Advertisement

An intervention to extend breastfeeding among black and Latina mothers after delivery

Published:November 20, 2013DOI:https://doi.org/10.1016/j.ajog.2013.11.028

      Objective

      The purpose of this study was to compare breastfeeding duration in mothers after delivery who were assigned randomly to a behavioral educational intervention vs enhanced usual care.

      Study Design

      We conducted a randomized trial. Self-identified black and Latina mothers early after delivery were assigned randomly to receive a behavioral educational intervention or enhanced usual care. The 2-step intervention aimed to prepare and educate mothers about postpartum symptoms and experiences (including tips on breastfeeding and breast/nipple pain) and to bolster social support and self-management skills. Enhanced usual care participants received a list of community resources and received a 2-week control call. Intention-to-treat analyses examined breastfeeding duration (measured in weeks) for up to 6 months of observation. This study was registered with clinicaltrial.gov (NCT01312883).

      Results

      Five hundred forty mothers were assigned randomly to the intervention (n = 270) vs control subjects (n = 270). Mean age was 28 years (range, 18–46 years); 62% of the women were Latina, and 38% were black. Baseline sociodemographic, clinical, psychosocial, and breastfeeding characteristics were similar among intervention vs control subjects. Mothers in the intervention arm breastfed for a longer duration than did the control subjects (median, 12.0 vs 6.5 weeks, respectively; P = .02) Mothers in the intervention arm were less likely to quit breastfeeding over the first 6 months after delivery (hazard ratio, 0.79; 95% confidence interval, 0.65–0.97).

      Conclusion

      A behavioral educational intervention increased breastfeeding duration among low-income, self-identified black and Latina mothers during the 6-month postpartum period.

      Key words

      For Editors' Commentary, see Contents
      Breastfeeding provides substantial health benefits for children and mothers; the American Academy of Pediatrics strongly recommends breastfeeding for the first year of life.
      • Singh G.K.
      • Kogan M.D.
      • Dee D.L.
      Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003.
      • Gartner L.M.
      • Morton J.
      • Lawrence R.A.
      • et al.
      Breastfeeding and the use of human milk.
      The health benefits of breastfeeding are consequential and include a lower risk of infection rates, obesity, and postneonatal death among children and a lower risk of breast and ovarian cancer among mothers.
      • Singh G.K.
      • Kogan M.D.
      • Dee D.L.
      Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003.
      • Gartner L.M.
      • Morton J.
      • Lawrence R.A.
      • et al.
      Breastfeeding and the use of human milk.
      Each additional week of breastfeeding confers benefit.
      • Pettigrew M.M.
      • Khodaee M.
      • Gillespie B.
      • Schwartz K.
      • Bobo J.K.
      • Foxman B.
      Duration of breastfeeding, daycare, and physician visits among infants 6 months and younger.
      Unfortunately, significant racial/ethnic disparities in breastfeeding initiation and duration exist in the United States, with black women having lower rates of both, compared with white women.
      Racial and ethnic differences in breastfeeding initiation and duration, by state–National Immunization Survey, United States, 2004-2008.
      Although national data suggest that Latina women have breastfeeding rates similar to those of white women, significantly different patterns of breastfeeding continuation rates exist among certain low-income subgroups of Latina women.
      • Chapman D.J.
      • Damio G.
      • Young S.
      • Perez-Escamilla R.
      Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: a randomized controlled trial.
      • Chapman D.J.
      • Perez-Escamilla R.
      Breastfeeding among minority women: moving from risk factors to interventions.
      Culturally sensitive interventions that target groups with the worst breastfeeding outcomes are needed.
      • Chapman D.J.
      • Perez-Escamilla R.
      Breastfeeding among minority women: moving from risk factors to interventions.
      We report results of a randomized trial that tested a behavioral educational intervention with the secondary aim of increasing breastfeeding duration among minority mothers.

      Materials and Methods

      The primary aim of this randomized controlled trial tested whether a 2-step behavioral educational intervention reduced postpartum depressive symptoms among minority mothers; details have been published elsewhere.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      Here, we report results on the secondary aim of this trial: to examine whether this 2-step intervention extended the duration of breastfeeding during the 6-month postpartum period.

      Eligibility

      We enrolled 540 self-identified black and Latina women who had delivered at a large tertiary hospital located in New York City between April 2009 and March 2010. The Icahn School of Medicine at Mount Sinai Program for Protection of Human Subjects approved this study. The patient sample was identified through an electronic documentation system for the labor and delivery unit. Eligible participants were black/African American or Latina/Hispanic, 18 years old, and had infants with birthweights ≥2500 g and 5-minute Apgar scores ≥7. Maternal race/ethnicity, maternal age, infant Apgar scores, and infant birthweight are contained in the electronic system. Bilingual clinical research coordinators asked additional questions related to race and ethnicity. Mothers were eligible if they self-identified as black/African American or Latina/Hispanic, spoke English or Spanish, and had a working telephone. Mothers who were recruited during their postpartum hospital stay gave consent, underwent a baseline interview, and were assigned randomly to intervention vs control.

      Intervention and control

      The behavioral educational intervention that aimed to prepare and educate mothers about postpartum symptoms and experiences (including tips on breastfeeding and breast/nipple pain) and to bolster social support and self-management skills included an in-hospital educational session with a social worker, educational materials, and a 2-week follow-up call. Mothers who were assigned randomly to the intervention arm were given a 2-step intervention. The first step occurred in the hospital when a masters-trained bilingual social worker reviewed an education pamphlet and partner summary sheet with each mother. Education materials included information on breastfeeding, breast/nipple pain, cesarean delivery, site pain, episiotomy site pain, urinary incontinence, back pain, headaches, hair loss, hemorrhoids, infant colic, and depressive symptoms. Additional information was provided on social support. A partner summary sheet spelled out the typical pattern of experience for mothers after delivery in an effort to normalize the experience. During the second step, which was the 2-week postdelivery call, the social worker assessed patients' symptoms, skills in symptom management, and other needs. Patients and the social worker created action plans to address current needs that included assessment of community resources. Enhanced usual care participants received a list of community resources and received a 2-week control call.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      The intervention was tailored culturally. The intervention was revised based on the results of a pilot-test with 50 diverse mothers during the postpartum period and a review with obstetricians, psychiatrists, and social workers. The intervention was further revised based on feedback from focus groups with black and Latina mothers during the postpartum period and our community action board. All materials were translated into Spanish and back-translated for accuracy and consistency of meaning. Content, pictures, wording, and length were revised according to these sources.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.

      Assessments

      Data were collected in person at baseline and by telephone during follow-up interviews by bilingual clinical research coordinators who were blinded to intervention status. Interviews occurred by phone at 3-week (mean, 27.6 ± 5.8 [SD] days), 3-month (mean, 83.5 ± 7.8 [SD] days), and 6-month (mean, 175.6 ± 8.9 [SD] days) intervals after delivery. Mothers were asked a series of questions about breastfeeding that included the importance of breastfeeding and breastfeeding support, physical and emotional symptoms, social support, and health care factors. The dependent variable, breastfeeding duration, was ascertained by asking mothers how long they breastfed their infants (in weeks). At each interview, mothers were asked if they currently were breastfeeding their infant. If they answered no, they were asked how long they breastfed their infant after delivery.
      Variables that were selected for inclusion in our analyses were maternal sociodemographic characteristics (age, race/ethnicity, nativity, language, educational attainment, insurance coverage, marital status, and work status), maternal health and clinical characteristics (parity, delivery type, presence of comorbid conditions, and antepartum complications), maternal psychosocial characteristics (social support, partner support, and history of depression), and breastfeeding characteristics (perceived importance of breastfeeding and breastfeeding support).
      Maternal depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report scale. The EPDS is a validated, widely used postpartum depression screening instrument.
      • Cox A.D.
      • Puckering C.
      • Pound A.
      • Mills M.
      The impact of maternal depression in young children.
      • Cox J.L.
      • Holden J.M.
      • Sagovsky R.
      Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale.
      We used an EPDS score ≥10 to indicate possible depression. Although a number of cut-off points have been used, it is recommended that, to minimize the failed detection of depressive cases, a cutoff score of 9/10 be used.
      • Cox A.D.
      • Puckering C.
      • Pound A.
      • Mills M.
      The impact of maternal depression in young children.
      • Cox J.L.
      • Holden J.M.
      • Sagovsky R.
      Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale.
      The Generalized Anxiety Disorder, 7-item scale, was used to assess generalized anxiety disorder.
      • Spitzer R.L.
      • Kroenke K.
      • Williams J.B.
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: the GAD-7.
      A cut-point of 10, which has been found to measure moderate anxiety, was used. General social support was assessed by taking the mean of 3 items that measured emotional support, instrumental support with the baby, and instrumental support with the household, responses (Cronbach's α, .701), responses ranged from 0–4.
      • Howell E.A.
      • Mora P.A.
      • Horowitz C.R.
      • Leventhal H.
      Racial and ethnic differences in factors associated with early postpartum depressive symptoms.
      • Howell E.A.
      • Mora P.A.
      • DiBonaventura M.D.
      • Leventhal H.
      Modifiable factors associated with changes in postpartum depressive symptoms.
      The partner support scale was constructed with the mean of the 2 items (Cronbach's α, .693) and had a range of 0–4.
      • Howell E.A.
      • Mora P.A.
      • Horowitz C.R.
      • Leventhal H.
      Racial and ethnic differences in factors associated with early postpartum depressive symptoms.
      • Howell E.A.
      • Mora P.A.
      • DiBonaventura M.D.
      • Leventhal H.
      Modifiable factors associated with changes in postpartum depressive symptoms.
      Women's breastfeeding characteristics were assessed by 4 questions. First, respondents were asked: “How important is breastfeeding?” Responses were coded as (1) extremely or quite a bit and (0) moderately, a little bit, or not at all. Subjects were also asked whether they received breastfeeding support from health care providers, partners, family, or friends. Each response was coded (1) yes and (0) no. In addition, each mother was asked whether her infant received breast milk only, formula only, or both at the 6-month assessment.

      Statistical analyses

      Randomization procedures and sample size calculations have been reported elsewhere.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      All statistical analyses were performed with personal computer SAS software (version 9.2; SAS Institute Inc, Cary, NC). Intervention status was the key independent variable in the current analyses. Bivariate analyses were conducted with the use of χ2 tests and t tests to assess the association between sociodemographic, clinical, and breastfeeding characteristics with intervention status. Intention-to-treat analyses examined breastfeeding duration (measured in weeks). Twenty-six women, who indicated that they were breastfeeding at baseline, were missing breastfeeding duration data at all 3 follow-up time points and were assigned the midpoint value of 2 weeks for breastfeeding duration, which represented the midpoint between the time from their baseline interview and the next scheduled follow-up assessment (mean, 27.6 days for trial participants). Kaplan Meier analysis was used to test the effect of the intervention on breastfeeding duration for up to 6 months of follow up; Kaplan Meier curves were compared with the use of the log rank test. Cox regression analysis was used to calculate hazard ratios with 95% confidence intervals. Additional analyses examined breastfeeding duration among the 451 mothers who initiated breastfeeding and results were similar. We therefore only present the results for all women randomized in the trial (intention to treat).

      Results

      The refusal rate was 19%.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      Among the 540 mothers who were enrolled, rates for follow-up interviews were 87% at 3 weeks, 89% at 3 months, and 78% at 6 months (Figure 1). The Table shows the baseline characteristics of the sample. The overall mean age of enrolled participants was 28 years (range, 18–46 years); 38% of the participants were black, and 62% of the participants were Latina. Thirty-six percent of participants were foreign born; 21% of them were primarily Spanish-speaking, and 63% of them had Medicaid insurance. There were no clinically important differences between intervention and control groups in baseline sociodemographic, clinical, and psychosocial characteristics, except that comorbid conditions were more prevalent among the control subjects than intervention subjects (27% vs 20%; P = .05). There was no difference in prevalence rates of returning to work between intervention and control subjects. In addition, there was no statistically significant differences by race in positive depression screens or positive screens for anxiety (results not shown).
      Figure thumbnail gr1
      Figure 1Participants' flow through the study
      Reproduced, with permission, from Howell et al.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      TableDemographic, clinical, and breastfeeding characteristics of study participants
      VariableTotal (n = 540)Intervention (n = 270)Control (n = 270)P value
      Sociodemographic characteristics
       Age, y
      Range, 18–46 years
      Data are given as mean ± SD.
      27.79 ± 6.0028.21 ± 5.8427.37 ± 6.13.10
       Race, n (%).44
      Black/African American203 (38)97 (36)106 (39)
      Hispanic/Latina337 (62)173 (64)164 (61)
       Foreign born, n (%)193 (36)101 (37)92 (34).41
       Primarily Spanish speaking, n (%)113 (21)60 (22)53 (20).45
       High school or less, n (%)248 (46)117 (43)131 (49).23
       Medicaid/Medicaid Managed Care, n (%)339 (63)168 (62)171 (63).78
       Single/separated/divorced/widowed, n (%)206 (38)102 (38)104 (39).85
       Returned to work after delivery, n (%)
      1 mo000
      3 mo126 (23)59 (22)67 (25).42
      6 mo178 (33)90 (33)88 (33).85
      Clinical characteristics
       Primiparous, n (%)220 (41)107 (40)113 (42).70
       Delivered by cesarean section, n (%)208 (39)105 (39)103 (38).83
       Comorbid condition, n (%)125 (23)53 (20)72 (23).05
       Antepartum complication, n (%)124 (23)65 (24)59 (22).52
      Psychosocial characteristics
       Screened positive for depression at baseline: Edinburgh Postpartum Depression Scale, n (%)82 (15)37 (14)45 (17).34
       Screened positive for anxiety: Generalized Anxiety Disorder-7 item scale, n (%)99 (18)49 (18)50 (19).91
       General Social Support Scale (0-4)
      Data are given as mean ± SD.
      3.24 ± 0.913.28 ± 0.923.21 ± 0.89.37
       General Partner Support Scale (0-4)
      Data are given as mean ± SD.
      2.87 ± 1.072.82 ± 1.122.92 ± 1.02.29
      Breastfeeding characteristics
       Initiated breastfeeding, n (%)451 (84)231 (86)220 (81).20
       Perceived breastfeeding as important, n (%)443 (82)220 (82)223 (83).74
       Received breastfeeding support by health care provider, n (%)339 (63)162 (60)177 (66).18
       Received breastfeeding support by partner, n (%)324 (60)159 (59)165 (61).60
       Received breastfeeding support by family/friend, n (%)357 (66)177 (66)180 (67).79
      Howell. Extending breastfeeding among minority mothers. Am J Obstet Gynecol 2014.
      a Range, 18–46 years
      b Data are given as mean ± SD.
      Eighty-four percent of participants initiated breastfeeding (in both trial arms), and most participants perceived breastfeeding as important and received breastfeeding support from partners, family, and health care providers. Kaplan Meier analysis revealed a statistically significant difference in time to cessation between the intervention and control groups (log rank test; P = .019) over the 6-month postpartum period (Figure 2). Median breastfeeding duration was 12.0 weeks for the intervention group and 6.5 weeks for women in the control group. Mothers in the intervention group were less likely to quit breastfeeding over the 6-month period (hazard ratio, 0.79; 95% confidence interval, 0.65–0.97). There was no statistically significant difference in exclusive breastfeeding at 6 months after delivery between the intervention group vs the control group (7% vs 4%, respectively).
      Figure thumbnail gr2
      Figure 2Breastfeeding duration for intervention vs control
      Howell. Extending breastfeeding among minority mothers. Am J Obstet Gynecol 2014.

      Comment

      The results of this trial suggest that a behaviorally focused, educational intervention that is delivered in the postpartum inpatient setting has the potential to increase the duration of breastfeeding among black and Latina mothers. Our intervention that was designed to educate and prepare mothers for the postpartum experience was successful in our primary aim of reducing postpartum depressive symptoms among black and Latina mothers.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      The current results demonstrate that this behaviorally focused, educational intervention was also successful in extending the duration of breastfeeding among a predominantly low-income group of black and Latina mothers. Our intervention is one of few successful interventions to improve breastfeeding rates among minority women.
      • Chapman D.J.
      • Perez-Escamilla R.
      Breastfeeding among minority women: moving from risk factors to interventions.
      The results of our trial are consistent with published literature that suggests that support and education are important factors that are associated with breastfeeding status.
      • Milligan R.A.
      • Pugh L.C.
      • Bronner Y.L.
      • Spatz D.L.
      • Brown L.P.
      Breastfeeding duration among low income women.
      • Anderson A.K.
      • Damio G.
      • Young S.
      • Chapman D.J.
      • Perez-Escamilla R.
      A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community.
      • Bentley M.E.
      • Caulfield L.E.
      • Gross S.M.
      • et al.
      Sources of influence on intention to breastfeed among African-American women at entry to WIC.
      • Bonuck K.A.
      • Trombley M.
      • Freeman K.
      • McKee D.
      Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months.
      Our intervention addressed situational factors that were correlated with postpartum depression and included education on physical symptoms, breast/nipple pain, breastfeeding problems, and social support.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      Studies suggest that women cite nipple pain as a major reason for stopping and that higher levels of support increase breastfeeding.
      • Milligan R.A.
      • Pugh L.C.
      • Bronner Y.L.
      • Spatz D.L.
      • Brown L.P.
      Breastfeeding duration among low income women.
      • Pugh L.C.
      • Milligan R.A.
      • Frick K.D.
      • Spatz D.
      • Bronner Y.
      Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women.
      • Grossman L.K.
      • Fitzsimmons S.M.
      • Larsen-Alexander J.B.
      • Sachs L.
      • Harter C.
      The infant feeding decision in low and upper income women.
      • Feinstein J.M.
      • Berkelhamer J.E.
      • Gruszka M.E.
      • Wong C.A.
      • Carey A.E.
      Factors related to early termination of breast-feeding in an urban population.
      Our intervention was conducted after the completion of the baseline survey and was not expected to impact breastfeeding initiation rates. The fact that rates of initiation, importance of breastfeeding, and breastfeeding support were similar among the intervention vs control groups suggests that our randomization was successful. This is important because each of these factors was correlated with breastfeeding duration. As with all randomized trials, women who consented to participate may be different than women who chose not to and thus may limit the generalizability of our findings. However, our refusal rate was very low.
      • Howell E.A.
      • Balbierz A.
      • Wang J.
      • Parides M.
      • Zlotnick C.
      • Leventhal H.
      Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
      Recall bias may have affected a mother's answers to duration of breastfeeding; however, mothers were asked this question several times over the first 6 months after delivery.
      A behavioral educational intervention extended breastfeeding duration among black and Latina mothers. The public health implications of this promising intervention are significant because the improvement of breastfeeding rates is included in Healthy People 2020 goals and because interventions to improve breastfeeding among those with the lowest rates are needed particularly.
      • Chapman D.J.
      • Perez-Escamilla R.
      Breastfeeding among minority women: moving from risk factors to interventions.
      Future research should be directed at the evaluation of dissemination efforts of successful interventions to increase breastfeeding among at-risk populations.

      References

        • Singh G.K.
        • Kogan M.D.
        • Dee D.L.
        Nativity/immigrant status, race/ethnicity, and socioeconomic determinants of breastfeeding initiation and duration in the United States, 2003.
        Pediatrics. 2007; 119: S38-S46
        • Gartner L.M.
        • Morton J.
        • Lawrence R.A.
        • et al.
        Breastfeeding and the use of human milk.
        Pediatrics. 2005; 115: 496-506
        • Pettigrew M.M.
        • Khodaee M.
        • Gillespie B.
        • Schwartz K.
        • Bobo J.K.
        • Foxman B.
        Duration of breastfeeding, daycare, and physician visits among infants 6 months and younger.
        Ann Epidemiol. 2003; 13: 431-435
      1. Racial and ethnic differences in breastfeeding initiation and duration, by state–National Immunization Survey, United States, 2004-2008.
        MMWR Morb Mortal Wkly Rep. 2010; 59: 327-334
        • Chapman D.J.
        • Damio G.
        • Young S.
        • Perez-Escamilla R.
        Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: a randomized controlled trial.
        Arch Pediatr Adolesc Med. 2004; 158: 897-902
        • Chapman D.J.
        • Perez-Escamilla R.
        Breastfeeding among minority women: moving from risk factors to interventions.
        Adv Nutr. 2012; 3: 95-104
        • Howell E.A.
        • Balbierz A.
        • Wang J.
        • Parides M.
        • Zlotnick C.
        • Leventhal H.
        Reducing postpartum depressive symptoms among black and latina mothers: a randomized controlled trial.
        Obstet Gynecol. 2012; 119: 942-949
        • Cox A.D.
        • Puckering C.
        • Pound A.
        • Mills M.
        The impact of maternal depression in young children.
        J Child Psychol Psychiatry. 1987; 28: 917-928
        • Cox J.L.
        • Holden J.M.
        • Sagovsky R.
        Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale.
        Br J Psychiatry. 1987; 150: 782-786
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        • Löwe B.
        A brief measure for assessing generalized anxiety disorder: the GAD-7.
        Arch Intern Med. 2006; 166: 1092-1097
        • Howell E.A.
        • Mora P.A.
        • Horowitz C.R.
        • Leventhal H.
        Racial and ethnic differences in factors associated with early postpartum depressive symptoms.
        Obstet Gynecol. 2005; 105: 1442-1450
        • Howell E.A.
        • Mora P.A.
        • DiBonaventura M.D.
        • Leventhal H.
        Modifiable factors associated with changes in postpartum depressive symptoms.
        Arch Womens Ment Health. 2009; 12: 113-120
        • Milligan R.A.
        • Pugh L.C.
        • Bronner Y.L.
        • Spatz D.L.
        • Brown L.P.
        Breastfeeding duration among low income women.
        J Midwifery Womens Health. 2000; 45: 246-252
        • Anderson A.K.
        • Damio G.
        • Young S.
        • Chapman D.J.
        • Perez-Escamilla R.
        A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community.
        Arch Pediatr Adolesc Med. 2005; 159: 836-841
        • Bentley M.E.
        • Caulfield L.E.
        • Gross S.M.
        • et al.
        Sources of influence on intention to breastfeed among African-American women at entry to WIC.
        J Hum Lact. 1999; 15: 27-34
        • Bonuck K.A.
        • Trombley M.
        • Freeman K.
        • McKee D.
        Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months.
        Pediatrics. 2005; 116: 1413-1426
        • Pugh L.C.
        • Milligan R.A.
        • Frick K.D.
        • Spatz D.
        • Bronner Y.
        Breastfeeding duration, costs, and benefits of a support program for low-income breastfeeding women.
        Birth. 2002; 29: 95-100
        • Grossman L.K.
        • Fitzsimmons S.M.
        • Larsen-Alexander J.B.
        • Sachs L.
        • Harter C.
        The infant feeding decision in low and upper income women.
        Clin Pediatr (Phila). 1990; 29: 30-37
        • Feinstein J.M.
        • Berkelhamer J.E.
        • Gruszka M.E.
        • Wong C.A.
        • Carey A.E.
        Factors related to early termination of breast-feeding in an urban population.
        Pediatrics. 1986; 78: 210-215