Birth Outcomes and Breastfeeding in Minnesota Hmong Women
Perinatal and breastfeeding outcomes are important indicators of maternal and child health. Adequate prenatal care, healthy full-term birth, and appropriate postpartum care have lifelong impacts on the health of mothers and babies. Perinatal factors also impact breastfeeding outcomes.
Breastfeeding improves the health of infants and mothers and results in cost savings for parents, insurers, employers, and society. Mothers who breastfeed have less risk of breast cancer, ovarian cancer, diabetes, and heart disease. Breastfed babies visit the physician less often, are less likely to be hospitalized or die from SIDS, and need fewer prescriptions than formula-fed infants.
Yog tsis muaj niam lub mis ces me nyuam yeej tsis loj hlob
Without breastmilk, children can’t grow.
Early and regular prenatal care is essential to a healthy pregnancy. Prenatal care includes maternal and child health education, physical exams and monitoring, and supplemental resources for pregnant women and their families (NICHD, 2017). In 2017, 99% of Hmong women who gave birth in Minnesota received prenatal care and attended an average of 10 prenatal appointments.
In 2017, there were 2,188 Hmong births in Minnesota. Hmong women living in Metro Counties had the most Hmong births – over 54% in Ramsey County alone. Birth facilities in Ramsey, Hennepin, and Anoka Counties served the most Hmong mothers.
The top five were:
1. Health East St. John’s Hospital
2. Regions Hospital
3. Maple Grove Hospital
4. United Hospital
5. Mercy Hospital
Type of delivery (vaginal or cesarean section) and birth outcomes such as prematurity (birth before 37 weeks gestation) and low birth weight (<2,500 g) affect maternal and child health outcomes.
Cesarean section, or surgical delivery, carries all the risks of any major surgery, including bleeding, infection, complications from anesthesia, blood clots and postpartum depression. Infants born by cesarean section are twice as likely to have breathing problems. Women’s risks for ectopic pregnancy, stillbirth, and decreased fertility also increase after a cesarean birth. These risks increase with each subsequent surgical birth. (Women's and Children's Health Network, 2018)
Infants born prematurely can suffer a host of different health consequences throughout their lifetimes. These may include intestinal and vision problems, hearing loss, asthma or chronic lung disease, neurological and behavioral problems, and high health care costs.
Low-birth-weight infants are more likely to have intellectual and developmental disabilities than babies born at a normal weight. Low birth weight also increases the chances of developing certain health conditions later in life, including diabetes, heart disease, high blood pressure and obesity. (March of Dimes, 2018)
• Hmong Minnesotans had markedly lower rates of Cesarean section births compared to the general Minnesota birth population.
• Fewer Hmong babies were born before 37 weeks compared to the overall Minnesota rate.
• More Hmong babies were born at a low birth weight, weighing less than 2,500 g.
Separating mothers and babies due to cesarean section births, prematurity or low birth weight can adversely affect both mothers and babies with delayed breastfeeding initiation and milk production, leading to more formula supplementation and shorter breastfeeding duration (Hobbs et al., 2016; Baley, 2015).
The postpartum period is a crucial time to give care to newborns and for mothers’ bodies to heal and adapt to changes after birth. Postpartum care is an ongoing process in the weeks following birth, and includes monitoring mothers and newborns for health complications and providing physical, social and psychological support.
In Hmong culture, nyob nruab hlis is the first 30 days immediately following childbirth. In this period, Hmong Women are instructed by their mothers and elders to observe certain practices to keep them, their babies, and other Hmong households in good health. Common practices include:
Postpartum (Chicken) diet:
Many Hmong women are encouraged to consume only ‘hot food’ to cleanse their body of childbirth blood, which is believed by many Hmong to cause health problems. Prior to childbirth, families of pregnant Hmong women prepare enough chicken and herbs (tshuaj rau qaib) to last through the nyob nruab hlis period. Postpartum, Hmong mothers prepare and eat hot rice with the boiled chicken broth and herbs.
No Visitations to other peoples’ homes (Caiv nruab hlis):
New Hmong mothers are prohibited from visiting other Hmong homes within 30 days after childbirth. Many Hmong believe that new mothers’ bodies are ‘unclean’, can disrupt household or clan spirits, and can bring health problems to a household (Rice, 1999).
The American College of Obstetricians and Gynecologists (ACOG) provides guidelines for optimizing postpartum care. In addition, skilled lactation care is crucial during the postpartum hospital stay and in the weeks and months following birth, to assist women in overcoming the challenges and barriers they encounter during the breastfeeding journey.
Breastfeeding is important for the health of both infants and mothers (MDH, 2015).
Breastfeeding is important for infants because it:
• Protects against infections
• Helps with eye and brain development
• Lowers the risks for cognitive and physical developmental delays
• Lowers the risks for diabetes and childhood cancers
Breastfeeding is also important for mothers because it:
• Lowers the risks for as diabetes, heart disease, breast and ovarian cancer, and osteoporosis
• Increases mother-infant interaction through physical touch
• Delays the return of fertility
The best health outcomes occur when infants and mothers breastfeed immediately after birth, exclusively feed breastmilk only (no supplements such as water or formula) and continue breastfeeding for at least one year (American Academy of Pediatrics, 2012).
The Hmong in Southeast Asia were a breastfeeding culture. Cross-nursing was practiced in instances where a mother was unable to breastfeed her own child. Hmong immigrants, however, quickly adopted what is perceived as the American way of feeding babies and abandoned breastfeeding in favor of feeding infant formula. Many believe formula will make children taller and stonger.
Traditional Hmong culture forbids drinking of breastmilk except by infants and young children who are not yet weaned from the breast. It is said that breaking this rule will result in being struck by lightning. Shamans can perform practices to exempt themselves from this rule, and there also may be an exception made if the milk will be used as a medicine for an ill person.
Breastfeeding Initiation among WIC Participants
The World Health Organization recommends breastfeeding initiation, without interruption, immediately after birth (within the first hour). Early breastfeeding initiation increases the practice of exclusive breastfeeding and longer breastfeeding duration.
In 2017, 89.6% of Minnesotan mothers initiated breastfeeding, meeting the Healthy People 2020 goal of 81.9%. In addition, breastfeeding initiation rates among most Minnesotan racial/ethnic groups increased over the years 2001-2016. However, wide disparities persist between cultural groups within racial groups.
Non-Hispanic Asian mothers ranked second lowest in initiating breastfeeding in 2016.
When the Asian category is further divided by ethnic group, Hmong mothers, U.S.-born and foreign-born, have the lowest breastfeeding initiation rates of all groups reported.
Breastfeeding Exclusivity and Duration
Exclusive breastfeeding is defined as breastmilk only with no supplementation by infant formula or water (medications are not considered supplements) (AAP, 2012). Feeding newborns supplements, such as infant formula, increases risks for health complications and disrupts the infant microbiome. It may also negatively affect milk supply and lead to early weaning (WIC, 2017).
Hmong mothers have the lowest rate of exclusively breastfeeding during the hospital stay (14%), compared to other groups.
Optimally, the breastfeeding relationship will continue for at least one (AAP, 2012) to two years (WHO, 2018) or longer as mutually desired. However, many women wean in the first days and weeks, often earlier than they had hoped.
In 2015, 1 in 8 Hmong WIC mothers was breastfeeding at 6 months and 1 in 27 Hmong mothers to or beyond 12 months (WIC, 2018).
Milk production is a major self-reported concern for Minnesota WIC Hmong mothers, especially in the early weeks of breastfeeding but continuing for several months. Although true inability to produce enough milk is rare, many turn to formula ‘just to be safe’, leading to less breastfeeding, lowered supply, and early weaning.
Many Hmong mothers report that they have changed their minds as a reason for stopping breastfeeding, perhaps due to breastfeeding difficulties, or lack of support from family members.
Other mothers describe weaning as ‘baby-led’, even in the first days postpartum. This may be due to misunderstanding of infant cues, such as assuming that crying always means the baby is hungry.
Reasons for Stopping Breastfeeding
WIC Breastfeeding Peer Counseling Program
The Breastfeeding Peer Program partners peer counselors with postpartum mothers to educate, support, and encourage breastfeeding. The peer counselors have experience breastfeeding and speak the same language as the mothers they serve.
Women who participate in the peer program receive support by telephone, text and/or face-to-face contact during pregnancy and postpartum for up to a year postpartum.
In 2015, 87% of Hmong mothers who enrolled in the peer program initiated breastfeeding. Hmong peer participants were 2½ times as likely to exclusively breastfed during the hospital stay as Hmong mothers not enrolled in the program (38% vs 14%).