Comparison of Breast Feeding Trends in Urban Versus Rural Areas: Recommendations to Improve Breast Feeding in Rural America

Abstract

Breast feeding can play a very important role in the development of strong, healthy children. Many studies over the years have shown that breast milk provides defense against common ailments of childhood such as otitis media, gastrointestinal distress, and atopic diseases (allergies). For these reasons the American Academy of Pediatrics recommends breast feeding for at least the first twelve months of an infant’s life.

Goals of the Health People 2010 Initiative include that at least 75% of mothers will be breast feeding upon discharge from the hospital and at least 50% will be still nursing at six months post-partum. Currently, about 60% of new mothers initiate breast feeding and about 26% are still breast feeding at six months.

However, research has shown that breast feeding trends are below these averages in rural areas of the United States. This may be due in part to lack of breast feeding knowledge and teaching in rural areas.

Rural hospitals and birthing centers have not initiated many of the breast feeding promotional programs, such as the Baby Friendly Hospital Initiative and Best Start, that have been successful in improving breast feeding trends in urban areas. Often new mothers who live in rural areas do not have access to a lactation consultant to help them with proper follow up. This paper will examine these concerns and propose

recommendations to improve breast feeding in rural areas.

Key words : Breast feeding, Trends, Lactation consultant, Recommendation

Breast Feeding

Breast feeding is defined as “suckling or nursing, giving a baby milk from the breast” (Mosby’s Medical, Nursing, &

Allied Health Dictionary, 1998). Breast feeding has been a means of infant nutrition since the dawn of time. In some long-ago civilizations, nursing mothers were highly regarded, and women were required by law to breast-feed all their children. Regulations for wet nursing, nursing another woman’s infant, have been found in documents dated from 1800 BC (Lawrence & Lawrence, 1999). Today, the American Academy of Pediatrics (AAP) encourages human breast milk because it has proven to be nutritionally superior to formula, playing a vital role in the development of strong, healthy children (1997). Because of the benefits of breast milk, breast feeding her newborn for at least six months is a noble goal for any new mother. However, mothers living in rural areas of

Review Article

Comparison of Breast Feeding Trends in Urban Versus Rural Areas: Recommendations to Improve Breast Feeding

in Rural America

Connie W. Lee

․Deborah Willoughby

․Rachel Mayo

1) Clemson University 2) The School of Nursing, Clemson University 3) Department of Public Health Sciences, and Lawrence R. Wood, MSN, FNP

투고일: 2004년 11월 15일 1차심사완료일: 2004년 12월 25일 2차심사완료일: 2005년 2월 21일 최종심사완료일: 2005년 3월 9일

∙ Address reprint requests to : Connie W. Lee(Corresponding Author) School of Nursing, Clemson University 518 Edwards Hall, Clemson, SC 29634-0743

Tel: +1-864-656-5511 Fax: +1-864-656-5488 E-mail: [email protected]

America are more likely than urban mothers to choose formula as the method of feeding their infants.

Women residing in rural areas who do initiate breast feeding often stop within a few days. Lack of breast feeding education, frail support systems, and misconceptions of the breast feeding experience contribute to the poor trends of nursing in rural communities (Timbo, Alterkruse, Headrick, &

Klontz, 1996). Rurally based hospitals and health-care systems have the responsibility to improve breast feeding trends in these areas. Interventions must be designed and implemented to increase rate and duration of infant nursing as millions of newborns are not receiving the benefits that breast milk provides.

Benefits of Breast Feeding to Child and Mother

The American Academy of Pediatrics recognizes that breast feeding newborns reduces the occurrence of many diseases and lowers childhood health-care costs (American Academy of Pediatrics, 1997). Breast milk contains over 200 health- promoting ingredients that are unavailable in formula, providing breast-fed babies protection and immunization against bacterial and viral infections (Calandro, 2000; Lawrence & Lawrence, 1999). Numerous studies associate breast feeding with reductions of ear infections, allergies, and diarrhea during the early years of a child’s life (Paradise et al., 1997; Saarinen &

Kajosaari, 1995; Fuchs, Victoria, & Martinez, 1996).

There is evidence as well that breast feeding offers protection against other infant illnesses, including sudden infant death syndrome, pyloric stenosis, and diseases that appear later such as diabetes, lymphoma, Crohn’s disease, tonsillitis, digestive disorders, and multiple sclerosis (Bocar, 1997;

Kaplan, 2000). Breast feeding is beneficial to the mother as well, reducing risk of ovarian cancer and premenopausal breast cancer. Infant nursing also induces uterine involution, helping the mother return to her pre-pregnancy weight sooner and more easily. Studies of mothers who breast-feed also report that mothers feel greater closeness to the child, creating a stronger mother-infant bond (Calandro, 2000).

Trends in Breast Feeding

There have been dramatic changes in breast feeding trends in the United States over the last half-century. By 1950, the American Academy of Pediatrics had established itself as a staunch advocate of breast feeding. Over the last thirty years, breast feeding research has led to a steady rise in the number of mothers who initiate nursing. In 1970, only 30% of mothers were still breast feeding their infants at one week of age (Calandro, 2000). By 1998 this percentage had nearly doubled, to about 60%, with 26% still nursing at six months (O’Mara, 1998). While this increase is encouraging, it continues to fall short of the goals established by the AAP through the Healthy People 2010 initiative. These goals are that at least 75% of mothers will be breast feeding upon discharge from the hospital and 50% or more will be breast feeding at six months post-partum.

Before and during the 1950s, breast feeding was common practice among the poor. The middle and upper classes chose to formula feed their infants and looked upon breast feeding with disfavor (Bass and Groer, 1997). This trend has now reversed, with higher rates of breast feeding within the upper classes and lower rates among the poor. Many studies have found lower rates of breast feeding among young, low-income, unmarried mothers (Bass and Groer, 1997; Wambach and Cole, 2000; Wiemann, DuBois, and Berenson, 1998).

Other factors negatively associated with breast feeding are

low education level, being socioeconomically disadvantaged,

industrial employment, little or no breast feeding education,

and lack of breast feeding support at home (Hammer et al.,

1999; Evers and Schellenberg, 1998). These characteristics are

common in the rural community and pose specific challenges

to breast feeding in these areas. They used a longitudinal

study to evaluate characteristics of breast feeding in relation to

initiation and duration in a rural community. Results showed

an initiation rate of less than 40%, with a tendency to

terminate breast feeding before three months. This was well

below the national mean for breast feeding initiation of about

60%. Common reasons for choosing formula feeding were a

belief that it is as good as breast feeding, and perceptions that

breast feeding is painful or inconvenient. The most common

reasons women terminated breast feeding were sore nipples,

worries about milk supply, tiredness, and lack of Breast-

feeding knowledge and support. Return to work was also

negatively associated with breast feeding as there was

insufficient time allotted to pump breast milk. Women who

had strong familial support or a friend who breast-fed continued to nurse their infants longer than women who did not.

These findings were mimicked in a study of breast feeding practices of socioeconomically disadvantaged mothers done by Jacobson et al. (1991). It was determined that initially only 22% of the women in the study chose to breast-feed. Of those who initiated nursing, more than one-quarter stopped within one week. The mean time for those who breast-fed for more than a week was only 2.8 months, with only two percent breast feeding an average of six months. As in other studies (Timbo et al., 1996; Wambach & Cole, 2000), a lack of awareness of the nutritional and medical benefits of breast feeding was evident in the sample population.

It is discouraging that breast feeding trends in rural areas are so dismal, simply because these infants and children begin life with a high risk for compromised health. Rural areas represent a largely under-served medical population, in part due to poor distribution of health care providers and facilities, geographic barriers, and inadequate communication and teaching services (Roberts, Battaglia, Smithpeter, and Epstein, 1999).

Preventive care in rural areas is frequently less adequate.

Inadequate access and utilization of health care in rural area leads to higher rates of infectious and communicable diseases, iron deficiency anemia, and hospitalization among infants in rural communities. Breast milk could boost defense against infections and other health problems in these under-served children. Bass and Groer (1997), in their study of infection and use of the health care system by breast-fed and formula-fed infants, state that the lack of acceptance of breast feeding in poor areas is potentially a “real health threat”. They describe breast feeding as a low cost, natural intervention to improve health outcomes in poor communities.

Promotion of Breast Feeding

With evidence mounting that rural mothers are choosing formula feeding over breast feeding researchers are left to wonder:

a) Why is there a growing discrepancy in the rate of breast feeding between rural and urban America?

b) What can be done to increase breast feeding rates in rural areas?

Answers to both questions may lie with the fact that urban

hospitals and health networks have implemented interventions to promote breast feeding, while rural health networks have not implemented such strategies.

About twenty years ago the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) recommended ten steps to help hospitals support breast feeding, known as the Baby Friendly Hospital Initiative(Lawrence and Lawrence, 1999). To be designated “Baby Friendly”, the hospital must provide evidence that it has met these ten criteria and demonstrate its effectiveness to a visiting team:

1. Have a written breast feeding policy that is routinely communicated to all health care staff

2. Train all health care staff in skills necessary to implement this policy

3. Inform all pregnant women about the benefits and management of breast feeding

4. Initiate breast feeding within an hour after birth

5. Show mothers how to breast-feed and maintain lactation, even if they must be separated from infant

6. Give newborns no food or drink other than breast milk, unless medically indicated

7. Room in - allow mothers and infants to stay together 24 hours a day

8. Encourage breast feeding on demand

9. Give no artificial teats, pacifiers, dummies or soothers to breast feeding infants

10. Foster the establishment of breast feeding support groups and refer mothers to them on discharge

While the number of designated Baby Friendly hospitals continues to expand, rural hospitals and birthing facilities lag behind in their implementation of these ten criteria to successful breast feeding. Indeed, no rural hospitals were included on a list designated as Baby Friendly (Calandro, 2000).

The effect that the ten steps have had on breast feeding

trends in urban areas cannot be underestimated. Wright, Rice,

and Wells (1996) evaluated these ten steps at University

Medical Center in Tucson, Arizona, to see if the program had

a positive impact on breast feeding. A breast feeding task

force, headed by the hospital’s lactation consultant, was formed

to enforce breast feeding strategies and ensure proper follow-up

for new mothers that were nursing their infants (n=270). The

duration of breast feeding in these women was markedly increased after the initiation of the ten-step program. Mothers who were given information about support groups after discharge from the hospital were significantly more likely to be breast feeding at four months post-partum.

Similar results were achieved after initiation of the ten steps in an urban Naval Hospital in Sigonella, Italy (Clauss and Hall-Harris, 1999). It was determined that many new mothers at the hospital did not initiate breast feeding because they did not have access to traditional breast feeding educational and support systems, such as Le Leche League. Thus, the hospital’s breast feeding counselor created a breast feeding support program utilizing the ten steps of the Baby Friendly Initiative.

Data collected for the 16-month period after the program’s implementation noted about a 7% increase in breast feeding initiation(from 80% to 86.8%). More impressive was the fact that 51.4% of the mothers who chose to breast-feed (n=105) were still nursing their infants at six months of age; in line with the Healthy People 2010 goal that at least 50% of mothers will nurse until six months of age (Lawrence and Lawrence, 1999). More research may be needed to discover which of the ten steps are most effective at breast feeding promotion, as this was not addressed in the research.

However, implementation of the program at hospitals and birthing centers in the US and around the world has proven successful in its purpose to improve breast feeding trends and provide optimal nutrition for babies. Other programs to educate new mothers and improve breast feeding, such as motivational videos and “Best Start”, have been successful as well (Hartley and O’Connor, 1996; Wright, Bauer, Naylor, Sutcliffe, and Clark, 1998; Gross et al., 1998). Unfortunately, rural-area hospitals continue to lag behind in their adoption of the ten steps and other strategies to promote breast feeding (Calandro, 2000).

A common denominator in the success of breast feeding in urban areas is the availability of a lactation specialist to assist mothers in the pre-natal period, immediate post-natal period, and most importantly, the period after discharge from the hospital. After all, it is difficult to promote and sustain breast feeding without access to an individual knowledgeable in lactation. Many rural birthing centers rely on medical and nursing staff to provide mothers with information on breast feeding while they are in the hospital, but research has shown that quite often staff members lack sound knowledge in this

area (Clauss and Hall-Harris, 1999). Short stays after delivery, often less than 48 hours, also make it difficult for nursing staff to teach and aid new mothers in breast feeding tasks.

Facing these challenges, it is not surprising that in many rural areas less than 25% of mothers initiate breast feeding, with over one-third of those who do breast-feed stopping within three weeks. Lack of breast feeding knowledge and support from hospital staff are common complaints from mothers who choose to formula-feed their babies.

Lactation consultants have been shown to have a positive impact on breast feeding through a multi-tiered approach, from pre-natal education extending through the period following delivery, that provides channels for proper support and follow-up for breast feeding mothers. By eliciting and acknowledging concerns and educating about breast feeding benefits and techniques, the lactation consultant increases the mother’s confidence and provides her a sense of empowerment.

Lactation consultants set up and lead breast feeding support groups, visit new mothers in the hospital to aid and assess breast feeding, and make follow-up phone calls to answer questions and offer reassurance.

The positive impact of lactation consultants on breast feeding is evident in the research. Jones and West (1986), in a randomized control trial of 649 mothers, noted that employment of a lactation specialist significantly increased the duration of nursing, particularly among women of lower social class. Their study states that “by consistent advice, assistance, support, and encouragement [the lactation consultant] enabled mothers to cope more successfully with difficulties, leading to significantly fewer ending breast feeding prematurely”. In another study, breast feeding initiation rates in New York City hospitals doubled (from 29% to 58%) in the years following a 1984 regulation requiring all hospitals to hire a lactation consultant (Rosenberg, McMurtrie, Kerker, Na, and Graham, 1998). Initiation rates in these hospitals continued to climb during the mid and late 1980s, as rates in the rest of the US were consistently dropping.

Many lactation consultants make home visits, which have

been effective at increasing duration of breast feeding as well

(Morrow et al., 1999). Lactation consultants have proven to be

instrumental in helping to develop and implement various

breast feeding programs such as motivational videotapes, the

Baby Friendly Initiative, and “Best Start” - a breast feeding

educational program presented to healthcare professionals

(Gross et al., 1998; Wright et al., 1998; Hartley and O’Connor, 1996). Unfortunately, women in many rural areas do not have access to a lactation consultant because healthcare facilities in these areas do not have one on staff. This places these new mothers at a tremendous disadvantage, because in many cases they are literally on their own without any type of support network to consult when questions or problems arise.

Follow Up

There are many challenges to breast feeding teaching and assessment during the immediate post-partum period. For these reasons it is essential that nursing mothers have proper follow-up to aid with the breast feeding experience. Mothers who do not have avenues to follow up often find it easier to discontinue breast feeding when faced with questions regarding sore nipples, latching on, milk supply, infant satisfaction, or any other concern. Proper follow up for breast feeding mothers is a problem in rural communities because of a lack of available resources.

In her article on facilitating Breast feeding Calandro (2000), a board certified lactation consultant, writes, “Because the first two weeks are so critical and most mothers leave the hospital in 24 to 72 hours, it is important to provide assistance beyond the hospitalization”. Initial follow-up should be two to three days post-discharge, by means of breast feeding support groups, peer counselors, and lactation consultants.

All nursing mothers should be referred to a breast feeding support group upon discharge from the hospital. Research has shown that attendance at lactation support group meetings is positively associated with continuation of breast feeding.

Chezam and Friesen (1999) compared duration of breast feeding in subjects who attended breast feeding support meetings (n=24) versus those who did not (n=65). Results showed that women who attended at least one meeting were more than three times as likely to still be breast feeding their babies at six months of age. Mothers who participated in meetings were also more likely to attain their breast feeding goals and felt more satisfied with the breast feeding experience. There was no difference in age, education, or income of the attendees and nonattendees. The authors noted that the knowledge, guidance, and reassurance offered by the meetings influenced the mothers feelings of success and had a positive impact on duration of nursing and attainment of breast

feeding goals.

Involving the entire family is ideal in breast feeding follow up. Chezam and Frieson (1999) note that breast feeding mothers “rely on health care professionals to provide informational support while family members are looked to for emotional and tangible support”. Studies have found that the likelihood of breast feeding was found to increase with higher social support from family (Bocanegra, 1998). One of the major factors sited by mothers who chose to bottle–feed their babies was a lack of breast feeding support by their families (Arora, McJunkin, Wehrer, and Kuhn, 2000). Attendance of family members at discussions or classes can encourage their support as well as correct any culturally based misinformation about breast feeding.

Breast feeding follow-up in rural areas may be shallow and unstructured at best, nonexistent at worst. Without meaningful follow up, rural communities will not improve breast feeding rates, and discrepancies will remain between urban and rural America.

Recommendations

Breast feeding is an inexpensive source of optimal nutrition that should be afforded to all infants when possible. Breast feeding rates and duration are higher in urban areas compared to rural areas because urban hospitals and birthing centers have more resources and have made a stronger effort to implement strategies that promote breast feeding. Some of these strategies include mandatory employment of certified lactation consultants, implementation of the Baby Friendly Initiative, well-structured avenues for breast feeding follow-up, 24-hour access to on-call lactation specialists, and prenatal and post-partum support groups for breast feeding mothers and their families.

A primary problem within rural communities is a lack of breast feeding educators. This is evident in the misconceptions that rural mothers have about breast feeding, such that breast feeding is painful, inconvenient, physically disfiguring, or that formula is more nutritious than breast milk. Rural birthing centers often rely on staff to provide a “crash course” on breast feeding during the immediate post-partum period, a time that is not conducive to effective learning. Many of these staff nurses feel that they are inadequately educated in breast feeding and unprepared to assist mothers with nursing tasks.

Employment of more lactation consultants into rural birthing

centers could make a positive difference. Not only can lactation consultants devote more time and higher quality teaching to breast feeding mothers while in the hospital, they can give instruction and guidance to mothers during the months preceding delivery, which has shown to increase breast feeding rates (Moreland and Coombs, 2000). Lactation consultants can help develop and lead breast feeding support groups and educational programs for new and expectant mothers and families. Home visits by lactation consultants have proven to lengthen duration of breast feeding, and could be an important tool in the rural community since many of these women may not have readily available transportation. Perhaps most importantly, lactation consultants can be available for breast feeding mothers during the critical juncture after discharge from the hospital, when so many new mothers in rural areas feel overwhelmed and terminate their efforts to breast-feed.

Rural hospitals and birthing centers should be encouraged to recruit lactation consultants into their communities. The prospect of “sharing” a lactation consultant among rural hospitals and birthing centers should be considered as well.

Competitive salaries, benefits, and mileage reimbursement could provide an attractive package to lure lactation professionals to these areas, or encourage healthcare workers in rural areas to become certified as lactation specialists. Jones and West (1986) noted that the addition of a lactation consultant “significantly extended the duration of breast- feeding…particularly among women of lower social class”.

The employment of lactation consultants into rural areas may prove to be quite cost-effective. Prior research done by Kaiser Permanente in a region of North Carolina where they were initiating a lactation support program found that infants who were breast-fed at least six months experienced an average of

$1,435 less in health care claims as compared to formula-fed infants. The savings were the result of fewer hospitalizations, office visits, and drug prescriptions. It has been estimated that the nation could save $3 to $4 billion per year if all newborns were nursed for even 12 weeks.

Changes within the rural community itself to facilitate breast feeding should be realized as well. Women with manufacturing jobs, common in rural areas, are less likely to breast-feed upon returning to work, likely because of a lack of time and privacy to pump breast milk (Hammer et al., 1999). Places of employment in rural communities should afford mothers with

necessary time and private rooms to pump breast milk. A proper schedule for pumping can be worked out between the mother, lactation consultant, and work supervisor. Rural communities should also be instrumental in developing breast feeding education and support groups. Billboards and other means of advertisement can inform community members of local breast feeding resources.

Rural areas need to improve means of follow-up for breast feeding mothers. Lactation consultants, peer counselors, and breast feeding support groups must be part of the breast feeding experience of rural mothers to improve outcomes.

Frequent call backs and on-call advice for breast-feeders should be implemented in rural communities. Structured follow-up in urban areas has made a remarkably positive impact on breast feeding trends. It is likely that improved breast feeding follow-up for rural mothers will yield positive results in their communities, as well.

Breast feeding trends in rural America are less than adequate. The literature shows the positive effects of lactation consultants, education programs, and support groups on breast feeding in urban areas. Steps must be taken to promote these strategies in rural communities, as well. Rural hospitals, birthing centers, health care workers, and community groups should step up their initiative and funding to promote infant nursing in their areas. Until this happens, breast feeding trends in rural communities are unlikely to show improvement.

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