Sociocultural aspects of the infant-feeding decision

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Sociocultural aspects of the infant-feeding decision
Smith, Teresa Rust
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xii, 115 leaves : ill. ; 29 cm.


Subjects / Keywords:
Bottle feeding ( jstor )
Bottles ( jstor )
Breastfeeding ( jstor )
Breasts ( jstor )
Childbirth ( jstor )
Infants ( jstor )
Mothers ( jstor )
Pregnancy ( jstor )
Women ( jstor )
Womens studies ( jstor )
Dissertations, Academic -- Sociology -- UF ( lcsh )
Sociology thesis, Ph. D ( lcsh )
bibliography ( marcgt )
non-fiction ( marcgt )


Thesis (Ph. D.)--University of Florida, 1997.
Includes bibliographical references (leaves 110-114).
General Note:
General Note:
Statement of Responsibility:
by Teresa Rust Smith.

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University of Florida
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University of Florida
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Copyright [name of dissertation author]. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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37840862 ( OCLC )

Full Text







Several years ago, as I contemplated continuing my graduate work beyond the

master's level, I talked this decision over with my daughter. After I listed the pros and

cons she said to me, "Mom, a master's degree is great but a Ph.D. is AWESOME!" In

that moment I knew that I had to go for awesome ... for her. So I dedicate this

dissertation to Sheila Dawn Robinson, my treasured daughter.


First and foremost, I want to acknowledge the chair of my dissertation

committee, Hernan Vera, Ph.D., for his support, encouragement, and most of all for

his confidence that I could succeed in receiving my Ph.D. It is not an exaggeration to

say that without his support, this dissertation would never have been written. I thank

Hernan from the bottom of my heart. I wish to thank the other members of my

dissertation committee, Lee Crandall, Ph.D., Felix Berardo, Ph.D., Barbara Zsembik,

Ph.D., and Robert Ziller, Ph.D., for their continuing support through the writing of

this dissertation. I also wish to express my gratitude to two other professors who were

members of my master's committee and who were influential in my education, Gary R.

Lee, Ph.D., and Constance L. Shehan, Ph.D. Gary's voice is heard in every class I

teach at Wake Forest University and his perspective on the integration of theory and

research influences each grant-writing group in which I participate. Connie's influence

is clearly seen in my teaching style and the way in which I relate to students. She

taught me by her excellent example that rigorous academic standards and compassion

can coexist.

Colleagues in Winston-Salem, where this research was carried out, have also

been extremely helpful. Michael O'Shea, M.D., was immediately supportive when I

first began to discuss the idea of conducting research on infant-feeding decision-

making. Mike read numerous versions of the proposal as it developed and offered


valuable feedback. He was instrumental in the process of obtaining permission of local

obstetricians for their patients to be interviewed during their postpartum stay. Mike

introduced me to Robert Dillard, M.D., Chief of Neonatology at Forsyth Memorial

Hospital, whose support was an important factor in making it possible to carry out this

project. I thank all of those obstetricians who graciously allowed me to interview their

patients. Nora Boyce, R.N., manager of the mother-baby unit at Forsyth Memorial

Hospital, generously gave her agreement to have the study carried out on her already-

busy postpartum floor. The nursing staff graciously cooperated with the interviewers in

identifying eligible women for the study and minimizing interruptions during the


Amy Lewis and Melanie Angiolillo were dedicated and thorough while

interviewing the participants in this study. Their excellent interviewing skills and

perseverance have allowed the project to be a success. Elizabeth Wilson carefully

transcribed the responses to the open-ended questions and assisted with article retrieval.

All three of these young women performed their work on this project while completing

their undergraduate degrees at Wake Forest University.

I thank Sally A. Shumaker, Ph.D., Section Head of Social Sciences and Health

Policy Department of Public Health Sciences, Bowman Gray School of Medicine, for

her mentoring and her friendship. I greatly appreciate being granted four months

educational leave to complete the dissertation.

I have been extremely blessed with the friendship of some remarkable women.

Julie Karen Netzer, Ph.D., has gone from graduate school colleague to friend, to


family. Though I lack siblings, I have found a sister in her. Through the years we have

shared concerns of all kinds, from professional to personal. I have always been able to

count on her to give me encouragement, support, understanding, and unconditional

acceptance. Debra Van Ausdale, Ph.D., lent her support in both tangible and intangible

ways. I especially thank her for handling graduate school red tape for me.

Jana Borino, A.A., Director of the Florida School of Traditional Midwifery,

has been a staunch supporter from early in my educational process. Her faith that I

would complete my studies successfully and use my degree in service to others has

been more valuable than she could possibly know. We have helped to birth each other's

babies, encouraged each other through many life events, and shared our spiritual

journey. Jana continues to be a blessing in my life. Sylvia Paluzzi gave her friendship

and her loving care of Adrian. Many other women in the Gainesville community gave

their support in so many ways.

A circle of women has provided a foundation of support that has literally kept

me going. Loyce White Longino, Ph.D., has shared the struggle with me. Having

recently received her own doctorate, she has been able to relate completely to the

unique issues of graduate work for mid-life women. Loyce's determination,

perseverance, and success have served to inspire me. Margaret Edwards Dailey,

M.P.H., is always there to offer support and encouragement to be true to myself.

Within minutes of stepping across the hall to her office, we are immersed in a deep

discussion of some profound subject or other. Also engaged in doctoral studies, Maggie

shares the struggle and makes my way so much more enjoyable. Patricia Anne Howell,

M.A., helps me to remember what really matters. Patti shares her wisdom generously.

An experienced childbirth educator, birth attendant and parent, she has a great deal to

share. Martha Anne McCarty Hinds, M.S., P.A.-C., reminds me of the value of open

sharing of our hard times as well as our good. Anne's trust and openness call forth the

same in others. This circle of women has provided a network of spiritual, emotional,

and practical support for each other over several years. I am so grateful to be a part of


Bonita Lara Lee, M.A., has evolved from student to friend. Another mid-life

woman pursuing graduate studies, Lara has provided a model of determination and

exemplary scholarship that serves as an inspiration to me. All of the other members of

the FemWIT group, Judy Bahnson, B.A., Anne Boyle, Ph.D., Pamela Goodman,

Ph.D., Patricia Hogan, M.A., M.P.H., Claudine Legault, Ph.D., Susan Margitic,

M.A., and Michelle Naughton, Ph.D., I thank for listening, and listening, and


My parents-in-law, Henry R. and Eleanor Smith, have always maintained their

faith that I would become the third Dr. Smith in the family. Their investment of

support has paid off!

My wonderful parents, Robert H. and Betty Lou Rust, gave me first, the

blessing of a happy childhood. I am increasingly aware how rare that is and I am

eternally grateful. My mother has always given me her support, even though I have

chosen a very different path from hers. Her acceptance and approval mean so much to

me. My father, even though I was an only child in the 1950s, never made me feel that


he would have preferred a son. He told me I was smart, which allowed me to see

myself that way. The confidence to begin college in my 30s and complete a doctoral

degree in my 40s is due in no small part to the excellent parenting I received as a child

and throughout my life.

My six children have been the real educators in my life. Sheila Dawn Robinson,

to whom this dissertation is dedicated, encouraged me as we shared our college

experiences. My first child, it was she who introduced me to motherhood, including

breastfeeding. Although I knew little of the advantages objectively, I knew without a

doubt that breastfeeding was valuable. The wonderful experience I had with her led to

a commitment to breastfeeding that resulted in the breastfeeding of five more children

and, now, research on the subject.

My two older sons, Stephen Gene Robinson and Jeffrey David Robinson, have

always given me their enthusiastic support for becoming "Dr. Mom." They have been

mostly grown and living elsewhere while I did my graduate work, but nevertheless, my

immersion in this endeavor has required their tolerance.

My three sons still at home, Justin Matthew Smith, Ethan Aleksandr Smith, and

Adrian Archer Smith, have spent most of their lives (Adrian his entire life) in a

household with student-parents. Many sacrifices have been required of them, in terms

of both time and money. They have been told times too numerous to count that we

cannot go somewhere or do something because of the need to study. They did without

many of the material advantages of many of their peers for seven long years while

living in university family housing. These years were not without value, however. The


exposure to other cultures and the lessons in living frugally are valuable, and we have

many happy memories of those times.

And finally, I give my heartfelt thanks to Mark Holland Smith, Ph.D., my

husband and soulmate. I would never have undertaken college in the first place without

his encouragement, and I surely would never have finished doctoral studies without his

support. When others could not understand how we could go through graduate school

together, I could never imagine doing it any other way. Few people believed that we

could do it, parents of small children pursuing two doctoral degrees, but we have done

it! Blessed be.



ACKNOW LEDGM ENTS ........................................ .............. iii

ABSTRACT ............................ ..... ................... xi


1 INTRODUCTION ...................... ....... ................... 1

2 REVIEW OF LITERATURE ................................... 7

Demographic Factors ................................................... 7
Social Support ........................................ ............ 10

3 M ETHODS ........................ ........................ ..................... 20

Participants .......................................... 21
Procedures .................................................. 23
Instruments .............................................. ....... 24
Interviewers ................. ...................... ....... 24
Coding and Data Entry ....................... ............................. 25
Analysis ........................................ ............ 25

4 RESULTS AND DISCUSSION ............................................ 27

Description of Sample ...................................... ............ 27
The Feeding Decision ...................... ....... ............... 31
Social Support ........................... .......... .......... .................... 36
Breastfeeding Knowledge and Belief ........................................ 46
Breastfeeding and Bottlefeeding Problems ................. .............. 53
Epistemological Questions .......................................... 55
Additional Open-ended Questions ............... ...... ............. 58
Logistic Regression of Selected Variables .................. .............. 63

5 SUMMARY AND CONCLUSIONS ....................................... 67

The Permission Theory of Breastfeeding ................................. 69
Socialization for Breastfeeding ................... .................. 74
Development of Breastfeeding Initiatives .................................. 75
Implications for Future Research ................ .................. 81


A BREASTFEEDING QUESTIONNAIRE .................................. 85

B BREASTFEEDING KNOWLEDGE QUIZ ................................ 93

C EPISTEMOLOGICAL QUESTIONS ........................................ 96

D DEMOGRAPHIC QUESTIONNAIRE ...................................... 99


REFERENCES ................................... ............. 110

BIOGRAPHICAL SKETCH ................. ... ....... ............ 115

Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



Teresa Rust Smith

August 1997

Chairman: Hernan Vera, Ph.D., Professor
Major Department: Sociology

This dissertation is an investigation of the factors that influence the infant-

feeding decision (whether to feed by breast or bottle). Variables examined include age,

race, marital status, education, knowledge and beliefs about breastfeeding,

epistemological perspective, plans to return to work and social support. One hundred

fifty first-time mothers were interviewed during their postpartum hospital stay. Both

bivariate and multivariate analyses were used. Bivariate findings revealed that women

who are older, better educated, married or living with their partner, and white were

more likely to breast-feed. Exposure to breastfeeding and breastfeeding supportive

beliefs and accurate knowledge of breastfeeding were shown to increase the likelihood

of breastfeeding. Support of breastfeeding by the woman's mother and husband or

partner were both significantly related to breastfeeding initiation. Planning to return to

work did not decrease the incidence of breastfeeding. Moreover, seeing herself as the


primary wage earner in the household or an equal earner with her husband or partner

increased the likelihood that a woman would breast-feed. Results of multiple logistic

regression showed that all of the previously significant sociodemographic variables

became insignificant with the exception of being primary of equal earner. Social

support variables remained significant as did high score on breastfeeding supportive

beliefs. The "permission theory of breastfeeding" is advanced to explain these findings.

This theory maintains that unless a woman is strongly socialized to value breastfeeding

or is financially self-sufficient, she will not breast-feed without a supportive partner

because of the cultural perspective that the female breast exists primarily for the sexual

pleasure of the male. Implications for the design and implementation of community

breastfeeding initiatives are discussed. Recommendations include the continuation of

existing programs and efforts and the addition of public service campaign to re-

socialize the general public to be more supportive of breastfeeding.


In 1969 I gave birth to my first child. During my pregnancy, I spent a great deal of

time reading and studying childcare and dreaming and planning about my coming baby. I

did not think much about how I would feed my child-to-be. I already knew that I wanted

to breast-feed. My first exposure to the idea of breastfeeding came from reading childcare

books while babysitting in my early teens. Although a few advantages of breastfeeding

were presented, the overall gist of the message was that either method of infant feeding

was just fine. While none of these books came out strongly in favor of breastfeeding, it

seemed clear to me that breastfeeding made much more sense. My young husband was

supportive of breastfeeding as was my mother. My baby was born and I set out to breast-

feed her. Despite hospital practices that hinder the establishment of breastfeeding, lack of

encouragement from health care providers, and no support network of other nursing

mothers, nursing my daughter went well. As I began to read about the subject, I

discovered that there were a great many advantages to breastfeeding that I had not known

about before. I found the bond that I formed with my baby to be very gratifying. It was a

source of some dismay to me that few of my contemporaries chose breastfeeding. Most

mothers took the position that it was too much trouble and not really necessary. After the

birth of my second child, I began to meet other women who felt as I did. For the first


time, I was part of support system that had knowledge about the practice of breastfeeding

and information on overcoming difficulties. Still, the majority of women who were

having babies in the early 1970s were choosing to bottle-feed. It was, after all, the nadir

of breastfeeding in this country (Ryan, Rush, Krieger & Lewandowski, 1991b). I had two

more children during the 1970s and when my fifth child was born in 1982, the

breastfeeding rate had rebounded to its highest level in several decades (Ryan et al.,

1991b). It was extremely interesting to me to contemplate who chose breastfeeding and

who chose bottlefeeding. What could account for the sharp increase over one ten-year

period? And what could account for the fact that by the time I had my sixth child in 1987

the rate had begun to fall again (Ryan et al., 1991b)? Through the years of breastfeeding

six children, I became increasingly convinced of the value of this method of infant

feeding, but also increasingly aware that not all women shared my views. While there is a

considerable body of literature that describes the sociodemographic characteristics of

breastfeeders and bottlefeeders, these factors alone are not adequate to explain the

decision-making process. The breastfeeding rate has fluctuated over the years while such

sociodemographic variables as age, race, marital status, education, and socioeconomic

status have not displayed corresponding changes. Knowledge of the benefits, which

might seem to be an important factor, is not adequate either, since the breastfeeding rate

declined during a time when knowledge of the benefits was high.

Increasing the number of mothers initiating and continuing breastfeeding of their

infants has been established as a national goal (U.S. Department of Health and Human

Services, 1990). A target level of 75% of new mothers initiating breastfeeding has been

established. Research supports that breast-fed infants suffer fewer ear and respiratory

infections, gastro-intestinal illnesses and skin disorders than bottle-fed infants

(Cunningham, Jelliffe & Jelliffe, 1991). Rates of breastfeeding, however, continue to be

lower than established targets and have even declined in recent years (Freed, 1993). In

order to increase rates of breastfeeding, it is first necessary to identify those factors that

affect the infant feeding decision. This study advances knowledge in this area.

As with the milks of all mammal species, human milk contains the optimal mix of

nutrients for the developing human infant. In addition to the best mix of proteins, lipids

and other nutrients, mother's milk contains beneficial hormones, enzymes, "growth

modulators," immunoglobulin, and anti-infective substances (Freed, 1993; Cunningham,

1981, 1979).

The health benefits of breastfeeding include lower rates of diarrheal illness, ear

and respiratory infections, atopic skin disorders, and lower rates of hospital admissions

than formula fed infants (Cunningham et al., 1991; Bahna, 1986). In addition to lowering

morbidity, breastfeeding reduces the risk of infant mortality, through reduction of the

likelihood and severity of infection, and reduction of diarrheal illness (Lithell, 1981).

In addition to the biological benefits for mother and infant, breastfeeding has

economic advantages for the family and for society. Bottlefeeding involves a substantial

investment of time and money for the family. Illness associated with formula feeding

also results in substantial medical expenditures as well as lost time from work.

Furthermore, as noted by Freed (1993), the costs to the taxpayers for formula feeding can

be dramatic. The Women, Infants, and Children (WIC) program pays for infant formula

for low income mothers who do not breast-feed. In 1992, the average cost to WIC for

bottle-fed infants in the state of North Carolina was $8,686 per year, compared with

$4,848 for breast-fed infants.

From a low of less than 20% just following World War II, breastfeeding

increased dramatically between the 1960s and the 1980s to 60% of mothers at time of

hospital discharge (Ryan et al., 1991). However, this increase was followed by a

substantial decline in the proportion of breastfeeding mothers between 1984 and 1989

(see Table 1.1). The rate of in-hospital breastfeeding declined from 59.7% in 1984 to

52.2% in 1989. The prevalence of breastfeeding at six months of age also declined, from

23.8% to 18.1%. These declines occurred across all sociodemographic groups, but were

more pronounced among blacks, low-income, and low-education women (Freed, 1993).

Rates of labor force participation by mothers of infants under one year of age increased

during this time period with the 50% mark being passed in 1987 (U.S. Bureau of the

Census, 1988).

This dissertation is concerned with how women make the infant-feeding decision

(whether to feed by breast or bottle). First, what do women know about breastfeeding?

Whom do they consider "experts" in infant care and feeding? Where do they obtain the

information they have, whether accurate or not? What factors do women consider most

important when they decide how they will feed their infants?


Year % Breast-fed Year % Breast-fed

1955-59 32.0 1978-79 44.3

1960-64 27.0 1980-81 52.5

1965-69 25.0 1981 57.9

1970 23.0 1982 59.1

1971 25.0 1983 55.3

1972 22.0 1984 54.2

1973 25.0 1985 55.6

1974 30.0 1986 53.5

1975 34.0 1987 56.3

1976-77 42.2

(Adapted from Ryan et al., 1991a)

What influence is exerted by the woman's husband or partner, if present? Is the opinion

of her mother relevant? Does she heed the advice of her prenatal care provider? Of

particular interest, do African American women and white women construct their

knowledge of breastfeeding in the same way? And, when women re-enter the labor force

soon after birth, does this affect their choice of method of infant-feeding?

The objectives of this study are to identify and evaluate factors that influence

infant feeding decision of new mothers. Factors studied include demographic variables,

breastfeeding knowledge and beliefs, mother's return to the labor force, attitude of the

baby's father, advice of health care providers, mother's history of having been breast-fed

or not, and opinion of the woman's mother.

Subgroups of subjects that are of specific interest are as follows:

(1) African American mothers. It is known that breastfeeding rates vary by age,

race, and socioeconomic status. Breastfeeding rates are lowest for minority mothers and

their infants have the highest infant mortality rates (Freed, 1993). Since increasing the

breastfeeding rate for African Americans might have even greater benefits than for the

general population in terms of reducing infant mortality, it is especially important to

understand the feeding decision for these women.

(2) Very young mothers. Another group with lower rates of breastfeeding than the

general population is women who bear children in adolescence. This dissertation will

investigate the breastfeeding behavior in this group.

(3) Working mothers. While the advantages of breastfeeding are sometimes

assumed to accrue primarily to infants in developing countries and disadvantaged infants

in developed nations, the numbers of infants of all socioeconomic levels in day care may

render the reduction of infant morbidities through breastfeeding a priority in other

populations as well. Maternal employment may constitute a disincentive to breastfeeding

while infants of working mothers may stand to receive particular benefit when breast-fed.

This study investigates this relationship.


Much of the previous work on initiation and maintenance of breastfeeding focuses

on sociocultural correlates. Such factors as age, race, ethnicity, and socioeconomic status

of the mother have been considered (Starbird, 1991; Weller & Dungy, 1986; Rassin,

Richardson, Baranowski, Nader, Guenther, Bee, & Brown, 1984) as well as history of

having successfully breast-fed previous children and having been breast-fed herself as an

infant (DaVanzo, Starbird, & Leibowitz, 1990; Entwisle, Doering, & Reilly, 1982.)

Higher maternal age, white race/ethnicity and higher socioeconomic status are positively

associated with initiation and maintenance of breastfeeding (Jacobson, Jacobson, & Frye,

1991; Bee, Baranowski, Rassin, Richardson, & Mikrut, 1991; Joffe & Radius, 1987;

Peterson & DaVanzo, 1992).

Demographic Factors

In an exploration of adolescent girls' attitudes toward breastfeeding in the mid-

1980s, Joffe and Radius (1987) found that only 17% of pregnant adolescents expressed an

intention to breast-feed. This compared to a breastfeeding rate of over 50% in the general

population (Ryan, Pratt, Wysong, Lewandowski, McNally, & Krieger, 1991a). Ryan et al.

(1991a) found that the rate of breastfeeding increased steadily with age. Peterson and

DaVanzo (1992) likewise found that younger mothers were much less likely to breast-


feed than their older counterparts, finding a rate of 30% for mothers under the age of 20

and 62% for mothers over the age of 25 years. In both of these studies, teenaged women

who breast-fed tended to do so for the same reasons as older mothers. The difference was

that younger mothers experienced these factors, such as perceiving benefits, having

supportive environments, being married and of higher socioeconomic status. Some of the

difference in breastfeeding behavior, however, was not accounted for in this way

(Peterson & DaVanzo, 1992).

White race has been consistently found to increase the likelihood of breastfeeding

(Rassin et al., 1984). Assessing the decline in the breastfeeding rate from 1984 to 1989,

Ryan et al. (1991b) found that the rate for white mothers was 65% in 1984 and had

declined to 58.5% by 1989. Non-white women were less likely to breast-feed in 1984,

with black mothers initiating breastfeeding at a rate of 33.3% and Hispanic women at a

rate of 53.8% in that time period. By 1989, the rates had dropped for both of these

groups, as well. Rates for Hispanic women had declined from 53.8% to 48.4%. The

decline for black mothers was even more pronounced, declining from 33.3% to 23% by

1989. Another study of breastfeeding and ethnicity found a similar order of likelihood of

breastfeeding, with white women the most likely followed by Hispanic women, and then

black women (Bee et al., 1991). These researchers concluded that women of different

ethnicity chose to breast-feed based on different factors. While this information

contributes to our knowledge about breastfeeding decision-making, it does not shed light

on interventions that might be useful because these factors are not subject to


Studies of modifiable variables frequently attend to such issues as hospital

practices and postpartum education that might influence the duration of breastfeeding.

These studies show that modeling of bottlefeeding by the practice of giving supplemental

formula in the hospital and sending bottles of formula home may overshadow verbal

support for breastfeeding given by the staff, and postpartum education of the mother

(Buxton, Gielen, Faden, Brown, Paige, & Chwalow, 1991; Grossman et al. 1990; Frank,

Wirtz, Sorenson, & Heeren, 1987.) These important findings suggest changes in

practices that might affect the maintenance of breastfeeding beyond the early postpartum

period but do not address the initial feeding decision at all.

Since efforts to increase rates of breastfeeding have been largely based on

increased understanding of the health benefits of breast-fed for infants (U.S. Department

of Health and Human Services, 1990), it has often been assumed that educating pregnant

women regarding the benefits of breastfeeding would be the most useful strategy to

increase the practice. While some studies show that educational interventions in

pregnancy can, in some cases, increase breastfeeding behavior (Sciacca, Dube, Phipps, &

Ratliff, 1995), other studies have other factors more influential, such as positive attitudes

toward breastfeeding (Black, Blair, Jones, & DuRant, 1990) and sociodemographic

variables (Bee et al., 1991) more predictive. One study found that women who breast-fed

were likely to have made the decision before becoming pregnant (Ekwo, Dusdieker, &

Booth, 1983). While it surely makes sense that increasing understanding of the

advantages of breastfeeding would increase the likelihood of that method being chosen,

clearly, it is not all that needs to be done.

Social Support

In a comparison of the social support available to women intending to breast and

bottle-feed, social support was found to be an important element in encouraging

breastfeeding (Matich & Sims, 1992). While some of the elements of social support

investigated in this study dealt specifically with breast-feed ("teaches me how to do some

things like getting prepared for breastfeeding"), many items dealt with social support in

the more general sense ("would loan me small amounts of money" and "makes me feel I

am cared about"). Less stress was placed on sources of approval of breastfeeding or

encouragement to breast-feed than on this more general kind of social support. Another

study found that friends and relatives were reported to have influenced and reinforced the

woman's choice to breast-feed whether it was her first or a later baby (Ekwo et al., 1983).

It seems clear that a distinction is needed between general social support and specific

support for breastfeeding in the form of approval and encouragement to choose that

method of infant feeding.

Studies dealing with the effects of female labor force participation on

breastfeeding are surprisingly few, particularly since recent, dramatic increases in

numbers of mothers of small children in the work force have coincided with a decrease in

the rate of breastfeeding. Previous studies addressing working and breastfeeding deal

with effects of hours worked and timing of the return to work on the duration, rather than

the initiation of breastfeeding (Kurinij, Shiono, Ezrine, & Rhoads, 1989.) Another study,

while concentrating primarily on duration, reported that women who were employed

fulltime and those who were not breast-fed at the same rate, but the working women


breast-fed for shorter durations than the non-employed women (Ryan & Martinez, 1989).

Structural barriers to breastfeeding while employed such as the lack of appropriate space

for expressing milk were also considered by most studies dealing with breastfeeding and

employment. These crucial issues, do not, however, shed much light on the relationship

between working and the decision to breast-feed.

Cultural influences on breastfeeding attitudes have considered the lack of trust in

the physiological process of breastfeeding common in a highly technological society

(Millard, 1990) and a sociocultural view of the female breast as an exclusively sexual

organ leading to embarrassment for breastfeeding women (Morse, 1989). The failure of

employers to provide space for nursing mothers to express milk, even though this has

been shown to increase the duration of breastfeeding among employed women (Katcher

& Sanese, 1985), is an example of structural barriers to breastfeeding.

Since rates of breastfeeding initiation have changed substantially over time, rising

since the middle of this century and recently declining, it is reasonable to conclude that

factors which may be susceptible to modification are at work. Furthermore, the influence

of some factors on the initiation of breastfeeding has been shown to change over time

(Starbird, 1991). This study furthers the investigation of under-researched psychosocial

influences on the infant feeding decision as well as providing current information on the

influences of recent socioeconomic changes, such as increasing employment of mothers

of young infants.' While structural influences such as age, race and socioeconomic status

have been examined, we do not know why these factors exert the influence that they do.

Much as the process of childbirth has been medicalized in the last century, the

cultural view of infant feeding has likewise shifted from a physiological process of the

female body to a matter requiring the supervision and intervention of the medical

profession. This is due, at least in part, to the technological imperative that exists in our

contemporary society. According to this view, science and technology are superior to

nature and unaided natural processes. As physicians worked to develop a nutritious and

safe substitute for mother's milk to meet the needs of those infants who could not be

breast-fed by their mothers, "scientific" formula feeding ascended to a position of

superiority over breastfeeding even in the absence of difficulties (Apple, 1987).

The routine use of an artificial formula to nourish human infants places the

control of infant feeding in the hands of experts, such as scientists and physicians, rather

than with mothers. This coincides with the medicalization of childbirth, in which the

birth process, once the province of women, mothers, and midwives, was transformed into

a surgical procedure requiring medical management. The movement by the (mostly

male) medical establishment to take control of childbirth and breastfeeding is explained

by Mary O'Brien as an attempt, on the part of men, to mediate their alienation from their

biological continuity (O'Brien, 1981). Men, according to O'Brien, are alienated from

biological genesis because of the temporal separation of conception and the birth of a

child, and by the essential uncertainty of paternity. Women, on the other hand, are able to

mediate this alienation through the physiological processes of reproduction, pregnancy,

childbirth, and breastfeeding. A woman who feels and sees a child emerge from her body

knows the child to be her own. Since men have no such biological mechanism for the

mediation of their separation from these processes, they have been driven to develop

cultural and political mechanisms to control women, and the children they bear in order

to accomplish this end. Efforts to do this have included, over time, a wide variety of

practices such as insistence on virginity before marriage and fidelity after (for women),

laws restricting women from participation in the political process, relegation of women to

the "private sphere," and the development of religious structures that support such

oppression. Extreme examples of the imposition of the male will upon women include

Chinese footbinding, the European witch trials, African female genital mutilation, and the

psychological deformation of middle- and upper-class American women in the severe

sexual repression of the Victorian Era.

Further examples of these attempts on the part of men to establish continuity with

biology is the appropriation of childbirth and breastfeeding by men.' Through

medicalization, these inherently female processes are transformed into dangerous and

unpredictable events that require management and the application of technology to render

them safe. Childbirth was taken out of female control and placed under the jurisdiction of

obstetrics. This has been accomplished despite the fact that none of the standard

obstetrical interventions has been demonstrated to improve infant or maternal outcomes

'The equation of men to the medical establishment is not negated by the fact that
women are a part of this establishment in increasing numbers. At the time that this
transformation was taking place, the overwhelming majority of physicians were male.
Even now, when women enter the profession of medicine, they conform to the same
medical paradigm as male physicians, bringing little female influence to bear in that

for normal births. Robbie Davis-Floyd suggests that we examine the latent function of

these interventions, rather than the manifest function (reduction of morbidity and

mortality) if we wish to understand their persistence (Davis-Floyd, 1990). Davis-Floyd

argues that obstetrical technologies serve to ritually transform childbirth from a process

that can empower women and emphasizes their close association with the power to give

life through the replication of the human species to an inherently dangerous and

unpredictable process than can be rendered safe only with the technological intervention

of and control by men (Davis-Floyd, 1990). In this transformation, women's bodies

become unreliable "maternal environments" liable to turn hostile at any moment, and men

become the experts who are able to monitor the process and intercede on behalf of the

infant in the not-so-infrequent event that the interests of the mother and the infant


Similarly, in the case of infant feeding, what began as an effort to improve

artificial formula for use when mother's milk was not available became another instance

in which technologies designed to assist when the natural process fails become elevated

to the preferred method, even when the natural process is not compromised. When

infant nutrition was sufficiently well understood to enable scientists to compound an

adequate substitute from modified animal milk, lactation began to be viewed as uncertain

and unreliable. While cow's milk could be scientifically standardized, sterilized, neatly

packaged and measured, mother's milk was viewed as variable, unsanitary, and difficult

to measure. The entire process of lactation came to be viewed as unscientific, messy,

unladylike, and unnecessary. Widespread acceptance ofbottlefeeding led to the


relegation of the female breast to the status of primarily a sexual organ, rather than a body

part with a dual role: organs of sexual pleasure for both men and women, and organs to

nourish the young.

While to physicians this meant the acquisition of additional medical "territory," it

meant to the manufacturers of infant formula a vast and constant market. And while, no

doubt, many infants and mothers have benefitted from the development of these artificial

infant foods, there is evidence that even in modern, industrialized countries, there are

many advantages to breastfeeding for both mother and infant (Freed, 1993). Again,

despite evidence to the contrary regarding the efficacy of medicalization, technology has

replaced the natural process of the female body as the giver and sustainer of life.

While recent evidence has confirmed the superiority of breastfeeding over

artificial feeding as a method of infant nutrition and medical authorities now recommend

that infants be breast-fed whenever possible, the rates of initiation and maintenance of

breastfeeding have remained relatively low. The process by which women decide how

they will feed their babies is not well understood. It seems that having been convinced

for several generations that their bodies were unreliable sources of infant nourishment,

many women have lost faith in their ability to lactate and lost sight of the value in doing

so. Some women, of course, do value breastfeeding and chose this method to feed their

infants. While some correlations can be drawn among breastfeeding and SES, race, age,

parity, and so on, there are breastfeeders and bottlefeeders in each category. How do

women construct their knowledge of breastfeeding and its desirability? Whom do women

view as "experts" on breastfeeding? Are the same factors at work in different groups of

women? An epistemological examination of breastfeeding knowledge may contribute to

our understanding of these issues.

In their book Women's Ways of Knowing: The Development ofSelf, Voice, and

Mind, Belenky, Clinchy, Goldberger, and Tarule (1986) offer five epistemological

perspectives from which women view the world, draw conclusions about knowledge, and

perceive truth and authority. These perspectives emerged from an extensive research

project in which they interviewed 135 women about their lives, experiences and feelings.

The perspectives were developed from the interviews, from what they heard the women

say about their lives. The authors' interest in the issue of women and knowledge arose

from their observations that women often experienced doubts about their intellectual

competence that resulted in academic difficulties not usually encountered by male

students. They were interested to know how women might experience learning and

knowing differently from men. The work of Carol Gilligan (1982) identified ways in

which women differ from men in their application of morals and ethics to issues of

decision-making and choice. The work of Belenky et al. (1986)

supports the view that women construct knowledge differently from men, and that their

epistemological perspectives can be classified into identifiable categories.

Belenky et al. (1986) described five distinct epistemological perspectives that

emerged from analyzing the 135 interviews.

1) Silence. In this position, a woman has no voice. A very small number of

women fell into this category. The ones who did tended to be young and disadvantaged.

"Silence," of course, does not mean that these women could not speak, but that they did


not consider that they had anything to say. In these women, representational thought was

underdeveloped. They did not find meaning in words beyond the immediate and

superficial, either their own, or the words of others. Silence is an extremely passive and

dependent position.

2) Received knowledge. In this perspective, words have meaning, but only the

words of others. Women in this category viewed themselves as knowers, but only as the

holders of knowledge given to them by others. Knowing is highly valued and those who

know are respected. They do not consider that they might evaluate, alter, or contribute to

this knowledge.

3) Subjective knowledge. Women in this perspective have experienced a dramatic

shift from silence or received knowledge to a state of trusting their own subjective

feelings above all else. In this category, all outside sources of information are suspect.

Truth is determined by intuition and "gut feelings." They understand truth to be multiple

and do not expect others to accept their version any more than they accept another's.

External authority is denied.

4) Procedural knowledge. In this category, women come to a position of reason

and rational thought. The women in this perspective have accepted, sometimes

reluctantly, the linear thought and rational process of the academy. These women came to

realize that they could play the game that in other categories they had either observed,

accepted, or dismissed. This is an objective rather than a subjective position. Women in

this category gain power by identifying with sources of authority.


5) Constructed knowledge. The women in this perspective have reached a position

of integrating various kinds of thought. For these women, knowing is not wholly

subjective but neither is it entirely objective. Constructed knowers are conscious of their

own processes of the construction of knowledge. They recognize themselves as inventors

of truth.

The concept of self-efficacy has been suggested as the primary contribution that

can be made by health care providers to encourage breastfeeding (Labbok, 1994). Labbok

encourages health care providers to shift from intervention strategies that are more

appropriate in treating illness to a role of support and counsel. The encouragement of

self-efficacy is viewed as especially helpful in supporting women to breast-feed.

Self-efficacy refers to a state of feeling confident of one's ability to carry out a

behavior. It does not refer to a global personality trait but rather is contextual, in that a

sense of self-efficacy in one area of life does not necessarily translate into self-efficacy in

other areas (Strecher, DeVellis, Becker, and Rosenstock, 1986). Self-efficacy results

when an individual believes herself or himself to be capable of a particular behavior

rather than from the individual's true abilities. Efficacy expectation can develop in

several ways. Personal experience in which a person achieves master over a previous

feared task, vicarious experience in which the person observes others and learns from

that, verbal persuasion, in which others, such as health educators exhort patients to

change their behavior, and finally, physiological state, for example, feeling nervous

before a presentation can result in a lowered sense of self-efficacy (Stretcher et al., 1986).

This concept has been used productively in several area of health including

smoking cessation, weight control, contraceptive behavior, alcohol abuse, and exercise

(Stretcher et al., 1986). This concept may also prove useful in understanding the infant-

feeding decision.

This dissertation will examine the factors that have been suggested as influential

in the infant-feeding decision. In addition to exploring whether the previous findings are

supported in this sample and at this time, one primary goal of this dissertation is to

understand why demographic variables are as predictive as they are and how they are

related to psychosocial variables such as attitude and social support. We lack a theory of

infant-feeding decision-making. One suggested theory, the theory of behavioral intentions

(Ajzen & Fishbein, 1977) asserts that behavioral intentions are the most important

predictors of behavior, with other factors, such as demographic variables relegated to the

status of indirect determinants. This theory has been applied successfully to infant-

feeding decision-making (Manstead, Plevin & Smart, 1984). However, predicting

behavior based on prenatal intentions is really of very little use unless we understand how

prenatal intentions are developed. This is the primary question that this dissertation will

attempt to answer: How do women decide whether to breast-feed or bottle-feed their

infants, and how can their choices be explained? A primary goal of this policy-oriented

dissertation is to provide information that will be useful in the design and implementation

of initiatives to raise the rates of breastfeeding and bring them in line with national goals.


Both quantitative and qualitative methods of data collection were employed.

Data were collected from new mothers during the postpartum hospital stay. The

quantitative component consists of a closed-ended questionnaire covering such topics as

labor force participation, attitude of child's father, advice of health care providers,

mother's history of having been breast-fed, the opinion of the woman's mother and the

feeding method chosen. The questionnaire includes a brief breastfeeding knowledge

"quiz" to assess the level and accuracy of knowledge of infant feeding. A short set of

open-ended, structured interview questions was asked in order to be able to place the

respondents into epistemological perspectives. Demographic and historical data were also

collected on all participants. Because of the likelihood of a low response rate to a mail

survey in this population due to the stresses of caring for a newborn infant, in-hospital

administration was chosen over a mail survey. In addition, one group of women that is of

particular interest in this project is African American mothers who are young and single.

These women, some of whom may have low literacy skills, would be among the least

likely to return a mail questionnaire. Interviewer administration was deemed the most

effective means of collecting accurate and complete data from the widest range of

participants. Furthermore, administering the instrument as an interview facilitates the

completion of the open-ended questions.


Participants were recruited from the postpartum floor at Forsyth Memorial

Hospital, which is the birth site of essentially all infants born in Winston-Salem and

surrounding Forsyth County, North Carolina. Agreement to participate served as

consent. The Clinical Research Practices Committee at Bowman Gray School of

Medicine waived the requirement for signed consent on the grounds that teenage mothers

would require parental consent to participate. This would have reduced the number of

women in this category that would participate in the study. Slightly more than 400 babies

are bor each month at this hospital. The sampling frame included all first-time mothers

who delivered healthy, full-term infants by uncomplicated vaginal birth during the study

period. Mothers ofpre-term infants or those infants having a condition that might make

breastfeeding difficult or impossible were not included. In such cases, the infant feeding

decision would be strongly influenced by the condition of the infant, making other factors

less relevant. In a few cases, infants weighing less than 5 pounds 8 ounces (2500 grams)

were included. Some infants of borderline weight or whose mothers gave birth before 37

weeks gestation were retained in the data base since these infants and mothers were

included by the postpartum staff in the hospital as healthy full-term mothers and infants,

and there was no reason to believe that the infant-feeding decision would be affected. No

infant was retained who weighed less than 5 pounds. Likewise, since cesarean section is

major surgery, it is assumed that the mother's condition during the postpartum stay would

differ from that of mothers who gave birth vaginally. This difference might affect the

infant-feeding decision and/or the mother's ability to be interviewed. For these reasons,

mothers who gave birth by cesarean section were excluded from the study. With the

expected rate of cesarean section about 25%, about 100 would be excluded on that basis.

Another 10% (40 women) might be expected to give birth to pre-term or ill infants and

would be excluded since having an ill infant would affect the feeding decision as well as

create a stressful situation under which participation in a research project might place an

undue burden on the mother. Allowing for some refusals among the remaining 260

women, we arrived at a goal of interviewing 200 participants over the course of the

Spring semester, the period during which interviewers were available. Initially, it was

intended that all mothers be included, regardless of parity (number of children). The

decision to interview only first-time mothers, however, resulted in about 100 interviews

completed by the end of the semester. By hiring one of the interviewers to continue

working through the summer, another 52 interviews were done, resulting in a final

number of 152. It was discovered during data entry that two mothers of pre-term infants

were accidentally included in the sample. These participants were not included in the


Potential participants were approached consecutively. African Americans

comprise about 25% of the population of Forsyth County. It was expected that African

Americans would be represented in this study in approximately that proportion. In the

event that they were not, oversampling of African American women was planned to bring

the ratio to representative levels.


When the instrument packet was finalized, a focus group was held to pretest it.

This group of new mothers reviewed the questionnaires in terms of clarity,

understandability, and appropriateness of language. Several changes in the wording of

the instrument were made based on the focus group data. In addition, the packet was

piloted using ten women on the postpartum floor. Minor adjustments, such as the

inclusion of additional categories on two closed-ended questions were made as a result of

the pilot test.

Upon arriving on the postpartum unit, the interviewers were given a patient

census, which listed all women on the floor and supplied their room numbers. Floor

nurses assisted the interviewers in determining who had given birth by cesarean, or which

mothers has premature or ill infants, or were otherwise excluded. Upon locating the

potential participant, the interviewer determined whether this was the woman's first baby.

After obtaining agreement to be interviewed, the measures were administered at the

participant's bedside. Every effort was made to complete the interview in one sitting. On

some occasions, however, the arrival of visitors or the need to carry out hospital routines

required that the interview be completed in two sessions. A questionnaire form was filled

out by hand by the interviewer for each participant. Open-ended questions were recorded

on tape. Careful notes were taken during the open-ended questions to supplement the tape

recording which can sometimes be difficult to hear, and to guard against loss of data due

to equipment failure.


The instrument packet includes a Breastfeeding Questionnaire, an instrument

designed for this study that measures variables such as feeding plans, breastfeeding

history, opinion of spouse/partner, opinion of the woman's mother, advice of the health

care provider, work plans, and so on (Appendix A). Second, a Breastfeeding Knowledge

Quiz assesses the extent and accuracy of knowledge about breastfeeding and

bottlefeeding, and beliefs about breast and bottlefeeding (Appendix B). A third

instrument is comprised of a subset of items from the interview schedule used in the

Education for Women's Development Project (Belenky et al., 1986) to place the women

in epistemological categories. In addition, several other open-ended questions were added

to this section including asking the woman the most important reason she chose the

feeding method she did, how she felt about the changes of pregnancy, and what the word

"woman" means to her. These questions were exploratory in nature (Appendix C).

Finally, a set of sociodemographic questions was administered (Appendix D).


Interviewers were recruited from upper-division sociology majors at Wake Forest

University. The Honors Coordinator and the Professor of Perspectives, the upper-

division core requirement for sociology majors, gave their consent for students to

participate in this project for course credit. Melanie Angiolillo and Amy Lewis were

selected. These students had completed course work in research methods, including

interview skills. The interviewers were given additional training in the administration of

both closed- and open-ended questions. They practiced the instrument on each other and


on several other students before conducting the pilot interviews. Pilot testing was carried

out using 10 women on the postpartum floor. Minor adjustments were made to the

instrument based on the pilot test.

Coding and Data Entry

Closed-ended questions were entered directly into SPSS for Windows. Open-

ended responses, which were collected on audio tape were transcribed and coded into

categories (see Appendix E). Fifteen question sets (10%) were recorded to assess intra-

coder reliability. The error rate was found to be 4.0%. Discrepancies were reconciled in

order to assure the highest level of accuracy in the data base.


Data entry and analysis were performed using SPSS for Windows. The open-

ended responses were transcribed from the tapes, supplemented by hand written notes.

Analysis of content was performed in order to place the responses in categories which

could then be entered into the computer. Five percent of the question sets (8) were re-

entered to determine data entry reliability. The error rate was found to be 0.04%.

The following hypotheses guided analysis.

H1 White women are more likely to breast-feed than non-white women.

H2 Older women are more likely to breast-feed than younger women.

H3 Women who receive encouragement to breast-feed from their mothers are

more likely to initiate breastfeeding than women who do not receive such


H4 Women who were themselves breast-fed as infants are more likely to initiate

breastfeeding than women who were not breast-fed.

H5 Women who receive encouragement to breast-feed from their husbands or

partners are more likely to initiate breastfeeding than women who do not receive

such encouragement.

H6 Women who receive encouragement to breast-feed from their prenatal care

providers are more likely to initiate breastfeeding than women who do not receive

such encouragement.

H7 Women with greater numbers of friends and relatives who breast-feed are

more likely to initiate breastfeeding than women with few or no friends and

relatives who breast-feed.

H8 Women who plan to return to work as soon as possible after giving birth are

less likely to initiate breastfeeding than those who do not return to work that


H, Women with greater knowledge of the benefits of breastfeeding are more

likely to initiate breastfeeding than women with less knowledge of the benefits of


H,, Women who perceive that they have a source of technical advice to deal

with breastfeeding problems are more likely to breast-feed than are women

who do not perceive such a source.

H,1 Women in different epistemological perspectives will differ with regard to

the factors that affect the infant-feeding decision.


Description of the Sample

This sample was young, as would be expected for first-time mothers. Participants

ranged in age from 14 to 40 years with the average age 23.3. Over 46% were 21 years of

age or younger. Only 12.2% were over the age of 30 (see Table 4.1). Seventy percent

were white, 25% African American, and 3.4% Hispanic. There was only 1 Asian

respondent, and 1 American Indian. Due to the small numbers of respondents who were

in categories other than African American and white, race was collapsed into "white" and

"non-white" for subsequent analyses unless otherwise noted. Half of the respondents were

married, with an additional 11.5% living as married. The remainder were single, either

with or without an involved partner not living with them. There were no respondents

reporting being divorced, separated, or widowed. In most subsequent analyses, marital

status was coded in two categories "married or living as married" and "single." Over 20%

had less than a high school education. However, this category included young women

who were still in high school at the time of the birth. Only about 17% had completed

college and just over 4% had advanced degrees (see Table 4.1). Almost 20% had

household incomes of less than $20,000 annually and a little over 8% had incomes of

over $75,000. Some 20% did not know what their household incomes were. Almost


Variable Frequency Percent


14-18 years 34 23.0

19-21 35 23.6

22-25 30 20.3

26-30 31 20.9

31-40 18 12.2


Asian or Pacific Islander 1 0.7

Hispanic 5 3.4

African-American 37 25.0

American Indian 1 0.7

White 104 70.3

Marital Status

Married 74 50.0

Living as married 17 11.5

Involved partner 19 12.8

Single 38 25.7

Table 4.1, continued

Variable Frequency Percent


Grade school 1 0.7

Some high school 29 19.6

High school graduate 34 23.0

Vocational or technical school 7 4.7

Some college 28 18.9

Associate degree 12 8.1

College graduate 25 16.9

Some graduate work 6 4.1

Master's degree 5 3.4

Doctoral degree 1 0.7


Less than $10,000 14 9.5

$10,000 to 19,999 14 9.5

$20,000 to 34,999 27 18.2

$35,000 to 49,999 26 17.6

$50,000 to 74,999 25 16.9

$75,000 to 99,999 4 2.7

$100,000 or more 8 5.4

don't know 30 20.3

Table 4.1, continued

Occupation Frequency Percent

Professional or Technical 47 32.5

Clerical 22 15.2

Sales 25 17.2

Service 24 16.6

Skilled Crafts 3 2.1

Equipment Operator 1 0.7

Laborer 6 4.1

Homemaker 3 2.1

Other (includes students) 14 9.7

one-third of the respondents reported professional or technical occupations. This

category included such jobs as teachers or professors, nurses, lawyers, physicians and

engineers. A little more than 15% had clerical occupations and another 17.2% worked in

sales. Service jobs were held by over 16% of the sample. Less than 7% held jobs as

skilled craftspersons, equipment operators or laborers combined. Only 2.1% reported

being homemakers. The "other" category included students and was reported by almost

10% of the sample.

The Feeding Decision

Categories for the item "How do you plan to feed to feed your baby?" included

"bottle--formula feed entirely," "both, a combination of breastfeeding and one or more

bottles of formula day," "breast with supplements--breastfeeding with regular

supplements less than one bottle of formula a day," breast--formula rarely or never," "try

to breast-feed," "breast-feed a little, then battlefield" (see Table 4.2). Over 43% reported

that they planned to bottle-feed. A small number of women planned to use both breast

and bottle, with 5.3% using one bottle a day or more, and 8% using less then one bottle a

day. One third planned to breast-feed entirely, using formula rarely or never. Six and

seven tenths percent would try to breast-feed and only 3.3% planned to breast-feed a

little, then bottle-feed. Given the small number of cases in groups other than bottle-feed

and breast-feed, categories were collapsed into bottle-feed (no breastfeeding) and breast-

feed (all of the others--any breastfeeding). Using these categories, 43.3% planned to

bottle-feed while 56.7% planned to breast-feed. The recorded categories will be used in all

subsequent analyses unless otherwise noted. Forty percent of the respondents decided

which feeding method they would use in the first 6 months of pregnancy. Over 28%

decided before becoming pregnant, 20.7% in the last 3 months of pregnancy and over

10% did not decide until the time of birth. This varied by feeding decision, with those

deciding which feeding method to use before becoming pregnant being much more likely

to breast-feed (72.1%) and those waiting until the time of birth being much more likely to

bottle-feed (68.8%) (see Table 4.3). Over one-third of breastfeeding mothers


Variable Frequency Percent (%)

Feeding Method

Bottle 65 43.3

Both (1 bottle or more daily) 8 5.3

Breast with supplements 12 8.0

Breast (formula rarely or never) 50 33.3

Try to breast-feed 10 6.7

Breast-feed a little, then bottle 5 3.3

Feeding Method, recorded

Bottle (no breastfeeding) 65 43.3

Breast (any breastfeeding) 85 56.7

When Decided

Before Pregnancy 43 28.7

In First 6 Months of Pregnancy 60 40.0

In Last 3 Months of Pregnancy 31 20.7

At Birth 16 10.7


When Decided Breast-feed Bottle-feed X2

Before Pregnancy (43) 72.1 [36.5](31) 27.9 [18.5] (12)

In First 6 Months of Preg. (60) 48.3 [34.1](29) 51.7 [47.7] (31)

In Last 3 Months of Preg. (31) 64.5 [23.5](20) 35.5 [16.9] (11)

At Birth (16) 31.3 [5.9](5) 68.8 [16.9] (11) 10.85'

'p<.05. "p<.01. "'p<.001. ""p<.0001.

decided before pregnancy while less than one-fifth of bottlefeeding mothers did so.

Almost 17% of bottlefeeding mothers did not decide until the time of birth while only

5.9% of breastfeeding women did so. These figures indicate that while breastfeeding

education at the time of childbirth education should not be abandoned, effort to

educate prospective parents about breastfeeding must begin well before the last few

weeks of pregnancy.

The rate of breastfeeding increased with age (see Table 4.4). At ages 14-18 only

32.4% planned to breast-feed while women in their late twenties and thirties breast-fed at

rates of over 77%. These findings support Hypothesis 2. White women are far more

likely to breast-feed than are non-white women. (see Table 4.4).


Variable Breast-feed Bottle-feed X2

or living as married (91)

Single (57)


45.7 (16)

63.3 (19)

77.4 (24)

77.8 (14)

63.5 (66)


68.1 (62)

38.6 (22)

67.6 (23)

54.3 (19)


22.6 (7)

22.2 (4) 19.15"'

36.5 (38)

59.1 (26) 6.4'


61.4(35) 12.46"*

14-18 (34)

19-21 (35)

22-25 (30)

26-30 (31)

31-40 (18)

White (104)

Non-white (44)

Marital Status

Table 4.4, continued


Less than high school (30)

High School Graduate (34)

Some college, voc. or tech. (47)

Bachelor's degree or higher (37)


Up to $19,999 (28)

$20,000 to 49,999 (53)

$50,000 or greater (37)

Do not know (30)

'p<.05. "p<.01. "*p<.001. ""p<.0001.


26.7 (8)

41.2 (14)

57.4 (27)

94.6 (35)

57.1 (16)

69.8 (37)

67.6 (25)

20.0 (6)


73.3 (22)

58.8 (20)

42.6 (20)

5.2 (2) 36.02""

42.9 (12)

30.2 (16)


80.0(24) 21.95""

Sixty-three and a half percent of white women planned to breast-feed while 59.1% of

non-white women planned to bottle-feed. These findings support Hypothesis 1. Women

who were married or living as married were more likely to breast-feed than women who

were single, even if they reported having an involved partner. It seems that living with a

partner whether married or not makes a difference in the likelihood of breastfeeding.

Women who were living with a partner were more than twice as likely to breast-feed as

bottle-feed. Those not living with a partner were much more likely to bottle-feed than

breast-feed (see Table 4.4).

As with age, education increases the likelihood of breastfeeding. Slightly more

than one fourth of women with less than a high school education chose breastfeeding but

over 94% of women with a college degree or higher did. Women with household incomes

of less than $20,000 annually were less likely to breast-feed than women with higher

incomes. Women who reported that they did not know their annual household income

were much more likely to bottle-feed than breast-feed (see Table 4.4).

Social Support

Social support is shown to be a very important factor in the infant feeding

decision. Respondents were asked whether they had discussed how to feed the baby with

various individuals included their mothers, their partners if applicable, their health care

providers, etc., and whether these individuals supported breastfeeding, bottlefeeding, or

neither method over the other. For women whose mothers supported breastfeeding, over

97% breast-fed their babies. Women whose mothers supported bottlefeeding breast-fed

only 25.8% of the time. While we cannot assume that the mother's support caused the

woman to breast-feed--it may be that the woman had already decided to breast-feed and

then enlisted her mother's support--it is reasonable to assume that the support of the

mother is important. Very few women who had the support of their mothers to breast-

feed chose to bottle-feed (see Table 4.5). Those whose mothers supported neither method

over the other were more likely to bottle-feed, 56.1 of the time, and women who did not

discuss infant feeding with their mothers breast-fed in about the same proportion as the


Other Breast-feed Bottle-feed X2


Supported Breastfeeding (34)

Supported Bottlefeeding (31)

Supported Neither or Both (41)

Did Not Discuss (43)

Husband or Partner

Supported Breastfeeding (56)

Supported Bottlefeeding (19)

Supported Neither or Both (43)

Did Not Discuss (30)

Prenatal Health Care Provider

Supported Breastfeeding (73)

Supported Bottlefeeding (1)

Supported Neither or Both (26)

Did Not Discuss (48)

"p<.05. "p<.01. "'p<.001. ""p<.0001.

97.1 (33)

25.8 (8)

43.9 (18)

58.1 (25)

83.9 (47)

15.8 (3)

48.8 (21)

43.3 (13)

65.8 (48)

0.0 (0)

34.6 (9)

56.3 (27)

2.9 (1)

74.2 (23)

56.1 (23)

41.9(18) 37.30""

16.1 (9)

84.2 (16)


56.7(17) 33.13""

34.2 (25)

100.0 (1)

65.4 (17)

43.8 (21) 8.91"



How Fed Breast-feed Bottle-feed X2

Breast-fed (17) 94.1(16) 5.9 (1)

Bottle-fed (110) 50.0 (55) 50.0 (55)

Both Breast and Bottle (12) 75.0 (9) 25.0 (3)

Do Not Know (10) 40.0 (4) 60.0 (6) 14.44"

'p<.05. "p<.01. "'p<.001. ""p<.0001.

sample as a whole, 58.1%. These findings support Hypothesis 3 that women whose

mothers encourage breastfeeding are more likely to breast-feed than women whose

mothers do not support that method. Looking at the feeding decision of the woman's

mothers we see a similar trend. Women who were themselves breast-feed as infants

breast-fed their own infants over 94% of the time (see Table 4.6). Women who were

bottle-fed as infants breast-fed 50% of the time. Women whose mothers used both breast

and bottle breast-fed 75% of the time. These results support Hypothesis 4 that women

who were themselves breast-fed as infants were more likely to breast-feed than women

who were not breast-fed.


The support of the husband or partner is likewise shown to be important. Women

whose husband or partner supported breastfeeding breast-fed almost 84% of the time. For

women whose husbands supported bottlefeeding, the rate of breastfeeding was an

extremely low 15.8%. It may be that while mother's support for breastfeeding is more

important in encouraging breastfeeding, husband support for bottlefeeding is more

influential in discouraging breastfeeding (see Table 4.5). Both women whose husbands or

partners supported neither method over the other and women who did not discuss infant

feeding with their husband or partner were somewhat more likely to bottle-feed. These

findings support Hypothesis 5 that women who receive encouragement from their

husband or partner are more likely to breast-feed than women who do not receive such


Almost one-third of the respondents did not discuss infant feeding with their

prenatal health care provider. In only one case did a respondent report that her prenatal

health care provider supported bottlefeeding. When the prenatal health care provider

supported neither method over the other, 65.4% bottle-fed. When this person supported

breastfeeding, 65.8% breast-fed. This supports Hypothesis 6 that women who receive

encouragement from their prenatal health care providers are more likely to breast-feed

than women with this support. Women reported discussing infant feeding with a variety

of others such as sisters, grandmothers, friends, pediatricians, etc. Since the number

responding in each of these additional categories was small, an additional variable was

constructed to count the total number of people each woman reported as supporting

breastfeeding. This variable was coded as "high--2 or more people supporting


Amount of Support Breast-feed Bottle-feed X2

High--2 or more supporting (86) 76.7 (66) 23.3 (20)

Low--1 or no one supporting (64) 29.7 (19) 70.3 (45) 33.08."

'p<.05. "p<.01. "'p<.001. ""p<.0001.



Exposure Breast-feed Bottle-feed X2

Low Brst/Low Botl (52) 53.8 (28) 46.2 (24)

High Brst/Low Botl (27) 88.9 (24) 11.1 (3) 9.70"

Low Brst/High Botl (34) 29.4 (10) 70.6 (24)

High Brst/High Botl (36) 61.1 (22) 38.9 (14) 7.08"

'p<.05. "p<.01. "'p<.001. ""p<.0001.

breastfeeding" and "low--1 person or no one supporting breastfeeding" (see Table 4.7).

Having high support for breastfeeding results in a breastfeeding rate of 76.7% while

having low support results in a rate of 29.7%.

An additional aspect of social support was investigated by looking at how many

women whom the respondent knew well and who had had babies in the last two years

breast-fed their babies versus those who bottle-fed their babies. Exposure to feeding

method was coded in four categories: low breastfeeding exposure/low

bottlefeeding exposure, high breastfeeding exposure/low bottlefeeding, low breastfeeding

exposure/high bottlefeeding exposure, and high breastfeeding exposure/high

bottlefeeding exposure. Low exposure refers to knowing only one or no

women using that method, high exposure refers to knowing two or more women using

that method. Results of this analysis conform to previously discussed findings that social

support increases the likelihood that a women will breast-feed (see Table 4.8). These

findings support Hypothesis 7 that women with greater numbers of friends and relative

who breast-feed are more likely to breast-feed than women with smaller numbers of

friends and relatives who breast-feed.

Employment Issues

The majority of women in the sample were employed fulltime both before and

during this pregnancy, 68% and 65.1% respectively (see Table 4.9). Over 60% continued

to work either full or parttime until the last month of pregnancy (see Table 4.10). Over

75% planned to return to work either full or parttime within a few months of birth (see

Table 4.11). While it was hypothesized that women who planned to return to


Employment Status Before Pregnancy During Pregnancy

Fulltime 68.0 (102) 65.1(97)

Parttime 16.7 (25) 18.1(27)

Not employed 15.3 (23) 16.8 (25)


When Stopped Working Frequency Percent

3 Months or Less 4 2.7

More than 3 but Less than 6 11 7.5

6 or 7 Months 17 11.6

8 Months or More 91 61.9

Not Employed During Pregnancy 24 16.3

work soon after birth would be less likely to breast-feed than women who did not

plan to return as soon, no significant relationship was found for these variables. In fact,

the trend was in the opposite direction with more women who planned to return to work

fulltime in the next few months breastfeeding than women who were planning to


Employment Plans Frequency Percent

No Immediate Plans 35 23.5

In a Few Months, Parttime 34 22.8

In a Few Months, Fulltime 80 53.7


Work Plans Breast-feed Bottle-feed X2

No Immediate Plans (35) 54.3 (19) 45.7 (16)

In a Few Months Parttime (34) 50.0 (17) 50.0 (17)

In a Few Months Fulltime (80) 61.3 (49) 38.8 (31) 1.37

work only parttime or who had no immediate plans to return to work (see Table 4.12).

Hypothesis 8 was therefore not supported. When looking at feeding decision by primary

wage earner in the household, even more surprising findings emerge. The husband or

partner was the most common primary wage earner, with over 45% of women reporting


Primary Earner Frequency Percent

Respondent 24 16.2

Husband or Partner 67 45.3

Father 16 10.8

Mother 15 10.1

Other Family Member 6 4.1

Respondent and Partner Equal 17 11.3


Primary Wage Earner Breast-feed Bottle-feed X2

Respondent/Equal Partners (41) 78.0 (32) 22.0 (9)

Other (109) 48.6 (53) 51.4 (56) 10.5"

.p<.05. "p<.01. '"p<.001. ""p<.0001.

this. In about another 25% of cases, the primary wage earner was one of the woman's

parents or another family member. In about an additional 25% of cases, the woman

herself was the primary wage earner or shared this role equally with her husband or

partner (see Table 4.13). When the woman was either the primary wage earner, or shared

this role with her husband or partner, she was much more likely to breast-feed than

women who were not in a primary earning role, with primary earner or equal partner

women breastfeeding 78% of the time as compared to women not in a primary or equal

earning role breastfeeding 48.6% of the time (see Table 4.14). Considering that women

with higher educational attainment, who are more likely to breast-feed, might also be

more likely to incur higher opportunity costs in not prioritizing their careers, this

relationship was examined controlling for education. While results of this analysis were

not significant, the trend was reversed for women with high school diploma or less, with

primary or equal earners breastfeeding 33.3% of the time as compared to women not in

that role who breast-fed 41.9% of the time. For women with some college, primary or

equal earners breast-fed 71.4% of the time compared to others who breast-fed 51.5% of

the time. Women who had a four year college degree or more and were primary or equal

earners breast-fed 100% of the time and women in that educational category who were

not primary or equal earners breast-fed 88.2% of the time. Women with high levels of

education are likely to breast-feed regardless of their earning role. Even though these

findings were not statistically significant, they lend some support to the idea that

educational attainment may help explain the finding that primary and equal earner women

are more likely to breast-feed than are women not in that role. A similar study with a

large sample would permit this relationship to be investigated more thoroughly.

Breastfeeding Knowledee and Belief

In developing a scoring scheme for the Breastfeeding Knowledge Quiz, it became

obvious that not all of the items had objective right or wrong answers. While some items

clearly called for factual knowledge, others must be more accurately classified as

attitudes or beliefs. Therefore, the Quiz was separated into two domains, resulting in two

scores, one for knowledge of breastfeeding, the other for beliefs supportive of

breastfeeding. For all breastfeeding knowledge items, those answering correctly breast-

fed more often than they bottle-fed. For six of the ten items, results were significant (see

Table 4.15). For the breastfeeding belief items answering "correctly," refers to answers

that indicate beliefs supportive of breastfeeding. As in the case of the knowledge items,

for of the items, those answering correctly breast-fed more often then they bottle-fed, and

for six of the ten items the relationship was significant (see Table 4.16). A score was

calculated for each of the two domains of the quiz, a knowledge score and a belief score.

The sample in general did poorly on the knowledge quiz with only 46.7% making a

passing grade of 7 or more items correct out of 10 (see Table 4.15). Additionally, only

49.3% of the sample obtained scores of 7 or more on the belief quiz. This information

underscores a lack of knowledge about breastfeeding among women who are having their

first baby, at least within this sample. It also illustrates the high degree of beliefs that are

not conducive to breastfeeding. Looking at the scores by feeding decision, we see that


Item Breast-feed Bottle-feed X2

Most women in the US today bottle-

feed their newborn babies. (F)

Bottle-fed babies are just as healthy

as breast-fed babies. (F)

Breastmilk contains elements not

found in formula. (T)

Almost all women are able to produce

enough milk to breast-feed

successfully. (T)

You must eat a lot of food to

produce good breastmilk. (F)

Most breastfeeding mothers can

eat their usual diet. (T)

65.4 (34) 34.6 (18) 2.46

69.5 (57) 30.5 (25)

59.4 (85) 40.6 (58)



65.0 (67) 35.0 (36) 9.40"

58.7(44) 41.3. (31) 0.24

57.4 (54) 42.6 (40)

Table 4.15, continued

Breast-feed Bottle-feed

A woman's sexual partner should

not touch her breasts if she is

breastfeeding. (F)

Strong emotions affect the quality of

breastmilk that a woman produces. (F)

Bottlefeeding is safer than breastfeeding

because you can always tell if the baby

is getting enough. (F)

There are many reasons why a

woman cannot breast-feed (cesarean,

twins, preemie, etc) (F)

65.1 (69) 43.9(37)

63.9(39) 36.1 (22)

62.8 (76) 37.2 (45)

63.5 (73) 36.5 (42)





'p<.05. "p<.01. '"p<.001. ""p<.0001.


Item Breast-feed Bottle-feed X2

It takes a lot of knowledge

to breast-feed correctly. (F) 66.1 (37) 33.9 (19) 3.21

Breastfeeding is more convenient

than bottlefeeding. (F) 75.0 (63) 25.0 (21) 25.32""

Weaning from the bottle is difficult. (T) 58.1 (43) 41.9(31) 0.32

Weaning from the breast is difficult. (F) 75.0 (45) 25.0 (15) 13.68"'

Breastfeeding will ruin

a woman's figure. (F) 57.1 (84) 42.9 (63) 0.67

Bottle-fed babies sleep better than

breast-fed babies. (F) 59.7 (74) 40.3 (50) 2.65

Table 4.16, continued

Breast-feed Bottle-feed

It is harder to lose weight

while breastfeeding than

while bottlefeeding. (F)

Breast-fed babies should always

be fed in private. (F)

It is too hard to breast-feed if you

have to go back to work. (F)

A woman cannot use many forms of

contraception if she is breastfeeding. (F)

61.5 (80) 38.5 (50) 9.42"

63.9(69) 36.1 (39) 8.19"

65.6 (63) 34.4 (33) 8.71"

72.6 (61) 27.4 (23) 20.05""

'p<.05. "p<.01. ""p<.001. ""p<.0001.

Note: Answering "correctly" indicates a belief that is supportive of breastfeeding.


Score Frequency Percent

Knowledge Score

Pass 70 46.7

Fail 80 53.3

Belief Score

Pass 74 49.3

Fail 76 50.7

Note: For the Belief Score, "correct" refers to breastfeeding supportive beliefs.


Score Breast-feed Bottle-feed X2

Knowledge Score

Pass 71.4(50) 28.6 (20)

Fail 43.8 (35) 56.3 (45) 11.64"'

Belief Score

Pass 82.4 (61) 17.6 (13)

Fail 31.6(24) 68.4 (52) 39.48""

'p<.05. "p<.01. "'p<.001. ""p<.0001.

Note: Answering "correctly" indicates a belief that is supportive of breastfeeding.

both scores are significantly related to the feeding decision. Over 70% of those passing

the knowledge quiz breast-fed while only 43.8% of those who failed the quiz did so.

More than 82% of those receiving grades of 7 or greater on the belief quiz breast-fed

while just 31.6% of those receiving scores of 6 or lower did so. These findings support

Hypothesis 9 that women with greater knowledge of the benefits of breastfeeding are

more likely to breast-feed than women with less knowledge of the benefits of

breastfeeding. Additionally, these findings illustrate that increasing general knowledge of

the benefits of breastfeeding should be one part any community level breastfeeding

initiative. Looking at the quiz item by item helps to identify the items most likely to be

associated with choosing to breast-feed, for example that breast-fed babies are healthier

than bottle-fed babies, that most women are able to produce an adequate milk supply and

breastfeeding can be done even with some special circumstances such as cesarean section,

twins, and premature babies. Examining items on the belief quiz likewise can help focus

public education efforts. Emphasizing the ease of breastfeeding and weaning from the

breast, and the compatibility of breastfeeding with a variety of contraceptive methods

appear to be important elements to include as well.

Breastfeeding and Bottlefeeding Problems

When asked whom they would ask or what they would do for breastfeeding

problems and bottlefeeding problems, there were significant differences only for

breastfeeding problems (see Table 4.19). Both breastfeeders and bottlefeeders were asked

about both feeding methods. There were no significant differences between breastfeeders

and bottlefeeders regarding the first response to whom they would ask or what they

would do for bottlefeeding problems. Both groups were much more likely to

say they would ask their doctor for help than any other person. While a few more


Breastfeeders For Breast- For Bottle-
Would Ask feeding Problems feeding Problems

Doctor 32.0 (27) 65.0 (55)

Other Expert 50.0(42) 13.1 (11)

Own Mother 8.3 (7) 11.9(10)

Others with Exp. 9.5 (8) 9.5 (8)

Bottlefeeders For Breast- For Bottle-
Would Ask feeding Problems feeding Problems

Doctor 69.8 (44) 71.4 (45)

Other Expert 14.3 (9) 7.9 (5)

Own Mother 7.9 (5) 14.3 (9)

Others with Exp. 4.8 (3) 6.3 (4)

Stop Breastfeeding 3.2 (2) NA

X2 28.95"" 1.67

'p<.05. "p<.01. "'p<.001. ""p<.0001.


breastfeeders then bottlefeeders would ask some other expert such as a nurse or lactation

consultant for help with bottlefeeding and a few more bottlefeeders than breastfeeders

would ask their own mothers, differences were small. Significant differences arise when

asked about breastfeeding, however. While bottlefeeders report a distribution of whom

they would ask for help breastfeeding problems that looks very similar to what they

would do for bottlefeeding problems, and what breastfeeders say they would do for

bottlefeeding problems, breastfeeders responses for what they would do for breastfeeding

problems is quite different, and highly significant. Only 32% of breastfeeders would go

first to their doctor for help with breastfeeding problems. Exactly 50% would ask another

expert such as a lactation consultant or nurse. Of the 51 women who would ask another

expert for help with breastfeeding problems, 82.4% breast-fed. Lactation consultants,

women who are personally experienced with breastfeeding and who have additional

training in that area, are employed by hospitals for the purpose of providing technical

support to breastfeeding women. These findings support Hypothesis 10 that women who

perceive that they have a source of technical advice to deal with breastfeeding problems

are more likely to breast-feed than are women who do not perceive such a source.

Epistemological Ouestions

Attempts at analysis of the epistemological questions soon revealed that the

framework advanced by Belenky et al. (1986), was not applicable to this sample.

Responses to the questions did not fall into the coding categories used so productively by

Belenky and her associates. Four alternative orientations or approaches to experts and

authority were developed which are similar to the epistemological perspectives of the

earlier research. The first category is called "expert orientation." In this orientation,

women have great faith in experts, rely on them for advice, and believe in the objective

truth of information garnered from medical experts. This category corresponds loosely to

the "received knowledge" perspective of Belenky et al. The second position is called

"traditional orientation." This category, which is not represented at all in the work of

Belenky et al. (1986), includes reliance on mothers, friends, family members, and others

with experience, including lactation consultants, but not physicians, for advice in the care

and feeding of infants. A third category, called "self orientation," corresponds to

Belenky's subjective orientation in which gut feelings and intuition are valued more than

advice and opinions of others. A fourth category is called "unknowable orientation" since

this represents the view that no one is really an expert and one cannot know what is right

or true--that there is no objective truth. Response categories of all five epistemological

questions were recorded according to these categories and scores were calculated for each

category. There was a much greater range of score for the expert category thatfor the

others, with scores ranging from 0 to 5. For this category, scores were dichotomized high-

-3, 4 or 5 and low--0, 1, or 2. The other categories scores ranged from 0 to 2 so those

scores were dichotomized some--1 or 2 and none--0. Looking at feeding method by

orientation scores we see that breastfeeding women are more likely to be low on expert

orientation and bottlefeeding women are more likely to be high on expert orientation

(see Table 4.20). Additionally, breastfeeding women are more likely to have some

traditional orientation while bottlefeeding women are more likely to have no traditional

orientation. This mirrors the finding reported previously that bottlefeeding women tend to


Orientation Breast-feed Bottle-feed X2

Expert Orientation

High (3, 4, or 5) (54) 44.4 (24) 55.6 (30)

Low (0, 1, or 2) (96) 63.5(61) 36.5(35) 5.13'

Traditional Orientation

Some (1 or 2) (110) 62.7 (69) 37.3 (41)

None (0) (40) 40.0 (16) 600 (24) 6.17'

Self Orientation

Some (1 or 2) (96) 58.3 (56) 41.7(40)

None (0) (54) 53.7 (29) 46.3 (25) 0.30

Unknowable Orientation

Some (1 or 2) (31) 41.9 (13) 58.1 (18)

None (0) (119) 60.5 (72) 39.5 (47) 3.45

'p<.05. "p<.01. '"p<.001. '"p<.0001.

rely on physicians for advice while breastfeeding women would look to others with

experience. Self orientation was not significantly related to feeding method. And while

scores on the unknowable orientation were not significant, some tendency for

bottlefeeding women to score in this orientation can be seen. While Hypothesis 11, that

women of different epistemological perspectives would differ with regard to the factors

that affect the infant feeding decision could not be tested, and therefore could not be

supported as it was originally advanced, these findings do lend support to the importance

of such factors in the infant feeding decision.

Additional Open-ended Items

Additional open-ended items not dictated by the hypotheses were also included in

the instrument packet. Analysis has revealed some interesting findings from these items.

The next item gets at the crux of the feeding decision. Women were asked what was the

number one reason that they chose the feeding method they did. As with all of the open-

ended questions, the drawbacks of beside interviews are clear. In-hospital administration

was chosen over mail survey or telephone surveys in the weeks following birth in an

effort to achieve the highest possible return rate and avoid bias. Acknowledging that new

mothers would be unlikely to complete mail survey questionnaires or be available for a

telephone interview, in-hospital administration seemed preferable. The trade-off has

proven to be the effects of being immediately post-partum and the intrusiveness of the

hospital routines limited the depth of the responses to the open-ended questions. While I

still feel that this method of data collection has its advantages, in a later study, I would

reduce the number of the open-ended questions and emphasize to the interviewers the


Reason Breast-feed Bottle-feed X2

Baby's Health (64) 75.3 (64) 0.0 (0)

Mother's Health (2) 2.4 (2) 0.0 (0)

Bonding (6) 7.1 (6) 0.0 (0)

Physical or mental

Discomfort of Breastfeeding (9) 0.0 (0) 14.3 (9)

Convenience (48) 8.2 (7) 65.1 (41)

Less Expensive (2) 2.4 (2) 0.0 (0)

No Reason (7) 0.0 (0) 11.1 (7)

Other (10) 4.7 (4) 9.5 (6) 113.72""

*p<.05. "p<.01. ""p<.001. ""p<.0001.

need to be persistent in obtaining more complete responses. While somewhat brief, the

responses to this item were, nevertheless, informative. There was very little overlap in the

reasons given for the feeding method chosen (see Table 4.21). The large majority of

breastfeeding women (75.3%) gave the baby's health as the primary reason for choosing

to breast-feed. A much smaller proportion of women gave each of the following reasons:

mother's health, bonding, convenience, less expensive, and "other." For breastfeeding

women this included such responses as "I always wanted to," and "Its what God made."

The number one reason given by bottlefeeding women for their choice was convenience

(65.1%). An additional 14.3% reported mental or physical discomfort with breastfeeding

as their reason for choosing to bottle-feed. Mental discomfort includes such responses as

"it just wasn't me," "it would be embarrassing in public," and "I just couldn't see myself

doing that." Slightly over 11% said they had no reason for their choice, and 9.5% gave a

reason coded in the "other" category. For bottlefeeding women this included such

responses as "I smoke and thought it would be bad for the baby," "baby will sleep better,"

and "my husband didn't want me to." These findings reiterate the need for education

stressing the ease as well as the benefits of breastfeeding. Some of these women said that

they were returning to work or school and it would be easier to bottle-feed for that reason.

While returning to work was not found to be a significant deterrent to breastfeeding, the

fact that it was mentioned by the women indicates the desirability of including

information on breastfeeding while working in any educational program.

When asked what advice they would give to another woman about infant feeding,

52% of the sample said they would give no advice. Of breastfeeders, 69.9% would advise

another woman to breast-feed, 1.9% (one woman) would advise someone else to bottle-

feed, and 28.9% would give no advice. Of bottlefeeders, 8.1% would advise

breastfeeding, 9.7% would recommend bottlefeeding and an overwhelming majority,

82.3% would offer no advice (see Table 4.22). Those offering no advice gave responses

like "its up to her," "no one can tell someone else what to do," and so forth. Those


Advice Breast-feed Bottle-feed X2

Breast-feed (63) 69.9 (58) 8.1 (5)

Bottle-feed (7) 1.2 (1) 9.7 (6)

No Advice (75) 28.9 (24) 82.3 (51) 56.01""

'p<.05. "p<.01. *"p<.001. ""p<.0001.

Those recommending breastfeeding gave reasons similar to the reasons giving by

breastfeeding women for their own choice. "She should at least try breastfeeding for the

health of the baby" is a typical response. Likewise, advise to bottle-feed was explained by

such statements as "its so much easier, especially if you work." Apparently, bottlefeeding

women are less likely to feel that one feeding method is objectively better than another.

Responses to the question "What does the word 'woman' mean to you?" have

proven to be most interesting (see Table 4.23). Although there was a tendency for


Meaning of "Woman" Breast-feed Bottle-feed X2

Definitional (41) 34.4 (29) 18.5 (12)

"Feminine" Traits (16) 10.6 (9) 10.8 (7)

"Masculine" Traits (67) 40.0 (34) 50.8 (33)

Other (26) 15.3 (13) 20.0(13) 4.73

'p<.05. "p<.01. "'p<.001. ""p<.0001.

breastfeeders to define "woman" definitionally more frequently than bottlefeeders--for

example, as an adult female over a certain age, or someone who has had a child--

differences were not significant. Over 34% of breastfeeders defined "woman" this way

while only 18.5% of bottlefeeders did so. Proportions defining "woman" in

stereotypically feminine terms--nurturing, caregiving, matemal--and those defining

"woman" in stereotypically masculine terms--strong, independent, able to work and raise

a family--were similar, as were proportions falling into the "other" category. What is

surprising is the proportion in the sample overall defining "woman" in stereotypically

masculine terms, almost 45% of all participants. Only 10.7% of the sample defined

"woman" in stereotypically feminine terms.

Logistic Reeression Analyses of Selected Variables

Unadjusted odds ratios of selected variables (see Table 4.24) reflect the results of

the Chi-Square analyses reported above. Including variables for theoretical reasons, we

can see how the odds of breastfeeding are effected by various levels of the these

independent variables. Passing the knowledge quiz increased the odds of breastfeeding by

3.21 over failing the knowledge quiz and passing the belief quiz, as compared to failing

the belief quiz increased those odds by 10.17. Women who planned to return to work

soon after the birth were not significantly more likely to breast-feed than those who did

not plan to return to work but women who viewed themselves as the primary earners in

the household or as equal earners with their husbands or partners were 3.76 times more

likely to breast-feed than those who did not view themselves this way. Women with high

exposure to bottlefeeding (knowing two or more women well who had bottle-fed their

babies in the past two years) were about half as likely (odds decreased by .44) to breast-

feed as women who did not have high exposure to bottlefeeding. Women with high

exposure to breastfeeding (knowing two or more women well who had breast-fed their

babies in the past two years) were almost 3 and 1/2 times as likely to breast-feed as

women without high exposure to breastfeeding. Having high support for breastfeeding

(having two or more individuals supporting breastfeeding) increased the odds of

breastfeeding by 7.81 as compared to women who did not have high support for

breastfeeding. Being an adult (over 21 years of age) as compared to being an adolescent

(less than 21 years of age) increased the odds of breastfeeding by 4.03 and having more

than a high school education increased those odds by 5.38 as compared to women a high


Variables Unadjusted Odds Ratio

Knowledge Score (pass) 3.21'"

Belief Score (pass) 10.17""

Primary or Equal Earner 3.76"

Exposure to Bottlefeeding (high) 0.44'

Exposure to Breastfeeding (high) 3.42"*

Support for Breastfeeding (high) 7.81""

Return to work fulltime 1.45

Age (adult--over 21) 4.03'"

Education (more than high school) 5.38""

Marital Status (living with husband or partner) 3.40"*

Race (white) 2.60"

*p<.05. "p<.01. "'p<.001. ""p<.0001.

Model 1 Model 2 Model 3 Model 4 Model

Belief score 10.24 7.93 8.75 7.85 6.78

Support for
breastfeeding 6.11 5.4 6.52 6.11

Primary or
equal earner 3.74 3.78 3.42

Exposure to
bottlefeeding 0.34 0.25

Exposure to
breastfeeding 2.68

Model X2 40.19 59.48 66.74 72.47 76.35
Improvement 40.19**** 19.28**** 7.26** 5.73* 3.88*

'p<.05. "p<.01. *"p<.001. ""p<.0001.
145 cases

school education or less. Being married or living with partner increased the odds of

breastfeeding by 3.4 over not living with a partner, and being white, as opposed to non-

white increased the odds of breastfeeding by 2.6.

Given the policy orientation of this research I am required to let relationships

among the variables take precedence over my initial assumptions and theoretical

considerations. I selected forward conditional logistic regression for the purpose of


identifying the most effective variables in predicting infant-feeding decision-making.

However, I chose the variables to be entered guided by theoretical notions and the results

that were reported earlier. Since there was evidence of high levels of multicolinearity

among the sociodemographic variables, marital status and education were dropped from

the analysis (See Table 4.25). These variables were highly correlated with age which was

included. Interestingly, the remaining sociodemographic variables, race and age were not

included in the final model. Knowledge about breastfeeding became non-significant as


Plans to return to work soon after birth was entered into this model for theoretical

reasons but did not gain significance. Breastfeeding supportive beliefs and having high

support for breastfeeding exerted the strongest effects on the odds of breastfeeding, with

each one increasing the odds of breastfeeding more than six times. Exposure to

breastfeeding increased the odds of breastfeeding by more than two, and high exposure to

bottlefeeding decreased the odds of breastfeeding by 25%. The only sociodemographic

variable that remained in the model was being primary or equal earner in the household.

This increased the odds of breastfeeding 3.42 times.

These findings underscore the ideological nature of the infant-feeding decision.

The fact that both race and age dropped out of the model indicates that differences in

these groups that are significant in the unadjusted odds ratios (see Table 4.24) are driven

primarily by ideological differences. These findings are encouraging from a policy

perspective because these ideological differences, by definition, are modifiable through



My findings regarding the relationship of demographic characteristics and

breastfeeding supported the findings of most previous research when examining

bivariate relationships of these variables. There is a clear trend for breastfeeding rates

to be higher among white women who are married or living with a partner, who are

older, and who have more education. There is also a relationship between number of

others supporting the decision to breast-feed and between both knowledge about

breastfeeding and breastfeeding supportive beliefs. Returning to the work force soon

after birth was not found to decrease the likelihood of breastfeeding, although that

reason was stated by some of the women as why breastfeeding would be too

inconvenient. One unexpected finding was that women who consider themselves to be

the primary wage earner in the family or an equal earner with their husband or

partner were more likely to breast-feed than women who did not see themselves that


Multivariate analysis was used to further investigate relationships among the

variables. Some variables that were previously significant became non-significant in a

logistic regression model (see Table 4.24). Only belief score, primary or equal earner

status, exposure to bottlefeeding, exposure to breastfeeding, and number supporting


breastfeeding retained significance. This implies that differences among those in

various sociodemographic categories can be explained by the fact that the significant

correlates of breastfeeding occur differentially in those various groups. Loss of

significance in multivariate analysis does not invalidate earlier bivariate findings. It is

still true that younger women are less likely to breast-feed and women with more

education are more likely to choose this method of infant feeding. Multivariate analysis

provides insight into why that relationship exists. For the purposes of developing

breastfeeding initiatives, it does not mean that we should ignore demographic

differences in target populations. Initiatives should still be tailored to various ages,

classes and races because different strategies might be appropriate to address this issue

among different groups.

Race was not significant when controlling for other variables in the model. This

suggests that the same factors that affect the breastfeeding decision for white women

are at work with non-white women, such as lower education or lack of support of

mother or partner. Further research is needed to more fully understand how African

American and other minority women decide on how to feed their infants.

Likewise, age became non-significant when controlling for other variables. As

in the case of non-white women, young women are apparently affected by the same

factors as other mothers.

Planning to return to work soon after birth did not significantly affect a

women's choice to breast or bottlefeed in either the bivariate or mulitvariate analyses.

The impact of returning to work on breastfeeding is more likely to be on duration,


rather than initation of breastfeeding. While not addressed in this study of breastfeeding

intentions, this issue is likely to be a productive area of research in the future. The one

way in which employ affects breastfeeding rates in this sample is the finding that

women who are primary earners in their households or equal earners with their

husbands or partners are more likely to breast-feed than women who are not in these


The Permission Theory of Breastfeeding

Knowledge of the benefits of breastfeeding is a more influential determinate of

infant feeding choice for some women than others. The benefits of breastfeeding are

known, even among many of those who choose bottlefeeding. Why, then, would

anyone choose a method of infant feeding that is "second best?" In this study, most

women who chose breastfeeding cited the baby's health as the primary reason for their

choice while most bottlefeeding mothers were most likely to say that it was for

convenience (see Table 4.21). Losch, Dungy, Russell, and Dusdieker (1995) suggest

that this represents a dichotomy between "mother-centered" and "infant-centered"

views. There is another possibility. In this still-patriarchal society, male approval is a

sought-after goal for a great many women. Cultural views of the breast as primarily a

sexual organ are pervasive (Morse, 1989; Small, 1994). Indeed, a woman's sexual

attractiveness may be viewed as her most valuable commodity. The female breast is of

primary importance in American culture in this regard. Breasts tend to be regarded as

existing to give sexual pleasure to a male partner, almost to "belong" to him (Morse,

1989). Evidence of the importance placed on meeting the cultural standard for female

beauty is ubiquitous. Recent controversy surrounding silicone breast implants has

revealed that breast augmentation surgery is quite common. The prevalence of anorexia

nervosa and bulimia further testify to the lengths to which women will go, often at the

expense of their health, in their attempts to achieve an illusive ideal of attractiveness.

To a lesser extent than major surgery or eating disorders, a large proportion of

American women are preoccupied with the pursuit of the cultural ideal that is currently

associated with female attractiveness to men. Ironically, studies show that women

underestimate the body size that most men find attractive (Rozin & Fallon, (1988).

Likewise, women tend to overestimate the degree of their husbands disapproval for

breastfeeding (Freed, Jones, and Schamler, 1992). While preference for a slim female

body and resistance to breastfeeding among men no doubt exist, women tend to

perceive greater levels of each than actually exist. This may be especially true for

younger women who have not yet established a long-term relationship with a man,

those single at any age, and those who are less well educated and are therefore more

dependent on male support in a pragmatic way. If a woman perceives that she would

risk the loss of male approval and/or male support by breastfeeding, it could be, for

her, an adaptive decision to bottle-feed. In this country, bottlefeeding an infant does

not result in severe health problems in most cases, and the advantages, while well

known, tend to be soft-pedalled in an effort to avoid generating guilt for women who

do not breast-feed. The decision then, for these women, is between a feeding method

that is perhaps not quite as good, but still acceptable, and one that is perceived as

having a negative effect on her ability to establish a relationship with a man, or to

maintain one if she has a partner. With the persistent cultural valuation of the intact

family, establishing a permanent and long term relationship with a man would tend to

be perceived as important for the woman herself as well as for her child. This

explanation also accounts for the importance of the approval of the male partner, if she

has one, on her feeding decision. Under patriarchy, she needs the "permission" of her

partner to infringe on his territory--her breasts--by using them to nourish a child.

Women who are better educated may be less affected by such considerations. These

women may not only place a higher value on health benefits to the child, having been

socialized to utilize scientific findings in decision-making in general, but they may also

be less dependent on male approval. If they are professionals, they have access to

economic resources directly and might be less likely to feel dependent on their sexual

attractiveness as a means to achieve financial security for themselves and their children.

Furthermore, men with higher levels of education as well as more knowledge of the

benefits of breastfeeding are more likely to approve of breastfeeding (Littman,

Medendorp & Goldfarb, 1994), so not only are these women less likely to feel

dependent on male approval, they are more likely to have "permission" to breast-feed.

Women without a long-term partner would tend to perceive the "generalized

male other" as disapproving of breastfeeding--and to some extent she may be correct.

Freed et al. (1993) found that men commonly held misconceptions about breastfeeding

that included the belief that breastfeeding was bad for breasts and that it would interfere

in sexual relations after birth. In one qualitative study of that asked people from all

walks of life what they thought about breastfeeding, one man revealed open hostility to

the idea with his response, "breastfeeding? I'd cut my wife's tits off if she ever tried

it!" (Raphael, 1976). Such extreme attitudes, while rare, color the cultural view of


Women with a male partner would have an opportunity to ask him about his

views regarding breastfeeding and base the decision on information more grounded in

the reality of her specific situation. In some cases this will, of course, be that her

partner disapproves. In these cases, only the most independent woman, in terms of both

emotional dependence on the relationship and financial dependence on the man would

be very likely to breast-feed over the objections of this significant other. In other

words, the lack of a supportive male partner--whether this is because she is single or

because she is married to a man who disapproves of breastfeeding--is a primary

deterrent to breastfeeding. The view of a particular man is not deterministic in all

cases, however. Some women might be so strongly affected by cultural influences that

they would not wish to breast-feed even if their partner did not object. Lack of

knowledge of breastfeeding and exposure to mostly bottlefeeding among women in the

peer group would also exert an influence. And some women, with a non-supportive

spouse, or without a partner, do choose to breast-feed. Women who have been strongly

socialized to value breastfeeding, particularly if they were breast-fed themselves, would

be less likely to see the breast as exclusively male territory and be less likely feel the

need for "permission" to breast-feed.

The concept of self-efficacy may be related to the permission theory of

breastfeeding in that women with high self-efficacy may be less likely to need male

permission to make the decision to breast-feed.. Utilizing a self-efficacy scale in a

future study of infant-feeding could investigate this relationship.

To better understand the origin of the appropriation of the female breast as an

organ for male pleasure we can look again to the work of Mary O'Brien (1981) and

Robbie Davis-Floyd (1990). O'Brien attributes the development of patriarchy to the

male need to mediate their sense of alienation from their biological paternity. Lacking

the physical mechanisms of pregnancy and childbirth that mediate the temporal gap

between conception and childbirth for women, and grappling with the essential

uncertainty of paternity that does not exist for women, men have sought to control

women and the children the bear in a variety of ways in various cultures throughout

recorded history. This has included the motivation to appropriate those mediating

mechanisms. Davis-Floyd argues that one of the elements that must be removed from

childbirth, if it is to support the technological paradigm rather than serve as a potential

route to empowerment for women, is its sexual associations. In childbirth this is

accomplished by shaving of the pubic hair and draping the area and by obliterating all

sensation through the use of anesthesia. Breastfeeding is, for many women, a sensual,

if not explicitly sexual experience. Bottlefeeding eliminates the possibility that the

breast will serve as a source of sensual pleasure for the women in the absence of her

male partner. Acknowledgment of breastfeeding as potentially sensual would require

the acceptance of the breast as a source of female pleasure whether as a result of the

sensually pleasing sensation of breastfeeding or as part sexual activity with her male

partner. Widespread bottlefeeding permits the female breast to become an object of

male pleasure, denying its potential as a source of sensual and sexual pleasure for

women. If, as according to O'Brien, the physiological processes associated with

childbearing give women a kind of advantage over men, cultural abandonment of

breastfeeding and the transformation of childbirth into a technological accomplishment

would eliminate that advantage for women. While few men or women would be likely

to articulate this explanation on an individual level, it is still a useful model of how this

culture view evolved.

Socialization for Breastfeedine

Two of the significant variables in the model fall into a category that might be

called "social support," with high exposure to bottlefeeding reducing breastfeeding

behavior and high numbers supporting breastfeeding increasing that behavior. These

variables might be more accurately classified as approval rather than social support,

however. The traditional general definition of social support address issues such as

having one or more individuals available to provide practical help, emotional support,

and technical information. Neither exposure to feeding method nor numbers supporting

feeding method are central concepts in social support. When further considering that

breastfeeding beliefs remained significant, while breastfeeding knowledge did not, a

picture emerges that suggests that socialization, rather social support may be a more

useful concept. Socialization, the lifelong social experience by which individuals

develop human potential and learn the patterns of their culture (Macionis, 1995),

includes the transmission of beliefs, behavior, attitudes and values. It also includes the

idea that socialization varies by class and that the process continues throughout the life

course. Numerous agents of socialization are acknowledged as contributing to the

socialization of any individual including parents, teachers, peers, and the media. Using

this framework, we can see that difference in attitudes toward breastfeeding in both

women and men, can be seen as resulting from differential socialization. Clearly,

knowledge of the health benefits of breastfeeding is more influential for some women

that for others, since the relationship between knowledge and breastfeeding disappeared

when controlling for other variables. Valuation of information regarding such health

benefits has been shown to vary demographically. For example, well educated

professionals are more likely to heed advice to exercise and eat low fat diets than are

members of lower socioeconomic status (Calnan & Rutter, 1986).

Development of Breastfeeding Initiatives

In addition to simply advancing knowledge about the decision to breast-feed

from an academic perspective, it is a goal of this study to provide information that can

be used to design community initiatives to increase the rate of breastfeeding.

In considering the best way to focus initiatives to increase breastfeeding rates, if

becomes clear that much more is needed than simply attempting to educate pregnant

women about the advantages of breastfeeding. This study supported previous findings

that the majority of women who breast-feed make that decision well before the last few

months of pregnancy when most prenatal education takes place. Most of the women in

this sample decided before the last trimester, with 40% deciding in the first 6 months

of pregnancy and over 28% deciding before pregnancy. Women who waited until birth

to decide were the most likely to choose bottlefeeding with almost 69% of women


waiting that long choosing bottlefeeding (see Table 4.3). This underscores the fact that

while prenatal education can have a positive effect, interventions should occur before

this point.

How then, should we proceed to develop effective initiatives? Since approval of

others for breastfeeding is so important, not only pregnant women, but society as a

whole must be re-socialized to support breastfeeding. While specific strategies to

accomplish this may vary in different age, socioeconomic and race/ethnic groups, the

idea remains the same. The pregnant woman is strongly influenced by those around

her, including her own mother, her husband or partner, her other relatives and friends,

and her health care provider. Efforts to increase rates of breastfeeding must therefore

include the general public. Much in the way that the use of child safety seats in

automobiles and the desirability of childhood immunizations have been promoted and

accepted by most Americans, breastfeeding must be promoted. Such promotion should

continue to include education of the benefits of breastfeeding--even though this variable

lost significance when other variables were controlled, it was the most common reason

cited for the choice to breast-feed. For some groups, such information is extremely

important in their decision-making process. Indeed, in education regarding the benefits

of breastfeeding, the advantages are often played down, apparently in an attempt to

avoid causing guilt for mothers who do not breast-feed. While it should not be the goal

of any promotional efforts to generate guilt, the full extent of the benefits of

breastfeeding should be made known. A public service campaign to raise breastfeeding

rates should also address "myths" about breastfeeding that were shown to be associated


with the decision to bottle-feed, such as the belief that weaning from the breast is more

difficult than weaning from the bottle, that bottlefeeding is more convenient than

breastfeeding, and concerns that contraceptive choices are limited by breastfeeding.

Beliefs that breastfeeding negatively affects the appearance of the breasts and that one's

sexual partner should avoid touching the breasts of a woman who is breastfeeding are

additional examples of myths that need to be corrected. A view of the breastfeeding

woman as asexual also needs to be altered. The opinion that breastfeeding should

always take place in privacy lend further support to the idea that breastfeeding, since it

involves the breasts, which are viewed as primarily a sexual organs, is itself classified

as a sexual act. Breastfeeding would therefore constitute a practice that falls somewhere

between infidelity and incest.

The finding that high exposure to bottlefeeding increased the likelihood of

bottlefeeding speaks to the critical need for appropriate interventions in groups with the

highest levels of bottlefeeding, such as young, minority women. Peer socialization may

be especially important in this group, so beginning to decrease bottlefeeding is a

particular challenge. Providing models of breastfeeding behavior is one promising

approach. The statement of one mother in this study, when responding to the question,

"why did you choose to [breast-feed or bottle-feed] your baby?" answered, "it just

wasn't me," and another, "I just couldn't see myself doing that." The challenge in this

group is, then, to find a strategy to overcome the powerful effects of peer socialization,

which would tend to reinforce the view that breastfeeding is incompatible with the

sexual attractiveness of women, until breastfeeding becomes more common. Providing

models of breastfeeding behavior, including peer counselors as well as celebrity

spokespersons for breastfeeding to whom these young women can relate seems a likely

avenue to pursue.

It is particularly important to develop an effective intervention for mothers of

the youngest ages. The proportion of teenage childbearing is high and these women

breast-feed at the lowest rates--in this study, almost one fourth (23%) were between the

ages of 14 and 18 years and over two thirds of them bottle-fed their infants.

Furthermore, the feeding decision for later children has been shown to be associated

with the feeding method chosen for previous children (DaVanzo et al. 1985). So even if

the circumstances that inclined a woman to choose bottlefeeding with her first child,

she would be less likely to breast-feed later born children.

Models of breastfeeding are lacking in our culture today. While it is somewhat

more common to see mothers nursing infants in such public places than it was 20 years

ago, it is still not the norm. And reports are still occasionally heard of women who are

arrested for breastfeeding or are asked to leave public places on the grounds that

breastfeeding constituted offensive behavior. Marchand and Morrow (1994) found that

the unacceptability of public breastfeeding was a key theme that emerged in a

qualitative study of minority women. Infants are seldom shown nursing in the media.

Neither television programming nor commercial messages frequently show babies

being breast-fed. Movies, likewise, seldom portray this activity. Incidental photographs

of infants in magazines generally portray them nursing from a bottle if they are shown

feeding at all. Children's books, with the exception of those intended to prepare young

children for the birth of sibling, likewise show mostly bottlefeeding. Indeed, even

college level texts conform to this pattern. One leading college sociology text uses a

close-up photograph of a newborn drinking from a bottle to illustrate the sucking reflex

(Macionis, 1995).

Just as the media have been enlisted in efforts to present the public with more

egalitarian roles for women and men and less stereotypical roles for minorities, the

cooperation of the media would constitute an extremely useful component in an national

breastfeeding initiative. The intentional portrayal of nursing babies could be a major

factor in changing socialization in the direction of favoring breastfeeding. Breastfeeding

could be portrayed as a casual, matter-of-fact occurrence in the lives of characters as

well as, in some cases, being spotlighted in the story lines of some programs. Public

service messages could be televised conveying information about advantages and

providing appropriate models of breastfeeding behavior. This would include the use of

spokespersons most appropriate for target groups. Such a campaign should utilize what

we know from the advertising world. For example, to reach young, single, black

mothers, an attractive young black woman, a bit older and a bit more affluent that the

average woman in the target group, would be shown breastfeeding her baby and talking

about breastfeeding as a desirable choice. Women of various races and ages should be

used to correspond to various target groups. In addition, men from various groups

should be depicted in some of these spots, reacting positively to the woman who is

nursing and speaking to prospective fathers regarding their favorable view of

breastfeeding. Subtle messages that the nursing mother is an attractive woman could be


an effective tool to dispel the idea of the incompatibility of these roles. These women

and couples could be portrayed in various settings, at home, in social situations where

they receive approval of others, at the pediatrician's office discussing benefits with him

or her, attending religious services, traveling, etc. The goal of these messages would

be to portray breastfeeding as something that a wide variety of women practice, that

breastfeeding can take place anywhere if done discreetly, and that others, especially

male partners, approve of the behavior.

Education about the benefits should take place in a variety of settings from

medical school to elementary school. The training of physicians should continue to

include the full range of benefits of breastfeeding as well as socialize medical students

to encourage women to breast-feed. Even though the feeding decision often takes place

before the woman discusses the matter with a health care provider, the input of this

professional is still an important factor, reinforcing the decision if it is already made.

Health classes from elementary school onward should include units on

breastfeeding appropriate to the age of the students. Family living classes in high

school and college courses in family, health and human sexuality should address the

issue ass well.

The advertising of infant formula manufacturers should be re-examined to

assure that the images and sub-text as well as the actual text do not convey the message

that their product is just as good as mother's milk. Distribution of formula to all new

mothers in the hospital should be curtailed. Although the infant-feeding decision is

likely to have been made long before the baby is born, the institutional approval of

these products that is conveyed when they given out by the hospital is


Efforts such as breastfeeding support groups and the provision of lactation

consultants should continue. Support groups such as La Leche League and others like it

should have the full support of health care providers and hospital personnel. Peer

counseling and other educational programs have been shown to have a positive effect

on breastfeeding behavior (Hartley & O'Connor, 1996). These efforts, in addition to

fulfilling their intended purpose of increasing breastfeeding rates in target populations

would contribute to a cultural image of breastfeeding as worthwhile.

While this study has contributed to knowledge of breastfeeding in a number of

ways, some shortcomings must be addressed. First, small sample size prevented some

kinds of analyses, especially the investigation of interactions among variables. Second,

interview conditions on the postpartum floor resulted in less depth of the open-ended

responses. The design of a later study should not only include larger numbers but

should make a special effort to facilitate fuller responses to the open-ended questions.

Implications for Future Research

The data presented in this dissertation offered evidence that suggested and

supported the development of the permission theory of breastfeeding, but this study

does not test the theory directly. A follow-up study should directly investigate the

attitudes which form the basis of this theory. Men and women of various ages as well

as children should be included. Questions would need to be carefully worded to access

ideas that may not be clearly articulated in the minds of those who hold them. Focus


groups would be a most useful method of data collection for such a study. The question

regarding why the woman chose the feeding method she did needs to be more fully

investigated. Particularly the response of bottlefeeding mothers that they chose to

bottle-feed because it was convenient needs further exploration. The concept of

convenience can include several issues, including, but not limited to, the time required

by breastfeeding itself. The time and energy required to pump and store breastmilk and

issues concerning the cooperation she has from her partner or other support person

should also be examined. The finding that women who are primary or equal earners

should be more fully explored in order to shed light on exactly why this should be the

case. Issues of balance of power as well as such factors as having a job that has enough

flexibility to permit breastfeeding while employed such be examined. Focus groups

could be used to investigate these issues.

One factor that could not be adequately explored in this study was

socioeconomic status. About 20% of the women did not know what their household

income was. (See Table 4.1). This indicates that others may have been unsure as well,

which renders these results unreliable. Evaluating this variable in a project that utilized

interviews would permit a trained interviewer to assess socioeconomic status

observationally and would help to confirm self-reported data.

A longitudinal study would allow the investigation of the influences of various

factors on the duration of breastfeeding. Do women vary in how likely they are to be

able to carry out their plans to breast-feed? The issue of returning to work needs


further investigation. Such a study would help to identify structural barriers to

breastfeeding and work.

A demonstration project should implement newly-developed initiatives so that

effectiveness can be evaluated. Such a project should target groups most at risk both in

terms of infant mortality and morbidity as well as low rates of breastfeeding.

It is my hope that this dissertation may prove useful increasing understanding of

the infant-feeding decision and in the development of initiatives that will increase the

rate of breastfeeding.



Patient's Name


Date / /


My name is I am working on this project with
doctors and researchers to better understand how mothers make decisions about
their babies and how health care providers can assist mothers in making these

In this questionnaire, we will ask you questions about your baby, your decisions
about how to feed your baby, and your attitudes and beliefs.

Your participation in this project is voluntary. You may refuse to be
interviewed, or you may stop the interview at any time. The obstetricians at
Forsyth Memorial Hospital have reviewed this project and given their approval
for their patients to participate.

All of your answers will be kept confidential. No one but the research staff will
know whether or not you participated. If results of the study are published, no
patients names will ever be used. Do you have any questions? May we begin?

Rev. 1-25-96

SECTION I. First we will ask a few questions about your baby.

1. What is your baby's date of birth? / /
mm dd yy
2. What is your baby's sex? male female

3. What was your baby's birth weight?

4. How long was your pregnancy? weeks

5. Where did you receive your prenatal care? Please circle the letter of your

1) Reynolds Health Center
2) County Health Department
3) Wake Forest University Physicians
4) Private obstetrician's office
5) Carolina Birth Center
6) no prenatal care
7) other (please specify)

6. How do you plan to feed your baby? (Read the question, allow
respondent to answer. If she says "formula feed," repeat back to her "will
formula feed entirely." If she says "breastfeed," say "with any
supplements?" then read the explanations that are in parentheses for
answers 2, 3, & 4 to place in the best category. Use 5 or 6 only if she says
those things.)

1) will formula-feed (entirely)
2) will both breast-feed and formula-feed (one bottle of formula a
day or more)
3) will breast-feed with some regular supplements (less than one
bottle of formula a day but at least one per week.)
4) will breast-feed (formula given rarely or never)
5) will "try to breast-feed"
6) will breast-feed a little, then bottle-feed.
7) still not sure

7. When did you decide whether to breast-feed or bottle-feed this baby?
(Circle one)

1) before this pregnancy
2) in the first 6 months of pregnancy
3) in the last 3 months of pregnancy
4) at the time of birth

8. How were you fed when you were an infant? (Circle one)

1) breast-fed
2) bottle-fed
3) both breast and bottle-fed
4) don't know

SECTION II. Next we will ask you about others who may have influenced your
choice to breast-feed or bottle-feed your baby. Circle the one best answer.

1. Did you discuss infant feeding methods with any of the following
people? (mark N/A, no, or yes.)

2. What was their response? (Ask for each person marked "yes" in Q1,
and mark in supported breastfeeding, supported bottlefeeding or
supported neither over the other.)

N\A no yes sup. BstF sup. BotF sup. neither
1. Mother
2. Sister
3. Gma
4. friend
5. hsb/prt
6. prt.hcp_
7. pedtrcn
8. others (specify) can be other sisterss, other friendss, other
grandmother, etc.

3. How many women that you know fairly well and spend time with,
including sisters, neighbors, friends, and so forth, have had babies in the
last two years?

women who have had babies

4. Of these women, how many bottle-fed their babies and how many breast-
fed them?

bottle-fed breast-fed

5. Did you attend childbirth classes during your pregnancy?

1) no
2) yes If yes, please tell us which classes you took and who
sponsored them.


Sponsored by:

6. Did you attend La Leche League meetings or any other class or meeting
specifically designed to provide information on breastfeeding?

1) no
2) yes If yes, please tell us the name of the organization that
sponsored the class or meetings that you attended.

1) La Leche League
2) Barbara Carter's breastfeeding classes
3) other (please specify)

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