MIDWIFERY DIPLOMA CLASS 2012-2013

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19660926-0044-2012 19750307-0083-2012 19591022-0069-2012 19800602-0047-2012 19741024-0043-2012 19740320-0020-2012 19620228-0025-2012 19800320-0113-2012 19810721-9000-2012

TABLE OF CONTENTS
PAGES TOPIC..............................................................................................................................................2 ACKNOWLEDGEMENTS.............................................................................................................3 HYPOTHESIS.................................................................................................................................4 What is breastfeeding......................................................................................................................5 Historical review of breastfeeding...............................................................................................5-8 Basic and natural reasons for the promotion of breastfeeding........................................................8 Benefits of breastfeeding..............................................................................................................8-9 Benefits of breastfeeding to society...............................................................................................10 Breastfeeding protocol..............................................................................................................10-11 Prevalence and support of breastfeeding in the 20th/21st century.............................................11-14 Uptake of exclusive breastfeeding table...................................................................................15-16 Synopsis of literature review....................................................................................................17-26 Abstract.....................................................................................................................................27-28 Adapting/Bonding....................................................................................................................28-29 Antenatal protocol......................................................................................................................... 30 Hypothesis and assumptions.....................................................................................................30-34 Methodology and description of data collection......................................................................35-39 Questionnaire............................................................................................................................39-43 Considerations when planning data collection.........................................................................43-44 Possible limitations...................................................................................................................44-46

References..........................................................................................................47-48

Topic

Breastfeeding Practices Among Barbadian Women

PRINCIPLE INVESTIGATORS
THADDAEUS TOPPIN-HOLDER..............................Defence of subject matter

MARTIA KING......................................................synopsis of Literature Review

EVADNE PARRIS-BAKER...............................................................Framework

MICHELLE KIRTON.............................................Hypothesis and Assumptions

SUSAN BROOMES.............................................................Methodology/ Editing

CHARMAINE BRATHWAITE-GROSVENOR.............................Methodology

NAKIA WILLIAMS.........Considerations made when planning data collection

DIANA COX......................................................................................Questionnaire

JOLENE MOORE................................................Limitations/ Editing/compiling

Postpartum women in Barbados aged 31-45 years are more likely to breast feed exclusively than postpartum women in Barbados aged 1830 years. (Precise Hypothesis)

WHAT IS BREASTFEEDING? During pregnancy a womans body goes through several changes one being for the production of breast milk within the breast and mediated by the hormone prolactin. Breastfeeding is the feeding of an infant or young child with breast milk directly from female human breasts (i.e., via lactation) rather than from a bottle or other container. Babies have a sucking reflex that enables them to suck and swallow milk. Many specialists recommend mothers exclusively breastfeed for six months or more, without the addition of infant formula or solid food. Breastfeeding therefore is the act of a mother having her newborn baby (babies) suck milk out of their breasts.

HISTORICAL REVIEW OF BREASTFEEDING In the ancient Egyptian, Greek and Roman empires, women usually fed only their own children. However, breastfeeding was considered as something too common to be done by royalty and noble families, thus wet nurses were employed to breastfeed the children of the royal families. This practice became common over the ages, particularly in Western Europe, where noble women often made use of wet nurses. The Moche artisans of Peru (1800 A.D.) represented women breastfeeding their children in ceramic vessels.

Shared breastfeeding is still practiced in many developing countries when mothers need help to feed their children. In the 18th century male medical practitioners started to practice in the areas of pregnancy, birth and babies. These were areas traditionally dominated by women. Also in the 18th century the emerging natural sciences promoted and encouraged that women should stay at home to nurse and raise their children, like animals also do. Governments in Europe started to worry about the decline of the workforce because of the high mortality rates among newborns. Wet nursing was thought and believed to be one of the main problems. Campaigns were launched against the custom among the higher class system of the day of using a wet nurse. Women were advised or even forced by law to nurse their own children. The biologist and physician Linnaeus, the English doctor Cadogan, Rousseau, and the midwife Anel le Rebours described in their writings the advantages and necessity of women breastfeeding their own children and discouraged the practice of wet nursing. In 1752 Linnaeus wrote a pamphlet against the use of a wet nurse. Linnaeus considered this against the law of nature. A baby not nursed by the mother was deprived of the laxative colostrum. Linnaeus thought that the lower class wet nurse ate too much fat, drank alcohol and had contagious (venereal) diseases, therefore producing lethal milk.

Mother's milk was believed to be a miracle fluid which could heal people and give wisdom. The mythical figure Philosophia-Sapientia, the personification of wisdom, was believed to have suckled philosophers at her breast and by this way they absorbed wisdom and moral virtue. On the other hand, lactation was what related humans with animals. Linnaeus who classified the realm of animals did not by accident rename the category 'quadrupedia' (four footed) in 'mammalia' (mammals). With this act he made the lactating female breast the icon of this class of animals in which humans were classified.

In the nineteenth century Historian Rima D. Apple writes in her book Mothers and Medicine. A Social History of Infant Feeding, 18901950 that in the United States of America most babies got breast milk. Dutch historian Van Eekelen researched the small amount of available evidence of breastfeeding practices in The Netherlands. Around 1860 in the Dutch province of Zeeland about 67% of babies were nursed, but there were big differences within the region. Women were obliged to nurse their babies: Every mother ought to nurse her own child, if she is fit to do it. Mother's milk was considered best for babies, but the quality of the breast milk was found to be varied. The quality of breast milk was considered good only if the mother had a good diet, had physical exercise and was mentally in balance. In

Europe (especially in France) and less in the USA it was a practice among the higher and middle class to hire a wet nurse. If it was too difficult to find a wet nurse, people used formula to feed their babies, but this was considered very dangerous for the health and life of the baby.

BASIC AND NATURAL REASONS FOR THE PROMOTION OF BREAST FEEDING Research is repeatedly proving that breastfeeding is more than the act of transferring milk. Breastfeeding is nurturing. Even before mother-infant attachment research, the major reason to breastfeed was to provide a special bond between mother and child." Surprisingly enough, the major contraindication to breastfeeding remains the lack of desire to do so. BENEFITS OF BREASTFEEDING 1. Breast milk is readily available and always at the right temperature. 2. Breast milk is always pre-packaged. 3. The lactational amenorrhea method (LAM) has been proven to be 99 percent effective in the prevention of pregnancy in the post six weeks period. In contrast formula feeding mothers start contraception within six weeks of

birth, it has been proven that once a female breastfeeds exclusively, she may not become impregnated for six months to a year. 4. Breast feeding assists the uterus that was home to the fetus to contract and retract causing uterus to return to pre -pregnancy state. It also causes the abdominal muscles to tighten, and stops postpartum hemorrhage. 5. Breast milk does not cost anything. 6. Breast milk is transportable at all times. 7. Breast feeding has natural health benefits such as, it keeps the female slim, it greatly reduces the risk of breast, ovarian and uterine cancer, osteoporosis, and cervical cancer. 8. Breast milk is the only food type that a baby cannot become allergic or constipated to. 9. Breast milk has all the antibodies, nutrients, vitamins, sugars and proteins; it is a holistic meal for baby. 10. Breast milk is produced and the mother able to breast feed regardless of her nutritional and or dieting habits. 11. Breast milk is easily digestible. 12. Breast milk causes the babys stool to be less odorous and softer than if baby was on conventional milk formulas. 13. Supply always meets demand where breastfeeding is concerned

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The benefits of breastfeeding to society are:1. Promotes psychological stability 2. Promotes a healthy population 3. Enhances social adaptation /bonding of the infant 4. Reduces Governments health expenditure 5. Saves on foreign exchange 6. Promotes a healthy environment 7. Formation of support groups to promote breastfeeding exclusively on demand Breastfeeding Protocol This protocol is derived during the ten steps to successful breastfeeding, which are:1. Have a written Breast feeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour of birth.

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5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk unless medically indicated. 7. Practice rooming in allows mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial Teats or pacifiers also called dummies or soothers to breastfeeding infants. If breast milk had to be exclusively used by all expectant mothers, it would save the economy millions of dollars especially in here in Barbados where we have to almost import everything we consume as customers.

PREVALANCE AND SUPPORT OF BREASTFEEDING IN THE 20TH/ 21ST CENTURY In third world countries, particularly those in the sub Saharan African Continent, parts of Asia and the Indian Pacific rim and South America where poor levels of health and malnutrition is a major factor of death in children under 5, with 50% of all those cases being within the first year of life. International organizations such as

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Plan International and La Leche League have helped to promote breastfeeding around the world, educating new mothers and helping the governments to develop strategies to increase the number of women exclusively breastfeeding. Traditional beliefs in many developing countries give different advice to women raising their newborn child. In Ghana babies are still frequently fed with tea alongside breastfeeding, reducing the benefits of breastfeeding and inhibiting the absorption of iron, important in the prevention of anemia. In response to public pressure, the health departments of various governments have recognized the importance of encouraging mothers to breastfeed. The required provision of baby changing facilities was a large step towards making public places more accessible for parents and in many countries there are now laws in place to protect the rights of a breastfeeding mother when feeding her child in public. The World Health Organization (WHO), along with grassroots non-governmental organizations like the International Baby Food Action Network (IBFAN) has played a large role in encouraging these governmental departments to promote breastfeeding. Under this advice they have developed national breastfeeding strategies, including the promotion of its benefits and attempts to encourage

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mothers, particularly those under the age of 25, to choose to feed their child with breast milk. Government campaigns and strategies around the world include: National Breastfeeding Week in the United Kingdom The Department of Health and Ageing Breastfeeding Strategy in Australia The National Women's Health Information Center in the United States World Breastfeeding Week

However, there has been a long, ongoing struggle between corporations promoting artificial substitutes and grassroots organizations and WHO promoting breastfeeding. The International Code of Marketing of Breast-milk Substitutes was developed in 1981 by (WHO), but violations have been reported by organizations, including those networked in IBFAN. In particular, Nestl took three years before it initially implemented the code, and in the late 1990s and early 2000s was again found in violation. Nestl had previously faced a boycott, beginning in the U.S. but soon spreading through the rest of the world, for marketing practices in the third world. Some people for instance view women who breastfeed in public as being obscene but here in Barbados we accept this practice as culture and as an action that is

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necessary. However in many countries laws had to be passed to protect women and their rights to breastfeed in public such as in the United States where the House of Representatives appropriations bill (HR 2490) with a breastfeeding amendment was signed into law on September 29, 1999. It stipulated that no government funds may be used to enforce any prohibition on women breastfeeding their children in Federal buildings or on Federal property. Further, U.S. Public Law 106-58 Sec. 647 enacted in 1999, specifically provides that a woman may breastfeed her ch ild at any location in a Federal building or on Federal property, if the woman and her child are otherwise authorized to be present at the location. In Cuba, their constitution has indicated at Article 68 in the 1975 that during the six weeks after delivery of the baby the woman be allowed two extraordinary daily rest period of a half hour each shall be allowed her to feed her baby. My personal advice here is that once breastfeeding is done discretely while in public it should provide mother and baby as well as the public the privacy and respect to all.

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The following table shows the uptake of exclusive breastfeeding.

Country Armenia

Percentage Year 0.7% 20.8%

Type of feeding

1993 Exclusive 1997 Exclusive 1996 Exclusive 1997 Exclusive 1989 Exclusive 1994 Exclusive 1995 Exclusive 1993 Predominant 1993 Exclusive

Benin

13% 16%

Bolivia

59% 53%

Central African Republic 4% ( Chile Colombia 97% 19%

95% (16%) 1995 Predominant (exclusive) Dominican Republic 14% 10% Ecuador Egypt Ethiopia Mali 96% 68% 78% 8% 12% Mexico Niger Nigeria Pakistan 37.5% 4% 2% 12% 1986 Exclusive 1991 Exclusive 1994 Predominant 1995 Exclusive 2000 Exclusive 1987 Exclusive 1996 Exclusive 1987 Exclusive 1992 Exclusive 1992 Exclusive 1988 Exclusive

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Country

Percentage Year 25%

Type of feeding

1992 Exclusive 1988 Exclusive 1995 Exclusive 1991 Exclusive 1993 Exclusive 1998 Exclusive 1992 Exclusive 1990 Predominant 1993 Exclusive 1987 Predominant

Poland Saudi Arabia Senegal South Africa Sweden

1.5% 17% 55% 7% 10.4% 55% 98% 61%

Thailand

90%

99% (0.2%) 1993 Predominant (exclusive) 4% United Kingdom[30] Zambia 62% 66% 13% 23% Zimbabwe 12% 17% 38.9% 1996 Exclusive 1990 1995 1992 Exclusive 1996 Exclusive 1988 Exclusive 1994 Exclusive 1999 Exclusive

Therefore to all expectant mothers and mothers who have recently experienced childbirth, breast milk is best and breastfeeding for as long as is possible is ideal.

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For the Midwife, breastfeeding and breast milk is important to their role as midwives as this facilitates healthy work ethic for their own benefit i.e. positive bonding between mother and baby will bring great satisfaction to the midwife fueling her drive and trust for her need to carry on the good and positive work in maintaining a healthy and stable mother plus baby. For the lay person and society at large, breast feeding needs to be appreciated and embraced as the natural and most health wise way for the mother and baby, needs to understand that it has no cost to society or negative effects to either mother child or economy.

SYNOPSIS OF LITERATURE REVIEW Breastfeeding has been initiated from the conception of time. It has been seen as the most nutritional form of nutrition for the infant. Kleinmann (2004) stated that breast feeding benefits both the mother and the infant; it remains the ideal nutritional source for infants through the first year of life. The World Health Organisation advocates exclusive breast feeding for newborns and infants for the first six months of life. To them breastfeeding is ideal, but this has been met with some challenges. According to Chatterji and Frick (2003) maternal employment is negatively associated with both breast feeding initiative and breast feeding duration. The study indicated that women who returned to work

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within three months were associated with a reduction in breast feeding of a length four to six weeks. Arora, McJunkin, Wehrer and Kuhn (2000) examined those factors which influenced breastfeeding as it related to: feeding decisions by mothers; breastfeeding and or bottle usage; and the duration of breastfeeding among mothers whose infants received well child care from birth to one year. Their results indicated that there was a breastfeeding initiation rate of 44.3% and that by the time the child had reached six (6) month of age ,only 13% of these mothers were still breast feeding. The most common reason mothers chose to breastfeed were: benefits to the baby, naturalness and emotional bonding with the infant while the most common reasons for bottle feeding was mothers perception of fathers attitude, uncertainty regarding the quantity of breast milk and returning to work. The conclusion to their study is that there is a need for extensive education regarding the benefits of breastfeeding to be provided for both parents and optimally the grandmother, by physicians, nurses and the media before pregnancy or within the first trimester. The department of Maternal and Child Health at the University of Alabama examined the influence of knowledge and attitudes among mothers who practice exclusive breastfeeding in St. Anne, Jamaican. They found that the knowledge and attitude about breastfeeding among mothers who exclusively and nonexclusively

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breast feed and its duration was poor, and that mothers were twice likely to exclusively breast feed their infants if their male counterparts were the main bread winner in the home. In this study Chatman et al (2004) found that there was a high incidence, 98.2%, of mothers who initiated breast feeding but by six months postnatal only 22.2% of these women were exclusively breast feeding. As with other studies the main reason given for partial breast feeding was that the mothers thought that the infants were receiving insufficient milk. Gueri, Jutsum, and Organ (1978) conducted a study in Trinidad analysing the role mass communication play as it relates to breastfeeding. Radio broadcasting had the most significant effect; a positive correlation was made between the avoidance of bottle feeding before two months of age and maternal familiarity with the campaign media message. Kuan, Britto, Decolongon, Schoettker, Atherton and Kotagal (1999) conducted a cohort study and examined the care that mothers would have received initially after giving birth and the follow up care by the community nurse. The care was rated good to very good as indicated by the participants. The results indicated that seventeen (17) Percent of these women had stopped breast feeding by their 4 week interview. These women were specially selected; they only had vaginal delivery of a healthy full tem child and the mothers had planned to breast feed. However these

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women were mostly white, educated (82% had some college degree) married, older (maternal age of 29.3 years) and insured. The expected outcome as indicated above is that with higher initiation rates more women are expected to breast feed for longer periods of time. However this showed different results in Australia. Despite high levels of breast feeding initiation only 47% were found to be breast feeding exclusively or partially six months later; with marked differences among social groups. Foster, McLachian, and Lumley (2006) identified negative factors on breastfeeding; giving babies infant formula while in hospital, high maternal body mass index, self reported maternal depression or anxiety in the post partum period. These mothers tend to breast feed for shorter periods of time. In a study conducted by Kurzewski and Gardner (2005) at the University Hospital of the West Indies (UHWI); Jamaica, among eighty nine mothers attending their post-natal clinic who were interviewed at six weeks post partum. Most mothers; 97.8% had practised breast feeding. Of theses 29.9% practiced exclusive breastfeeding and 70.1% partial breastfeeding. Two women only practised bottle feeding. The results of the study revealed that breastfeeding patterns were not significantly affected by maternal parity, age, education, employment, or socioeconomic status as had been indicated in other studies. Of the 70.1% of babies who were being partially breastfed; 32% received commercial feeds, 52%

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received water, 14% juice and bush tea and 4% glucose water. Reasons given by the mothers for introducing supplemental items were to give extra water, breast milk not satisfying for baby, hiccups, insufficient breast milk, Grandma said, needed to return to work, to get the baby use to the bottle and to be able to leave the house. To give extra water and breast milk not satisfying scored the highest; 20% and 17% respectively. According to Melville, between 1987 to 1991, in Jamaica, despite deteriorating economic conditions when the Jamaican dollar was depreciated by more than two hundred percent (200%), there was a dramatic increase in consumer price index for food and drink and artificial feeding. Breast feeding decreased by ten percent during this time. He stated that though the price of formula during this time was out of reach for low income mothers they continued to bottle feed. His rationale given for the increase of bottle feed was related to the reduction of postpartum visits made on the third, fifth, seventh, and tenth days following post delivery by district nurses and a reduction in the number of group educational sessions carried out by the primary health care nurses at the antenatal clinic. The concept of breast feeding is becoming most important not only in health care centres but nationally and internationally. Countries; Governments, hospitals have signed on to becoming baby friendly; encouraging mothers to breast feed and discouraging the use of formula feeds.

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In 2000 the Sange Grande Hospital in Trinidad amended their Breast feeding policy. Their goal was to protect, promote and support breastfeeding in the Sangre Grande and the Eastern Region. Their main objective was to achieve a 90% initiation at their institution by 2002. It was done in accordance with National breastfeeding policy of Trinidad and Tobago (1996) and the joint WHO and UNICEF statement on Protecting, Promoting and Supporting Breastfeeding. The amendment policy compared exclusive breast feeding practices for the time periods 1992 to 1994 at one, two and three months of age for the island. At the time of report Trinidad and Tobago had a national prevalent breast feeding population of about 24%. Of the 24% exclusive breastfeeding during the first month of the infant fell from 68% in 1992 to 41% in 1994. During the second month the rate fell from 45% to 26%, and while during the third month from 29% to 19% during the same time period.

The degree of breast feeding in America has been established and they have set target goals for themselves. In a research study by Fein, Mandal and Roe (2008), entitled success of strategies for combining employment with breastfeeding, it concluded that feeding the infant from the breast during the working day is the most effective strategy for combining breast feeding and work. They examined four strategies used to feed neonates and infants; feed directly from the breast only,

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both pump and feed directly, pump only and neither pump nor breastfeed during the working day. For the outcome of breastfeeding duration; the two strategies that allowed direct feeding from the breast were associated with longer periods of breast feeding. In a cohort study conducted by Win, Binns and Zhao et al. (2006) they also found that mothers who express breast milk (at one or more time period) were less likely to discontinue any breast feeding before six months than those who had never express breast milk. In a Report of the Council on Scientific Affairs entitled Factors that influence Differences in Breast Feeding rates by Melvyn L. Sterling under the caption factors affecting breastfeeding he highlighted that employment policies and workplace characteristics can affect breast feeding rates. This is because the Family and Medical Health Act of 1993 (USA) provides full-time employees of large companies the right to twelve weeks of unpaid leave plus job reinstatement of for a range of medical and family reasoning including family leave. However some employees are not protected under this action especially those employed under a year. In his report sterling identified employer day care as a means to influence day care. There, mothers could take breaks to express their milk, or nurse their child who

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participates in employee-sponsored on site or nearby day care supporting breast feeding for mothers. Other work place accommodation for nursing mothers is the lactation room. Sterling alluded to a study which revealed that some races were more likely to breast feed than others. Mexican American showed a higher percentage (55%) to breast feed their babies than African Americans (15%). It was suggested that African Americans seem not to have been encouraged to breastfeed by health care providers. In his report he brought out the important role of health care providers. There was a need for medical doctors to assume a more active role in promoting breastfeeding to mothers. The Caribbean food and Nutrition Institute (CFNI) in 1999 documented guidelines for young child feeding practises in the Caribbean. They too promote breastfeeding practise for the first six months of life. Consideration, however, is given to mothers who have contracted HIV, HTLV1 and Hepatitis C infections to use breast milk substitutes as these infections can be transmitted during breast feeding. Mothers who have Hepatitis, Tuberculosis or have Type 1 diabetes are allowed to breastfeed; some with considerations attached.

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The Pan American Health Organization (PAHO) and the World Health Organization (WHO) in 1994 examined breastfeeding practices and the trends and the implementation of the international code of marketing and breast feeding institutes in the Americas. The breast feeding practices analysed were exclusive breast feeding, partial breastfeeding and bottle feeding. The report alluded to the fact that there was low prevalence of full exclusive breast feeding at four mo nths of age in most countries and territories contrary to the recommendations and goals set by the 1990 World Summit for Children. Only five of the twenty two countries who were analysed, reported predominant breast feeding practices. From the above mentioned report in 1993, the Dominica Republic reported 90 to 98% of mothers initiate breastfeeding exclusively at birth. Ten percent exclusively breast feed during the first three months and by six months very few mothers had continued the practice. Belize indicated that in1993 there was an increase of 6% more infants who at four months were breast feeding when compared to their 1988 data. In 1991 Mexico reported a prevalence of 5% partial breastfeeding rate which increased by 50% by the first month of age. Cuba reported a partial breast feeding rate at birth of 21.5%.it increased to 38.0% by the third month. Honduras reported

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partial breast feeding of 72.2% at birth which increased to 89.7% at four months of age. The report cited a study done by Calma (1991) which found that 28.5 percent of persons from El Salvador were exclusively breastfeeding at 4 months of age. This was up by 10 % of a similar study conducted by the same author in 1981. Breast feeding practices in Barbados appears not to have been greatly researched due to the unavailability of written literature. Two studies were found which addressed breast feeding in Barbados. Galler et. al (1999) research psychological variables which affect early infant feeding practices in Barbados. They found that there was a prevalence of 16% of mild depression at seven weeks and 19% at six months. A few cases of moderate to severe depression were present. Some disadvantage environmental conditions were present. Depressive symptoms at seven weeks postpartum predicted a reduced preference for breastfeeding at current and later infant ages. Galler et. al (1999) examined how infant feeding practices in Barbados predicted later growth in infants. This longitudinal study assesses infants at seven weeks, three months and six months.

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Abstract In the 18-30 age groups, body image is a main concern especially to the younger mothers. Their main concern are sagging breast due to breastfeeding, alteration in body image, the fact of wearing a bra more often, not being able to wear certain outfits, how the public would view them, breastfeeding minimally to break the bond between themselves and the infant as they may want to further their studies, go back to work or start a job for those who were unemployed before. In the 31-45 age groups, these mothers are more willing to breastfeed their infant exclusively as stability in this group are more settled emotionally and financially. They are not too interested in new trends in some fashions so the sagging breast is not a reflection to altered body image which is well defined. The objective of the framework is to examine postpartum mothers between the two age groups mentioned. The framework which is best suited to substantiate this study is Callista Roys Adaptation Theory. In her model she states that health is a state of being also a process of becoming an integrated whole. The client is being viewed as an adaptive system. The framework this model provides is to help in understanding human adaptive responses and interventions that can be used to foster their

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adaptation and the minimizations of stress. The nursing goal is to help the client to adapt to these changes in self-concept, physiological needs, role functions and their interdependent relations regardless of health, illness or age. As a mean, all postpartum breastfeeding mothers should and must adapt to lifes demands such as those outlined below to promote bonding. Meeting their infants demands Meeting their infants psychological needs Developing a positive self-concept to their needs Performing social and economic roles Achieving balances between dependence and independence, to fulfill their infants needs. ADAPTING/BONDING Adapting /bonding are emotional from one person to another. Psychologist John Bolby was the first attachment theorist, describing attachment as a lasting psychological connectedness between human beings and that it is believed to be the earliest bonds formed by children with their caregivers and have a tremendous impact that continues throughout life. Stating this serves to keep the infant close to the mother, thus improving the childs chances of survival.

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Adapting to breastfeeding can be a joy for some postpartum breast feeding mothers, while on the other hand it can be complex for others within both age groups mentioned. This involves continuous physiological, psychological and social time factors mainly the age factor. Adaptation/infant bonding however is pivotal for both age groups. Psychologically, adaptation / infant bonding can be difficult and demanding especially in a depressed client. This is a process which overlaps other physiological, biological and psychosocial processes associated with gains, losses, challenges mid-life crisis, and loss of self-care abilities throughout the remaining of their lifespan. Postpartum breastfeeding mothers who are non-compliant to breastfeeding their infants on demand is seen as a mal-adaptive and non-bonding parent to their infants. When such atrocity interferes, the non-compliance to breastfeeding on demand creates problems in bonding as well as the problems in the implementing of the ten steps to successful breastfeeding by the Baby-Friendly Hospital Initiative (BFHI) launched in 1991 in an effort by UNICEF and the World Health Organization (WHO) to ensure that all maternities, whether free standing or in a hospital become centers of breastfeeding. (Class notes) This can also cause interference to the mother, infant and society through health and finance to each.

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Antenatal Protocol During the Prenatal period, specific guidelines are outlined and handed down to mothers in the form of teaching and pamphlet by nurses in the polyclinics or doctors offices. These are set out to initiate the establishment of lactating to their infants. In this protocol mothers are thought of the importance of breastfeeding to mother, baby and society. What to expect while the infant is sucking such as tingling sensation, and the difficulties which can arise from baby not latching on, to sore nipples, flat nipples, cracked nipples, engorgement of the breast, warmth or infection of the breast, multiple birthing problems, expulsion of milk through the pump device especially when there is a large supply and storing of milk in the refrigerator. Hypothesis Breastfeeding mothers of both ages who are well educated about the ten steps to successful breastfeeding and who understands the importance of breastfeeding to the mother, baby and society, are more likely to breastfeed their infants on demand regardless of age more than those who are not educated and have no understanding. The above hypothesis is a complex hypothesis stating a predictable relationship between two or more independent variables and two or more dependent variables.

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Variable Independent: Level of educated and understanding of the ten steps to successful breastfeeding and the importance to mother, baby and society. Dependent: Breastfeeding. Conceptual: Participants were able to express their views through the method of interviews while filling out questionnaires at the interview site and knowledge tests through open ended question on the questionnaires. Operational: The ten steps to successful breastfeeding and the importance of breastfeeding to mother, baby and society was the measurement tool used. Sample technique: The technique used to research the topic was a Simple Random Sampling. Population: Postpartum breastfeeding mothers in Barbados between the 1830 and 31-45 age groups. Sample: This comprises of participants from the postnatal clinics at various polyclinics across Barbados. Participants were all living in the community of the research, their family members and their spouses.

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Hypothesis: If postpartum women are influenced by certain factors, then this will determine if they will choose to breast feed or not to breast feed. Variables: Independent Variable - influencing factors. Dependent Variables - choosing their method of infant feeding. Controlled Variable - postpartum women. Assumptions: The hypothesis of this study will assume the following: - what these certain influencing factors are. -Have postpartum women gave thought to the idea of breast feeding or bottle feeding. - Do postpartum women know the benefits of either method of infant feeding. - Have postpartum women who chose not to breast feed feel guilty for making that choice. Reviewing the Assumptions: For many women the decision to breast feed or bottle feed is based on their comfort level, lifestyle and specific medical considerations that they may have.

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Influences To Breast Feed: - Social Factors: These are the facts are experiences that guide an individual's personality, values and lifestyle. As it relates to breast feeding, it has been shown, based on breast friendly initiatives among communities, health care facilities and international organizations that women and families in Barbados have been heavily influenced and educated on the importance of breastfeeding their babies. The Queen Elizabeth Hospital, (the country's primary acute care medical facility, serving the community since 1964) is listed among the more than 134 countries that have been awarded baby friendly status. The Baby Friendly Hospital Initiative (BFHI) was launched by World Health Organization (WHO) and UNICEF in 1991 to promote breastfeeding worldwide. This initiative has allowed ten specific steps to be practiced which involve management and educating of women on the benefits of breastfeeding. This allows the woman to make an informed decision with the satisfaction that both she and her baby will gain benefits from breasting. Influences to not breastfeed: A variety of social factors contribute to a woman's decision not to breastfeed regardless of her knowledge of the benefits of breastfeeding. Medical factors also play a role in the woman's decision; with the incidence of HIV/AIDS it is advocated that infected women do not breastfeed their babies as a measure to prevent HIV transmission from mother to baby.

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Social Factors: As previously mentioned, these are the facts and experiences that influence an individual's lifestyle. As it relates to a woman's decision not to breastfeed the following may also be included among the social factors: - Time Constraints: some mothers have jobs or other children and nursing is a time consuming process; they may have only a short time home from work and don't want to start breastfeeding and then can't continue, due to intense dedication it takes to express milk, work and still breastfeed. - Family Influences: often times a husband doesn't want his wife to breastfeed because he feels that his wife's breast should be reserved for their sexuality. - Embarrassment: some women feel that it would be indecent to nurse in front someone else or simply she may not be comfortable with her anatomy as a food source. Deciding to breastfeed is a decision only the woman can make, and she should not feel pressured into choosing one way or the other, however, she should keep in mind the following points while making her decision. Breastfeeding is the healthiest method for young infants and it confers nutritional and immunological benefits for the infant that cannot be matched by non-human milk or formula.

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METHODOLOGY AND DESCRIPTION OF DATA COLLECTION The sample technique used would be random sampling. Cherry (2008) states that random sample is a subset of individuals that are randomly selected from a population. Because researchers usually cannot obtain data from every single person in a group, a smaller portion is randomly selected to represent the entire group as a whole. The goal is to obtain a sample that is representative of the larger population. In random sampling, each item or element of the population has an equal chance of being chosen at each draw. A sample is random if the method for obtaining the sample meets the criterion of randomness (each element having an equal chance at each draw). The actual composition of the sample itself does not determine whether or not it was a random sample. Least biased of all sampling techniques, there is no subjectivity - each member of the total population has an equal chance of being selected and information can be obtained using random number tables Obtaining information Consent for the study would be obtained prior to the visits to collect data through communication by letter from the Barbados Community College's Nursing

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Department, to the Director of Nursing Services at the Queen Elizabeth Hospital, Polyclinics and other private care facilities. Permission will be sought for the student researchers to conduct their surveys of clients in the antenatal clinic and wards such as B2 and B3. The respective institutions will notified their staff of the study and that they would be visited by the students. The student researchers then visited the clinical areas to be surveyed, Ward B3 and the Antenatal Clinic at the Queen Elizabeth Hospital, and the nursing office at the prospective institutions at a convenient date. The institutions will then be notified in advance that the student researchers will be visiting to conduct they surveys the following week. On a sole day the surveys will be conducted, the student researchers will seek the permission of the Ward Sisters and Nurses-in-charge at the Queen Elizabeth Hospital on entering the wards to conduct the patient surveys. When permission is granted, the student researchers will ask for recommendations of suitable clients between the ages of 16 and 45 years both primigravida and multigravida women. Data will be gathered from clients using structured interview schedules to record each individual's responses. The participation of the clients will be sought by explaining the topic and purpose of the study, and guaranteeing confidentiality. The overall number of clients participating in the study will be approximately 100 mothers. Completing questionnaires will be one hundred (100), which will be equivalent to the sample size desired to represent the population. The sample size

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desired to represent the population of antenatal and postnatal mothers who are breasting and who opt not to breast feed. One issue that will compound the sampling of the antenatal client population will be that there are eight polyclinics and all cannot be equally represented as students are attached to various polyclinics sometimes two students to one polyclinic. With student researchers being limited all the polyclinics cannot be adequately represented. The research may be compound by factors limiting their participation, such as, minor disorders such a nausea, vomiting, tiredness, fatigue, frequent micturition and abdominal discomfort. On post natal ward and postnatal clinic factors such as the crying baby, tired mothers a few clients napping at the time those interviews are to be conducted, some choosing not to participate, and some others being under the age of 16 years old. The ethical considerations in conducting clients interviews and questionnaires would be in keeping with the Belmont Report's principles of beneficence, human dignity and justice. Within the principle of beneficence, the right to freedom from harm will be enforced by reviewing all questions. Questions are not to be too intrusive and should not inflict psychological harm on participants before finalizing

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questionnaires and interview schedules. The right to freedom from exploitation will be upheld by assuring participants that confidentiality would be guaranteed in data collection as no names or other forms of identification will be recorded and data would in no way be used against them. Careful consideration should also be given to ensure that the potential benefits of the study to breast feed or not to breast feed will outweigh the risks taken by participants in the study. The principle of human dignity will also be a major consideration to the student researchers conducting this study. The right to self-determination will be afforded to every participant in the study, that is, each person will be made aware that participation will be voluntary and not mandatory. Great care will be taken to ensure that participants clearly understand their autonomous right to refuse participation. In keeping with the right to full disclosure, participants will also be informed of the title and purpose of the study, what will be involve in participating, and will be assured that there are no danger of them being victimized as a result of their participation owing to the level of confidentiality being enforced. Informed consent will be verbally obtained from clients before proceeding with the interview schedules and implied consent should be gained on receipt of the completed questionnaires. The principle of justice will also be a consideration. The right to fair treatment will be exercised in selecting participants in an unbiased way, and purposive sampling

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will be used to select clients (that is, based on clients who were eligible for the interviewing process, ie pregnant women 16 to 45 years old) The right to privacy will endure by taking care that questions were not more intrusive than necessary and that confidentiality and anonymity of participants was guaranteed.

QUESTIONNAIRE
Breast Feeding Practice among Postpartum Mothers in Barbados Dear Participant, We are interested in factors contributing to breast feeding. It is hoped that the results of the study can be useful in helping nurses to assist mothers in promoting and maintaining good breast feeding practices. Your participation would clarify factors contributing to the decision of postpartum women in Barbados to breastfeed or not to breastfeed and identify ways in which they can be improved. Results of this research are beneficial to the patient, the nurse and the institution. If you agree to participate, you will be asked to complete a 20 minute questionnaire. This questionnaire consists of statements relating to breast feeding. Although some studies have some degree of risk, the potential in this investigation is quite minimal. Your performance is anonymous and you will not incur any cost as a result of your participation in the study. Your participation is voluntary. If at any time during the session you wish to withdraw your participation you are free to do so without prejudice. If you have any questions prior to your participation or any time during the study, please do not hesitate to contact us. AUTHORIZATION: I have read the above and understand the nature of the study. I understand that by agreeing to participate in the study I have not waived any legal or human right and that I may contact the researchers at the Barbados Community College; Ms. Hutton Taylor (426-5944) department of nursing) or Mrs. Diana Cox at 255-1302 at any time. I agree to participate in this study. I understand that I may refuse to participate or may withdraw from the study at anytime without prejudice. I understand that if I have concerns about my treatment during the study, I can contact the Nursing Department at the Barbados Community College at any time. Participants signature: ____________________________________ Date: ______________ Witness signature: ____________________________________ Date: ______________

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PLEASE ANSWER ALL QUESTIONS

1. Age (18-22) 2. Marital status

(23-27)

(28-32)

(33-37) >38

Single

Married

Divorced

3. Level of education completed

Primary
4. Presently employed

Secondary

Tertiary

Yes

No

5. Amount of time worked at present job

2-5 years

Over 5 years

6. Was this pregnancy planned? Yes No

7. Primi gravida
8. Parity

Multi gravida

>4

9. Have you previously breastfed?

YES

No

Not applicable

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10. Where did you receive antenatal care with this pregnancy?

Polyclinic Private GP Private GYN/OBGYN Hospital

11. Did you attend birthing classes?

Yes

No

12. During the pregnancy did you plan to breast feed your baby? If no please state why

Yes

No..................................................................

13. Do you have a medical condition which will prevent you from breast feeding? If yes please state

Yes..........................................

No

14. Are you aware of the benefits of breast feeding to the mother and infant?

Yes

No

15. How long do you plan to breast feed your baby? ................ 16. Who influenced your decision to breast feed?

Family member peers Not applicable

mother

grandmother

Other Please state..............................................

17. Was your decision to breast feed influenced by a health care worker?

Yes

No

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18. Which health care worker was most influential in your decision to breast feed?

Nurse
19. Type of delivery

Doctor

Other

Vaginal Other

Caesarean section

Instrumental

20. How soon after giving birth did you receive a visit from your community health nurse? 4 weeks 6weeks Other....................... 21. How many teaching sessions did you have in relation to breast feeding? ......... 22. How soon after delivery did you initiate breastfeeding?............. 23. During the first three weeks post delivery did you

Exclusively breastfeed Other please state

partially breast feed

bottle feed

....................................................................................

24. What foods/ liquids have you given your infant other than breast milk since delivery?................................................................................................................. 25. How long do you plan to breastfeed your baby? .......................................................................................................................... 26. Does breast feeding make you feel closer to your baby? Yes No 27. When did you introduce formula? ................days ...................weeks

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28. Why did you introduce formula to your baby? ..................................................................................................................................... .................................................................................................................................... 29. Current age of infant.............. Weeks

Considerations made when planning data collection Our Target group as mentioned before will be primi-gravida and multi-gravida women at the QEH in the form of an interview and questionnaire, considerations that will be taken in this form will be: Obtaining the women permission to carry out the interview, explaining to them whats my purpose of conducting the interview. Objectivity versus Subjectivity in carrying out my interview will try to keep own personal biases and opinions out and both sides will be given a fair consideration In an interview for these ante and postnatal mothers can have a standardize open ended interview where the women are allowed to answer the question how they would like instead of yes or no answer, this facilitates faster interview that can be analyzed and compared.

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In conducting this interview privacy should be considered to all patients therefore, a time, venue, amount of people will be interviewed at the time if agreed by the women should be taken into consideration . In collecting an interview one would like to cost less physical or emotional harm as much as possible from this target group of women from the Queen Elizabeth Hospital, therefore, when collecting information will be careful on how I word any questions asked. These clients should know whether their information will remain anonymous and confidential before conducting these interviews or questionnaire. The questionnaire will be easily readable and understandable, clearly relevant and to the point, not confusing and not too long it consist of 100 questions that the women will not lose interest in the questionnaire.

Possible limitations of the research project include: Reliability of the information received Obtaining suitable clients to participate in the study Obtaining permission to conduct the study in each area Students being able to reach all the locations to obtain data

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Educational level of the clients chosen Students are not allocated to all of the 8 polyclinics Clients comfort and cooperation Wording of questions so that clients understand

The main limitation identified for the study was obtaining suitable clients to participate in the study. Our research is based on clients between the ages of 18years to 30years. Most clients in recent times are between the ages of 15 to 45+. So although possible it might still be a challenge. Also finding suitable clients especially when encountering clients with antenatal or postnatal problems which may prohibit them from breastfeeding exclusively e.g. HIV positive clients. The reliability of information received is also another limitation which we may encounter, to combat this we have decided to ask clients the questions as opposed to the client completing the questionnaire. This method of obtaining information also ensures the reliability of it and omits misunderstandings which can occur due to clients level of understanding and education. Therefore attention was placed on the construction of questions so that clients understand what is being asked and answer accordingly.

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Obtaining permission and being able to reach the chosen areas for the research study is another perceived limitation. Letters detailing the research topic and target group need to be sent to the chosen areas in order to inform and obtain required permission to do the study. This also allows the heads of each institution to assist where possible and direct us in obtaining relevant data by choosing appropriate clients. The number of areas chosen outweighs the number of researchers. This can affect data collection since at least 100 participants are required in order to complete the study. Therefore group members have been allocated to the institution in their area to allow easy access to obtain data, along with the clinic they have been assigned to for their clinical allocation. The clients comfort and cooperation throughout the study can also be a limitation since some clients are sceptical about divulging pertinent information to students. Therefore the clients must be ensured of confidentiality and this can be assured by the head of the institution or someone assigned from the institution to assist students by introducing them to the clients with explanation of the study. A confidentiality clause should also be mentioned on the questionnaire and clients are assured that names are not used in the study.

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REFERENCES Arora, S., McJunkin, C., Wehrer, J., and Kuhn, P. (2000, November) Major factorsinfluencing breastfeeding rates: mothers perception of fathers attitude and milk supply. Paediatrics 106 (1) 67 Retrieved from the World Wide Web from http://www.paediactricsdigest.mobi/content/106/5/e67.full

Blackburn B, Silverman B, Schroeder B, Reitman D, Ambroz A (1981). "A method for assessing the quality of a randomized control trial Chalmers TC, Smith H Jr, Blackburn B, Silverman B, Schroeder B, Reitman D, Ambroz A (1981). "A method for assessing the quality of a randomized control trial" Chatterji, P., & Frick, K. (2003, April) Does returning to work after childbirth affect breast feeding practices? NBER Working Paper Series. Retrieved on October 29, 2012 from the world wide web from http://www.nber.org/papers/w9630

http://www.essortment.com/breast-feeding-nursing-women-choose-not-to55730.html http://www2-lv.psu.edu/j http://www.wisegeek.com/what-is-a-hypothesis.htm http://eprints.soton.ac.uk/34211/ http://www.askdrsears.com/topics/breastfeeding/why-breast-best/7-waysbreastfeeding-benefits-mothers

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https://www.llli.org/nb/nbjulaug01p124.html http://en.wikipedia.org/wiki/Breastfeeding

Kuan, L., Britto, M., Decolongon, J., Schoettker, P., Atherton and Kotagal, U. (1999, September). Paediatrics 104 (3). Retrieved November 25, 2012 from the world wide web from: http://www.ncbi.nlm.nih.gov/pubmed/10469811

Schroeder B, Reitman D, Ambroz A (1981). "A method for assessing the quality of a randomized control trial" Sergio B. Volchan What Is a Random Sequence? The American Mathematical Monthly, Vol. 109, 2002, pp. 4663 Sterling, M. (NYD) Report on the council on scientific research; factor that influence differences in breastfeeding CSA Report 2-A-05. Retrieved November 25, 2012 from the world wide web from www.amaassn.org/resurces/doc/csaph/a05csa2-fulltext.pdf

Win, N., Binns, C., Zhao, Y., Scott, J., Oddy, W. (2006) Breastfeeding duration in mothers who express milk. International Breast Feeding Journal 1 (28) Retrieved October 29, 2012 from the world wide web from http://www.internationalbreastfeedingjournal.com/content

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