Mục tiêu để mô tả thái độ cho con bú và hành vi giữa phụ nữ Việt Nam tại thành phố Hồ Chí Minh. Thiết kế một nghiên cứu định tính mô tả đã được sử dụng. Lý thuyết hành vi kế hoạch cung cấp khuôn khổ khái niệm. Thiết lập Bệnh viện Vângem bé, Khoa Sản và Phụ khoa của một bệnh viện trường đại học tại thành phố Hồ Chí Minh, Việt Nam. Tham gia 23 bà mẹ Việt Nam tự nguyện. Thu thập và phân tích dữ liệu bán cấu trúc phỏng vấn sâu với năm câu hỏi và quan sát mở được sử dụng. Các cuộc phỏng vấn ghi âm và sao chép nguyên văn. Các dữ liệu từ các cuộc phỏng vấn và quan sát được phân tích bằng cách sử dụng phân tích nội dung. Phát hiện năm loại thái độ và hành cho con bú được xác định: cho con bú tốt nhất, nhưng không độc quyền, văn hóa và truyền thống tín ngưỡng, nuôi trẻ sơ sinh là một quá trình học tập, các yếu tố ảnh hưởng đến quyết định vú thức ăn, và ý định để nuôi các con. Kết luận quan trọng và tác động đối với thực hành văn hóa tín ngưỡng và truyền thống và thực hành, và tình hình kinh tếxã hội, ảnh hưởng cho con bú các bà mẹ Việt Nam. Nhân viên y tế nên xem xét bối cảnh văn hóa và các vấn đề kinh tế xã hội khi chuẩn bị các chương trình giáo dục và can thiệp cho trẻ ăn. Kiến thức phù hợp về giá trị văn hóa cần được đưa vào giáo dục chăm sóc sức khỏe để chăm sóc đồng dạng văn hóa cho các bà mẹ Việt Nam ở Việt Nam cũng như ở các nước phương Tây.
Breast-feeding attitudes and practices among Vietnamese mothers in Ho Chi Minh City Pranee C. Lundberg, PhD, BSc (Nursing and Midwifery), RN (Associate Professor) a, n , Trieu Thi Ngoc Thu, MSc, BSc (Midwifery) (Head of the Department of Midwifery) b a Department of Public Health and Caring Sciences, Uppsala University, Box 563, SE-751 22 Uppsala, Sweden b Faculty of Nursing and Medical Technology, University of Medicine and Pharmacy in Ho Chi Minh City, Vietnam article info Article history: Received 19 December 2010 Received in revised form 17 February 2011 Accepted 28 February 2011 Keywords: Breast feeding Vietnam Attitudes Practices abstract Objective: to describe breast-feeding attitudes and practices among Vietnamese women in Ho Chi Minh City. Design: a descriptive qualitative study was used. The theory of planned behaviour provided the conceptual framework. Setting: the Well-baby Clinic, Department of Obstetrics and Gynaecology of a university hospital in Ho Chi Minh City, Vietnam. Participants: 23 voluntary Vietnamese mothers. Data collection and analysis: semi-structured in-depth interview with five open-ended questions and observation was used. The interviews were tape-recorded and transcribed verbatim. The data from the interviews and observations were analysed by use of content analysis. Findings: five categories of bre ast-feeding attitudes and practices were identified: breast-feeding best but not exclusive, cultural and traditional beliefs, infant feeding as a learning process, factors influencing decision to breast feed, and intention to feed the child. Key conclusion and implications for practice: cultural and traditional beliefs and practices, and socio- economic situation, influenced the Vietnamese mothers’ breast feeding. Health-care professionals should consider cultural context and socio-economic issues when preparing infant feeding education and intervention programmes. Appropriate knowledge about cultural values should be included in health-care education in order to provide culturally congruent care to Vietnamese mothers in Vietnam as well as in Western countries. & 2011 Elsevier Ltd. All rights reserved. Introduction Breast milk is the best form of nutrition for infants. The World Health Organization has recommended that infants should b e exclu- sively breastfed d urin g the first six mo nths. Thereafter it recommends the addition of appropriate co mplementary food (Kramer and Kakuma, 2002). It is reco gnised th at the i mmunological a nd nutri- tional properties of breast milk are beneficial to babies (Arifeen et al., 2001; Dewey et a l., 2001) and that breast feeding is associat ed w ith decreased childhood morbidity and mortality (Simmer, 2000). The theory of planned behaviour The theory of planned behaviour (TPB) is based on the construct that most behaviours of social relevance a re under volitional c ontrol (Ajzen and Madden, 1986); specifically, the intention to perform a behaviour, is considered the most important determinant of a behaviour. According to the TPB, the behavioural intention depends on (1) attitude toward the behaviour (an individual’s positive or negative evaluation of the behaviour), (2) s ubjective norm (an individual’s perception of social normative pressure or relevant others’ beliefs that he or she should o r should not p erform the behaviour), and (3) perceived b ehavioural control (an individual’s perceived ease or difficulty of pe rforming the behaviour). The TPB provided the conceptual framework for understanding the breast- feeding attitudes and practices of Vietnamese mothers. Factors influencing breast feeding Even after a decision to breast feed, many mothers fail to reach their own breast-feeding goals because of factors discouraging them (Thomson, 1990). Forster and McLachlan ( 2010 ) found that many women had both positive and negative feelings about breast f eeding, and that factors which influence breast feeding are numerous and complex. Early introduction of c omplementary food, including solid food, is a common phenomenon and the pattern of feeding varies Contents lists available at ScienceDirect journal homepage: www.elsevier.com/midw Midwifery 0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.midw.2011.02.012 n Corresponding author. E-mail address: Pranee.Lundberg@pubcare.uu.se (P.C. Lundberg). Midwifery 28 (2012) 252–257 (Norris et al., 2002; Fewtrell et al., 2003; Duong et al., 2005). Factors influencing breast feeding have been published by a number of investigators. It has been found that breast feeding is healthier for babies than artificial milk but there are sometimes difficulties in maintaining breast feeding due to work and family constraints (Babington a nd Patel, 2008). Mother-related factors, such as employ- ment and perceived breast milk insufficiency, infant-related f actors (Bulk-Bunschoten et al., 2001; McCarter-Spaulding and Kearney, 2001; Moffat, 2002 ), and husband-related factors (Earle, 2000; Kong and Lee, 2004) have been reported. Duong et al. (2005) fo und that the mother’s educational level and comfort with breast feeding in public places, the father’s occupation and f eeding p reference, and the a vailability o f sufficient food for the family significantly influ- enced the practice of exclusive breast feeding. M eed ya et a l. (2010) also found breast-feeding intention, breast-feeding self-efficacy and social support to be modifiable factors that influence women’s breast-feeding decisions. In addition, breast feeding is influenced by health providers (DiGirolamo et al., 2003) and the marketing of infant artificial milk (Adair et al., 1993). Decisions regarding infant feeding are also influenced by the social, cultural and economic environments (Rossiter, 1992). Vietnamese mothers often believe that maternal health is weakened by childbirth, and to restore health they follow traditional postnatal rituals and dietary restrictions (Lundberg and Trieu, 2010). Breast feeding in Vietnam In Vietnam, 19% of four-month-old infants and 12% of six- month-old infants are breastfed exclusively (UNICEF, 2007). Accord- ing to UNICEF (2004), causes of low rates of exclusive breast feeding are women’s lack of support and education regarding this matter and their long working days. The early introduction of complemen- tary food and the common use of artificial milk are also a parts of the problem. Ergenekon-Ozelei et al. ( 2006) showed that mothers generally have a positive attitude towards b reast feeding. However, they usually perceive colostrum negatively, and no mother was found to feed her infant exclusively by breast f eeding. Only 9.9% of mothers initiated breast feeding within the first hour of birth, and 40% started with solid food before f our months. Almroth et a l. (2008) foun d t hat exclusive breast f eedi ng w as r are because it w as poorly understood and little appreciated, by health professionals as w ell a s lay per sons , as th e best w ay t o feed a n in fant during the first 6 months. E arly fluid su pplementation was the rule, and most infants received water and milk in addition to breast milk. In a study of three groups of women in Australia, McLachlan and Forster (2006) fo und t hat women born in Vietnam used breast feedingless(75%)thanwomenborninTurkey(98%)andAustralia (84%). The Vietn amese-b orn women pe rceived th eir par tners as being negative to breast feeding and not appreciating the h ealth benefits of colostru m. During the last decades, after long periods of war and i solation, Vietnam has experienced a rapid economical development. W estern views have influenced the country, cities have grown, the quality of life has increased, extended families have given way to nuclear ones, and w omen’s conditions have changed (H ¨ agerdal, 2005). Such changes may have affected the breast-feeding attitudes and practices of Vietnamese mot hers, e special ly in urba n areas. As l ittle res earch has been devoted to these important matters, the present study of Vietnamese mothers in a major Vietnamese city was undertaken. Aim The aim of the study was t o describe the breast-feeding a ttitudes and practices among Vietnamese mothers in Ho Chi Minh City. Method Design A descriptive qualitative study was conducted to explore breast-feeding attitudes and practices among Vietnamese mothers in Ho Chi Minh City. Setting Data were collected during the months of June and July 2009 at the Well-baby Clinic, Department of Obstetrics and Gynaecol- ogy, of a university hospital in Ho Chi Minh City, the largest city in Vietnam with more than 6 million inhabitants (General Statistics Office of Vietnam, 2008). Sample Purposive convenience sampling was used to select the partici- pants. The sample consisted of mothers visiting the Well-baby Clinic with their babies. They should (a) have given birth to a child w ithin the last t wo ye ars, ( b) be o f ag e at le ast 1 8 y ears, a nd (c ) giv e informed consent. Twenty-three mothers participated. All of them belonged to the ethnical majorit y g roup Kinh,andmostofthemwere Buddhists. The ir age ran ged from 2 5 to 40 yea rs. Their edu catio nal level varied from primary school to bachel or’s degree. The most common oc cupati ons we re go vernmen t of ficer a nd mer chant . The majority lived in ext ended families (with husband and/or other relatives and children) in Ho Chi Minh City. The number of children varied from one to three. They had not experienced difficulty with childbirth. Ethical considerations The Head of the Well-baby Clinic approved the study after having conferred with a committee of the university. All partici- pants had been fully informed about the purpose of the study and assured that anonymity and confidentiality would be maintained. They had been told that anyone wishing to drop out could do so at any time. They had also given their informed consent verbally and in writing prior to the study. Data collection The data collection involved semi-structured interviews and observation. Five open-ended questions were developed for this study on the basis of unpublished results of a previous study. The questions were: (1) What is your opinion on breast feeding your infant? (2) What do you believe about breast feeding your infant? (3) How do/did you breast feed your infant? (4) Do/did you give extra milk or food to your infant? (5) If yes, what kinds of extra milk or food? Please give examples. Individual interviews lasting 30–90 minutes were conducted by the two female investigators (both midwives, one of Vietna- mese and one of Thai ethnicity). The participants were encouraged to narrate what they thought about breast feeding and how they practiced it, and while they were doing this their facial expres- sions and gestures were observed. Some participants were also observed while breast feeding their babies at the clinic. The interviews were tape-recorded until no new information emerged. After 23 interviews, saturation was achieved with regard to the main topics. The recorded interviews were translated from Viet- namese into English and transcribed verbatim. The correctness of the language of the transcripts was checked by an expert. The notes from observations were made in English. P.C. Lundberg, T.T. Ngoc Thu / Midwifery 28 (2012) 252–257 253 Data analysis The data from translated interviews and observations were analysed by using qualitative content analysis. It involves a subjective interpretation of the content of the textual data through a systematic classification process and deals with manifest and latent. The method has been used in a previous study by Lundberg and Trieu (2010). The merging categories and themes were tested and revised through analysis of the interviews. The data were analysed separately and the outcomes were discussed and chan- ged to ensure reliability. Peer checking, validation of emerging codes and categories in subsequent interviews, and debriefing by two experts with experience of the research method and the subject were used to enhance credibility. There was 85% agree- ment between the investigators and the experts. Disagreements were discussed to reach a final consensus (Kvale, 1989). Pseudo- nyms were used in the findings to maintain confidentiality. Findings Five themes represent ing the Vietnamese mothers’ breast-feed- ing attitudes and practices emerged: breast-feeding best but not exclusive, cultural and traditional beliefs (dietary precautions, traditional practices to maintain breast m ilk, following grand- mother, mother and mother-in-law, and use of traditional medi- cine), infant feeding as a learn ing process, fa ctors influencing decision t o breast feed (husband support, employment, media and advertisement, and information from health professionals), and intention to feed the child (different time periods of breast feeding, and infant feeding pattern). Breast-feeding best but not exclusive All mothers described breast milk as the best for their infant. They believed that it enhanced optimal growth and development of their infants. Breast milk, natural food made in the body of the mother, has all nutrients that the infant needs and antibodies for immunity. It is convenient and clean, free of charge, and takes no time to prepare. Breast feeding also creates a close tie between a mother and her infant. Mrs. Hanh, with two children, stated: Breast milk (sua me) is the best food for the baby. I think it helps maternal-infant bonding. My first child was not breastfed, and he easily got sick. The second child I gave breastfeeding to prevent my baby from getting allergies, colds, diarrhoea and colic. I have breastfed up to now and I don’t need to buy any kind of formula milk (sua bot). Even though all mothers said that breast milk was the best, no one was exclusively breast feeding. Some mothers gave water to their baby after breast feeding. They believed that the infant might be thirsty and they wanted to prevent tongue diseases. Mrs. Long who had her first child described: I give a little water after breastfeeding so that my baby’s tongue does not get thick and he gets good digestion. Most of the mothers discarded the colostrum because they believed that it was not good for the infant. However, some of them had the opinion that the colostrum w as associated with good infant health, so they used it. They also mentioned that they could decrease the risk of br east disease, e .g. b reast cancer, b y b reast f eeding. Mrs. Ngan, who gave colostrum to her baby, stated: I know that colostrum has more antibodies. I believe that the baby will get good health (from it), so I breastfed directly after birth. Some mothers started to feed their babies with artificial milk during their stay in the hospital, others after having come back from the hospital or two to four months after the birth. They were afraid that their breast milk was not sufficient. Therefore several mothers mixed breast milk and artificial milk when they fed their babies, e.g. half of each. They used different brands of artificial milk, e.g. Abbot, Dielac and Ridielac. Mrs. Que, who had two children and mixed breast milk and artificial milk, stated: I mix breastfeeding (nuoi con bang sua me) and bottle feeding (nuoi con bang sua bot), once breast milk and next time bottle milk, because my daughter got bottle milk in the hospital and she continues at home. I want her to be familiar with bottle feeding. Cultural and traditional beliefs This theme consists of four categories related to cultural and traditional beliefs: dietary precautions, traditional practices to maintain breast milk, mother, mother-in-law and grandmother, and use of traditional medicine. Dietary precautions This category r eflects that the mothers followed practices for increased production of breast milk tha t had been re commended to them. The majority believed that they should consume ‘hot (am)’ and avoid ‘cold (duong)’ food during one month after birth to restore their balance. They indicated that the nutritional value of breast milk was dependent upon the health of the lactating mother and the availability of her traditional postnatal diet. If a mother was weak, suffering from any illness or taking medications, or if she had had operations, her milk was believed to be inferior. The lactating mothers s hould eat l arge quantities o f food and drink much warm water. They avoided eating sea food bec ause such food would give rise to allergy. The most common food eaten to stimulate lactation was pig nails with green papaya or red bean and p otato, cooked a s a soup and eaten with rice. Some mothers also drank large quantities of milk. By doing this th ey believed that t hey would produce more breast milk. Mrs. Phuong described her experience: I have been told to eat soup with nails of pig or pork ragout and green papaya every week during four months and drink a lot of milk to produce more breast milk. Some mothers ate a kind of Chinese food to produce more breast milk. Mrs. Ngan said: I eat everything and also several special kinds of food such as a soup with black chicken to produce more milk. I don’t eat sea food because it would make me allergic. Traditional practices to maintain breast milk Some mothers used different traditional methods to produce more breast milk. During the first month they mixed warm sticky rice and onion and put the mixture on their breasts. They believed that this would make the breasts produce more milk with good taste. Mrs. Hanh said: My grandmother told me to put warm sticky rice on my breasts, around 15 minutes per breast, a nd massage my brea sts. Then I took it away. I did this seven days after birth to produce good milk and a larger amount of milk. Several mothers used a warm cloth to clean their breasts and they massaged them with their thumbs. They believed this would help them produce more milk. Mrs. Loan, who had one son, P.C. Lundberg, T.T. Ngoc Thu / Midwifery 28 (2012) 252–257254 demonstrated how to massage her breast and said: I use my thumb to do like this nine times on each breast. Sometimes I also put a warm towel on my breasts to stimulate the production of milk. I do this during one month. Following grandmother, mother and mother-in-law Most of the mothers mentioned that they followed what grandmother, mother and mother-in-law told them about breast feeding. These family members encouraged them to breast feed, and told them how to maintain milk production and add supple- mentary food. The mothers also got help with cooking of special food that would stimulate the production of breast milk and with housework so that they could rest and concentrate on the care of the infant. Mrs. Thanh, who lived in an extended family and had her first child, stated: My grandmother encouraged me to breastfeed my son. Also, she told me how to breastfeed. I followed what she told me. Some mothers decided themselves about breast feeding because their grandmother, mother and mother-in-law lived far away from them. They looked at people living near them, such as sisters and friends, and then made their decisions. Mrs. Nhien, who lived with her husband, described: My mother lived far from me. I talked with my sister and decided myself how to feed my baby. Use of traditional medicines A traditional practice related to the production of breast milk is the use of herbal medicines. Some mothers were e ncouraged to drink herbal medicine in order to produce breast milk abundantly. Herbal drinks were believed to help flush out remainders of child- birth blood and p lacenta i n t he woman’s ut erus, in th is w ay making it clean and ready for the next baby. Therefore, they drank herbal medicine during three or four months after birth, even though they had established their breast milk. Mrs. Ngan, mother of her first child, s aid: I boil some kinds of Vietnamese traditional medicine together to drink. My mother brought them from the drugstore. She told me that they would make my body healthier and give me more breast milk. Infant feeding as a learning process Many mothers described infant feeding as a process of learn- ing. They learnt from doctors and midwives when they attended classes for pregnant women, from grandmothers, mothers and mothers-in-law, from television, magazines and books, and from their experiences of breast feeding and supplement food. Their increased knowledge gave them self-confidence. Mrs. Thanh, who had her first child, stated: I feel that I learnt little by little after childbirth how to feed my child. I think of feeding my child as a process of learning what I should do y. I learnt about the benefits of breast milk from the doctor, the midwife and from my mother-in-law. Also, I learnt about baby food from television and magazines. I have no difficulty to breastfeed my baby. Factors influencing decision to breast feed The majority of the mothers described factors influencing the decision to breast feed. Four categories were identified: husband support, employment, media and advertisements, and lactation problems. Husband support Some mothers indicated that they w ere encouraged by their husband to breast feed the i nfant. They felt more confident to breast feed because of such support. Their husband also helped them take care of the infant. Mrs. Nhien, who had a three-month-old son, said: My husband told me that breast milk will help my son have good health. He encouraged me to breastfeed. Employment Most of the mothers mentioned that a difficulty with breast feeding is that of not being able t o leav e the infant at home for someone else to feed when they had to go back to work. The mothers g enerally returned to work soon after childbirth, a majority ofthembeforethebabywassixmonthsold.Theycombinedbreast feeding and bottle feeding in o rder to familiarise the infant w ith bottle feeding so that he o r she could be taken ca re of by mother, mother-in-law, grandmother, some other relative or a maid. Mrs. Giang, who had a daughter of age four months, stated: Up to now, I give my daughter breastfeeding and bottle feeding. I will go back to work this month y I prepare her for bottle feeding so that she can stay with my mother. Media and advertisements Infant feeding was influenced by media and advertisements. Through these channels, most mothers were taught that artificial milk and milk powder contain vitamins, minerals and nutrients which lead to improved growth and development. Advertisements for artificial milk and supplementary food, and people using such food, had important influence on the mothers’ decisions on infant feeding. Mrs. Hanh, mother of two children, said: I got information about formula milk (sua bot) from advertise- ments on the TV. I also read in magazines what kinds of food I should give to my baby. Lactation problems Some mothers replaced breast feeding by artificial milk feed- ing before six months when they encountered problems such as sore or cracked nipples, engorgement of the breast, or inadequate lactation. Mrs. Lan, who after two months thought her breast milk was insufficient and not good for her infant, said: I had little milk and it looked like water. It was so thin and not good for my baby that I stopped breastfeeding. Mrs. Han, who had problems with cracked nipples, stated: My baby bites my nipples. They become very sore and need to be relieved by occasionally giving bottles so that I can continue to breastfeed longer. Intention to feed the child All mothers mentioned that in the beginning they intended to breast feed but after some time they introduced different kinds of infant feeding because they believed that the infant needed more nutrients. This theme consists of two categories: schemes of breast feeding, and patterns of infant feeding. Schemes of breast feeding The majority planned to breast feed during 12–24 months. Some mothers mentioned that the scheme of breast feeding depended on the growth of the infant; if the infant was small they would feed more. The majority breastfed during about 30 minutes every two hours. Some breastfed every hour or when P.C. Lundberg, T.T. Ngoc Thu / Midwifery 28 (2012) 252–257 255 the infant cried, whereas others breastfed every three hours. Mrs. Giang, who had a two-month-old infant, said: I breastfeed my baby every two hours, each time around 20 to 30 minutes. I plan to continue until I have no milk. Some mothers gave both breast milk and artificial milk to the infant. Mrs. Lan, who had a three-month-old son, stated: I feed my son every two hours and change between breast milk and a bottle of formula milk y I use Abbot Company formula milk. I intend to give supplementary food after my milk is finished. Patterns of infant feeding The mothers’ pattern of infant feeding was to give breast milk and add artificial milk and supplement food. They believed that the combination of breast milk and other milk would help the infant grow and become strong. Most of the mothers started to add supplement fo od after four months. They thought that after such time breast milk would no longer be s uitable for the infant. They also wanted the infant to become familiar with the food and to be able to eat it easily when he or she grew up. The supplement food was of different brands depending on the mother. Some mothers started with sweet powder and continued with salt powder whereas others mixed sweet and sa lt powder. Some mothers thought that the food they cooked was better than nutrient pow der, so they gave rice soup to the infant. Mrs. Nguyet, who had a six- month-old daughter, described how she gave supplement f ood: After four months I gave my daughter supplementary food (thue adam). I started with sweet powder milk (bot ngot)duringone month and salty powder (bot man) during half a month because I wanted her to be familiar with the food. I also plan to give her rice soup (chao) with some fish or beef and vegetable. After one year I will give her rice. Mrs. Long, with two children, said: I mixed sweet and salt powder milk once every day during the fourth month. I gave it twice per day in the fifth month. Now when he is six months old I give him three times a day. I give the sweet powder milk in the morning, and the salt one around 12 o’clock and six o’clock in the afternoon. I plan to give him rice porridge (chao dac) or rice-floured porridge (bot) after six months. Discussion As all mothers believed that breast milk was beneficial for the infant, they had a positive attitude to breast feeding. The s ubjective norm, reflecting t he beliefs of relevant others, such as grandmothers, mothers, mothers-in-law and husbands, also favoured breast feed- ing. However, the perceived behavioural control was influenced by the belief t hat colostrum was not good for the infant, by lactation problems, by media and advertisements, and by the necessity to go back to work soon after childbirth. In the context of TPB (Ajzen and Madden, 1986), these mixed but predominantly positive influences gave the m others an intention to u se breast feeding which, however, was not strong enough to rule out r elatively early use of b ottle feeding. Traditionally, Vietnamese women do not start with breast feeding within the first few hours after birth (Morrow, 1996). The early introduction of artificial milk and supplementary food is in accord with Almroth et al. (2008) who described that exclusive breast feeding was rare and that most infants received water and milk in addition to breast milk. The majority stated that they followed traditional cultural beliefs about breast feeding, and were influenced by grandmothers, mothers and mothers-in-law. It is important that health-care professionals consider such beliefs and practices in culturally sensitive ways in infant feeding education and in interventions to pregnant women and new mothers. The mothers seemed to have good knowledge about the psychological benefits of breast feeding, and they commonly stated that breast feeding increases the b onds between mothe r and infant. Yet, many of them discarded colostrums which they believed to be unhealthy for the infant (Rossiter, 1992; Bui et al., 2008). Cultural beliefs rela ted to colostrum may partially explain why the Vietna- mese mothers gave s upplementary arti ficial m ilk w hile they were in hospital. However, some of them gave colostrum to the infant, which may indicate a change in the beliefs about colostrum. The mothers’ habit of following traditional dietary restrictions seems to be explained by the conviction that a well-balanced maternal diet enhances maternal and infant health and encourages lactation (Rossiter, 1992). For example, the postnatal traditional meal of pork ragout and green papaya is meant to produce fresh, nourishing milk, where ‘fresh’ connotes ‘balanced’ and should be understood in the context of Vietnamese theory of health (Groleau et al., 2006; Lundberg and Trieu, 2010). As maternal health was weakened by childbirth, the mothers got support from grand- mothers, mothers and mothers-in-law. This allowed them to rest and restore their ‘vital energy (chi’i)’. In this way, they prevented excessive ‘cooling’ of their bodies and assured fresh, nourishing and abundant maternal milk for their babies. Because of the Vietnamese culture, the women were dependent on their husbands and the senior members of their f amilies. Attitudes of spouse (Scott et al., 2001), parents (Sharps et al., 2003)andrelatives(Kendall-Tackett and Sugarman, 1995; Reid et al., 2010) play important roles for the start and duration of breast feeding. In developing countries, where t he position of women in the society is relatively low, the role of spouse and relatives in encouraging breast feeding is crucial (Kendall-Tackett and Sugarman, 1995; Arora et al., 2000; Meedya et al., 2010). Many of the mothers had confidence in br east f eeding because of the support from grandmothers, mothers and m others-in-law. Ekstr ¨ om et al. (2003) showed that social support, for e.g. from grandmothers, improved the confidence of the mothers. Together with socio- cultural determinants such as feeding p references of husban d and family members, factors relating t o the health of mothers, such as childbirth methods and locations, could influence the breast-feeding patterns. Because of t he traditional a nd socio-cultural features of Vietnam, it is important that health promotion on breast feeding should target not only pregnant women but also family members, especially husbands and grandmothers. The early introduction of supplementary food is a major problem of infant feeding among Vietnamese women (Duong et al., 2005; Babington and Patel, 2008). Work has been found to have important influence on the method of infant feeding (McCarter-Spaulding and Kearney, 2001; Moffat, 2002; Babington and Patel, 2008). Mothers seem to think that artificial milk feeding is a good choice when they plan to return to work. The opinions of family members have also been found to affect the choice of infant feeding method (Sj ¨ ogren, 2005; Mistry et al., 2008). Therefore, health-care professionals should have the influence of work and family in mind when informing new mothers about the direct and long-term benefits of breast feeding. Kramer and Kakuma (2002) described that WHO has c hanged the recommended length of exclusive breast feeding from three or four to six m onths. The recommendations might h ave been mis- understood by some mothers so that t hey added supplementary food earlier. It i s important that health-care professionals who give advice to pregnant women and new mothers regularly update their knowledge and counselling skills as regards exclusive breast f eeding. P.C. Lundberg, T.T. Ngoc Thu / Midwifery 28 (2012) 252–257256 The influence of marketing of commercial infant artificial milk on the breast-feeding behaviour of mothers in this study is in accord with several studies (Rossiter, 1992; Bentley et al., 2003). Mothers may misperceive infant artificial milk as the norm for western infants and get the impression that artificial milk has the same nutritional value as breast milk. Another threat to breast feeding is posed by the rapid social and economic changes taking place in Vietnam. New opportunities to get incomes present obstacles to exclusive breast feeding and make mothers vulner- able to the vigorous advertising of infant artificial milk. Therefore, Vietnamese authorities should closely monitor artificial milk promotion activities in mass media and health-care settings and take actions aimed at limiting their harmful effects. This study was limited by the small number of participants. It may not be possible to generalise the findings because of the use of convenience samples. However, as the participants had differ- ent ages, educational background, occupations, type of family and number of children, the findings provide a relatively broad over- view of breast-feeding attitudes and practices among Vietnamese mothers in Ho Chi Minh City. Further research should be carried out regarding midwives’ perspectives on exclusive breast feeding. Conclusion and implications Although the mothers had intention to breast feed during a long period they relatively early introduced bottle milk and supplemen- tary food. Cult ural a nd traditio nal b eliefs and practices regarding breast feeding remained among the Vietnamese mo thers. In addi- tion, breast feeding was influenced by socio-economic factors, media and marketing. Health-c are professionals should consider the cultural context and socio-economic issues when preparing infant feeding education and intervention programmes. Appropri- ate knowledge about cultural and tradi tional values should be included in the health-care education in order to achieve culturally congruent care to pregnant women and new mothers in Vietnam, as well as in Western c ountries. Acknowledgements This study was supported by the International Programme Office for Education and Training, Sweden, thro ugh its exchange pro- gramme Linnaeus-Palme between Uppsala University and Univer- sity of Medicine and Pharmacy in Ho Chi Minh City. We are thankful to the Vietnamese mothers for their participation in the study. References Adair, L.S., Popkin, B.M., Guilkey, D.K., 1993. 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Exclusive breastfeeding—safe, sound and sustainable, says UNICEF. UNICEF. /http://www.unicef.org/vietnam/media_522.htmlS. UNICEF, 2007. Breastfeeding within one hour of birth can significantly reduce infant mortality in Viet Nam. UNICEF. /http://www.unicef.org/vietnam/ media_7147.htmlS. P.C. Lundberg, T.T. Ngoc Thu / Midwifery 28 (2012) 252–257 257 . Vietnamese mo thers. In addi- tion, breast feeding was influenced by socio-economic factors, media and marketing. Health-c are professionals should consider the cultural context and socio-economic. university hospital in Ho Chi Minh City, the largest city in Vietnam with more than 6 million inhabitants (General Statistics Office of Vietnam, 2008). Sample Purposive convenience sampling was used. of Vietnamese mothers in a major Vietnamese city was undertaken. Aim The aim of the study was t o describe the breast-feeding a ttitudes and practices among Vietnamese mothers in Ho Chi Minh City. Method Design A