Copyright by TYRA MARTIN CARTER 1978

FACTORS AFFECTING THE DECISION OF LOW SOCIOECONOMIC

WOMEN NOT TO BREAST FEED

by

TYRA MARTIN CARTER, B.S. in H.E.

A THESIS

IN

FOOD AND NUTRITION

Submitted to the Graduate Faculty of Texas Tech University in

Partial Fulfillment of the Requirements for

the Degree of

MASTER OF SCIENCE

IN

HOME ECONOMICS

Approved

c n a i r m a n / o r r n e uommi-cree y

A c c e p t e d

May, 1978

ACKNOWLEDGMENTS

I would like to express my appreciation to Mrs. Clara

M. Mcpherson for her direction in preparation of this thesis

and to other members of my committee. Dr. Joe D. Cornett and

Dr. Charles V. Morr for their continued encouragement, help­

ful suggestions, and criticism. Special gratitude is ex­

tended to Miss Linda Affleck for her guidance in analysis of

statistical data.

Special acknowledgments are extended to the Lubbock

City Health Department Maternity Division for making this

research possible and to all the respondents for their will­

ingness to participate in this research project.

Special thanks are accorded to my husband for his

understanding and support throughout my graduate studies.

11

TABLE OF CONTENTS

ACKNOWLEDGMENTS ii

LIST OF TABLES v

Chapter

I. INTRODUCTION 1

Statement of the Problem 2

Hypothesis 3

Limitations of Study 4

II. REVIEW OF LITERATURE 5

History of Infant Feeding Practices . . . . 5 ^ I

Advantages of Human Milk for the Infant 6

Maternal Advantages of Nursing 12

Contra-indications of Breast Feeding . . . 17

Economics of Breast Feeding 21

Factors Which Negatively Affect Breast Feeding 24

Mothers' Decisions Regarding Infant Feeding 3 2

Role of Education in Increasing Breast Feeding 33

III. METHODOLOGY 36

Selection of Subjects 36

Development of Instrument 36

Collection of Data 37

Treatment of Data 38

111

IV

IV. RESULTS AND DISCUSSION 39

Part I. Demographic Data 39

Part II. Survey Results 40

V. SUMMARY AND CONCLUSIONS 53

REFERENCES 57

APPENDIX 63

LIST OF TABLES

Table Page

1. Age and Race Distribution of Subjects 39

2. Educational Background of Subjects by Race 40

3. Physician's Communication with Patient Concerning Method of Infant Feeding 41

4. Relationship of Physician's Attitude to Patient's Decision to Breast Feed . . . . 42

5. Convenience Factors Associated with Breast Feeding 43

6. Relationship of Breast Feeding to Social Attitudes 45

7. Relationship of Husband's Attitude to Breast Feeding 46

8. Relationship of Husband's Attitude to Breast Feeding If a Positive Choice Was Made 47

9. Factors Contributing to Success or Failure in Breast Feeding 48

10. Mothers' General Knowledge Concerning Breast Feeding 50

11. Product Distribution As an Influence on Decision to Breast Feed 52

V

CHAPTER I

INTRODUCTION

Methods of infant feeding consist of a blend of

biological constants modified by cultural factors, both

ancient and modern, which are strongly influenced by local

food availability (1). Following the scientific medical

revolution of 100 years ago, infant feeding in Euro-America

(and increasingly in urban areas elsewhere) became mainly

influenced by the Western world. Biological considerations

and traditional practices were regarded as old-fashioned,

outdated, and out-of-phase with present day urban life styles

Infant feeding came to be considered by some as an engineer­

ing exercise, with the child being "refueled" with specific

nutrients by mechanical means, e.g., from a feeding bottle

(1. 2) .

It is estimated that two-thirds of all mothers in

the world currently nurse their infants for at least the

first three months. The average incidence of breast feeding

ranges from a low of about 25 per cent in the United States

to nearly 100 per cent in rural areas of developing countries

(3). Moreover, rural women in developing countries often

breast feed for two years or longer compared with the average

of two to six months for women in developed countries. I In

the last decade, however, breast feeding declined sharply in

urban areas of many developing countries (2, 4). This has

been caused by vigorous commercial promotion of milk for­

mulas and supplemental foods for infants, by lack of strong

medical support for breast feeding, by a changed perception

of the acceptability and social status of breast feeding,

and, to a lesser degree, by increased employment of women

in places outside the home where little provision is made

for breast feeding (3)(

The unique value of human milk for the infant and

the value of breast feeding for the mother has become in- •

creasingly clear in all parts of the world with respect to

economics, health, nutrition, and even fertility. The basic

issue is to use an educational approach to improve the pat­

tern of breast feeding by decelerating the present rate of

decline. As of yet, no wi'de-spectrum efforts have been at­

tempted to counter the current trend (1).

Statement of the Problem

^ Despite significant benefits for both mother and

child, the rates for breast feeding in the United States

are the lowest in the world.( Although breast feeding rates

are presently rising among educated and middle-class women,

it remains lowest among the poor—those populations with

the highest infant and maternal mortality rates which have

the greatest need for better nutrition (5). The reasons

for decreased breast feeding rates among the poor are com-\

plex and vary according to the specific area.\ Therefore,

jiield research is needed to make detailed community diag­

nosis of the factors affecting the decision of low socio­

economic women not to breast feed. It is for this purpose

that the present study was undertaken.

The questionnaire is useful for obtaining personal

facts, beliefs, and attitudes to allow one to solve problems

within the sample group. It is known that a survey produces

reliable results, particularly when subjects are asked to

respond to an area of personal concern. Because of the

information the survey reveals, it prepares the way for

future experimental studies from which inferences can be

drawn.

Hypothesis

This research was designed to test the hypothesis

that the various independent variables to be studied af­

fect the choice of low socioeconomic women not to breast

feed. The independent variables include: professional

influence, urbanization and modernization, inconvenience,

negative social attitudes, previous exposure and experiences,

physical complications, the early introduction of semisolids

to infants, knowledge of the advantages of breast feeding,

advertising of infant formulas, number of children in the

family, and age, education, and marital status of the woman.

Limitations of Study

The following are limitations of the study:

1. Survey research may not produce responses which

are indicative of true behavior. Subjects may respond in a

way that they feel will be pleasing to the interviewer.

2. Survey information may not reveal in-depth

feelings of the respondents.

3. Descriptive research, by the survey method,

does not necessarily provide inferential sample information

which can be applied to the general population.

CHAPTER II

REVIEW OF LITERATURE

History of Infant Feeding Practices

Lactation is a most ancient physiological process

dating back millions of years. It antecedes placental ges­

tation, as earlier mammals were egg-laying marsupials (6).

During these vast periods of time, adaptation of milks has

occurred to meet the different needs of the many species

of mammals.

This principle can be observed with the whale and

other cold water mammals, in whose milks there is a very

high percentage of fat. This matches high caloric require­

ments of their offspring and the need to put on a thick

layer of blubber rapidly. Similarly, species such as the

rabbit, whose newborn grow extremely fast, have a very high

protein content in their milk (6).

Historically, human milk has been universally rec­

ognized and revered as the only means of infant feeding.\

Frequent references to it are found in religion, folklore,

and value systems. In ancient Egypt, nursing was commonly

continued for three years, and in biblical Israel for two

years. In Babylonia, the mother goddess Ishtar was often

depicted nursing her baby,—A Spartan royal law of the

fourth century B.C. required mothers to breast feed their

babies, and Caesar ridiculed Roman mothers who retained

nurses for their children (4).

When observing recent changes in patterns of infant

feeding, it becomes apparent that cow milk has been the

food of man for only the last ten or twenty thousand years.

The major part of the human race does not use animal milk

at all. More relevantly, the widespread use of cow milk

for feeding young infants has occurred in the last fifty

years, and was made possible by spectacular advances in

scientific dairy farming and in food technology (7). Even

so, this extraordinary, anti-mammalian situation spread

widely throughout the Western world and is now regarded as

the norm, fin terms of man's history, use of cow milk for

infant feeding is highly experimental. Unexpected nutri­

tional and related problems are coming to the forefront as

modern knowledge unfolds.

Advantages of Human Milk for the Infant

As pointed out by Kon (8),("It stands to reason that

milk, which only for a limited time and with certain reser­

vations is the ideal food for the young of any one species,

is further restricted in value when used by another species,

and the limitations of milks of domesticated animals in

human nutrition must be frankly accepted and understood^. "1

Basic to the whole issue is the question of the existence

of specific and unique ingredients in human breast milk,

as opposed to the milk of other mammals. Numerous studies

P^

on the biochemical and nutritional properties of different

types of mammalian milk have been conducted in the past

decade. Essentially, these have shown that each milk source

is a highly complex system differing greatly from one

another (9).

Human- milk contains over a hundred constituents.

This is not to say that milk of other species is not equally

complicated, but they are totally different (6). It is

worth noting that the growth rates of the human infant and

the calf are quite different, the human infant requiring

about twice as long as the calf to double its birth weight

(100 versus 50 days). Thus, the ratio of nutrient require­

ment for growth to that for maintenance is greater for the

calf than for the human infant. Furthermore, protein and

minerals account for a smaller percentage of weight gain in

the human infant than in the calf (10, 11). f

Proteins

\ Both human and cow milk contain approximately 67

kcal. per 100 ml. Seven per cent of the calories of human

milk come from protein, 30-55 per cent from fat, and 40 per

cent from sugar (1^) . Human milk contains approximately

1.1 per cent protein compared to_^.3 per cent protein in j

cow milk. The protein in human milk is mainly lactalbumin

rather than casein; the reverse is the case in cow milk

(11) .7 Both are complete proteins, but the increased casein

8

in cow milk leads to higher curd tension and poorer absorp­

tion. Lower protein levels in human milk decrease BUN and

thus, also decrease the solute mineral load in breast fed

infants. This makes it unnecessary to give extra water to

breast fed infants, except in unusual circumstances that

cause excessive water loss.

Lipids

j The fatty acid composition of human milk differs

from cow milk in that it has a much higher percentage of

linoleic acid (9). Medium-chain triglycerides, also well

absorbed, are present in human milk (11). The enzyme lipase

is one of the most important constituents of human milk.

It has been recently confirmed how effective this is in

producing lipolysis and initiating the digestion of milk

fat (12). This means that the main source of calories in

human milk is already undergoing digestion while in the

mouth, esophagus, and stomach.

The amount of cholesterol in human milk is higher

than in cow milk and even higher than most commercial infant

formulas, which are often made with various vegetable oils

containing no cholesterol (9, 10, 11, 13) J Results of

animal experiments have shown that relatively high intakes

of cholesterol are needed in early life to insure the de­

velopment of appropriate enzyme systems needed in later

life to control the level of cholesterol in the blood (14).

An exogenous source may be desirable to prevent excessive

cholesterol blood levels later in childhood or adulthood

(10) .

Lactose

1^ Lactose, a disaccharide of glucose and galactose,

is present in greater amounts in human milk than in cow

milk (7 per cent compared to 5 per cent) (7, 11) . This is

a readily available source of galactose which is needed for

the formation of galactolipids, one of the main constituents

of the brain (6, 7)

Vitamins and Minerals

r̂^ E[uman milk from a well nourished woman, if taken in

adequate quantity by the infant, may be expected to satisfy

advisable intakes for vitamin A, thiamin, riboflavin, niacin,

vitamin B^/ vitamin B-|2' folacin, vitamin C, and vitamin E

(10). Although human milk is not a particularly rich source

of preformed niacin, it is a good source of tryptophan,a

niacin precursor, so the total intake of niacin is more than

adequate. Human milk provides little vitamin D thus sup­

plementation of the infant's diet with a daily dosage of

400 I.U. is recommended (10, ll)~v

[ Concentrations of phosphorus, sodium, potassium,

and zinc have been noted to decrease as duration of lacta­

tion increases (10). Flouride, even when present in optimal

amounts in water, is not contained in human milk in

10

sufficient amount. Flouride supplementation of 0.5 mg.

should be given daily (10, 11). some research indicates

that full-term infants who receive only human milk do not

need iron supplementation for the first four to six months

of life (15, 16, 17, 18). Fomon and Filer (10), however,

strongly recommend iron supplementation for all infants.

They believe a daily intake of 7 mg. (as ferrous sulfate),

beginning no later than age four weeks, is adequate to

prevent development of iron-deficiency anemia.(

Anti-infection Agents

\ It has long been recognized that breast fed infants

seem to be protected against many infections, especially in

surroundings of poor hygiene. Until recently, this protec­

tion was thought to be associated with the fact that human

milk is sanitary and has no opportunity for contamination

(7). It is now apparent that human milk contains positive

and active host-resistant factors, both cellular and humoral

(1).

The cellular content of human milk is almost as

great as in blood, with a hierarchy of cells, ranging from

mobile, ameboid macrophages, to interferon-producing lym­

phocytes (19). These are present in colostrum and have a

protective function in the mammary lacteals as well as

within the infant. Humoral constituents are numerous and

include secretory immunoglobulin A (IgA), lactoferrin.

11

lysozymes, and the bifidus factor (1, 10, 11). These sub­

stance.̂ , 'p.rp'o a bactericidal effect and also protect the

newborn's gastrointestinal tract from foreign protein al­

lergens. The bifidus factor, not present in appreciable

concentrations in cow milk, is responsible for the dominance

of Lactobacillus bifidus in the infant's intestinal flora;

the acid environment inhibits _in, vitro growth of Escherichia

coli and the enteroviruses (20).

Allergenic Factors

Covy^milk is the most common foo.d responsible for

allergy in bottle-fed infants (1). Up to 7 per cent of all

infants may be sensitive to cow milk (11). Among carefully

proven cases, almost 60 per cent occur in the first month

and 80 per cent in the first three months of life. Detailed

studies show the most frequent al^lergens to be beta-

lactoglobulin and serum bovine albumin,_neither of which

are found in breast milk (2ixj Gerrard (22) recommends.

that human milk, with^its low allergenicity and its supply

of IgA, should be used for at least the first six months of

infancy, especially in infants with allergic heritage

Obesity

There is a rising incidence of infantile obesity in

the United States and other industrialized countries, which

seems to be related to the pattern^f infant feeding (6) .

The volume and concentration of milk consumed are controlled

12

by the mother (or other person) but, in the breast fed

infant, they are biologically controlled (1). Because the

composition of human milk from a well nourished woman changes

daily, the P^eve_ntion of obesity is aided. The fat content

of breast milk increases during nursing and the baby auto­

matically develops an appetite control mechanism to decrease

consumption (13). Breast feeding is also associated with a

delay in earli^r^jLntroduction of semi-solid foods, whi_ch

influences the onset of obesity (1, 6).

Maternal Advantages of Nursing

The child spacing effect of breast feeding, well

recognized in many cultures, has been long regarded as an

old wives' tale (1). Recent endocrinological investigations

have demonstrated that prolactin, a pituitary hormone, sup­

presses ovulation (23, 24). Postpartum plasma prolactin

levels differ greatly in nursing and non-nursing mothers

(25, 26). The secretion of prolactin has been shown to vary

quantitatively with the sucking stimulus to the breast (3).

The success of lactation in suppressing ovulation

occurs when the baby suckles frequently and at short inter­

vals during both day and night. The contraceptive effect

of_lactation is greatly reduced if breast feeding is par­

tially replaced with even occasional formula feedings or

with early introduction of semi-solids (13). The effect of

lactation on postpartum amenorrhea therefore, varies with

13

custom in relation to surVi-in . . . ^ sucKimg practices, with the addition

of other foods, and thus tn a ' ^^^^ ^° ^ ma:or extent to maternal

understanding and motivation.

in the lactating mother, ̂ ^n^ruation and ovulation

aj_e_commo^^ delayed from ten ^eeks to as long as twenty-

six months (27, 28, 29) I The ^ *. x. • i JT n a.

.̂ ^ ' ' ^^>- \ ^^^\ contraceptive value of lacta-

^!flJf """̂ ^ effective if, in_the first four to six months,

the infant receives only huma^ milk. Evidence concerning

the suppression of ovulation and prolongation of postpartum

amenorrhea resulting from lactation is available from basal

temperature recordings, by histological examination of endo­

metrial biopsies, and from fi^id observations in developing

countries (29, 30).

A study in the Philippines demonstrated that a

twenty-four to thirty-five mo^th birth-spacing interval was

achieved in 51.2 per cent of hiothers who breast fed their

infants for seven to twelve muj^ths, as opposed to only 30

per cent in mothers whose infants were artificially fed (31).

In Taiwan it is estimated that lactation prevents as many as

20 per cent of the births that would otherwise occur. In

India the same ratio would mean a prevention of approxi­

mately five million births eatih year (4) .

Q j f breast feeding decunes and other fertility con­

trol measures are not introdut:ed, birth rates can be expected

to increase (3).' Studies in the Eskimo culture of Canada and

Alaska substantiate this. As bottle feeding in Canadian

14

Eskimo villages increased from 5 per cent to 30 per cent

between 1940 and 1960, the mean duration of lactation de­

creased from fifteen to five months (32). Schaefer (33)

reported that the difference in birth rates in Alaskan

Eskimo villages, which ranged between 40 and 64 per 1,000,

was directly related to the proximity of the nearest trad­

ing center providing canned milk.

In some areas of the world where breast feeding is

regarded as essential to a baby's survival, social custom

limits sexual intercourse for lactating women, thus rein­

forcing the link between breast feeding and contraception.

Intercourse is avoided as long as one year after giving

birth in parts of India, for two years in New Guinea, and

twenty-seven months in Nigeria. In some societies the taboo

reflects the belief that intercourse will dry up the milk

flow and in others that it will poison the milk. In parts

of South Africa, if a baby dies, it is assumed that the

mother has ignored the taboo, thus killing her baby with

"bad milk" (4). However, the strength of this taboo in

reducing births should be viewed with caution since the

traditional culture of many societies is changing rapidly

and these strictures on sexual behavior are being modified

(3). ^

( Delay in onset of menstruation has another benefi­

cial effect on maternal_nutrition. The nursing woman is

allowed to replenish and conserve her iron stores, which

15

is a very important consideration in poorer communities

where^many women are anemic (4, 34, 35)7] Up to 40 per cent

of the reproductive lives of Indian women of ages twelve to

forty years can be in an anovulatory phase because of either

pregnancy or lactation (36).

There are significant differences in the incidence

rates of carcinoma of the breast not only from country to

country, but even within the same country. For example,

Puerto Rico and Japan show a much lower breast carcinoma

rate than that in the United States and some European coun­

tries (37). Moreover, data obtained in the national cancer

survey have shown that the incidence of breast cancer in

Japanese women in the San Francisco Bay area is about five

times as high as in Japanese in their homeland (38). Such

significant differences between migrants and their com­

patriots in their original homeland suggest that environ­

mental factors play a large part in maintaining the, low

incidence of breast cancer in Oriental women.

Mammary function is one environmental factor which

has recently been shown to be strongly associated with the

development of mammary carcinoma (39). Malhotra (40) com­

pared twenty-four patients with carcinoma of the breast,

twenty-four healthy controls, and forty-eight patients suf­

fering from other diseases. He found that breast cancer

patients married later, had shorter lactational histories,

and had fewer children as compared with controls. It is

16

suggested that one carcinogenic factor may be an alkaline

milieu produced by the stasis of milk in the breast. An

alkaline milieu surrounding epithelial surfaces produces

cell proliferation leading to a 40-fold increase in mitotic

activity; this may eventually lead to hyperplasia, meta­

plasia, and chronic inflammatory changes. /

\ A lower incidence of breast cancer has been observed

in communities of less technically developed countries in

which breast feeding is widespread and prolonged. In the

United States, as breast feeding has declined in frequency,

the incidence of breast cancer has increased (13jV "^Avail­

able human data support the claim that breast feeding pro­

tects against breast^caricer (33, 34, 40, 41, 42) . I However,

further research is needed to explain specific relationships

affecting carcinogenesis.

'One of the most important benefits of breast feeding

may be its effect on psychological development. Although

evidence linking breast feeding with later emotional adjust­

ment is inconsistent, the quality of mother-infant inter­

action seems_J:^i_be_eiih^ncsd--whsn a good breast feeding

relationship is established (43). Research on nursing women

shows that they are more likely than bottle-feeders to touch

their babies, to keep nipples in the infants' mouths longer,

to rock them, and to sleep or rest with them (1, 44). The

timing and coming together in meeting each other's needs are

well demonstrated when the "milk-ejection reflex" effects a

17

generalized warm and pleasurable sensation in the mother

(11) . Breast feeding provides the infant with maximum

sensory stimulation which cannot be equivocated from bottle — - ^ ^

feeding (1)./

During established successful lactation, a mother

will experience painless uterine contractions throughout

nursing and up to twenty minutes following a feeding (34).

This process of lactation causes the uterus to shrink more

quickly to its prepregnancy size (43) .\ The breast feeding

mother also does not face the slightly increased risk of

blood clots associated with the use of estrogens to sup­

press lactation (43).1

The convenience aspect of human milk is often under­

appreciated. An increasing number of mothers in the Western

world are conveniently and quietly breast feeding their chil­

dren in public without any particular bother or danger of

arrest for indecent exposure. It is largely a question of

attitude (of both the mother and the public) and of having

clothes which are both fashionable and suited to breast

feeding in the Western culture (6).

Contra-indications of Breast Feeding

For a small proportion of women, there are some valid

medical reasons for not breast feeding. Women with active

tuberculosis, debilitating disease, or severe malnutrition

should not nurse./ Also continued maternal ingestion of

18

medications deleterious to the infant, or high levels of

maternal pollutants, such as mercury or fungicides, would

contraindicate breast feeding (11, 43).

Considerable information has been gathered on the

interrelationships of poor maternal nutrition and lactation

in developing countries. Gopolan and Belavady (45) show

some variation in composition of the breast milk of malnour­

ished mothers in different parts of the world. As a gener­

alization, lactose is unchanged; the pattern of fatty acids

varies considerably with the mother's past and present diet;

the water soluble vitamins and also vitamin A are decreased

with inadequate maternal intakes; the protein was often

found to be within lower limits of normal values. Lindblad

and Rahimtoola (46) found low levels of lysine and methionine

in a group of poor, urban Pakistan women. The diets of these

mothers consisted mainly of rice or wheat, which suggests

that a dietary deficiency of these amino acids is reflected

in milk production. The milk volume, which is the most im­

portant variable contributing to failures in breast milk

feeding, is decreased in poorly nourished women (35, 46, 47).

Almost all compounds ingested by the lactating mother

are excreted in her milk, though in most instances in such

small amounts as to be barely detectable and insignificantly

hazardous (48). Arena (48), however, advises against the

use of the following drugs while^reast_feeding: any drug

or chemical in excessive amounts, diuretics, oral

19

contraceptives, atropine, reserpine, steroids, radioactive

preparations, morphine and its derivatives, hallucinogens,

anticoagulants, bromides, antithyroid drugs, anthraquinones,

dihydrotachysterol, and antimetabolites. These limitations

should in no way discourage the majority of mothers requir­

ing medication who want to breast feed. When the possibility

of potential harm for the nursing infant exists, the offend­

ing drug can usually be discontinued, or the chemical removed

from the mother's immediate environment.

In some instances, it is the infant who cannot or

should not be nursed. An infant born with a blockage of the

nasal passage, oral defects, gastrointestinal anomalies and

diseases, or congenital__heart disease may require an artifi-

cial feeding mechanism (11). Certain genetic disorders,

such as inborn errors of metabolism, will make an infant

intolerant to human milk (43).f Very small, premature in­

fants may not be able to suck vigorously enough to nurse,

although they still might be fed with human milk (11,^43) .

Promotion of feeding prematures human milk is supported by

past clinical studies and current experimental data (7, 11);

however, Fomon and Filer (10), feel that protein intake is

inadequate for low-birth-weight infants fed only human milk.

They recommend that one or two bottle feedings be given each

day to supplement the intake of protein and minerals found

in human milk.

20

It has been observed that breast feeding may in­

crease the risk of future breast cancer in female infants.

An RNA tumor virus is known to be present in certain human

milks and in human mammary carcinomas (49, 50) . Such par­

ticles were detected in milk of 60 per cent of American

women with a familial history of breast cancer and in only

5 per cent of those with no familial history of breast

cancer (50). The significance of these viruses is not yet

known. Although there is the implication that RNA mole­

cules appear in cancer cells because human milk virus is

replicating in these cells, the findings by no means prove

that human breast cancer virus causes breast cancer (10).

Epidemiologic data generally fail to support the

hypothesis that breast feeding is the major mode of trans­

mitting breast cancer in the human (51). If breast feeding

were a major factory in transmission of breast cancer, the

decreasing frequency of breast feeding between 1900 and 1950

should have been associated with decreasing rates of breast

cancer in the 1950s and 1960s. However, breast cancer rates

actively increased during that period of time (52) . In

countries where breast feeding is common, rates of breast

cancer are generally low (53).

Thus, there is at present time some basis for concern

that human breast cancer virus may be transmitted from mother

to infant by breast feeding. However, from the evidence

currently available it seems unlikely that total elimination

21

of all breast feeding in the United States would substan­

tially alter breast cancer rates (10). Additional studies

of mother-daughter occurrences of breast cancer in relation

to infant feeding are urgently needed.

A[<- Economics of Breast Feeding

Breast feeding is the traditional and ideal form of

infant nutrition, usually capable of meeting a child's nu­

tritional needs for his first four to six months of life.

Even after the essential introduction of supplemental foods,

human milk can serve as an important continuing source of a

child's nutritional well-being. \^t can supply up to three-

quarters of a child's protein needs from their sixth to

twelfth month.

The differences in financial cost of breast feeding

and bottle feeding are significant. On an individual family

basis, the cost of formula can be compared with the extra

nutrients needed by a lactating woman (500 kcal. and 20 gm.

protein). A 1974 Los Angeles study showed that bottle feed­

ing a three-month-old infant would cost 50 to 75 cents per

day compared to 17 to 21 cents for extra amounts of every­

day foods for the mother (in the United States, a peanut

^oTtter sandwich and a glass of milk) (54). Lann, et al.

(55) report that breast feeding costs 50 to 60 per cen^_of

that of formula feeding.

22

In developing countries, the economic significance

is much more serious. Comparison of the cost of cow milk

formulas and basic wages in poorer areas shows that the

purchasing of adequate quantities would take from 25 to 50

per cent of the family's earnings (1). These costs for

commercial milk do not take into consideration any waste or

diversion to other members of the family. Nor do they re­

flect the cost of bottles, nipples, cooking utensils, refrig­

eration of fresh milk, fuel, and perhaps most important,

medical care, which is frequently ten times greater than

for breast fed babies (4).

j Bottle feeding will inevitably be attempted by lower

socioeconomic populations with increased incidence of maras­

mus and diarrheal disease as a result of giving dilute feed­

ings in unsanitized bottles (56)^VThe parents' lack of

education prevents them from reading or understanding in­

structions for preparation and, together with ignorance of

sanitary requirements, fosters a high incidence of illness.

Even mothers aware of hygienic needs often find it difficult

to meet sanitary requirements, due to limited and unclean

water, inadequate fuel, poor storage, and use of a single

bottle and nipple (4). Cunningham (57) found that respira­

tory and gastrointestinal illness occurred___two to three

times as frequently in bottle fed babies as with breast fed

babies at a New York outpatient clinic. He observed that

the health advantages were most evident in babies who were

23

breast fed^in excess of four to five months. Medical treat­

ment for malnutrition, largely related to inadequate lacta­

tion, was calculated over a recent decade to be the equiva­

lent of 10 million dollars in the English-speaking Caribbean

(56) .

As breast feeding has decreased over the past two

decades, the average age of youngsters suffering from severe

forms of malnutrition has also dropped—from eighteen to

eight months (4). ̂ Generally in India, severe protein-

calorie malnutrition is found less frequently among those

under one year than those between one and two. However,

among Indian immigrants in south Trinidad, protein-calorie

malnutrition is much higher in the first year than in the

second, and the decline in breast feeding of infants in this

age group is believed to be responsible (56). Since malnu­

trition in the early months of life is most critical to

brain development, this lowering of the average age of inci­

dence of severe nutritional deficiencies takes on special

significance.

CHuman milk should also be recognized as a national

resour'ce in agronomic planning and energy conservation (56) . ,

For example, the recorded decline in breast feeding in

Singapore between the 1950s and 1960s required an approxi­

mate expenditure by families or agencies equivalent to 1.8

million dollars to purchase substitute formulas; in 1968 in

the Philippines, the expense was about 33 million dollars (4)

24

Declining lactation can also be visualized in terms of

appropriate food production to make good these losses.

Thus, if all women in India ceased to breast feed and used

cow milk formulas as replacement, an additional 114 million

lactating cattle would be needed (56).

In addition, the energy cost and loss of raw mate­

rials in processing, packing, and distributing cow milk

formulas should be considered. An infant reared on ready-

to-feed formula based on cow milk will use approximately

150 cans in six months of bottle feeding. With three mil­

lion births in the United States in 1974, an overall annual

consumption of 450 million nonrecycleable cans will result,

with a waste of 70,000 tons of tinplate each year (56)

Factors Which Negatively Affect Breast Feeding

The current trend away from extended nursing among

lower income families has been strongly influenced by upper

income families. A continuing nationwide study of 2.5 mil­

lion babies in the United States found that the number of

mothers who were breast feeding at the time they left.the

maternity hospital has declined by nearly half in only ten

years; the national average, which had dropped from 38 per

cent to 21 per cent from 1946 to 1956, decreased again to

18 per cent in the following decade. The decline is most

pronounced in the poorest states. In Arkansas, 84 per cent

of infants were totally or partially breast fed in 1946;

25

by 1966, only 22 per cent. The analogous figures for

California were 60 per cent and 38 per cent (58).

Encroaching urbanization and modernization are

significant influences resulting in the dramatic decline

in breast feeding. Breast feeding is often viewed as an

old-fashioned or backward custom and, by some, as a vulgar

peasant practice (4). Bottle feeding seems to be one

sophistication of city life the urban migrant adopts, often

referred to as "the urban avalanche" (2). In most coun­

tries, the greater the sophistication, the worse the lacta­

tion; the bottle has become a status symbol (4, 56).

Fear of failure, exhaustion, frustration, or any

stress-producing situation associated with the modern life­

styles of many American women may hinder lactation (5).

Failure to initiate or continue breast feeding is rarely

traced to a physical cause but often to psychophysiological

causes that interfere with the key "let-down reflex" (4).

The "let-down reflex" is a psychobiological mechanism by

which sphincter muscles are relaxed to allow the milk to

flow (5). If this mechanism does not take place, the infant

obtains only a small portion of the milk contained in the

breast; inadequate emptying of the breast, on the other

hand, is likely to cause inadequate milk production (3).

For many women, improved communication has brought

knowledge of the alternatives to breast feeding. Aggres­

sive sales promotion tactics often persu_ade the new mother

26

to succumb to the blandishments of the processed food and

^£^.^^^Ju_^ompanies. Complimentary samples oj formula are

also made available to mothers at many maternity clinics

and hospitals. The easy availability of free formula being

distributed by various government assistance programs has

also been blamed for defections from breast feeding (4).

Emphasis should be given to providing food for lactating

mothers whenever possible, rather than to distributing

formula. This position has been recently endorsed by the

World Health Organization, the Food and Agriculture Orga­

nization, and the Protein Advisory Group of the United

Nations (56).

Changing social attitudes regarding the body rein­

force the downward trend. Weichert (34) believes that a

"functional castration of women has occurred." There is

presently an overemphasis of the breast as a primary sex

symbol and as a result feminine desirability has been

divorced from its nurturing role (34, 56). Given the iden­

tification of the breast with feminine desirability, one of

the major anxieties women experience in relation to breast

feeding is that they fear lactation will change the shape

of their breasts, and hence it is threatening to their

notions of continued attractiveness (4, 34).

Confusions and anxiety over breast size and adequacy

to nurse also exist. Some women assume that the larger the

breasts, the more glandular tissue (34). Engel's (59)

27

study of twenty-six breasts removed from women who had died

during or shortly after delivery, points out that there was

no correlation between breast size and amount of glandular

tissue. The larger breasts were often found to contain

much fibrous tissue and fat and relatively little glandular

tissue.

Low breast feeding rates are also consequences of

cultural forces. in cultures where it is accepted that

women breast feed their babies, the rates are high (4, 5).

This is true of the majority of preliterate and traditional

societies, where there was, or is, no such thing as a mother

who is unable to nurse her child. It is in cultures that

have socially accepted alternatives to breast feeding that

the rates drop and some mothers "cannot" nurse (5, 60).

Negative feelings concerning public breast feeding cause

many women to feel too embarrased to discuss the subject

(5, 61)7' Brack (5) speculates that most women in the United

States have not seen another woman nursing a baby, which

probably internalizes negative feelings towards breast

feeding.___,.

Conflicts may also arise from objections on the part

of the father to the mother's breast feeding. At stake here

are anxieties concerning how the new infant will affect the

marital relationship and incipient feelings of displacement

and/or jealousy on the part of the father for the new

mother's attention (59). The father may also desire to

28

assist in feeding the infant after delivery. In Masters

and Johnson's (62) study 64 per cent of the women rejected

nursing post partum for this reason. Other studies also

confirm that the husband influences the mother's decision

regarding breast feeding (61, 63, 64, 65).

A mother with other young children in the family

may find that breast feeding, rather than promoting a psy­

chological bond between herself and the new addition, actu­

ally causes a feeling of antagonism or resentment because

it may be very difficult to adequately care for her other

young children during the nursing period. The anxiety the

mother may feel while other children are relatively unat­

tended would certainly communicate itself to the newborn

(66).

Convenience also is a factor in the abandonment of

breast feeding. Women no longer bound by tradition and now

enabled by the changing pattern of home life to take advan­

tage of an increasing number of diversions, have turned to

artificial feeding to free themselves from the constraints

of motherhood (4, 5). Although this is especially true of

those who wish to join the organized work force, they are

only a small part of the women who have abandoned breast

feeding (4, 13, 65).

It is acknowledged that physicians and nursing per­

sonnel have control over the situation in which breast feed­

ing is initiated; but as a rule they do not understand the

29

psychobiological processes involved, seldom know how to

help a mother who has problems nursing, and often do not

want to take the time and patience necessary to solve the

problem (34, 61). When mothers report difficulties with

breast feeding such as an inadequate milk supply (the most

frequent reason given for weaning), many pediatricians

respond by suggesting solids or perhaps supplemental formula

or even weaning, rather than encouraging the women to build

up their milk supply through more frequent nursing sessions

and greater intake, of fluids (61) .

In a study of 301 primiparas by Sacks, et al. (63)

during 1974, most doctors were reported by mothers as being

uninformative even though they had been seen by 9 5 per cent

of the mothers. Halpern, et al. (67) found that among 1,700

infants seen by eleven pediatricians in the Dallas, Texas,

area, a significantly greater number of mothers did breast

feed when their pediatricians felt positively about the

subject. Jelliffe and Jelliffe (68), Scott (69), Washburn

(70), Leeson (71), and Winter (72) have all editorialized

recently on the critical role of their profession in either

encouraging or discouraging breast feeding- However, to

attribute the decline in the popularity of breast feeding

to the medical profession is much too simplistic; they are

components of the larger culture that has put little value

on breast feeding in recent years (61).

30

Another problem is that the mother and infant are

sepaxated by hospital routine, and in most instances they

do not have the same personnel for medical care (5). This

may mean that the nursing care is not ideally coordinated

between the nursery and the mother. Cole (61) reports that

mothers who had the experience of "rooming-in" in the hos­

pital, as opposed to a central nursery with scheduled feed­

ing, were more successful in establishing lactation and

breast fed longer. In this same study, only one-third of

the new mothers indicated that hospital nurses had supplied

helpful information. In our modern culture, many hospitals

lack a relaxed, supporting atmosphere in which a mother can

learn and practice the art of breast feeding (5).

Early introduction of solid foods is thought to

reduce the mother's milk supply_since the baby nurses less

often (6). In developed countries solid foods are presently

being given in excessive amounts to infants at the age of

four weeks or under as a result of cultural pressure. This

is often practiced by parents who wish to decrease the fre­

quency of feeding, especially at night (13). Advocates of

breast feeding generally recommend delaying the introduction

of solid foods (pureed baby foods) until the infant is three

to four months old. Cole (61) found that early introduction

of solids and early weaning from the breast were signifi­

cantly associated with each other.

31

Lack of milk, and/or the fear of lack of milk, seem

to be the most common reasons for weaning in early months

(61, 63, 65). This could be due to a genetically poor milk-

producing capacity, but it is more likely to be related to

a widespread lack of support of breast feeding in the United

States (61). Failure of the "let-down reflex", nipple ab­

normalities, mastitis, and breast engorgement hinder breast

feeding and milk removal (3, 61). These physiological com­

plications could be eliminated with the proper information

being related to mothers before lactation begins (73).

However, with appropriate attention, any of these problems

can be corrected so that lactation may be continued (3).

Eastham, et al. (64) found no significant differ­

ences between breast and bottle feeding with respect to the

numbers, age, or sex of other children in the household.

However, the mothers' knowledge of how they had been fed

as infants showed a similar positive relationship with their

own choice in this study. There is a greater chance of

successful lactation if the mother was herself breast fed

as an infant (74). This is related to the fact that mothers

often seek advice from family members concerning infant

feeding (63).

Although there has been a resurgence of interest

in breast feeding in the United States, it has been concen­

trated among the college-trained and well-to-do. Nation­

wide surveys in 1971 showed that 32 per cent of college-

32

educated mothers breast fed_compared__with 8 per cent of

grade-school educated mothers (4). in the Boston area,

breast feeding was found to be nearly twice as prevalent

among upper income as among lower income families (75).

Middle income mothers in New York and San Francisco were

six times more likely to breast feed their babies than

lower income mothers (58). Sacks, et al. (63) found breast

feeding to be more common in families of nonmanual workers

as compared to manual workers. There was also a tendency

for mothers who breast fed to be older, better educated,

and married. Cunningham (57) also observed that breast

feeding was significantly associated with educational ad­

vancement in both parents and with increased maternal age.

Mothers' Decisions Regarding Infant Feeding

Most mothers decide on a method of feeding before

they become pregnant (61, 64). Those who bottle feed tend

to decide later than those who breast feed, but only a few

women leave the choice until after delivery (61). A mother

most often seeks advice about infant feeding from her

family and friends; professional help was reported by Sacks,

et al. as being important in only 9 per cent of cases (61,

63). Eastham, et al. (64) reported that the source of lay

advice with which a breast feeding mother's decision most

frequently agreed was that of her husband.

33

The results of the study by Sacks, et al. (61)

showed that the discontinuation rate was highest during

the first week post partum and declined thereafter. At

the end of two weeks one-third of the mothers who breast

fed had discontinued, and by one month only one-half were

still breast feeding. Cole (61) failed to find a positive

correlation between the length of time a woman expected to

breast feed, and the actual length of breast feeding. In

her study, only one mother had intended to breast feed for

less than one month, yet nineteen ended up by doing so.

One might conclude that complications arising during initial

stages of the lactation period account for a high drop-out

rate among mothers who breast feed. The primary difference

in experience between those who continue breast feeding and

those who stop seems to lie in the availability of support

and other resources to which one can turn when problems

arise, rather than to the presence or absence of problems,

since both groups reported difficulties (61).

Role of Education in Increasing Breast Feeding

The most essential objective to reverse the current

downward trend in breast feeding is improved understanding

of its benefits and of the dangers associated in foregoing

it (4). Obstetricians, pediatricians, general practition­

ers, nurses, dietitians, and other health workers should

be indoctrinated in the importance of breast feeding and

34

breast feeding methods (1, 4, 5, 13). Medical education

generally gives little attention to nursing and often em­

phasizes the importance of artificial feeding (4, 13). Con­

sequently, those who should be most knowledgeable about the

subject are ill prepared by education or experience to ad­

vise and educate parents in this area.

Educating the lay public concerning the benefits of

breast feeding should be done at an early age. Most mothers

who bottle feed do not consider that breast feeding offers

advantages over bottle feeding; in fact, many consider breast

feeding as having disadvantages (63, 65). Education on this

subject should be encouraged for both boys and girls (63,

64) . This is evidenced by the fact that most women decide

on_a method of infant feeding before becoming pregnant and

that fathers often influence their choice, as discussed

previously.

Finally, efforts must be undertaken to prevent com­

plications and failure in lactation, which has become in­

creasingly important under stress of modernization. A

program should include information not only on the "why" of

breast feeding, but also on its "how" (4). A new mother who

is overly fearful about being able to breast feed seems more

likely to have difficulty in breast feeding, particularly

when her environment fails to provide information and emo­

tional support (9, 73, 76, 77). Breast feeding should be

a natural sequel to pregnancy and childbirth (9, 61, 76).

35

For the vulnerable infant and young child, an effective

public effort to counter the current trend may be of greater

significance than any other form of nutrition intervention

(4).

CHAPTER III

METHODOLOGY

Selection of Subjects

Subjects for this research were selected from a

group of low socioeconomic, pregnant women attending a

Maternity Clinic at the Lubbock City Health Department.

A total of sixty-three subjects was selected including

sixteen Anglo, thirteen Black, and thirty-four Mexican-

American women. Each subject was informed of the purpose

of the study and was asked to participate on a voluntary

basis.

Development of Instrument

A Likert-type questionnaire was developed to measure

the influence of the independent variables on the single

dependent variable. The evaluation instrument included

twenty-eight questions to which each respondent replied in

one of the following ways: yes, undecided, unfamiliar with

the subject, no, or non-applicable. A copy of the question­

naire used appears in the Appendix.

A pilot testing of the questionnaire was performed

to establish reliability and validity. A group of seventeen

pregnant women attending a La Maze natural childbirth class

were asked to complete and evaluate the instrument follow­

ing an explanation of its intended purpose. These subjects

36

37

were given freedom to make written or verbal comments con­

cerning the effectiveness of the questionnaire in measuring

attitudes toward breast feeding. They also were asked to

give suggestions for improvement of the instrument. After

reviewing all questionnaires from the pilot subject group,

revisions were made to facilitate the collection of perti­

nent data.

The questionnaire also provided for collection of

data such as age of the mother, highest grade completed in

school, number of children in the family, marital status,

and ethnic origin of each subject.

Collection of Data

The questionnaire was administered to each subject

individually through a personal structured interview by the

researcher. The interview method was considered to be the

best procedure for collecting data from these subjects so

that further explanation or restatement of questions for

simplification could be done when necessary. The inter­

view also allowed one to determine the motivation behind

answers given by individuals, thus facilitating a more

thorough understanding of the problem under study.

Each subject was given a printed card supplying all

answers for each question. They were verbally instructed

to give honest answers since no question had a "right" or

"wrong" answer. They were also informed that the

38

information obtained would be held in confidence and would

remain anonymous. Approximately ten minutes was necessary

for completing each interview.

Treatment of Data

The statistical method employed for analysis of

data was the chi-square technique. This technique allowed

testing for independence between responses of women from

the questionnaire and the independent variables. A fre­

quency distribution was also used to organize data and

indicate percentages of various levels of responses for

each question.

CHAPTER IV

RESULTS AND DISCUSSION

Part I. Demographic Data

The total sample for this study consisted of sixty-

three pregnant females, of which 25 per cent (16) were

Anglo, 21 per cent (13) were Black, and 54 per cent (34)

were Mexican-American. Ages ranged from fourteen to thirty-

eight with the mean age being twenty-two years. Table 1

shows the age and race distribution of the subjects.

TABLE 1

AGE AND RACE DISTRIBUTION OF SUBJECTS

Age Total Ethnic Group

Anglo Black Mexican-American

N N

6 16

17 33

11 14

14-17

18-25

26-38

Total

N

6

9

1

16

N 4

7

2

13 34 63

For the total sample, 20.6 per cent (13) were single,

69.8 per cent (44) were married, 4.8 per cent (3) were di­

vorced, and 4.8 per cent (3) were separated. Approximately

one-half of the women were primagravidas and the remaining

women had one to eleven other children.

39

40

Table 2 gives the educational background of the

subjects. Thirty-three had only grade school education,

twenty-nine had high school training, and one had attended

college. A greater percentage of Anglos had higher levels

of education than either Blacks or Mexican-Americans.

TABLE 2

EDUCATIONAL BACKGROUND OF SUBJECTS BY RACE

Education Ethnic Group Total

Anglo Black Mexican-American

Grade School 6 5 22 33

N

6

10

0

N

5

8

0

High School 10 8 11 29

College _2. _£ _1 -Jt Total 16 13 34 63

Part II. Survey Results

Professional Influence on Breast Feeding Rates

Table 3 summarizes data obtained from Question 1 on

the survey concerning whether physicians discussed with these

patients a method of feeding their infants following deliv­

ery. It should be noted that of the sixty-three women in­

terviewed, only fifty-seven had previously visited a doctor

for maternity care and responded to this question. Of the

fifty-seven respondents, 8.5 per cent (5) reported that

their doctor had discussed this topic and 91.2 per cent (52)

41

reported that the topic had not been discussed.

TABLE 3

PHYSICIAN'S COMMUNICATION WITH PATIENT CONCERNING

METHOD OF INFANT FEEDING

Response Anglo Black Mexican-American Total

Yes Number Percentage

No Number Percentage

2 3.5

13 22.8

0 0.0

9 15.8

3 5.2

30 52.6

5 8.7

52 91.2

These results indicate that, in this particular group

of women, there was a lack of communication with their doctor

concerning plans for infant feeding after delivery. This

could be due to lack of interest or motivation by the physi­

cian concerning infant feeding. Many physicians may be un­

educated with respect to infant nutrition due to lack of

emphasis in this area during their professional training,

as supported in the literature (4, 13). This may lead to

an avoidance of the subject when confronting patients. Most

women (96.5 per cent) were unfamiliar with their doctor's

attitude towards breast feeding, which relates to the sub­

ject not being discussed as mentioned above.

From the total number of women interviewed, sixteen

planned to breast feed their infants. In these particular

women, the choice seemed to be independent of their

42

physician's attitude. Table 4 indicated that 93.8 per cent

(15) of the women had not discussed a feeding method with

their doctor and were consequently unfamiliar with the

doctor's attitude towards breast feeding. One person who

planned to breast feed was not able to respond to these

questions because she had not visited a doctor. Even though

a small percentage of women interviewed had plans to breast

feed despite their doctor's attitude, it seems reasonable

to conclude that the number of breast feeding mothers could

be increased if doctors' attitudes were more favorable.

TABLE 4

RELATIONSHIP OF PHYSICIAN'S ATTITUDE TO PATIENT'S DECISION TO BREAST FEED

Survey Question Response Un- Un- Non-

Yes decided familiar No applicable

1. Doctor discussed method of feeding

Number Percentage

2. Doctor in favor of breast feed­ing

Number Percentage

Modernization and ( Factors

0 0.0

0 0.0

0 0.0

0 0.0

:;:onvenience

0 0.0

15 93.8

15 93.8

0 0.0

1 6.2

1 , 6.2

Table 5 shows that 74.6 per cent (47) of the women

felt that bottle feeding is a more modernized way to feed

43

an infant as compared to breast feeding. The majority of

women (68.3 per cent) said that it would be convenient for

them to breast feed, while 28.6 per cent (18) said that it

would be inconvenient for them to breast feed. Employment

after delivery was one major factor contributing to the in­

convenience of breast feeding, as shown in Question 6. How­

ever, 52.4 per cent (33) had no plans to be employed follow­

ing delivery. These results indicate that many women who

choose not to breast feed are doing so for factors other

than their personal convenience.

TABLE 5

CONVENIENCE FACTORS ASSOCIATED WITH BREAST FEEDING

Survey Question Response Un- Un- Non-

Yes decided familiar No applicable

4. Bottle feeding modern method

5.

6.

Number Percentage

Convenient to breast feed

Number Percentage

Employed after delivery

Number Percentage

47 74.6

43 68,3

23 36.5

4 6.3

2 3.2

7 11.1

1 1.6

0 0.0

0 0.0

11 17.5

18 28.6

33 52.4

0 0.0

0 0.0

0 0.0

44

Social Factors Affecting Breast Feeding

Data concerning the effect of social factors on

breast feeding rates are shown in Table 6. In response to

Question 1, 60.3 per cent (38) had previously been associ­

ated with family members or friends who had breast fed their

infants. However, 39.7 per cent (25) had not had this as­

sociation. This indirectly may account for the fact that

many young mothers are choosing to bottle feed due to lack

of exposure to the art of breast feeding, as supported in

the literature (5, 61). Approximately one-third of the

women reported that they were unfamiliar with attitudes of

family and friends towards breast feeding, which indicated

that the subject is not being discussed. The majority of

women felt that their family and friends would be in favor

of breast feeding. Embarassment concerning breast feeding

was not a significant factor in determining a feeding

method. During the interview period, many women indicated

that they would not be embarassed to breast feed their

infant in the privacy of their home, but would not breast

feed in public.

45

TABLE 6

RELATIONSHIP OF BREAST FEEDING TO SOCIAL ATTITUDES

Survey Question Response Un- Un- Non-

Yes decided familiar No applicable

7. Associated with family or friends

Number 38 Percentage 60.3

0 0.0

0 0.0

25 39.7

0 0.0

8.

11.

Family and friends in favor

Number Percentage

Embarassed

Number Percentage

24 38.1

10 15.9

12 19.0

2 3.2

22 34.9

0 0.0

5 7.9

51 81.0

0 0.0

0 0.0

Table 7 summarizes the importance of the husband's

opinion in relation to breast feeding; the results include

data from forty-four women who were married. No prevalence

of opinion existed among husbands' opinions, as shown in

the responses to Question 9. It is significant to note

that 27.3 per cent (12) husbands were against their wives'

breast feeding. This becomes important if assessed in

relation to the fact that 75 per cent (33) of the women

felt that their husband's opinion was of major importance

in determining how they would feed their child. This is

in agreement with the literature (64), which stated that

the husband was the person with whom the mother most often

agreed when selecting a feeding method.

46

TABLE 7

RELATIONSHIP OF HUSBAND'S ATTITUDE TO BREAST FEEDING

Survey Question Response Un- Un- Non-

Yes decided familiar No applicable

9. Husband prefer

Number 17 7 Percentage 38.6 15.9

8 12 18.2 27.3

0 0.0

10. Husband important

Number 33 Percentage 75.0

2 4.5

0 9 0.0 20.5

0 0.0

Because of the importance of the husband's opinion,

it is relevant to determine if the women in this study who

chose to breast feed were influenced by their spouse.

Table 8 reveals that 68.8 per cent (11) of the husbands

preferred that their wives breast feed and, again, 75 per

cent (12) of the women felt that the husband's opinion was

of major importance. It is apparent that the husband's

attitude strongly influences the wife's decision in this

regard. Two women who planned to breast feed were not

married

47

TABLE 8

RELATIONSHIP OF HUSBAND'S ATTITUDE TO BREAST FEEDING IF A POSITIVE CHOICE WAS MADE

Survey Question Response ^__ Un- Un- Non-

Yes decided familiar No applicable

9. Husband prefer

Number 11 2 0 1 2 Percentage 68.8 12.5 0.0 6.2 12.5

10. Husband important

Number 12 0 0 2 2 Percentage 75.0 0.0 0.0 12.5 12.5

Various Factors Relating to Success or Failure of Lactation

Of the thirty-two women who had other children, 2 5

per cent (8) indicated they had previously breast fed while

75 per cent (24) had not. Of the eight women who had breast

fed, one-half felt that they had been successful and one-

half considered themselves to have been unsuccessful. The

majority of women interviewed did not experience physical

complications associated with breast feeding. In response

to Question 15 which asked if the hospital nursing staff

was cooperative and helpful in establishing breast feeding,

62.5 per cent (5) answered positively. Data are shown in

Table 9.

48

TABLE 9

FACTORS CONTRIBUTING TO SUCCESS OR FAILURE IN BREAST FEEDING

Survey Question Response Yes No

13. Feel successful Number 4 4 Percentage 50.0 50.0

14. Experience physical complications

Number 2 6 Percentage 25.0 75.0

15. Nursing staff helpful

Number 5 3 Percentage 62.5 37.5

Reasons given for success in breast feeding were

predominantly associated with the well-being of the infant

Mothers felt that their infants were healthier, happier,

and growing satisfactorily on breast milk. Also, mothers

expressed that breast feeding afforded a pleasurable ex­

perience which resulted in their spending more time with

their infant.

The most common reason given for failure of lacta­

tion was lack of milk production and, consequently, an

unsatisfied baby. This problem frequently results in a

mother ceasing to breast feed, as reported by other re­

searchers (61, 63, 65). Out of desperation, the mother

49

turns to bottle feeding not realizing that this problem

could be easily solved with more frequent feedings at the

breasts.

The mean age given for continuing breast feeding

before weaning was two months. Most women (90.6 per cent)

who had other children, had introduced solid foods to their

child before age four months. This is perhaps an important

factor contributing to the relatively short lactation periods

of most of the women interviewed.

-Mothers' Knowledge of Advantages of Breast Feeding

Table 10 summarizes the sixty-three respondents

general knowledge of breast feeding and associated topics.

It is encouraging to note that 93.7 per cent (59) of the

women considered that the mother's diet influenced her suc­

cess or failure with lactation. When asked if breast feed­

ing offered emotional, physiological, or psychological ad­

vantages which could not be obtained from bottle feeding,

55.6 per cent (35) felt positive concerning this subject.

However, 20.6 per cent (13) felt that breast feeding offered

no advantages over bottle feeding. When asked if breast

feeding would delay pregnancy and if breast feeding would

protect against breast cancer, the majority of women were

unfamiliar with either subject. These responses indicate

a lack of education concerning breast feeding and its

advantages among the respondents.

50

TABLE 10

MOTHERS' GENERAL KNOWLEDGE CONCERNING BREAST FEEDING

Sur^

18.

19.

20.

21.

27.

/ey Question

Diet important

Number Percentage

Maternal advantages

Number Percentage

Delay pregnancy

Number Percentage

Breast cancer

Number Percentage

Breast feeding best

Number Percentage

Yes

59 93.7

35 55.6

5 7.9

6 9.5

40 63.5

Response Undecided

0 0.0

12 19.0

2 3.2

0 0.0

11 17.5

Unfamiliar

2 3.2

3 4.8

29 46.0

41 65.1

1 1.6

No

2 3.2

13 20.6

27 42.9

16 25.4

11 17.5

Breast feeding was considered to be best for a baby

by 63.5 per cent (40) of the women. Even though these

women verbalized a positive attitude towards breast feed­

ing, they were not generally following through by feeding

their infants in this manner. This is evidenced by the

fact that only 25.4 per cent (16) had planned to breast

feed. Eleven women were undecided concerning whether or

not breast feeding was best for a baby, and the same num­

ber felt that bottle feeding was best.

51

Infant Formulas and Breast Feeding

Of the sixty-three women interviewed, 42.9 per cent

(27) said that they had previously been given complimentary

formula packets at a doctor's office, clinic, or hospital.

More women (36) said they had never received any such prod­

uct. This is assumed to be due to the fact that formula is

most often distributed to women upon leaving the hospital

after delivery and approximately one-half of the women in

this study were primagravidas. Of the twenty-seven women

who reported to have received complimentary formula, twenty-

five continued to use the same brand of formula for their

child's feedings. One must conclude that the distribution

of complimentary formula packets strongly encourages bottle

feeding.

When asked if bottle feeding would be more expen­

sive than breast feeding, 93.7 per cent (59) of the women

agreed that it would be. Even though the subjects were

all of low socioeconomic status, 77-8 per cent (49) indi­

cated that a free formula program would not influence their

choice of feeding method in any way. Many women expressed

that they would purchase formula for their infant regard­

less of the possibility of receiving free formula at a

health clinic. Data are summarized in Table 11.

52

TABLE 11

PRODUCT DISTRIBUTION AS AN INFLUENCE ON DECISION TO BREAST FEED

Survey Question

22. Complimentary formula given

Number Percentage

23. Continue to use same brand

Number Percentage

Yes

27 42.9

25 39.7

Un­decided

0 0.0

0 0.0

Response Un­familiar

0 0-0

1 1.6

No

36 57.1

1 1.6

Non-app: Licable

0 0.0

36 57.1

24. More expensive to bottle feed

Number Percentage

25. Receive free formula

Number Percentage

Personal Data and Feeding

59 93.7

11 17.5

Breast

2 3.2

3 4.8

0 0.0

0 0.0

2 3.2

49 77.8

0 0.0

0 0.0

The chi-square test indicated that there was no

significant relationship between age, education, or marital

status of the women and their responses to items on the

questionnaire. This is due primarily to the homogeneity

of responses within the subject group. The number of

children within the family similarly did not affect

responses.

CHAPTER V

SUMMARY AND CONCLUSIONS

This study was undertaken to determine factors which

influence the decision of low socioeconomic women not to

breast feed. A survey was conducted to determine attitudes

of pregnant women towards this subject. Sixty-three women

attending a Lubbock City Health Department Maternity Clinic

were interviewed during January 1978.

Of the fifty-seven subjects who had previously

visited a physician, 91.2 per cent (52) indicated that a

method of feeding their infant had not been discussed with

the physician. Only sixteen women from the total inter­

viewed had plans to breast feed their infants; all of these

women reported that their doctor had not discussed a feed­

ing method with them. Even though a small percentage of

women planned to breast feed, despite their doctor's atti­

tude, it seems reasonable to conclude that a positive at­

titude by physicians would increase breast feeding rates.

The majority of women felt that bottle feeding is

a more modernized method of feeding an infant, compared to

breast feeding. Lack of convenience does not seem to be a

major factor contributing to low breast feeding rates, as

most women stated that it would be convenient for them to

breast feed. Employment after delivery was planned by

eighteen women.

53

54

Because breast feeding is not the norm in our pres­

ent culture, twenty-five women reported that they had never

been associated with family or friends who had breast fed.

Although the majority of women felt that their family and

friends would be in favor of breast feeding, twenty-two

women reported that the topic had not been discussed. Em­

barassment concerning breast feeding was not a significant

factor in determining a feeding method.

The husband's opinion concerning breast feeding

seemed to be more important to the woman compared to her

family and friends. Of the forty-four married women inter­

viewed, this topic had been discussed with husbands by

thirty-six subjects. Thirty-three women felt that the

husband's opinion was of major importance in determining

how they would feed their child. Fourteen married women

planned to breast feed their infants. Of this number,

eleven felt that their husbands were in favor of breast

feeding.

Eight women in the study had previously experienced

breast feeding; four of these women felt that they had been

successful and four felt that they had been unsuccessful.

The most common reason given for failure of lactation was

lack of milk production. The early introduction of solid

foods was common among mothers with other children, regard­

less of method of feeding.

55

Among the total women interviewed, 93.7 per cent

(59) considered that a lactating mother's diet influenced

her success or failure with lactation. Although the ma­

jority of women felt that breast feeding offered maternal

advantages, 20.6 per cent (13) felt contrarily. The ma­

jority of women were unfamiliar with contraception and

cancer as related to breast feeding. Breast feeding was

considered to be best for a baby by 63.5 per cent (40) of

the women, although only 25.4 per cent (16) of the women

planned to breast feed after delivery.

The majority of women interviewed had never received

complimentary formula in the past. However, of the twenty-

seven women who reportedly received formula packets, twenty-

five continued to use the same brand of formula. When asked

if bottle feeding would be more expensive than breast feed­

ing, 93.7 per cent (59) of the women agreed that it would

be. Even so, most women indicated that a free formula

program would not influence their choice of feeding method.

Due to the homogeneity of responses, there was no

significant relationship between age, education, or marital

status of the women and their responses to items on the

questionnaire. The number of children within the family

similarly did not affect responses.

Major factors which seem to affect women's decisions

concerning breast feeding are the attitudes of physicians,

family/ friends, and, most important, the husband. A

56

general lack of education on the part of the women, as well

as the individuals mentioned above, seems to prevail con­

cerning all aspects of breast feeding. Because of multiple

health, nutritional, and psychological advantages of breast

feeding for both the mother and infant, it is apparent that

an educational approach is the first logical step in revers­

ing the current downward trend in its use frequency. Vari­

ous problem areas have been described concerning the lack

of breast feeding among a low socioeconomic sample; an ex­

perimental study attempting to reverse negative attitudes

is imperative.

REFERENCES

1. Jelliffe, D. B. World trends in infant feeding. Am. J. Clin. Nutr. 29:1227, 1976.

2. Jelliffe, D. B., and Jelliffe, E. F. The urban ava­lanche and child nutrition. J. A. Dietet. A. 57:111, 1970.

3. Buchanan, R. Breast-feeding: Aid to infant health and fertility control. Population Reports, Series J, No. 4, 1975.

4. Berg, A. The Nutrition Factor. Washington: The Brookings Institute, 1973.

5. Brack, D. C. Social forces, feminism, and breast­feeding. Nurs. Outlook. 23:556, 1975.

6. Jelliffe, D- B. Unique properties of human milk. J. Reprod. Med. 14:133, 1975.

7. Jelliffe, D. B., and Jelliffe, E. F. Nutrition and human milk. Postgrad. Med. 60:153, 1976.

8. Kon, S. K. Milk and Milk Products in Human Nutrition. FAO Nutritional Studies No. 17, Rome, Food and Agriculture Organization, 1959.

9. Jelliffe, D. B., and Jelliffe, E. F. The uniqueness of human milk. Am. J. Clin. Nutr. 24:968, 1971.

10. Fomon, S. J., and Filer, L. J. Milks and formulas. In Fomon, S. J., eds. Infant Nutrition. Philadelphia: W. B. Saunders Co., 1974.

11. Oseid, B. J. Breast-feeding and infant health. Clin. Obstet. Gynecol. 18:149, 1975.

12. Olivecrona, T.; Billstrom, A.; Fredrikzon, B.; Johnson, O.; and Samuelson, G. Gastric lipolysis of human milk lipids in infants with pyloric stenosis. Acta. Paediatr. Scand. 65:520, 1973.

13. . Jackson, R. L. Long-term consequences of suboptimal nutritional practices in early life. Pediatr. Clin. North Am. 24:63, 1977.

57

58

14. Reiser, R., and Sidelman, Z. Control of serum choles­terol homeostasis by cholesterol in the milk of the suckling rat. J. Nutr. 102:1009, 1972.

15. Tsuchiya, S. Study of infant nutrition: Intestinal digestion and absorption of iron present in milk. Acta. Paediatr. Jap. 76:84, 1972.

16. World Health Organization Technical Report, Series No. 503, Geneva, 1972.

17. Josephs, H. W. Absorption of iron as a problem in human physiology. A critical review. Blood. 13:1, 1958,

18. Coulsen, K. M.; Cohen, R. L.; Coulsen, W. F.; and Jelliffe, D. B. Hematocrit levels in breast-fed American babies. Clin. Pediatr. 16:649, 1977.

19. Smith, C. W. ; GolcMan, A. S.; and Yates, R. D. The interaction of lymphocytes and macrophages from human colostrum. Exp. Cell Res. 69:409, 1971.

20. Gyorgy, P. Biochemical aspects. Am. J. Clin. Nutr. 24:970, 1971.

21. Goldman, A. S. Cow milk sensitivity: A review. Iji Food and Immunology, Swedish Nutrition Foundation Symposium, 1976.

22. Gerrard, J. W. Breast-feeding: Second thoughts. Pediatrics. 54:757, 1974.

23. Jacobs, L. S., and Daughday, W. H. Physiologic regu­lation of prolactin secretion in man. In Josimovich, J. V.; Reynolds, M.; and Cobo, E., eds. Lactogenic Hormones, Fetal Nutrition and Lactation. New York: John Wiley and Sosn^ 1974.

24. L'Hermite, M.; Vekemans, M.; Deloye, P.; Nokin, J.; and Robyn, C. Prolactine studies in normal sub­jects. Proc. R. Soc. Med. 66:864, 1973.

25. Bonnar, J.; Franklin, M.; Nott, P. N.; and Macneilly, A. S. Effect of breast feeding on pituitary-ovarian function after childbirth. Br. Med. J.

• 4:82, 1975.

59

26. Turkington, R. W. Pathophysiology of prolactin secre­tion in man. ni Larson, B. L., and Smith, V. B., eds. A Comprehensive Treatise. Vol. II. New York: Academic Press, 1974.

27. Kippley, S. A. Breast Feeding and Natural Child Spacing. New York: Harper and Row, 1974.

28. El-Minawi, M. F., and Foda, M. S. Postpartum lacta­tion amenorrhea. Am. J. Obstet. Gynecol. 111:19, 1970.

29. Cronin, T. J. Influence of lactation upon ovulation. Lancet. 2:4-22, 1968.

30. Udesdy, I. C. Ovulation in lactating women. Am. J. Obstet. Gynecol. 59:843, 1950.

31. Del Mundo, F., and Adiao, A. Lactation and child spacing as observed among 2,102 rural Filipino mothers. Phillip. J. Pediatr. 19:128, 1970.

32. Romaniuk, A. Modernization and natural fertility: The case of the James Bay native Indians. Iri Natural fertility. Liege Belgium, International Population Conference, 1973.

33. Schaefer, O. When the Eskimo comes to town. Nutr. Today. 6:8, 1971.

34. Weichert, C. Breast-feeding: First thoughts. Pediatrics. 56:987, 1975.

35. Jelliffe, D. B., and Jelliffe, E. F. Lactation, con­ception, and the nutrition of the nursing mother and child. J. Pediatr. 81:829, 1972.

36. Salber, E. J.; Feinleib, M.; and MacMahon, B. The duration of postpartum amenorrhea. Am. J. Epidemiol. 82:347, 1966.

37. Dorn, H. F., and Culter, S. J- Morbity from cancer in the United States. Public Health monograph No. 29, Washington, U.S. Department of Health Education and Welfare, 1955.

38. Buell, P. Changing incidence of breast cancer in Japanese-American women. J. Natl. Cancer Inst. 51:1479, 1973.

60

39. Haagensen, C. D- Diseases of the Breast. Philadel­phia: W. B. Saunders Co., 1971.

40. Malhotra, S. L. A study of cancer of the breast with special reference to its causation and prevention. Med. Hypotheses. 3:21, 1977.

41. Morgan, R. W.; Vakil, D. V.; and Chipman, M. L. Breast feeding, family history, and breast disease. Am. J. Epidemiol. 99:117, 1974.

42. Anderson, J. D. Breast feeding and breast cancer. S. Afr. Med. J. 49:479, 1975.

43. . Is breast-feeding best for babies? Consumer Reports. 42:152, 1977.

44. Klaus, M. H.; Kennall, J. H.; Plumb, N.; and Zuehlke, S, Human maternal behavior at the first contact with the young. Pediatrics. 46:187, 1970.

45. Gopolan, C., and Belavady, B. Nutrition and lactation. Fed. Proc. 20:3, 1961.

46. Lindblad, B. S., and Rahimtoola, R. J. A pilot study of the quality of human milk in a lower socio­economic group in Kurachi, Pakistan. Acta. Paediatr. Scand. 63:125, 1974.

47. Belavady, B., and Gopolan, C. Effect of diatary sup­plementation on the composition of breast milk. Indian J. Med. Res. 48:518, 1960.

48. Arena, J. M. Contamination of the ideal food. Nutr. Today. 5:2, 1970.

49. Feller, W. F., and Chopra, M. C. Studies of human milk in relation to the possible viral etiology of breast cancer. Cancer. 24:1250, 1969.

50. Moore, D. H. ; Chareney, J.; Kramarsky, B.; Lasfargues, E. Y.; Sarkar, N. H.; Brennan, M. J.; Burrows, J.; Sirsat, S. M. ; Paymaster, J. C ; and Vaidya, A. B. Search for a human breast cancer virus. Nature. 229:611, 1971.

51. Miller, R. W., and Fraumeni, J- F., Jr. Does breast­feeding increase the child's risk of breast cancer? Pediatrics. 49:645, 1972.

61

52. Feinleib, M., and Garrison, R. J. Interpretation of the vital statistics of breast cancer. Cancer. 24:1109, 1969.

53. MacMahon, B.; Lin, T. M.; Lowe, C. R.; Mirra, A. P.; Ravnihar, B.; Salber, E. J.; Trichopoulos, D.; Valaoras, V. G.; and Yuasa, S. Lactation and cancer of the breast. A summary of an inter­national study. Bull. W.H.O- 42:185, 1970.

54. Jelliffe, D. B., and Jelliffe, E. F. Human Milk in the Modern World. St. Louis: The C. V. Mosby Co., (in press).

55. Lann, E.; Delaney, J.; and Dwyer, J. Economy of feed­ing infants. Pediatr. Clin. North Am. 24:71, 1977.

56. Jelliffe, D. B., and Jelliffe, E. F. Human milk, nutrition, and the world resource crisis. Science. 188:557, 1975.

57. Cummingham, A. S. Morbidity in breast-fed and artifi­cially fed infants. J. Pediatr. 90:726, 1977.

58. Meyer, H. F. Breast feeding in the United States. Clin. Pediatr. 7:708, 1968.

59. Engel, S. Anatomy of the lactating breast. Br. J. Child. Dis. 38:14, 1941.

60. Newton, N. , and Newton M. Psychologic aspects of lacation. N. Engl. J. Med. 277:1179, 1967.

61. Cole, J. P. Breastfeeding in the Boston suburbs in relation to personal-social factors. Clin. Pediatr. 16:352, 1977.

62. Masters, W., and Johnson, V. Human Sexual Response. Boston: Little Brown & Co., 1966.

63. Sacks, S. H. ; Brada, M.; Hill, A. M.; Barton, P.; and Harland, P. S. To breast feed or not to breast feed. Practitioner. 216:183, 1976.

64. Eastham, E.; Smith, D.; Poole, D.; and Neligan, G. Further decline of breast feeding. Br. Med. J. 1:305, 1976.

62

65. Evans, N.; Walpole, T. R.; Qureshi, M. U.; Memon, M. H.; and Jones, H. W. Lack of breast feeding and early weaning in infants of Asian immigrants to Wolver­hampton. Arch. Dis. Child. 51:608, 1976.

66. McWilliams, M. Nutrition for the Growing Years. New York: John Wiley & Sons, inc., 1975.

67. Halpern, S. R.; Sellars, W. A.; Johnson, R. B.; Anderson, D. W. ; Saperstein, S.; and Shannon, S. Factors influencing breast-feeding: Notes on observations in Dallas, Texas. South Med. J. 65:100, 1972.

68. Jelliffe, D. B., and Jelliffe, E. F. Doulas, confi­dence and science of lactation. J. Pediatr. 84:462, 1974.

69. Scott, R. B. Is breast feeding obsolete? J. Natl. Med. Assoc. 66:446, 1974.

70. Washburn, T. C. Bottle or breast feeding of infants. J.A.M.A. 229:141, 1974.

71. Leeson, R. G. Breast feeding—success or failure. Med. J. Austr. 59:942, 1972.

72. Winter, S. T. Breast feeding and the lying-in ward. Clin. Pediatr. 11:127, 1972.

73. Ladas, A. K. How to help mothers breast feed: Deduc­tions from a survey. Clin. Pediatr. 9:702, 1970.

74. Sloper, K.; McKean, L.; and Baum, J. D. Factors influencing breast feeding- Arch. Dis. Child. 50:165, 1975.

75. Eva, J. S., and Feinleib, M. Breast feeding in Boston-Pediatrics. 37:299, 1966.

76. Applebaum, R. M. TTie modern management of successful breastfeeding. Pediatr. Clin. North Am. 17:203, 1970.

77. Newton, N. Psychological differences between breast and bottle feeding. Am. J. Clin. Nutr. 24:993, 1971.

APPENDIX

ATTITUDE SURVEY QUESTIONNAIRE

63

6 4

ATTITUDE SURVEY QUESTIONNAIRE

Age of Mother M a r i t a l S t a t u s : Sg M D Sp

Highes t g rade completed i n school Ethnic Or ig in : A B C

Number of c h i l d r e n i n fami ly

Yes Y

Undecided Ud

Unfamiliar with subject Uf

No N

Y Ud Uf N NjA 1. Has your doctor discussed with you a method of feeding your baby?

Y Ud Uf N 2. In your opinion, is your doctor in favor of breast feeding?

Y Ud Uf N 3. Has your doctor instructed you in preparing to breast feed?

Y Ud Uf N 4. Is bottle feeding a more modernized way of feeding

an infant as compared to breast feeding?

Y Ud Uf N 3. Would it be convenient for you to breast feed?

Y Ud Uf N 6. Will you be employed after your baby's delivery?

Y Ud Uf N 7. Have you been associated with family members or friends who breast feed?

Y Ud Uf N 8. Would your family and friends be in favor of you' breast feeding?

Y Ud Uf N 9. Does your husband prefer that you breast feed your baby?

Y Ud Uf N 10. Do you consider your husband's opinion to be of major importance in determining the final decision in feeding your infant?

Y Ud Uf N' 11. Would you feel embarassed or ashamed to breast feed your baby?

Y Ud Uf N 12. Have you breast fed a previous baby ?

65

Y Ud Uf N 13. If the answer to #12 was yes, do you feel you were successful in breast feeding?

A. If you feel you were successful, why?

B, If you feel you were unsuccessful, why'

G. How long did you breast feed before weaning?

Y Ud Uf N 1^, If the answer to #12 was yes, did you experience any physical complications?

Y Ud Uf N 15. If the answer to #12 was yes, do you feel that the hospital nursing staff where you delivered was cooperative and helpful in establishing breast feeding?

Y Ud Uf N 16. If the answer to #12 was yes and you feel you were unsuccessful in breast feeding, do you feel you have failed as a mother?

Y Ud Uf N 17. If you have at least one other child, did he/she eat any solid foods before age k months?

Y Ud Uf N 18. Does a lactating mother's diet influence her success or failure with breast feeding?

Y Ud Uf N 19. In your opinion, does breast feeding offer emotional, physiological, or psychological advantages for the nursir.p- mother which cannot be obtained from bottle feediiur'̂

'o

Y Ud Uf N 20. Does breast feeding delay your becoming pregnant?

Y Ud Uf N 21. Does breast feeding lower the incidence of breast cancer?

Y Ud Uf N 22. Have you ever been given complimentary formula packets at a doctor's office, clinic, or hospital?

Y Ud Uf N 23. If so and you have at least one other child, did you continue to use this brand of formula?

Y Ud Uf N 24. Would it be more expensive to bottle feed an infant rather than to breast feed?

Y Ud Uf N 25. If you could receive free formula at this clinic, would this influence your choice of feeding method?

66

Y Ud Uf N 26. Were you breast fed as an infant?

Y Ud Uf N 27. Do you feel that breast feeding is best for a baby?

Y Ud Uf N 28. Do you plan to breast feed your infant?