The following are many links to websites providing an excellent resource to both Latina breastfeeding women and their physicians. These sites provide physicians with culturally appropriate medical information as well as materials available in Spanish that are useful in promoting breastfeeding in the office setting.

For patients, these sites make available excellent illustrated manuals that address commonly encountered questions among Latina breastfeeding women. Many of these manuals are available for reproduction in printed form for those women who do not currently have easy access to the Internet. Especially useful in these sites are guides and advice aimed toward women with a limited level of literacy.

These sites were recommended as some of the best currently available on issues around breastfeeding in the Latina population by Dora Gutierrez, a physician who has been very active in international organizations to promote breastfeeding success.

http://yabiru.fmed.uba.ar/mspba/manulac/manulac.htm

A website developed in Guatemala containing an excellent illustrated manual with detailed advice regarding breastfeeding technique, troubleshooting, and promoting advantages of breastfeeding to Latina women. An excellent guide for women of low literacy.

http://www.lalecheleague.org/LangEspanol.html

For providers, will increase awareness of commonly held myths around breastfeeding, frequently asked questions, and medical references. Also provides a link to LLL International pages coming from many Latin American countries, including Mexico, Chile, Colombia and the Dominican Republic. Spanish-language office materials available to order, including posters and patient handouts.

http://www.aed.org/lactanciamaterna/

Manual for patients field tested in Honduras. Another resource with excellent illustrations useful for low literacy patients. Available in print version for use in the office.

http://habitantes.elsitio.com/madres/

Site from Argentina which provides information and suggestions in Spanish in question and answer format for breastfeeding Moms.

http://www.aed.org/first_steps/index.html#links

this site is maintained by the Academy for Educational Development, a non-profit organization “committed to addressing human development needs in the United States and around the world”. Provides citations of current references in the medical literature substantiating many stated claims currently held regarding the health benefits of breastfeeding for mother and baby

http://www.lalecheleague.org/Lang/LangVentajas.html

Spanish-language link with useful patient information on benefits of breastfeeding to mother and child

As a community pediatrician, family practitioner or OB/GYN in the Hartford area, you have undoubtedly encountered patients of a multitude of cultural backgrounds, each rich in its unique traditions and belief systems with which you may frequently find yourself unfamiliar. Spending time in a variety of clinical situations in and around Hartford as a third-year medical student, I recognized the challenge this brings to both patients and providers in allowing for optimal communication in the clinical context. This link will provide resources to community physicians seeking effective ways to encourage breastfeeding in a culturally-appropriate framework to positively impact breastfeeding rates among Latina women in the community.

I recognize that time to peruse the web is in short supply and the information available seemingly endless. I continue to believe, however, that this issue is of great importance to you as a provider and encourage your picking and choosing among the various components made available at this site as you work with Latina women either in the process of choosing infant feeding methods or struggling to make breastfeeding work for them. The materials included will be continually updated as new research from the Hispanic Health Council is made available and new physician resources emerge. Take a look at some of the information included and links provided for the benefit of both you and for your patients. We hope that you will find the information informative and useful.

Community Issues for Providers

1. Why is it important for Hartford-area physicians to be aware of breastfeeding issues specific to Latina women ?
   
   
2. What are some of the major differences between the countries of origin and the United States that influence breastfeeding rates?
   
   
3. What reasons do Hartford-area women give for not breastfeeding?
   
   
4. What is the impact of acculturation on breastfeeding rates?
   
   
5. Commonly encountered culturally-based myths on breastfeeding
   
   
6. What are some of the important benefits of breastfeeding to the mother?
   
   
7. How can I counsel patients regarding contraindications to breastfeeding?
   
   

Answer to Question #1

• Among Latinos in the United States, Puerto Ricans have experienced the highest infant mortality rates and one of the lowest breastfeeding initiation rates.
  
  
• 31% of Hartford's population is Latino, the overwhelming majority of which are of Puerto Rican descent.
  
  
• About half of the children attending Hartford's public schools are Latino. Given the many health benefits of breastfeeding for child health, efforts to increase rates of breastfeeding in Hartford's Latino community can have a profound impact on the health of children attending Hartford schools.
  
  

Answer to Question #2

• The following themes emerged from the Boston-area survey of Latina women at a community health center. Over half the participants were from the Dominican Republic, with the remainder from Puerto Rico, Guatemala, El Salvador, Chile and Mexico.
  
  
• Many women, especially those from the Dominican Republic, described their native countries as being more supportive of breastfeeding than the United States, with mothers frequently breastfeeding in public.
  
  
• Breastfeeding was more of an expectation, and the cost of formula more expensive, in the home country than in the U.S.
  
  
• Lifestyle differences: Life in the United States was noted to be busier and more stressful than in the home country
  
  

Answer to Question #3

In a 1997 needs assessment of inner-city Hartford's Latino children, mothers surveyed* revealed the following reasons for not breastfeeding : (Source: Perez-Escamilla, et al)

- Among this same cohort of women, the top reason given for stopping breastfeeding was again the mother feeling uncomfortable or embarrassed (34.6%).

- The second most frequently cited reason for stopping breastfeeding was the baby "rejected" the breast (20.2%), which is likely a reflection of the widespread bottle supplementation with formula, cereals, juices and water.

* 93% of respondents were of Puerto Rican descent.

Answer to Question #4

• A 1994 study of pregnant women in a city on the border between the U.S. and Mexico found that initiation of breastfeeding was highest among those least acculturated (52.9%), and lowest among those most acculturated (36.1%). (Source: Wood)
  
  
• Data from a 1982 Puerto Rican Fertility and Family Planning Assessment show that in 1980, while 54% of infants in the U.S. had ever been breastfed, approximately 40% of infants born in Puerto Rico had ever been breastfed, and of infants to Puerto Rican women living in the northeastern region of the U.S., only 26% had been breastfed. (Of note, overall rates in Latin America during the same time period indicate that 74-97% of all infants in select countries had ever been breastfed).

Answer to Question #5

(Source: Assisting the Latina Breastfeeding Mother, published in English)

a. "Colostrum is 'dirty milk' and you must get it out before the baby can be fed the white milk"

b. "My milk will make the baby sick if I get mad or upset".

c. "If I get sick I must stop breastfeeding or the baby will get sick, too".

d. "If the baby cries a lot, my milk is weak or bad".

e. "I don't have enough milk".

f. "I have to give herb teas and or rice water between breastfeedings".

g. "My milk will dry up if my breasts get cold".

Answer to Question #6

A review article published in the American Family Physician (April 1, 2000) provides a summary of current published data regarding health benefits of breastfeeding. While research in this area is ongoing, available data to date supports the following health benefits (all original studies are cited in the above referenced article).

Additional benefits to the mother and child useful in promoting breastfeeding: (American Family Physician, Promoting and Supporting Breast-Feeding, April 1, 2000: 61 (7)).

• Promotes mother-infant bonding
• Promotes uterine involution
• Economical for family and society
• Convenient
• Better cognitive development in children
• Lower incidence of premenopausal breast cancer
• Lower incidence of premenopausal ovarian cancer
• Lower incidence of maternal osteoporosis

Answer to Question #7

( Source: Lawrence, Ruth A. Breastfeeding: A Guide for the Medical Profession, St. Louis, 1999, Mosby, Inc., pp. 224-227)

In general, acute infectious diseases are not a contraindication to the continuation of breastfeeding. Since most maternal infections are acquired during breastfeeding, the infant has already been exposed and will benefit from the passively acquired antibodies and other immune components of the mother's breast milk.

Exceptions to this general rule do exist, however, and in order to appropriately weigh the risks and benefits of the continuation of breastfeeding in the setting of maternal illness, the clinician must have a clear understanding of the mother-infant dyad and evaluate each situation as indicated by the unique circumstances of the pair. Frequently encountered exceptions include:

• HIV and AIDS- Currently in the U.S. where the risk of infant mortality from infection is less than in the developing world, the CDC and Public Health Service recommend counseling HIV-positive mothers not to breastfeed to avoid the possibility of vertical transmission to the infant. The issue is less clear in the developing world, however, where controversy among public health officials exists regarding the relative risks and benefits of infant mortality due to infectious disease versus vertical transmission of HIV. IV Drug Abuse-
  
  
• HIV and HTLV-1 (rare in the U.S,) are currently the only infections that are absolute contraindications to breastfeeding. Because IV drug abusers are at high risk for these infections, in addition to the very real possibility of significant amounts of drug passed to the infant via breastmilk, women who are IV drug abusers should be counseled not to breastfeed.