Date Published: July 3, 2017
Publisher: Public Library of Science
Author(s): Tessa M. Swigart, Anabelle Bonvecchio, Florence L. Théodore, Sophia Zamudio-Haas, Maria Angeles Villanueva-Borbolla, James F. Thrasher, Jacobus P. van Wouwe.
Breastfeeding is recommended exclusively for the first 6 months after birth, with continued breastfeeding for at least 2 years. Yet prevalence of these recommendations is low globally, although it is an effective and cost-effective way to prevent serious infections and chronic illness. Previous studies have reported that social support greatly influences breastfeeding, but there is little evidence on perceived social norms in Mexico and how they affect actual behavior.
Our objective was to investigate breastfeeding intention, practices, attitudes, and beliefs, particularly normative, among low-resource communities in central and southern Mexico.
We performed a secondary analysis using the theory of planned behavior with cross-sectional data, which included semi-structured individual interviews with fathers (n 10), 8 focus groups with mothers (n 50), and 8 focus groups with women community leaders (n 44) with a total of 104 participants. Our data also included a quantitative survey among pregnant women and mothers (n 321).
Women reported supplementing breast milk with water and teas soon after birth, as well as introducing small bites of solid food a few months after birth. Social norms appeared to support breastfeeding, but not exclusive breastfeeding or breastfeeding for periods longer than about a year. This may be partially explained by: a) behavioral beliefs that for the first 6 months breast milk alone is insufficient for the baby, and that water in addition to breast milk is necessary to hydrate an infant and b) normative beliefs related to the appropriateness of breastfeeding in public and as the child gets older.
Future strategies should focus on positively influencing social norms to support recommended practices, and emphasize the specific reasons behind the recommendations. Future efforts should take a multi-pronged approach using a variety of influences, not only directed at healthcare providers but close family members, including fathers.
The World Health Assembly and World Health Organization recommend exclusive breastfeeding (EBF) for the first 6 months of an infant’s life, with continued breastfeeding (BF) and complementary feeding introduced after the first 6 months up to age 2 years or more . Compared to infants who are partially breastfed or not breastfed, infants with EBF for the first 6 months (i.e., without introduction of any other foods or liquids) experience better nutritional intake, fewer micronutrient deficiencies, fewer infectious episodes, fewer hospital visits, greater cognitive ability and lower mortality [2–5]. Additional evidence suggests a protective effect of BF in the prevention of childhood obesity  and mounting data indicate chronic disease protection lasting well-into adulthood, possibly reducing the likelihood of obesity, diabetes, and hypertension .
A framework of our key findings using the IM of the TPB is shown in Fig 2.
Our study found that behavioral and normative beliefs and BF practices among our study populations supported BF, but were not aligned with recommmended practices. In general, women breastfed, but not exclusively, for about the first 6 months, and sporadic BF after 6 months was normal to about 8 months or a year. Our study gave new insight into the reasons why and in what way recommended practices are not followed, which can help illuminate how to improve future promotional efforts in Mexico and in other parts of the world.
What most greatly motivates BF intentions and behavior among the study population was what was considered the best and healthiest care for their baby, and these beliefs appeared to be significantly shaped and influenced by the behavioral and normative beliefs perceived from the family and community, as well as from healthcare providers. While the norms shed a positive light on BF, they did not support EBF for the first six months or continued BF up to 2 years. Future strategies to promote BF among low-resource communities need to specifically address the difference between BF and EBF, and why EBF is superior. Also important is to better understand the causes of perceived insufficient milk and how to counteract them, and to promote self-efficacy for and knowledge about milk production. Efforts should include different instruments such as mass media to inform social norms, as well as improving knowledge and influence among healthcare providers as well as close family members, including fathers. BF promotion should try to reverse the practices and norms of giving water, tea, and small bites to infants before 6 months after birth, and improve the acceptability of BF in public, thereby empowering women to do so.