Cultural Influences in Infant Feeding

Ever wonder why some hospitals have very high breast feeding rates in spite of little support of breast feeding and others have low breast feeding rates with what should be good support programs? We know there are many things that can influence the decisions of mothers to breast feed or not, but it is also known that many women have made this decision before coming to the hospital to deliver their infant. In fact, some have made the decision before getting pregnant. If breast feeding is a cultural norm, women are more likely to initiate breast feeding. However, cultural norms are difficult to identify.

Pak-Gorstein, Hag and Graham discuss several effects culture may have on breast feeding but point out several times that there are significant differences, even within the same culture.¹ For instance, foreign-born mothers, particularly from low-income countries, generally have higher breast feeding rates and breast feed longer than do U.S. born mothers from the same culture.

Gibson-Davis & Brooks-Gunn reported that Hispanic women born outside of the US had a greater likelihood of breastfeeding with the odds of breastfeeding reduced by 4% for each year that the parents reside in the U.S.² However, practices of Hispanic populations vary greatly by specific areas of the world, since Hispanic encompasses a widely heterogenic population. One source (www.pewhispanic.org) lists the 10 largest Hispanic origin groups as Mexicans, Puerto Ricans, Salvadorans, Cubans, Dominicans, Guatemalans, Colombians, Hondurans, Ecuadorians and Peruvians. As one can see, these categories cover a wide range of people and likely different cultures. Although they share a language, the customs and practices may be quite different.

Harley, Stamm & Eskenazi found that length of time in the U.S. for Mexican women specifically resulted in a decreased length of exclusive breast feeding.³ This varied from exclusive breast feeding for 2 months in women who had lived in the U.S. for less than 5 years, to those having lived in the U.S. for more than 11 years and breast feeding exclusively for only 1 week. Anderson et al found that this trend in decreased breast feeding or time of exclusive breast feeding did not apply to the Puerto Rican Hispanic population.⁴ This group in the Anderson study had no difference in breast feeding initiation or duration related to length of time in the U.S.   Generally, the Hispanic population has a high rate of breast feeding initiation.

There are many cultures whose breast feeding/peripartum practices we may be much less familiar with. Here are just a few.

From the Southeast Asia area (ethnomed.org)

• • Colostrum is believed “dirty” and “stale”. As with many other cultures, this is not fed to the infant. In the Southeast Asian population, the infant is often fed by other, often lactating, women in the first few days.
  • For Southeast Asian immigrants, the mothers often revert to bottle-feeding because of lack of family support to allow for the rest thought to be necessary in the post-partum period. In addition, breastfeeding is considered more expensive because the quality of mother’s milk can only be enriched by consuming a special diet that is costly.
  • According to Hue Thai (https://ethnomed.org/clinical/pediatrics/post-partum-viet-chin-brochure.pdf/view) other practices may impact breast feeding such as avoiding certain foods during the post-partum period and perhaps even restricting fluid intake.

From Somalia (ethnomed.org)

• • Breast milk is not good if in the breast for more than 3 hours. Therefore, colostrum is not good since it has been there since before the infant was born.
  • Fear of inadequate milk supply, and “plump” babies are considered healthy babies. This often leads to overfeeding – breast feeding followed by formula supplementation or just switching to formula feeding.
  • In Somalia, infants are often supplemented with formula, cow/goat milk or solid foods early on.
  • For immigrants, many do not have adequate family support to allow for enough rest and are not familiar with pumping and storage as an option to provide breast milk.
    • https://ethnomed.org/clinical/pediatrics/breast_feeding_soma_mothers.pdf/view

For both of the above cultures and others who believe colostrum is not good for the baby, pre-lacteal feedings may be given that may include sugar water, teas, including herbal teas, salty liquids as well as milk, porridge and honey. For infants born in the U.S. in the hospital, it is less likely that these will be fed but bears assessment during lactation counseling.

Newly immigrated women are often at a disadvantage regarding pumping and storage of breast milk. It is a foreign concept to many that milk can be pumped and stored for feeding at another time when the mother is not present. Given less extended family support, this may be an important addition to result in a longer period of exclusive breast milk provision, particularly if the mother must return to work.

Native Americans

• • Rates of breast feeding for Native Americans may vary in urban versus rural settings.
  • Rob Capriccioso (http://indiancountrytodaymedianetwork.com/2011/03/01/breast-feedings-role-taking-back-native-culture-19365 ) quotes a lactation counselor for the American Indian Health and Family Services center in Detroit who said that Native Americans have low breast feeding rates related to lack of breast feeding education and support, including from health care workers who may push the use of formula.
  • Rural Native Americans may be more likely to initiate breast feeding and possibly sustain breast feeding. In my own experience with this population in New Mexico, almost all Native American mothers initiate breast feeding. Perhaps part of this is cultural and partly related to the ease of access to breast milk as compared to infant formulas. Camie Jae Goldhammer (http://lastrealindians.com/?s=Goldhammer&x=0&y=0) tells the story of a Native American mother who, after having 4 children of her own, provided breast milk to the local NICU for many years by pumping. This was a foreign concept to her initially, but the hospital provided the pump so that the milk could be taken to the sickest babies at the hospital.

As mentioned earlier, an awareness of the cultural beliefs and practices is important but cannot be assumed to be common to everyone who has that cultural heritage. Many factors may influence a mother’s decision to breast feed and the duration of breast feeding. Many of these factors have been shown to influence the decisions of mothers of all cultures and include those items included in the Breast Feeding Friendly designation and Ten Steps to Successful Breast feeding. (http://www.unicef.org/newsline/tenstps.htm )

For all cultures, support from women of their own culture appears to be important and possibly more important for those less acculturated or newer to the U.S. Someone from their own culture may know about, understand the origin of, and be able to effectively change practices when necessary to improve initiation and duration of breast feeding. It is known that breast feeding related outcomes are dose dependent. By improving not only breast feeding initiation but duration as well, these benefits will be greater. One national study of low-income WIC participants found that while breast feeding initiation rates were high, only 13% were exclusively breastfed at 1 month and rates declined from there. The median age for introduction of formula in the following ethnicities were African American infants at 16 days, Caucasian infants at 12 days and Hispanic infants at 20 days.⁵

References:

1. Pak-Gorstein, Suzinne, Aliya Haq, and Elinor A. Graham. “Cultural influences on infant feeding practices.” Pediatrics in Review 30.3 (2009): e11.

2. Gibson-Davis CM, Brooks-Gunn J. Couples’ immigration status and ethnicity as determinants of breastfeeding. Am J Public Health. 2006;96:641–646.

3. Harley K, Stamm NL, Eskenazi B. The effect of time in the US on the duration of breastfeeding in women of Mexican descent. Matern Child Health J. 2007;11:119–125.

4. Anderson, A. K., Damio, G., Himmelgreen, D. A., Peng,Y., Segura-Perez, S.,& Perez-Escamilla, R. (2004). Social capital, acculturation, and breastfeeding initiation among Puerto Rican women in the United States. Journal of Human Lactation, 20(1), 39-45.

5. McCann MF, Baydar N, Williams RL. Breastfeeding attitudes and reported problems in a national sample of WIC participants. J Hum Lact. 2007;23:314–324.

About the Author

Sandy Sundquist Beauman has over 30 years of experience in neonatal nursing. In addition to her clinical work, she is very active in the National Association of Neonatal Nurses, has authored or edited several journal articles and book chapters, and speaks nationally on a variety of neonatal topics. She currently works in a research capacity to improve healthcare for neonates. Sandy is also a clinical consultant with Medela. You can find more information about Sandy and her work and interests at https://www.linkedin.com/in/sandy-beauman-0a140710/.