Significance

Breastfeeding is positively associated with long-term benefits for infants and mothers. Yet breastfeeding rates in the United States are suboptimal. Changes in breastfeeding behavior among US Hispanics have been attributed to increased acculturation. However, Hispanics’ own perceptions of how cultural assimilation may affect breastfeeding behaviors have not been explored. Our study describes specific cultural influences and perceptions that may affect this change in infant feeding behavior among rural US Hispanics. Given the growing racial/ethnic diversity in the United States, an understanding of culture-specific attitudes and perceptions of infant feeding is critical to informing interventions and policy to achieve optimal breastfeeding rates.

Introduction

Breastfeeding is positively associated with long-term benefits for infants and mothers alike, reducing risk of obesity, diabetes, and certain cancers [1, 2, 9, 10, 16, 18]. The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for the first 6 months of life, and continued breastfeeding until a child reaches 1 year [10, 34]. In the United States, rates of ever-breastfed children are lower than desired (79 %). Maternal and child health priorities identified in Healthy People 2020 aim to increase the rate of ever-breastfed infants to 82 % [31]. Hispanics, the largest growing ethnic group in the United States [6, 21], were meeting this breastfeeding initiation goal in 2011 (84 %) [20]. However, rates of exclusive breastfeeding at 3 and 6 months are suboptimal, with less than half of Hispanics breastfeeding at 6 months, falling short of the 61 % Healthy People 2020 target [20, 31]. Additionally, Hispanics are more likely than any other racial/ethnic group to supplement with formula before 2 days of life [20], which is associated with shorter breastfeeding duration overall [5].

In the United States, a variety of factors have been shown to influence breastfeeding patterns. Lower socioeconomic and educational status, younger maternal age, low infant birth weight, and participation in the Women, Infant, and Children (WIC) Special Supplemental Nutrition Program are all negatively associated with breastfeeding among all racial/ethnic groups [7, 28]. Although Hispanic immigrants display many characteristics associated with lower rates of breastfeeding, they are significantly more likely to initiate breastfeeding than Hispanics born in the United States [11, 13, 17, 24]. Furthermore, the longer Hispanics spend in the United States, the less likely they are to initiate breastfeeding or breastfeed to 6 months [11, 13, 17]. Several studies have attributed changes in breastfeeding behavior among US Hispanics to increased acculturation [5, 17, 24, 33].

Hispanics’ own perceptions of how cultural assimilation may affect breastfeeding behaviors have not been explored, and no studies have investigated breastfeeding perceptions and practices among rural Hispanics. Such data may help inform appropriate policy and public health interventions relevant to specific Hispanic populations in the United States. In this paper, we use a community-based, qualitative approach to examine how Hispanic and US culture and society may influence infant feeding behaviors among Hispanic women living in rural Washington State.

Methods

Setting

The study was conducted in the Lower Yakima valley, a rural agricultural region in Eastern Washington State, where 67 % of the population is of Hispanic origin [30], the majority of whom (95 %) identify as Mexican–American [29]. Residents of the Yakima Valley experience high poverty levels, relatively few years of education, and low rates of insurance coverage [8].

Participant Recruitment

Between September and October 2013, bilingual promotores (lay health workers from the community) from the Fred Hutchinson Cancer Research Center’s (FHCRC) Center for Community Health Promotion located in the Lower Yakima Valley, recruited Hispanic women at community events and WIC clinics in the region. Women were approached by a promotora, informed of the study, and asked if they were interested in participating. Women were eligible for the study if they (1) resided in the Lower Yakima Valley; (2) self-identified as Hispanic or Latina; (3) were aged 21–45 years. This study was part of a larger study in which eligible women were also required to have (4) had at least one child >5 years old so anthropomorphic data could be gathered on that child… The study was performed with the approval of the Fred Hutchinson Cancer Research Center Institutional Review Board, in accordance with an assurance filed with and approved by the United States Department of Health and Human Services. Written informed consent was obtained from each participant.

Data Collection

Qualitative questioning provides an opportunity for respondents to share unique beliefs and experiences using their own language [3] and is an approach often used to conduct initial assessments of unexplored topics [19], in this case, perspectives on infant feeding among rural Hispanics in Washington State. The team developed a semi-structured interview guide, comprising 21 questions that aimed to elucidate perceptions, personal and community experiences, and attitudes towards infant feeding. One promotora, trained in qualitative data collection, traveled to participants’ homes to conduct interviews in Spanish (n = 18) or English (n = 2), depending on participant preference. The promotora obtained verbal consent and administered a brief demographic and acculturation survey, followed by a. 20–25 min interview. Interviews were audio-recorded. Upon completing the interview, participants received a $25 gift card.

Data Analysis

Members of the project team transcribed interviews verbatim from audio files. A bilingual, native Spanish-speaker translated Spanish interview data into English. All interviews were checked by a third bilingual, native-Spanish speaker for accuracy. Interviews were uploaded into Atlas.ti, Version 7 (Berlin, Germany) for coding. Through an iterative process, the study team applied a combined deductive and inductive thematic content analysis approach [4, 15]. Two team members collaboratively developed a list of deductive start-codes based on research questions identified prior to data analysis and constructs of the social–ecological model [22]. They applied the start list to all transcripts. Throughout coding, they developed and applied additional inductive codes to facilitate identification of emergent themes based on participant responses [23]. The coders discussed interpretations, agreed on a final codebook to be applied across all interviews, and grouped codes into categories representative of emergent themes.

Results

In October 2013, 20 Hispanic women aged 25–48 years, all residents of the Lower Yakima Valley, completed an interview. Participants demonstrated low levels of acculturation: ninety percent were born outside of the United States [Mexico (n = 17); El Salvador (n = 1)] and preferred to communicate in Spanish. Fifty-five percent of participants had <9 years of formal education; and on average had given birth to three children (Table 1). Three (15 %) exclusively breastfed all of their children and one (5 %) exclusively formula fed all of her children. The remaining 16 (80 %) of participants practiced combination feeding with some or all of their children (Table 2). The average age of participants’ youngest child was 4 years old. Nine themes emerged from the qualitative analysis and were grouped into three overarching thematic categories: (1) Breast is best; (2) Hispanic cultural and familial expectations to breastfeed; and (3) Adapting to life in the United States: cultural norms in conflict. Emergent themes and illustrative quotes are presented in Table 3.

Table 1 Participant characteristics Lower Yakima Valley, WA 2013 (n = 20)
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Table 2 Infant feeding practices, lower Yakima Valley, WA 2013 n = 20
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Table 3 Themes and illustrative quotes from interview participants (n = 20)
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Breast is Best

The Message is Clear

All women interviewed said they had received messages from family, friends, healthcare providers, and health workers at organizations like WIC that breastmilk was the best, healthiest choice. One of their greatest motivators to breastfeed was the mutual health benefits they experienced personally and observed in other breastfeeding mothers and children. Participants acknowledged the difficulty that pain presented, but explained that such challenges were mitigated by the positive health effects of breastfeeding. This respondent illustrated:

[Breastfeeding] is painful, but also it helps….I lost all the pregnancy weight. That helped…with the cramps…in a certain way the baby then too. They all grew up very healthy. Never have they had problems with their ear, fevers…even to this day, never. And they even slept more peacefully all night, no, no colicky.

Participants added that they had not observed these benefits in children who were formula fed, and, as noted by this participant, “Breastfeeding is better than formula, because formula doesn’t have all the nutrients that we can make with the milk produced by our body and we give them …everything that a child needs to grow strong.”

Hispanic Cultural and Familial Expectations to Breastfeed

“Breastfeeding is What Hispanics Do”

Regardless of which infant feeding practice they adopted, participants described breastfeeding as a behavior deeply ingrained in their Hispanic origins. One participant explained, “Us being Hispanics, we come from a race that breastfeeds.”

Others connected a long cultural history of breastfeeding with their Mexican heritage, and a lack of exposure to formula feeding, which they said influenced Hispanics’ infant feeding choices. This participant explained, “Latinas and, well, from Mexico, we come from Mexican roots and we grew up with pure breastfeedings. I tell you, like me, I wasn’t raised with baby bottles, I wasn’t raised with little cups.” Another responded speculated that her family members and predominately Hispanic social circle chose breastfeeding over formula feeding because it was the only example they had been shown. “We (Hispanics) don’t know much about baby bottles and stuff like that. What do I know, right? Nobody ever showed me baby bottles. Only breast from my mother.”

Wisdom Passed Down from Generations of Mothers

Respondents underscored the importance of maternal role models—including mothers, grandmothers, and female relatives—in shaping their infant feeding decisions. Participants said they were influenced by both their own mothers’ infant feeding choices as well as the importance their mothers placed on breastfeeding, and that their mothers were often directive about infant feeding choices. This respondent explained, “[My mother] told me it was healthier. The vitamins that the kids get from, you know, from their own mother. She wouldn’t let me give them the other milk.”

Observations About Children’s Health and Infant Feeding

Participants said they were influenced by differences they observed between breastfed and formula-fed children in their family and community. “[My mother] breastfed me for 9 months…. [She] says that none of us were sick and I saw that my sister [breastfed her son] until he was 5 years old, and he never has a cold, nothing.” Another respondent reported:

One friend of mine didn’t breastfeed, and she almost always is at the hospital, be it for diarrhea,… for a fever. And [this] boy, he doesn’t grow up normally… When they formula feed, the children keep getting sick and they (mothers) see among one another, then they say, ‘No well, that—he, she breastfed her child and they rarely get sick so I am going to do that.’

Husbands’ Influence

Although respondents widely reported that they had discussed infant feeding options with their husbands, who were generally supportive of their choices, most participants said their husbands’ opinions were inconsequential: “It was me who made the decision [to breastfeed]…He agreed, [but,] well, I felt that that was my decision. It was me that was going to suffer breastfeeding so what he thought, truthfully, I didn’t, didn’t care much.” A few participants said they educated their husbands on the benefits of breastfeeding, and were later reassured by the positive reinforcements they received. This participant summarized:

At the beginning he was like, ‘Well whatever, it’s your choice.’ But once we got talking about the benefits of [breastfeeding], he was like, ‘Hmm, okay, that sounds good.’ So we decided to do it. [His support] encouraged me to keep on with my decision. To be firm on it and continue [breastfeeding].

Adapting to Life in the United States: Cultural Norms in Conflict

Despite Hispanic cultural expectations to breastfeed and participants’ belief that breastfeeding is the healthiest infant feeding choice, 8 (40 %) respondents reported that they believed most Hispanics in the United States would be more likely to choose formula over breastfeeding. Women acknowledged several physiological challenges they faced while breastfeeding, such as pain, discomfort, and lack of production, but said these difficulties were surmountable for most women, especially with support and instruction from health workers and family members. However, they said a growing number of Hispanic mothers faced a different set of barriers that were not as easily overcome, such as US cultural norms and the economic need to work.

Cultural Norms and Avoiding Embarrassment

Women said they perceived that people in the United States were offended by breastfeeding mothers. Consequently, they said Hispanics in the United States may be less likely to breastfeed their children because of the reaction they would receive if they needed to breastfeed in public. This participant summarized:

It’s just that here [in the U.S], there are many people that don’t see [breastfeeding as] normal…I think that it’s normal. And many people see it as dirty and they’re always with that mentality, that, ‘Oh look, how is she not embarrassed?’

Similarly, another participant said the conflict of her familial norms around breastfeeding with cultural norms she had experienced in the United States influenced her choice to combination feed her child, saying, “All of my family has breastfed their babies. It’s normal for my family, to show your chest. For other people, it’s like, ‘Oh look, how gross, what is she doing? She’s not ashamed.’ But not for Hispanics.” Participants said that women could avoid embarrassment by choosing to formula feed in addition to, or instead of, breastfeeding. As this participant explained, “You avoid offensive people on the street. Instead, you carry your bottles and you feed them and you avoid those dirty looks.”

Avoiding Undesirable Physical Changes

No respondents identified changes in their own body as a barrier to breastfeeding; in fact, many reported positive physiological changes, such as faster recovery from pregnancy and delivery, and post-partum weight loss. However, respondents said younger Hispanics perceived breastfeeding to cause undesirable changes to their breasts, which respondents said would prevent them from breastfeeding. A respondent stated, “I see that other people don’t want to [breastfeed] because, oh, because [their breasts] get small or because they get saggy.”

“You Have to Have a Second Income to Make It Here”

Women reported that Hispanic women in the United States faced economic pressure to work, and that the type of jobs women were able to secure affected their choices about infant feeding. They explained that agricultural work in particular—in which most Hispanics in the Yakima Valley are employed—was not conducive to continuing to breastfeed. This respondent said, “Here (in the United States) formula feeding [is more common], because the majority of women here go to work in the field with their children still very young.”

Women also perceived that caregivers were often unwilling to feed their children breast milk. Some participants indicated that it was easier for working Hispanics to replace breastfeeding entirely by formula. Others noted that Hispanics who work outside of the home practice combination feeding. For example, this participant said, “Well, you have to give them formula sometimes because of work. But if one was at home, it’s better to give mother’s milk, but when there’s work one has to, well, have both parts, mother’s milk and formula.” A few participants noted their family members’ roles in a difficult decision to incorporate formula into their children’s diet. One participant said both her husband and mother-in-law’s advising was that formula feeding:

was the easiest option. [My mother-in-law] said, well, to give formula because I was giving—I was leaving the milk that I took out in little bottles in the refrigerator but she would forget…[She wanted] to take down the can of milk and she could make it faster that way….[My husband said] that it was good, that I should give formula instead because I had to go to work. I would have preferred to stay and continue to insist on breastfeeding.

United States Infrastructure and Resources

Most respondents said they learned about infant feeding from health workers at WIC, who they identified as a key influence on their infant feeding decisions, providing them with clear messages about the value of breastfeeding, as illustrated by this respondent, who reported that the health workers “from WIC [said] that it was best to breastfeed. The children would grow up healthier and stronger.” However, participants also said that free formula provided by WIC made it possible for women to combination feed, or stop breastfeeding altogether. For example, a respondent explained that her friends in Mexico were all breastfeeding, while “the majority [of friends in the United States] only give formula… Well you know over in Mexico, well, they don’t give you the formula there like here.” Another respondent added, “In Mexico, one’s poorer over there, one doesn’t have as much money to buy milk and since one gets the milk here…you know that here [in the United States] is the WIC, they give you milk.”

Discussion

In this community-based, exploratory study, we describe the perceptions, experiences, and attitudes towards infant feeding among 20 Hispanic women living in rural Washington State. Our study builds upon previous research that demonstrates negative associations between acculturation and breastfeeding [5, 17, 24, 33] by describing specific cultural influences and perceptions that may affect this change in infant feeding behavior among rural US Hispanics. Specifically, our participants, who themselves demonstrated low levels of acculturation, articulated a clear understanding of the breastfeeding benefits paired with a strong sense of cultural pride surrounding breastfeeding. However, the majority practiced combination feeding with most or all of their children, and predicted that younger generations of Hispanics in the United States who are likely more acculturated—would be even more likely to exclusively formula feed. Participants described challenges to breastfeeding that have been identified in other studies, such as issues of pain, discomfort, and production [5, 13, 24, 27, 33], but said all were surmountable, largely due to combined family support and practical assistance offered by health workers at WIC.

Study participants highlighted the role of the normative cultural value of familismo—the importance of family ties [26]—and cultural pride among Hispanics in infant feeding decisions. They described a longstanding Hispanic cultural practice and subsequent expectations to breastfeed, reinforced through advice and examples provided by maternal figures in their families and community. Support from husbands further reinforced women’s decisions about infant feeding. Interventions that involve family members in educating rural Hispanics about benefits of breastfeeding, mitigating challenges such as pain and production, and providing strategies for increasing breastfeeding duration, may be particularly salient for this population, given success of similar approaches for chronic disease prevention and management [12, 25]. Fostering Hispanic pride in breastfeeding is something that should be encouraged, and might be a method to promote continued breastfeeding among Hispanic communities in the US with low levels of acculturation.

Participants described some unexpected barriers to breastfeeding that Hispanics encounter in the United States, including society’s reactions towards breastfeeding in public, and a perception of undesirable physical changes in one’s body after breastfeeding among younger Hispanic women. Thus, interventions and policies that promote messages that breastfeeding is a US cultural norm may help increase the number of women who choose to breastfeed. Less surprising are barriers such as the economic necessity to work outside of the home, and the lack of support women encountered in the workplace and among their children’s caregivers. However, both barriers and facilitators to breastfeeding appear to be culture- and community-specific. For example, working in fields is very specific to rural agricultural areas and innovative strategies are needed to allow continued breastfeeding. Leveraging cultural pride among Hispanics to support breastfeeding is another strategy that may tip the balance point to ongoing breastfeeding. Given the heterogeneity among Hispanic sub-groups, studies such as this one that examine perceptions, experiences, and attitudes towards infant feeding elucidate unique themes among specific groups.

Changes among the Hispanics that promote less breastfeeding leads to poorer health among the children, both as infants and in later life, where studies have shown that breastfed children do better in later life compared to formula-fed children [14, 32]. In this area where Hispanic children could have the benefit of breastfeeding, the pressures to formula-feed leads to increasing health inequities among the underserved [32].

Limitations

A limitation of qualitative work is that sample sizes are smaller, therefore not necessarily generalizable beyond the population under study. As 90 % participants in this study were born outside the United States and had low levels of education, our sample was representative of many rural Hispanic populations; however a larger, more diverse sample that would enable comparison of perspectives among Hispanics of varying levels of acculturation and birth countries would further elucidate barriers and facilitators underlying infant feeding decisions among this vulnerable group. The average age of participants’ youngest child was 4 years old. It is possible but unlikely that workplace practices and cultural norms around breastfeeding have changed. Despite these limitations, our findings point to previously unreported findings about the important role of culture on infant feeding practices. Thus, our findings have implications for both interventions and policies to increase breastfeeding initiation and duration among this vulnerable group.

Conclusion

Given the growing racial/ethnic diversity in the United States, an understanding of culture- and sub-group-specific attitudes and perceptions of infant feeding is critical to informing interventions and policy to foster achievement of the Healthy People 2020 targets for breastfeeding. Continued support through family-level interventions as well as work place policies that sustain Hispanic cultural pride in breastfeeding and promote breastfeeding behavior are needed for Hispanics to reach optimal breastfeeding rates.