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. Author manuscript; available in PMC: 2016 Feb 1.
Published in final edited form as: J Hum Lact. 2015 Aug 19;32(1):103–111. doi: 10.1177/0890334415599400

Exclusive Breastfeeding Experiences among Mexican American Women

Karen Wambach 1, Elaine Williams Domian 1, Sallie Page-Goertz 2, Heather Wurtz 3, Kelli Hoffman 4
PMCID: PMC4710489  NIHMSID: NIHMS749849  PMID: 26289059

Abstract

Background

According to the Centers for Disease Control and Prevention, Hispanic breastfeeding mothers begin early formula supplementation at higher rates than other ethnic groups, which can lead to shorter breastfeeding duration and decreased exclusive breastfeeding. Acculturation, the process of adopting beliefs and behaviors of another culture, appears to influence breastfeeding practices of Hispanic women in the United States. Little is known about Mexican American mothers’ formula use and exclusive breastfeeding within the context of acculturation.

Objective

Our study identified perceived benefits and barriers to exclusive breastfeeding and levels of acculturation among Mexican American women living in a Midwestern city.

Methods

We used a qualitative descriptive design integrating Pender’s Health Promotion Model concepts. Individual interviews were conducted in English or Spanish (N = 21). The revised Acculturation Rating Scale for Mexican Americans was used to examine acculturation levels.

Results

Acculturation scores indicated that the majority (66%) of the sample was “very Mexican oriented.” Most women exclusively breastfed, with a few using early supplementation for “insufficient milk production.” Three themes emerged: (1) It is natural that a woman give life and also provide the best food for her baby; (2) Breastfeeding is ultimately a woman’s decision but is influenced by tradition, guidance, and encouragement; and (3) Breast milk is superior but life circumstances can challenge one’s ability to breastfeed.

Conclusion

Strong familial/cultural traditions supported and normalized breastfeeding. Barriers to exclusive breastfeeding were similar to breastfeeding women in general, in the United States. Findings support the need for culturally competent and individualized lactation care.

Keywords: acculturation, breastfeeding, exclusive breastfeeding, Mexican American

Background

It is a US public health priority to promote, protect, and support breastfeeding.1 Exclusive breastfeeding for 6 months confers the greatest health benefits for mother and child, including reduced childhood obesity.2–5 Accordingly, Healthy People 2020 (HP2020) objectives call for 46.2% of infants to be exclusively breastfed through 3 months and 25.5% through 6 months.6 Because early formula introduction can lead to shorter breastfeeding duration,7–10 HP2020 also calls for reducing formula supplementation in the first 2 days of life.

Rates of breastfeeding initiation and duration differ by ethnicity and race.11 African American mothers have the lowest initiation, duration, and exclusivity rates. Hispanic and non-Hispanic white mothers have similar rates of initiation, duration, and exclusivity.11 However, Hispanic mothers begin formula supplementation within the first 2 days after birth at higher rates than white or African American mothers (32.8% vs 23% and 28.2%, respectively),12 thus leading to declines in their subsequent exclusive breastfeeding.13 Because the prevalence of obesity among US Hispanic children ages 2 to 5 years is high (18.3%),14 it is important to reduce early formula supplementation to support exclusive breastfeeding and protect against childhood obesity. The significance of the problem is heightened by the fact that Hispanics are the largest ethnic minority group15 and have the highest birth and fertility rates of all minority groups.16

Acculturation, adopting the beliefs and behaviors of another culture, influences Hispanic breastfeeding practices; highly acculturated women have lower rates of breastfeeding initiation and exclusivity than less acculturated women.17 Increased years of US residence for women of Mexican descent was associated with decreased likelihood of initiating breastfeeding and shorter duration of exclusive and any breastfeeding.18 Using preferred spoken language as a proxy for acculturation, researchers19–21 found Spanish-speaking women to be more likely to breastfeed, exclusively breastfeed, and breastfeed longer.

Because people of Mexican descent make up the largest proportion of US Hispanics,22 understanding the context of breastfeeding practices and acculturation within this population is necessary. However, only 2 qualitative studies of low-income Hispanics of Mexican descent have explored these issues. Gill’s team23 used focus groups in a Texan Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) setting to identify themes of breastfeeding benefits, decision making, barriers, lack of support, and cultural beliefs. Each theme demonstrated the familial, social, and cultural context of breastfeeding, but the effect of acculturation was not studied directly. Bunik et al24 used focus groups and individual interviews with low-income primiparous Hispanic mothers and separate focus groups with grandmothers and fathers. The study revealed that many endorsed combined use of breastfeeding and formula (“las dos cosas”), that breastfeeding can be a struggle and often not under the mother’s control, and that familial and cultural beliefs influenced feeding decisions. The researchers concluded that these exclusive breastfeeding barriers were similar to the general population, thus suggestive of acculturation.

The purpose of our study was to identify perceived benefits and barriers to exclusive breastfeeding as well as levels of acculturation among Mexican American women, the predominant Hispanic group, living in a Midwestern US city. We used Pender’s Health Promotion Model25 as a way to understand Mexican American women’s breastfeeding experiences and perceptions through this theoretical lens as it encompasses (1) behavior-specific cognitions and also individual characteristics, such as age and gender; (2) psychological factors of self-esteem, self-motivation, and personal competence; and (3) sociocultural factors of race/ethnicity, acculturation, education, and socioeconomic status.25,26 Concepts from Pender’s model provided support in the development of interview questions.27

Methods

We used a qualitative descriptive design to explore and describe the meanings ascribed to the perceptions and experiences of breastfeeding for Mexican American women, thereby providing a “comprehensive summary of an event in the everyday terms of those events.”28(p336) The Revised Acculturation Rating Scale for Mexican Americans (ARSMA-II) was used to measure acculturation levels of the participants.29

Congruent with the design, a purposive sample was employed.30 Sampling criteria consisted of English-speaking, bilingual, and/or Spanish-speaking Mexican American women with singleton, full-term infants up to 6 months of age who had breastfed for at least 2 weeks. Participants were recruited by a nurse practitioner or physician assistant during well-child exams in a pediatric clinic or by home visitors in a community health project. The institutional review board of University of Kansas Medical Center approved the study.

Data Collection

Semistructured interviews, lasting approximately 1 hour, were conducted in a private office at the clinic or the participants’ homes by 1 of 3 trained bilingual interviewers. Participants completed a short demographic questionnaire. Interviews, conducted in Spanish or English depending on the participant’s preference, were recorded, transcribed verbatim, and analyzed. Interviews conducted in Spanish were transcribed by a certified Spanish transcriptionist and then translated and transcribed in English with back translation in Spanish to ensure the closest possible original meaning.31

Concepts of Pender’s model were reflected in the open-ended interview questions (Table 1) to obtain participants’ breastfeeding experiences and perceptions. Probing questions were used to delve deeper into experiences. Questions were also asked about beliefs and practices related to exclusive breastfeeding, defined as “only breastfeeding or using only mother’s milk,” and mixed feeding, defined as “using mother’s milk and formula.” We focused on mothers’ total experiences of breastfeeding from birth to the present. Field notes of observations of interactions between mother and infant, other children, and extended family, recorded by a trained research assistant accompanying the interviewer, added contextual data. The principle of data saturation for establishing when to stop collecting data was used in this study.30

Table 1.

Selected Interview Questions.

Pender’s Health
Promotion Model Concept		 Example of Corresponding Interview Question
Behavior Tell me about your experiences of breastfeeding.
Beliefs Tell me how you make the decision to breastfeed your baby.
Perceived benefits and barriers What benefits/difficulties have you experienced with breastfeeding?
Self-efficacy How do you believe someone becomes confident or feels that she is able to breastfeed?
Cognitions How do you feel about yourself since you are breastfeeding or have breastfed your baby?
Situational influences How has your current lifestyle supported or challenged your ability to breastfeed your baby?
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After the interview, each participant completed the ARSMA-II, scale 1.29 The interviewer assisted participants as needed in completing the scale. Two subscales, the Anglo Orientation Subscale (AOS; 13 items) and Mexican Orientation Subscale (MOS; 17 items), are scored on a 5-point Likert-type scale and assess (1) language use and preference; (2) ethnic identity and classification; (3) cultural heritage and ethnic behaviors; and (4) ethnic interaction. A linear acculturation score is calculated by subtracting the mean MOS score from the mean AOS score and is used to place the individual along a 5-level acculturation continuum from very Mexican oriented to very Anglo oriented (levels are based on standard deviation units from the mean). An additional approach to multidimensional categorization of the ARSMA-II was also used and involves plotting the AOS and MOS scores on the x and y axes, respectively, resulting in 4 acculturation categories (integrated high and low bicultural, Mexican-oriented bicultural, and assimilated bicultural).29 The ARSMA-II has evidence of construct validity and adequate internal consistency reliability.29,32 Internal consistency for our study was .92 (AOS) and .86 (MOS). Acculturation data are reported and integrated in theme 2 of the results.

Data Analysis

SPSS was used for all quantitative analyses: (1) descriptive statistics to summarize the demographic data, AOS and MOS scores, and acculturation scores; and (2) Pearson correlation to quantify the relationship of acculturation and length of time in the United States. Qualitative analysis began after the first interview and continued until all data were collected. Transcribed interviews were reviewed against recordings for accuracy and read and reread for a sense of the whole.

Consistent with qualitative descriptive design,33,34 qualitative inductive analysis was used to generate meaning units, codes, categories, and overarching themes.30,35 Initial interviews were hand-coded by 2 authors. This initial coding scheme was further developed using NVivo 9.36 Analysis of field notes, interviews, and observations were used in the development of the themes.

Trustworthiness of data analysis was ensured in multiple ways.37,38 Credibility was confirmed through the process of transcription, translation, and back translation of Spanish interviews; multiple reads of the data; peer debriefing; and member checks. Data triangulation was accomplished through multiple qualitative methods (interviews, field notes, observations) and use of the ARSMA-II. Vivid description of participant beliefs and experiences was represented via direct quotes. An audit trail was kept to support and maintain consistency of all research stages.

Results

Our sample consisted of 21 Mexican American women, 19 of whom were still breastfeeding and planned to breastfeed for 12 to 16 months (Table 2). Two participants had weaned at 6 and 8 weeks, respectively, due to illness and returning to school. About 43% of mothers were breastfeeding exclusively since birth, and a few mothers had used formula in the early days after birth, mainly because they felt they were not producing enough milk. Using data from the ARSMA-II, our participants fell into 3 of 5 acculturation categories representing a very Mexican-oriented to slightly Anglo-oriented sample (Table 3), with 66% classified as “very Mexican oriented.” The 4-category acculturation scoring approach resulted in 48% of the sample categorized as “Mexican-oriented bicultural” (Figure 1).

Table 2.

Demographic Characteristics (N = 21).

Characteristic Range or Frequency, n (%) Descriptive Statistic, Mean (SD)
Maternal age, y 16–39 27 (6)
Time in United States, y 1–26 9.8 (6.9)
Birth country
 Mexico 19 (90)
 United States   2 (10)
Preferred language
 Spanish 16 (76)
 English   3 (14)
 Both 2 (9)
Marital status
 Married   8 (38)
 Partnered   9 (19)
 Single   4 (43)
Education
 Elementary   3 (14)
 Grade 7–8   4 (19)
 Grade 9–12 11 (52)
 1–2 years college   2 (10)
 3–4 years college 1 (5)
Income
 $10 000 or less   3 (14)
 $10 001–$25 000 13 (62)
 $25 001–$40 000   4 (19)
 Missing 1 (5)
Number of children
 1   8 (38)
 2   3 (14)
 3   7 (33)
 4 1 (5)
 5   2 (10)
Infant age, wk 4–28 13 (6.48)
Breastfeeding status
 Exclusive   9 (43)
 Breast with sporadic/limited formula use   5 (24)
 Breast and formula   5 (24)
 Weaned     2 (9.5)
Employment status
 Full-time or part-time   5 (24)
 Not employed 16 (76)
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Table 3.

Revised Acculturation Rating Scale for Mexican Americans (ARSMA-II) Acculturation Scores and Categories (N = 21).

Scale Name Range Mean (SD)
Anglo Orientation Scale     1.23–4.69   2.78 (.98)
Mexican Orientation Scale 2.76–5   4.36 (.56)
Acculturation scores   −3.53–1.16   −1.58 (1.33)
Acculturation Category Frequency %
Level I: very Mexican oriented (< −1.33) 14   66.7
Level II: Mexican oriented to approximately balanced bicultural (> −1.33 & < −.07)   4   19.0
Level III: slightly Anglo oriented bicultural (> −.07 & < 1.19)   3   14.3
Total 21 100.0
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Figure 1.

Figure 1

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Multidimensional, Orthogonal, Bicultural Classification.

Three primary themes were identified in this study.

Theme 1: It Is Natural that A Woman Give Life and also Provide the Best Food for Her Baby

Infant health and well-being

Participants described breastfeeding as the superior feeding option to ensure the highest level of infant health, preventing illnesses, infections, and allergies while promoting growth and development. “They’ll get higher immune system. It reduces the risk of, like, diseases, like, I would say cancer,” and “He [infant] seems to be very active, very attentive compared to what I’ve seen with family members that never breastfed their kids.” Most participants felt that their infants preferred and were more satisfied with breastfeeding over formula.

Maternal health and well-being

Mothers described the physical benefits of breastfeeding such as quicker recovery, postpartum weight loss, delayed return of menses, and breast cancer prevention. Many described the psychological benefits of breastfeeding as feeling content, self-confident in their ability to breastfeed, and most important, emotional closeness with their infant. Participants also reported infants’ continued growth and development as motivation. “Before, I said I would stop breastfeeding after 3 months. Now, I say I will breastfeed until 6 months, and at 6 months, I will say 9 months. Seeing the baby get bigger motivates me.” Mothers who had previously breastfed already felt confident, but first-time mothers were more likely to question their ability to successfully breastfeed. However, continued milk production and successful infant feeding enhanced their feelings of security and confidence.

Maternal–infant bonding

All mothers cited an increased sense of connectedness with their infants when breastfeeding, describing it as happiness, love, affection, closeness, and joy. A teen mother who experienced difficulties breastfeeding her first child, due to pressures of school and the ease of obtaining formula, found that with maturity, greater information, and support for breastfeeding, she was able to exclusively breastfeed her second child for 2 months.

Well with my first baby … obviously I just hold her and give her the bottle, wrap her, and put her to bed … and with him, he’s obviously right there, and I can see every single detail of him and how he’s doing and … he’s satisfied. And it just makes me feel so good.

Theme 2: Breastfeeding Is Ultimately a Woman’s Decision but Is Influenced by Tradition, Guidance, and Encouragement

Cultural traditions

Most participants pointed to cultural beliefs, practices, and values of their country of origin as influencing their breastfeeding decision. Two participants described how breastfeeding is the social and familial norm of Mexico. The sample’s very Mexican orientation supported this strong identification of values and beliefs from Mexico. Further support of the link between acculturation and time of US residence was demonstrated in our sample’s data (r = .74, P > .01).

A Mexican-born participant described how cultural differences influence the breastfeeding decision: “Because in my country women work less [outside the home] … very committed to their children. One spends the entire day with her children. In this country we all work [outside the home].” She conveyed that breastfeeding is an important aspect of motherhood but is often devalued in US society. After women move here, she relayed, they begin to think formula is best. Another mother described how love and breastfeeding are connected: “Above all, everyone in my country believes that the babies grow up with a lot of love, with breastfeeding.”

Social/familial and professional support

All participants cited that social and familial support contributed to their breastfeeding decisions. Many participants identified that they were able to exclusively breastfeed since their husbands/partners supported the decision, believing breastfeeding was the best. Husbands/partners also were primary financial providers, thus allowing mothers to remain close to their infants.

Overall, participants described female family members and friends, particularly the grandmother, as primary role models and sources of support. One teen participant who continued to breastfeed via pumping after returning to school stated, “I only wanted to breastfeed ever since he’s [infant] been with me.… My mom told me for sure that I had to breastfeed him.” Participants described support as emotional support; advice and guidance; provision of information, demonstration, and example; and sharing of breastfeeding stories and beliefs.

A majority of participants identified professional information (eg, literature, clinic posters) and guidance from WIC counselors, nurses, physicians, and lactation specialists, in influencing their decisions and/or experiences of breastfeeding. The most noted supporter was the nurse who provided guidance during the initial attempt to breastfeed. One participant did not think she would have breastfed, “but a nurse came out and she had asked me, did you breastfeed, and I said no. And she asked me, do you know how, and I was like no. So that’s how everything started.”

Maternal identity

Participant narratives revealed the importance of maternal identity in making the breastfeeding decision and maintaining the determination to continue. Maternal identity was described in terms of empowerment, ownership, pride, and responsibility in being the infant’s primary source of nourishment. Mothers reported that, because of breastfeeding, they felt that their infants were completely reliant on them for food; this increased their belief in their abilities to protect their babies and to help them grow strong and healthy. One participant stated,

Yes, it was a very happy feeling, like a mother’s pride. I felt more womanly. It is a feeling of maturity that I can provide for him.

Theme 3: Breast Milk Is Superior but Life Circumstances can Challenge One’s Ability to Breastfeed

Work and school

Returning to work and school were reported as the most significant challenges to exclusive breastfeeding. Some participants pumped milk and found this worked well if there was employer or school support to pump during the work or school day and a place to refrigerate breast milk. Other participants stated that exclusive breastfeeding was just not possible with work. Another stated that her working friends “always use formula because they work and they say that [formula] is better for them.”

One of 2 teen mothers returning to school seemed to have the greatest challenges with continuing exclusive breastfeeding. As she shared,

I was at school. I couldn’t provide enough milk to store it for him to drink when I was gone.… We would feed him formula. They [school] wouldn’t let me [pump].… There was not time, no place, and I didn’t have enough milk to pump out.… They said they could be flexible, but it’s not that way.

Insufficient milk production and other personal concerns

Insufficient milk production was described as a source of distress and uncertainty among participants and a reason for formula supplementation. Four participants stated that they ended up supplementing within the first few days of the infant’s life. As 1 mother described, “Those first 2 days [after giving birth] I cried because I was not producing milk, and he [the baby] was hungry.” For 2 participants, breastfeeding was challenged by maternal illnesses and treatment, with 1 mother afraid to have medication go through her milk to the baby.

Discussion

Our findings extend knowledge on less acculturated Mexican American women’s breastfeeding beliefs and practices. Most of these “very Mexican-oriented” women breastfed exclusively or used formula sporadically, some only in the early days after birth. Therefore, our findings do not necessarily reflect national data regarding Hispanic formula supplementation patterns in the early postpartum.12

Findings from our study share similarities and differences with previous qualitative research regarding breastfeeding among Mexican American mothers. The participants in this study, like those in Gill et al23 and Bunik et al,24 expressed beliefs in the physical and emotional benefits of breastfeeding. However, in contrast to the study by Bunik et al in which participants considered a mixture of formula and breastfeeding—the “best of both”—to be most beneficial, our participants strongly believed in the benefits of exclusive breastfeeding for infants and mothers.

For the mothers in our sample, breastfeeding was supported by cultural beliefs, practices, and values as well as social and professional encouragement. Similar to Gill et al,23 study participants reported that although the maternal decision to breastfeed was independent of others, they did ask female family members for advice. Bunik et al24 also reported that a breastfeeding woman’s mother was a common source of advice. In contrast to Gill et al and Bunik et al, in which negative support of breastfeeding or mixed messages regarding formula from hospital providers was prevalent, professional support was frequently cited in our study as an important influence on women’s decision to breastfeed. Neither Gill et al nor Bunik et al spoke to breastfeeding beliefs and practices in Mexico as the “norm,” although both studies reported on cultural practices supportive of breastfeeding such as dietary restrictions and avoidance of negative emotions. A finding unique to our study was the belief of mothers that breastfeeding was central to maternal identity.

Despite the facilitating beliefs and practices our study participants reported, exclusive and continuing breastfeeding were challenged by demands outside the home, limited breast milk supply, and other personal concerns. Gill et al23 and Bunik et al24 reported many of these same barriers, with time, pain, and modesty being prevalent concerns. Some mothers in our study who used infant formula in the early period following birth progressed to exclusive breastfeeding. There is evidence of this phenomenon in an intervention study with Hispanic women in which 10% of the control group transitioned to exclusive breastfeeding at their own initiative.39

Our findings support assumptions of Pender’s Health Promotion Model.25

  1. Individuals seek to actively regulate their own behavior. This was well demonstrated in our study through descriptions of physical and emotional support garnered through interactions with female relatives and through the recounting of their own breastfeeding experiences. For participants, breastfeeding was central to maternal identity and provided a sense of accomplishment. Participants were adamant that they independently chose to breastfeed.

  2. Individuals interact with their environment with reciprocal progression of transforming the environment and being transformed over time. The findings demonstrated how participants believed that the decision of US women to use formula was often based on working outside the home, convenience, and/or thinking formula was as good as breast milk. Participants found breastfeeding to be the culturally preferred method. Most participants believed that breastfeeding was practical, convenient, and economical and saw pumping as an acceptable alternative to direct breastfeeding.

  3. Health professionals constitute a part of the environment. This was evident because the majority of the participants identified nurses, physicians, lactation specialists, WIC personnel, and health materials as influencing their decisions or experiences. It appears that health professionals added to the synergistic effect of interpersonal support along with exposure to breastfeeding women during childhood and adolescence.

Limitations

Findings of this qualitative descriptive study may not be generalizable to other non-Mexican Hispanic groups or to other Mexican American groups in different US geographic areas. Causal inferences of the relationship between acculturation and breastfeeding beliefs and practices of this sample cannot be made. However, the data provide context to the findings. In addition, findings may not be generalizable because participants self-selected to the study and therefore may have strong positive beliefs about breastfeeding.

Implications for Clinical Practice

The findings of this study extend our knowledge base related to less acculturated Mexican American women’s beliefs and practices regarding breastfeeding and exclusive breastfeeding. It demonstrates that barriers to exclusive breastfeeding for Mexican American women are not different from those of breastfeeding women in general: concerns about insufficient milk,40 nipple pain,41 and return to work or school prevail.42,43 To protect exclusive and continued breastfeeding in the face of these barriers, culturally competent support and education are needed as well as evidence-based interventions provided by nurses and lactation consultants, especially during the critical time immediately following the birth before hospital discharge. Using hospital maternity practices known to support breastfeeding duration44,45 and exclusive breastfeeding duration such as the World Health Organization’s Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative46 with Mexican American mothers is important. For example, educate Mexican American women on the benefits of skin-to-skin care and encourage them to participate in this important practice immediately after giving birth. Encourage rooming-in with the infant and discourage use of formula supplements. Provide contact information for lactation support for after discharge. Finally, educate family members of the Mexican American mother to assist mothers to follow these practices.

Study findings reveal that breastfeeding within the context of strong familial and cultural support provides mother and child with numerous benefits. Education of health care professionals about Mexican American cultural beliefs and practices will enhance their abilities to provide culturally competent breastfeeding promotion and assistance. Health care professionals working with Mexican American women can draw on knowledge of cultural and familial beliefs and practices that endorse breastfeeding as a cultural norm. Providers can also reinforce the health and economic advantages of breastfeeding and provide education and advice to prevent or manage common barriers to breastfeeding among this population.

Conclusion

In conclusion, in our sample of Mexican American women, formula supplementation in the early postpartum was not as prevalent as that reflected in national data. Although unexpected, it is positive and serves as a basis for caring for Mexican American women; health care personnel should not assume that Mexican American women will want to provide formula in the hospital. Instead, each woman should be treated individually with teaching, support, and encouragement given in a culturally competent fashion.

Well Established.

Early formula supplementation can lead to shorter duration of breastfeeding and reduced exclusive breastfeeding. Hispanic women begin formula supplementation in the first 2 days after birth at higher rates than other US ethnic groups. Acculturation influences breastfeeding practices.

Newly Expressed.

Study findings extend knowledge on less acculturated Mexican American women’s breastfeeding beliefs and practices. Most of these “very Mexican-oriented” women breastfed exclusively or used formula sporadically. Country of origin influenced their breastfeeding beliefs regarding health benefits and decisions on breastfeeding practices.

Acknowledgments

The authors thank the clinic staff at the University of Kansas Medical Center pediatric clinic, Project Eagle, and the research assistants who worked on their study. Finally, they thank the mothers who participated in the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the University of Kansas School of Nursing Office of Grants and Research and the Department of Ambulatory Pediatrics, Kansas University Medical Center.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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