Kel4 Child Feeding Questionnaire

7/28/2019 Kel4 Child Feeding Questionnaire

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E x p l a i n i n g I n fa n t F e e d i n g S t yleo f L o w - I n c o m e B la ck W o m e nK a r e n S . C o r b e t t , P h D

U n s t r u c t u r e d i n t e r v ie w s w e r e c o n d u c t e d w i t h 1 0 l o w - i n c o m e b l a c k w o m e n t o e x p l o r e i n f a n t f e e d i n g s t y le . F o r m u l a - f e e d i n gw i t h e a r l y i n t r o d u c t i o n o f c e r e a l i n t h e b o t t l e w a s t h e m o s t c o m m o n p a t t e rn u s e d b y m o t h e r s i n t h e f ir s t 3 m o n t h s . B y 6 m o n t h s ,f o r m u l a - f e d i n f a n ts h a d a c o m p l e x d i e t o f a v a r ie t y o f f o o d s . H a l f t h e w o m e n i n t e n d e d t o b r e a st - fe e d , b u t o n l y o n e e x c l u s i v e l yb r e a s t - f e d . Be l ie f s a b o u t h e a l t h y i n fa n t s a n d c r y i n g i n f l u e n ce d fe e d i n g . T h e r e w a s a l a ck o f kn o w l e d g e a b o u t a n d su p p o r t f o rb r e a s t - fe e d i n g in t he s e w o m e n ' s e n v i r o n m e n t . S u p p o r t a n d a d v i c e a b o u t i n f a n t f e e d i n g f r o m t h e h e a l t h c a r e sy s te m w e r eu n e v e n .Copyr ight 200 0 by W.B. Saunders Compan y

D E Q U A T E N U T R I T I O N a n d e a r l y f e e d i n gpa t t e rn s a re i m por t an t de t e rm i nan t s o f hea l t h

du r i ng i n fanc y ( In s t it u t e o f Med i c i ne [ IOM] , 1991 ) .Th e nu t r i t iona l , hea l t h , and p s yc ho l og i ca l bene f i t so f b r e a s t - f e e d in g a r e w i d e ly a c c e p t e d ( L a w r e n c e ,1997 ). B reas t - f eed i ng i s r ecom m e nded f o r t he f ir st12 m on t hs o f l if e . I t is a l s o r ecom m e nde d t ha t s o l idfoods be i n t roduced beg i nn i ng a t 6 m on t hs o f age(Am er i can Acad em y o f P ed i a tr i c s , 1997 ). Hea l t hp rom ot i on goa l s fo r t he yea r 2000 i nc l ude goa ls t oi n c r e a s e t o 7 5 % t h e p e r c e n t a g e o f m o t h e r s w h obreas t - f eed t he i r i n fan t s a t hos p i t a l d i s cha rge and t o50% t hos e wh o con t i nue t o b reas t - f eed un t i l 5 t o 6m o n t h s o f a ge . L o w - i n c o m e a n d b l a c k w o m e n a r ei den t i fi ed a s s pec i a l popu l a t i on t a rge t s becaus e t heyhave t he l owes t r a t e s fo r bo t h i nc i dence anddu ra t i on o f b reas t - f eed i ng and a re a s i gn i f i can tp r o p o r t i o n o f a l l n e w m o t h e r s ( D e p a r t m e n t o fHea l t h and Hum an S erv i ces , 1991 ) . The IOMr e c o m m e n d s t h a t " f u r t h e r r e se a r c h i s n e e d e d t oi den t i fy t he de t e rm i nan t s o f t he dec i s i on t o bo t hi n i ti a te and con t i nue b r ea s t f ee d i n g . . , i n pa rt i cu la r ,am ong ado l es cen t s , t hos e wi t h l i m i t ed educa t i on ,a n d b l a c k , H i s p a n i c , a n d o t h e r m i n o r i t y w o m e n "(1991, p . 240) .

Th i s s t udy exp l o red t he i n fan t f eed i ng s t y l e o fl o w - i n c o m e b l a c k w o m e n . I n f a n t f e e d i n g s t y l eincludes pract ices as wel l as the values , a t t i tudes ,and be l i e f s a s s oc i a t ed wi t h i n fan t f eed i ng (VanEs t e r i k & E l l i o tt , 1986) . F ee d i ng s t y l e com bi nesac t ua l behav i o r r e s u l t i ng f rom de l i be ra t e cho i cesand t he m ean i ng o f t hes e p rac t i ces . In fan t f eed i ngs t y l e i s a f f ec t ed by bo t h ex t e rna l and i n t e rna lf ac t o r s and r e f l ec t s i n t e rac t i on am ong i nd i v i dua l sand g roups .

CONCEPTUAL ORIENTATIONIn fan t f eed i ng i s a com pos i t e o f behav i o r s t ha t

ex i s t i n a com pl ex env i ronm en t and a l s o a p roces st ha t occu r s ove r t i m e and i nvo l ves a r ange o fbehav i o r s i nc l ud i ng b reas t - f eed i ng , fo rm u l a - feed -i ng , i n t roduc t i on o f s upp l em en t a ry foods , and wean -i ng (R aphae l , 1984 ) . C oncep t s f rom an t h ropo l ogy ,c h i ld d e v e l o p m e n t , a n d h u m a n e c o l o g y h a v e b e e ns yn t hes i zed t o deve l op a cu l t u ra l - eco l og i ca l f r am e-work t ha t gu i des t he s t udy o f i n fan t f eed i ng . Acu l t u ra l - eco l og i ca l f r am ework (C orbe t t , 1999 ) a l -l o w s f o r t h e e x a m i n a t io n o f c o n t e x t a n d m o v e sb e y o n d t h e i n f a n t - m o t h e r d y a d t o c o n s i d e r im p a c to f t he en t i r e ecos ys t em on t he i nd i v i dua l . I t r ecog -nizes that b io logical , psychological , socia l , cu l -t u ra l , and eco nom i c f ac t o r s a ll a f f ec t a ca reg i v e r ' sac t i ons and be l i e f s r ega rd i ng i n fan t f eed i ng .

M c E l r o y a n d T o w n s e n d ( 1 9 8 5 ) s u g g es t a m o d e lo f an ecos ys t em i n wh i ch t he env i ron m e n t cons is t so f phys i ca l , b i o ti c , and cu l t u ra l e l em en t s . T hecu l t u ra l com p onen t is com p os ed o f s oc ia l o rgan i za -t i on , t echno l ogy , and i deo l ogy . An i nd i v i dua l ' scu l t u ra l env i ronm en t i n f l uences d i e t a ry p rac t i ces ,f am i l y l i f e pa t t e rn s , and be l i e f s and p rac t i cesre la ted to heal th and i l lness (Tr ipp-Reimer , 1984) .

LeVi ne (1977 ) deve l oped a t heo ry o f ch i l d

From the M edical U niversiO, of South Carolina. C ollege ofN,trsing, Charleston. SC

Address reprint requests to Karen S. Corbett , PhD, MedicalUn iver si~ of South Calvl ina, College of Nursing, 171 Ash leyAve, Charleston, SC 29425.Copyright 2000 by W.B. Saunders Company

0882-5963/00/1502-0003510.00/0doi: 10.1053/jn.2000.5445

Journ al of PediatricNursing,Vo115, No 2 (Apr i l ), 2000 73


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74 KAREN S. CORBEI- r

r ea r i ng a s cu l t u ra l adap t a t i on . As one a s pec t o fchi ldrear ing , infant feeding i s the resu l t o f cu l turaladap t a t i on t o pa r t i cu l a r env i ronm en t a l cond i t i ons .In fan t f eed i ng p rac t i ces a r e i m bedded i n t he con -t ex t o f cu lt u ra l va l ues and behav i o r s . Ogbu (1981 )s ugges t ed t ha t t he na t i ve t heo ry o f ch i ld r ea r i ngcon t a i n s a cu l t u re ' s be l i e f s abou t p rope r ways t ora i s e ch i l d ren and t he i r o rgan i za t i on o f ch i l d -r ea r i ng t a s ks . Th i s na t i ve t heo ry o f ch i l d rea r i ngdoes no t neces s a r i l y co r res pon d t o t he " s c i en t i f i c "m ode l o f ch i l d rea r ing , bu t i s a l ay m ode l t ha tguide s adul t s in thei r re la t ionsh ip to ch i ldren .

Th i s s t udy focus ed on t he i n t e r r e l a t i ons h i p sbe t ween t he i n fan t f eed i ng p rac t i ces o f i nd i v i dua lca reg i ve r s and t he cu l t u ra l env i ronm en t . The cu l -t u ra l env i ronm en t i s com pos ed o f bo t h m i c ros ys -t em s and m acros ys t em s (B ron fenb renner , 1977 ) .The m i c ros ys t em i s a com pl ex o f r e l a t i ons h i p sam ong va r i ous l i f e s t y l e f ac t o r s and t he hous eho l dto which the infant belongs . At the micro level , thehous eho l d i s the focus wi t h i n w h i ch i n fan t f eed i ngp rac t i ces a r e o rgan i zed and enac t ed . E x t e rna l va r i -ab l es a f f ec t t he op t i ons ava i l ab l e and t he cho i ce -m ak i ng s t r a t eg i es o f hous eho l d m em bers . Thecul tural envi ro nm ent inf luences the househ old s t ruc-ture and l i fes ty le factors that in teract wi th andi m pac t on t he hous eho l d . L i f e s t y l e f ac t o r s t ha ti n f luence i n fan t f eed i ng a re occ upa t i on , educa t i on ,incom e, re l ig ion , e thnic i ty , and fo lk bel iefs .

The m acros ys t em concep t enab l es t he i nves t i ga -t o r to i den t i fy and exp l o re t he i m p ac t o f a s pec t s o ft he l a rge r s oc ie t y on t he i nd i v i dua l ' s m i c ro s ys t em .The hea l t h ca re s y s t em rep res en t ed t he m acros ys -t e rn com pone n t exam i ned i n t h i s s tudy . Th e hea l t hca re s y s t em i m pac t s on l i f e s ty l e f ac to r s and i n tu rni n f l uences t he m i c ros ys t em con t a i n i ng t he ca re -g i ve r and t he i n fan t . Hos p i t a l p rac t i ces , adv i cef rom hea l t h ca re p ro fes s i ona l s , and t he Wom an ,In fan t s and C h i l d ren (WIC ) p rog ram were t hes pec i f ic a s pec t s o f t he hea l t h ca re s y s t em t ha t weres tudied .

LITERATURE RE VIEWA var i e t y o f dem ograph i c f ac t o r s have been

i nves t i ga ted i n r e l a t i ons h i p t o i nc i dence and du ra -t i on o f b reas t - f eed i ng . Na t i ona l e s t i m a t es a r e ava i l -ab l e on educa t i on , i ncom e , em p l oym en t , r ace ,par i ty , age, and mar i ta l s t a tus ( IOM, 1991; Ryan,1997) . Older mothers in i t i a te breas t - feeding andcon t i nue l onge r than you nge r m o t he r s . B o t h i n i ti a -t i on and du ra t i on o f b reas t - f eed i ng a re pos i t i ve l yas s oc i a t ed wi t h m a t e rna l educa t i on and f am i l yi ncom e . Mar r i ed m o t he r s a r e m ore l i ke l y t han

unm ar r i ed m o t he r s t o b reas t - f eed and exper i ence alow er a t t ri t ion ra te a t 5 to 6 mo nths ( IOM , 1991).

In 1995 , 59 .7% o f al l wo m e n b reas t - f ed i n thehos p i t a l and 21 .6% were s t i l l b r eas t - f eed i ng a t 6m on t hs . Thes e r a t e s va ry by r ace , w i t h wh i t ew o m e n h a v i n g a h i g h e r i n c i d e n c e ( 6 4 . 3 % ) c o m -pared wi t h b lack wom en (37% ) . B y 6 m on t hs , t hes era t e s had dec reas ed t o 21 .6% fo r wh i t e s and 11 .2%fo r b l acks (R yan , 1997 ). A l t hough w e have s een arecen t i nc reas e i n bo t h i nc i dence and du ra t i on fo rb lacks , they s t il l have the lowe s t ra tes of breas t -f eed i ng and du ra t i on o f b reas t - f eed i ng . B l acksl i v ing i n t he S ou t h At l an t ic r eg i on h ad an i nc i denceo f 35 .3% i n t he hos p i t a l and a con t i nued b reas t -f eed i ng r a t e o f 10% a t 6 m on t hs .

Ear l y i n t roduc t i on o f fo rm u l a (Kur i n i j , S h i ono ,& R hoads , 1988 ; Loug h l i n , C l app -C h ann i ng , G eh l -bach , P o l l a rd , & McC ut chen , 1985 ) and s o l i d s(Hawki ns , N i cho l s , & Tanner , 1987 ) has beenrepo r t ed a s r i s k f ac t o r s fo r ea r l y t e rm i na t i on o fb reas t - f eed i ng . Wom en who i n i t i a t e pa r t i a l b reas t -f eed i ng i n t he hos p i t a l a r e u s ua l l y em p l oyed andb l ack and t end t o have l ow-b i r t h -we i gh t bab i es(R yan , Wys ong , Mar t i nez , & S i m on , 1990 ) . B l ackw o m e n h a v e a h i g h e r i n c i d e n c e o f s u p p l e m e n t a lfo rm u l a u s e i n t he hos p i t a l t han wh i t e wom en ,wh i ch i s t he p r i m ary de t e rm i nan t o f a s ho r t e rdurat ion of breas t - feeding (Kurin i j e t a l . , 1988) .Many b l ack wom en s t op b reas t - f eed i ng i n t he f i r s tf ew weeks pos t pa r t um be fo re l ac t a t i on i s fu l l yes t ab l i s hed (B evan , Mos l ey , Lobach , & S o l i m ano ,1984: Kur in i j , Shiono, & Rhoads , 1988) . Even thenum ber o f exc l u s i ve l y b reas t - f ed i n fan t s dec reas edrap i d l y (20% a t 3 weeks t o 7% a t 6 m on t hs ) i n as t udy o f l ow- i ncom e b l ack u rban i n fan t s (P a r raga ,Weber , Enge l , R eeb , & L erne r , 1988 ).

Mo s t s t ud ies o f i n fan t f eed i ng focus on fo rm u l a -ve r s us b reas t - f eed i ng , bu t i n fo rm at i on on s upp l e -m en t a t i on pa t t e rn s and t r ends i s li m i t ed . S t ud i es o ff e e d i n g p ra c t ic e s a m o n g l o w - i n c o m e b l a c k m o t h -e r s r evea l pa t t e rn s o f ea r l y i n t roduc t i on o f s o l i d sand t he f eed i ng o f ce rea l and h i gh s ugar con t en tbeverages by bo t t l e (Ada i r , 1983 ; B rogan , & F ox ,1984; Burki & Reis , 1985; Parraga et al . , 1988;Solem, Norr , & Gal lo , 1991) . Several s tudiesrepo r t ed i n t roduc t i on o f s o l id s i n t o t he i n fan t 's d i e tdu r i ng t he f ir s t m on t h o f l i fe , and t he m a j o r i t y hads t a r ted s o l i d s be t b re t he r ecom m e nde d age o f 4 to 6m on t hs (B urk i & R e i s , 1985 ; Douce t & B er ry ,1988; Parrag a e t a l. , 1988). Fe edin g cereal by bo t t l ei s a c o m m o n p r a c t i c e a m o n g b l a c k s ( A n d r e w ,Clanc y, & K atz , 1980; Burki , & Reis , 1985) . Ju icesa re a l s o com m on l y f ed t o i n fan t s a s ea r l y a s 3weeks (Douce t & B er ry , 1988 ; P a r raga e t a l . ,


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INFAN T FEEDING STYLE 75

1988) . Thus there i s a need fo r in fo rmat ion onc u r r e n t p a t t e r n s o f i n f a n t f e e d i n g a mo n g l o w -i n c o m e b l a c k w o m e n .

T w o b r o a d c a t e g o r i e s o f d e t e r mi n a n t s i n f l u e n c et h e c h o i c e o f i n f a n t f e e d i n g m e t h o d : i n f a n t f e e d i n gideo logy and ex terna l cons t ra in t s ( IOM, 1991) .I n f a n t f e e d i n g i d e o l o g y i n c l u d e s b e l i e f s a b o u tp e r c e i v e d b e n e f it s o f d i ff e r e n t f e e d in g me t h o d s a n dv a l u e s p l a c e d o n b r e a s t - o r f o r mu l a - f e e d i n g . I n f a n tfeed ing ideo logy resu l t s f rom pas t exper i ence . I t i sused to gu ide in fan t feed ing p rac t i ces and i s theresu l t o f p r io r cu l tu ra l adap ta t ion to par t i cu la re n v i r o n me n t a l c o n d i t i o n s o r i n f l u e n c e s ( Ch i b n i k ,1982).

E t h n i c g r o u p me mb e r s h i p i n f l u e n c e s h e a l t h b e -l i e f s a n d k n o w l e d g e a n d ma y a l s o i n f l u e n c e w h owi l l be the mos t in f luen t i a l person in t e rms o fs u p p o r t a n d a d v i c e a b o u t v a r i o u s a s p e c t s o f i n f a n tfeed ing (Baranowsk i , e t a l . , 1983 ; Bryan t , 1982 ;McClorg & Bryan t , 1989) . Kin , f r i end , and ne igh-b o r n e t w o r k s t r a n s mi t i n f o r ma t i o n a b o u t t he a d v a n -tage o f in t roducing so l id foods a t an ear ly age , aswel l as va lues and be l i e fs abou t spec i f i c feed ingprac t i ces (Black , Bla i r , Jones , & DuRant , 1990 :Bryant , 1982; Burki & Reis , 1985).

Heal th p ro fess iona l s were no t a s ign i f i can t in f lu -e n c e f o r l o w i n c o me w o me n ; b u t f a mi l y , f r i e n d s ,and peers were iden t i f i ed as hav ing the mos ti n f l u e n c e ( Br y a n t , Co r e i l , D 'A n g e l o , Ba i l e y , &Laz arov , 1992 ; Dix , 1991). Wo me n o f low incom es ta tus were l es s l ike ly td rece ive he lp f rom a l lsources in the i r in fan t feed ing dec i s ion than womeno f mi d d l e a n d u p p e r i n c o me s t a t u s ( G r o s s ma n ,F i t z s i mmo n s , L a r s e n - A l e x a n d e r , Sa c h s , & H a r t e r ,1 99 0) . L o w - i n c o me w o m e n i d e nt if ie d l a c k o f r o lemo d e l s i n th e c o m mu n i t y a n d l a c k o f s u p p o r t a sbar r i e rs to b reas t - f eed in g (Bry an t e t a l. , 1992).

Ex terna l cons t ra in t s inc lude separa t ion f rom thei n f a n t r e s u l t i n g f r o m d e ma n d s o f h o u s e h o l d a n df a mi l y r e s p o n s i b il i ti e s a n d c o m mi t m e n t s o u t s id e o ft h e h o me s u c h a s w o r k . Be h a v i o r s a n d l i f e st y l e s o fb l a c k s a r e d i f f e r e n t f r o m t h o s e o f o t h e r e t h n i cg r o u p s . T h e a t t i t u d e s a n d p a t t e r n s o f b e h a v i o r , a swel l as ch i ld rear ing p r io r i t i es , a re the resu l t o fun ique , economic , cu l tu ra l , and rac ia l c i rcum-s tances in the i r env i ronment (Pe te rs , 1997) . Todevelop da ta -based in te rven t ions , the be l i e fs , a t t i -tudes , and s i tua t iona l fac to rs tha t a f fec t ch i ld -r e a r i n g o f b l a c k l o w - i n c o me c a r e g i v e r s mu s t b eiden t i f i ed and descr ibed .

I n t e r v e n t i o n s t o i n c r e a s e t h e i n c i d e n c e o f b r e a s t-f e e d in g a m o n g l o w - i n c o m e a n d b la c k w o m e n h a v eb e e n s u c c e s s f u l ( Br e n t , Re d d , D w o r e t z , D 'A mi c o ,& G r e e n b e r g , 1 99 5; H e a l t h y Pe o p l e 2 00 0 , 1 9 9 5) ;

h o w e v e r , t h e d u r a t i o n o f b r e a s t - f e e d i n g h a s n o ti mp r o v e d . T h e l i m i t e d d a t a a v a i l a b l e s u g g e s t t h a tma n y w o m e n w h o a r e b r e a s t - f e e d i n g a t th e t i me o fd i s c h a r g e f r o m t h e h o s p i t a l s t o p b r e a s t - f e e d i n gwel l befo re the des i red 5 to 6 months o f age . Therei s l i t t l e in fo rmat ion abou t the low- income b lackw o ma n w h o i n i t i a t e s b r e a s t - f e e d i n g a n d e v e n l e s sa b o u t t h o s e w h o n u r s e f o r a p r o l o n g e d p e r i o d .

A l t h o u g h w e k n o w t h a t l o w - i n c o me b l a c k w o m e nhave low ra tes o f b reas t - feed ing , there i s l i t t l ei n f o r ma t i o n a b o u t d e c i s i o n s ma d e r e g a r d i n g n o to n l y b r e a s t - f e e d i n g a n d f o r m u l a - f e e d i n g b u t i n t r o -duc t ion o f so l id food s and the be l i e fs tha t in f luencethese p rac t i ces . I t i s necessary to iden t i fy thefac to rs tha t in f luence the dec i s ion to b reas t - feed o rf o r mu l a f e e d ( L a w r e n c e , 1 98 8) . Mo r e i n f o r ma t i o nabou t s ty les o f in fan t feed ing and the in f luence o ft h e m i c r o e n v i r o n m e n t a n d m a c r o e n v i r o n m e n t o nb l a c k l o w - i n c o m e w o m e n is n e e d e d t o pl a n c u l tu r e -spec i f i c and e f fec t ive in te rven t ions to ach ieve theh e a l th p r o m o t i o n g o a l f o r 2 0 0 0 a n d i m p r o v e i n f a n theal th s tatus .

METHODSAn e thnograph ic f i e ld s tudy des ign us ing in ten -

s ive in te rv iewing was used . F ie ldwork i s the p ro -c e s s o f s t u d y i n g p h e n o m e n a f ir st h a n d i n t hee n v i r o n m e n t s i n w h i c h t h e y n a t u r a ll y o c c u r ( G l a s e r& St rauss , 1967) . E thnography recogn izes tha tbehav io r i s con tex t re l a t ed and a ims to cap tu re tha tc o n t e x t i n d e ta i l. T h r o u g h t h e e t h n o g r a p h i c m e t h o do f i n t e n s i v e i n t e r v i e w i n g , t h e r e s e a r c h e r " l e a r n sf r o m i n f o r ma n t s t h e me a n i n g s t h e y a t t a c h t o t h e i rac t iv i t i es , even t s , behav io rs , knowledge , r i tua l s ando ther aspec t s o f the i r l i fe -s ty le" (Germ ain , 1993 , p .2 3 9 ) . E t h n o g r a p h y i s a p p r o p r i a t e f o r t h e s t u d y o fp h e n o m e n a o f w h i c h w e h a v e l i tt le k n o w l e d g e ,p a r t i c u l a r l y p h e n o me n a t h a t i n v o l v e i mp l e me n t a -t io n o f p r o c e s s e s o v e r t i me s u c h a s i n f a n t f e e d i n g .Setting and Sam ple

Cr i t e r ia f o r s a m p l e s e l e c t i o n w e r e t h e f o l l o w i n g :b l a c k , a g e 1 8 o r o v e r , a n d l o w - i n c o me h o u s e h o l d .An add i t iona l c r i t e r ion was tha t the in fo rmant wasthe mother o f a hea l thy , fu l l - t e rm in fan t de l iveredb y a n u r s e mi d w i f e . T h r e e c o u n t i e s s u r r o u n d i n g amet ropo l i t an cen ter in the sou theas te rn Uni t edS t a t e s p r o v i d e d t h e s e t t i n g . T h e s a mp l e c o n s i s t e do f I 0 mo t h e r s w h o d e l i v e r e d t h e i r i n f a n t s a t t h ec o u n t y h o s p i t a l a n d w h o r a n g e d i n a g e f r o m 1 8 t o2 7 y e a r s . E i g h t in f o r ma n t s w e r e h i g h s c h o o l g r a d u -a t e s; t w o h a d c o m p l e t e d I 1 y e a r s o f s c h o o l . Se v e no f t h e i n f o r ma n t s w e r e s i n g l e p a r e n t s w h o l i v e d i ne x t e n d e d f a mi l y h o u s e h o l d s . T h e o t h e r t h r e e w e r e


4/9

76 KAR EN S . C OR BET I

m a r r i e d a nd r e s ide d in nuc l e a r house ho lds . S e ve no f t he house ho lds w e r e i n u r ba n a r e a s , a nd th r e ew e r e r u r a l . A l l i n f a n t s w e r e e n r o l l e d i n M e d ic a ida n d W I C p r o g r a m . H a l f t h e i n f o r m a n t s w e r e f i rs t-t im e m o the r s a nd the r e s t ha d e i t he r one o r tw oo the r c h i ld r e n . The r e w e r e s e ve n f e m a le a nd th r e em a le i n f a n t s , w i th b i r th w e ig h t s r a ng ing f r om 5 . 5 t o8 .5 poun ds . S ix o f the m o the r s w e r e i n t e nd ing tob r e a s t - f e e d a nd f ou r w e r e i n t e nd ing to f o r m u la f e e da t the t im e o f d i s c ha r ge f r om the hosp i t a l .Data Co l lec t ion

P o te n t i a l sub j e c t s w e r e c on ta c t e d by t he i nve s t i -ga to r , in pe r son , be f o r e d i s c ha r ge f r om the hosp i t a l .The f i r s t 13 sub j e c t s w ho a g r e e d to pa r t i c ipa t e i nthe s tudy w e r e e n r o l l e d , bu t t he i nve s t i ga to r w a suna b le t o c on ta c t t h r e e sub j e c t s a f t e r hosp i t a ld i s c ha r ge . Ea c h o f t he sub j e c t s a g r e e d t o e igh tin t e r v i e w s du r ing t he i n f a n t ' s f i r s t ye a r o f l i f e a ndw a s pa id $10 pe r i n t e r v i e w . I n p r e v ious s tud i e s ,i n f o r m a n t s o f t e n ha d d i f f i c u l ty r e m e m be r ing pa s tpa t t e r n s o f f e e d ing a nd r e a sons f o r m a k ing de c i -s ions r e l a t e d t o f e e d ing . F r e que n t i n t e ns ive i n t e r -v i e w ing w a s done t o ga the r m or e de t a i l e d a nda c c u r a t e da t a .

I n t e r v i e w s w e r e c onduc t e d t h r oughou t t he i n -f a n t ' s f i r s t ye a r o f l i f e t o ga the r da t a a bou t t hep r oc e s s o f f e e d ing a s t he c h i ld g r e w a nd de v e lope d .The in i t i a l i n t e r v i e w took p l a c e w he n the i n f a n tw a s 2 w e e ks o ld , and in t e r v i e w s w e r e done m on th lythe r e a f t e r un t i l t he i n f a n t w a s 6 m on ths o ld .I n t e r v i e w s w e r e s c he du le d m or e f r e que n t ly i n t hef i r s t ha l f o f t he ye a r w he n the i n f a n t w a s g r ow inga n d d e v e l o p i n g m o r e r a p i d l y . T h i s a l l o w e d f o rga the r ing da t a on p r a c t i c e s suc h a s i n t r oduc t ion o fso l id t bods a nd o the r f l u id s . The r e m a in ing in t e r -v i e w s took p l a c e w he n the i n f a n t s w e r e 9 a nd 12m o n t h s o l d .

A l l i n t e r v i e w s w e r e he ld i n t he m o the r ' s hom e .T h e y w e r e a u d i o t a p e d a n d t r a n s c r i b e d b e f o r e t h en e x t i n t e r v i e w . T h e s a m p l e w a s c o n s i d e r e d a d -e qua t e w he n da t a s a tu r a t i on ha d oc c u r r e d , t ha t i s ,w h e n n o n e w t h e m e s o r d i m e n s i o n s w e r e i d en t if ie dtha t c on t r i bu t e d t o a nsw e r ing t he r e se a r c h que s -t ions (Morse & F ie ld , 1995) .

D a ta w e r e c o l l e c t e d u s ing i n t e ns ive i n t e r v i e w s , ag u i d e d c o n v e r s a t i o n w h o s e g o a l w a s t o " d i s c o v e rin f o r m a n t s ' e xpe r i e nc e s o f a pa r t i c u l a r t op i c o rs i tua t ion " (Lof lan d & Lof lan d, 1984, p . 12) . Th ec o n v e r s a t i o n a l w a y s s t a r t e d w i t h t h e s a m e " g r a n dt o u r " q u e s t i o n : " T e l l m e h o w y o u a r e fe e d i n g y o u rba b y . " I n t e r v i e w s w e r e f a i rl y uns t r uc tu r e d t o a ll owf o r t he i n f o r m a n t t o i n i t i a t e t op i c s . A f t e r t hei n f o r m a n t h ad a n s w e r e d t h e " g r a n d t o u r " q u e s t i o n ,

t op i c a l a r e a s de r ive d f r om the c onc e p tua l f r a m e -w o r k a nd the l i t e ra tu r e r e v i e w w e r e u se d a s a gu idef o r a m or e f oc use d in t e r v i e w . Top ic a l a r e a s i n -c lude d in f a n t f e e d ing p r a c t i c e s , sou r c e s o f know l -e dge , v i e w s o f " w ha t i s a he a l t hy ba by , " l i f e s ty l ea c t i v i t i e s , suc h a s w or k o r o the r house ho ld r e spon -s ib i l i t i e s t ha t i n f lue nc e d f e e d ing de c i s ions , a ndp r e v ious e xpe r i e nc e s f e e d ing c h i ld r e n . A va r i e ty o fd e m o g r a p h i c d a t a w a s c o l l e c te d t o e x a m i n e h o u s e -ho ld s t r uc tu r e a nd l i f e s ty l e f a c to r s .Protect ion of H um an Subjects

T h e p r i v a c y a n d c o n f i d e n t i a l i t y o f i n f o r m a n t sw e r e p r o t e c t e d du r ing t he s tudy . C onf ide n t i a l i t y ,goa l s o f t he s tudy , a nd pa ym e n t f o r pa r t i c ipa t i onw e r e d i s c u s s e d w i t h i n f o r m a n t s b e f o r e b e g i n n i n gin t e r v i e w s . I t w a s m a de c l e a r t ha t i n f o r m a n t s c ou ldr e f use t o a nsw e r a ny que s t i ons o r d i s c on t inuepa r t i c ipa t i on a t a ny t im e . The U n ive r s i t y I n s t i t u -t i on a l R e v i e w B o a r d g r a n t e d e x e m p t s t a tu s t o t h iss tudy.Data A na lys is

D a ta a na ly s i s be ga n in t he f i e ld a nd gu ide df u r the r da t a c o l l e c t i on . I n t e r v i e w s w e r e t r a nsc r ibe dve r ba t im a nd t r a nsc r ip t s r e v i e w e d f o r a c c u r a c y .M e t h o d s d e r i v e d f r o m t h e w o r k o f S p r a d l e y ( 1 9 7 9 )a nd Lof t a nd a nd Lof l a nd ( 1984 ) w e r e u se d t oide n t i f y a nd a na lyz e c a t e go r i e s , pa t t e r n s , a ndthe m e s . I n t e r v i e w t r a nsc r ip t s w e r e f i r s t s c a nne d toide n t i f y c a t e go r i e s a nd r e l a t i onsh ip s a m ong va r iousc a t e go r i e s . Te n ta t i ve c od ing c a t e go r i e s w e r e de ve l -ope d induc t ive ly a nd the i n t e r v i e w w a s c ode d . Th i sp r oc e s s w a s c on t inue d th r ough a l l subse que n t da t ac o l l e c t i on . S ubse que n t i n t e r v i e w s w e r e a l so t r a n -sc r ibe d a nd c ode d . A l l p r e v ious ly c o l l e c t e d da t aw e r e r e v i e w e d a s c a t e go r i e s a nd the i r a t t r i bu t e sr e f ine d . A f t e r a l l i n t e r v i e w s w e r e c om ple t e d a ndc ode d , a c ode book l i s t i ng c ode s , de f in i t i ons , a nda t t r ibu t e s w a s de ve lope d f o r the f i na l da t a a na ly s i s .D a ta a na ly s i s w a s gu ide d by the a im s o f t he s tudy :t o d e s c r i b e s t y l e s o f i n f a n t f e e d i n g a m o n g l o w -inc om e b l a c k m o the r s a nd to de sc r ibe t he i n f lue nc eo f house ho ld s t r uc tu r e , l i f e s ty l e f a c to r s , a nd thehe a l th c a r e sy s t e m on in f a n t f e e d ing s ty l e .

F I N D I N G SP a t te r n s o f B r e a s t - f e e d i n g

S ix i n f o r m a n t s p l a nne d to b r e a s t - f e e d a t t he t im eof d i s c ha r ge f r om the hosp i t a l . A t t he i n i t i a l i n t e r -v i e w ( 2 w e e k s o f a g e ) , t w o w o m e n w e r e e x c l u -s i v e l y b r e a s t- f e e d in g , t h r e e w e r e c o m b i n i n g b r e a s t -a n d f o r m u l a - f e e d i n g , a n d o n e n e v e r b r e a s t - fe d a f t e rd i s c h ar g e . B o t h o f t h e m o t h e r s w h o w e r e e x c l u -


5/9


s i v e l y b r e a s t - f e e d i n g h a d t r i e d t o g i v e f o r mu l a t othe i r in fan t s , bu t repor t ed tha t t he in fan t s " w ou ldn ' tt ake a bo t t l e . "

H o w f o r m u l a a n d b r e a s t- f e e d in g w e r e c o m b i n e dv a r i e d . O n e i n f o r ma n t b r e a s t - f e d a t n i g h t a n df o r mu l a f e d d u r i n g t h e d a y t i me . A n o t h e r mo t h e rw o u l d u s e a b o t tl e i f s h e w e r e " g o i n g o u t . " A th i rdmo t h e r c o mb i n e d b r e a s t - a n d f o r mu l a - f e e d i n g i n ar a n d o m f a s h i o n t h a t v a r i e d d a y t o d a y . T h e t h r e em o t h e r s w h o c o m b i n e d b r e a s t - a n d f o r m u l a -f e e d i n g f r o m b i r t h h a d a s h o r t d u r a t i o n o f b r e a s t -f e e d i n g ( I , 2 , a n d 3 mo n t h s ) a n d a l l w h e r e e x c l u -s i v e l y f o r mu l a - f e e d i n g b y 3 mo n t h s o f a g e . T h et w o i n f o r m a n t s w h o w e r e e x c l u s i v e l y b r e a s t -feed ing in i t i a l ly con t inued to b reas t - feed longert h a n mo t h e r s w h o c o mb i n e d b r e a s t - a n d f o r mu l a -feed ing . Th i s f ind ing i s s imi l a r to tha t o f a s tudys h o w i n g l o n g e r d u r a t i o n o f b r e a s t - f e e d i n g w h e nmo t h e r s r e p o r t e d e x c l u s i v e b r e a s t - f e e d i n g d u r i n gt h e s e c o n d m o n t h o f l i fe ( H i ll , H u m e n i c k , B r e n n a n ,& W ool l ey , 1997) . One o f the mothe rs b reas t fedher in fan t un t i l he was 11 months o ld . She begans o l id f o o d s w h e n t h e i n fa n t s w a s 4 m o n t h s o l d . T h eo t h e r mo t h e r b e g a n c o m b i n i n g b r e a s t - a n d f o r m u l a -f e e d i n g w h e n t h e i n f a n t w a s 2 mo n t h s o l d a n dcon t inued th i s pa t t e rn un t i l t he in fan t was weanedf r o m t h e b r e a s t a t 9 m o n t h s .D e c i d in g t o B r e a s t - f e e d

A l l mo t h e r s w h o c h o o s e b r e a s t - f e e d i n g d i d s ob e c a u s e o f i n f o r ma t i o n ma d e n c o u r a g e me n t t h e yr e c e i v e d f r o m h e a l t h c a r e p r o v i d e r s d u r i n g p r e n a t a lc a r e . T h e y w a n t e d t o b r e a s t - f e e d b e c a u s e " i t w a sb e s t f o r t h e b a b y " o r b e c a u s e o f " c o n v e n i e n c e . "Mo t h e r s r e p o r t e d s p e c i f i c a d v a n t a g e s o f b r e a s t -feed ing fo r the in fan t : "ga in a lo t o f weigh t , "" d o n ' t g e t s i c k as mu c h , " " e a s i e r to f e e d a t n i g h t , "" h e l p s b o w e l s , " " b a b y w i l l b e c l o s e r t o m e , "" m a k e s ( b a b y ) m o r e s e c u r e , " a n d " d o n ' t s p i t a sm u c h . " T h e m o t h e r w h o e x c l u s i v e l y b r e a s t - f e ds t a te d " I 'm r e a l l y th e o n l y o n e t h a t c a n g i v e h i mb r e a s t m i l k , a n d t h a t ma k e s me h a p p y . H e l o o k s f o rme to feed h im, I l i ke tha t a lo t . "K n o w le d g e a b o u t B r e a s t- fe e d in g

K n o w l e d g e a b o u t b r e a s t - f e e d i n g w a s l i m i t e d .N o n e o f t h e i n f o r ma n t s i d e n t i f i e d p h y s i o l o g i c a lb e n e f i ts o f b r e a s t - f e e d i n g f o r t h e m o t h e r , w h i c h i sc o n s i s t e n t w i t h t h e v i e w o f b r e a s t m i l k a s a p r o d u c tr a t h e r t ha n b r e a s t - f e e d i n g a s a p r o c e s s ( V a n E s t e r i k& El l io t t , 1986) . I t i s a l so cons i s t en t wi th ano thers t u dy o f l o w - i n c o me b r e a s t - f e e d i n g mo t h e r s ( Co r e i l ,B r y a n t , W e s t o v e r , & Ba i l e y , 1 9 9 5 ) . T h e s e w o me nd i d n o t h a v e mu c h k n o w l e d g e a b o u t t h e p r o c e s s o f

b reas t - feed ing such as the re l a t ionsh ip be tweenf r e q u e n t f e e d i n g a n d i n c r e a s e d b r e a s t m i l k s u p p l y .O n e mo t h e r q u it b r e a s t f e e d i n g a t 1 mo n t h b e c a u s es h e " n e e d e d t o l o o s e w e i g h t " w h i l e a n o t h e r s a i dt h a t s h e s t o p p e d b r e a s t - f e e d i n g " b e c a u s e I w a s n ' tea t ing f igh t , and I d idn ' t wan t her to ge t s i ck . "I n f o r ma n t s w e r e a w a r e t h a t t h e y n e e d e d t o e a t" r i g h t " a n d t h a t f o o d s t h e y a t e c o u l d a f f e c t t h ei n fa n t . O n e i n f o r ma n t s ta t e d " I d o n ' t e a t t ha t mu c hs tu f f l i ke I used to . L ike sausage and s tu f f . S tu f fwi th a lo t o f g rease in i t , I don ' t ea t no m ore . I j u s tdec ided no t to do i t , because then she would ge tg a s , a n d th e n i t w o n ' t g o a w a y . "A t t i tu d e s a n d B e l i e f s a b o u t B r e a s t -fe e d i n g

N o n e o f t h e m o t h e r s w h o b r e a s t - f e d w e r e m a r -r ie d , a n d e a c h l i v e d w i th h e r e x t e n d e d f a mi l y w h ow e r e n o t s u p p o r t i v e o f b r e a s t - f e e d i n g . O n l y o n ei n f o r ma n t k n e w a n y o n e e l s e w h o h a d s u c c e s s f u l l ybreas t - fed . Al l i n fo rmant s repor t ed nega t ive a t t i -t u d e s t o w a r d b r e a s t - f e e d i n g s u c h a s i t ' s " n a s t y . "O n e i n f o r ma n t w a s t o l d b y h e r mo t h e r w h o h a db r i e f l y a t t e mp t e d b r e a s t - f e e d i n g t h a t " g i r l t h a tth ing hur t s " and "you are no t go ing to l i ke tha t . "Br e a s t - f e e d i n g mo t h e r s d e s c r i b e d b o t h a n a t t i t u d eo f r e v u l s i o n a n d c u r i o s i t y a b o u t b r e a s t - f e e d i n g .O n e i n f o r ma n t ' s mo t h e r t o l d h e r t o " g o i n t h eb a t h r o o m a n d d o t h a t . "A n o t h e r t o l d o f c u r i o s i t y o f f r i e n d s w h o w e r ev i s i t i n g a n d w a n t e d t o w a t c h b e c a u s e t h e y h a dn e v e r s e e n a w o ma n b r e a s t f e e d . E v e n t h e b r e a s t -f e e d i n g mo t h e r s b e l i e v e d t h a t b r e a s t - f e e d i n g w a sn o t s o me t h i n g t h a t s h o u l d b e d o n e i n p u b l i c . O n ei n f o r ma n t n e v e r b r e a s t - f e d i n f r o n t o f t h e i n f a n t ' sf a t h e r a n d a n o t h e r d i d n o t b r e a s t - f e e d i n f r o n t o f h e r7 - and 10-year -o ld ch i ld ren . Breas t - fed in fan t sw e r e t e d f o r mu l a w h e n mo t h e r s w e r e g o i n g o u t i npub l i c .

H a l f t h e mo t h e r s c h o s e f o r mu l a - f e e d i n g , a l -t h o u g h t h e y h a d h e a r d t h a t b r e a s t - f e e d i n g w a s" b e s t f o r t h e b a b y . " B r e a s t - f e e d i n g s e e m e d t o b e a nunfami l i a r and undes i rab le ac t iv i ty as re f l ec t ed inc o m m e n t s su c h as " t h a t ' s n o t m e " a n d " I c a n ' t s e emy s e l f t a k i ng m y b r e a s t o u t a n d g i v i n ' h e r . "A n o t h e r i n f o r ma n t w a s t o l d t h a t i t " h u r t t o b r e a s tfee d" by he r s is t e r , who had t r i ed and d id no t l i ke it .F o r m u l a - F e e d i n g

O f the 10 in fan t s in th i s study , 9 were fo rm ulafed dur ing in fancy , and on ly t was exc lus ive lyb r e a s t f e d . F i v e i n f a n t s w e r e e x c l u s i v e l y f e d f o r -mu l a b y b o t t l e f r o m b i r t h . A n o t h e r f o u r i n f a n t sw e r e f o r mu l a f e d i n c o mb i n a t i o n w i t h b r e a s t -f e e d i n g f r o m b i r t h . Mo t h e r s o f t e n h a d a h a r d t i me


6/9

78 KAREN S. CORBE'I-r

r e c a l li n g e x a c t a m o u n t s a n d f r e q u e n c i e s o f fe e d -i ng s . T h e a m o u n t s a n d f r e q u e n c y o f f o r m u l a f e e d -i n g s w e r e t y p i c a l o f w h a t o n e w o u l d e x p e c t a n dv a r i e d b y s i z e a n d a g e o f t h e i n fa n t . I n f o r m a n t s f e di n f a n t s o n a " d e m a n d s c h e d u l e , " t h a t i s w h e n t h e yb e l i e v e d t h e i n f a n t w a s h u n g r y . T h e y l et t he i n f a n td e t e r m i n e t h e a m o u n t o f a f e ed i n g . I n a d d i ti o n t of o r m u l a , w a t e r , c e r e a l , K a r o s y r u p , s t r a i n e d f o o d s ,a n d j u i c e w e r e a l l l e d b y b o t t le . I t w a s a c o m m o nb e l i e f th a t i n f a n ts m u s t b e f e d w a t e r . O n e i n f o r m a n te x p l a i n e d " S o m e t i m e s l ik e i f s h e g e t h u n g r y a n d Ik n o w s h e h u n g r y , t h e n I g i v e h e r a li tt l e b it o f w a t e rf i r s t , s o s h e c a n g e t u s e d t o i t . S h e g o t t a h a v e s o m ew a t e r . " I n f o r m a n t s e m p h a s i z e d t h e i m p o r t a n c e o fb o i l i n g w a t e r a n d s t e r i l i z i n g b o t t l e s a s p a r t o ff o r m u l a p r e p a r a t i o n a n d a l l w a r m e d t h e f o r m u l ab e f o r e f e e d i n g .S o l i d Food

S e v e n i n f an t s r e c e i v e d c er e a l b e f o r e 3 m o n t h s o fa g e , a n d t h e m a j o r i t y o f m o t h e r s f e d c e r e a l i n th eb o t tl e . T h e r e w a s n o c o n s i s t e n t p a t t e rn o f h o w t h ec e r e a l - f o r m u l a m i x t u r e w a s p r e p a r e d o r h o w o f t e ni t w a s g i v e n . S e v e r a l i n f o r m a n t s p u t c e r e a l i n e a c hb o t t l e w h i l e o t h e r s l e d c e r e a l i n o n e b o t t l e a d a y .O n e m o t h e r t o l d m e t h a t s h e w o u l d b e g i n c e r e a ls o o n b e c a u s e t h a t ' s " w h a t i n f a n t s n e e d e d " a n d w a s" ' h o w s h e f e d h e r o t h e r t w o c h i l d r e n . " H e r r e a s o nw a s b e c a u s e " m i l k c o u l d n ' t b e e n o u g h t o s a t i s f yt h e i n f a n t . "

A s e c o n d m o t h e r p u t 2 V2 t e a s p o o n s o f c e r e a l i ne a c h 4 - o z b o t tl e . S h e s t at e d " W h e n s h e j u s t h a d t h ep l a i n m i l k , s h e w o u l d n ' t s l e e p a s l o n g . I f I fe e d h e r ,s h e w o u l d w a k e u p a g a i n l i k e p r o b a b l y t w o o rt h r e e , w a n t i n g a n o t h e r b o t t l e . W i t h t h e c e r e a l s h ej u s t e a t , s h e g e t f u ll , s h e d o n ' t w o r r y i f h e r b o t t l ec a m e . " A t h i rd i n f o r m a n t , w h o s t a r te d c e r e a l w h e nh e r s o n w a s 3 w e e k s o l d , d e s c r i b e d h o w s h e m a d et h e d e c i s i o n . " A t t h a t t i m e , h e w a s h u n g r y a l l t h et i m e , s o I t h o u g h t o f p u t t i n g c e r e a l i n h i s b o t tl e ,c a u s e h i s li t tl e s t o m a c h w o u l d g r o w l , s o I j u s ts t a r t e d g i v i n g h i m s o m e c e r e a l . " S h e t h o u g h t t h a ta d d i n g t h e c e r e a l " h e l p e d , b e c a u s e h i s s l e e p p a t -t e r n s w e r e m e s s e d u p c a u s e h e w o u l d n ' t s l e e p t h a tl o n g . B u t l i k e r i g h t n o w h e ' l l s l e e p l i k e a l l m o r n i n gl o n g . " T h e s e t h r e e i n f a n t s h a d t r i p le d t h e i r b i r thw e i g h t s b y 6 m o n t h s o f a g e a n d w e r e c o n s i d e r e do v e r w e i g h t b y t he W I C p r o g r a m .

B y 6 m o n t h s o f a g e , a ll b u t o n e i n f a n t w e r ee a t i n g a w i d e v a r i e t y o f c o m m e r c i a l i n f a n t f o o d s .I n f o r m a n t s u s e d a v a r i et y o f f r u it s a n d v e g e t a b l e sa n d r e p o r t e d d e f i n i t e i n f a n t p r e f e r e n c e s f o r a n dr e f u s al o f c e r ta i n f o o d s . N o m o t h e r s r e p o r t e dp r e p a r i n g t a b l e f o o d s s u c h a s m a s h i n g a b a n a n a o r

v e g e t a b l e s . A l l f o r m u l a - f e d i n f a n t s w e r e s t i l l d r i n k -i n g f r o m b o t t le s a t 1 y e a r o f a g e .In f lu e n c e o f F a m i ly a n d F r ie n d s

A l l i n f o r m a n t s e i t h e r l i v e d w i t h t h e i r m o t h e r s o rw i t h i n a f e w m i le s o f t h e ir m o t h e r s ' h o m e s . S i s te r s ,g r a n d m o t h e r s , a n d c o u s i n s w e r e a l s o n e a r b y . I n f o r -m a n t s l e a r n e d a b o u t i n f a n t s a s t h e y c a r e d f o ry o u n g e r s i b li n g s o r i n f an t s o f o t h e r r e l a t iv e s a s t h e yw e r e g r o w i n g u p . F a m i l y a n d f r i e n d s w e r e m o r ei m p o r t a n t s o u r c e s o f a d v i c e a b o u t i n f a n t f e e d i n gt h a n t h e h e a l t h c a r e s y s t e m . I n f o r m a n t s h a d i n f o r -m a t i o n a b o u t s c i e n t i f i c r e c o m m e n d a t i o n s s u c h a s" d o n ' t s t a r t s o l i d s e a r l y " a n d " f e e d c e r e a l b ys p o o n " b u t m a d e t h e d e c i s i o n t o s t ar t c e re a l a n d p u ti t i n t h e b o t t l e . O n e i n f o r m a n t , w h o l i v e d w i t h h e rp a r e n t s , d e s c r i b e d t h e a d v i c e s h e r e c e i v e d a b o u tf e e d i n g h e r 3 - w e e k - o l d i n f an t :

My g randmother, she tell me to giv e the ba by cereal. Shesaid she needed it and w ould sleep longer. She say "shehungry cause she just drinking milk and that m ilk can't fillher up that much." They come over and they see me givingher formu la and they say, "Th at's all she's drinking? Is thatsupposed to fill her up?"B y 2 V 2 m o n t h s t h i s m o t h e r h a d s t a r t e d t o f e e d h e rc h i l d c e r e a l i n th e b o t t l e .

T h e f a t h e r a n d h i s e x t e n d e d f a m i l y o f t e n w e r ei n v o l v e d w i t h t h e i n f a n t e v e n w h e n t h e p a r e n t sw e r e n o t m a r r i e d a n d d i d n o t l i v e i n t h e s a m eh o u s e . O n e i n f a n t w o u l d b e s e n t t o s p e n d w e e k e n d so r h o l id a y s a t t h e f a t h e r ' s f a m i l y h o m e w h e n h ew a s h o m e f r o m c o l l e g e . T h i s i n f a n t , w h o w a se x c l u s i v e l y b r e a s t - f e d b y h e r m o t h e r , w a s f e df o r m u l a a n d c e r e a l ( a t 2 m o n t h s ) w h e n s h e s p e n t 3d a y s a t h e r f a t h e r ' s f a m i l y h o m e d u r i n g t h e h o l i -d a y s . T h e o n e i n f o r m a n t w h o e x c l u s i v e l y b r e a s t -f e d w a s g i v e n g i f ts o f s t r a in e d f o o d s a n d c e r e a lw h e n s h e w o u l d t a k e t h e i n f a n t t o v i s i t t h e p a t e r n a lg r a n d p a r e n ts . S h e r e p o r te d t h a t " H i s f a t h e r ' s m o t h e rw a n t e d m e t o s t a r t g i v i n g h i m f o o d w h e n h e w a sl ik e t w o m o n t h s a n d I t o ld h e r I d i d n ' t w a n t t o. B u ts h e w o u l d a l w a y s b u y h i m f o o d s a n d s e n d m eh o m e w i th i t b u t I w o u l d j u s t a l w a y s s t i c k i t[ a w a y ] . "I n t e r a c t i o n a l S t y le

A m o t h e r ' s r e s p o n s e t o a n d i n t e r p r e t a t i o n o fc r y i n g , a s w e l l a s b e l i e f s a n d a t t i t u d e s a b o u tc u d d l i n g a n d f o n d l i n g a n i n f a n t , a l l c o n t r i b u t e d t of e e d i n g s t y l e . I n t e rp r e t a t io n o f c r y i n g a s n o t b e i n gs a t i s f i e d , c o n t r i b u t e d t o c e r e a l b e i n g a d d e d t o t h ed i e t o f in f a n ts . A l l m o t h e r s s a i d t h a t t h e y d e c i d e dt h a t t h e i n f an t w a s h u n g r y i f th e b a b y c r i ed . S o m em o t h e r s r e p o r t e d t h a t t h e y k n e w t h a t b a b i e s w e r e n ' t


7/9


sa t i s f i ed a f t e r be ing fed a bo t t l e because they c r i edo r " s ma c k o n t h e i r h a n d s . " I n f o r ma n t s r e p o r t e d av a r i e t y o f r e s p o n s e s t o t h e i r i n f a n t s ' c r y i n g s u c h a sus ing pac i f i e rs , p i ck ing in fan t s up , walk ing wi tht h e m, o r a t t i me s l e t t i n g t h e m c r y t h e ms e l v e s t os l eep .T h e b e l i e f " t h a t i n f a n t s c a n b e s p o i l e d " i n f l u -enced in t e rac t iona l s ty l e and response to c ry ing .Ba b i e s w e r e o f t e n d e s c r i b e d a s g o o d o r s p o i l e d . Ag o o d b a b y d i d n ' t c r y a l o t . O n e i n f o r ma n t s a i d ." Sh e i s a g o o d b a b y , s h e o n l y c r y i f s he i s h u n g r y o rwet . " A spo i l ed baby wan t s to be he ld a l l t he t ime.I f y o u p i c k e d u p i n f a n ts w h e n t h e y c r ie d , t h e yw o u l d a l w a y s w a n t t o b e h e l d . F r i e n d s a n d f a mi l yw o u l d w a r n mo t h e r s a b o u t s p o i l i n g t h e i n f a n t .W h e n a s k e d t o e x p l a i n w h a t s p o i l e d me a n t , o n ei n f o r ma n t s a i d " h e w a n t s t o st a y in my l a p , my a r ma n d h e d o e s n ' t w a n t t o s t a y d o w n . H e c r i e s t o g e t inmy l a p. W h e n h e g e t s in my l a p h e ' s f i n e . "

P i c k i n g a n i n f a n t u p w h e n s h e c r ie d w a s b e l i e v e dto spo i l t he ch i ld and resu l t i n an in fan t a lwaysw a n t i n g t o b e h e l d . Fe e d i n g w a s a f r e q u e n t r e -spons e to c ry ing . I t was a s t ra t egy to s top the c ry ingw i t h o u t " s p o i l i n g " t h e i n f an t .

Influence of the H ealth Ca re SystemPrac t i ces a t t he hosp i t a l where a l l i n fan t s wereborn inc luded those tha t a re cons idered nonsuppor t -

i v e o f b r e a s t - f e e d i n g i n c lu d i n g s u p p l e m e n t i n gbreas t - fed in fan t s wi th fo rn~u la and g luscose water ,separa t ing mother and in fan t , and d i s t r ibu t ing fo r -mu l a d i s c h a r g e k i ts . I n f a n t s w e r e o f t e n d e s c r i b e d a ss l eepy o r un in te res t ed in b reas t - feed ing whi l e theywere in the hosp i t a l . A l ac t a t ion consu l t an t f r om theW I C p r o g r a m s a w s o me mo t h e r s i n t h e h o s p i t a l ,a n d a p e e r c o u n s e l o r p r o g r a m w a s i n p l a c e . H o w -e v e r , s o me mo t h e r s i n t h i s s t u d y s t o p p e d b r e a s t -f e e d i n g b e f o r e t h e y w e r e c o n t a c t e d b y a c o u n s e l o ro r w e r e n e v e r c o n t a c t e d . A l t h o u g h i n f o r ma n t s h a db e e n g i v e n s o me i n f o r ma t i o n a b o u t b r e a s t - f e e d i n g ,t h e y d i d n o t h a v e p r a c t i c a l k n o w l e d g e a n d l a c k e ds u p p o r t o r a s s i s t a n c e o n c e t h e y w e r e h o me . T h i sl ack o f suppor t be tween the hosp i t a l and the f i r s tpos tpar tum v i s i t was a l so iden t i f i ed by Core i l e t a l .( 1 9 9 5 ) in a s t u d y o f l o w - i n c o me w o m e n w h o b r e a s tfed.

I n f o r ma n t s i d e n t i f i e d i n f o r ma t i o n g i v e n d u r i n gthe p rena ta l care , as s i s t ance in the hosp i t a l , andbeing ab le to ca l l fo r in fo rmat ion as he lp fu l wi thb r e a s t - f e e d i n g . Su p p o r t f o r t h e b r e a s t - f e e d i n gmother was cons i s t en t ly iden t i f i ed as he lp fu l i na n o t h e r s t u d y o f b r e a s t - fe e d i n g m o t h e r s w h o p a r t i c i -p a t e d i n t h e W I C p r o g r a m ( T r a d o & H u g h e s ,

1 9 9 6 ) . So me w o me n a l s o u s e d v i d e o t a p e s , b o o k s ,a n d p a m p h l e t s a s s o u r c e s o f i n f o r ma t i o n .

Heal th care fo r the in fan t s was f ragmented . Al lin fo rm ant s too k the i r in fan t s to pub l i c hea l th c l in i csf o r w e l l - c h i l d c a r e , ma d e s e p a r a t e v i s i t s t o W I Ccl in i cs , and saw a p r iva te med ica l doc to r o r usedt h e e me r g e n c y r o o m w h e n t h e c h i l d w a s s i c k . T h eW I C p r o g r a m p r o v i d e d t h e m o s t a d v i c e a b o u tin fan t feed ing .

So m e h e a l th c a r e p r o v i d e r s g a v e a d v i c e t h a t w a sn o t s u p p o r t i v e o f b r e a s t - f e e d i n g . O n e p h y s i c i a nt o l d a n i n f o r ma n t t o " g i v e a t w o w e e k o l d b r e a s tf e d i n f a n t o n e b o t t l e o f f o r mu l a a d a y a n d s t a r tc e r e a l a t o n e mo n t h . " A n o t h e r mo t h e r w a s t o l d b yh o s p i ta l s t a f f " i f s h e d o e s n ' t t a k e t o t h e b r e a s t d o n ' tf o r c e a n d g i v e a b o t t l e . " Se v e r a l i n f o r ma n t s w e r eto ld tha t b reas t - fed in fan t s needed water . O thers t u d ie s h a v e i d e n t if i ed t h e l a c k o f k n o w l e d g e a b o u tb r e a s t - f e e d i n g i n a v a r i e t y o f h e a l th c a r e p e r s o n n e l(Core i l e t a l. , 1995 , Trad o & Hu ghes , 1996).

DISCUSSIONT h e s h a r e d s t y l e o f i n f a n t f e e d i n g p r a c t i c e d b y

women in th i s s tudy i s s imi l a r to p rev ious s tud ieso f in fan t feed ing in o ther reg ions o f the coun t ry .Fo r m u l a f e e d i n g w i t h e a r l y i n tr o d u c ti o n o f c e re a lin the bo t t l e i s a way to feed in fan t s . Cerea l i sin i t i a l ly fed in the bo t t l e . O ther so l id foods andj u i c e a r e i n t r o d u c e d e a r l y s o t h a t b y 6 mo n t h s o fa g e , i n f a n t s h a v e a c o mp l e x d i e t o f a v a r i e t y o ffoods . The be l i e f t ha t mi lk a lone cou ld no t sa t i s fyan in fan t under l i es the p rac t i ce o f feed ing cerea l .Feed ing cerea l i n the bo t t l e i s a s t ra t egy mothersuse to ge t t he in fan t to s l eep longer a t n igh t andd e c r e a s e t h e f r e q u e n c y o f f e e d i n g s d u r in g t h e da y .Re s u l t s o f f e e d i n g a r e j u d g e d b y i mm e d i a t e a n dv i s i b l e c r i t e r i a s u c h a s a p p e a r a n c e a n d b e h a v i o r .Fe a r o f s p o i l i n g t h e i n f a n t ma y c o n t r i b u t e t ofeed ing the in fan t as a response to c ry ing ra therthan ho ld ing . A hea l thy baby i s one tha t had a goodappet i t e , i s happy , g rowing wel l , and no t s i ck .Breas t - feed ing i s no t a way to feed in fan t s and i sc o n s id e r e d a " n a s t y " b e h a v i o r b y m a n y .

Mo t h e r s w h o b r e a s t f e d w e r e a t t e mp t i n g t o a d o p ta n e w s t y l e o f i n f a n t f e e d i n g . T h e y v i e w e d b r e a s tmi lk as a p roduct and t r i ed to incorpora te b reas t -feed ing in to the s ty l e o f in fan t feed ing tha t t heyk n e w . Br e a s t - a n d f o r mu l a - f e e d i n g f r o m b i r t h o c -c u r r e d b e c a u s e o f a l a c k o f k n o w l e d g e a b o u t a n ds u p p o r t f o r b r e a s t -f e e d i n g . B r e a s t - f e e d i n g w a s s e e nas a p r iva te behav io r , and a bo t t l e was o f t en usedwhen mothers needed to feed the i r i n fan t s in f ron to f o t h e r s . W h e n t h e s e w o me n s t o p p e d b r e a s t -feed ing , t hey re tu rned to the s ty l e o f in fan t feed ing


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80 KAREN S. CORBETT

.that they learned about from family and friends.Informants breast-fed their infants in a context thatwas not supportive of breast-feeding. The womenin their environment whom they turned to foradvice were not knowledgeable about lactation andoften had negative attitudes toward breast-feeding.Support from the health care system was uneven,and mothers who had a short duration of breast-feeding had the least support. Formula supplemen-tation has been associated with shortened durationof breast-feeding. Morse, Harrison, and Prowse(1986) identified a pattern of minimal breast-feeding in which formula- and breast-feeding arecombined, but only after a period of exclusivebreast-feeding during which lactation has beenestablished.

Health promot ion goals for the year 2000 includeincreasing both the incidence and duration ofbreast-feeding. Low-income and black women havebeen targeted for special attention because theyhave the lowest rates of breast-feeding. If we hopeto increase breast-feeding among low-income blackwomen, we need to invest in and support those whodecide to breast-feed. Styles of infant feeding are

passed from older to younger women and are basedon successfully feeding infants over centuries. Ifwe can assist some low-income black women tohave successful breast-feeding experiences, they inturn can be models for a new style of infantfeeding.

N u r s i n g I m p l ic a t io n sA l l i n f o r m a n t s i n t h i s s t u d y h a d i n f o r m a t i o n

a b o u t cu r r en t f e e d i n g r e c o m m e n d a t i o n s ; h o w e v e r ,k n o w l e d g e , a t t i t u d e s , a n d b e l i e f s d o n ' t a l w a y s l e a dt o p r a c t i c e . N u r s e s n e e d t o b r o a d e n t h e i r a s s e s s -m e n t b y e l i c i ti n g a c l i e n t 's b e l i e f s a b o u t w a y s o ff e e d i n g i n f a n ts a n d i d e n t i f y c o n s t r a i n t s a n d o p p o r -t u n i ti e s i n t h e c li e n t ' s e n v i r o n m e n t . D e s c r i p t i o n s o ff e e d i n g s t y l e a n d e n v i r o n m e n t a l f a c t o r s t ha t in f lu -e n c e s t y l e s a r e n e c e s s a r y t o d e s ig n c u l t u r e - s p e c i fi ca n d e f f e c t i v e i n t e r v e n t i o n s t o i m p r o v e t h e h e a l t hs t a t u s o f l o w - i n c o m e b l a c k c h i l d r e n . E x a m i n a t i o no f e n v i r o n m e n t a l i n f l u e n c e s o n i n f a n t f e e d i n g s t y l em a y p r o v i d e a w i n d o w t o v ie w h o w t h es e s a m efactors operate to influence other aspects of childrearing.

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u rban U.S. se t t ing . M e d i c a l A n t h r o p o l o g y 7 , 1 1 9 .Am er ican Academ y o f Ped ia t ri c s . (1997 ). Brea s t feed ing andt h e u s e o f h u m a n m i l k . P e d i a t r i c s , 1 0 0 ( 6 ) , 1035-1039.Andrew , E .M . , C lancy , K .L . , & K a tz . M . (1980 ). In fan t

feed ing p rac t ice s o f f ami l ie s be long ing to a p repa id g roupp rac t ice hea l th ca re p lan . P e d i a t r i c s , 65, 978-988.

Ba ranow sk i , D . , Bee , D . , R icha rdso n , J . , Brown , J . , Guen the r ,N . , & Nade r , R . (1983 ) . Soc ia l suppo r t , soc ia l in f luence ,e thn ic i ty and the b rea s t f eed ing dec i s ion . S o c i a l S c i e n c e a n dM e d i c i n e , 1 7 . 1599-161 I.

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Brogan , B .D. , & Fox , H .M . (1984 ) . In fan t f eed ing p rac t ice so f l o w a n d m i d d l e i n c o m e f a m i l i e s i n N e b r a s k a . J o u r t l a l o fA m e r i c a n D i e t e t i c A s s o c i a t io n , 8 4 , 560 -563 .

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Kel4 Child Feeding Questionnaire