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Christina Inouye FSN 416, Fall 2013 Dr.

Ramirez November 19, 2013 HP 2020 Paper #2 The HP 2020 goal I am trying to improve is the Maternal, Infant, and Child Health objective MICH-21.5, which is to increase the proportion of infants who are breastfed exclusively through 6 months. The target is at 25.5%; however, as of 2008, the national total is only at 14.6%.1 Exclusive breastfeeding is defined as the infant receiving only breast milk as their form of nutrition. Short-term benefits for the baby are protection from illness and mortality from infections; long-term benefits are lower risks for developing obesity and type 2 diabetes.2 Breastfeeding also helps the mother recover from childbirth more quickly and decreases the frequency of doctors visits due to the infant getting sick less often. While breastfeeding is known to be the best feeding method for the infant, its practices among mothers vary depending on factors such as ethnicity, education, socioeconomic status, and maternal age. The highest rates of breastfeeding are among mothers whose social characteristics include non-African American ethnicity, higher education, older maternal age, and being married. On the other hand, the lowest rates are observed among younger and undereducated mothers, and African American women. There is a wide disparity between those with the highest and lowest rates of breastfeeding, which is why the population of interest that I will be focusing on is teen mothers of black ethnicity ages 15 to 19 years old in Los Angeles County. Both the age of the mother and her race are relevant social factors when it comes to her decision to breastfeed. Young mothers are substantially less likely than older mothers to

breastfeed their infants. For babies born in 2007, 51% of mothers ages 30 and up breastfed their child at 6 months, compared to only 22% of mothers ages 19 or younger.6 In terms of race, the breastfeeding rates among African American women continue to lag behind those of other ethnicities. The rate falls well below the HP 2020 goal. Only 26% of black mothers continued to breastfeed at six months, while 64% of white mothers continued.7 In Los Angeles County since 1999, the rate fluctuated from 60% to 81% in 2005, but back down 69% in 2011.7 The average exclusive breastfeeding rate in California is 21.7%, while the average is 33% in LA County.8 Even though LA County fares slightly better than the state for exclusive breastfeeding at six months, the county is ranked 44th in the California (out of 58 counties).9 African American mothers in LA County are most likely to discontinue breastfeeding before 6 months compared to other ethnicities. The prevalence of breastfeeding among black infants remains below that for whites, Hispanics, and Asian/Pacific Islanders, suggesting that black mothers may be facing unique barriers to meeting breastfeeding goals and need additional support and targeted interventions to promote and support breastfeeding.10 Los Angeles County stretches for 2,100 square miles and contains nearly 10 million residents. About half (50.2%) of Los Angelinos are female and about 9.3% are African-American. There are 15.2% living in poverty, but 24.4% of African Americans lives below the poverty line.3 The teen birth rate in LA County is currently 28.8 per 1,000 and in 2010, the non-Hispanic black teen birth rate was almost double (52 births per 1,000).4 African-American teens are pregnant 3.6 times more than white teens and 6.5 times more than Asian Americans.5 Several causes may explain the lower levels of breastfeeding among black adolescent mothers. Due to their age, teen mothers are more likely than older mothers to be single and to have lower levels of education and income, all of which are characteristics that are negatively

associated with breastfeeding. Other factors that may contribute to the low breastfeeding rates among teens include returning to school, discomfort with the act of breastfeeding, embarrassment about breastfeeding in public, and shyness to ask for help.11 Other potential reasons for poor breastfeeding practices include a high level of comfort with the idea of formula feeding, the availability of free formula from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), limited availability and lower intensity of WIC breastfeeding support for minority women.12 Past interventions on this issue included teams composed of a lactation consultant and a peer counselor on the breastfeeding outcomes of black adolescents living in the Midwestern United States. This intervention consisted of two prenatal group classes, one peer counseling hospital visit, five post-partum telephone calls by the peer counselor or lactation consultant, and provision of breast pumps. In this study, the intervention group was compared with an attention control group (taught prenatal and childbirth material by an advanced practice nurse + peer counselor) and a usual care group (controls).13 There was nearly a three-fold increase in the median duration of any breastfeeding among the intervention group compared with the attention control and usual care groups. The large effect on the duration of any breastfeeding may be partially due to the social support created in this teen clinic. The concept of the breastfeeding team has potential and can be modified to fit LA Countys needs for a breastfeeding intervention for teens. Currently in Los Angeles County, several efforts are working to improve the breastfeeding issue and involve outpatient community healthcare settings and peer support. In outpatient community healthcare settings, the Comprehensive Perinatal Services Program (CPSP) is a state-administered set of services available to clinicians providing obstetric care to

women enrolled in Medicaid. It includes education and support in areas of nutrition, lactation and mental health, as well as education and training for all professional office staff. This intervention has proven effective; the baseline in the pilot sample was 24% exclusive breastfeeding and post-intervention it climbed to 55%.14 Additionally, there is a social marketing program in LA County currently in development that will promote breastfeeding in the African American community called Soul Food for your Baby. The project would educate members of the target community and reset social norms that exist around breastfeeding through both social media and mass media.12 It is important to understand that not all mothers have the same flexibility of schedule for breastfeeding, with lower-income mothers and those with younger age having more barriers to exclusive high-duration breastfeeding. Addressing these disparities requires additional efforts to recruit and work with hospitals in communities serving minorities and lower-income neighborhoods. The target audience for this intervention will be adolescents 15 to 19 years old in the Los Angeles County and will focus on decreasing the stigma and increasing breastfeeding support for this population. The intervention name will be Boost for Breastfeeding. The intervention would include involve a team of professionals, including lactation consultants, peer counselors, and school nurses in the area to develop a specialized afterschool program for recent young mothers, focusing on African Americans and their breastfeeding skills and knowledge. The project would begin in three communities in Los Angeles county: South Los Angeles, Florence-Firestone, and South Central Northeast. These areas have a relatively higher rate of teen births among African American girls ages 15 to 19 than other communities in the county.15 The team will work with approximately 150 adolescent mothers who participate in WIC programs, and the school nurses who will encourage and recruit teen mothers from the local

high schools to go to the nearest WIC facilities. Meetings will be held every weekday in the afternoon, when school lets out. However, in order for the mother and her infant to receive all the benefits, meetings will be mandatory only twice a week. The support team will provide the teens with nutrition education and tips for successful breastfeeding during gatherings at the local WIC centers. The afterschool program will allow the adolescent mothers to meet other moms of similar ages, with similar situations and become more comfortable with motherhood and all its aspects. With consultations, teens will also be provided a breast pump and lessons on how to use it regularly. I will get in touch with agencies, including Soul Food for your Baby so that they can use social media to decrease the stigma of breastfeeding and encourage young moms in the area to apply for WIC if eligible. In order to evaluate progress, I will administer a survey before and at the end of the six-month period. This anonymous survey will consist of questions regarding attitudes towards breastfeeding as well as information on adherence and compliance with their current breastfeeding practices. Peer counselors and lactation consultants will report to me once a month with changes in their teen mentees. Change can be observed if the mothers have not returned the breast pumps after six months, suggesting that they are continuing to use it, accompanied with continued visits to the WIC center. Also, increased participation of teen mothers in the area would imply an improved attitude and perception on breastfeeding among peers. This intervention will improve the quality of life of young African American mothers and their infants through consistent and high-duration breastfeeding support.

1. DATA 2020 - Maternal, Infant, and Child Health. Available at: http://www.healthypeople.gov/2020/Data/SearchResult.aspx?topicid=26&topic=Maternal, Infant, and Child Health&objective=MICH-21.5&anchor=102929. 2. Horta B, Bahl R, Martines J, Victora C. Evidence on the long-term effects of breastfeeding. World Heal. Organ. 2007. Available at: http://whqlibdoc.who.int/publications/2007/9789241595230_eng.pdf. 3. Los Angeles County Multicultural Health Fact Sheet. Available at: http://www.cpehn.org/pdfs/Los Angeles County Data Fact Sheet.pdf. 4. Teen Births - Kidsdata.org. Available at: http://www.kidsdata.org/topic/314/teenbirths/table#fmt=1127&loc=364&tf=64. 5. LA Best Babies Network | Perinatal Indicator: Teen Births in LA County. Available at: http://labestbabies.org/data/perinatal-indicator-teen-births-la-county. 6. Breastfeeding | Child Trends. Available at: http://www.childtrends.org/?indicators=breastfeeding. 7. Breastfeeding Disparities and Trends in Los Angeles County. Available at: https://publichealth.lacounty.gov/ha/present/APHA2012/Breastfeeding_Trends_APHA_2012_FI NAL_102512.pdf. 8. Breastfeeding Report Card - United States, 2012. Available at: http://www.cdc.gov/breastfeeding/pdf/2012BreastfeedingReportCard.pdf. 9. Policies, Promises, and Practices: Los Angeles County: 2012 Data. Available at: http://www.calwic.org/storage/documents/factsheets2013/losangeles2012.pdf. 10. Progress in increasing breastfeeding and reducing racial/ethnic differences - United States, 2000-2008 births. MMWR. Morb. Mortal. Wkly. Rep. 2013;62(5):7780. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23388550. Accessed November 12, 2013. 11. Tucker CM, Wilson EK, Samandari G. Infant feeding experiences among teen mothers in North Carolina: Findings from a mixed-methods study. Int. Breastfeed. J. 2011;6:14. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3197474&tool=pmcentrez&renderty pe=abstract. Accessed November 18, 2013. 12. Chapman D, Prez-Escamilla R. Breastfeeding Among Minority Women: Moving from Risk Factors to Interventions. Am. Soc. Nutr. 2012;3:95104. Available at: http://advances.nutrition.org/content/3/1/95.full.pdf. 13. Wambach KA, Aaronson L, Breedlove G, Domian EW, Rojjanasrirat W, Yeh H-W. A randomized controlled trial of breastfeeding support and education for adolescent mothers. West.

J. Nurs. Res. 2011;33(4):486505. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20876551. Accessed November 18, 2013. 14. Fielding J, Gilchick R. Positioning for Prevention from Day 1 (and Before). Breastfeed. Med. 2011;6(5). Available at: http://online.liebertpub.com/doi/pdf/10.1089/bfm.2011.0059. 15. Teen Births in California: A Resource for Planning and Policy. Available at: http://www.cdph.ca.gov/programs/mcah/Documents/MO-TeenBirthsinCalifornia.pdf.