Social Science and Medicine 52 (2001) 7181

Determinants of breastfeeding in the Philippines: a survival analysis

Teresa S.J. Abada*, Frank Trovato, Nirannanilathu Lalu
Department of Sociology and Population Research Laboratory, The University of Alberta, Edmonton, Alberta, Canada T6G 2H4

Abstract This study examines modern and traditional factors that may lengthen or shorten the duration of breastfeeding. Specically, health sector, socio-economic, demographic, and supplementary food variables are analysed among a large representative sample of women in the Philippines. It is proposed that while modernisation can lead to the adoption of western behaviours, traditional cultural values can also prevail, resulting in the rejection of certain aspects of modernity. The Cox Proportional Hazards model is employed for the analysis of breastfeeding. The results show that traditional factors associated with breastfeeding (use of solid foods such as porridge and applesauce, and prenatal care by a traditional nurse/midwife) do not play a signicant role in the mothers decision to continue breastfeeding. Factors associated with modernity are signicant in explaining early termination of breastfeeding (respondents education, prenatal care by a medical doctor, delivery in a hospital and use of infant formula). The ndings of this study suggest that health institutions and medical professionals can play a signicant role in promoting breastfeeding in the Philippines; and educational campaigns that stress the benets of lactation are important strategies for encouraging mothers to breastfeed longer. # 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Breastfeeding; Promotion of breastfeeding; Philippines

Introduction Breastfeeding plays a particularly important role in child survival in developing countries: it contributes to the childs immunologic defense system, and increases its resistance to disease. Breastfeeding also facilitates child survival through postpartum annovulation and postpartum abstinence as these increase the intervals between births (Human & Lamphere, 1984). According to Williamson (1986), both the incidence and duration of breastfeeding in the Philippines are on the decline. This trend is of major concern to ocials because family income is generally low, child nutrition is often inadequate, and there is little use made of modern family planning methods. To the extent that breastfeeding becomes less prevalent among mothers, fertility will remain high and child survival probabilities will not rise as much as they could.

*Corresponding author.

The decline in the initiation and duration of breastfeeding is an inevitable consequence of the modernisation process (Adair, Popkin & Guilkey, 1993; Akin, Bilsborrow, Guilkey & Popkin, 1986; Guilkey, Popkin, Akin & Wong, 1989; Guthrie, Guthrie, Fernandez & Estrera, 1983; Kent, 1981). In a broad sense, modernisation entails a rapid abandonment of traditional approaches to childrearing, and the adoption of modern practices, including the use of modern health services and the use of supplementary foods for infants, in favour of breastfeeding or prolonged lactation. Notwithstanding this generalisation, modernisation is seldom a process that involves a sudden change in behaviours from traditional to modern. This is particularly true during the early stages of modernisation (Romaniuk, 1980). As such, some aspects of breastfeeding behaviour can take on both modern and traditional features simultaneously. In this study, we examine both modern and traditional factors that may aect the duration of breastfeeding. Socio-economic, demographic, supplementary food and health sector variables will be

0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 2 3 - 4

72

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

analysed among a large representative sample of women in the Philippines. An understanding of these factors should prove useful in formulating policies that seek to promote breastfeeding in developing countries. Socio-economic and demographic factors Urbanisation is usually associated with lower incidence and a shorter duration of breastfeeding (Castle, Solimano, Winiko, Samper de Paredes, Romero & Morales de Look, 1988; Akin et al., 1986; Human & Lamphere, 1984; Ferry & Smith, 1983). The adoption of bottlefeeding in the urban areas is widespread both because it is considered to be more modern, sophisticated and convenient (especially if the mother works outside the home), and because there are fewer breastfeeding role models for urban women to emulate (Trussell, GrummerStrawn, Rodriguez & Vanlandingham, 1992). In the rural environment, however, breastfeeding calls for little change in lifestyle. The presence of additional family members in the household, in particular mothers-in-law, provides positive support for breastfeeding practices, encouraging mothers to breastfeed for a longer period of time (Stewart, Popkin, Guilkey, Akin, Adair & Fleiger, 1991; Butz, Habicht & De Vanzo, 1981). One of the key determinants of the decline in breastfeeding in the Philippines is the increasing level of education among women, a factor which plays a role in the adoption of modern ideas, and which usually leads to the abandonment of traditional practices regarding child care. This shift in the balance of family relations can manifest itself in the abandonment of traditional sources of inuence, namely extended family members, which can often result in breastfeeding of a shorter duration (Caldwell, 1979). The amount of time a mother has to breastfeed is determined by her occupation. Women involved in modern work, such as clerical, factory and professional jobs in the urban centres are often required to work away from home, thus reducing a mothers access to her child. On the other hand, women who are involved in traditional or informal work (agricultural activities, cottage industries and small scale marketing (especially in the rural areas)), have more exible schedules and this allows them to nurse their infants more often, thus maintaining longer periods of lactation (Human, 1984; Ho, 1979). The transition from traditional to modern societies has prompted a move away from breastfeeding of long duration, particularly among younger generations of women. For older women, a strong attachment to traditional customs and the experience of raising many children usually means a more rigid view of infant feeding patterns. Such women are more likely to reject modern breast milk substitutes and to rely on traditional forms of infant feeding, including prolonged breastfeeding (Kent, 1981).

On the other hand, increasing maternal age and high parity can also lead to breastfeeding of a shorter duration. Higher parity leads to shorter birth intervals and hence shorter times available for breastfeeding. It is also well established that parity is closely related to maternal age (Smith & Ferry, 1984). An older woman is more likely to have a greater number of children; hence the demands on her time are considerable which may lead to early termination of breastfeeding. Indeed, a large family size may not be compatible with the modern lifestyle in the city, leading to a shorter duration of breastfeeding. The demands of childcare coupled with the demands of a highly structured employment only increases the conict between the maternal role and the work role, which in turn reduces the duration of breastfeeding. High parity also leads to breastfeeding of a shorter duration among rural women. Poor nutritional status, particularly among older women can diminish the volume as well as the fat and vitamin content of breast milk (Jellie & Jellie, 1978). The result is that not enough adequate breast milk will be provided to the infant, thus hastening the early termination of breastfeeding. Supplementary food variables In the Philippines, certain supplementary foods, such as rice water, are considered culturally important and can aect the timing of the weaning process. For example, rice water, apple juice and tea brews are used as folk remedies for infant diarrhoea (Simpson-Hebert & Makil, 1985). Such beliefs strongly inuence the timing of the introduction of supplemental foods, which in turn aects the duration of breastfeeding. The early introduction of milk supplements results in the reduction in frequency of breastfeeding; this in turn may lead to a decrease in the mothers breast milk, which ultimately hastens the termination of breastfeeding. Moreover, the marketing activities of the infant formula industry have played an important role in providing alternative infant foods, especially in the urban areas, where the use of such substitutes alleviates the time constraints prompted by the changes in maternal lifestyle (Guthrie et al., 1983). Other solid supplements such as rice porridge, or applesauce may promote breastfeeding of longer duration. The infants weight is often a sign of successful breastfeeding and if such supplements are used early on the infants diet, then the improved overall health of the infant can encourage mothers to breastfeed for a longer period of time (Adair et al., 1993). The role of the health sector The type of advice provided by medical practitioners to mothers regarding breastfeeding is often conditioned by the marketing activities of the infant formula

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

73

industry. Health professionals who are involved in the prenatal care and the delivery of babies are often provided with advertising materials as well as free samples of infant formula to be distributed to new mothers (Adair et al., 1993; Stewart et al., 1991). Health professionals who consider infant formula to be better than breast milk can inuence their patients to adopt infant formula over breastfeeding. Studies have shown that prenatal care from a medical doctor and institutional delivery often results in breastfeeding of a shorter duration. This suggests that the movement away from breastfeeding is also a consequence of the replacement of traditional health care systems by the modern medical establishment (Mock, Franklin, Bertrand & OGara, 1985; Popkin, Yamamoto & Grin, 1985; Solimano, Winiko & Laukaran, 1984; Adair et al., 1993).

doctor have a greater probability of early termination of breastfeeding. 2. Women who deliver in a hospital as opposed to their own home have a greater probability of early termination of breastfeeding. Data and methods of analysis Data This study is based on data from the Individual Womens Questionnaire in the 1993 Philippines National Demographic Health Survey, conducted between April and June 1993. Information was collected on topics that included background characteristics (education, age), reproductive behaviour and intentions, availability of family planning supplies and services, breast-feeding, child health and maternal mortality. The maternity history contains a maximum number of six entries relating to births in the 5 years preceding the interview.1 The Integrated Survey of Households (ISH) developed in 1980, comprised samples of primary sampling units (PSU) and was employed to generate information on employment and socio-economic characteristics among a nationally representative sample of women aged 1549 years. A total of 2100 PSU was systematically selected for the ISH, 750 of which were selected for the 1993 DHS, with a probability of selection inversely proportional to the size of the barangay.2 The PSU selection, which was self-weighted in each of the 14 regions, was carried out separately for the rural and urban areas, using a two stage sampling design. The rst selection consisted of barangays and the second selection consisted of households within the barangay. A total of 1659 valid cases were obtained for the study.

Hypotheses A number of hypotheses are outlined in relation to each of the factors discussed in the preceding section. (A) Socio-economic and demographic factors } Wifes Education, Husbands Education, Wifes Occupation, Husbands Occupation, Maternal Age, Parity. 1. The higher the level of education the greater the probability of early termination of breastfeeding. 2. Involvement in professional/administrative jobs denotes a greater probability of early termination of breast-feeding, whereas involvement in agricultural/ domestic household services denotes a lower probability of early termination of breastfeeding. 3. The older the mother, the earlier the cessation of breastfeeding. 4. High parity women have a greater probability of early termination of breastfeeding. (B) Supplementary foods } Other Liquids, Infant Formulas, Solid Foods: 1. The earlier the introduction of other liquids and infant formulas into the infants diet, the greater the probability of early termination of breastfeeding. 2. The earlier the introduction of solid foods, the lower the probability of early termination of breastfeeding. (C) Health Sector Variables } Prenatal Care received from Traditional Nurse/Midwife, Prenatal Care from Medical Doctor, Delivery in a Hospital. 1. Women who receive prenatal care advice from a traditional nurse/midwife have a lower probability of early termination of breastfeeding, whereas women who receive prenatal care advice from a medical

Measurement of variables Dependent variable In this study, duration of breastfeeding is the dependent variable and is based on information pertaining to the last child of the respondent.3 The variable is
1 If the respondent had more than six births in the last 5 years, then only the last six are included in the maternity history. 2 Barangays are considered to be the smallest political subdivision that corresponds to a census enumeration area. 3 Potential errors may arise in the data, particularly for respondents who breastfed for a short time only, and may have failed to report this. But the study minimises the recall error regarding this concern since it focuses on the last child born in the last ve years.

74

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

calculated as the number of months that the mother reports having breastfed the child. The maximum number of months recorded in the survey was 40 months. Independent variables Socio-economic and Demographic Variables } Age, Parity, Highest Level of Education (Respondents and Husbands), Occupation (Respondents and Husbands). The age of the mother is measured as a continuous variable, in single years of age from 15 to 49 years. Parity is measured as the total number of children. Since the study focuses on women who have had at least one child, the lowest possible value assigned to parity is one. The education of both respondent and spouse is the highest level of schooling attained, measured as no education, primary, secondary, and post-secondary. The respondents and husbands occupation is also measured as a categorical variable: not working, agricultural job, self-employed, and household/domestic comprise one category, and professional/administrative, clerical/sales the other. Supplementary Food Variables } Age for Infant Formula, Age for Solids and Age for Liquids. These three variables represent the last childs age in months when the mother started to use food supplements on a regular basis. The maximum number of months is 30 months. Health Sector Variables } Prenatal Care } Doctor, Prenatal Care } Traditional Nurse/Midwife and Place of Delivery. Categories relating to prenatal care are dichotomous: no prenatal care from a doctor, and prenatal care from a medical doctor; no prenatal care from a traditional nurse/midwife, and prenatal care from a traditional nurse/midwife. The place of delivery is measured as either in a home, or in a hospital. Methods Survival analysis has been used in the analysis of breastfeeding. The 1993 Philippines DHS is a retrospective cross-sectional survey that provides maternity histories completed up to the time of the survey. It is expected, therefore, that the period between the start and the end of breastfeeding would vary signicantly among women. The survival analysis technique adjusts for truncation bias by incorporating both complete and incomplete segments of histories in the breastfeeding analysis (some women may be continuing to breastfeed at the time of the survey). The Cox proportional hazards (PH) model may be viewed as a multivariate life table, but unlike other regression techniques, this method uses censored data, and thus controls for truncation bias (Allison, 1984). This model allows one to stratify across factors that do not meet the proportionality assumption. In the present case, it was discovered that rural-urban

residence did not meet this assumption4 (SPSS, 1997; Kleinbaum, 1996). For this study, rural-urban residence is used as stratication variable (i.e. urban, rural) rather than as a covariate. Each stratum has a dierent baseline hazard function, resulting in hazard functions for the rural and the urban models. Descriptive statistics and the individual eects of the Cox regression analysis for each variable are given to provide a general overview of the covariates in the analysis. The Cox regression analysis is set in two stages. First, the various predictors are grouped into separate models. Model I consists of the socio-economic and demographic variables (education, occupation, age, and parity); Model II consists of the supplementary food variables; Model III consists only of the health sector variables. Next, all the predictors found to be statistically signicant from the previous three models are grouped into Model IV and analysed accordingly. The hazard function5 is expressed as: ht; z h0 tebz where h(t,z) is the hazard rate at time t, h0(t) is the baseline hazard function of t, b is a vector of coecients and z is a vector of covariates. It is assumed in this model that: (1) there is a hazard or risk of occurrence of the event of interest (in this case, the termination of breastfeeding) at each time t, and this is applicable to all members of the population; (2) at each time t, the respondents at one level of a given sub-group experience a hazard proportional to the reference category; the models are a function of time and regressor variables; (3) even though there will only be one set of coecients, the model is partitioned into two strata, one for rural residence, and the other for urban residence (Kleinbaum, 1996). The dierent baseline hazards for each rural and urban residence yields dierent estimated survival curves (see Fig. 1).

Results Fig. 1 shows the respective survival curves for rural and urban women. The survival curves represent the
The proportionality of hazards was checked via inspection of the plots of the log minus log survival function [hi(ti, Zi)] for strata dened by variables suspected of having a nonproportional eect on the hazard function. Results indicated that among all the predictors, ruralurban residence did not meet the assumption of proportionality of hazards. 5 A likelihood ratio test was also carried out to compare the log-likelihood statistics for the interaction model (ruralurban residence predictor variables) and the non-interaction model. The dierence in the LR statistic of the two models was 295.529291.616=3.913, which is not signicant at the 0.05 level. Therefore, we can conclude for these data that the noninteraction model is acceptable (at least at the 0.05 level).
4

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

75

Fig. 1. Survival curves for duration of breastfeeding in the Philippines: rural and urban samples, 1993.

probability of women who continue to breastfeed at any given time. The survival curve for rural women is consistently above that of urban women. At each point of duration, urban women have a lower probability surviving (continuing to breastfeed) relative to rural women. For example, at duration one, the probability of continuing to breastfeed for among urban women is only 0.650, whereas for rural women, the probability of continuing to breastfeed is approx. 0.825. Table 1 presents means and standard deviations of covariates. The average duration of breastfeeding is 7.5 months. The mean age of the mother for the sample is 33 years, while the average number of children born is 3.9. The following categorical variables are expressed in percentage values. About one half of respondents only attained up to a primary education, and only 22.1% have attained a post-secondary education. Only 16.1% are involved in professional and administrative work, whereas about 83.4% are involved in agricultural work, indicating that the majority of mothers still work close to home. The husbands education shows a similar pattern to the wifes education. Only 21.6% have achieved a post-secondary education. Unlike the respondents occupation, a greater percentage of husbands (50.1%) are involved in professional and administrative work. The mean age of the child at the time of the introduction of infant formula and other liquids on a regular basis is 9.4 months and 8.7 months respectively. Infants are weaned to solid foods earlier around 7.5 months of age, denoting the importance of certain cultural foods (rice porridge) as a means of promoting the infants health (Simpson-Hebert & Makil, 1985). Table 2 presents the individual eects of each of the variables on the duration of breastfeeding. Maternal age

is not statistically signicant. Women with a postsecondary education and those involved in professional/ administrative work and women with high parity are associated with early termination of breastfeeding. The husbands education and occupation were not statistically signicant. Women who had prenatal consultation with a medical doctor had a risk of ceasing to breastfeed that was 25% higher than women who did not consult a medical doctor. Those who delivered in a hospital were also associated with breastfeeding of shorter duration. Women who consulted a midwife had a risk ceasing to breastfeed that was 11% lower than their counterparts who sought prenatal care advice elsewhere. As hypothesised, those women who used infant formula and other liquids (such as rice water) early had a higher probability of ceasing to breastfeed. The eect for solid foods was not statistically signicant. The next three tables show the changes in the eects of the predictors once we control for other variables. Three separate Cox regression analyses were computed for the three models. Model I: socio-economic and demographic variables Table 3 shows that among the socio-economic and demographic variables, the respondents education, occupation, and parity are the only predictors that remain statistically signicant. For women with postsecondary education, the risk of ceasing to breastfeed is 1.52 times greater than in women without postsecondary education. Women who are involved in professional/managerial positions have a higher probability of ceasing to breastfeed than women involved in low skilled/agricultural positions. This nding is con-

76

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

Table 1 Means/percentages and standard deviations of covariatesa Variable Duration of breastfeeding Maternal age Respondents education No education Primary education Secondary education Post-secondary and higher Respondents occupation Household/domestic/agricultural work Professional/administrative/clerical Total number of children born Husbands education No education Primary Secondary Post-secondary and higher Husbands occupation Household/domestic/agricultural Professional/administrative/clerical Prenatal-care doctor Prenatal-care nurse/midwife Place of delivery (home) Place of delivery (hospital) Age for infant formula Age for other liquids Age for solids
a

Mean/percentages 7.5 33 3.3% 41.8% 32.8% 22.1% 83.4% 16.1% 3.9 2.7% 42.9% 32.8% 21.6% 49.9% 50.1% 49.6% 54.2% 59.0% 41.1% 9.43 8.74 7.59

Standard deviation 7.21 7.93

2.47

11.86 9.93 8.14

Source: in this and subsequent tables, gures, computed using data from 1993 Philippines National Demographic Health Survey.

sistent with other studies regarding maternal work and compatibility with childrearing, suggesting that the rigid hours associated with such types of employment can encourage the mother to use infant formula early, resulting in a shorter duration of breastfeeding (Van Esterick & Grenier, 1981; Butz et al., 1981; Ho, 1979). The relative risk for parity (as represented by total number of children born) is 1.4923 and is highly signicant at the 0.0001 level. It appears that the presence of additional children in the household would place more constraints on the mothers time thereby increasing the conict between work and motherhood. Model II: supplementary food variables Table 4 shows the eects of the supplementary food variables on the probability of termination of breastfeeding. Contrary to the hypothesis, the age for solids was in the negative direction, whereas the age for liquids was in the expected negative direction. Both eects were not signicant. The older the age at which infant formula is introduced into the infants diet, the lower the hazard rate. The relative risk is 0.9735, indicating that the hazard is reduced by 0.03% for each additional

month of infants age at which the introduction of infant formula is delayed. This nding is consistent with other studies in which the introduction of breast milk substitutes is associated with a relatively rapid cessation of breastfeeding (Winiko, Durongdej & Cerf, 1988; Castle et al., 1988). Model III: health sector variables Table 5 presents the estimated coecients and the relative risks for the health sector variables. The only predictor that was not statistically signicant is the prenatal care advice } traditional nurse/midwife. The estimated risk of ceasing to breastfeed is 1.1964 times greater for women who sought prenatal care advice from a medical doctor, in comparison to women who did not consult a medical practitioner. Women who delivered in a hospital had an estimated risk of stopping breastfeeding that was 15% higher than women who gave birth at home. Our study also shows that the movement away from breastfeeding is a function of the practices of medical practitioners in those facilities. These factors can aect the mothers attitudes towards breastfeeding negatively, which in turn encourage early use of infant formula, leading to early termination of breastfeeding.

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

77

Table 2 Proportional hazards (gross eects) of duration of breastfeeding: socio-economic, demographic, health sector and supplementary food variablesa Variable Maternal age h0(0)rural=0.0262; h0(0)urban=0.0631 No education (Ref) Primary Secondary Post secondary h0(0)rural=0.0301; h0(0)urban=0.0652 Respondents occupation Not working (ref) Agricultural Professional/administrative h0(0)rural=0.0339; h0(0)urban=0.0806 Parity h0(0)rural=0.0186; h0(0)urban=0.0459 Husbands education No educ (ref) Primary Secondary Post-secondary h0(0)rural=0.0318; h0(0)urban=0.0691 Husbands occupation Not working (ref) Agricultural Professional/clerical/administrative h0(0)rural=0.0438; h0(0)urban=0.0983 No doctor (ref) Prenatal Care } Doctor h0(0)rural=0.0420; h0(0)urban=0.0755 No Nurse/midwife(ref) Prenatal Care-Nurse h0(0)rural=0.0297; h0(0)urban=0.0807 Delivery-home (ref) Place of delivery-hospital h0(0)rural=0.0364; h0(0)urban=0.0801 Age for infant formula h0(0)rural=0.0452; h0(0)urban=0.0991 Age for other liquids h0(0)rural=0.0374; h0(0)urban=0.0871 Age for solids h0(0)rural=0.0363; h0(0)urban=0.0878
a

Coecients 0.0100 Education 0.0820 0.0779 0.4973

Standard error 0.0056

Relative risk 1.0101

0.0671 0.0636 0.0669

0.9213 1.0810 1.6443

0.1086 0.2196 0.3456

0.0444 0.0428 0.0385

0.8971 1.2456 1.4129

0.0748 0.0526 0.3673

0.0698 0.0681 0.0726

0.9282 1.0537 1.4438

0.2776 0.0400

0.3351 0.3367

0.7577 0.9612

0.2284

0.0406

1.2566

0.1194

0.0387

0.8874

0.1733 0.0235 0.0116 0.0108

0.0297 0.0027 0.0037 0.0064

1.1892 0.9768 0.9884 0.9893

L2 (Baseline) 15099.7550; P40.05;

4P 0.01; In these and the next tables, h0(0) represent the hazard at time 0.

Model IV: socio-economic, demographic, supplementary food and health sector variables Table 6 presents the results of the proportionality hazards model for the duration of breastfeeding. In this analysis, the socio-economic and demographic, health sector, and supplementary food variables that were found to statistically signicant from Models 1, 2 and 3 are entered together in one model. Education is used as a categorical variable. As education increases at the postsecondary level, the hazard rate is increased, suggesting

a greater probability of ceasing to breastfeed. The estimated risk of ceasing to breastfeed is 1.53 times that of women with no education. Women with postsecondary education are more likely to be involved in modern work requiring them to be away from their infants during the day, thus encouraging the early use of breast milk substitutes. The results also show that involvement in professional or administrative jobs increases the likelihood of ceasing to breastfeed by 15%. High parity, as represented by the total number of children born, is also associated with breastfeeding of

78

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181

Table 3 Proportional hazards model of duration of breastfeeding: socio-economic and demographic variables eectsa Variable Maternal age Respondents education no educ (ref) primary education secondary education post-secondary and higher Respondents occupation not working (ref) agricultural/domestic/home services professional/administrative/clerical/sales Husbands education no educ (ref) primary education secondary education post-secondary and higher Husbands occupation not working (ref) agricultural/domestic/low skilled agricultural/domestic/manual professional/administrative Parity
a

Coecients 0.0047

Standard error 0.0064

Relative risk 0.9953

0.0958 0.0967 0.4271

0.0812 0.0795 0.0892

0.9086 1.1015 1.5327

0.0014 0.1177

0.0480 0.0491

1.0014 1.1249

0.0838 0.0484 0.1013

0.0840 0.0838 0.0931

0.9196 0.9528 1.1066

0.1216 0.1158 0.4003

0.3367 0.3378 0.0406

0.8929 0.8906 1.4923

h0(0)rural=0.0197; h0(0)urban=0.0410. L2 (Baseline) 14045.0110; 2 Log Likelihood 13874.4420 (14 d.f.); model w2 improvement 170.5690; P40.05; P40.01.

shorter duration.6 Its relative risk is 1.47, indicating that an increase in parity by one child increases the hazard rate by 47%. This suggests that additional children place more constraints on the mothers time, thereby increasing the time costs involved with children, resulting in early termination of breastfeeding.7 For the health sector variables, prenatal care } medical doctor and delivery in a hospital remain statistically signicant. Consistent with the ndings in Model 3, prenatal care advice from a medical doctor and delivery in a private hospital are associated of breastfeeding of shorter duration. The relative risk for women who sought prenatal care from a medical doctor is 1.3319 while the estimated risk for women who delivered

6 The non-signicant eect of age in the previous models can be explained by the close relationship of age to parity. Since older women also have high parity, the eect of parity in this case masks the eects of maternal age. As such, parity has a more signicant eect than maternal age on the duration of breast-feeding. If age was included in this model, the 2 Log Likelihood was computed to be 14869.212 with a model w2 improvement of 280.590 and 10 degrees of freedom. When age was dropped from the analyses, the 2 Log Likelihood was 14609.388 with a model w2 improvement of 275.497 and 9 degrees of freedom. Since there has not been a huge dierence in the w2 improvement between the two models, dropping age from the analyses does not change the improvement in the model as much.

in a hospital is 15% higher relative to women who did not deliver in a hospital. It should also be noted that women who are more likely to consult with medical doctors are more likely to use a hospital for place of delivery. The weak eect of place of delivery can be explained by the close relationship between this predictor and prenatal care } doctor; i.e. prenatal caredoctor masks the eect of place of delivery on the duration of breastfeeding. The later infant formula is introduced in the infants diet the longer the duration of breastfeeding. The relative risk for age for infant formula is 0.98, indicating that an increase in the infants age as the time at which infant formula is used on a regular basis reduced the hazard of terminating breastfeeding by 3%. As previous studies also show, it would appear that for most children, milkfeeding involves either breast milk or
The eect of parity on breast-feeding also depends on who substitutes for the mothers childcare time (Uyanga, 1986). If the responsibility of childcare is allocated to older siblings and adult relatives then the mother may have less constraints in terms of balancing work and family which may encourage her to breastfeed for a longer duration. In rural areas, such support is more readily available. Unfortunately however, the data does not allow one to determine who is responsible for the child when the mother works, which then makes it dicult to establish a causal relation between substitutes for the mothers childcare time and the duration of breast-feeding.
7

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181 Table 4 Proportional hazards model of duration of breastfeeding: supplementary food variables eectsa Variable Age for infant formula Age for solids Age for other liquids
a

79

breast milk substitutes together. When mixed feeding is seen, it is likely part of a transitional phase leading to the cessation of breastfeeding (Castle et al., 1988, p. 23).

Coecients 0.0268 0.0027 0.0061

Standard error 0.0026 0.0067 0.0039

Relative risk

Conclusions
0.9735 0.9973 0.9939

h0(0)rural=0.0485; h0(0)urban=0.1032. Initial L2 (baseline) 15020.8620; 2 Log Likelihood 14894.1970 (3 d.f.); Model improvement 126.6650; P40.01.

Table 5 Proportional hazards model of duration of breastfeeding: health sector variables eectsa Variable Coecients Standard Relative error risk

Prenatal care No doctor (ref) Medical doctor 0.1793 No nurse/midwife (ref) Traditional nurse/midwife 0.0071 Place of delivery Home delivery (ref) Hospital 0.1363
a

0.0491 0.0457

1.1964 1.0072

0.0312
2

1.146

h0(0)rural=0.0431; h0(0)urban=0.0756. Initial L (baseline) 15100.4910; 2 Log Likelihood 15049.6590; Model w2 improvement 50.8320 (3 d.f.); P40.05; P40.01.

This analysis examined both traditional and modern determinants of lactation in the Philippines during 1993. The results indicated that traditional factors associated with breastfeeding (age for liquids, age for solids, prenatal care traditional nurse/midwife) did not play a signicant role in the mothers decision to continue breastfeeding. Factors associated with modernity were signicant in terms of early termination of breastfeeding. These include the respondents education, prenatal care with a medical doctor, place of delivery and the age at which infant formula is introduced. High parity was associated with shorter breastfeeding of shorter duration, indicating that the presence of additional children in the household can incur greater costs to the mothers time, thus resulting in early termination of breastfeeding (Becker, 1981). The time constraints imposed by work and motherhood, particularly among women with a post-secondary education and those involved in the wage sector, encourage early use of breast milk substitutes, which then leads to early termination of breastfeeding. The implications for labour force and educational policies points in the direction of the promotion of timesaving methods that can increase the likelihood of breastfeeding for a longer duration. These

Table 6 Proportional hazards model of duration of breastfeeding: socio-economic, demographic, health sector and supplementary food variables eectsa Variable Education No educ (ref) Primary Secondary Post Secondary Parity Respondents occupation Not working (ref) Agricultural/Domestic Professional/administrative Prenatal care No doctor (ref) Prenatal care } doctor Place of delivery Home (ref) Place of delivery } hospital Age for infant formula Coecients Standard error Relative risk

0.0485 0.1765 0.4282 0.3871

0.2146 0.2149 0.2225 0.0382

1.0497 1.1930 1.5345 1.4726

0.1111 0.1438

0.0710 0.0724

1.1175 1.1547

0.2866

0.0863

1.3319

0.1414 0.0230

0.0669 0.0027

1.1518 0.9773

a h0(0)rural=0.0162; h0(0)urban=0.0274. Initial L2 (Baseline) 14882.3890; 2 Log Likelihood 14609.3880 (9 d.f.); Model w2 improvement 275.4970; P40.05; P40.01.

80

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181 Butz, W. P., Habitch, J., & DeVanzo, J. (1981). Improving infant nutrition, health and survival: policy and program implication from the Malaysian family life survey. Santa Monica, CA: The Rand Corporation (The Rand Paper Series). Caldwell, J. (1979). Education as a factor in mortality decline. Population Studies, 33(3), 395413. Castle, M. A., Solimano, G., Winiko, B., Samper de Paredes, B., Romero, M. E., & Morales de Look, A. (1988). Infant feeding in Bogota, Columbia. In B. Winiko, M. A. Castle, & V. H. Laukaran, Feeding infants in four societies: Causes and consequences of mothers choices (pp. 4366). New York: Greenwood Press. Ferry, B., & Smith, D. P. (1983). Breastfeeding Dierentials. In World Fertility Survey Comparative Studies No. 23. London: International Statistical Institute. Guilkey, D. K., Popkin, B. M., Akin, J. S., & Wong, E. (1989). Prenatal care and pregnancy outcome in the Philippines. Journal of Development Home Economics, 30, 241272. Guthrie, G. M., Guthrie, H. A., Fernandez, T. L., & Estrera, N. (1983). Early termination of breastfeeding among Philippine urban poor. Ecology of Food and Nutrition, 12(4), 175202. Ho, T. J. (1979). Time costs of child rearing in the rural Philippines. Population Studies, 5(4), 643662. Human, S. L. (1984). Determinants of breastfeeding in developing countries: Overview and policy implication. Studies in Family Planning, 15(4), 170184. Human, S., & Lamphere, B. (1984). Breastfeeding performance and child survival. Population and Development Review, 10(Suppl.), 93116. Jellie, D. B., & Jellie, E. F. P. (1978). Human milk in the modern world. Oxford: Oxford University Press. Kleinbaum, D. G. (1996). Survival analysis: A self-learning text. New York: Springer. Kent, M. M. (1981). Breastfeeding in the developing world: Current patterns and implications for future trends. Washington, DC: Population Reference Bureau Inc. Mock, N. B., Franklin, R. R., Bertrand, W. E., & OGara, C. (1985). Exposure to the modern health service system as a predictor of the duration of breastfeeding: A cross-cultural study. Medical Anthropology, 9(2), 123138. Popkin, B. M., Yamamoto, M. E., & Grin, C. C. (1985). Breastfeeding in the Philippines: The role of the health sector. Journal of Biosocial Science, 23(1), 521. Romaniuk, A. (1980). Increase in natural fertility during the early stages of modernization evidence from an African case study. Zaire Population Studies, 24(2), 293310. Simpson-Hebert, M., & Makil, L. (1985). Breastfeeding in Manila, Philippines: Preliminary results from a longitudinal study. Journal of Biosocial Science, 9(Suppl.), 137146. Smith, D. P., & Ferry, B. (1984). Correlates of breastfeeding world fertility survey. Comparative Studies, No. 41. Vooberg: National Statistical Institute. Solimano, G., Winiko, B., & Laukaran, V. H. (1984). The determinants of infant feeding practices: Preliminary results of a four country study. In Research Consortium for the Infant Feeding Study. New York: Population Council, International Programs. SPSS (1997). SPSS Advanced Statistics 7.5. Chicago: SPSS Inc. Stewart, J. F., Popkin, B. M., Guilkey, D. K., Akin, J. S., Adair, L., & Fleiger, W. (1991). Inuence on the extent of

include improving the transportation that takes women to and from their barrios to their place of employment, provision of nursing breaks, exible working hours, and the availability of creches (Human, 1984). The results for the health sector variables showed that having prenatal care under the care of a medical doctor and delivery in a hospital was associated with breastfeeding of a shorter duration. This reveals that medical institutions and associated professionals are important sources of social inuence. The attitudes and practices of medical personnel can aect the reproductive and childcare practices. In addition, a hospital environment that encourages breastfeeding practices can aect the mothers decision to breastfeed for a longer time. For example, rooming-in policies, in which the infant is near the mother night and day and not kept separately in a nursery, allow the infant to be fed whenever he demands feeding rather than being fed according to a hospital schedule (Human, 1984). Increasing urbanisation, a key structural determinant of breastfeeding behaviour in many developing societies, will most likely limit the ability of policymakers to promote an increased awareness of lactation. The rise in education and labour force participation among women may enhance their economic status, but it will also likely lead to the abandonment of traditional values or practices regarding infant feeding. Lifestyle changes as inuenced by the mass media, the modern health sector, and the increased availability of modern consumer goods, will continue to aect the mothers decision to initiate, continue or terminate breastfeeding in modernising societies.

Acknowledgements A note of thanks is extended to the anonymous reviewers of this journal for having provided insightful comments and suggestions for revision. Of course, any errors or omissions are the sole responsibility of the authors.

References
Adair, L., Barry, P., & Guilkey, D. (1993). The duration of breastfeeding: how is it aected by biological, sociodemographic, health sector and food industry factors?. Demography, 31, 6380. Akin, J., Bilsborrow, R., Guilkey, D. K., & Popkin, B. M. (1986). Breastfeeding patterns and determinants in the near East: an analysis of four countries. Population Studies, 40(2), 247262. Allison, P. D. (1984). Event history analysis: Regression for longitudinal event data. London: Sage. Becker, G. (1981). A treatise on the family (1st edition). Cambridge, MA: Harvard University Press.

T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 7181 breastfeeding: A prospective study in the Philippines. Demography, 28(2), 181199. Trussell, J., Grummer-Strawn, L., Rodriguez, G., & Vanlandingham, M. (1992). Trends and dierentials in breastfeeding behavior: Evidence from the WFS and DHS. Population Studies, 46(2), 285307. Uyanga, J. (1986). Ruralurban dierences in child care and breastfeeding behavior in Southeastern Nigeria. Social Science and Medicine, 14(1), 2329. Van Esterick, P., & Grenier, T. (1981). Breastfeeding and womens work: constraints and opportunities. Studies in Family Planning, 12(4), 184197.

81

Williamson, N. E. (1986). Breastfeeding trends and the breastfeeding promotion programme in the Philippines. In M. Labbock, & M. MacDonald, Proceedings of the Intra Agency Workshop on Health Care Promotion Related to Breastfeeding. Washington, DC: Georgetown University Press. Winiko, B., Durongdej, S., & Cerf, B. (1988). Infant feeding in Bangkok, Thailand. In B. Winiko, M. A. Castle, & V. H. Laukaran, Feeding infants in four societies: Causes and consequences of mothers choices (pp. 1542). New York: Greenwood Press.