Chapter 1

INTRODUCTION

Background of the study

Breastfeeding, also known as nursing, is the feeding of babies

and young children with milk from woman’s breast. Health

professionals recommend that breastfeeding begin with the first hour

of baby’s life and continue as often and as much as the baby wants.

During the first weeks of life babies may nurse roughly every two to

three hours. The duration of a feeding is usually ten to fifteen minutes

on each breast. Older children feed less often. Breastfeeding has a

number of benefits to both mother and baby.

Breastfeeding mothers have to be very careful about what they

consume as food. This because the food consumed might be passed

onto a baby. Breastfeeding also provide good nutrition for

babies/infants. It has nearly perfect mix of vitamins; protein and fat,

everything that the babies needs to grow. However, breastfeeding has

various disadvantages. The first challenge related to breastfeeding is

personal comfort. Usually, many mothers do not feel comfortable with

breastfeeding.

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 Although experts believe breast milk is the best nutritional

choice, breastfeeding may not be possible for all women so that they

also need the bottle-fed.

Most who bottled-feed, whether using expressed breast milk or

anything else, should be aware that while artificial feeding may seem

to be a very accurate measure of volume consumed, in fact it is often

not. Bottled-fed infants more often regurgitate some quantity of a

feed, or get a less than perfect balance of fore and hind milk than they

might if feeding directly from the breast. If a substance other than

breast milk is used, the increased metabolic workload for the baby,

lower digestibility of nutrients and increased waste substantially dilute

the benefit of a feed, although it is more easily measured.

Review of Related Literature

Mother’s bodies are a battlefield, and the weapons are

information. Information, subject to selection, manipulation, and

interpretation, derived by scientists and endorsed by governments, is

too often employed to create a circumstance where the choice to

breast or bottle-feed an infant in the manifold complexities of family

life is reduced to a judgment of good or bad, right or wrong. While

certain benefits of breastfeeding to both infant and mother have been

determined to exist, those findings and their value are not

2
uncontested. The pressure to sort through this information and make

correct choices is particularly high stakes in a social and cultural

environment that sees, and blames, personal choices as the root cause

of life’s ills, from obesity to miscarriage to breast cancer (Wolf, 2014).

In this environment, trusted authorities in governments and

health care systems have an obligation to provide sound policies and

recommendations, but even these organizations and professionals can

be bogged down by rhetoric, ideologies, and resentments. There is at

present a need for research and analysis to determine what

advantages to breastfeeding exist, the standard by which possible

advantages will be determined, and how and to what extent

breastfeeding can and should be promoted. These decisions should be

made with both the impact on the infant’s health and the health and

dynamic of families in mind (Wolf, 2014).

Current debates on breastfeeding stem from the development of

viable substitutes for breast milk in the early twentieth century. In the

1920s, the development of infant formulas, prescribed by doctors and

used under their supervision, took off in an environment that

increasingly valued the authority of science and the submission of life

choices to scientific measure, study, and knowledge. By the mid-

twentieth century, bottle-feeding was the norm (Wolf, 2014).

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 Infants were subjected to scheduled feedings of fixed quantities.

Their healthy development was measured by weight on the

paediatrician’s scale. At the same time, pregnancy and birth were fully

medicalized, with general anaesthesia and surgical intervention

common, and mothers and infants rooming separately in hospitals for

days and nights at a time (Nathoo & Ostry, 2013).

In response to this set of circumstances, La Leche League was

born in suburban Chicago and made its way to Canada in the early

1960s. Arguing that breastfeeding was a womanly art‖ that had been

usurped by (male) physicians, La Leche League provided breastfeeding

support for women unable to find it elsewhere (Nathoo & Ostry, 2013).

Though the group’s perspective and messages were considered

radical at the time because they opposed the medical establishment, in

essence much of its philosophy was and is socially conservative and

aimed at supporting married, heterosexual mothers who stay at home

with their children (Nathoo & Ostry, 2013).

Social conservatives generally have supported this upswing in

breastfeeding promotion against practices they see as threatening the

root of the traditional family and its defined gender roles. Making for

rather strange bedfellows, also in support have been feminists who

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find over-medicalization disempowering to women by usurping their

bodily agency (Wall, 2013).

In the 1970s and 1980s, attitudes within the medical community

shifted in favor of breastfeeding and it has joined in advocating

breastfeeding over formula feeding, citing studies that suggest health

benefits to both infant and mother (Nathoo&Ostry, 2013). The World

Health Organization (WHO) now recommends infants be breastfed

exclusively for the first six months of life, and supplementing table

foods for two years or more. These guidelines have been adopted by

Health Canada (HC) (Health Canada, 2014).

Even manufacturers of formula are apparently in agreement that

breast milk is best for babies. The website for Nestlé says of its Good

Start formula, nothing else is breast milk. But for those who can't

breastfeed, or for those who choose to supplement, one thing is clear:

nothing else is Good Start Probiotic our closest formula to breast milk‖

(Nestlé Good Start, 2013).

With such disparate groups in apparent agreement, the question

of whether an infant should be breastfed might seem an

uncomplicated one. Yet, though 89% of Canadian women initiate

breastfeeding, only 24% meet HC and WHO guidelines to breastfeed

exclusively for six months, suggesting that the way to sustain those

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initial efforts is eluding Canadian women. Furthermore, a new backlash

has arisen, primarily representing feminist voices which question the

validity of the empirical foundation behind medical recommendations

to breastfeed and criticize a policy of advocacy that shrouds ideology

in scientific data (Statistics Canada, 2014).

At the heart of the backlash is that while a wide range of the

health benefits to children are ascribed to breastfeeding by health

authorities and breastfeeding advocates, including reduced risk of ear

infections, asthma, gastrointestinal diseases, and greater IQ scores,

among other benefits, the scientific backing behind all of these claims

some consider weak (Wolf, 2014).

Only breastfeeding’s small benefit to the gastro-intestinal system

meets the standards of proof to the strictest critics. Breastfed babies

can expect to suffer one less bout of diarrhea in their first year,

compared to their bottle-fed peers. All other benefits are open to

debate (Rosin, 2013).

The new backlash does not represent advocacy of formula-

feeding or denigration of breastfeeding or breast milk. At issue is the

quality and implementation, some would say manipulation, of

information that is used to persuade and promote the practice (Knaak,

2014).

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 Debates surrounding breastfeeding and its merits demonstrate

the lack of neutrality of information, and the power of information.

Though attitudes and practices are changing, the lack of success in

achieving breastfeeding rate goals has been shown not to be the result

of a lack of persuasive information, but an incomplete information

package, one that often does not sufficiently acknowledge the context

in which it will be employed and interpreted. The result is that amidst

the barrage of data, statistics, anecdotes, policies, wisdom, and

certainties, the information families need to make well-informed and

clear-headed choices most appropriate to them is often lacking.

Instead, mothers are compelled to adopt or justify their choices in an

environment of bias and judgment ( Heinig, 2013).

Information about infant feeding comes from a wide range of

sources. A number of variables will determine how these rank in

influence and perceived authority to shape attitudes and settle

choices. For the purposes of this paper, it is sufficient to survey the

sources and the nature of the information widely available in order to

obtain a sense of the information environment in which parents make

decisions about infant feeding (Heinig, 2013).

For the present generation of women of childbearing age, their

own mothers may not be a particularly helpful resource on

breastfeeding issues because women of the previous generation

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overwhelmingly bottle-fed. While they cannot provide information on

their own breastfeeding experiences, they can point to their own

success with formula, which might be an appealing message for some

women who otherwise feel bombarded and pressured by the pro-

breastfeeding message (Andrew & Harvey, 2014).

Internet sources, magazines, and newspapers can present a

variety of perspectives, some of which I will consider below. A popular

Canadian parenting magazine is Today’s Parent which advocates

adherence to HC guidelines. An overwhelming number of websites are

dedicated to some aspect of infant care. One of the most popular is

the American BabyCenter.com, which has recently started new sites in

other countries, including BabyCenter.ca. Both sites consistently were

among the first listed in Google.ca searches for baby care and various

aspects of it (Andrew & Harvey, 2014).

A study by Rashley (2014) found that although the site provides

a wealth of authoritative information in the form of articles by

paediatricians and other experts on a broad range of issues pertaining

to pregnancy, birth, and infant care, it also contains a subtle bias in

favour of traditional gender roles, epitomized by married middle-class

breastfeeding stay at home moms. Articles, sometimes explicitly, tend

to assume this is the position of the site’s readers. This bias

marginalizes women who do not meet that description.

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 Discussion board sand reader responses to posted questions

could sometimes be quite hostile towards these mothers. Yet Rashley

also found the site’s sponsorship by formula companies compromised

its contents and suggested that women with breastfeeding problems

were better served elsewhere. Certainly, websites abound to cater to

almost every possible bias, but for a goggling parent looking for

general, trustworthy information, BabyCenter is a commonly consulted

family of sites (Rashley 2014).

Commercials, ads, and other marketing efforts on behalf of

formula manufacturers also contribute to the information environment.

As we shall see, though expectant mothers might not deliberately

consult such a source, aggressive marketing ensures that the message

as to how formula can benefit families is widely disseminated (Rashley

2014).

Another source, ostensibly neutral and therefore trustworthy, is

the federal government, working in tandem with doctors, other health

care professionals, and provincial governments to promote adherence

to HC guidelines. These efforts include the production of posters,

pamphlets, television commercials, and websites designed to inform

Canadians of the advantages of breastfeeding, counter the marketing

of formula, and alert the public to resources available to assist them,

including those not part of the government. Breastfeeding Basics, a

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publication of the government of Nova Scotia and distributed to new

mothers, includes La Leche League among services and programs

available to assist. It is the only body on the list not a part of the

government, which might cause confusion as to its nature (Statistics

Canada, 2013).

Times have changed since the heyday of formula feeding in the

mid-twentieth century, and many of the medical interventions

favoured at that time, including the promotion of formula, are largely

considered excessive today. Even so, the sale of formula is big

business; as we have seen above, 76% of Canadian women fall short

of meeting WHO and HC breastfeeding goals (Statistics Canada,

2013).

This shortfall is often understood as the result of inadequate

support to overcome the serious difficulties often experienced by new

mothers in their attempts to breastfeed (Hoffman, 2013), but other

factors, including the difficulty of sustaining breastfeeding after

mothers return to work, discomfort with the notion of breastfeeding

arising from the sexualisation of breasts, a desire for more equitable

division of child care within a couple, and a host of other purely

personal reasons are possible explanations (Friedman, 2013).

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 Nonetheless, formula manufacturers have seen their profits

jeopardized by current pushes to breastfeed and the concurrent

scrutiny of the relationships between formula manufacturers and

hospitals. Companies have long competed for exclusive contracts to

provide formula samples to hospitals. As research shows mothers have

tended to have brand loyalty to the formula they were given by

hospitals, these contracts have been critical marketing tools (Nathoo &

Ostry, 2013).

Hospitals are increasingly abandoning these contracts, however,

in order to gain compliance with WHO guidelines designed to support

breastfeeding. As a result, formula makers have changed their

strategies, marketing directly to mothers and grafting themselves onto

the message of breastfeeding advocates (Nathoo & Ostry, 2013).

When hospitals pass out formula samples, they do two things to

assist the formula manufacturer: they ensure that the product is on

hand should the temptation to use it ever arise, and by virtue of their

dual role as a centre of health authority and distributor of formula,

they endorse the product with reassurances of its safety and benefits.

Finding that they cannot continue to depend on the cooperation of

hospitals to ensure their product is on hand, formula companies have

sought to replace that tool in two ways. Websites, magazines, and

maternity clothing stores provide customers with the opportunity to

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sign up for product giveaways that include formula samples and

coupons in order to get the product into the homes of potential

consumers (Nathoo & Ostry, 2013).

To replace the endorsement of hospitals, formula markets have

coped their message, seemingly supporting breastfeeding advocacy

while offering their product as a complement to breast milk. In echoing

the position of health officials, formula advertisers borrow their

authority, and do not inspire the consumer to examine their claims

critically (Van de Geyn, 2014)

But these advertising campaigns do more than repeat

recommendations to breastfeed, they subtly add to them. While

searching Factiva for articles on breastfeeding in Canadian

newspapers, I came across an advertisement, disguised as an article,

in the Montreal Gazette. Entitled when feeding baby, breast is best, it

contained much basic, general information about the intentions of

many Canadian mothers to breastfeed and tips for how expectant

mothers should prepare for the arrival of their babies. It was only

when in the concluding paragraphs the author quoted a physician

recommending a specific brand of formula Nestlé Good Start and

extolling its unique qualities and benefits that I was alerted to the fact

that I was reading an advertisement (Van de Geyn, 2014).

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 Examining the ad once more with a critical eye, I saw how

skilfully information about breastfeeding was manipulated. The

advertisement cited an unspecified study that found the majority of

women expect breastfeeding to be natural and easy. This is not saying

that breastfeeding is natural and easy, but it does suggest the idea to

the unwary reader. Since the shock of the difficulty common in initial

breastfeeding attempts is believed to be an obstacle to sustained

efforts, this ad does its part to ensure that the reader is unprepared to

persevere when these difficulties occur to her (Hoffman, 2013).

The ad then goes on to suggest supplies needed for

breastfeeding moms: lanolin cream for sore nipples, ice packs for

engorged breasts, and formula, just in case the need arises. While

breastfeeding is made to sound easy, it is also made to sound

frightening and painful, which makes the suggestion to ensure there is

some formula on hand seem reasonable (When feeding baby, 2013).

Often the message of breastfeeding promotion is a narrow,

targeted one: breast is best, sometimes expressed as a corollary,

formula is bad. Since a major part of infant care and its measure is

infant feeding, the message then progresses to bad mothers feed their

babies formula. This message leaves very little room for mothers who

would prefer not to breastfeed, who cannot for health reasons, or

13
whose circumstances make it difficult or problematic (When feeding

baby, 2013).

Even Nestle (2013), in its advertising for its Good Start formula

quoted above, makes no room for these mothers when it explicitly

targets its product for those who can't breastfeed, or for those who

choose to supplement. Nestle has not lost track of its bottom line here,

but is nevertheless shying away from a direct conflict with the

language of breastfeeding promotion.

The message that formula-feeding is deviant is widespread and

explicit among breastfeeding advocates. Advocacy language that

focuses on the risks of formula has become increasingly popular in

response to the failure to achieve sustained breastfeeding rates to

match the high rates of breastfeeding initiation (Heinig, 2013). INFACT

Canada, a breastfeeding advocacy group, has 14 Risks of Formula

Feeding at the top of its website’s list of factsheets (INFACT Canada

Fact Sheets, n.d. 2013).

The use of risk language is significant because it increases the

intensity and judgement surrounding infant feeding decisions. Parents

who choose to formula feed are seen as not only not doing what is

best for their babies, but putting them at risk of compromised health.

This is particularly troubling in a cultural environment of limited

14
tolerance for risk and the expectation that mothers should be selfless

moderators and managers of all risks to their children (INFACT Canada

Fact Sheets, n.d. 2013).

Because of an understanding that formula-feeding mothers are

not acting for their children’s best interest, there is a widespread

belief, sometimes internalized by the formula-feeder themselves, that

they are not good mothers (Blum, 2013). That risk language is seen in

a Toronto Star article from earlier this year. In a criticism of a

proposed draft on infant feeding recommendations by Health Canada

that including formula feeding as an acceptable, though not best,

alternative, Kelly Matijcio, a lactation consultant was quoted saying,

We should be talking about the risks of artificial feeding and infant

formula and treating those methods of feeding as a separate

intervention that is only considered when medically indicated.

Breastfeeding is the biggest single factor that can affect a baby's

health. (Douglas, 2014)

The definition of formula as a medical intervention only allowable

under certain circumstances is an extreme one that makes formula

feeding aberrant with no allowances for personal circumstances.

Survivors of sexual abuse, who often find breastfeeding psychologically

traumatizing (Kukla, 2013), as well as women whose need or desire to

work outside the house does not facilitate sustained breastfeeding, are
15
villainies and marginalized by such a statement. This point of view is

given voice not only by Ms. Matijcio to her clients, but broadcast to the

Canadian population at large in this article that quotes her without

dissent, criticism, or context. It contributes to a culture of harsh

judgment and intolerance that spreads beyond the readership of the

Toronto Star (Stearns, 2013).

It is this kind of declaration that creates a difficult environment

for mothers who formula feed, no matter what the reason.

Demonstrating the persistence, and danger, of this message is a

recent editorial in the Vancouver Sun, in which the author railed

against the hostile atmosphere toward women who cannot or do not

breastfeed. The author struggled to breastfeed but hesitated to try the

alternative, brainwashed by the (National Childbirth Trust) NCT and

other hard-liner members of the Breastpin, I almost believed it was

better to starve my son than pollute him with formula (Maxted, 2014).

The attitudes described in these pieces have been in place for

over a decade. A Today’s Parent article title asked, in our zeal to

promote breastfeeding, have we turned our backs on the women who

don't? (Hoffman, 2013). The article cites a number of stories of women

who cannot breastfeed and resort to formula in an environment that

judges and shames them. One woman initially tried to hide the fact

16
that she was using formula even from a public health nurse. The

article’s author declares in response, we’ve worked so hard to make

breastfeeding the norm that we seem to have created a social

underclass of mothers who bottle-feed. Yet all of the examples used in

the article were of women who went to extremes in their efforts to

nurse before giving up reluctantly, and the conclusions of the article

were that more supports need to be in place for such women so that

their efforts will be rewarded with the success they have earned. While

sympathetic to women who have valiantly struggled to breastfeed

despite physiological difficulties, other women who, for whatever

reason, have simply chosen not to breastfeed are absent from the

article, and absent from the extension of sympathy and support

(Hoffman, 2013).

The author’s thesis is not that formula is an acceptable choice,

but confirms that it is a shameful one by explicitly placing blame for

the embarrassment and guilt the women described having suffered on

medical professionals for not doing more to assist breastfeeding,

instead of affirming that formula feeding is a legitimate alternative

whose use ought not to be condemned. Bottle-feeding women looking

for support will not find it here, and a message that initially looks

broader and more inclusive is revealed to be narrower (Wente, 2014).

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 More recently, Brian Goldman, host of the CBC radio show,

White Coat, Black Art addressed the topic of mothers who struggled

with breastfeeding and received a deluge of stories of women who felt

great pressure to breastfeed, even when extended efforts did not see

success (Wente, 2014).

One mother, whose infant was perpetually fussy, unsatisfied,

and continued to lose weight went for four weeks before tests

confirmed that she did not have an adequate milk supply and had

been starving her son. During that time her struggle was supervised

by public health nurses. Despite her baby’s failure to thrive, which is

measured through weight gain, formula had never been suggested to

her, even as a supplement. The women who shared their stories had

been made to feel that failing to nurse their babies was tantamount to

child abuse (Wente, 2014).

What voice fathers should have, and what role they should play

as caregivers when their partners breastfeed, are usually unaddressed

in breastfeeding promotion. Yet, they are far from unaffected by

infant-feeding decisions. The close bond that breastfeeding fosters

between mother and infant sometimes comes at the expense of the

father/infant attachment (Friedman, 2013).

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 Breastfeeding also fosters a dynamic in which mothers become

the primary child caregivers in general, even when a more equitable

division of lab our is desired by both parents (Stearns 2013). The time

and energies of fathers deserve to be better appreciated in households

where mothers struggle to fulfil all of their work and family

responsibilities, yet there are relatively few resources to address how

their contributions can be best utilized when mothers breastfeed

(Friedman, 2013).

Considering the widely shared beliefs of the benefits of

breastfeeding and breast milk for infants, it is perhaps not surprising

that there are widespread efforts to promote and support

breastfeeding practices. This is especially so given that formula

manufacturers have not been inactive in pursuing the largest possible

portion of a limited market share. But the quality of the information

available from all sources has begun to be questioned within the last

few years, even while the notion that breast milk is the only

acceptable food for infants has flourished (Friedman, 2013).

Many of the dissenting voices come from feminist academics

critical of an agenda that promotes a practice for the benefit of infants

without consideration of the possible negative impacts on mothers, or

without consideration of mitigating circumstances in the mother’s life

(Friedman, 2013).
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 One dissenting voice in popular media appeared in 2009, in an

article in The Atlantic Monthly by Hanna Rosin entitled “The case

against breastfeeding”. The title was inflammatory, and not truly

reflective of Rosin’s thesis which was that the scientifically-backed

benefits of breastfeeding are limited and thus the choice to breastfeed

or not should truly be a free and open choice, done without shame,

coercion, or judgement (Tiryakian, 2013).

The article lit a firestorm of controversy, with many knee-jerk

reactions responding more to the title than the contents. The United

States Committee on Breastfeeding urged its members to send a form

letter in protest to The Atlantic Monthly, and 976 people from 49

states did so (Tiryakian, 2013). Many of these reactions, including the

form letter just mentioned, did not address the question of limited

medical evidence. Instead, they refocused the issue on the lack of

support that adds to the difficulties of breastfeeding and called on

Rosin to join in attacking the institutions, norms, and practices that

contribute to those difficulties More recently, Joan B. Wolf’s book, Is

Breast Best? Taking on the Breastfeeding Experts in the New High

Stakes of Motherhood has challenged received wisdom of the medical

community (Wolf, 2014).

Wolf examines the question of breastfeeding in its cultural

context, including biases that inform scientific research. Among her

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conclusions is that the benefits of breast milk are framed in terms of

risk that is not contextualized. For example, every time a child is

loaded into a car, there comes risk of a possibly fatal accident, but

that risk is tolerated in the broader context of life. However, medical

studies framed in terms of risk are difficult to measure against other

factors, and quickly become absolutes (Wolf, 2014).

A further, more controversial criticism is that many of the

studies measuring the benefit of breastfeeding are not scientifically

sound. One frequent problem is a failure to control for confounding, or

other variables that might influence an outcome. For example,

breastfeeding rates are higher among well-educated, upper-middle-

class families. Is the good health enjoyed by children in those families

due to breast milk, or the other advantages at their disposal? (Wolf,

2014).

Too often, that question is not addressed. Wolf’s survey of

medical literature found that the more tightly the studies controlled for

other variables, the more equivocal the evidence to support

breastfeeding becomes, except in the case of gastrointestinal

infections, where proof of some benefit has been empirically

established (Wolf, 2014). Michael Kramer, a professor of paediatrics at

McGill University and a researcher who has designed some of the most

respected breastfeeding research agrees that better evidence is

21
needed to support many of the claims made by breastfeeding

advocates. Nevertheless, Kramer expresses belief that further research

will provide additional justification for breastfeeding advocacy, though

having just admitted the slim basis on which current advocacy rests,

one is left uncertain as to the foundation of this belief (Rumbelow,

2014).

The language with which medical research is communicated

within the medical community and to the public also skews the

information. One of the problems is the overwhelming quantity of

information that is produced, which makes appreciating its finer points

more difficult, especially for non-specialists. Wolf describes physicians

and scientists relying on conventional wisdom, passed on and repeated

without critical examination. For example, even when the authors of a

study find no statistically significant advantage to breastfeeding, they

repeat in their conclusions its established advantages, thereby

perpetuating this conventional wisdom within medical literature. At the

heart of this cycle is an inability to process and communicate the

critical details amidst an overwhelming wealth of information (Wolf,

2014).

The evolution of conventional wisdom about breastfeeding

exemplifies what economists call informational cascades,‖ a process of

information-diffusion in which an individual accepts the judgment of

22
another person or critical mass of others largely because the costs of

making his or her own evaluation in regard to time, money, or

intellectual energy, are too steep (Wolf, 2014).

This situation escalates when the information is exported from

the scientific community into popular discourse, where the training and

mindset to criticize established authorities are often lacking. Thus,

statistically insignificant suggestions become scientific facts (Wolf,

2014).

Others before Wolf have challenged the extent of the health

benefits claimed by breastfeeding advocates (Blum, 2013), but Wolf’s

extensive study and her conclusions are particularly important because

they have received attention from the popular media. The Globe and

Mail article that described the mothers featured on Brian Goldman’s

CBC show tied their struggles in with Wolf’s thesis (Wente, 2014).

In the UK, Helen Rumbelow (2014) wrote an article for The

Times later republished in Significance that followed up on Wolf’s

conclusion with established medical authorities, including Michael

Kramer. These are small, but hopefully significant steps towards more

responsible reflection of the state of information surrounding the

choice to breastfeed or not (Rumbelow, 2014).

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 Breastfeeding advocates convinced of the value and advantages

of breastfeeding over formula feeding, have implemented strategies to

provide women with the information they feel mothers need in order to

make the choice to breastfeed. Television commercials, pamphlets,

posters, magazine articles, and parenting websites have all been

utilized to popularize the conclusion that breast is best. When rates of

initiation or sustained breastfeeding have fallen short of expectations,

the solution has largely been to put out more information, centered on

the notion that mothers should be patient with the process of learning

and fear the risks of using formula. The limited success of these

information campaigns is an indication that the problem with the

failures to sustain breastfeeding rates is not solely due to a lack of

information (Heinig, 2013).

Studies have shown that the benefits purported by advocates are

widely known, even among mothers who chose not to breastfeed at

all. While Canada has guaranteed maternity leave and provincial laws

that largely protect the rights of nursing mothers to breastfeed in

public or find accommodation in their workplaces, problems remain.

Poor families, for example, may find that employment insurance

payments for maternity leave that come to 45% of usual earnings are

simply insufficient (Heinig, 2013).

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 In other cases, cultural associations, especially the sexualisation

of female breasts, make breastfeeding in front of others uncomfortable

and leave mothers vulnerable to lascivious or hostile gazes (Kukla,

2013). Many women find breast pumps uncomfortable and inadequate

for maintaining their milk supplies, which makes it difficult or

impossible for working mothers to continue to breastfeed even when

employers provide time and a comfortable space for pumping. Some

women, especially survivors of sexual abuse or assault but not limited

to them, do not like to breastfeed and do not want to do it (Kukla,

2013).

Better study and utilization of the information as to why some

women avoid breastfeeding and others do not meet WHO and HC

guidelines might help improve those numbers, though they are often

not likely to be problems that a little more information in another

public relations campaign can fix (Kukla, 2013).

A great service could be done to all Canadian parents by

acknowledging just what the stakes are in the breast versus bottle

contest. While some health benefits of breastfeeding are supported by

scientific findings, the medical support behind the more grandiose

claims of breast milk benefits is weak or non-existent. This is not to

say that greater benefits, currently unproven, may not be found to

exist with later study, but the present state of medical knowledge does
25
not justify the sometimes inflammatory message that serves to instil

guilt and shame in mothers and families who are doing their best to

cope with the challenges of infant rearing in the complexity of real life

(Kukla, 2013).

Those charged with the responsibility of supplying the public with

information on the health benefits of breastfeeding need to take into

consideration the incomplete state of knowledge regarding

breastfeeding’s purported benefits. The attitude found in medical

literature (Wolf, 2014) that suggests women should be advised to go

ahead and breastfeed even if the medical foundation for that advice is

weak assumes that message does no harm. For those people who for

any possible personal or physical reason cannot or desire not to

breastfeed in an environment where there is tremendous pressure to

do so, that message does do harm (Wolf, 2014)

Those concerned with the well-being of families, particularly

provincial and federal governments and associated agencies, should be

concerned not only with the quality and accuracy of the information

they provide, but the manner and tone in which it is provided (Wolf,

2014).

While a relationship between hospitals and formula

manufacturers is inappropriate, the relationship between hospitals and

26
health care workers with an ideologically driven organization like La

Leche League is also worthy of reconsideration. The group, run by

passionate volunteers with a number of resources at their disposal,

can provide much emotional as well as practical support for new

nursing mothers. For the current generation of women whose mothers

likely did not breastfeed, such an organization can provide tremendous

help and alleviate some of the burden from the health care system.

Yet, at the very least, clear information about the nature of the

organization and its agenda, and how it is distinct and different from a

department within the health care system should be plain to mothers

who are referred to their services and support (Wolf, 2014).

Coming up against the marketing tactics of formula

manufacturers, it is not difficult to understand why the voices of

breastfeeding advocates can be so strident. In the words of Kramer, a

leading expert on breastfeeding research, The trouble is that the

breastfeeding lobby is at war with the formula milk industry and

neither side is being very scientific when it comes to a crusade, people

are not very rational (Rumbelow, 2013). Among the causalities of this

war are the subtle bits of information, the equivocations, the details,

the contexts that turn a black-and-white issue into shades of grey.

With them, too often, fall comfort, peace of mind, and the ability of

loving, responsible women to be “good mothers” (Rumbelow, 2013).

27
 Exclusive breastfeeding for the first six months of a child’s life

has been promoted by the World Health Organization, the American

Academy of Paediatrics, the U.S. Department of Health and Human

Services, and Healthy People. The choice to breastfeed rather than

formula feed an infant as well as the duration of doing so has been

scrutinized, with more recent studies showing limited benefits

regarding the returns to breastfeeding when cognitive performance is

the outcome being analysed. Yet Healthy People 2010 had as its goal a

prevalence of 75% for breastfeeding and 50% for breastfeeding at six

months U.S. Department of Health and Human Services (USDHHS,

2014).

Nevertheless, empirically identifying the influence of

breastfeeding on child development is challenging for several reasons.

Breastfeeding may be the natural preference since it contains all the

nutrients a child needs and is designed for human infants. As the

primary or single source of sustenance in the first months of life, we

might anticipate an array of immediate and or longer-term

developmental benefits for the child. Yet understanding the potential

mechanism through which breastfeeding affects children’s outcomes is

important. Is it solely due to the nutrients contained in milk and the

lack of preservatives? Is it due to the increased bonding a mother

experiences with her child? Or is it due to potential problems with

28
formula? U.S. Department of Health and Human Services (USDHHS,

2014).

If the quality of the formula is at issue, joint policies to both

encourage breastfeeding and tighten regulations on infant formula

may be proposed to improve child health outcomes. Moreover,

breastfeeding is not a monolithic activity of given duration and

intensity, and is often undertaken in conjunction with some formula-

feeding. Finally, a potential identification issue that arises in this type

of study is that of statistical endogeneity (Baker and Milligan 2013).

Unobservable family inputs to child health (such as the mother’s

education) or circumstances related to the birth of the child (such as

prematurity) may be associated with breastfeeding. Such endogeneity

may show an effect of breastfeeding on child outcomes in linear

probability models when there is no causal effect (Baker and Milligan

2013).

This study attempts to address these issues using the Early

Childhood Longitudinal Survey – Birth Cohort. We use several

measures of breastfeeding in our analysis: (1) breastfed ever, (2)

duration of breastfeeding, (3) breastfed in the week prior to survey,

and (4) formula-fed at birth. Specifically, our comprehensive analysis

examines a range of developmental outcomes measured at multiple

29
points in time, including health, physical, and cognitive outcomes. With

detailed information on the birth circumstance, the family

characteristics, and the early development of the child, we are able to

take potential confounding factors into account. Our empirical method

is based on covariate models, propensity score measures, and

instrumental variables models using internally generated instruments

to understand the link between breastfeeding and child outcomes. We

also exploit the large subsample of twins available in our data to

estimate twin fixed effects models (Baker and Milligan 2013).

We believe these estimates are an advance over prior results.

Few prior studies simultaneously use longitudinal data where outcomes

at multiple points in time are analysed to gauge duration of effect;

explore a range of outcomes relating to health, physical, and cognitive

outcomes; and address causality using several econometric methods.

In addition, to our knowledge, this study is the first to assess

outcomes pertaining to maternal attachment, motor scores, and

physical activity. Our results indicate that breastfeeding and not

formula-feeding at birth are associated with increased probabilities of

being in excellent health at 9 months (Fein and Roe 2013).

Furthermore, breastfeeding is protective against obesity and

improves cognitive outcomes at 24 months and 54 months, but has

little effect on respiratory outcomes after 9 months. Breastfeeding for

30
6 months or more increases motor scores at 9 months. Broadly, these

results are not sensitive to model specifications (Fein and Roe 2013).

There are many independent determinants of the decision to

breastfeed and, as such, it is necessary to control for many different

factors. While difficulty with technique and concern over sufficient food

for the child have also been reported as obstacles to breastfeeding, not

being able to take time off work is the main reported reason not to

breastfeed (Baker and Milligan 2013), causing the marginal cost of

breastfeeding to be high if generous maternity leave laws are not in

place.

Baker and Milligan (2013) use variation in maternity leave

mandates across provinces in Canada to show that mother’s time away

from work is a predictor of breastfeeding duration. Prior to 2013,

mothers were allowed a maximum of six months of compensated

maternity leave. For those children born after December 21, 2013,

compensated maternity leave was extended to one year, generating

an exogenous variation across mothers with infants born before and

after the policy change.

A higher wage rate implies a higher opportunity cost of time

associated with breastfeeding. In light of the higher opportunity cost of

breastfeeding for those women with higher incomes, in addition to

31
some evidence that minorities are more likely to breastfeed due to

cultural differences, one might be led to believe that effects of

breastfeeding on subsequent cognitive and health outcomes for the

child may be downward biased (Chapman and Perez-Escamilla 2013).

Interestingly, breastfeeding has been found to be more

prevalent among lower SES groups in certain populations and among

foreign-born mothers (Gibson-Davis and Brooks-Gunn 2013), even

though breastfeeding is more likely among the college educated (Ryan

2014), older mothers, and those not participating in the Women,

Infants, and Children (WIC) program (Gibson-Davis and Brooks-Gunn

2013). Very low birth weight (Smith 2013), private insurance, and

delivery via Caesarean section (Perez-Escamilla 2013) are associated

with lower probabilities of breastfeeding. Not being encouraged by a

clinician to breastfeed and being depressed are associated with a

mother’s lower likelihood of breastfeeding (Taveras, 2013).

Regional differences are observed, with the prevalence of

breastfeeding highest in the West and lowest in the South (Ryan

2014). As pointed out in the American Medical Association’s Family

Medical Guide, “some people prefer the convenience of bottle-feeding

because other people can help out with feedings. It also gives the

father and older siblings and opportunity to participate in feedings and

form their own attachment to the baby” (AMA 2014).

32
 A comprehensive review of scholarly articles on the possible

benefits of breastfeeding in developed countries was conducted by the

Agency for Healthcare Research and Quality in 2014. We draw heavily

on this report, which screened over 9000 abstracts and included 400

studies in their final review. The report concluded that breastfeeding

was associated with a reduction in the risk of ear infections;

gastroenteritis, lower respiratory tract infections, atopic dermatitis,

asthma, obesity, diabetes, childhood leukaemia, sudden infant death

syndrome (SIDS), and necrotizing enter colitis ( Agency for Healthcare

Research and Quality in 2014).

However, little effect was found for cognitive ability as measured

by the Peabody individual achievement test (PIAT) administered to 5-

to 14-year olds. Moreover, the summary did not provide a

comprehensive inventory of possible impacts. Outcomes related to

maternal attachment, motor scores, and physical activity were not

mentioned in the report, which cautioned that the majority of the

articles were based on observational studies, and “one should not infer

causality based on these findings.” (Der 2013).

A summary of the literature on the effects of breastfeeding

provided by the American Academy of Paediatrics (2013) reaches

similar conclusions. In addition to the aforementioned Baker and

Milligan (2014), which primarily focused on determinants of

33
breastfeeding, studies that attempt to address causality from

breastfeeding to health outcomes include Kramer (2014), who find

effects on gastrointestinal infection and dermatitis using randomly

assigned maternity support in Belarus, and Der (2014), who use the

1979 cohort of the National Longitudinal Survey of Youth to analyze

sibling pairs and whose study will be discussed in more detail in the

next paragraph (American Academy of Paediatrics, 2013).

Baker and Milligan (2014), relying heavily on variation over time,

find little effect of breastfeeding on child health, as measured by

health status, nose and ear infections, asthma, allergies, chronic

conditions, and injuries. They control for gender, age, province, city

size, parents’ age and education, immigration status, presence of

siblings, and unemployment (to capture labour market changes over

time) in their regressions. Mild effects that disappear at older ages are

found among 7- to 12-month olds for asthma, allergies, and chronic

conditions. They do note, however, that their main contribution is

showing how a mother’s increased time at home, through the

Canadian maternity leave mandates, affected breastfeeding.

Their primary focus is not on the effects of breastfeeding on

outcomes. Moreover, their health outcomes analysis is of the

mandates and not breastfeeding per se. Research using historical data

34
from Germany finds that breastfeeding has substantial positive effects

on adult stature (Haines and Kintner 2014).

Of these studies, we focus on two that use data from the United

States – namely, those of Der (2014) and Rees and Sabia (2014).

Using the 1979 cohort of the National Longitudinal Survey of Youth,

Der (2014) analyze sibling pairs and conclude that family background

explains much of the observed correlation between breastfeeding and

cognitive outcomes. They use the total PIAT scores (Peabody individual

achievement test), even though the test was administered biennially

to respondents between the ages of 5 and 14. It is unsurprising that

no effect in general is found using their methods (Haines and Kintner

2014).

Their analysis relies on sibling pairs and controlling for maternal

intelligence, which has the potential to soak up most variation that can

be found, particularly due to the potential endogeneity of mother’s IQ

itself. The authors also exclude low birth weight and premature babies.

That being said, the authors do find significant effects of the duration

of breastfeeding on cognitive outcomes, yet dismiss the effects as

being too small. However, combined with the benefits of breastfeeding

on physical and health outcomes, the overall effects may not be

insubstantial (Haines and Kintner 2014).

35
 Rees and Sabia (2014) use a similar method (sibling fixed

effects) and find a positive and significant effect of breastfeeding on

educational attainment, as measured by high school GPA and college

attendance. Using data from the National Longitudinal Survey of

Adolescent Health and controlling for measures of cognitive ability and

maternal attachment, they also conduct falsification tests, using

outcomes relating to drunkenness, smoking, television watching, and

having been in a physical fight. They acknowledge that while

comparing siblings accounts for family-level unobservable factors, it

reduces sample size and identifying variation, may not be

generalizable to all children, and, perhaps most importantly, does not

account for “unmeasured within-family heterogeneity resulting from

the fact that the decision to breast-feed is not random” (Rees and

Sabia 2014).

Our analysis builds on these studies in that we are able to use

more recent data, younger children, multiple time points, and various

methods to address potential confounding factors. We estimate the

relationship between formula-feeding and child outcomes, largely

missing in most studies carefully accounting for causality.5 We analyze

a rich set of outcomes at 9, 24 and 54 months, so we are not

concerned with disentangling factors that may affect the child at later

stages in life (Rees and Sabia 2014).

36
 We apply an economic framework to modelling both the

determinants of breastfeeding and its outcomes. While there has been

some opposition by economists to the use of utility functions to discuss

the economics of the family (such as Samuelson 2014), this may serve

as a useful tool originally posed by Becker (2013, 2014) and modified

by Pollak (2014), with assumptions that may be relaxed (Pollak 2014).

However, the economic approach that an individual maximizes

utility subject to constraints and thus reaches equilibrium is taken

here. Investment in a child’s health is presented in the context of a

household production function with one parent for simplicity (the

mother in the context of breastfeeding), whose child’s health enters

into the parent’s utility function in a paternalistic fashion (Pollak

2014).

A child’s health may thus enter directly into parent’s utility

function but may also increase a future income stream, leading it to be

both a consumption and investment good (Grossman 2014).

Using the standard controls on the RHS, we analyzed the

following health, physical, and cognitive outcomes at 9 months:

Respiratory problems; gastroenteritis; asthma; excellent health;

maternal attachment; motor scores; and cognitive scores. The

following outcomes were analyzed at 24 months: Respiratory

37
problems; gastroenteritis; asthma; excellent health; maternal

attachment; motor scores; underweight; overweight; obese; and

cognitive scores. The following outcomes were analyzed at 54 months:

Respiratory problems; gastroenteritis; asthma; excellent health; motor

and copy form skills scores (based on block tower building); high

physical activity; underweight; overweight; obese; reading score;

math score; and literature score (Grossman 2014).

These outcome measures come from various sources: the

health conditions measures are self-report by the parent of diagnosed

incidences; the maternal attachment and some of the cognitive and

motor measures are based on independent observers’ reports within

the home; the later cognitive scores are based on tests administered

to the children; and the underweight, overweight and obesity

indicators are calculated based on measured BMI (Body Mass Index)

(Grossman 2014).

We use basic ordinary least squares and probity specifications,

with controls for covariates, as a base case for the results. However, a

potential concern with analyzing the effect of breastfeeding on child

outcomes using linear probability models is that unobserved

characteristics common to both breastfeeding and child outcomes are

not controlled for and, as discussed in Section 2 above, these

characteristics are many. We attempt to identify the potential causal

38
effect of breastfeeding on outcomes using a variety of techniques

(Helen Graham, 2014).

Excluded instruments in our instrumental variables models

pertain to Caesarean birth, mother’s behaviour regarding smoking and

alcohol consumption prior to the child’s birth, whether the mother

wanted to become pregnant, maternity leave, and county-level

establishments related to health care and social assistance. In order to

be valid, these instruments must jointly predict breastfeeding in

addition to passing the appropriate over identification tests for

exclusion restrictions. However, there may still be concern that these

variables cannot theoretically be excluded from the child health

equation, in that they may be correlated with the error term in the

second stage. We therefore perform several robustness checks and

find our external instruments to be invalid as they are not legitimately

excludable from the main equations of interest. Results from these

models are therefore not reported (Helen Graham, 2014).

Helen Graham (2014) revealed that the changes commonly seen

include tenderness / pain, lumpiness / lump and nipple changes.

Unlike the many other normal changes that occur to the breasts,

pregnancy offers many visible signs that the breasts are changing.

Initial changes experienced by many women include tenderness of the

breast and nipple and an increase in the size of the breasts. Early in
39
pregnancy, the breasts begin to secret colostrum’s. The breasts are to

be bathed daily.

DOH (Department of Health) midwifes, health visitors and

general practitioners are considered to be the first point of contact for

women with breast changes. Midwives should take every opportunity

to educate women about the importance of being breast aware and

encourage women to take an active role in their own breast health and

helps to reduce anxiety in these women empowering them to take

control of their own breast health (Helen Graham 2014).

Stoppard (2014) identified that the pregnant women commonly

experience the sensations such as tingling and soreness. As the

pregnancy progresses other visible signs such as darkened color of the

nipple, areola and prominent veins on the surface of the breast are

seen. For many women, changes such as breast lumps and nipple

discharge developed during pregnancy can cause uncertainty with

many women fearing they have breast cancer. During the second and

third trimester, growth of the mammary glands accounts for the

progressive breast enlargement.

The high levels of lacteal and placental hormones in pregnancy

promote proliferation of the lactiferous ducts and lobule –alveolar

40
tissue, so that palpation of the breasts reveals a generalized coarse

modularity (Stoppard, 2014).

Lawrence (2013) changes in breast begin during pregnancy with

development of the ducts, lobules, and alveoli ion response to the

hormones estrogens, progesterone, placental lactose, prolactin, and

chorionic gonadotrophin. The breasts begin to secret colostrums by the

second trimester, and women whom give birth after the 16th week of

gestation produce colostrums.

Reeder and Martin (2013) have given the tips that every

pregnant woman wears a well-fitted brassiere to support the breasts in

a normal uplifted position. Proper support of the breasts is conducive

to good posture and thus helps to prevent backache. The selection of

brassiere is determined by the size of the breasts and the need for

support. Brassiere cup is large enough and that the underarm is built

high enough to cover all the breast tissue. Wide shoulder straps afford

more comfort for the woman who has large and pendulous breasts and

brassiere size is approximately two sizes larger than that usually worn.

Stoppard (2014) aimed to uncover the perceived usefulness of a

contemporary antenatal education strategy for mother's experience of

breastfeeding initiation. This was a simple descriptive pilot study with

ten first time mothers as participants; all of who were booked into an

41
Australian private maternity unit for antenatal breastfeeding

education, labor, birth and postpartum care. Semi-structured

interviews were transcribed verbatim and thematically analyzed. The

findings of the study were antenatal education was beneficial for

informing first time mothers of the practical skills required to positively

initiate breastfeeding.

Lin (2014) assessed the effectiveness of structured prenatal

education programmers on breastfeeding and to evaluate the

effectiveness of the program through experimental study. The

experimental group had higher scores in breastfeeding knowledge and

breastfeeding attitude at three days postpartum. The experimental

group showed higher breastfeeding satisfaction at three days and one

month postpartum. There were no significant differences in

experiencing breastfeeding problems. The rate of exclusive

breastfeeding was higher for the experimental group at three days and

one month postpartum, but the differences were not statistically

significant. On conclusion this study demonstrated the effectiveness of

a prenatal education programmed on maternal knowledge, attitude

and satisfaction toward breastfeeding.

Ekstrom and Widstrom, (2014) investigated if mothers who were

attended by midwives and nurses specially trained in breastfeeding

counselling perceived better continuity of care and emotional and

42
informative breastfeeding support than mothers who received only

routine care. Ten Municipalities, each with an antenatal center and

child health center, in southwest Sweden was randomized either to

intervention or control municipalities. The intervention included a

process-oriented training in breastfeeding counselling and continuity of

care at the antenatal and child health centers. Primiparous were asked

to evaluate the care given, and those living in the control

municipalities were divided into control groups A and B. Data collection

took place at different points in time for the two control groups. The

540 mothers responded to 3 questionnaires at 3 days and at 3 and 9

months postpartum.

The perception of support provided by the health professionals

and from the family classes was rated on Liker scales. Intervention

group mothers rated the breastfeeding information given during the

family class as significantly better during pregnancy than both control

groups, and better that control group B mothers at 3 months

postpartum; compared with both control groups, intervention group

mothers perceived that they received significantly better overall

support and that postnatal nurses provided better information about

breastfeeding and the baby's needs. At 9 months, intervention group

mothers were more satisfied with knowledge about social rights,

information about the baby's needs, and their social network than

43
control group B mothers. Both intervention group and control group B

mothers perceived better overall support than control group A during

pregnancy. At 3 and 9 months, intervention group mothers perceived

that postnatal nurses were more sensitive and understanding

compared with both control groups (Ekstrom and Widstrom, 2014).

The study concluded that after implementation of a process-

oriented breastfeeding training program for antenatal midwives and

postnatal nurses that included an intervention guaranteeing continuity

of care, the mothers were more satisfied with emotional and

informative support during the first 9 months postpartum. The results

lend support to family classes incorporating continuity of care

(Ekstrom and Widstrom, 2014).

Judy Kerpear (2014) conducted a qualitative in-depth interview

study with the objective to explore how women experience

breastfeeding difficulties with the sample of 39 postnatal mothers, who

had breast feeding problems. The study concluded that lack of prenatal

preparation is the cause for breastfeeding difficulties.

Nandhini Subbiah (2013) did a study to assess the knowledge,

attitude, practice and problems on postnatal mothers regarding

breastfeeding. The study findings among 100 mothers depicted that

only 14 of them were antenatal prepared fro breastfeeding and nearly

44
75% knew about necessity to feed from both the breast. She

concludes that the time is ripe enough to awaken the health care

providers who have great influence on the family, especially on the

mothers on breastfeeding.

Spinelli, (2014) examined the characteristics of women attending

antenatal classes and evaluated the effects of these classes on

mothers' and babies' health among 9004 women resident in 13 regions

of Italy who delivered in a 4-month period and they were interviewed.

The outcomes studied were attendance at antenatal classes, Cesarean

section, bottle feeding, satisfaction with the experience of childbirth,

knowledge of contraception, breast feeding and baby care. A total of

2065 (23.0%) women attended antenatal classes. Women without

previous children, those with a higher level of education and office

workers were more likely to attend classes.

Women who attended antenatal classes had a much lower risk of

cesarean section and were about half as likely to bottle feed while in

hospital compared with non-attendee. They received better

information on contraception, breast feeding and baby care. Women

who attended classes and applied the techniques were more satisfied

with the experience of childbirth. The study concluded antenatal

classes seem to improve women's knowledge and competence on

breastfeeding (Spinelli, 2014).

45
 Sarah Earle (2014) conducted a study to explore women’s

experience and perceptions of baby feeding and to explore the

explanations offered by women who chose to either breast (or) bottle

feed. The study concluded that to increase the incidence of breast

feeding, health care professionals should consider the need for

preconception heath promotion. The role of paternal involvement in

baby feeding decisions also needs to be acknowledged and men need

to be included in breastfeeding promotion campaigns.

Athena Sheehan (2013) compared a women- centered antenatal

breastfeeding programmed based on concepts of peer and husband /

partner support with a control group, who received antenatal breast-

feeding education led by a midwife childbirth educator. The findings

revealed maternal perceptions of success using the Maternal

Breastfeeding Evaluation Scale (MBFES) and breastfeeding duration up

to 25 weeks after birth. No differences were found between groups in

relation to maternal perceptions of success or duration rates. Overall,

breastfeeding duration rates were high when compared to previously

reported breastfeeding duration rates in Australia.

There were no differences in breastfeeding duration rates or in

maternal perceptions of success between those with babies who were

given supplementary feeds in hospital and those were not, although

46
early supplementation at home appeared to reduce breast-feeding

duration (Athena Sheehan, 2013).

Jay Move land (2013) suggested that breastfeeding should be

discussed at the first and subsequent prenatal visits. Most women

would have made a decision about breastfeeding early in pregnancy.

Breastfeeding education that’s given repeatedly in person could have a

significant influence on breastfeeding outcomes and appears to be

superior to only postnatal support (or) only telephone support.

Jennifer Coomb (2013) concluded that prenatal encouragement

increases breastfeeding rates and identifies potential problem areas.

Encouragement by health care professionals could have a significant

influence on breastfeeding outcomes.

Dunkley (2013) stated that by preparing partners with antenatal

education they too progress through the birth and postnatal

experience feeling empowered, able to offer support which is

important for the transitions into parenthood.

Alasfoor, (2013) reported that only 16.2% of the mothers

prepare the breast prior to the delivery. It was observed that 20% of

the mothers had the problems that are related to breast.

Lowdermilk (2014) stated that the key to encourage the mothers

to breastfeed is through education beginning as early as possible

47
during pregnancy and even before pregnancy. Prenatal breastfeeding

classes are an excellent vehicle to relay important information to

expectant mothers.

Barnes (2014) in his article explored that demographic

characteristics independently related to intentions to breastfeed

included older maternal age, more maternal education, prime parity

and not smoking; in the previous work all these had been associated

with actual feeding behaviour. Social relationship variables had a small

influence. Of the psychological variables, a notable finding was that

women who were preoccupied with their body shape and those who

expressed concern were, less child-centered, and their responses to

manage an infant in the postnatal months were less likely to have

intentions to breastfeed. Depression did not predict breast feeding

intentions once the other factors had been taken into account.

Health care professionals may be able to intervene to increase

breastfeeding by making routine enquiries during antenatal care and

targeting appropriate subgroups (Barnes, 2014).

What voice fathers should have, and what role they should play

as caregivers when their partners breastfeed, are usually unaddressed

in breastfeeding promotion. Yet, they are far from unaffected by

infant-feeding decisions. The close bond that breastfeeding fosters

48
between mother and infant sometimes comes at the expense of the

father/infant attachment (Friedman, 2013).

Conceptual Framework

Independent Variable Dependent Variable

 Breastfeed Infant  Perception

 Bottled feed  Attitudes
Infant  Knowledge
 Beliefs
 Preference
 Awareness

Moderating Variable

 Age
 Culture
 Religion
 Educational
Attainment
 Annual Income

Figure1.1 Conceptual Model of Comparative Assessment of

Breastfeeding and Bottle-fed base on the Perceptions of Mothers

49
 Conceptual Framework is a written or visual presentation that

explains either graphically, or in narrative form, the main things to be

studied the key factors, concepts or variables and the presumed

relationship among them.

Factors, Characteristics, or Condition is introduced in

Independent Variable. It manipulated to cause a change in the

dependent variable that is to be observed. The independent variables

in this study are the Breastfeed Infant and Bottled-feed Infant.

Dependent Variable is a secondary independent variable that is

included in a study to determine whether it affects, modifies or alters

the relationship between the primary or main independent variable

and the dependent variable. Perception, Attitudes, Knowledge, Beliefs,

Preference, and the Awareness. These are the dependent variable of

the study where we can observed and know this trough asking them

that could bring information about the independent variable.

Moderating Variable is a variable that modifies the original

relationship between the independent and dependent variables. Age,

Culture, Religion, Educational Attainment, and Annual Income are the

moderating variable of this study. These variables can affect the

original relationship between independent variable and the dependent

variable.

50
Statement of the Problem

1. What is the difference between Bottle-feeding and

Breastfeeding?

2. What are the perception of the mothers in terms of

breastfeeding and bottle-feeding?

3. How good the breastfeeding in the relation of the health of

babies?

4. Why some mother chose bottle-feeding for their babies?

5. Are all mothers comfortable in breastfeeding?

6. Which do mothers prefer most? Breastfed or bottle-fed?

7. Why is breastfeeding better than bottle-feeding base on the

perception of mothers?

8. Do breastfed or bottle-fed make babies sleep better base on the

perception of mothers?

9. Can mother do breastfed and bottle-fed at the same time base

on the perception of mothers?

Significance of the Study

Studying the health of every individual in the Province of Davao

Oriental is very important. Individuals are part of a community, what

individuals behavior will reflect to institution. Moreover, thinking about

51
the health of babies is extremely important. They could bring the

health that they have now until they grow up and in their daily living.

This study could really help the mothers in terms of feeding their

babies. They could get the details that they needed especially to those

whose not yet ready for being a mother. Many of the mothers are not

at the right age so that they don’t have enough knowledge about how

to take good care of a child. This research would be helpful for them

because this study brings information and details that are essential to

the health of a child.

The importance of this study in the society, the City of Mati is to

give an awareness or information to the mothers on how to give a

good health to their babies. Awareness of mothers is very important

because the health of their child will depend on how they take good

care of them. Moreover, the teenagers nowadays are already pregnant

in a wrong time. They are not totally aware of what to do because they

don’t have any idea on how to take good care of a child.

Because of this research, the DOH (Department of Health)

would be able to put up some activities in relation to the importance of

breastfeeding and bottle-feeding for the children. The government

could also give help to the mothers and also the young one whose

already have a baby and for those whose pregnant in terms of paying

52
a doctor to check up them enable to know the condition of their

babies.

In the help of this research, we would be able to have a guide in

studying our strand in terms of medicine. We would be able to get a

good idea of information that could help us to give awareness to the

mothers on how to take good care of the baby and also for the future

mothers. We could help our family, friends, neighbours and other

people in our community so that they could give a good health and a

better life to their child.

Scope & Delimitation

This research talks about the comparative assessment between

breastfeeding vs. bottle-feeding base on the perception of the

mothers. In the help of this research, we would be able to know if

what is the best feeding for the babies to have a good health. If this

research paper will be approve, we would like to conduct a survey in

Sto. Niño Street, Barangay Central, City of Mati. We would also want

to have this survey on January until March 2018.

53
 CHAPTER II

METHOD

The methodologies are presented in this chapter and these are

the research design, research locale, participants, and research

instruments, in depth interview guide, procedure, data analysis and

ethical consideration that will be essential in our study.

Research Design

This study will use qualitative approach because we are going to

get the perception of the mothers about the two variables and its

differences. Types of research according to its purpose are also

included in this study which are (a) Descriptive Research where it aims

to define and give a verbal portrayal to the information needed. In (b)

Correlational Research, it shows the relationship or connectedness of

the breastfed and bottle-fed to the health of the babies.

Moreover, this study will be easily conducted because this will be

also beneficial to the parents in terms of getting an additional

knowledge in carrying their children. A good health of a child was in

the hand of the mother. Therefore, mothers should have enough

knowledge about the health of the babies because they are the one

who will take care of their child. Mothers have a big responsibility in

54
our society and this is on taking good care of their children. The health

of their children will depend on them.

Research Locale

In this study, we would like to conduct this at Sto. Niño Street,

Barangay Central, City of Mati. We choose this place because aside

from being accessible and safe, the resources are also available.

Participants

In conducting this research, our primary resources of getting the

data will be the parents especially the mothers. We would also collect

details by asking help to their center for our secondary resources.

Research Instrument

In gathering data, we will use the three (3) research instruments

which are Questionnaires, Interview and the Record. These three (3)

instruments could really help us to gain enough information. In

questionnaire and interview, we will gather different questions to be

answered by respondents. This could help us to determine the

perception of the parents especially the mothers and also to determine

the difference between breastfed and bottle-fed in terms of the health

of a child base on their perception. When it comes to the record, we

could get those records of children in their center. This record could

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help us to know more about the condition of the child when it comes to

their health until they grow up.

In Depth Interview Guide

The following questions below are the questions that will written in

the questionnaires and also be use when we gather interview.

1. What did you used after you gave birth, breastfeed or bottle-

feed?

2. Which do you prefer for your baby? Why?

3. Are you comfortable in breastfeeding?

4. How does breastfeed and bottle-feed affect the health of your

child?

5. When do you think is the right time to stop breastfeeding or

bottle-feeding?

6. How far is your knowledge about the health of a child?

7. Is the combination of breastfeed and bottle-feed good for your

baby?

8. Are you considering the alternative method of feeding? Why?

9. Is it really true that if you’re using breastfeed the closeness

between you and your child will develop?

10. Is using breastfeed advantageous to reduce expenses?

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Procedure

Procedure is a step by step sequence of activities or course of

action with definite start and end points that must be followed in the

same order to correctly perform a task.

Thirty mothers will be interview in this study in person. Initial

contact with participants reiterated confidentiality and the ability to

withdraw from the study at any time and to convey interest in

participating. Before conducting this research, the researchers will

follow this several steps in order to accomplish the study. These are

the following: Seeking of permission to conduct the study. The

researchers will write a letter to be address in barangay captain in the

said place requesting that the researcher will be allow to conduct the

study. After the approval, the itinerary to gather data was set.

Orientation with the respondents. After securing the said permit,

the researchers will be given some background or information of what

are our intentions and what is the study all about.

Administration of instrument. After orienting the respondents,

the researchers will gather information from the mother’s perception

using the standardized and validated questionnaires.

Collating and subjecting of data to statistical analysis. The

responses to the items of the questionnaire by the mother’s perception

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on the comparative assessment between breastfeed and bottle-feed

will be accurately tally and record correspondingly. The results will be

encoded, tabulated, analyze and will be interpreting to give essence to

the investigation.

Data analysis

In continuity of our research, we will also make a bar graph.

Using this bar graph, we would be able to measure the percentage of

the mothers who used bottled feed and breast feed as well. This could

help us to identify how the mothers feed their babies in formula

feeding and breastfeeding. In addition, we would also be able to know

how the mother are aware in thinking what is the best and how to take

good care of their child to have a good, healthy and normal life.

In addition, to discover more concepts, the sampling are also

present in this study which refers to the method or process of selecting

respondents or people to answer the questions meant to yield data for

a research study. There are two types of sampling that are also

present in this study. In Probability Sampling, Simple Random

Sampling is introduced. This is the best type of probability sampling

which you can choose respondents that will suit to your data needed

which are the mothers. Availability Sampling is also part of this study

which is one of the type of Non-Probability Sampling. This availability

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sampling shows the willingness of a person to interact with you that

you could consider as your respondents.

Ethical Consideration

Conducting our research entitled Comparative Assessment

between Bottled feed and Breastfeed base on the perception of the

mother is expected that most of the respondents are females. Females

are more often close to babies maybe because the babies are more

comfortable with their mothers. Females are also knowledgeable about

carrying a baby rather than males. But there are also males whose

carrying their babies because he maybe don’t have a wife to do it or

he just want what he is doing.

Culture will have a big impact if we also talk about breast feed

and bottled feed it is just because we have different kinds of beliefs

that we are practicing in our daily living. When it comes to our religion,

some are the same and some are not. For example, Islam, if you gave

birth to a child in a very young age you are not allowed to feed your

child using your breast it should be bottled feeding because that was

their belief unlike Catholic we are free to do whatever we want to do

for the sake of our baby’s health.

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