4 4
'All mothers gave at least one reason for not feeding colostrum. tMost mothers gave at least one reason for offering prelacteal feeds.
This study attempted to understand the neonatal feeding practices of Asian Indian women living in India and Asian Indian American and Anglo American mothers residing in the southeastern region of the United States.The central research question addresses whether Asian Indian women immigrating to America adapt to the norms and infant feeding practice of the country they reside in or whether they retain the cultural norms and practices from India, their country of birth. The findings fiom this study indicate that the recommended practice of initiating breast-feeding within the first few hours of birth was more common among Anglo American
318
Kannan
et
al/NEONATAL FEEDING PRACTICES OF ASIAN INDIAN MOTHERS I N INDIA AND THE US
participants than among mothers ofAsian Indian origin. Compared with Anglo American mothers, a majority of the Asian Indian mothers living in the United States and Asian Indian mothers residing in India delayed initiation of breast-feeding and used prelacteal feeds in place of colostrum. According to the World Health Organization/UNICEF recommendations, initiating breast-feeding within 12 to 30 hours after childbirth ensures adequate amounts of colostrum intake for the infants.’ As previously stated, mothers in this study were not discarding colostrum; instead, they were delaying their initiation of the feeding of colostrum. A similar postpartum delay in the initiation of breast-feeding was seen among Hmong mothers living in Northern California.” In contrast to the feeding practices of the mothers in our study, whereby the Asian Indian American and Asian Indian mothers delayed the introduction of colostrum, mothers in some cultures expel and throw away the colostrum because they believe that “the colostrum is dirty.”13 The strong influence of family advice and cultural tradition on postpartum feeds is evident in the reasons given by both groups of Asian Indian mothers, although the degree of this influence may vary for these 2 groups. That is, 64% of Asian Indian mothers living in India compared with 20% ofAsian Indian mothers in the United States cited the influence of relatives and friends as a reason for not feeding colostrum immediately after birth. We speculate that because Asian Indian mothers living in India who participated in this investigation were younger than the Asian Indian mothers in the United States and also had greater access to family members, the magnitude of the combined influence of network members on the feeding decisions of the young Asian Indian mother living in India would be a greater proportion than of the Asian Indian mother residing in the United States. For both groups of Asian Indian mothers, the family’s influence is accompanied by cultural traditions that impact colostrum feeding decisions.This finding is partly based on our previous report that both groups ofAsian Indian mothers initiated breast-feeding at an auspicious time of the day called Mahurat. For the first year of an Indian infant’s life, the timing of major infant feeding milestones is determined by the mother and her family members based on an annual solarlunar astrological calendar that gives the auspicious times of each day for 365 days of the year.’” It is interesting to note that for both groups of mothers of Asian Indian origin, health-related reasons for neonatal feeding decisions were more numerous than other reasons reported (see Table). The mothers of Indian origin believed in the infant-centered fbnctional health benefits of prelacteal feeds, such as gastrointestinal, purgative, medicinal, physiological, developmental, and more specific nutritional benefits.This is a significant finding because neonatal prelacteal feeding practices are not in compliance with “Guidelines h m the Baby Friendly Hospital Initiative” and “Recommendations from the Expert Meeting on Optimal Feeding Practices.”’ From a cultural perspective,Asian Indian scriptures recommend feeding honey to the neonate with the objective of expelling meconium.’ Based
on our previously published results,’” neonatal feeding behaviors have a basis in the mother’s belief system about promoting wellness in the first days of an infant’s life. The introduction of prelacteal feeds may present a cultural challenge to health professionals. Rural low-income mothers in India are known to give prelacteal feeds of plain water, diluted animal milk, or milk sweetened with sugar, honey, glucose, or jaggery and an herbal concoction,Janam Ghutti.14O f 152 Egyptian neonates studied by Hossain et al, 60% were offered prelacteal feeds in the form of sugar water and regular and/or herbal teas.4 Similarly,Mexican American mothers fed herbal tea or glucose water immediately following birth.l5ll6 The current study has several 1imitations.The sample size was too small to analyze the responses for significant differences between groups. Furthermore, the overlapping nature of the categories of self-reported responses associated with the maternal reasons for colostrum and prelacteal feeding practices reported precludes the evaluation of betweengroup differences. Another important limitation is that only women residing in the southeastern United States and India were sampled.These findings may not be applicable to other Anglo American or Asian Indian mothers in the United States or Asian Indian mothers living in India. We also caution against extrapolation of findings to other ethnic groups residing in the United States. T h e results presented here are best viewed as a preliminary step toward exploring the differences between the neonatal feeding practices of mothers belonging to these 3 ethnic groups. T h e findings of this research contribute to the existing literature on cross-cultural infant feeding practices. We concluded that those Asian Indian women living in the United States who participated in our study are, in fact, adopting recommended neonatal feeding practices.Accu1turation is a slow process, one that involves several stages.We have previously shown that the longerAsian Indian mothers lived in the United States, the more similar their feeding beliefs are to that of the host culture.I0 As a function of their time of residence in the United States,Asian Indian mothers may seek and obtain increased access to feeding information that may substitute for and/or displace the family-centered resources that were reported by mothers living in 1ndia.This study adds to the literature in describing some Asian Indian primiparous mothers who are culturally changing with their current environment, whereas other primiparous mothers are not.
IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study have major implications for the design of nutrition education programs for Asian Indian mothers immigrating to the United States.The study findings further support the fact that health organizations and the people served may perceive a guideline or recommendation differently. Assessing the cultural viewpoints of the population served will meet a dual purpose: it will enhance the cultural
Journal of Nutrition Education and BehaviorVolume 36 Number 6
competencies of health professionals and the effectiveness of the nutrition education programs. We can anticipate initial resistance to recommended changes in infant feeding practices from the primiparous mothers and from their supporting social network. Because time plays an important role in the acculturation process for immigrant^,'^^'^*'* the question remains as to how to accelerate positive changes in neonatal feeding practices through education and health services. The health-related reasons cited by the Asian Indian mothers living in the United States and Asian Indian mothers living in India and participating in this study reflect a universal concern about infants’ health. Focus on these health concerns may offer an opportunity to counsel Asian Indian mothers about nonrecommended prelacteal feedings.
REFERENCES 1. World Health Organization/UNICEEThe ten steps to successful breastfeeding. In: Baumslag N, ed. Breastfeeding: The Pussport to L$. New York, Ny: Sage Publishers; 1989:15-20. 2. American Dietetic Association. Position of the American Dietetic Association. Promotion and support of breast-feeding. J Am Diet Assoc. 1997;97:662-666. 3. American Academy of Pediatrics Committee on Nutrition. On the feeding of solid foods to infants. Pediatrics. 1980;65:1178-1181. 4. Hossain MM, Reves RR,Radwan MM, Habib M, Dupont HL.The timing ofbreastfeedmg initiation and its correlates in a cohort ofrural Egyptian infants.J?iop Pediatr. 1995;41:354-359. 5. Ibrahim MM, Penson LA, Omar MM, Wall S. Breast feeding and the dietary habits ofchildren in rural Somalia. Acta Pediatr. 1992;81:480-483. 6. Levin SS.A Philosophy ofInfanf Feeding. Springfield,Ill: Charles C.Thomas Publishing; 1963.
November
December 2004
319
7. Singhal GD, Guru LVAnatomical and obstetrical considerations in ancient surgery based on Susruta Samhita.Varanasi, India: B.H.U. Press; 1971. 8. Hollingshead AB. Four Factor Index o/Social Status.New Haven, Conn:Yale University Press; 1975. 9. Fomon SJ. Nutritional Disorders of Children-Prevention, Screening, Followup. Bethesda, M d US Dept of Health Education and Welfare, U S Government Printing Office; 1977. 10. Kannan S, Carruth BR, Skinner JD. Cultural influences on infant feeding beliefs of mothers.JAm Diet Assoc. 1999;99:88-90. 11. On L. An Introducfion f o Statistical Methods and Data Analysis. 3rd ed. Boston, Mass: PWS-Kent Publishing Co.; 1988. 12. Tuttle C R , Dewey KG. Impact of a breastfeeding promotion program for Hmong women at selectedWIC sites in northern California.JNutr Educ. 1995;27:69-74. 13. Gittelsohn J, ShankarAVWest KP Jr, Ram R,Dhungel C, Dahal B. Infant feeding practices reflect antecedent risk of xerophthalmia in Nepah children. EurJ Clin Nutr. 1997;51:484-490. 14. Bhandara S, Tak SK, Goyal S. Breast-feeding vs top feeding: impact on growth, morbidity, and mortality in neonatal period. Indian] Nutr Diet. 1983;20:255-258. 15. Kokmos M, Dewey KG. Infant feeding practices of migrant Mexican American families in northern California. Ecol Food Nutr. 1986;18:209-220. 16. Zive MM, McKay H, Spohner GC, Boyles SL. Nelson JA, Nader PR. Infant feeding practices and adiposity in four year old Anglo- and Mexican-Americans. AmJ Clin Nufr. 1992;55:1104-1108. 17. Dixon LB, Sundquist J,Winkleby M. Differences in energy, nutrient and food intakes in a US sample of Mexican-American women and men: findings from theThird National Health and Nutrition Examination Survey, 1988-1994. AmJ Epidemiol. 2000;152:548-557. 18. Suarez L, Hendricks KA, Cooper SP, Sweeney AM, Hardy RJ, Larsen RD. Neural tube defects among Mexican Americans living on the US-Mexico border: effects of folic acid and dietary folate. Am J Epidemiol. 2000; 152:1017-1023.