A Critical Ethnographic Study of the Cultural Values, Beliefs, and Practices of Recently

Immigrated Mexican Primiparas Regarding Infant Feeding with a Focus on Exclusive

BreastfeedingBonita Shviraga, PhD, CNM

Sept. 15, 2012

Funding provided by Sigma Theta Tau Alpha Kappa Chapter-At-Large and American College of Nurse-Midwives Chapter V-3

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Purpose

To investigate the cultural values, beliefs, and practices regarding infant feeding with a focus on exclusive breastfeeding in Mexican primiparas who have immigrated to the United States within the last five years using a critical ethnographic approach.

Aims To describe the cultural values, beliefs, and practices of recently

immigrated Mexican primiparas surrounding infant feeding with a focus on exclusive breastfeeding during the first three months of life.

To explore if (and how) culture, gender, and issues of power/marginalization affect recently immigrated Mexican primiparas’ attitudes, beliefs, and practices regarding infant feeding and exclusive breastfeeding.

To gain an understanding of how recently immigrated Mexican primiparas respond to nurses’ and healthcare providers’ “authoritative” knowledge regarding exclusive breastfeeding, to determine how the women “sort through” this information, and if and how they integrate this knowledge/information to create new unique understandings/approaches to exclusive breastfeeding.

Significance (So What?)In order for nursing to support exclusive

breastfeeding in this population, it is important to understand the factors which may affect the sustainability of exclusive breastfeeding

To provide direction to change individual provider care management and system processes to increase exclusive breastfeeding in this population

Ultimately health of infants can be improved if exclusive breastfeeding is increased in this population

BackgroundWorldwide acknowledged exclusive breastfeeding

(EBF) is preferred method for feeding infants through the first year of life

Infant benefits: decreases otitis media, atopic dermatitis, gastroenteritis, URI, asthma, obesity, diabetes, SIDS, childhood leukemia, NEC.

Maternal benefits: decreased Type 2 diabetes, decreased breast and ovarian cancer, decreased weight, child spacing.

No breastfeeding increases risk of postpartum depression.

Several governmental agencies agenda to increase BF/EBF in United States: CDC, , DHHS, CDPHE, U.S. Breastfeeding Committee. U.S. Surgeon General 2011.

JCAHO outcome indicator: EBF at hospital dischargeHealthy People 2010 (U.S. DHHS) added EBF target

goals in 2007 and continued focus on EBF in Healthy People 2020Initiation BF 81.9% (Hispanic 81%; Hispanic 90%

state)EBF 46.2% at 3 months (Hispanic 23%)EBF 25.5% at 6 months (Hispanic 13%)Formula by 2 days (Hispanic 33%)Formula by 3 months (Hispanic 43%)

Research Site and ParticipantsWomen’s Infants Childrens (WIC) Program Western StateTwo offices in Metro AreaPrimary site large Hispanic PopulationWomen’s homes for some interviews

Inclusion Criteria>18 years oldRecently immigrated from Mexico < 5 yearsPlanning to breastfeed>37 weeksNot in NICU; no structural abnormalities

Demographic Description of ParticipantsCharacteristic N = 13 Range

Age Mean age = 25 19 - 35

Marital statusMarried /partner=11Single = 2

Education (years) Mean 12 6 - 15

Months in United States Mean 27.8 4 - 59

Rural or UrbanRural = 7Urban = 5Unknown = 1

Breastfeeding intentionEBF = 11Los dos = 2Los dos when work = 3

Intended duration exclusive breastfeeding (months) Mean 8.8 3 - 24

Critical Ethnographic Method and Analysis

Figure 1 Hermeneutic Circle of Methodology Utilizing Carspecken’s (1996) CQR Stages

Preliminary steps List 1 & List 2 Researcher journal ing

Stage 1 Observation Journaling

Stage 2 Researcher interpretation (etic); document analysis; preliminary analysis and coding

Stage 3a Individual interviews & participant observation; Journaling; Document analysis

Stage 3b Analysis & coding of interviews and field notes (emic), document analysis; reflections

Results

WIC Embraces a Culture of Exclusive Breastfeeding

Respect and caring toward women: respect choiceWIC as gatekeeper to resources: rules and economic

incentivesBusiness of WIC limited time to discuss women’s

concernsPeer counselor programInconsistent messaging of information

NEW FINDINGSWIC environment encourages breastfeedingWIC is major source of information regarding

breastfeeding for women

Theme One “Breastfeeding is a Natural Choice”

Breastfeeding is a cultural norm

“There’s not choice…it’s not like you can choose. Everybody, when they’re going to have a baby, they already know they’re going to breastfeed…They ask for advice…they ask the mom, or the sister…once the baby is born that’s what follows, breastfeeding.”

Theme One “Breastfeeding is a Natural Choice”

Values claims regarding exclusive breastfeedingBest for babyMaternal-infant bond

Cultural practices to support breastfeedingPractices to increase breast milk e.g. atole, caldoBeliefs regarding practices that decreased breast milk

Susto (fright) and coraje (anger) Cold

Challenges to exclusive breastfeeding Insufficient milk Pain

Theme Two “Breastfeeding is Woman’s Work”

Identity“in Mexico breastfeeding is woman’s work. Men don’t talk about that,

or women don’t talk to their husbands. It only between women. Since I don’t have someone here that I can talk to – well, it’s with my husband.”

NEW FINDINGS:“I am a Mother” Values EBF and ability to EBF and provide “best for baby” influenced

maternal identity “see how my baby has grown, and as for being a mother, it feels good.” “I feel more like a mom.”

Difficulties breastfeeding challenged maternal identity“It doesn’t mean I am a bad mother…that I am a bad woman for not being able to produce milk…psychologically, it was eating me up.”

“Breastfeeding is Woman’s Work”“Estoy sola.” (“I am alone.”)

Limited supportStruggling aloneMany female family or friends not viewed as supportiveMothers long-distance support (usually, one advised los

dos)Change in male gender role; husbands more involved “it’s

just us”

Loss of the cuarentena“…I was used to seeing how it is there, that they (sister,

mother) tend to you and everything…and not here…I will be on my own. Only with my husband.”

Isolation: “here one has to try to take care of oneself… on my own.”

Theme Two “Breastfeeding is Woman’s Work”

Isolation: Doubt, Frustration, Desperation

“I try to latch him and…he cries and cries and I don’t know what to do at that moment.”

“it was difficult because I didn’t have support at home. I was on my own and my husband went to work, so then I had to do it alone…there are times that you feel desperate, and I called, they calmed me down…and then I was able to do it by myself…it was so much desperation that I said, “…I will give formula” but then I said, “…no, it’s not fair…because of my desperation.”

Theme Two “Breastfeeding is Women’s Work”Women Demonstrated Agency

NEW FINDINGS: AGENCY

Women Demonstrated Agency EBF Decisions “I made the final decisions about exclusively breastfeeding the baby.” Authoritative knowledge and voices Women valued and sought out biomedical knowledge and information Use of Internet and technology Willing to question healthcare providers

How Women Made Decisions Importance Can Do 5, stomach model, comparisons of nutrients Infant cues Decisions to give los dos based upon: crying infant, pain, fatigue Value-based decisions: best for baby and bonding

NEW FINDINGS: THE INFLUENCE OF AUTHORITY

Cultural and familial authority Cultural norms: American and Mexican and American healthcare Mothers Husbands: sometimes “told” women, gave “permission;” male authority over

women’s work “Breast is best”

Authoritative knowledge of healthcare providers Ascendance of scientific knowledge WIC, hospital, and pediatric providers Messaging: “like learning to walk”, “baby love you more,” “more

intelligent,” “Breast is best”

Authoritative messages challenge maternal identity esp. “breast is best” Could they be a good mother, fulfill maternal role, doubt What is out of their control e.g. surgery->still affect thoughts not “best for

baby”

Theme Three “How Do We Manage…”Support Systems

SUPPORT SYSTEMSSocial supportProfessional support

NEW FINDINGS: SUPPORT SYSTEMSHusband main support and day-to-day supportMothers long-distance emotional supportWIC main professional support!!! Then pediatricians and

hospital 24-hour nurse line.OB providers do not discuss EBF and not viewed as

source of support for EBF

Theme Three “How Do We Manage…”Modesty

NEW FINDINGS: MODESTY

Mixed messages from healthcare providers and American norm

Friends advised formula when out in publicFelt marginalized “stares” when in publicHusbands “think differently” re: modesty here in U.S.Husbands either empowered women or restricted EBF

in public

Theme Three “How Do We Manage…”Working and Exclusive Breastfeeding

NEW FINDINGS: WORKING AND EBF

Working and exclusive breastfeedingMost women planned “los dos” upon return to workSome delayed return to work or sought jobs could BF or

pump at workInformation women receivedLittle antepartum information re: working and EBFEmployers“Shamed to ask “permission” from employers; male bossVulnerability at job if requested time and space

Implications for PracticeEducation of OB providers: toolkits, resources, & management

of common problems EBFAntepartum information sooner & also more from OB providersAntepartum begin discussions working and EBF; You TubeTeach women regarding growth spurts and frequent feedingsAnticipatory guidance re: EBF problems & challengesKeep giving educational material-women read it!Provide list of “good” internet sitesContinue 24-hour hospital nurse line criticalCommunication & awareness between providers, WIC, hospitalMessaging of information and “best for baby”Continue Can Do 5!

WICStreamline paperwork more time counselingWIC checks SpanishContinuity caseload? two sessions antepartumMen involved/invited to classes (? Next Step also?)Peer counselor program

Antepartum meeting to establish relationshipPostpartum depression trainingContinuity and community weekly availability of groupsEliminate barriers: no phone

Implications for ResearchPopulationsOther Hispanic ethnicitiesVarying levels acculturationMexican-Americans born in United States Other ethnic groups esp. African AmericansMultiparasWomen who plan to combination feedWomen who plan to EBF and los dos by dischargeOB and Pediatric healthcare providers’ perspectives

SettingsOther antepartum settings: WIC, private practices, clinicsHospital

Regression analysis of women EBF, los dos, discontinue breastfeeding

Participatory action research with women

Interventions researchCentering pregnancy groups for EBFMotivational interviewing techniques and phone support

AcknowledgementsRuth O’Brien, Advisor

Jacqueline Jones, ChairEileen ThomasLauren Clark

Mary O’ConnorWIC Study Site Staff

Women Who Participated in Study

Thank You

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