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Understanding Breastfeeding Initiation and Continuation in Rural Communities: A Combined Qualitative/Quantitative Approach

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Abstract

Objective

To determine factors associated with breastfeeding in rural communities.

Methods

We combined qualitative and quantitative data from the Family Life Project, consisting of: (1) a longitudinal cohort study (N = 1292) of infants born September 2003–2004 and (2) a parallel ethnographic study (N = 30 families). Demographic characteristics, maternal and infant health factors, and health services were used to predict breastfeeding initiation and discontinuation using logistic and Cox regression models, respectively. Ethnographic interviews identified additional reasons for not initiating or continuing breastfeeding.

Results

Fifty-five percent of women initiated breastfeeding and 18% continued for at least 6 months. Maternal employment at 2 months and receiving WIC were associated with decreased breastfeeding initiation and continuation. Ethnographic data suggested that many women had never even considered breastfeeding and often discontinued breastfeeding due to discomfort, embarrassment, and lack of assistance.

Conclusions

Breastfeeding rates in these rural communities lag behind national averages. Opportunities for increasing breastfeeding in rural communities include enhancing workplace support, maximizing the role of WIC, increasing hospital breastfeeding assistance, and creating a social environment in which breastfeeding is normative.

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Abbreviations

NC:

North Carolina

PA:

Pennsylvania

WIC:

Women, infants and children supplemental nutrition program

OR:

Odds ratio

CI:

Confidence interval

AAP:

American Academy of Pediatrics

FLP:

Family Life Project

TANF:

Temporary assistance for needy families

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Acknowledgements

The authors gratefully acknowledge the Family Life Project field sites and research assistants in North Carolina and Pennsylvania, and thank families for their participation. The study was funded by grant PO1HD039667 from the National Institute of Child Health and Human Development. The authors report no conflict of interest. Support for R. Jean Cadigan was provided by the National Institute of Child Health and Human Development (grant 5-T32-HD007376: Human Development: Interdisciplinary Research Training) to the Center for Developmental Science, University of North Carolina, Chapel Hill. Support for Eliana M. Perrin was provided by the National Institute of Child Health and Human Development (grant #HD01441). We thank Debra Skinner and Margaret Bentley for manuscript review.

Author information

Authors and Affiliations

  1. Charles Drew Community Health Center, Piedmont Health Services, 221 North Graham-Hopedale Road, Burlington, NC, USA

    Kori B. Flower & Greg Randolph

  2. Frank Porter Graham Child Development Institute, University of North Carolina, Chapel Hill, NC, USA

    Michael Willoughby

  3. Center for Developmental Science, University of North Carolina, Chapel Hill, NC, USA

    R. Jean Cadigan

  4. Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA

    Eliana M. Perrin

Authors
  1. Kori B. Flower
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  2. Michael Willoughby
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  3. R. Jean Cadigan
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  4. Eliana M. Perrin
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  5. Greg Randolph
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Consortia

The Family Life Project Investigative Team

Corresponding author

Correspondence to Kori B. Flower.

Appendices

Appendix

The Family Life Project Ethnographic Study

Infant Feeding Interview Guide

  • □ Did you ever breastfeed your baby?

If yes, proceed to Section A. If no, proceed to Section B.

Section A

[FOR WOMEN WHO EVER BREASTFED, ask]:

  • □ Did you also use formula to feed your baby? What kind of formula did you use?

    • ○ If yes, when did you use it?

      • ■ [Probes: (when breastfeeding was inconvenient, wasn’t able to pump, etc.]

    • ○ If no, did you ever consider formula feeding? What made you decide not to use formula?

  • □ How long did you breastfeed? How many days/weeks/months?

  • □ What factors influenced your decision to stop?

    • Probes:

      • ■ child characteristics (e.g., gestational age, health, temperament)

      • ■ maternal characteristics (e.g., previous experience, mood, fatigue, unsupportive family, work schedule, nature of childcare)

      • ■ social climate (e.g., embarrassment)

      • ■ difficulty with breastfeeding

      • ■ not enough support/instruction/information

  • □ Do/did work constraints ever get in the way of your breastfeeding? If yes, how so?

  • □ Does/did anything else sometimes prevent you from breastfeeding? If so, what?

[Proceed to Section C]

Section B

[FOR WOMEN WHO NEVER BREASTFED, ask]:

  • □ What kind of formula did you feed your baby?

  • □ Did you ever consider breastfeeding? Why or why not?

[Proceed to Section C]

Section C

  • □ When did you decide whether or not to breastfeed? (i.e., Before getting pregnant? During pregnancy? How far into pregnancy? After birth?)

    • ○ Did you change your mind at some point? If so, when and why?

  • □ What would you say most influenced your decisions about breastfeeding or formula feeding?

    • ○ [probes: relatives, friends, health clinic professional, doctors, previous experience, work schedule, childcare situation, media/advertisements, mood—fatigue]

    • ○ Did you use WIC resources during your pregnancy? If so, did you feel the WIC office had any particular view on breastfeeding or formula feeding?

    • ○ Was there anything about your pregnancy, labor, and/or delivery that influenced your decisions about breastfeeding or formula feeding? (i.e., low birth weight of infant, early surgery, etc.)

  • □ What are your husband’s/partner’s views on breastfeeding?

  • □ How much of a factor was your husband/partner in your decision regarding breastfeeding? (or to stop breastfeeding?)

  • □ Of your family and friends who have had children, how many of them have breastfed?

  • □ What are your family and friends’ views on breastfeeding?

  • □ Did anyone at the health clinic/doctor’s office ever talk to you about breastfeeding?

    • ○ If yes, who spoke to you and what did they say?

    • ○ Were you ever offered any breastfeeding classes or assistance (i.e., lactation consultant advice)?

    • ○ If yes, what did you think of this program/assistance?

    • ○ Did it change what you were doing?

  • □ Have you heard how long doctors typically recommend that women breastfeed babies? What have you heard?

  • □ What other liquids did you feed to your baby in the first 3 months? (ie. soda, tea, chicken broth, juice, YooHoo, etc)

  • □ What about when the baby was 4–6 months? What other liquids did you feed your baby during this period? (i.e., soda, tea, chicken broth, juice, YooHoo, etc.)

  • □ When did you begin feeding your child cereal? What influenced your decision to do this?

  • □ For any children you have in the future, do you think you’ll breastfeed or formula feed them? Why?

  • □ What do you see as the benefits to breastfeeding? What are the drawbacks?

  • □ What do you see as the benefits to formula feeding? What are the drawbacks?

  • □ Are there places where it is inappropriate to breastfeed? Why or why not?

  • □ Do you think most women in your community breastfeed or formula feed?

  • □ How do you think people in your community view breastfeeding?

  • □ What do you think influences women in this country to breastfeed or formula feed? (i.e., media advertisements, friends/relatives, work schedule, childcare situation, woman’s concern about leaking/breasts sagging, etc.) Do you think that most women in this country breastfeed or formula feed?

  • □ How do you think people in this country view breastfeeding?

  • □ Is there anything else you would like to share about breastfeeding or formula feeding?

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Flower, K.B., Willoughby, M., Cadigan, R.J. et al. Understanding Breastfeeding Initiation and Continuation in Rural Communities: A Combined Qualitative/Quantitative Approach. Matern Child Health J 12, 402–414 (2008). https://doi.org/10.1007/s10995-007-0248-6

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