"I wanted to do a good job": experiences of 'becoming a mother' and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit

In mothers of preterm infants, the process of becoming a mother is initiated in a public and medical environment, in which the mothers become dependent on the benevolence and support of the staff. This setting and an experience of insecure social bonds impair the ability to become a mother during the infant's stay at the neonatal unit (NU), and breastfeeding may become a duty and not be mutually satisfying. Studies on how women experience becoming a mother and breastfeeding after the infant's discharge are sparse and this question is addressed in the present grounded theory study. Twenty five mothers, whose very preterm infants had received care in seven NUs in Sweden, were interviewed once, 1-12 months after discharge. We propose a model to increase understanding of the process of becoming a mother and breastfeeding, after the infant's discharge from the NU. The mother's emotional expressions in this process showed pendular swings from feeling emotionally exhausted to feeling relieved, from experiencing an insecure to a secure bond, and from regarding breastfeeding as being non-reciprocal to being reciprocal. Unresolved grief, the institutional authority at the NU and experiences of shame were three of the central barriers to a secure and reciprocal relationship. The pendular changes give us a deeper understanding of the variations in both attachment and attunement. Perhaps the negative extremes are more prominent among these mothers on account of their infant's illness and their NU experiences. If our proposed model is valid, it is vital that these findings are considered by those involved in the short- and long-term care in order to support the mothers to establish a secure bond, comprising both attachment and attunement.     

Cycling and the city: a case study of how gendered, ethnic and class identities can shape healthy transport choices

As a form of 'active transport', cycling has been encouraged as a route to improving population health. However, in many high-income countries, despite being widely seen as a 'healthy' choice, few people do cycle for transport. Further, where cycling is rare, it is not a choice made equally across the population. In London, for instance, cycling is disproportionately an activity of affluent, White, men. This paper takes London as a case study to explore why the meanings of cycling might resonate differently across urban, gendered, ethnic and class identities. Drawing on qualitative interview data with 78 individuals, we suggest first that the relative visibility of cycling when few do it means that it is publicly gendered in a way that more normalised modes of transport are not; conversely, the very invisibility of Black and Asian cyclists reduces their opportunities to see cycling as a candidate mode of transport. Second, following Bourdieu, we argue that the affinities different population groups have for cycling may reflect the locally constituted 'accomplishments' contained in cycling. In London, cycling represents the archetypal efficient mode for autonomous individuals to travel in ways that maximise their future-health gain, and minimise wasted time and dependence on others. However, it relies on the cultivation of a particular 'assertive' style to defend against the risks of road danger and aggression. While the identities of some professional (largely White) men and women could be bolstered by cycling, the aesthetic and symbolic goals of cycling were less appealing to those with other class, gendered and ethnic identities.     

Moral work in women's narratives of breastfeeding

Women's narratives of their breastfeeding experiences are sites of construction and reconstruction of self as they undertake moral work in relation to feeding their baby. We engaged Foucault's ‘technologies of the self’ and his notion of ethics (the relationship with self) to examine that moral work (individual actions rather than adherence to universal moral codes) in relation to women's subjectivity constructed in interviews with 49 women from the UK. Four categories of moral work were identified: biographical preservation, biographical repair, altruism and political action. We describe each of these and conclude that women's embodied experience and sense of self are disciplined within current, limited, often punishing discourses by undertaking painful moral work in order to maintain or repair their subjective positions. We suggest the development of new subject positions around infant feeding practices.     

不同健康宣教形式对产妇母乳喂养影响的研究

目的分析不同孕期健康宣教形式对产妇母乳喂养的影响,为促进母乳喂养干预提供依据。方法依据产妇孕期在医院接受母乳喂养健康宣教形式分组,比较医护人员门诊宣教、孕妇学校宣教和两种形式结合宣教的产妇生后第1天和出院前24小时的母乳喂养情况。结果两种宣教形式结合组产妇出院前24小时的母乳喂养率64.67%,高于门诊宣教组(57.29%)和孕妇学校宣教组(49.55%)。采用门诊和孕妇学校结合的宣教形式对产妇生后第1天和出院前24小时的母乳喂养效果优于单纯门诊宣教和单纯孕妇学校宣教。结论医院门诊宣教与孕妇学校宣教相结合的母乳喂养健康教育方式,更有利于促进母乳喂养的成功。     

Progestogen-only contraceptive use among breastfeeding women: a systematic review

Background

The use of progestogen-only contraceptives by breastfeeding women raises theoretical concerns regarding possible adverse effects on breastfeeding success, and infant health or growth. This review was conducted to determine from the literature whether use of progestogen-only contraceptives by breastfeeding women leads to adverse effects on lactation, or infant growth or health when compared to nonuse.

Study Design

We searched the Medline, Popline, Cochrane and LILACS databases for all articles published from database inception through May 2009. Studies were included if they investigated the use of progestogen-only methods in breastfeeding women and reported on clinical outcomes in either women or their infants. Standard data abstraction templates were used to systematically assess and summarize. Summary odds ratios were not calculated, given the heterogeneity of interventions, results and non-quantifiable outcomes reported.

Results

We identified 43 articles for this review. Overall, five randomized trials and 38 observational studies demonstrated no adverse effects of various progestogen-only methods of contraception on multiple measures of breastfeeding performance through 12 months in women using these methods in the postpartum period. Many of these studies also demonstrated no adverse effects of progestogen-only methods on infant growth, health or development from 6 months to 6 years of age. Additional studies demonstrated no effects on infant immunoglobulins or sex hormones of exposed male infants. A single study of a desogestrel pill reported two cases of gynecomastia in exposed infants.

Conclusions

Evidence suggests that progestogen-only methods of contraception do not adversely affect breastfeeding performance when used during lactation. Evidence that progestogen-only contraception does not adversely affect infant growth, health, or development when used by breastfeeding women is consistent but methodologically limited.     

The interactions between breastfeeding mothers and their babies during the breastfeeding session

Breastfeeding mothers and their babies were videotaped during breastfeeding sessions in order to investigate maternal-infant interactions occurring during breastfeeding sessions. The videotaped sessions were later observed and analyzed. The interactions observered during the breastfeeding sessions were elaborate and complex, with each breastfeeding dyad interacting with its own individual style. The study also explored important benefits and disadvantages that breastfeeding provides for different couples.     

Conformity with current guidelines on oral contraceptive prescribing for breastfeeding women: a New Mexico survey

BACKGROUND: National and international contraceptive guidelines reflect expert opinion that recommends against the use of estrogen-containing hormonal contraception in the early postpartum period. This study was undertaken to estimate providers' practices in prescribing hormonal contraception to breastfeeding women. METHODS: A 19-item survey was mailed to 397 obstetrician gynecologists, midwives and family physicians in the state of New Mexico. The survey included items covering attitudes about the impact of hormonal contraception on breastfeeding and prescribing practices. One hundred ninety-nine (50%) providers completed the survey. RESULTS: The majority (70%) of providers prescribe progestin-only contraceptive methods to breastfeeding women within the first 6 weeks. Despite these recommendations, a sizable minority of providers prescribe combined pills in the early postpartum period: 27% of providers have prescribed combined pills and 13% of providers, mostly those in a university setting, routinely recommend them within the first 6 weeks postpartum. CONCLUSION: Most providers follow expert recommendations regarding the initiation of hormonal contraception for breastfeeding women.     

Secrets and lies: Breastfeeding and professional paid work

This paper explores the conflict between health advice and organisational practice regarding breastfeeding. It focuses on the group of mothers with the highest rates of both breastfeeding initiation and of continuous employment following maternity leave: specifically, educated mothers in managerial and/or professional occupations. In this context, the paper investigates, through in-depth interviews, the embodied experiences of 20 heterosexual UK mothers, qualified to degree level, who returned to professional employment within 1 year of childbirth. The paper observes that mothers who attempted to combine breastfeeding with paid work did so with difficulty because the material activity of breastfeeding was 'taboo' within the workplace. Thus, the requirement to conform to organisational expectations regarding 'suitable' embodied behaviour contradicted health advice about what was 'best' for infant children. In order to comply with workplace requirements, mothers in the study were obliged either to cease breastfeeding or to conceal breastfeeding activities. In the light of mothers' experiences, the paper suggests that breastfeeding duration rates among professionally employed mothers can only be improved if negative attitudes about maternal bodies and employment are challenged and if employers, as well as mothers, are the focus of health initiatives aimed at promoting breastfeeding.     

Why do interventions work in some places and not others: A breastfeeding support group trial

In a cluster randomised controlled trial of a policy to provide community breastfeeding support groups in Scotland, breastfeeding rates declined in 3 of 7 intervention localities. From a preliminary study, we expected breastfeeding outcomes to vary and we prospectively used qualitative and quantitative methods to ask why. Ethnographic in-depth interviews, focus groups, observations and survey data were analysed to build seven embedded case studies. A pyramidal model of how primary health service organisations implemented the policy was constructed prior to knowing trial outcomes to minimise bias. Informed by a realist approach, the model explained variation in (a) policy implementation (b) the breastfeeding outcomes, whereas the quantity of intervention delivered did not. In the three localities where breastfeeding rates declined, negative aspects of place including deprivation, unsuitable premises and geographical barriers to inter-professional communication; personnel resources including staff shortages, high workload and low morale; and organisational change predominated (the base model tiers). Managers focused on solving these problems rather than delivering the policy and evidence of progress to the higher model tiers was weak. In contrast, where breastfeeding rates increased the base tiers of the model were less problematic, there was more evidence of leadership, focus on the policy, multi-disciplinary partnership working and reflective action cycles (the higher model tiers). We advocate an ethnographic approach to the design and evaluation of complex intervention trials and illustrate how this can assist in developing an explanatory model. More attention should be given to the complex systems within which policies and interventions occur, to identify and understand the favourable conditions necessary for a successful intervention.     

The pharmaceutical corporation and the 'good work' of managing women's bodies

Pharmaceutical companies are intricately intertwined with every aspect of contemporary medical reality, and they increasingly drive the social process of medicalization in order to establish and dominate markets for their drugs and devices. In addition to funding the majority of clinical research, organizing it to generate an evidence base that favors their innovations, and influencing the regulation of pharmaceutical drugs and devices, companies still spend substantial resources on direct attempts to shape the attitudes, dispositions, and prescribing behavior of physicians. This article sheds new light on our picture of the relationship between the pharmaceutical industry and physicians by examining a novel form of physician-directed communication produced by one prominent corporation. An interpretive, thematic analysis of ORGYN - the unique, full-length magazine published by the Organon Corporation between 1990 and 2003 - reveals two overarching messages it communicated to physicians during that period. First, it offered a compelling picture of the "good work" obstetricians and gynecologists do, which involves enabling women of reproductive age to control their fertility through contraception and infertility treatment, and providing symptom relief and preventive benefits to older women by increasing compliance with hormone therapy regimes. Second, it included pharmaceutical technology in every aspect of the doctor's work, portraying pharmaceutical corporations as the physician's "natural partner", and women patients as passive, disempowered objects of medical practice. Through these consistent messages, the print magazine ORGYN represented one important set of mechanisms by which a pharmaceutical corporation helped drive and sustain medicalization. The article ends with a consideration of the implications of ORGYN's messages for companies, doctors, women patients, and the study of medicalization.     

工作场所母乳喂养支持研究进展

目的 引进母乳喂养支持的员工感知问卷（EPBS-Q）进行翻译及修订,评价中文版问卷的信效度。 方法 汉化EPBS-Q,并通过专家评定、预调查和认知访谈对中文版问卷进行修订,在郑州市两所三甲医院儿童预防保健门诊,便利抽取产后返岗的346名职业母亲,发放中文版EPBS-Q,评价其信度和效度。 结果 中文版EPBS-Q共包含30个条目,5个维度,总的Cronbach′s α 系数为0.917,5个维度的Cronbach′s α 系数为0.817～0.946,组合信度为0.835～0.994。I-CVI均 > 0.80,S-CVI/Ave为0.99。每个维度的AVE值较高,AVE的算数平方根均大于每个维度之间的相关系数,收敛效度、区别效度和结构效度均较好。 结论 中文版母乳喂养支持的员工感知问卷适用于中国的文化背景,具有良好的信度和效度。     

婴儿期母乳喂养与孤独症发生的关系

目的:探讨婴儿期母乳喂养与孤独症发生之间的关系。方法:选取2004年1月～2005年12月期间在我院就诊的372例孤独症患儿作为孤独症组,同时随机抽取在我院儿童保健门诊参加系统保健的正常儿童1116例作为对照组,两组儿童的年龄、性别构成一致。参照国外同类调查问卷并结合我国具体情况设计自制调查问卷对研究对象的生长发育情况和婴儿期喂养情况等进行调查,分析婴儿期母乳喂养与孤独症发生之间的关系。结果:单因素分析发现孤独症组儿童4个月内纯母乳喂养率为20.97%,对照组儿童4个月内的纯母乳喂养率为51.08%,对照组明显高于孤独症组(χ2=102.874,P<0.01)。在母乳喂养持续时间方面,孤独症组儿童平均母乳喂养持续时间为(3.82±0.46)月,对照组为(6.61±0.49)月,两组儿童的平均母乳喂养持续时间不同(t=2.74,P<0.01);孤独症组儿童母乳喂养持续时间小于3个月和3～6个月的比例分别是26.34%和15.32%,对照组分别是9.23%和10.66%,孤独症组高于对照组(P<0.01,0.05);孤独症组儿童母乳喂养持续时间大于或等于9个月的比例为35.22%,而对照组为55.02%,孤独症组低于对照组(P<0.01)。多因素Logistic回归分析发现喂养类型是孤独症发生的危险因素(OR=1.429),母乳喂养持续时间是孤独症发生的保护因素(OR=0.528)。结论:婴儿期喂养方式与孤独症的发生有关;4个月内母乳喂养比例越高,母乳喂养持续时间越长,儿童孤独症的发生率越低。     

Combined oral contraceptive use among breastfeeding women: a systematic review

Background

Postpartum women need effective contraception, but using hormonal contraceptives may affect breastfeeding performance and infant health outcomes.

Study design

We searched the MEDLINE and Cochrane databases for all articles published through May 2009 for primary research studies that investigated clinical outcomes among breastfeeding women who used hormonal contraception or their infants.

Results

Three randomized controlled trials reported decreased mean duration of breastfeeding and higher rates of supplemental feeding among combined oral contraceptive (COC) users than among nonusers, while one multicountry trial found no differences in these parameters. Only one study demonstrated lower average weights during the first year of life for infants whose mothers used COCs while breastfeeding. None of the eight studies, four of which were observational, included in this review documented adverse infant health outcomes.

Conclusions

Limited evidence demonstrates an inconsistent effect of COC on breastfeeding duration and success. The evidence is inadequate to determine whether a mother's use of these drugs affects breastfeeding duration or the infant's health.     

In practice, the theory is different: a processual analysis of breastfeeding in northeast Brazil

'Na prática, a teoria è outra' (in practice, the theory is different) is an old Brazilian saying. This phrase summarizes well the general practice of breastfeeding in Brazil: 'Breast is best' is central in the pregnant women's future oriented 'theory' of how their infant should be fed. In the subsequent weeks after delivery, however, in the daily practicalities of feeding their infant, this theory is, to a large extent, abandoned. The present study is based on a sample of 300 mothers in the city of Aracaju in the Northeast of Brazil. Through interviews, the differences and similarities between knowledge and practice with respect to infant feeding were established. An explanation of these differences is developed on the basis of a processual analysis of the qualitative and quantitative results of the interview data. Nearly all mothers were knowledgeable of the need to breastfeed, and nearly all mothers had initiated breastfeeding. However, only a minority was exclusively breastfeeding at the time of the interview. A distinction is made between a breastfeeding process and a de-breastfeeding process. The data suggest that mothers, in general, start the de-breastfeeding process with the positive intention of ameliorating the infant's situation without realizing the negative processual consequences that most likely ends in a cessation of breastfeeding. The study supports the view that health policy should underline the processual character of both breastfeeding and de-breastfeeding when promoting the importance of exclusive breastfeeding.     

Maternal breastfeeding and autism spectrum disorder in children: A systematic review and meta-analysis

Objectives: Autism spectrum disorder (ASD) refers to a group of conditions variably affecting communicative and social interactive abilities presenting alongside behaviors with various restricted and repetitive patterns. In addition to genetic factors that influence the onset of the symptoms, there is growing interest in the potential involvement of non-genetic environmental factors. Some aspects of breastfeeding practices, including rates, timing, or optimality, have been put forward as environmental risk factors for autism. However, previous studies showed a controversial relationship between ASD and breastfeeding.

Methods: A meta-analysis on the association between maternal breastfeeding and ASD in children was conducted. We also explored potential moderating factors which might influence this association. Articles reporting the association between breastfeeding and a diagnosis of ASD were included.

Results: Seven articles were included in the meta-analysis. Cumulatively, children with ASD (n?=?1463), either in the form of clinical diagnosis or self-report, were significantly less likely to have been breastfed than children without ASD (n?=?1180) (OR?=?0.61, 95% CI?=?0.45–0.83, P?=?0.002). Subgroup analyses revealed that results remained significant for children who were breastfed with additional supplementation.

Discussion: This meta-analysis provides evidence that breastfeeding (exclusively or including additional supplements) may protect against ASD. Prospective longitudinal research is required to disentangle the complex relationships and to explore potential pathophysiological mechanisms.     

Power to negotiate spatial barriers to breastfeeding in a western context: When motherhood meets poverty

Although breastfeeding is beneficial to the health of babies born into poverty, rates have remained consistently low among this group. This paper presents findings from a study conducted with poor French Canadian women, who were exposed to breastfeeding promotion. Analysis of 31 qualitative interviews suggests that the ‘good mother’ imperative in context of poverty and the western hypersexualization of breasts acted as major deterrents to breastfeeding. Poor mothers, lacked access to the power required to negotiate these barriers in their social space. Public health should prioritize the transformation of social and public spaces when promoting breastfeeding to poor mothers.     

职业女性母乳喂养影响因素及其干预的研究进展（综述）

随着职业女性人数的增多,职业母亲的母乳喂养问题也日益凸显。职业母亲的母乳喂养率和母乳喂养持续时间明显低于非职业女性。职业女性的母乳喂养率受多层面因素的影响,包括母亲自身、家庭、工作场所及社会。要改善职业母亲的母乳喂养状况,也要从这几个层面着手采取相应的干预措施。     

Maternal employment, breastfeeding, and health: evidence from maternity leave mandates

Public health agencies around the world have renewed efforts to increase the incidence and duration of breastfeeding. Maternity leave mandates present an economic policy that could help achieve these goals. We study their efficacy, focusing on a significant increase in maternity leave mandates in Canada. We find very large increases in mothers' time away from work post-birth and in the attainment of critical breastfeeding duration thresholds. We also look for impacts of the reform on self-reported indicators of maternal and child health captured in our data. For most indicators we find no effect.     

Ethnicity and registration as a kidney donor: the significance of identity and belonging

Studies of attitudes towards cadaveric organ donation have failed to adequately explain the disproportionately low rates of cadaveric organ donation among ethnic minorities. This may reflect an unhelpfully static and narrow definition of 'culture' entailing a collection of predefined cognitive 'beliefs' and 'attitudes.' This paper takes a more integrative approach and considers how ethnicity shapes perceptions of identity and belonging that underpin organ donation discourse among a section of Black British Caribbean people, one of largest migrant groups in the UK. The study is based on 14 in-depth interviews with men and women of Caribbean descent living in south London. Respondents' accounts identified their Caribbean heritage and racial identity as producing a divided sense of loyalty and belonging accompanied by perceptions of discrimination and exclusion from the mainstream society that may have contributed to their lack of trust in doctors and the medical system in relation to organ donation. Furthermore, despite being supportive of kidney donation, death appeared to take on special significance in reaffirming their ethnic identity. This was reflected in their view of the Caribbean as their ideal place of burial and desire that their body should return whole. The study underlines the need for a fresh approach to the understanding of organ donation based on greater knowledge of the construction and significance of ethnic identity and belonging.