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1.  INADEQUATE: A Metaphor for the Lives of Low-Income Women? 
Exclusive breastfeeding of infants for the first six months of life with continued breastfeeding for at least six more months occurs only 11.9% of the time in the US. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most US women. This paper analyzes the term ‘inadequate’ not just as self-description of a woman’s milk supply, but also as a metaphor for the lives of low-income women in the US, the group least likely to breastfeed. Low-income women in the US not only have inadequate incomes as compared to the general population, but inadequate child-care, education, preventive health services, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding. (190 words)
doi:10.1089/bfm.2009.0035
PMCID: PMC2763322  PMID: 19827922
2.  Poor Adherence to National and International Breastfeeding Duration Targets in an Australian Longitudinal Cohort 
PLoS ONE  2013;8(1):e54409.
Objectives
To report on the proportion and characteristics of Australian infants who are fed, and mothers who feed, in accordance with the national and international breastfeeding duration targets of six, 12 and 24 months. Furthermore, to examine the longitudinal breastfeeding duration patterns for women with more than one child.
Methods
Breastfeeding duration data for 9773 children have been self-reported by a national sample of 5091 mothers aged 30–36 years in 2009, participating in the Australian Longitudinal Study on Women’s Health.
Results
Only 60% of infants received the minimum recommended 6 months of breast milk, irrespective of breastfeeding exclusivity. Less than 30% of infants received any breast milk at 12 months, and less than 3% were breastfed to the international target of 24 months. Young, less educated, unmarried or low-income women were at an increased risk of premature breastfeeding cessation. For women with three or more children, nearly 75% of women who breastfed their first child for at least six months reached this breastfeeding duration target for their next two children.
Conclusion
While national breastfeeding rates are typically evaluated in relation to the infant, a novel component of our study is that we have assessed maternal adherence to breastfeeding duration targets and the longitudinal feeding practices of women with more than one child. Separate evaluations of maternal and infant breastfeeding rates are important as they differ in their implications for public health policy and practice.
doi:10.1371/journal.pone.0054409
PMCID: PMC3559550  PMID: 23382897
3.  Human donor milk for the vulnerable infant: a Canadian perspective 
Breast milk is the normal way to feed infants and is accepted worldwide as the optimal first source of nutrition. Though the majority intend to breastfeed, many mothers of sick, hospitalized newborns, particularly those of very low birth weight, are unable to provide a full volume of milk due to numerous physical and emotional barriers to breastfeeding. This vulnerable population of infants may benefit most from receiving breast milk nutrition and thus pasteurized donor milk should be the first consideration for supplementation when there is an inadequate supply of mother’s own milk. This commentary will briefly review the history of milk banking in Canada, as well as the best available evidence for donor milk use in the very low birth weight population, including available economic analyses, with a view to advocate for its use in these vulnerable infants.
doi:10.1186/1746-4358-9-4
PMCID: PMC4005909  PMID: 24742283
Breast milk; Mother’s own milk; Pasteurized human donor milk; Very low birth weight infants
4.  Racial/Ethnic Differences in Breastfeeding Initiation and Duration Among Low-income, Inner-city Mothers 
Social science quarterly  2009;90(5):1251-1271.
Objectives
Despite the promotion of breastfeeding as the “ideal” infant feeding method by health experts, breastfeeding continues to be less common among low-income and minority mothers than among other women. This paper investigates how maternal socio-demographic and infant characteristics, household environment, and health behaviors are related to breastfeeding initiation and duration among low-income, inner-city mothers, with a specific focus on differences in breastfeeding behavior by race/ethnicity and nativity status.
Methods
Using data from a community-based, longitudinal study of women in Philadelphia, PA (N=1,140), we estimate logistic regression and Cox proportional hazard models to predict breastfeeding initiation and duration.
Results
Both foreign-born black mothers and Hispanic mothers (most of whom were foreign-born) were significantly more likely to breastfeed their infants than non-Hispanic white women, findings that were partly explained by foreign-born and Hispanic mothers’ prenatal intention to breastfeed. In contrast to previous studies, we also found that native-born black women were more likely to breastfeed than non-Hispanic white women.
Conclusion
Our findings suggest that when poor whites and African Americans are similarly situated in an inner-city context, the disparity in their behavior with respect to infant feeding is not as distinct as documented in national surveys. Breastfeeding was also more common among low-income immigrant black women than white or native-born black mothers.
doi:10.1111/j.1540-6237.2009.00656.x
PMCID: PMC2768401  PMID: 20160902
Breastfeeding; Inner-city; Nativity; Race/Ethnicity; SES
5.  A Month of Breastfeeding Associated with Greater Adherence to Pediatric Nutrition Guidelines 
Background
Research has shown that both breastfeeding and delaying the introduction of solids or liquids other than breast milk protect against obesity later in early childhood.
Objectives
To compare whether breastfeeding mothers adhere to more of the American Academy of Pediatrics (AAP) feeding recommendations for infants.
Method
This longitudinal study compared the breastfeeding knowledge, intentions, and practices as well as complementary feeding choices of 163 ethnically diverse, primiparous women over the first 18 months of motherhood.
Results
Although almost all women knew about the health benefits of (98%) breastfeeding and intended to (98%) breastfeed, only 85% initiated and 51% continued beyond 4 weeks. Breastfeeding for longer durations was associated with better feeding choices. Mothers who breastfed for more weeks were more likely to adhere to AAP guidelines on liquids other than breast milk at 4, 6, and 12 months, and introduce solids, liquids other than breast milk, and other complimentary foods at later ages. Furthermore, mothers who breastfed for less than 1 month were more likely to introduce solids by 2 months in comparison to mothers who breastfed for 1 month or more (OR=3.22).
Conclusion
Knowledge and intentions do not explain breastfeeding initiation or continuation. However, when women committed to more weeks of breastfeeding, especially more than 4 weeks, they made better nutrition choices for their infants.
doi:10.1080/02646838.2013.784898
PMCID: PMC3779139  PMID: 24062596
Breastfeeding; Complimentary Feeding; Nutrition; Food Introduction; AAP Nutrition Guidelines; Infant nutrition; Breast milk
6.  Factors affecting intention to breastfeed among Syrian and Jordanian mothers: a comparative cross-sectional study 
Background
Breastfeeding is considered the ideal method of infant feeding for at least the first six months of life. This study aimed to compare breastfeeding intention between Syrian and Jordanian women and determine factors associated with breastfeeding intention among pregnant women in these two countries.
Methods
A cross-sectional design was used to collect data from1200 pregnant women aged 18 years and above (600 participants from each country). A self- administered questionnaire was used to collect data on socio-demographic characteristics and breastfeeding intention.
Results
Intention to breastfeed was reported by 77.2% of Syrian and 76.2% of Jordanian pregnant women. There was no significant difference in intention to breastfeed between Syrian women and Jordanian women. In both countries, women with a more positive attitude to breastfeeding, women with previous breastfeeding experience and women with supportive partners were more likely to intend to breastfeed. Syrian women with a monthly family income of more than US$200, younger than 25 and primiparous or having one child were more likely to report an intention to breastfeed their infants. Jordanian women with an education level of less than high school and not living with their family-in-law were more likely to intend to breastfeed.
Conclusions
In Syria and Jordan, a more positive attitude to breastfeeding, previous breastfeeding experience and presence of supportive husbands are associated with intention to breastfeed. These factors should be considered when planning programs designed to promote breastfeeding in these two countries.
doi:10.1186/1746-4358-5-6
PMCID: PMC2907311  PMID: 20598137
7.  Breastfeeding and Smoking among Low-Income Women: Results of a Longitudinal Qualitative Study 
Birth (Berkeley, Calif.)  2008;35(3):230-240.
Background
The benefits of breastfeeding for infants and mothers have been well established, yet rates of breastfeeding remain well below national recommendations in the United States and even lower for women who smoke during pregnancy. Primary goals of this study were to explore contextual factors that contribute to breastfeeding intentions and behavior and to examine how smoking status affected women’s decision making about breastfeeding.
Methods
This paper is based on a longitudinal qualitative study of smoking, pregnancy, and breastfeeding among 44 low-income women in the southwest U.S. who smoked during pregnancy. Each woman was interviewed 9 times; 6 times during pregnancy and 3 times postpartum using semistructured questionnaires. Interviews lasted 1 to 3 hours and were tape-recorded, transcribed, and analyzed.
Results
Despite 36 (82%) respondents stating that they intended to breastfeed for an average duration of 8 months, rates of breastfeeding initiation and duration were much lower than intentions. By 6 months postpartum, only two women were breastfeeding exclusively.
Conclusions
Women perceived that a strong risk of harming the baby was posed by smoking while breastfeeding and received little encouragement to continue breastfeeding despite an inability to stop smoking. The perceptions of the toxic, addictive, and harmful effects of smoking on breastmilk constitution and quantity factored into reasons why women weaned their infants from breastfeeding much earlier than the recommended 6 months. The results indicate a need for more consistency and routine in educating women on the relationship between smoking and breastfeeding and in promoting breastfeeding in spite of smoking postpartum. (BIRTH 35:3 September 2008)
doi:10.1111/j.1523-536X.2008.00244.x
PMCID: PMC2830716  PMID: 18844649
smoking; breastfeeding; weaning; qualitative data; harm perceptions
8.  Factors influencing infant feeding method in an urban community. 
The benefits of breastfeeding are well established. However, despite this fact, rates of breastfeeding continue to be low, falling far below the goals of Healthy People 2010. Rates are even lower among ethnic minority and low-income women. In this study, we attempt to identify the factors that most influence a mother's choice of infant feeding method in an urban predominately African-American population. Phone interviews of 70 women who delivered full-term infants at an urban tertiary care hospital were conducted in order to explore knowledge, attitudes, and beliefs about breastfeeding of the mothers and that of members of their social support network. Ten mothers (14%) exclusively breastfed. Older, caucasian, and married women were more likely to breastfeed. Breastfeeding mothers reported more partner support as well as more family knowledge about breastfeeding and had more positive attitudes about breastfeeding. Healthcare providers were not directly influential in mother's feeding choice. From this study, we conclude that in this population, the mother's partner and family are most influential in the choice of infant feeding method and, thus, should be included in breastfeeding promotion programs.
PMCID: PMC2594896  PMID: 15040514
9.  Trends in Breastfeeding: It’s Not Only at the Breast Anymore 
Maternal & child nutrition  2012;9(2):180-187.
Background
The past characterizations of breastfeeding as being only at the breast of the mother may no longer be applicable in the United States as mothers now frequently express their milk.
Methods
We conducted a retrospective cohort study with women who visited the Cincinnati Children’s Breastfeeding Medicine Clinic to understand breast milk feeding behaviors of healthy mothers and infants that included questions specifically about breast milk expression.
Results
All 40 mothers in the cohort expressed their milk and all 40 infants were fed expressed milk. One infant was fed another mother’s milk for 30 days. Two-thirds (13/40) of infants received their mother’s expressed milk at least a week after it was first expressed and 25% (10/40) of infants continued to be fed expressed breast milk after mothers had stopped expressing milk. There were 14 sequences of breast milk production by the mothers and 16 sequences of consumption by the infants. Early in the postpartum period, mothers started expressing milk even though their infants were consuming all of the breast milk that they needed at the breast.
Conclusions
As a result of breast milk expression by all mothers in this cohort, we observed highly variable patterns of maternal breast milk production and infant breast milk consumption, which were not necessarily synchronous within a dyad. It is now time to develop appropriate ways to characterize the production and consumption of breast milk more accurately and investigate whether these behaviors have consequences for the health of mothers and infants.
doi:10.1111/j.1740-8709.2012.00416.x
PMCID: PMC3448825  PMID: 22625407
human milk; breastfeeding; breast milk pumping; breast milk expression
10.  Determinants of breastfeeding initiation among mothers in Kuwait 
Background
Exclusive breastfeeding is recommended as the optimal way to feed infants for the first six months of life. While overall breastfeeding rates are high, exclusive breastfeeding is relatively uncommon among Middle Eastern women. The objective of this study was to identify the incidence of breastfeeding amongst women in the six governorates of Kuwait and the factors associated with the initiation of breastfeeding.
Methods
A sample of 373 women (aged 17-47 years), recruited shortly after delivery from four hospitals in Kuwait, completed a structured, interviewer-administered questionnaire. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.
Results
In total, 92.5% of mothers initiated breastfeeding and at discharge from hospital the majority of mothers were partially breastfeeding (55%), with only 30% of mothers fully breastfeeding. Prelacteal feeding was the norm (81.8%) and less than 1 in 5 infants (18.2%) received colostrum as their first feed. Only 10.5% of infants had been exclusively breastfed since birth, the remainder of the breastfed infants having received either prelacteal or supplementary infant formula feeds at some time during their hospital stay. Of the mothers who attempted to breastfeed, the majority of women (55.4%) delayed their first attempt to breastfeed until 24 hours or more after delivery. Breastfeeding at discharge from hospital was positively associated with paternal support for breastfeeding and negatively associated with delivery by caesarean section and with the infant having spent time in the Special Care Nursery.
Conclusions
The reasons for the high use of prelacteal and supplementary formula feeding warrant investigation. Hospital policies and staff training are needed to promote the early initiation of breastfeeding and to discourage the unnecessary use of infant formula in hospital, in order to support the establishment of exclusive breastfeeding by mothers in Kuwait.
doi:10.1186/1746-4358-5-7
PMCID: PMC2917400  PMID: 20667112
11.  Factors Related to Breastfeeding Duration 
Canadian Family Physician  1984;30:1479-1484.
The purpose of this study was to discover factors related to breastfeeding duration. Of the 131 women who volunteered to complete questionnaires at one, three and six months postpartum, 46 provided baseline data, and 37 and 48 (randomly assigned) constituted low and high intervention groups respectively. Comparisons were made between breastfeeding and bottle feeding. Factors shown at three and six months to be related to duration of breastfeeding at the p < .05 level were: identified high risk factors in labor and delivery, admission of the infant to the intensive care nursery, and length of mother's and/or infant's hospitalization. The three months' data also showed a significant relationship between spontaneous births and `breastfeeding only'. No positive relationship was found between breastfeeding duration and support from nursing staff. The results suggest that when mothers and infants experience intrapartum high risk factors, delivery by cesarean section and long hospital stay, the mothers are likely to stop breastfeeding early.
PMCID: PMC2153583  PMID: 21278959
12.  What Predicts Intent to Breastfeed Exclusively? Breastfeeding Knowledge, Attitudes, and Beliefs in a Diverse Urban Population 
Breastfeeding Medicine  2011;6(6):413-420.
Abstract
Background
Maternal knowledge and comfort with breastfeeding affect prenatal feeding intentions, and these intentions are strong predictors of feeding outcomes. However, predictors of exclusive breastfeeding intention have not been well characterized.
Methods
We measured the association between intentions to exclusively breastfeed and knowledge of infant health benefits, feeding guidelines, and comfort related to breastfeeding in social settings. Participants were lower-income, ethnically diverse women in two randomized, controlled trials of breastfeeding support. We compared results with data from the national Infant Feeding Practices Study II.
Results
Among 883 women in our trials, exclusive breastfeeding, mixed feeding, and exclusive formula feeding intentions were 45.9%, 46.1%, and 8.0%, respectively. In multivariate-adjusted models, women who disagreed that “Infant formula is as good as breastmilk” were more likely to intend exclusive breastfeeding versus exclusive formula feeding (odds ratio 3.44, 95% confidence interval 1.80–6.59) compared with women who agreed with this statement. Increasing levels of agreement that breastfed infants were less likely to develop ear infections, respiratory infections, diarrhea, and obesity were positively associated with intentions to exclusively breastfeed (p for trend < 0.001 for all). Compared with the national sample, our study participants were more likely to agree with all of these statements. Women who felt comfortable breastfeeding in public intended to exclusive breastfeed for 0.84 month longer (95% confidence interval 0.41–1.28) than those who felt uncomfortable.
Conclusions
Maternal knowledge about infant health benefits, as well as comfort with breastfeeding in social settings, was directly related to intention to exclusively breastfeed. Prenatal interventions that address these issues may increase exclusive breastfeeding intention and duration.
doi:10.1089/bfm.2010.0088
PMCID: PMC3263301  PMID: 21342016
13.  Associations among breastfeeding, smoking relapse, and prenatal factors in a brief postpartum smoking intervention 
Postpartum smoking contributes to child health problems and is a barrier to breastfeeding, which promotes child health. There is a risk of postpartum smoking relapse for smokers and they are less likely to breastfeed. Understanding of smoking–breastfeeding associations must be improved. Enhancing smoking cessation advice simultaneously with breastfeeding counseling could increase smoking abstinence and breastfeeding rates. A low income sample of 31 volunteer maternal smokers and ex-smokers were recruited for this pilot intervention in an urban hospital’s postpartum unit. Following pre-intervention interview, participants received either smoking relapse prevention plus breastfeeding counseling, or smoking relapse prevention only counseling. At one-month follow-up, we hypothesized that breastfeeding duration would positively relate to 7-day point prevalence abstinence rates and days to relapse and explored prenatal care and pregnancy smoking behavior associations with postpartum smoking and breastfeeding. Of the mothers, 75% completed follow-up. Days to relapse was related to duration of breastfeeding (r = 0.92, p = 0.08); however, counseling group differences in one-month smoking status were not significant. Earlier prenatal care initiation was associated with smoking abstinences at one month postpartum (χ2 = 4.87, p = 0.05). Early prenatal care and breastfeeding is associated with postpartum smoking abstinence.
doi:10.3109/00016341003678435
PMCID: PMC3767151  PMID: 20235894
Breastfeeding; postpartum smoking; smoking relapse
14.  A systematic review of maternal obesity and breastfeeding intention, initiation and duration 
Background
Breastfeeding behaviour is multifactorial, and a wide range of socio-cultural and physiological variables impact on a woman's decision and ability to breastfeed successfully. An association has been reported between maternal obesity and low breastfeeding rates. This is of public health concern because obesity is rising in women of reproductive age and the apparent association with increased artificial feeding will lead to a greater risk of obesity in children. The aim of this paper is to examine the relationship between maternal overweight and obesity and breastfeeding intention and initiation and duration.
Methods
A systematic review was conducted in January and February 2007, using the following databases: Medline, CINAHL and the Australian Breastfeeding Association's Lactation Resource Centre. Studies which have examined maternal obesity and infant feeding intention, initiation, duration and delayed onset of lactation were tabulated and summarised.
Results
Studies have found that obese women plan to breastfeed for a shorter period than normal weight women and are less likely to initiate breastfeeding. Of the four studies that examined onset of lactation, three reported a significant relationship between obesity and delayed lactogenesis. Fifteen studies, conducted in the USA, Australia, Denmark, Kuwait and Russia, have examined maternal obesity and duration of breastfeeding. The majority of large studies found that obese women breastfed for a shorter duration than normal weight women, even after adjusting for possible confounding factors.
Conclusion
There is evidence from epidemiological studies that overweight and obese women are less likely to breastfeed than normal weight women. The reasons may be biological or they may be psychological, behavioral and/or cultural. We urgently need qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.
doi:10.1186/1471-2393-7-9
PMCID: PMC1937008  PMID: 17608952
15.  Using community volunteers to promote exclusive breastfeeding in Sokoto State, Nigeria 
Background
Exclusive Breastfeeding (EBF) refers to the practice of feeding breast milk only, (including expressed breast milk) to infants; and excluding water, other liquids, breast milk substitutes, and solid foods. Inadequately breastfed infants are likely to be undernourished and have childhood infections. EBF knowledge and infant feeding practices have not been studied sufficiently in Sokoto State, Nigeria. We describe the results of a randomized community trial to promote Exclusive Breastfeeding (EBF) in two local government areas Kware and Bodinga selected as intervention and control groups respectively.
Methods
During advocacy meetings with community leaders, a Committee was formed. Members of the Committee were consulted for informed consent and selection of ten female volunteers who would educate mothers about breastfeeding during home visits. Participants comprised mothers of infants who were breastfeeding at the time of the study. A total of 179 mothers were recruited through systematic random sampling from each community. Volunteers conducted in-person interviews using a structured questionnaire and counseled mothers in the intervention group only.
Results
At baseline, intervention and control groups differed significantly regarding maternal occupation (P=0.07), and age of the index child (P=0.07). 42% of infants in the intervention group were up to 6 months old and about 30% of them were exclusively breastfed. Intention to EBF was significantly associated with maternal age (P=0.01), education (P=0.00) and women who were exclusively breastfeeding (P=0.00). After counseling, all infants up to 6 months of age were exclusively breastfed. The proportion of mothers with intention to EBF increased significantly with maternal age (P=0.00), occupation (P=0.00) and women who were exclusively breastfeeding (P=0.01). Post-intervention surveys showed that source of information and late initiation of breastfeeding was not significantly associated with intention to EBF. Mothers who reported practicing EBF for 6 months, were older (P=0.00) multi-parous (P=0.05) and more educated (P=0.00) compared to those who did not practice EBF. Among them, significantly increased proportion of women agreed that EBF should be continued during the night (P=0.03), infant should be fed on demand (P=0.05), sick child could be given medication (P=0.02), EBF offered protection against childhood diarrhea (P=0.01), and helped mothers with birth spacing (P=0.00).
Conclusion
This study shows that there is a need for reaching women with reliable information about infant nutrition in Sokoto State. The results show decreased EBF practice among working mothers, young women, mothers with poor education and fewer than five children. Counseling is a useful strategy for promoting the duration of EBF for six months and for developing support systems for nursing mothers. Working mothers may need additional resources in this setting to enable them to practice EBF.
PMCID: PMC3282933  PMID: 22187590
Exclusive Breast Feeding; community interventions; health promotion; Nigeria
16.  Maternal Variables Influencing Duration of Breastfeeding Among Low-Income Mothers 
This study used a retrospective comparison of 2 naturally occurring groups, first to examine how exclusive versus partial breastfeeding relates to duration of breastfeeding and, second, to determine if factors such as age and body mass index are associated with exclusive versus partial breastfeeding duration. These factors were hypothesized to influence the amount of breastfeeding in a sample of 42 low-income mothers enrolled in the Supplemental Nutrition Program for Women, Infants, and Children of a predominately rural, Midwestern county. This study examined de-identified data from a state database spanning a calendar year. Breastfeeding behavior, age, and body mass index measurements for mothers giving birth within the first 6 months of that year were analyzed. Exclusive breastfeeding mothers breastfed longer, were of older age, and had lower body mass indexes than partial breastfeeding mothers. These findings further describe characteristics of low-income breastfeeding women. Understanding how factors associated with exclusive versus partial breastfeeding affect breastfeeding duration may inform clinicians and researchers of areas for future interventions.
doi:10.1177/1941406409334379
PMCID: PMC3085246  PMID: 21544253
exclusive breastfeeding; partial breastfeeding; low income; WIC; BMI
17.  Breastfeeding and weaning practices among Hong Kong mothers: a prospective study 
Background
Breastfeeding provides optimal and complete nutrition for newborn babies. Although new mothers in Hong Kong are increasingly choosing to breastfeed their babies, rates of exclusive breastfeeding are low and duration remains short. The purpose of this study was to describe the breastfeeding and weaning practices of Hong Kong mothers over the infant's first year of life to determine the factors associated with early cessation.
Methods
A cohort of 1417 mother-infant pairs was recruited from the obstetric units of four public hospitals in Hong Kong in the immediate post-partum period and followed prospectively for 12 months or until weaned. We used descriptive statistics to describe breastfeeding and weaning practices and multiple logistic regression to investigate the relationship between maternal characteristics and breastfeeding cessation.
Results
At 1 month, 3 months, 6 months and 12 months only 63%, 37.3%, 26.9%, and 12.5% of the infants respectively, were still receiving any breast milk; approximately one-half of breastfeeding mothers were exclusively breastfeeding. Younger mothers, those with a longer duration of residence in Hong Kong, and those returning to work postpartum were more likely to wean before 1 month. Mothers with higher education, previous breastfeeding experience, who were breastfed themselves and those who were planning to exclusively breastfeed and whose husbands preferred breastfeeding were more likely to continue breastfeeding beyond 1 month. The introduction of infant formula before 1 month and returning to work postpartum were predictive of weaning before 3 months.
Conclusions
Breastfeeding promotion programs have been successful in achieving high rates of breastfeeding initiation but the focus must now shift to helping new mothers exclusively breastfeed and sustain breastfeeding for longer.
doi:10.1186/1471-2393-10-27
PMCID: PMC2887376  PMID: 20509959
18.  Breastfeeding Education and Support Trial for Overweight and Obese Women: A Randomized Trial 
Pediatrics  2013;131(1):e162-e170.
OBJECTIVE:
To evaluate a specialized breastfeeding peer counseling (SBFPC) intervention promoting exclusive breastfeeding (EBF) among overweight/obese, low-income women.
METHODS:
We recruited 206 pregnant, overweight/obese, low-income women and randomly assigned them to receive SBFPC or standard care (controls) at a Baby-Friendly hospital. SBFPC included 3 prenatal visits, daily in-hospital support, and up to 11 postpartum home visits promoting EBF and addressing potential obesity-related breastfeeding barriers. Standard care involved routine access to breastfeeding support from hospital personnel, including staff peer counselors. Data collection included an in-hospital interview, medical record review, and monthly telephone calls through 6 months postpartum to assess infant feeding practices, demographics, and health outcomes. Bivariate and logistic regression analyses were conducted.
RESULTS:
The intervention had no impact on EBF or breastfeeding continuation at 1, 3, or 6 months postpartum. In adjusted posthoc analyses, at 2 weeks postpartum the intervention group had significantly greater odds of continuing any breastfeeding (adjusted odds ratio [aOR]: 3.76 [95% confidence interval (CI): 1.07–13.22]), and giving at least 50% of feedings as breast milk (aOR: 4.47 [95% CI: 1.38–14.5]), compared with controls. Infants in the intervention group had significantly lower odds of hospitalization during the first 6 months after birth (aOR: 0.24 [95% CI: 0.07–0.86]).
CONCLUSIONS:
In a Baby-Friendly hospital setting, SBFPC targeting overweight/obese women did not impact EBF practices but was associated with increased rates of any breastfeeding and breastfeeding intensity at 2 weeks postpartum and decreased rates of infant hospitalization in the first 6 months after birth.
doi:10.1542/peds.2012-0688
PMCID: PMC3529944  PMID: 23209111
breastfeeding; peer counseling; obesity; overweight; exclusive breastfeeding; hospitalization; breastfeeding self efficacy
19.  Breastfeeding practices in a cohort of inner-city women: the role of contraindications 
BMC Public Health  2003;3:28.
Background
Little is known about the role of breastfeeding contraindications in breastfeeding practices. Our objectives were to 1) identify predictors of breastfeeding initiation and duration among a cohort of predominately low-income, inner-city women, and 2) evaluate the contribution of breastfeeding contraindications to breastfeeding practices.
Methods
Mother-infant dyads were systematically selected from 3 District of Columbia hospitals between 1995 and 1996. Breastfeeding contraindications and potential predictors of breastfeeding practices were identified through medical record reviews and interviews conducted after delivery (baseline). Interviews were conducted at 3–7 months postpartum and again at 7–12 months postpartum to determine breastfeeding initiation rates and duration. Multivariable logistic regression analysis was used to identify baseline factors associated with initiation of breastfeeding. Cox proportional hazards models were generated to identify baseline factors associated with duration of breastfeeding.
Results
Of 393 study participants, 201 (51%) initiated breastfeeding. A total of 61 women (16%) had at lease one documented contraindication to breastfeeding; 94% of these had a history of HIV infection and/or cocaine use. Of the 332 women with no documented contraindications, 58% initiated breastfeeding, vs. 13% of women with a contraindication. In adjusted analysis, factors most strongly associated with breastfeeding initiation were presence of a contraindication (adjusted odds ratio [AOR], 0.19; 95% confidence interval [CI], 0.08–0.47), and mother foreign-born (AOR, 4.90; 95% CI, 2.38–10.10). Twenty-five percent of study participants who did not initiate breastfeeding cited concern about passing dangerous things to their infants through breast milk. Factors associated with discontinuation of breastfeeding (all protective) included mother foreign-born (hazard ratio [HR], 0.55; 95% CI 0.39–0.77) increasing maternal age (HR for 5-year increments, 0.80; 95% CI, 0.69–0.92), and infant birth weight ≥ 2500 grams (HR, 0.45; 95% CI, 0.26–0.80).
Conclusions
Breastfeeding initiation rates and duration were suboptimal in this inner-city population. Many women who did not breastfeed had contraindications and/or were concerned about passing dangerous things to their infants through breast milk. It is important to consider the prevalence of contraindications to breastfeeding when evaluating breastfeeding practices in high-risk communities.
doi:10.1186/1471-2458-3-28
PMCID: PMC194636  PMID: 12930560
20.  Marketing Breastfeeding—Reversing Corporate Influence on Infant Feeding Practices 
Breast milk is the gold standard for infant nutrition and the only necessary food for the first 6 months of an infant’s life. Infant formula is deficient and inferior to breast milk in meeting infants’ nutritional needs. The infant formula industry has contributed to low rates of breastfeeding through various methods of marketing and advertising infant formula. Today, in New York City, although the majority of mothers initiate breastfeeding (~85%), a minority of infants is breastfed exclusively at 8 weeks postpartum (~25%). The article reviews the practices of the formula industry and the impact of these practices. It then presents the strategic approach taken by the NYC Department of Health and Mental Hygiene and its partners to change hospital practices and educate health care providers and the public on the benefits of breast milk, and provides lessons learned from these efforts to make breastfeeding the normative and usual method of infant feeding in New York City.
doi:10.1007/s11524-008-9279-6
PMCID: PMC2443254  PMID: 18463985
Breastfeeding; Corporate influence; Infant; Nutrition; Infant feeding; Infant formula
21.  Breast milk pasteurisation in developed countries to reduce HIV transmission. Do the benefits outweigh the risks? 
BACKGROUND: Transmission of HIV through breastfeeding is well documented. The World Health Organisation advise HIV-infected women in developed countries to use alternatives to breastfeeding together with highly active antiretroviral therapy and optimal management of delivery to prevent transmission of HIV to their infant. CASE REPORT: We present the case of an HIV-infected woman electing to exclusively breastfeed for six months and applying milk pasteurisation techniques without transmission to her infant. Two paired samples of her breast milk were tested for HIV RNA prior to and after pasteurisation. The first pair of specimens reported no change in HIV RNA copy number, the second pair of specimens reported an increase in copy number. DISCUSSION: This technique, the evidence for HIV inactivation and the effects pasteurisation has on nutritional and immunological components of breast milk are discussed. CONCLUSION: In conclusion, we believe there is currently insufficient data to recommend this technique either as a safe alternative to formula feeding in resource-rich countries or as a method for providing intact immunological components of breast milk to the infant.
doi:10.1080/10647440500097627
PMCID: PMC1784574  PMID: 16338785
22.  Is breastfeeding really invisible, or did the health care system just choose not to notice it? 
There are innumerable myths and misconceptions about breastfeeding that minimize its importance; these often keep health workers from providing effective care to support and protect breastfeeding. They are compounded by lack of basic and applied research, and by the cultural invisibility of breastfeeding in the United States. This paper highlights some of the blind spots and suggests the importance of an approach that places breastfeeding promotion and advocacy within the context of women's lives. As we work to ensure that the health care system provides good breastfeeding care, we need to guard against letting the medicalization of infant feeding keep us from remembering that breastfeeding is something that mothers and children do, in all the aspects of their private and public lives.
doi:10.1186/1746-4358-3-13
PMCID: PMC2516507  PMID: 18680580
23.  Independent predictors of breastfeeding intention in a disadvantaged population of pregnant women 
BMC Public Health  2001;1:10.
Background
Breastfeeding rates in Scotland are very low, particularly in the more disadvantaged areas. Despite a number of interventions to promote breastfeeding very few women actually intend to breastfeed their baby. The aim of this study was to identify personal and social factors independently associated with intention to breastfeed.
Methods
Nine hundred and ninety seven women from two socio-economically disadvantaged housing estates located on the outskirts of Glasgow participated in a study that aimed to increase the prevalence of breastfeeding. Self-administered questionnaires completed by each participant collected information in early pregnancy, prior to exposure to the study intervention, on feeding intention, previous feeding experience and socio-demographic data.
Results
Five factors were independently predictive of breastfeeding intention. These were previous breastfeeding experience, living with a partner, smoking, parity and maternal age. After adjusting for these five factors, neither deprivation nor receipt of milk tokens provided useful additional predictive information.
Conclusion
In this population of socially disadvantaged pregnant women we identified five variables that were independently predictive of breastfeeding intention. These variables could be useful in identifying women at greatest risk of choosing not to breastfeed. Appropriate promotional efforts could then be designed to give due consideration to individual circumstances.
doi:10.1186/1471-2458-1-10
PMCID: PMC59841  PMID: 11710967
24.  Perceived Incentives and Barriers to Exclusive Breastfeeding Among Periurban Ghanaian Women 
Focus group discussions were conducted to elicit the perceived incentives and barriers to exclusive breastfeeding in Ghana. Thirty-five breastfeeding women were recruited from the Manya and Yilo Krobo districts of the eastern region. Participants had a mean age of 27.5 years and had at least one child < 4 months old. Almost all of the participants believed that exclusive breastfeeding is the superior infant feeding method and should be practiced for the first 6 months postpartum. However, there was widespread belief that infants can be given water if it is clean. Mothers reported that exclusive breastfeeding was easier when breast milk began to flow soon after delivery. The main obstacles to exclusive breastfeeding identified were maternal employment, breast and nipple problems, perceived milk insufficiency, and pressure from family. Addressing the concerns put forward by these participants can be used to enhance exclusive breastfeeding promotion in this region.
doi:10.1177/0890334408325072
PMCID: PMC4048713  PMID: 18971507
Africa; exclusive breastfeeding; Ghana; incentives; barriers; focus groups
25.  BREASTFEEDING PRACTICE IN DAMMAM AREA OF SAUDI ARABIA 
Objectives:
The main objective of this study was to determine the breastfeeding status for children under 24 months and assess the causes of breastfeeding failure among those mothers who do not breastfeed their babies.
Methodology:
This study was conducted on a sampled population of 1185 children under 24 months of age, using breastfeeding indicators recommended by World Health Organization, for assessing breastfeeding practices within a recall period of 24 hours, in the Dammam area of Saudi Arabia.
Results:
The exclusive breastfeeding rate and predominantly breastfeeding rates were 33% and 11.5%, respectively, under 4 months of age among these children. The timely complementary feeding rate was 31.7% only. All the values were far behind those recommended. The reasons given in order of their frequencies by the mothers for failure to breastfeed were insufficient milk, advice and example of other mothers and formula milk advertisement.
Conclusion:
This study recognizes the low level of exclusive breastfeeding among children under 4 months of age and lays emphasis on changing the behavior of mothers towards exclusive breastfeeding. This can be achieved by special integrated community-based approaches among potential mothers by supporting them after delivery and proper follow-up, to prevent failure of milk formation and discontinuation of breastfeeding.
PMCID: PMC3437121  PMID: 23008584
Exclusive breastfeeding; complementary feeding; breastmilk failure

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