Formula use in a breastfeeding culture: changing perceptions and patterns of young infant feeding in Vietnam
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Date
2015-04-04
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Johns Hopkins University
Abstract
Background: Child malnutrition, including both undernutrition and overweight, is a global issue with consequences for survival, incidence of acute and chronic diseases, healthy development, and the economic productivity of individuals and societies. Exclusive breastfeeding in the first six months along with continued breastfeeding has been identified as the single most effective preventive intervention for improving the survival and health of children. Exclusive breastfeeding is associated with decreased mortality and morbidity, and is the globally endorsed optimal feeding method for infants in the first six months of life. Despite high rates of any breastfeeding, formula use is known to be one of the main contributors to low exclusive breastfeeding rates in Vietnam. The overall objective of this thesis was to explore perceptions and practices related to formula use among rural Vietnamese households, to understand options and support for infant feeding for women who work outside the home, and to evaluate the association between breastfeeding problems and other risk factors at three months postpartum and subsequent use of formula.
Methods: In-depth interviews were conducted as part of the “Alive and Thrive” (A&T) initiative, which enrolled 120 mothers, fathers, and grandparents of infants between May and June 2012 in Thanh Hóa and Vĩnh Long provinces as part of a process evaluation conducted by the Institute of Social and Medical Studies (ISMS) under the supervision of The International Food Policy Research Institute (IFPRI), an independent organization contracted to perform a rigorous evaluation of the A&T initiative in Vietnam. A maximum variation sampling approach was used to efficiently capture three dimensions defined a priori as: location, exposure to the intervention, and age of infant. Households within communes were purposively selected fill these dimensions. Interview guides were designed to focus on facilitators and barriers to project implantation and impact, and asked for respondents’ recollections of prenatal care and birth experiences, as well as plans for infant feeding, care, and work and household responsibilities in the first year of the infant’s life. All interviews were conducted in Vietnamese and recorded with digital recording devices in respondents’ homes by ISMS field staff. A complete transcript was made in Vietnamese from the recorded interview, which was translated into English by ISMS staff based in Hanoi, Vietnam. A subset of 24 households, each comprising a mother, father, and cohabitating grandparent, were analyzed to understand perceptions, decision-making and behaviors related to formula use for infants in rural Vietnam using a case study approach. Feeding formula when mothers returned to work emerged as a theme from this analysis, and the full set of 120 transcripts were subsequently coded to explore maternal work in-depth in relation to this practice. Pumping breastmilk was also coded as a potential solution to this constraint.
Data previously collected from the A&T 2010 baseline study were also analyzed. The baseline study was conducted as part of a clustered randomized controlled trial in four rural Vietnamese provinces to measure the impact of the A&T initiative on breastfeeding and stunting rates in Vietnam. Descriptive analysis explored types of breastfeeding difficulties and support-seeking behaviors in the full sample. A subset of 604 women who were breastfeeding infants between 3-6 months of age were used to investigate the association between experiencing breastfeeding difficulties at three months postpartum and formula feeding between three and six months of age. Logistic regression, was used to determine the magnitude and significance of the association of breastfeeding difficulties and subsequent formula use after adjusting for potential confounding factors.
Results: Families valued and practiced breastfeeding, but relied on formula in the absence of other support. At birth, infant crying was perceived as a sign that colostrum or breastmilk was insufficient to satisfy infant hunger, mothers reported a lack of hands-on support for breastfeeding difficulties, and some fathers perceived formula feeding as a way to support the mother while she rested and recovered after birth. In the first few months of an infant’s life after birth, formula was often used when mothers perceived insufficient milk. Complementary foods were introduced around four months, and families reported formula was often introduced at the same time as other complementary foods and a means to enhance child development. Intelligence and height were two of the most desirable qualities formula was thought to provide, information respondents identified from television and other media advertisements.
The message to exclusively breastfeed was widely known, but was not thought to be achievable for working mothers in particular. Formula was perceived as the only solution for feeding when mothers and infants were physically separated for long hours. Acceptability toward the idea of pumping breastmilk was low, due to a lack of awareness about the practice, concerns about safe storage, and that the same term (vắt sữa) was used for both the traditional practice of expressing unsuitable milk to discard and pumping milk to feed a child.
The baseline survey showed that 12.7% of women experienced breastfeeding difficulties. The most common breastfeeding difficulties at 3 months postpartum were perception of insufficient milk (38.2%), breast pain (15.5%), and poor latch (15.5%). Only half of mothers sought help for insufficient milk, and seeking help for breast pain or latch was more common (75.9% and 67.1%, respectively). Mothers most often sought support from their mother/mother-in-law (52.7%), another family member (32.2%), or a doctor (31.3%), and each source of support recommended formula use more than any other solution.
Experiencing breastfeeding difficulties at 3 months postpartum was found to be associated with higher odds of subsequent formula feeding in infants 3 to 6 months of age (OR=2.32; 95% CI: 1.38, 3.91), as was maternal work outside the home (OR=2.03; 95% CI: 1.30, 3.18), formula feeding at birth (OR=1.86; 95% CI: 1.27, 2.73), and child age (mo) (OR=1.34; 95% CI: 1.06, 1.68) whereas higher birth weight (kg) was associated with lower odds of formula use (OR=0.60; 95% CI: 0.40, 0.91) in a multivariable logistic regression analysis. No association was found between formula use and maternal education, social and wealth conditions, having heard about exclusive breastfeeding, household food security, maternal body mass index, breastfeeding difficulties at birth, or recent child illness.
Conclusions: Breastfeeding is culturally normative in Vietnam, but our study suggests that formula feeding is a leading factor undermining exclusive breastfeeding. Using a mixed methods approach, reasons for formula use were elicited in a rural Vietnamese context where mothers were employed and faced the challenge of continued breastfeeding when returning to work. In this context, formula feeding was often perceived as a solution for mothers returning to work, whereas breastfeeding difficulties (both at birth and within the first six months), also led to formula use. Formula feeding was also perceived by family members as a way to provide rest to the mother after birth, and advertised properties of formula appealed to caregivers as a way to enhance child development.
It is essential to incorporate the perspective of Vietnamese families, who receive messages regarding infant feeding, particularly regarding formula, interpret them, and ultimately make the decisions that impact child feeding, growth, and survival within their culturally and politically determined world. This research contributes new information about reasons for formula use in a rapidly industrializing setting, and suggests future areas of research and policy change so that exclusive breastfeeding messages are reinforced with breastfeeding support at the workplace, health facilities, and within households.
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Keywords
public health, nutrition, breastfeeding, exclusive breastfeeding, infant and young child feeding, non-breastmilk liquids and solids, formula feeding