MIDWIFERY DIPLOMA

CLASS 2012-2013

TEAM MEMBERS

19660926-0044-2012

19750307-0083-2012

19591022-0069-2012

19800602-0047-2012

19741024-0043-2012

19740320-0020-2012

19620228-0025-2012

19800320-0113-2012

19810721-9000-2012

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TABLE OF CONTENTS

PAGES

TOPIC..............................................................................................................................................2

ACKNOWLEDGEMENTS.............................................................................................................3

HYPOTHESIS.................................................................................................................................4

What is breastfeeding......................................................................................................................5

Historical review of breastfeeding...............................................................................................5-8

Basic and natural reasons for the promotion of breastfeeding........................................................8

Benefits of breastfeeding..............................................................................................................8-9

Benefits of breastfeeding to society...............................................................................................10

Breastfeeding protocol..............................................................................................................10-11

Prevalence and support of breastfeeding in the 20th/21st century.............................................11-14

Uptake of exclusive breastfeeding table...................................................................................15-16

Synopsis of literature review....................................................................................................17-26

Abstract.....................................................................................................................................27-28

Adapting/Bonding....................................................................................................................28-29

Antenatal protocol......................................................................................................................... 30

Hypothesis and assumptions.....................................................................................................30-34

Methodology and description of data collection......................................................................35-39

Questionnaire............................................................................................................................39-43

Considerations when planning data collection.........................................................................43-44

Possible limitations...................................................................................................................44-46

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

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Topic

Breastfeeding Practices Among Barbadian Women

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PRINCIPLE INVESTIGATORS

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

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

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

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

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

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

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

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

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

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Postpartum women in Barbados aged 31-45 years are more likely to breast feed exclusively than postpartum women in Barbados aged 18-30 years. (Precise Hypothesis)

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WHAT IS BREASTFEEDING?

During pregnancy a woman’s body goes through several changes one being for the

production of breast milk within the breast and mediated by the hormone prolactin.

Breastfeeding is the feeding of an infant or young child with breast milk directly

from female human breasts (i.e., via lactation) rather than from a bottle or other

container. Babies have a sucking reflex that enables them to suck and swallow

milk. Many specialists recommend mothers exclusively breastfeed for six months

or more, without the addition of infant formula or solid food.

Breastfeeding therefore is the act of a mother having her newborn baby (babies)

suck milk out of their breasts.

HISTORICAL REVIEW OF BREASTFEEDING

In the ancient Egyptian, Greek and Roman empires, women usually fed only their

own children. However, breastfeeding was considered as something too common

to be done by royalty and noble families, thus wet nurses were employed to

breastfeed the children of the royal families. This practice became common over

the ages, particularly in Western Europe, where noble women often made use of

wet nurses. The Moche artisans of Peru (1–800 A.D.) represented women

breastfeeding their children in ceramic vessels.

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Shared breastfeeding is still practiced in many developing countries when mothers

need help to feed their children.

In the 18th century male medical practitioners started to practice in the areas of

pregnancy, birth and babies. These were areas traditionally dominated by women.

Also in the 18th century the emerging natural sciences promoted and encouraged

that women should stay at home to nurse and raise their children, like animals also

do. Governments in Europe started to worry about the decline of the workforce

because of the high mortality rates among newborns. Wet nursing was thought and

believed to be one of the main problems. Campaigns were launched against the

custom among the higher class system of the day of using a wet nurse. Women

were advised or even forced by law to nurse their own children. The biologist and

physician Linnaeus, the English doctor Cadogan, Rousseau, and the midwife Anel

le Rebours described in their writings the advantages and necessity of women

breastfeeding their own children and discouraged the practice of wet nursing. In

1752 Linnaeus wrote a pamphlet against the use of a wet nurse. Linnaeus

considered this against the law of nature. A baby not nursed by the mother was

deprived of the laxative colostrum. Linnaeus thought that the lower class wet nurse

ate too much fat, drank alcohol and had contagious (venereal) diseases, therefore

producing lethal milk.

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Mother's milk was believed to be a miracle fluid which could heal people and give

wisdom. The mythical figure Philosophia-Sapientia, the personification of wisdom,

was believed to have suckled philosophers at her breast and by this way they

absorbed wisdom and moral virtue. On the other hand, lactation was what related

humans with animals. Linnaeus – who classified the realm of animals – did not by

accident rename the category 'quadrupedia' (four footed) in 'mammalia'

(mammals). With this act he made the lactating female breast the icon of this class

of animals in which humans were classified.

In the nineteenth century Historian Rima D. Apple writes in her book Mothers and

Medicine. A Social History of Infant Feeding, 1890–1950 that in the United States

of America most babies got breast milk. Dutch historian Van Eekelen researched

the small amount of available evidence of breastfeeding practices in The

Netherlands. Around 1860 in the Dutch province of Zeeland about 67% of babies

were nursed, but there were big differences within the region. Women were

obliged to nurse their babies: “Every mother ought to nurse her own child, if she is

fit to do it.

Mother's milk was considered best for babies, but the quality of the breast milk

was found to be varied. The quality of breast milk was considered good only if the

mother had a good diet, had physical exercise and was mentally in balance. In

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Europe (especially in France) and less in the USA it was a practice among the

higher and middle class to hire a wet nurse. If it was too difficult to find a wet

nurse, people used formula to feed their babies, but this was considered very

dangerous for the health and life of the baby.

BASIC AND NATURAL REASONS FOR THE PROMOTION OF BREAST

FEEDING

Research is repeatedly proving that breastfeeding is more than the act of

transferring milk. Breastfeeding is nurturing. Even before mother-infant

attachment research, the major reason to breastfeed was to provide a special bond

between mother and child." Surprisingly enough, the major contraindication to

breastfeeding remains the lack of desire to do so.

BENEFITS OF BREASTFEEDING

1. Breast milk is readily available and always at the right temperature.

2. Breast milk is always pre-packaged.

3. The lactational amenorrhea method (LAM) has been proven to be 99 percent

effective in the prevention of pregnancy in the post six weeks period. In

contrast formula feeding mothers start contraception within six weeks of

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birth, it has been proven that once a female breastfeeds exclusively, she may

not become impregnated for six months to a year.

4. Breast feeding assists the uterus that was home to the fetus to contract and

retract causing uterus to return to pre -pregnancy state. It also causes the

abdominal muscles to tighten, and stops postpartum hemorrhage.

5. Breast milk does not cost anything.

6. Breast milk is transportable at all times.

7. Breast feeding has natural health benefits such as, ‘it keeps the female slim,

it greatly reduces the risk of breast, ovarian and uterine cancer, osteoporosis,

and cervical cancer.

8. Breast milk is the only food type that a baby cannot become allergic or

constipated to.

9. Breast milk has all the antibodies, nutrients, vitamins, sugars and proteins; it

is a holistic meal for baby.

10. Breast milk is produced and the mother able to breast feed regardless of her

nutritional and or dieting habits.

11. Breast milk is easily digestible.

12. Breast milk causes the baby’s stool to be less odorous and softer than if

baby was on conventional milk formulas.

13. Supply always meets demand where breastfeeding is concerned

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The benefits of breastfeeding to society are:-

1. Promotes psychological stability

2. Promotes a healthy population

3. Enhances social adaptation /bonding of the infant

4. Reduces Government’s health expenditure

5. Saves on foreign exchange

6. Promotes a healthy environment

7. Formation of support groups to promote breastfeeding exclusively on

demand

Breastfeeding Protocol

This protocol is derived during the ten steps to successful breastfeeding, which

are:-

1. Have a written Breast feeding policy that is routinely communicated to all

health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of

breastfeeding.

4. Help mothers initiate breastfeeding within half an hour of birth.

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5. Show mothers how to breastfeed and how to maintain lactation, even if they

should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk unless

medically indicated.

7. Practice rooming in allows mothers and infants to remain together 24 hours

a day.

8. Encourage breastfeeding on demand.

9. Give no artificial Teats or pacifiers also called dummies or soothers to

breastfeeding infants.

If breast milk had to be exclusively used by all expectant mothers, it would save

the economy millions of dollars especially in here in Barbados where we have to

almost import everything we consume as customers.

PREVALANCE AND SUPPORT OF BREASTFEEDING IN THE 20 TH / 21 ST

CENTURY

In third world countries, particularly those in the sub Saharan African Continent,

parts of Asia and the Indian Pacific rim and South America where poor levels of

health and malnutrition is a major factor of death in children under 5, with 50% of

all those cases being within the first year of life. International organizations such as

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Plan International and La Leche League have helped to promote breastfeeding

around the world, educating new mothers and helping the governments to develop

strategies to increase the number of women exclusively breastfeeding.

Traditional beliefs in many developing countries give different advice to women

raising their newborn child. In Ghana babies are still frequently fed with tea

alongside breastfeeding, reducing the benefits of breastfeeding and inhibiting the

absorption of iron, important in the prevention of anemia.

In response to public pressure, the health departments of various governments have

recognized the importance of encouraging mothers to breastfeed. The required

provision of baby changing facilities was a large step towards making public

places more accessible for parents and in many countries there are now laws in

place to protect the rights of a breastfeeding mother when feeding her child in

public.

The World Health Organization (WHO), along with grassroots non-governmental

organizations like the International Baby Food Action Network (IBFAN) has

played a large role in encouraging these governmental departments to promote

breastfeeding. Under this advice they have developed national breastfeeding

strategies, including the promotion of its benefits and attempts to encourage

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mothers, particularly those under the age of 25, to choose to feed their child with

breast milk.

Government campaigns and strategies around the world include:

National Breastfeeding Week in the United Kingdom

The Department of Health and Ageing Breastfeeding Strategy in Australia

The National Women's Health Information Center in the United States

World Breastfeeding Week

However, there has been a long, ongoing struggle between corporations promoting

artificial substitutes and grassroots organizations and WHO promoting

breastfeeding. The International Code of Marketing of Breast-milk Substitutes was

developed in 1981 by (WHO), but violations have been reported by organizations,

including those networked in IBFAN. In particular, Nestlé took three years before

it initially implemented the code, and in the late 1990s and early 2000s was again

found in violation. Nestlé had previously faced a boycott, beginning in the U.S. but

soon spreading through the rest of the world, for marketing practices in the third

world.

Some people for instance view women who breastfeed in public as being obscene

but here in Barbados we accept this practice as culture and as an action that is

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necessary. However in many countries laws had to be passed to protect women and

their rights to breastfeed in public such as in the United States where the House of

Representatives appropriations bill (HR 2490) with a breastfeeding amendment

was signed into law on September 29, 1999. It stipulated that no government funds

may be used to enforce any prohibition on women breastfeeding their children in

Federal buildings or on Federal property. Further, U.S. Public Law 106-58 Sec.

647 enacted in 1999, specifically provides that “a woman may breastfeed her child

at any location in a Federal building or on Federal property, if the woman and her

child are otherwise authorized to be present at the location.

In Cuba, their constitution has indicated at Article 68 in the 1975 that during the

six weeks after delivery of the baby the woman be allowed two extraordinary daily

rest period of a half hour each shall be allowed her to feed her baby.

My personal advice here is that once breastfeeding is done discretely while in

public it should provide mother and baby as well as the public the privacy and

respect to all.

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The following table shows the uptake of exclusive breastfeeding.

Country Percentage Year Type of feeding

Armenia 0.7% 1993 Exclusive

20.8% 1997 Exclusive

Benin 13% 1996 Exclusive

16% 1997 Exclusive

Bolivia 59% 1989 Exclusive

53% 1994 Exclusive

Central African Republic 4% 1995 Exclusive

( Chile 97% 1993 Predominant

Colombia 19% 1993 Exclusive

95% (16%) 1995 Predominant (exclusive)

Dominican Republic 14% 1986 Exclusive

10% 1991 Exclusive

Ecuador 96% 1994 Predominant

Egypt 68% 1995 Exclusive

Ethiopia 78% 2000 Exclusive

Mali 8% 1987 Exclusive

12% 1996 Exclusive

Mexico 37.5% 1987 Exclusive

Niger 4% 1992 Exclusive

Nigeria 2% 1992 Exclusive

Pakistan 12% 1988 Exclusive

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Country Percentage Year Type of feeding

25% 1992 Exclusive

Poland 1.5% 1988 Exclusive

17% 1995 Exclusive

Saudi Arabia 55% 1991 Exclusive

Senegal 7% 1993 Exclusive

South Africa 10.4% 1998 Exclusive

Sweden 55% 1992 Exclusive

98% 1990 Predominant

61% 1993 Exclusive

Thailand 90% 1987 Predominant

99% (0.2%) 1993 Predominant (exclusive)

4% 1996 Exclusive

United Kingdom[30] 62% 1990

66% 1995

Zambia 13% 1992 Exclusive

23% 1996 Exclusive

Zimbabwe 12% 1988 Exclusive

17% 1994 Exclusive

38.9% 1999 Exclusive

Therefore to all expectant mothers and mothers who have recently experienced

childbirth, breast milk is best and breastfeeding for as long as is possible is ideal.

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For the Midwife, breastfeeding and breast milk is important to their role as

midwives as this facilitates healthy work ethic for their own benefit i.e. positive

bonding between mother and baby will bring great satisfaction to the midwife

fueling her drive and trust for her need to carry on the good and positive work in

maintaining a healthy and stable mother plus baby. For the lay person and society

at large, breast feeding needs to be appreciated and embraced as the natural and

most health wise way for the mother and baby, needs to understand that it has no

cost to society or negative effects to either mother child or economy.

SYNOPSIS OF LITERATURE REVIEW

Breastfeeding has been initiated from the conception of time. It has been seen as

the most nutritional form of nutrition for the infant. Kleinmann (2004) stated that

breast feeding benefits both the mother and the infant; it remains the ideal

nutritional source for infants through the first year of life.

The World Health Organisation advocates exclusive breast feeding for newborns

and infants for the first six months of life. To them breastfeeding is ideal, but this

has been met with some challenges. According to Chatterji and Frick (2003)

maternal employment is negatively associated with both breast feeding initiative

and breast feeding duration. The study indicated that women who returned to work

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within three months were associated with a reduction in breast feeding of a length

four to six weeks.

Arora, McJunkin, Wehrer and Kuhn (2000) examined those factors which

influenced breastfeeding as it related to: feeding decisions by mothers;

breastfeeding and or bottle usage; and the duration of breastfeeding among mothers

whose infants received well child care from birth to one year. Their results

indicated that there was a breastfeeding initiation rate of 44.3% and that by the

time the child had reached six (6) month of age ,only 13% of these mothers were

still breast feeding. The most common reason mothers chose to breastfeed were:

benefits to the baby, naturalness and emotional bonding with the infant while the

most common reasons for bottle feeding was mother’s perception of father’s

attitude, uncertainty regarding the quantity of breast milk and returning to work.

The conclusion to their study is that there is a need for extensive education

regarding the benefits of breastfeeding to be provided for both parents and

optimally the grandmother, by physicians, nurses and the media before pregnancy

or within the first trimester.

The department of Maternal and Child Health at the University of Alabama

examined the influence of knowledge and attitudes among mothers who practice

exclusive breastfeeding in St. Anne, Jamaican. They found that the knowledge and

attitude about breastfeeding among mothers who exclusively and nonexclusively

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breast feed and its duration was poor, and that mothers’ were twice likely to

exclusively breast feed their infants if their male counterparts were the main bread

winner in the home. In this study Chatman et al (2004) found that there was a high

incidence, 98.2%, of mothers who initiated breast feeding but by six months

postnatal only 22.2% of these women were exclusively breast feeding. As with

other studies the main reason given for partial breast feeding was that the mothers

thought that the infants were receiving insufficient milk.

Gueri, Jutsum, and Organ (1978) conducted a study in Trinidad analysing the role

mass communication play as it relates to breastfeeding. Radio broadcasting had the

most significant effect; a positive correlation was made between the avoidance of

bottle feeding before two months of age and maternal familiarity with the

campaign media message.

Kuan, Britto, Decolongon, Schoettker, Atherton and Kotagal (1999) conducted a

cohort study and examined the care that mothers would have received initially after

giving birth and the follow up care by the community nurse. The care was rated

good to very good as indicated by the participants. The results indicated that

seventeen (17) Percent of these women had stopped breast feeding by their 4 week

interview. These women were specially selected; they only had vaginal delivery of

a healthy full tem child and the mothers had planned to breast feed. However these

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women were mostly white, educated (82% had some college degree) married, older

(maternal age of 29.3 years) and insured.

The expected outcome as indicated above is that with higher initiation rates more

women are expected to breast feed for longer periods of time. However this

showed different results in Australia. Despite high levels of breast feeding

initiation only 47% were found to be breast feeding exclusively or partially six

months later; with marked differences among social groups. Foster, McLachian,

and Lumley (2006) identified negative factors on breastfeeding; giving babies

infant formula while in hospital, high maternal body mass index, self reported

maternal depression or anxiety in the post partum period. These mothers tend to

breast feed for shorter periods of time.

In a study conducted by Kurzewski and Gardner (2005) at the University Hospital

of the West Indies (UHWI); Jamaica, among eighty nine mothers attending their

post-natal clinic who were interviewed at six weeks post partum. Most mothers;

97.8% had practised breast feeding. Of theses 29.9% practiced exclusive

breastfeeding and 70.1% partial breastfeeding. Two women only practised bottle

feeding. The results of the study revealed that breastfeeding patterns were not

significantly affected by maternal parity, age, education, employment, or

socioeconomic status as had been indicated in other studies. Of the 70.1% of

babies who were being partially breastfed; 32% received commercial feeds, 52%

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received water, 14% juice and bush tea and 4% glucose water. Reasons given by

the mothers for introducing supplemental items were to give extra water, breast

milk not satisfying for baby, hiccups, insufficient breast milk, ‘Grandma said”,

needed to return to work, to get the baby use to the bottle and to be able to leave

the house. To give extra water and breast milk not satisfying scored the highest;

20% and 17% respectively.

According to Melville, between 1987 to 1991, in Jamaica, despite deteriorating

economic conditions when the Jamaican dollar was depreciated by more than two

hundred percent (200%), there was a dramatic increase in consumer price index for

food and drink and artificial feeding. Breast feeding decreased by ten percent

during this time. He stated that though the price of formula during this time was

out of reach for low income mothers they continued to bottle feed. His rationale

given for the increase of bottle feed was related to the reduction of postpartum

visits made on the third, fifth, seventh, and tenth days following post delivery by

district nurses and a reduction in the number of group educational sessions carried

out by the primary health care nurses at the antenatal clinic.

The concept of breast feeding is becoming most important not only in health care

centres but nationally and internationally. Countries; Governments, hospitals have

signed on to becoming baby friendly; encouraging mothers to breast feed and

discouraging the use of formula feeds.

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In 2000 the Sange Grande Hospital in Trinidad amended their Breast feeding

policy. Their goal was to protect, promote and support breastfeeding in the Sangre

Grande and the Eastern Region. Their main objective was to achieve a 90%

initiation at their institution by 2002. It was done in accordance with National

breastfeeding policy of Trinidad and Tobago (1996) and the joint WHO and

UNICEF statement on Protecting, Promoting and Supporting Breastfeeding. The

amendment policy compared exclusive breast feeding practices for the time

periods 1992 to 1994 at one, two and three months of age for the island. At the

time of report Trinidad and Tobago had a national prevalent breast feeding

population of about 24%. Of the 24% exclusive breastfeeding during the first

month of the infant fell from 68% in 1992 to 41% in 1994. During the second

month the rate fell from 45% to 26%, and while during the third month from 29%

to 19% during the same time period.

The degree of breast feeding in America has been established and they have set

target goals for themselves. In a research study by Fein, Mandal and Roe (2008),

entitled success of strategies for combining employment with breastfeeding, it

concluded that feeding the infant from the breast during the working day is the

most effective strategy for combining breast feeding and work. They examined

four strategies used to feed neonates and infants; feed directly from the breast only,

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both pump and feed directly, pump only and neither pump nor breastfeed during

the working day. For the outcome of breastfeeding duration; the two strategies that

allowed direct feeding from the breast were associated with longer periods of

breast feeding.

In a cohort study conducted by Win, Binns and Zhao et al. (2006) they also found

that mothers who express breast milk (at one or more time period) were less likely

to discontinue any breast feeding before six months than those who had never

express breast milk.

In a Report of the Council on Scientific Affairs entitled Factors that influence

Differences in Breast Feeding rates by Melvyn L. Sterling under the caption factors

affecting breastfeeding he highlighted that employment policies and workplace

characteristics can affect breast feeding rates. This is because the Family and

Medical Health Act of 1993 (USA) provides full-time employees of large

companies the right to twelve weeks of unpaid leave plus job reinstatement of for a

range of medical and family reasoning including family leave. However some

employees are not protected under this action especially those employed under a

year.

In his report sterling identified employer day care as a means to influence day care.

There, mothers could take breaks to express their milk, or nurse their child who

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participates in employee-sponsored on site or nearby day care supporting breast

feeding for mothers. Other work place accommodation for nursing mothers is the

lactation room.

Sterling alluded to a study which revealed that some races were more likely to

breast feed than others. Mexican American showed a higher percentage (55%) to

breast feed their babies than African Americans (15%). It was suggested that

African Americans seem not to have been encouraged to breastfeed by health care

providers.

In his report he brought out the important role of health care providers. There was

a need for medical doctors to assume a more active role in promoting breastfeeding

to mothers.

The Caribbean food and Nutrition Institute (CFNI) in 1999 documented guidelines

for young child feeding practises in the Caribbean. They too promote breastfeeding

practise for the first six months of life. Consideration, however, is given to mothers

who have contracted HIV, HTLV1 and Hepatitis C infections to use breast milk

substitutes as these infections can be transmitted during breast feeding. Mothers

who have Hepatitis, Tuberculosis or have Type 1 diabetes are allowed to

breastfeed; some with considerations attached.

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The Pan American Health Organization (PAHO) and the World Health

Organization (WHO) in 1994 examined breastfeeding practices and the trends and

the implementation of the international code of marketing and breast feeding

institutes in the Americas. The breast feeding practices analysed were exclusive

breast feeding, partial breastfeeding and bottle feeding. The report alluded to the

fact that there was “low prevalence of full exclusive breast feeding at four months

of age in most countries and territories contrary to the recommendations and goals

set by the 1990 World Summit for Children.” Only five of the twenty two countries

who were analysed, reported predominant breast feeding practices.

From the above mentioned report in 1993, the Dominica Republic reported 90 to

98% of mothers initiate breastfeeding exclusively at birth. Ten percent exclusively

breast feed during the first three months and by six months very few mothers had

continued the practice.

Belize indicated that in1993 there was an increase of 6% more infants who at four

months were breast feeding when compared to their 1988 data.

In 1991 Mexico reported a prevalence of 5% partial breastfeeding rate which

increased by 50% by the first month of age. Cuba reported a partial breast feeding

rate at birth of 21.5%.it increased to 38.0% by the third month. Honduras reported

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partial breast feeding of 72.2% at birth which increased to 89.7% at four months of

age.

The report cited a study done by Calma (1991) which found that 28.5 percent of

persons from El Salvador were exclusively breastfeeding at 4 months of age. This

was up by 10 % of a similar study conducted by the same author in 1981.

Breast feeding practices in Barbados appears not to have been greatly researched

due to the unavailability of written literature. Two studies were found which

addressed breast feeding in Barbados. Galler et. al (1999) research psychological

variables which affect early infant feeding practices in Barbados. They found that

there was a prevalence of 16% of mild depression at seven weeks and 19% at six

months. A few cases of moderate to severe depression were present. Some

disadvantage environmental conditions were present. Depressive symptoms at

seven weeks postpartum predicted a reduced preference for breastfeeding at

current and later infant ages.

Galler et. al (1999) examined how infant feeding practices in Barbados predicted

later growth in infants. This longitudinal study assesses infants at seven weeks,

three months and six months.

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Abstract

In the 18-30 age groups, body image is a main concern especially to the younger

mothers. Their main concern are sagging breast due to breastfeeding, alteration in

body image, the fact of wearing a bra more often, not being able to wear certain

outfits, how the public would view them, breastfeeding minimally to break the

bond between themselves and the infant as they may want to further their studies,

go back to work or start a job for those who were unemployed before.

In the 31-45 age groups, these mothers are more willing to breastfeed their infant

exclusively as stability in this group are more settled emotionally and financially.

They are not too interested in new trends in some fashions so the sagging breast is

not a reflection to altered body image which is well defined.

The objective of the framework is to examine postpartum mothers between the two

age groups mentioned.

The framework which is best suited to substantiate this study is Callista Roy’s

Adaptation Theory. In her model she states that health is a state of being also a

process of becoming an integrated whole. The client is being viewed as an

adaptive system. The framework this model provides is to help in understanding

human adaptive responses and interventions that can be used to foster their

adaptation and the minimizations of stress. The nursing goal is to help the client to

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adapt to these changes in self-concept, physiological needs, role functions and their

interdependent relations regardless of health, illness or age. As a mean, all

postpartum breastfeeding mothers should and must adapt to life’s demands such as

those outlined below to promote bonding.

Meeting their infant’s demands

Meeting their infant’s psychological needs

Developing a positive self-concept to their needs

Performing social and economic roles

Achieving balances between dependence and independence, to fulfill

their infant’s needs.

ADAPTING/BONDING

Adapting /bonding are emotional from one person to another. Psychologist John

Bolby was the first attachment theorist, describing attachment as “a lasting

psychological connectedness between human beings and that it is believed to be

the earliest bonds formed by children with their caregivers and have a tremendous

impact that continues throughout life. Stating this serves to keep the infant close to

the mother, thus improving the child’s chances of survival.”

Adapting to breastfeeding can be a joy for some postpartum breast feeding

mothers, while on the other hand it can be complex for others within both age

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groups mentioned. This involves continuous physiological, psychological and

social time factors mainly the age factor.

Adaptation/infant bonding however is pivotal for both age groups.

Psychologically, adaptation / infant bonding can be difficult and demanding

especially in a depressed client. This is a process which overlaps other

physiological, biological and psychosocial processes associated with gains, losses,

challenges mid-life crisis, and loss of self-care abilities throughout the remaining

of their lifespan. Postpartum breastfeeding mothers who are non-compliant to

breastfeeding their infants on demand is seen as a mal-adaptive and non-bonding

parent to their infants. When such atrocity interferes, the non-compliance to

breastfeeding on demand creates problems in bonding as well as the problems in

the implementing of the ten steps to successful breastfeeding by the Baby-Friendly

Hospital Initiative (BFHI) launched in 1991 in an effort by UNICEF and the World

Health Organization (WHO) to ensure that all maternities, whether free standing or

in a hospital become centers of breastfeeding. (Class notes) This can also cause

interference to the mother, infant and society through health and finance to each.

Antenatal Protocol

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During the Prenatal period, specific guidelines are outlined and handed down to

mothers in the form of teaching and pamphlet by nurses in the polyclinics or

doctor’s offices. These are set out to initiate the establishment of lactating to their

infants. In this protocol mothers are thought of the importance of breastfeeding to

mother, baby and society. What to expect while the infant is sucking such as

tingling sensation, and the difficulties which can arise from baby not latching on,

to sore nipples, flat nipples, cracked nipples, engorgement of the breast, warmth or

infection of the breast, multiple birthing problems, expulsion of milk through the

pump device especially when there is a large supply and storing of milk in the

refrigerator.

Hypothesis

Breastfeeding mothers of both ages who are well educated about the ten steps to

successful breastfeeding and who understands the importance of breastfeeding to

the mother, baby and society, are more likely to breastfeed their infants on demand

regardless of age more than those who are not educated and have no

understanding.

The above hypothesis is a complex hypothesis stating a predictable relationship

between two or more independent variables and two or more dependent variables.

Variable

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Independent: Level of educated and understanding of the ten steps to

successful breastfeeding and the importance to mother, baby and society.

Dependent: Breastfeeding.

Conceptual: Participants were able to express their views through the

method of interviews while filling out questionnaires at the interview site

and knowledge tests through open ended question on the questionnaires.

Operational: The ten steps to successful breastfeeding and the importance of

breastfeeding to mother, baby and society was the measurement tool used.

Sample technique: The technique used to research the topic was a Simple

Random Sampling.

Population: Postpartum breastfeeding mothers in Barbados between the 18-

30 and 31-45 age groups.

Sample: This comprises of participants from the postnatal clinics at various

polyclinics across Barbados. Participants were all living in the community

of the research, their family members and their spouses.

Hypothesis:

If postpartum women are influenced by certain factors, then this will determine if

they will choose to breast feed or not to breast feed.

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Variables:

Independent Variable - influencing factors.

Dependent Variables - choosing their method of infant feeding.

Controlled Variable - postpartum women.

Assumptions:

The hypothesis of this study will assume the following:

- what these certain influencing factors are.

-Have postpartum women gave thought to the idea of breast feeding or bottle

feeding.

- Do postpartum women know the benefits of either method of infant feeding.

- Have postpartum women who chose not to breast feed feel guilty for making that

choice.

Reviewing the Assumptions:

For many women the decision to breast feed or bottle feed is based on their

comfort level, lifestyle and specific medical considerations that they may have.

Influences To Breast Feed:

- Social Factors: These are the facts are experiences that guide an individual's

personality, values and lifestyle. As it relates to breast feeding, it has been shown,

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based on breast friendly initiatives among communities, health care facilities and

international organizations that women and families in Barbados have been heavily

influenced and educated on the importance of breastfeeding their babies. The

Queen Elizabeth Hospital, (the country's primary acute care medical facility,

serving the community since 1964) is listed among the more than 134 countries

that have been awarded baby friendly status. The Baby Friendly Hospital Initiative

(BFHI) was launched by World Health Organization (WHO) and UNICEF in 1991

to promote breastfeeding worldwide. This initiative has allowed ten specific steps

to be practiced which involve management and educating of women on the

benefits of breastfeeding. This allows the woman to make an informed decision

with the satisfaction that both she and her baby will gain benefits from breasting.

Influences to not breastfeed:

A variety of social factors contribute to a woman's decision not to breastfeed

regardless of her knowledge of the benefits of breastfeeding. Medical factors also

play a role in the woman's decision; with the incidence of HIV/AIDS it is

advocated that infected women do not breastfeed their babies as a measure to

prevent HIV transmission from mother to baby.

Social Factors:

As previously mentioned, these are the facts and experiences that influence an

individual's lifestyle. As it relates to a woman's decision not to breastfeed the

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following may also be included among the social factors:

- Time Constraints: some mothers have jobs or other children and nursing is a time

consuming process; they may have only a short time home from work and don't

want to start breastfeeding and then can't continue, due to intense dedication it

takes to express milk, work and still breastfeed.

- Family Influences: often times a husband doesn't want his wife to breastfeed

because he feels that his wife's breast should be reserved for their sexuality.

- Embarrassment: some women feel that it would be indecent to nurse in front

someone else or simply she may not be comfortable with her anatomy as a food

source.

Deciding to breastfeed is a decision only the woman can make, and she should not

feel pressured into choosing one way or the other, however, she should keep in

mind the following points while making her decision. Breastfeeding is the

healthiest method for young infants and it confers nutritional and immunological

benefits for the infant that cannot be matched by non-human milk or formula.

METHODOLOGY AND DESCRIPTION OF DATA COLLECTION

The sample technique used would be random sampling.

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Cherry (2008) states that random sample is a subset of individuals that are

randomly selected from a population. Because researchers usually cannot obtain

data from every single person in a group, a smaller portion is randomly selected to

represent the entire group as a whole. The goal is to obtain a sample that is

representative of the larger population. In random sampling, each item or element

of the population has an equal chance of being chosen at each draw. A sample is

random if the method for obtaining the sample meets the criterion of randomness

(each element having an equal chance at each draw). The actual composition of the

sample itself does not determine whether or not it was a random sample.

Least biased of all sampling techniques, there is no subjectivity - each member of

the total population has an equal chance of being selected and information can be

obtained using random number tables

Obtaining information

Consent for the study would be obtained prior to the visits to collect data through

communication by letter from the Barbados Community College's Nursing

Department, to the Director of Nursing Services at the Queen Elizabeth Hospital,

Polyclinics and other private care facilities. Permission will be sought for the

student researchers to conduct their surveys of clients in the antenatal clinic and

wards such as B2 and B3. The respective institutions will notified their staff of the

36

study and that they would be visited by the students. The student researchers then

visited the clinical areas to be surveyed, Ward B3 and the Antenatal Clinic at the

Queen Elizabeth Hospital, and the nursing office at the prospective institutions at a

convenient date. The institutions will then be notified in advance that the student

researchers will be visiting to conduct they surveys the following week.

On a sole day the surveys will be conducted, the student researchers will seek the

permission of the Ward Sisters and Nurses-in-charge at the Queen Elizabeth

Hospital on entering the wards to conduct the patient surveys. When permission is

granted, the student researchers will ask for recommendations of suitable clients

between the ages of 16 and 45 years both primigravida and multigravida women.

Data will be gathered from clients using structured interview schedules to record

each individual's responses. The participation of the clients will be sought by

explaining the topic and purpose of the study, and guaranteeing confidentiality.

The overall number of clients participating in the study will be approximately 100

mothers. Completing questionnaires will be one hundred (100), which will be

equivalent to the sample size desired to represent the population. The sample size

desired to represent the population of antenatal and postnatal mothers who are

breasting and who opt not to breast feed.

37

One issue that will compound the sampling of the antenatal client population will

be that there are eight polyclinics and all cannot be equally represented as students

are attached to various polyclinics sometimes two students to one polyclinic. With

student researchers being limited all the polyclinics cannot be adequately

represented.

The research may be compound by factors limiting their participation, such as,

minor disorders such a nausea, vomiting, tiredness, fatigue, frequent micturition

and abdominal discomfort. On post natal ward and postnatal clinic factors such as

the crying baby, tired mothers a few clients napping at the time those interviews

are to be conducted, some choosing not to participate, and some others being under

the age of 16 years old.

The ethical considerations in conducting clients’ interviews and questionnaires

would be in keeping with the Belmont Report's principles of beneficence, human

dignity and justice.

Within the principle of beneficence, the right to freedom from harm will be

enforced by reviewing all questions. Questions are not to be too intrusive and

should not inflict psychological harm on participants before finalizing

questionnaires and interview schedules. The right to freedom from exploitation

will be upheld by assuring participants that confidentiality would be guaranteed in

38

data collection as no names or other forms of identification will be recorded and

data would in no way be used against them. Careful consideration should also be

given to ensure that the potential benefits of the study to breast feed or not to breast

feed will outweigh the risks taken by participants in the study.

The principle of human dignity will also be a major consideration to the student

researchers conducting this study. The right to self-determination will be afforded

to every participant in the study, that is, each person will be made aware that

participation will be voluntary and not mandatory. Great care will be taken to

ensure that participants clearly understand their autonomous right to refuse

participation. In keeping with the right to full disclosure, participants will also be

informed of the title and purpose of the study, what will be involve in participating,

and will be assured that there are no danger of them being victimized as a result of

their participation owing to the level of confidentiality being enforced. Informed

consent will be verbally obtained from clients before proceeding with the interview

schedules and implied consent should be gained on receipt of the completed

questionnaires.

The principle of justice will also be a consideration. The right to fair treatment will

be exercised in selecting participants in an unbiased way, and purposive sampling

will be used to select clients (that is, based on clients who were eligible for the

interviewing process, ie pregnant women 16 to 45 years old) The right to privacy

39

will endure by taking care that questions were not more intrusive than necessary

and that confidentiality and anonymity of participants was guaranteed.

QUESTIONNAIRE

Breast Feeding Practice among Postpartum Mothers in Barbados

Dear Participant,We are interested in factors contributing to breast feeding. It is hoped that the results of the study can be useful in helping nurses to assist mothers in promoting and maintaining good breast feeding practices.Your participation would clarify factors contributing to the decision of postpartum women in Barbados to breastfeed or not to breastfeed and identify ways in which they can be improved. Results of this research are beneficial to the patient, the nurse and the institution.If you agree to participate, you will be asked to complete a 20 minute questionnaire. This questionnaire consists of statements relating to breast feeding.Although some studies have some degree of risk, the potential in this investigation is quite minimal. Your performance is anonymous and you will not incur any cost as a result of your participation in the study.Your participation is voluntary. If at any time during the session you wish to withdraw your participation you are free to do so without prejudice.If you have any questions prior to your participation or any time during the study, please do not hesitate to contact us.

AUTHORIZATION: I have read the above and understand the nature of the study. I understand that by agreeing to participate in the study I have not waived any legal or human right and that I may contact the researchers at the Barbados Community College; Ms. Hutton Taylor (426-5944) department of nursing) or Mrs. Diana Cox at 255-1302 at any time. I agree to participate in this study. I understand that I may refuse to participate or may withdraw from the study at anytime without prejudice. I understand that if I have concerns about my treatment during the study, I can contact the Nursing Department at the Barbados Community College at any time.

Participant’s signature: ____________________________________ Date: ______________

Witness signature: ____________________________________ Date: ______________PLEASE ANSWER ALL QUESTIONS

1. Age □ (18-22) □ (23-27) □ (28-32) □(33-37) □ >38

40

2. Marital status

□ Single □ Married □ Divorced

3. Level of education completed

□ Primary □ Secondary □ Tertiary

4. Presently employed

□Yes □ No

5. Amount of time worked at present job

□ 2-5 years □ Over 5 years

6. Was this pregnancy planned?

□Yes □No

7. □ Primi gravida □ Multi gravida

8. Parity

□ 1 □ 2 □ 3 □ >4

9. Have you previously breastfed?

□ YES □ No □ Not applicable

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

□ Polyclinic □ Private GP □ Private GYN/OBGYN □ Hospital

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11. Did you attend birthing classes?

□Yes □No

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

state why

□Yes □No..................................................................

13. Do you have a medical condition which will prevent you from breast

feeding? If yes please state

□ Yes.......................................... □ No

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

□ Yes □ No

15. How long do you plan to breast feed your baby? ................

16. Who influenced your decision to breast feed?

□ Family member □ peers □ mother □ grandmother

□ Not applicable □ Other Please state..............................................

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

□ Yes □ No

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

feed?

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□ Nurse □ Doctor □ Other

19. Type of delivery

□Vaginal □ Caesarean section □ Instrumental

□Other

20. How soon after giving birth did you receive a visit from your community health nurse?

□ 4 weeks □ 6weeks □Other.......................

21. How many teaching sessions did you have in relation to breast feeding? .........

22. How soon after delivery did you initiate breastfeeding?............. 23. During the first three weeks post delivery did you

□ Exclusively breastfeed □ partially breast feed □ bottle feed

□ Other please state ....................................................................................

24. What foods/ liquids have you given your infant other than breast milk since delivery?................................................................................................................. 25. How long do you plan to breastfeed your baby? ..........................................................................................................................

26. Does breast feeding make you feel closer to your baby?

□ Yes □ No

27. When did you introduce formula? ................days ...................weeks

28. Why did you introduce formula to your baby? ...............................................................................................................................

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

.....29. Current age of infant.............. Weeks

Considerations made when planning data collection

Our Target group as mentioned before will be primi-gravida and multi-gravida

women at the QEH in the form of an interview and questionnaire, considerations

that will be taken in this form will be:

Obtaining the women permission to carry out the interview, explaining to them

what’s my purpose of conducting the interview.

Objectivity versus Subjectivity in carrying out my interview will try to keep own

personal biases and opinions out and both sides will be given a fair consideration

In an interview for these ante and postnatal mothers can have a standardize open

ended interview where the women are allowed to answer the question how they

would like instead of yes or no answer, this facilitates faster interview that can be

analyzed and compared.

In conducting this interview privacy should be considered to all patients

therefore, a time, venue, amount of people will be interviewed at the time if agreed

by the women should be taken into consideration .

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In collecting an interview one would like to cost less physical or emotional harm

as much as possible from this target group of women from the Queen Elizabeth

Hospital, therefore, when collecting information will be careful on how I word any

questions asked.

These clients should know whether their information will remain anonymous and

confidential before conducting these interviews or questionnaire.

The questionnaire will be easily readable and understandable, clearly relevant and

to the point, not confusing and not too long it consist of 100 questions that the

women will not lose interest in the questionnaire.

Possible limitations of the research project include:

Reliability of the information received

Obtaining suitable clients to participate in the study

Obtaining permission to conduct the study in each area

Students being able to reach all the locations to obtain data

Educational level of the clients chosen

Students are not allocated to all of the 8 polyclinics

Clients comfort and cooperation

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Wording of questions so that clients understand

The main limitation identified for the study was obtaining suitable clients to

participate in the study. Our research is based on clients between the ages of

18years to 30years. Most clients in recent times are between the ages of 15 to

45+. So although possible it might still be a challenge. Also finding suitable clients

especially when encountering clients with antenatal or postnatal problems which

may prohibit them from breastfeeding exclusively e.g. HIV positive clients.

The reliability of information received is also another limitation which we may

encounter, to combat this we have decided to ask clients the questions as

opposed to the client completing the questionnaire. This method of obtaining

information also ensures the reliability of it and omits misunderstandings which

can occur due to client’s level of understanding and education. Therefore

attention was placed on the construction of questions so that clients understand

what is being asked and answer accordingly.

Obtaining permission and being able to reach the chosen areas for the research

study is another perceived limitation. Letters detailing the research topic and

target group need to be sent to the chosen areas in order to inform and obtain

46

required permission to do the study. This also allows the heads of each institution

to assist where possible and direct us in obtaining relevant data by choosing

appropriate clients.

The number of areas chosen outweighs the number of researchers. This can

affect data collection since at least 100 participants are required in order to

complete the study. Therefore group members have been allocated to the

institution in their area to allow easy access to obtain data, along with the clinic

they have been assigned to for their clinical allocation.

The clients comfort and cooperation throughout the study can also be a limitation

since some clients are sceptical about divulging pertinent information to students.

Therefore the clients must be ensured of confidentiality and this can be assured

by the head of the institution or someone assigned from the institution to assist

students by introducing them to the clients with explanation of the study. A

confidentiality clause should also be mentioned on the questionnaire and clients

are assured that names are not used in the study.

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