Women and Birth
Volume 23, Issue 1 , Pages 22-28, March 2010

Infant feeding in the first 12 weeks following birth: A comparison of patterns seen in Asian and non-Asian women in Australia

  • Hannah G. Dahlen

      Affiliations

    • University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 2 96859118; fax: +61 2 96859599.
    • ,
  • Caroline S.E. Homer

      Affiliations

    • Centre for Midwifery, Child and Family Health, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, New South Wales, Australia
    • Tel.: +61 2 9514 4834; fax: +61 2 9514 4835.

Received 22 December 2008; received in revised form 19 March 2009; accepted 22 March 2009.

Article Outline

Summary 

Background

There is a belief amongst midwives that Asian women are less likely to breastfeed compared to non-Asian women. The aim of this research was to compare the infant feeding decisions of Asian and non-Asian women on discharge from two Sydney hospitals, and at 6 and 12 weeks following birth.

Participants

235 Asian and 462 non-Asian first time mothers.

Methods

A secondary analysis was undertaken into data from a randomised clinical trial of a perineal management technique (perineal warm packs). Simple descriptive statistics were used for analysis and Chi-square and logistic regression was used to examine differences between women from Asian and non-Asian backgrounds.

Results

Compared with non-Asian women, Asian women were no less likely to exclusively breastfeed on discharge from hospital (83% vs. 87%, OR 0.7, 95% CI 0.4–1.2), at 6 weeks (60% vs. 61%, OR 1, 95% CI 0.7–1.4) or 12 weeks postpartum (51% vs. 56%, OR 0.8, 95% CI 0.6–1.2). They were, however, significantly more likely to be partially breastfeeding on discharge from hospital (10% vs. 2%, OR 5.3, 95% CI 2.3–12.4), at 6 weeks (22% vs. 11%, OR 1.9, 95% CI 1.2–3.2) and 12 weeks postpartum (17% vs. 8%, OR 2.2, 95% CI 1.2–3.9).

Discussion

Asian women were more likely than non-Asian women to be giving their baby some breast milk at 6 and 12 weeks postpartum when partial breastfeeding was taken into account. This contradicts popular beliefs amongst midwives regarding the infant feeding practices of Asian women.

Conclusion

Further research into this important issue is needed in order to improve breastfeeding support for women from different cultural backgrounds. The issue of causes of, and variations in, the levels of partial breastfeeding between different ethnic groups needs more investigation.

Keywords: Childbirth, Asian, Non-Asian, Breastfeeding, Practices

 

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Introduction 

Breastfeeding is supported both nationally and internationally as a superior means of infant feeding that has many short and long term benefits for mothers and babies.1, 2, 3 For babies, breastfeeding has positive effects on survival, growth, development and general health. It is also associated with greater social and economic benefits.4 Breastfeeding has a protective effect against many acute and chronic conditions in children.1, 5, 6, 7, 8, 9 Likewise, there are considerable benefits for the mother, such as quicker recovery from childbirth, delaying ovulation and menstruation and encouraging attachment with the baby.1 Due to the significant health benefits for the baby and mother, exclusive breastfeeding for the first 6 months of life, whereby the baby receives only breast milk, is recommended by a number of authorities.1, 2, 10

In Australia in 2006–2007, 92% of babies were breastfed at birth but the rate of exclusive breastfeeding had already dropped to 80% at 1 week following the birth.17 By the age of 3 months the rate of exclusive breastfeeding declined to 56%, dropping to 14% by 6 months. Beyond this very few children were fully breastfed. The breastfeeding rate in Australia11, 16, 17 is higher than in the United Kingdom, where 69–71% of infants are initially breastfed;12, 13 however, it is lower than countries such as Norway, where 92% of mothers are breastfeeding their child at 3 months of age, 80% by 6 months and 40% at 1 year.14

Breastfeeding is complex and is constructed and practiced within the social environment in which women live. Variations do exist in breastfeeding initiation and duration amongst different socio-economic and cultural groups.15, 18, 20 Australia is one of the most multicultural countries in the world due to the active support given by the government to immigration.11, 21 Despite the large multicultural population there is still limited research into the infant feeding practices of women from culturally and linguistically diverse (CALD) backgrounds.22, 23 A number of researchers have reported that women from CALD backgrounds are less likely to breastfeed than those from Australia-born backgrounds.24, 25, 26 Even where breastfeeding is considered normal in the woman's country of birth, such as in Vietnam, it appears early weaning and artificial feeding seems common following migration.27 This is not the case for all women of CALD backgrounds however, with Middle Eastern women showing greater rates of breastfeeding duration when compared with women born in Australia, New Zealand and the United Kingdom.28 The issue may be more complex than ethnicity alone with factors such as lower education levels and lower socio-economic background rather than ethnicity effecting breastfeeding rates.22

As a result of this contrasting evidence concerning infant feeding decisions and practices for women from CALD backgrounds, we were interested in whether differences would be seen in a cohort of women from Asian countries, who gave birth in Sydney, Australia. We derived a cohort of women for this analysis from the sample recruited for a randomised controlled trial of perineal warm packs used in the second stage of labour. The primary analysis of the effect of perineal warm packs showed no differences in initiation and duration of breastfeeding between the two groups.29

The aim of this secondary analysis was to compare the infant feeding patterns of Asian and non-Asian women on discharge from two Sydney hospitals, and at 6 and 12 weeks following the birth. The hypothesis was that Asian women are less likely to breastfeed than Non-Asian women on discharge from hospital and at 6 and 12 weeks following birth.

The Ethics Committee of the Central Sydney Area Health Service and the University of Technology, Sydney approved the study. The clinical outcomes for the trial have been reported elsewhere.29, 30

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Method 

The data for this secondary analysis was from a randomised clinical trial known as the Warm Pack Trial. The trial took place in two hospitals in Sydney between November 1997 and July 2004. One was a level 6 hospital with over 4000 births and the other a level four hospital with 1500 births per annum. Primiparous women were approached to participate in the trial after 36 weeks gestation. Eligibility criteria included: a singleton pregnancy; cephalic presentation; anticipating a normal birth; not having performed perineal massage or intending to perform perineal massage antenatally; and, being over 16 years of age.

All information, consent forms and questionnaires were translated into the main languages of women attending the hospitals in the trial (Arabic, Turkish, Mandarin, Vietnamese and Korean). Women anticipating a vaginal birth were randomised close to or in second stage to having perineal warm packs applied or not. Primary analysis was on an intention-to-treat basis.

Randomisation was stratified according to age (<25; 25–34; >35 years) and ethnicity (being from an Asian or non-Asian background). Asian was defined as being born in China, Vietnam, Hong Kong, Indonesia, Japan, Laos, Cambodia, Taiwan, North Korea, South Korea, Thailand, Philippines, Burma and Malaysia. This particular focus on Asian women was due to the high rates of severe perineal trauma already identified in the population being studied31 and the large number of Asian women attending these two maternity units for care.

Seven-hundred-and-seventeen nulliparous women giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Of these, 33% (n=235) was Asian. Asian women were equally distributed between the two groups (116/360 vs. 119/357). Data was collected on birth outcomes including method of infant feeding on discharge from hospital.29 Final data collection occurred at 6 and 12 weeks postpartum during a telephone interview. Interpreters were used if the woman did not feel she spoke English well enough to answer the questions. Data was collected on maternal health such as, pain, resumption of sexual intercourse, urinary incontinence and method of infant feeding.

The secondary analysis consisted of 606 (87%) women who had a spontaneous vaginal birth, 20 women (3%) who had a forceps delivery, 71 (10%) who had a vacuum extraction. Twenty women who had a caesarean section were not followed up, as the intent was to examine postpartum outcomes related to perineal trauma. At 6 weeks, 553 women were interviewed by telephone (79%) and at 12 weeks, 531 women (76%) were interviewed, again by telephone. Women not interviewed were those unable to be contacted (53 women at 6 weeks and 75 women at 12 weeks) due to an incorrect telephone number, a disconnected telephone, or having departed for overseas.

In this analysis, women were also grouped into the five major ethnic groups to compare breastfeeding rates between the groups. These groups (based on country of birth) were: Australia, Asia, the Middle East, Europe and New Zealand.

A definition of exclusive breastfeeding (no other liquid or solid is given to the infant), partial breastfeeding (some other liquid or solid is given to the infant as well as breast milk) and formula fed (no breast milk given to the infant) was used as these were the definitions used in the hospitals involved in the research at the time and so the staff were familiar with them. Labbok and Krasovec recommended differentiating levels of partial breastfeeding, such as high, medium and low. These authors also recommended having token breastfeeding (breastfeeding with little or no nutritional impact) as a separate category.32 We were not able to distinguish between these levels of partial breastfeeding in this study.

All data was analysed using Statistical Package for Social Sciences (SPSS) version 12. The Alpha level was set at 0.05 for all analyses. Simple descriptive statistics were used for analysis and Chi Square and logistic regression33 was used to examine differences between women from Asian and non-Asian backgrounds.

A univariate analysis was initially conducted for the main outcomes and calculated odds ratios and 95% confidence intervals. A logistic regression model was fitted to account for potential confounders on method of infant feeding. Potential confounders were identified from the literature and from the results of the original trial. A screen of p<0.25 was used to justify retaining the variables in the model, except for the randomised group that was retained regardless. For the model these dichotomous variables were: major perineal trauma; age (≤34 vs. ≥35); Asian ethnicity and trial group (warm pack vs. control group). Perineal trauma was classified for the purpose of this trial as no, or minor trauma (<second-degree tear) and major trauma (≥second-degree tear). This method has been fully described in previous papers.29, 30

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Results 

Labour and birth outcomes 

Asian women were not significantly more likely than non-Asian women to be over 35 years of age (11% vs. 7%, OR 1.6, 95% CI 0.9–2.7), receive analgesia during labour (82% vs. 86%, OR 0.7, 95% CI 0.5–1.1), have epidural anaesthesia (17% vs. 22%, OR 0.7, 95% CI 0.5–1.2), have a second stage ≥60min (58% vs. 55%, OR 0.9, CI 0.6–1.2) or have a spontaneous vaginal birth (82% vs. 86%, OR 0.8, 95% CI 0.5–1.2) compared with non-Asian women. Asian women were significantly less likely to give birth in an upright position (15% vs. 25%, OR 0.5, 95% CI 0.4–0.8) or have a baby weighing over 3500g (62% vs. 77%, OR 0.5, 95% CI 0.3–0.7) compared with non-Asian women. Asian women had significantly more perineal trauma compared with non-Asian women. They were significantly more likely to: require perineal suturing (90% vs. 77%, OR 2.7, 95% CI 1.7–4.3); have major perineal trauma, such as a second-, third- and fourth-degree tear or an episiotomy (76% vs. 51%, OR 3.1, 95% CI 2.2–4.4); have an episiotomy (18% vs. 8%, OR 2.4, 95% CI 1.5–3.8); and have a third or fourth degree perineal tear (11% vs. 4.5%, OR 2.6, 95% CI 1.4–4.7). Perineal trauma differences between Asian and non-Asian women have been explored in previous papers.29, 31

Overall rates of infant feeding on discharge from hospital and at 6 and 12 weeks postpartum 

In the trial, the application of perineal warm packs was not associated with differences in method of infant feeding on discharge from hospital and at 6 and 12 weeks postpartum.

Information about the method of infant feeding on discharge was obtained for 578 women (83%). On discharge (average hospital stay 2.2 days), 495 (86%) women were exclusively breastfeeding on discharge from hospital, 56 women (10%) were formula feeding and 27 women (5%) were partially breastfeeding. The rate of exclusive breastfeeding amongst all women declined to 61% at 6 weeks to 54% at 12 weeks. The proportion of formula feeding had increased from 10% on discharge from hospital to 25% at 6 weeks and 35% at 12 weeks. Partial breastfeeding peaked at 6 weeks (15%) and then declined at 12 weeks (11%) as it was replaced with formula feeding.

Method of infant feeding for Asian and non-Asian women at discharge from hospital, at 6 and 12 weeks 

Asian women were not significantly less likely to be exclusively breastfeeding on discharge compared with non-Asian women (83% vs. 87% OR 0.7, 95% CI 0.4–1.2). Asian women were also not significantly less likely to be exclusively breastfeeding at 6 weeks (60% vs. 61% OR 1.0, 95% CI 0.7–1.4) and 12 weeks postpartum (51% vs. 56% OR 0.8, 95% CI 0.6–1.2).

Asian women were however significantly more likely to be partially breastfeeding on discharge from hospital (10% vs. 2%, OR 5.3, 95% CI 2.3–12.4). The rate of partial breastfeeding continued to be more likely at 6 weeks (22% vs. 11% OR1.9, 95% CI 1.2–3.2) and 12 weeks (17% vs. 8%, OR 2.2, 95% CI 1.2–3.9) for Asian women (Table 1). The proportion of women giving their baby some breast milk was higher for Asian women compared with non-Asian women, when exclusive breastfeeding and partial breastfeeding was taken into consideration on discharge (93% vs. 89%), at 6 weeks (82% vs. 72%) and 3 months (68% vs. 64%) following the birth (Figure 1, Figure 2).

Table 1. Method of infant feeding on discharge from hospital and at 6 and 12 weeks postpartum.
Method of infant feedingAsian, N (%)Non-Asian, N (%)ORCI
On discharge from hospital
Exclusive breastfeeding153/185 (83)342/393 (87)1.0Reference
Formula feeding13/185 (7)43/393 (11)0.70.4–1.3
Partial breastfeeding19/185 (10)8/393 (2)5.32.3–12.4

At 6 weeks
Exclusive breastfeeding108/179 (60)226/373 (61)1.0Reference
Formula feeding32/179 (18)105/373 (28)0.60.4–1.0
Partial breastfeeding39/179 (22)42/373 (11)1.91.2–3.2*

At 12 weeks
Exclusive breastfeeding88/174 (51)199/356 (56)1.0Reference
Formula feeding57/174 (33)127/356 (36)1.00.7–1.5
Partial breastfeeding29/174 (17)30/356 (8)2.21.2–3.9*

Relationship between major perineal trauma and exclusive breastfeeding 

Women who had major perineal trauma (third and fourth degree tears and episiotomy) were less likely to be exclusively breastfeeding their babies on discharge from hospital compared to women who had no or minor perineal trauma (≤second-degree tear) (83% vs. 90% OR 0.6, 95% CI 0.3–0.9). When logistic regression analysis was carried out for exclusive breastfeeding on discharge, including influencing variables such as, major perineal trauma; age; Asian ethnicity; and, trial group (warm pack vs. control group), this only reached borderline significance (Table 2). By 6 and 12 weeks, women who had major perineal trauma were not less likely to exclusively breastfeed.

Table 2. Logistic regression model for exclusive breastfeeding on discharge and influencing variables.
VariablesN=578, N (%)Unadjusted OR (95% CI)Adjusted OR (95% CI)
Age
≤34460/535 (87)1.01.0
≥3535/46 (76)0.5 (0.2–1.0)0.6 (0.3–1.2)

Major trauma
No223/249 (90)1.01.0
Yes272/329 (83)0.6 (0.3–0.9)0.6 (0.4–0.1)

Asian ethnicity
No342/393 (87)1.01.0
Yes153/185 (83)0.7 (0.4–1.2)0.8 (0.5–1.3)

Warm pack applied
No255/287 (89)1.01.0
Yes240/291 (83)0.6 (0.4–1.0)0.6 (0.4–1.0)

Method of infant feeding for the five major ethnic groups 

When other ethnicities were considered, women born in New Zealand were the least likely to be exclusively breastfeeding on discharge from hospital (80%), at 6 weeks (51%) and at 12 weeks (48%). Women born in the Middle East had the highest rate of exclusive breastfeeding on discharge (91%) but this was no longer the case at 6 and 12 weeks (Table 3). Women born in Australia had the highest exclusive breastfeeding rate by 6 and 12 weeks (Fig. 3). However, at 6 and 12 weeks Asian women were more likely to give their babies some breast milk compared with all other ethnic groups (Table 4).

Table 3. Method of infant feeding on discharge from hospital and at 6 and 12 weeks postpartum for women from different countries.
Method of infant feedingAustralian born %Asian born %Middle Eastern born %European born %New Zealand %
On discharge from hospital
Exclusive breastfeeding8683918880
Formula feeding1377915
Partial breastfeeding110335

At 6 weeks
Exclusive breastfeeding6260596151
Formula feeding3018233029
Partial breastfeeding72218920

At 12 weeks
Exclusive breastfeeding5851525648
Formula feeding3633353640
Partial breastfeeding61713913
Table 4. Infant receiving some breast milk on discharge from hospital and at 6 and 12 weeks postpartum for women from different countries.
Infant receiving some breast milkAustralian born %Asian born %Middle Eastern born %European born %New Zealand %
On discharge8793949185
At 6 weeks6982776971
At 12 weeks6468656561

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Discussion 

Australian research indicates that women from CALD backgrounds are less likely to breastfeed than women born in Australia.24, 25, 26, 34 Asian women are reported to have lower breastfeeding duration rates than other ethnic groups, such as those from the Middle East.19 In our study, while Middle Eastern women had the highest rates of exclusive breastfeeding on discharge from hospital, by 6 and 12 weeks this was no longer the case. Women born in New Zealand had the lowest overall breastfeeding rates. Compared with all other ethnic groups, women born in an Asian country were more likely to give their baby some breast milk at 6 and 12 weeks compared with women born in Australia, the Middle East, Europe, and New Zealand.

Researchers have suggested that even when breastfeeding is a normal part of the culture, such as with Chinese and Vietnamese women, they appear to be more likely to wean early and artificially feed following immigration.26, 27, 35, 36 There is also a perception that Australian women do not breastfeed because they are not seen doing so in public and that formula feeding is readily available and often seen as ‘normal’ in Australia.27, 37 Another Australian study found that fewer Chinese women stated an intention to breastfeed, however, more of those who did initiate were still breastfeeding at 8 weeks compared with English speaking women.25 In our study, by 6 and 8 weeks, more Asian women compared with non-Asian women were giving their babies some breast milk, mostly in the form of partial breastfeeding.

Asian women were no less likely to be exclusively breastfeeding in this study compared with non-Asian women at discharge from hospital or at 6 and 12 weeks. Previous Australian reports indicate that Asian women have lower exclusive breastfeeding rates than non-Asian women on discharge from hospital.26 The Child Health study in the United Sates of America, however, identified higher rates of Asian women who had ever breastfed compared to other populations when they combined exclusive breastfeeding with supplemental breastfeeding.38 Other studies have demonstrated that Asian women may be more likely to cease breastfeeding and return early to work.39 These contradictory results may be due to different classifications of Asian and different socio-economic groups within these populations.

Lower breastfeeding rates amongst some migrant groups have been attributed to the transition from an extended to a nuclear family, an increased interest in Western mores and a need to work or study as well as the availability of infant formula.40 Other factors, such as religion and cultural beliefs, can influence breastfeeding practices. Amongst Asian groups in particular, certain foods and rituals are important during the postpartum period.27, 41 The inability to practice these can influence breastfeeding initiation and duration.36 There are suggestions that because breastfeeding is encouraged by Islamic teachings this may be a positive influence on rates amongst Moslem groups.42 In our study, whilst women from the Middle East had the highest exclusive breastfeeding rate on discharge from hospital, this fell sharply by 6 and 12 weeks, with Asian women being more likely to give their babies some breast milk, contrary to expectations of midwives.26

Reasons for the high rate of partial breastfeeding amongst Asian women may come from beliefs around low supply, which have been consistently cited in the literature for over a decade.26, 43, 44, 45, 46, 47 In previous research conducted in one of the hospitals involved in this trial, Chinese women indicated that the belief that there was not enough milk was not common amongst Chinese women, rather that they were more likely to breastfeed in China because of access to family support.26 Other issues raised in this research were that Chinese women in particular did not like to breastfeed in public,26 perhaps further explaining the high rate of partial breastfeeding in the Asian women. In this previous study we were able to increase the rate of Chinese women exclusively breastfeeding on discharge from hospital through a program of culturally appropriate support and education.26 Other research has also shown that a culture and language specific program to promote breastfeeding was able to increase knowledge, positive attitudes, intended and actual behaviour about breastfeeding.48

There are several limitations in this study. At 6 and 12 weeks the data was gathered by phone interview conducted by midwives. We acknowledge inherent bias in this method of data collection. For example, there may be errors in how exclusive breastfeeding is defined. Also some women may have been reluctant to report that they had ceased breastfeeding to a midwife during follow up interviews. It is likely, however, that these would be similar across all the different cultural groups. We acknowledge that there would be ethnic cultural and religious differences between women in the groups as well, making a heterogeneous group. We did not obtain data on socio-economic backgrounds or education levels, due to the poor quality of the data available—limiting the ability to examine the effect on breastfeeding rates. Some research suggests lower education and lower socio-economic backgrounds may affect breastfeeding rates more strongly than ethnicity22; but other research has found that Chinese women that reported higher levels of tertiary education had the lowest levels of breastfeeding initiation.25 It has, however, been recognised that recent immigrants are more likely to have a lower socio-economic status compared to Australian born families.49 Women who migrate to countries such as Australia may not be typical women in their country of origin as well and this may reflect their infant feeding decisions and practices.25 The research is also limited by definitions of ethnicity being country of birth rather than ancestry, so in some cases for example, such as with New Zealand women it would have been hard to identify Polynesian women.

We also acknowledge that following Labbok and Krasovec's definitions of breastfeeding more closely would have been ideal. While our definition of exclusive breastfeeding (no other liquid or solid is given to the infant) was identical, our definition of partial breastfeeding (some other liquid or solid is given to the infant as well as breast milk) was not divided into levels such as high, medium and low. Token breastfeeding (breastfeeding with little or no nutritional impact) was also not identified as a separate category.32 Future studies should look at the variation in levels of partial breastfeeding, as differences may well be found between different ethnic groups.

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Conclusion 

This paper reports on a secondary analysis of a randomised controlled trial. As this is a secondary analysis the results should be interpreted with caution. Nonetheless, the data suggests that Asian women in this study population were not less likely to exclusively breastfeed on discharge from hospital or by 6 or 12 weeks postpartum compared to no-Asian women. Asian women were more likely than any of the groups to be giving their baby some breast milk at 6 and 12 weeks postpartum when partial breastfeeding was taken into account. This study contributes to the knowledge about women from CALD backgrounds in relation to infant feeding in Australia. Further research into this important issue is needed in order to improve breastfeeding support for women from different cultural backgrounds.

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Conflict of interest 

There are no conflicts of interests that the authors are aware.

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PII: S1871-5192(09)00030-4

doi:10.1016/j.wombi.2009.03.001

Women and Birth
Volume 23, Issue 1 , Pages 22-28, March 2010

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