mp asi filipina

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Community and International nutrition

Low Birth W eight Reduces the Likelihood ofB reast-F eeding among F ilipino Infants1'2LINDA S. ADAIR3 AND BARRY M. POPKIHDepartment of Nutrition, University of North Carolina at Chapel H ill, Chapel Hill, NC 27516

ABSTRACT W e studied the relationship of low birthweight (LBW ) to concordance of mother's feeding inte ntio ns d urin g p re gn an cy w ith a ctu al fe ed in g p ra ctic es;initiation of breast-feeding; and patterns of feeding inthe first 6 m o. Data cam e from the Ceb LongitudinalHealth and Nutrition Survey, which followed 3080m othe r-in fan t p airs from urb an an d ru ral comm un itieso f Metro C eb, Ph ilip pin es. We u se d lo gis tic re gre ssio nto estimate the effects of LBW on feeding practices,co ntrollin g fo r p lace o f d eliv ery (h om e, p ub lic o r p riv ateh ealth facility), re ceip t of free in fan t fo rm ula samp le s;in fant sex , u rban residen ce; prim ipa rity , ed ucatio n lev eland age of the mother; and family income and assets.Birth of a LBW infant significantly decreased the likelihood that women would initiate breast-feeding. Ofp articular no te is the find in g o f th is d ecreased like lih oo damong women who during pregnancy had stated anin te ntio n to b re ast-fe ed . In a c ompa ris on o f 6 -rn o fe ed in gpatterns, w e also found that LBW increased the likelihood of not breast-feeding or of weaning before 6 mo.Among breast-feeding mothers, LBW increased thelike lih ood of fu ll breast-feed in g fo r 6 m o com pared w ithp attern s cha rac terized b y earlier su pplem en tatio n w ithother foods and liquids. The negative relationship ofLBW to breast-feeding w as strongest w hen births tookplace in private or public health facilities. G iven theknown health risks of LBW and the proven benefits ofbreast-feeding, these results emphasize the need forspecial effo rts to promo te b reast-fe eding o f L BW in fan tsborn in clinical settings. J. N utr. 126: 103-112,1996.INDEX ING KEY WORDS:nfant feedin g ow bir th , weigh t breast-feedinghuman mi lk

Low birth weight (LBW )4 continues to be a problemof particular concern for developing countries, w herethe estim ated overall prevalence of LBW is 19% (W orldHealth Organization 1992), and in some countries, upto 50% of infants are born weighing 2000 g, require no special care (Narayanan 1986).The question of how LBW infants in developingcountries are fed is an important one. Some researchhas suggested that LBW infants are less likely to bebreast-fed at all or are breast-fed for shorter periodsof time (Barros et al. 1986, Butz and DaVanzo 1981,W orld Health Organization 1981). G iven its provenbeneficial effects in red ucing m orbidity and m ortality,breast-feeding is of special importance to infants already at risk because of LBW (Popkin et al. 1986).The small amount of available data on feeding ofL BW infants in d eveloping countries is based prim arily

' Funding for parts of the program design, data collection, andcom puterization w as provided by the N ational Institutes of H ealth(N IH ) (g ran ts ROI-HD 1 998 3A , ROl-HD 1 88 80 a nd ROI-HO2 31 37 ).D ata a nalys is w as su ppo rted b y a g ra nt fro m Wellstart In te rna tio nal.1 The costs of publication of this article were defrayed in partb y the p aymen t o f p ag e ch arg es. T his artic le m ust th erefo re b e h ereb ym arked "advertisem ent" in accordance w ith 18 U SC section 1734solely to indicate this fact.3 T o w hom correspondence should be addressed at C arolina P opulation Center, U niversity of N orth C arolina, U niversity Square,C B #8120, 123 W . Franklin St., Chapel H ill, N C 27516-3997.4 Abbreviations: CI = confidence interval; LBW = low birthw eight; R RR = relative risk ratio.

0 022 -3 16 6/9 6 $3 .0 0 1 99 6 Am erica n In stitu te o f N utrition .M anuscript received 30 M arch 1995. Initial review com pleted 16 June 1995. Revision accepted 25 A ugust 1995.103


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10 4 A DA IR A ND POPK INon re tro spec tiv e data and is mos tly des crip tiv e , u suallypresenting only the prev alence of breast-f eedingam o ng inf ants of dif ferent w eights at birth. Furthermo re , the re is n o c on sisten cy in resu lts f rom dif feren tpopulations. For ex am p le, the W HO C ollaborativ eS t udy on Breas t-Feed ing (W orld Health Organ iz ation1 98 1) f ou nd n o relatio nsh ip b etw e en birth w e ig ht an dth e p re v ale nc e o f b re ast-f ee din g in E th io pia, N i ge ria,Z aire, G uatem ala and India, nor w as a relationshipfound in M achak os, K eny a (R enquist et al. 1985). Incon tras t, among urban poor and ru ral s ub jects in Ch ile ,a low er percentage of L BW inf ants w ere breast-f ed at3 m o of age com pared w ith inf ants w hose w eights exceeded 2500 g at birth (W o rld H ealth O rganiz ation1981). In an u rban B raz il p opulatio n, in fan ts w e ig hin g


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FEEDING OF LOW B IRTH W EIGHT IN FA N TS 105c he ck ed an d calib rated . T he B allard m e th od w as u se dto asse ss g estatio nal ag e c lin ic ally o f all LBW in fan ts,all inf ants w hose m o thers had com p lications such asbleeding during pregnancy and all infants w hosem others w ere uncertain about the date of their lastm e nstru al p erio d (B allard et al. 1 97 9). W he n b oth B allard and las t menstrual period e st ima te s o f ges tat ionalag e w e re availab le , w e u se th e Ballard e stimate s as th emo st ac cu rate re pre se ntatio n. Pre v io us analy se s h av eshow n a high lev el of agreem ent betw een these tw omeasu re s in th e C eb samp le .In fan t-f ee din g data w e re colle cte d durin g th e b irthinf orm ation surv ey and subsequent bim o nthly interv iew s w ith m o thers. A t each interv iew , m o thers w ereask ed w hether they breast-f ed and to recall all f oodsand liquids fed to the infant in the past 24 h. For thesam e period, detailed inf orm ation w as collected onthe ty pes, quantities and m ethod of preparation of allf oods and liquids giv en to inf ants. M o thers w ere alsoask ed to recall general f eeding patterns (ex clusiv eb re ast-f ee din g, f ee din g o f n onnu tritiv e liq uid s, n utritiv e liq uid s, so lid s and sem iso lid f oods) 7 d b ef ore e achinterview.Using a health facilities surv ey adm inistered tohospit al and c li ni c pers onne l, we gathered in f orma ti onon f ac ility p rac tic es re late d to in fan t f ee din g. Pe rso nnel w ere ask ed questions about receipt and distribution of inf ant f orm u la, room ing-in policies, breastf ee din g edu catio n, p olic ie s re gard in g f ee din g o f wate ran d f ormu la, e tc.Ana lysis meth ods. Alth ou gh Ceb da ta wereav ailable for the f irst 24 m o of lif e, w e focused ourw ork on the f irst 6 m o because this is the tim e perioddurin g wh ic h LBW is lik e ly to in flu en ce in fan t-f ee din gpatterns, and f ull breast-f eeding is rare in this population af ter 6 m o . Furtherm o re, in prelim inary analy ses, w e f ou nd n o c onsisten t ef fe cts of L BW on f ee din gpatterns af ter 6 m o .W e d ef in ed th re e f ee din g outc ome s f or analy sis. T h eanaly sis sam p les f or the three outcom e s dif fer in siz eb ec au se th e f eed in g p attern analy sis req uires th at inf an ts h av e complete d ata f or th e f irst 6 mo an d b ecau seof m issing data critical to the def inition of the outcome.1. C oncordance of breast-feeding intentions andpractices (n = 2955). O ne m ajor w ay to understandhow b io logical and o ther f ac to rs in the perinatal periodaf f ec t f ee din g b ehav io rs is to e x plo re th e ro le o f b re astf eeding intentions (see S tew art et al. 1991) and theirc on co rdan ce w i th ac tu al f ee din g p rac tic es. Du rin g th ebase lin e su rv e y , mo th ers w e re ask e d how th ey p lannedto f ee d th eir in fan t. W e compared th eir in te ntio ns w i thac tu al f ee din g p rac tic es and d ef in ed th e f ollow in g f ou rg roup s: 1 } in te nd ed to b re ast-f ee d and d id b re ast-f ed ,n = 2498 (84.5% ); 2) intended to breast-feed but didnot breast-feed, n = 85 (2.9%); 3) did not intend tobreast-f eed but did breast-f eed, n = 260 (8.8% ) and 4)

d id n ot in te nd to b reast-f ee d an d did n ot b re ast-f eed ,n = 1 12 (3 .8%).O f p artic ular in terest is the seco nd gro up , b ecau secondition of the infant at birth or other barriers tob re ast-f ee din g e nco un te re d at d eliv ery may c au se th em o ther to change her m ind about f eeding.2. Initiation of breast-feeding (n = 2991). A di-chotom ous v ariable indicates w hether or not themo th er e v er in itiate d b re ast-f ee din g, e ith er in th e f irstsev eral day s af ter birth or subsequently . S tudies ofprelacteal f eeding patterns in the C eb sam p le (Fernandez and Popk in 1988) show ed that w om en m aydiscard co lo strum an d n ot in itiate b re ast-f eed in g f orsev eral day s. O nly 6.75% of m others in this sam plenever ini tiat ed breas t- f eed ing .3. Patterns of f eeding in the f irst 6 m o of lif e (n= 275 7). In fa nts w ere cla ssifie d in g rou ps on th e b asisof ov erall f eeding patterns during the f irst 6 m o. W ef irst an aly z ed re su lts f rom six g ro up s in w h ich in fantsw ho nev er breast-f ed w ere dif ferentiated f rom thosew ho w ere w eaned early , and those w ho fully breastf ed f or only 2 m o w ere in a dif ferent group than thosef ully breast-f ed for 4 m o. W e f ound no dif f erences inthe determ inants of nev er breast-f eeding v s. earlyw eaning, nor did w e f ind dif ferences in predictors of2 v s. 4 m o of f ull breast-f eeding. T hus although therem ay be im portant policy reasons to identify thesegroups separately for studies of infant grow th andm orbidity , none of the v ariables of interest in thepresen t analysi s s ign if ican tl y d if f eren tiated the groups .T h ese re su lts p ro vid ed th e ratio nale f or a sim p lif ication to only f our groups as f ollow s: )ul ly breas t- fedf or at least 6 m o , n = 388 (14.1% ); 2) f ully breast-f edfor m ore than 2 but few er than 6 m o and then m ix edfed, n = 1321 (47.9% ); 3) m ix ed fed throughout, n= 307 (11.1% ) and 4) not breast-f ed or w eaned early ,n = 741 (26.9% ).Inf ants w ere considered f ully breast-f ed if , on thebasis of the 24-h f ood recall, they receiv ed 83 k j/d from supplem ental foodsor liquids at 4 m o, w ere still considered to be fullybreast-f ed f or 6 m o. Inf ants w ere considered to hav eb ee n w e an ed early if th ey in itiated b reast-f eed in g b utw ere totally w eaned from the breast before 6 m o ofage. Infants w ere considered not breast-fed if theynever ini tiat ed breas t- f eed ing .W e u se d mu ltin om ial lo gistic reg ressio n mo de ls top re dic t membersh ip in th e d if f ere nt g ro up s (c ate go rie sof each outcom e v ariable). A rev iew of the estim atedcoef ficients allow ed an assessm ent of how each indep en den t v ariable in th e mo de l af fec ted th e lik elih oo d


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106 A DA IR A ND POPK INof m em bership in each group. Coef f icients w ere exp on entiate d to c alcu late re lativ e risk ratio s (R RR ) f ora 1-u nit c hange in e ach in depend en t v ariab le . R i sk wasm easured for a com parison of each category to a refe rence cat egory . A ll pos si bl e in te rg roup comparis on sw ere m ade and used to calculate the predicted probability of m em bership in each feeding category . Foreach m o del, our prim ary independent v ariable of interest w as L EW . W e also com pared L EW term w ithLEW pre te rm b irth s.B e cau se in fan t b irth w e ig ht and mo th ers' d ec is io nsabout w here to deliv er and how to feed the infant areh ig hly in te rre late d, w e had to tak e se v eral p ote ntiallyimpo rtan t statistic al p ro blems in to c on sid eratio n. W ec on tro lled f or th e e ff ec ts of co nf ou nd ing b y in clu din gp lac e o f d eliv e ry (h ome , p ub lic o r p riv ate f ac ility ); receipt of a free sam ple of infant form ula at deliv ery ;sex of the inf ant, place of residence (urban or rural);prim iparity , education lev el and age of the m other;and hou seho ld in come and asse ts. Howev e r, in clu sio no f th ese v ariab le s d oes n ot elim in ate p oten tial b iase sas sociated w i th endogeneity . V ari ab le s are consideredendogenous to a m odel w hen they are jointly determ ined by a set of commo n, underly ing, unobserv ablev ariab le s. C onsid er th e c ase w h ere a mo th er's in natehealthiness af fects both the lik elihood that she w illbreast-f eed her inf ant and w hether the inf ant is L BW .In a mu ltip le re gre ssio n model, e rro r te rm s asso ciate dw ith estim ates of feeding and of L BW w ill be correlated. If w e ignore these relationships, w e m ay m istak en ly attrib ute p art o f the v ariatio n in f ee din g p ractices to L BW , w hen in f act, it should be attributed tothe unmeasured ma te rnal health s tatu s. ( S eeadd iti onale xamp le s o f en do gen eity b ias in th e article b y B risco eet al. 1990.) N ote that if the v ariables are observ ablean d me asu rab le, the n th ey are po ten tial c on fo un dersan d c an b e in clu ded in th e mo de l as c on tro l v ariab le s.W e hy pothesiz ed that L BW and place of deliv ery v ariables w ould be endogenous to our f eeding m o dels.E co nom ists h av e d ev elo ped ap pro ac he s to c orrectf or endogeneity of ex planatory v ariables, w hich inv olv e the u se o f instrum en tal v ariab les (se e B risco e etal. 1990, Ceb S tudy T eam 1991 and M addala 1988f or further inform ation and another ex am ple of useof the instrum e ntal v ariables approach). A n instrum ent or v ariable predicted from a set of strictly exogenous factors is substituted in the m odel for theac tu al v alu e o f th e v ariab le . W e te ste d th e assump tio nof endogeneity of the L BW and place of deliv ery v ariab le s u sing th e Hau sman te st (H au sman 1 97 8), w h ichreq uires th at bo th th e in strum ent an d actu al v alu es o fthe v ariable be included in the m odel. W hen the instrumen t h as a s tatistic ally sig nif ic an t c oe ff ic ie nt, it isconsidered endogenous to the m odel. Using thism ethod, w e found place of deliv ery but not L BW tobe highly endogenous in all of our m odels. T his indicates that unm easured factors such as the innateh ealth in ess o f th e mo th er af fe ct th e d eliv ery d ecisio n

and th e lik e lih ood th at th e in fan t is LBW .A c co rd in gly ,all m odels w ere specif ied w ith place of deliv ery instrumen ts, b ut ac tu al v alu es f or all o th er v ariab le s.R R R and 95% conf idence interv als (CI) w ere calculated f or each independent v ariable in the m o dels.T he n, to assist in the in terpretatio n o f resu lts, w e p redicted the lik elihood of m em bership in each of thegroups based on m e an v alues of the independent v ariables. Finally , w e sim ulated the ef f ects of specif iedconditions, principally L BW v s. norm al birth w eightand p lac e o f d eliv e ry .

RESULTSD escr iptive resu lts. Ta ble 1 pr esen ts ch ara cteristics of sam ple w om en in strata def ined by place ofdeliv ery (at hom e, in public or priv ate hospitals orclinics). T he decision of w here to giv e birth is an imp ortan t matern al ch oic e, co nd itio ne d b y a w id e ran geof sociodem o graphic f actors. W om en w ho gav e birthat hom e w ere signif icantly m o re lik ely than m o thersdeliv ering in health facilities to be f rom rural communities, h av e less ed uc ation and low e r h ou se ho ld incom e and assets. In addition, higher parity w om enw ere m ore lik ely to deliv er at hom e. Ex posure to f ormu la in du stry p ractice s v aried c on sid erab ly by p lac eof deliv ery . M o thers deliv ering in priv ate hospitalsw ere m o st lik ely to receiv e f ree f orm u la sam p les andh ad sig nif ican tly lo ng er h osp ital stay s. In o th er w o rk(A d air et al. 1993), w e show ed that such practices dec reas ed t he duration o f b reas t-f e ed ing. Finally , d elayedf irst co ntact b etw e en mo th er an d in fant af ter b irth o ccurs m o re f requently in health f acilities, especiallyp riv ate f acilities th at are mo re lik ely to h av e n ew b ornnurseries. T able 1 also show s dif ferences in the prevalen ce of LBW among samp le in fan ts b orn in d if fe re ntsettings. A higher percentage of L BW infants w ereborn in public f acilities, w hich tended to serv e popu latio ns at th e h ig he st risk f or LBW (e .g ., p rim i parae ,y ounger w om en, w om en w ith com plications of pregnancy and w om en from comm unities w ith higher disease prevalence) .T a b le 2 sh ow s com p a rison s of f eed in g p ract ices in

L BW v s. norm al w eight infants by place of deliv ery .W ithin each f acility , w e tested f or signif icant dif ferences in the distribution of f eeding practice by birthw eight status. W ithin a f acility category , there w as aconsistent trend of low er percentages of L BW compared w ith norm al w eight inf ants breast-f eeding ate ach poin t in time . T h ese d if f ere nc es, alth ough sim i larac ro ss th e th re e d eliv ery settin gs, w e re mo st o fte n statistically sign if ic an t in p ub lic f acilities. W ith in e ac hplace of deliv ery , there w as a trend tow ard increasedp re vale nce o f f ull b reast-f ee din g in LBW inf an ts at allages. For inf ants born in public f acilities, there w as ah ig hly sig nif ican t d if fe re nce in th e p re vale nce o f f ull


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FEEDING OF LOW B IRTH W EIGHT INFA NTS 107T ABL E 1

C haracteristics of w om en deliverin g in fan ts in dif feren t settin gs1'*Plac e o f d el iv e ry

Mother'sharacteristicsA ge,y3Education,yompleted^Urban,%cParity0Primiparous,%cHeldbaby in f irst 4 h,bReceived

a sam ple of inf ant f orm ula,Duration o f h osp ital stay ,~ L BW ,%aPr terai,% |


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108 A DA IR A ND POPK INTABL E 2

Com parison of feedin g pattern s am on g low birth weigh t {L BW Jan d n orm al weigh t in fan ts (N BW ) in dif feren t delivery settin gsPlac e o f d el iv e ry

Home Pub l ic faci li ty Private fac i li tyN BW(n= 1641)L EW (n = 202)P1N BW |n = 462)L EW (n = 83)P1N BW [n-571]LEW |n = 63)P1

Feed ing pat te rnsEv er breast-fed, % 96.6 93.0 0.01 93.2 90.0 ns2 85.4 79.3 nsB reast-fed at 2 m o, % 90.5 90.6 ns 83.9 75.7 0.08 66.2 64.2 nsB reast-fed at 4 m o, % 87.4 84.9 ns 77.4 67.6 0.07 58.1 61.4 nsB reast-fed at 6 m o, % 85.0 82.8 ns 73.1 58.2 0.01 51.7 50.0 nsB reast-fed at 12 m o, % 70.8 68.3 ns 60.0 46.0 0.03 37.1 33.3 nsFully breast-f ed at 2m o, % 71.8 74.6 ns 60.8 59.5 ns 34.2 37.7 nsFully breast-f ed at 4m o, % 58.3 60.3 ns 43.5 45.6 ns 23.3 22.5 nsFully breast-f ed at 6m o, % 18.1 19.0 ns 10.6 22.4 0.01 4.7 4.6 nsHom e Public facility Priv ate facility

N BW LEW NBW LEW NEW LEWD istrib utio n o f f ee din gpatterns3N o. in groupFully breast-f ed f or 6m o, %N o. in groupFully breast-f ed f or > 2but < 6 m o and thenm ix ed-f ed, %N o. in groupM ixed-fed for 6 m o, %N o. in groupN ev er breast-f ed orw eaned early , %

27017.783 454.716110.626017.1

33

18.29954.7116.13821.0

45

10.820 549.24811.5

11 928.5

1521.42231.422.931

44.3

234.514 7

28.78015.626251.2

3.914

27.959.63159.6

1 P v alues for com parison of prev alence of age-specif ic feeding m ethod in L BW versus N EW infants, w ithin each place of deliv ery arebased on A N OV A .2 ns = not signif icant, P > 0.05.3 R esults of chi-squared tests f or signif icant dif ferences in distribution of feeding patterns in L BW v s. N BW inf ants, by place of deliv eryare as f ollow s: H om e, chi-squared = 4.69, P = 0.196; public f acility , chi-squared = 18.75, P < 0.000; priv ate facility chi-squared = 1.88, P= 0 .598 .and norm al birth w eight colum ns w ithin each placeof deliv ery . T he ov erall pattern w as the sam e acrossall sites. T he predicted probability of nev er breastf ee din g o r w ean in g early was h ig he r in LBW comparedw ith n ormal w e ig ht in fan ts.Consistent w ith the f requencies of the dif ferentf e ed ing patte rn s p re sent ed in Tab le 2 , th e mu l tivari ateanaly ses also show ed th at if w omen ele cte d to b reastfeed, L BW increased the probability of f ull breastfeeding for 6 m o. T his w as true for hom e and publicf ac ility deli v erie s. A mong private deli v erie s; LBW hadno im p act on the lik elihood of f ull breast-f eeding f or6 m o , probably because f ull breast-f eeding is a relativ ely rare practice am o ng w om en deliv ering in thissetting.

T he ef f ects of term v s. preterm deliv ery w ere exam ined in general because a further break dow n byplace of deliv ery resulted in a v ery sm all num ber ofp reterm LBW in fan ts in each p lace . T h e RRR s f or te rmand preterm L BW deliv eries w ere sim ilar f or m o st in-te rg ro up comparison s, b ut sin ce the stan dard erro rsw e re large r f or th e estim ate s o f th e LBW p reterm e ff ec tb ec au se o f th e small n umber o f in fan ts in th is c ate go ry ,the R R R f or L BW preterm generally did not reach stat is tical s ignif icance.T hese predictions w ere based on the use of instrum ental v ariables f or place of deliv ery . U sing instrum e nts, w e obtained unbiased estim ates of the ef fectsb ut n ote d th at some o f c oe ff ic ie nts f or p lac e o f d eliv e ryw e re v e ry larg e. T h e re su ltin g p re dic te d p robab ilitie s


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FEEDING OF LOW B IR TH W EIGHT INFA NTS 10 9T ABL E 3

C on c ord an ce o f b re ast-f ee din g in te ntio n s a n d p ra ctic es a m on g C L H N S w o m en : p re dic te d p ro ba bilitie sof m em bersh ip in grou ps are af fected by place of delivery an d low birth weigh t1NBW Z LEW

1 N um bers represent predicted probability (% ) of m em bership in specif ied group.2 N BW = norm al birth w eight; L EW = low birth w eight.

LEW pr te rai L EW termGroupIntended,breast-fedIntended,did notreast-feedDidnot i nt end,reast-fedDidnot intend, did notreast-feedByf ac il it y: p re dic te d p ro bab il it y o f in te nd in gobreast-feed but notreast-feedingHomePublicPrivate85.02.28.93.80.61.36.182.96.38.31.63.04.016.782.57.18.81.682.86.08.33.1

of full breast-f eeding in the public facility group w erehigher than w ould be expected on the basis of observation of actual f eeding practices in the sam ple. T otry to understand the basis of this result, w e estim atedthe m odels using actual v alues for place of deliv eryinstead of instrum ents. For hom e d eliv eries, the resultsw ere v ery sim ilar. For public facility deliv eries, ourpredicted probability of full breast-feeding for 6 m ow as quite close to the expected value. T he m ost important result of this com parison relates to the LB Wfindings. T he m agnitude and direction of the ef fectsof L BW w ere the sam e. T hat is, regardless of w hetherw e used instrum ental variables, a consistent f indingw as that L BW signif icantly increased the probabilitythat an infant w ould nev er be breast-f ed or w ould bew e an ed early .M oth ers' perception s of th e size of th e infan t. M oth ers were ask ed wh eth er th ey th ou gh t th eirinfant w as of norm al siz e, big or sm all at birth. W eused this inform ation in an ef f ort to sort out the ef fectsof m others' perceptions of the infant f rom biologicalfactors that inf luence feeding decisions. A bout 18%of m others thought their infant w as sm all, and ofthese, 40% w ere actually LBW . W e looked at the effects of m others' perceptions by substituting sm all forLBW in the m odels and by adding sm all to the m odelw ith LBW , to m easure the independent ef fect ofm others' perceptions. W e found no signif icant ef fectso f m o th ers' p ercep tio ns o n in itiatio n o f b reast-f eed in g.In the breast-feeding intention m odel, both sm all andL BW signif icantly predicted m em bership in the groupw ho intended to breast-feed but did not breast-feed,suggesting independent ef fects of infant biology andm others' perceptions. In the f eeding pattern analy sis,sm all w as statistically signif icant, but LB W w as notsignif icant w hen both term s w ere included in thatmodel.

H ospital policies. W ith in categories of facilities,there w as little v ariation in practices related to inf ant

f eeding. B etw een f acility ty pes there w as considerablev ariation. Priv ate hospitals w ere m ost lik ely to receiv eand distribute form ula sam ples and to of fer all inf antsother liquids in the f irst sev eral day s of life. R oom ing-in w as m ore prev alent in public hospitals. A ll f acilitiesclaim ed to have personnel instructing m others on theinitiation and m aintenance of breast-feeding. However, w ithin facilities, w e had no inform ation on specif ic treatm ent of LBW infants. T hus, although w efound im portant facility ef fects on breast-feedingpractices in general, w e could not point to specif icpractices af fecting L BW inf an ts in particular.W e initially hy pothesiz ed that delay ed contact w ithL BW infants w ould reduce the lik elihood of establishing breast-f eeding. W e f ound a signif icant associationof delay ed f irst contact w ith infants and reduced lik elihood of breast-feeding in general but no signif icantinteraction w ith LBW . Furtherm ore, there w ere nosignif icant dif ferences w ithin f acilities in the proportion of LBW vs. norm al w eight infants w ho had earlycontact w ith their m others.

DISCUSSIONThe set of analy ses presented here show s a strongand consistent ef fect of L BW on infant-feeding practices. G iv ing birth to a LB W infant w as a deterrent tobreast-f eeding, but in cases w here m others still electedto breast-feed, the infant's L BW status increased thelik elihood that m others w ould fully breast-feed theirinfant. W e also found im portant ef fects of place ofdeliv ery , show ing a larger im pact of LB W on feedingdecisions of m others w ho deliv er aw ay from hom e inpriv ate or p ublic health f acilities.Our analy ses w ere unable to identify clearly the underly ing reasons for the L BW ef fect on feeding. However, w e have som e im portant clues from our com -


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11 0 A DA IR A ND POPK INT ABL E 4

D eterm in an ts of th e lik elih ood of n ever in itiatin g breastf ee din g : r es alta f ro m m u ltin o m ia l lo gistic re gre ss io nRRRLEW

model1'2LEWPublic de liveryPrivateeliveryFormulasampleMaleinfantUrbanPrimiparousLoweducationY oung(35)LowestSESMiddleSESLEWterm v s.EW pretermmodel^LEWtermLEWpretermPublicdeliveryPrivatedeliveryFormulasampleMaleinfantUrbanPrimiparousLoweducationY oung(35rs)LowestSESMiddleSES1.67

4.155.4410110010.36.83.42.32.52.34.50.460.7511.75464.856.101011.37.84,32300.55010035.44.48.77SE0.30000000003872162413482515154212140.450.664.382.460.0.24130.450.0.00.00251615411215z2.1.4.1.-1.1.1-2.-2.1,-3.-12,01.2559288022034623474608531584744.501.101.-2.-2.1.-2.-1.781783390341267833P>

|z|0.02

0.110.000.070.220.300.140.020.010.140.000.120.030.400.080.000.070.270.410.170.040.020.210.000.1995%

CI 1

02..07-2.6271-24.09.50-11.830.97-10000000-01002000000000,61-173-291-130-014-087-228-051-105-260-3.9212.7490

1 L EW = low birth w eight; RR R = relativ e risk ratio (for a 1-un it c han ge in th e c orresp on din g v ariab le , e xpre sse d re lativ e to th einitiated breast-f eeding category ; C I = conf idence interv al; S ES =so cioe co nom ic statu s b as ed o n h ou seh old in co m e an d ass et tertiles .2 L EW m odel = num ber of observ ations = 2976; chi-squared= 152.89, P < IO "4; log lik elihood = -627.419; pseudoR 2 = 0.1086.^ L EW term v s. L EW preterm m odel. N um ber of observ ations= 2 84 7; ch i-sq uared = 1 46 .9 0, P < IO "4 ; lo g lik elih oo d = -6 13 .7 98 ;pseudoR 2 = 0.1069.

pariso n o f c harac te ristic s o f f ac ilitie s, as w e ll as someo f th e mu ltiv ariate f in din gs.First, w e found a strong ef f ect of LBW am ongw om e n w ho had intended to breast-f eed their inf ant.T his strongly suggests that the m other's plans w erealte re d eith er b y th e b io lo gic al co nd itio n o f th e in fan tat birth (such as poor infant health or poor suck ingability in preterm inf ants), by her perceptions of theab ility o f th e in fan t to b re ast-f ee d o r th e appropriaten ess o f b re ast-f eed ing f or a small in fan t o r b y b arrie rsto breast-f eeding encountered in the postnatal env ironm ent. W e hav e no additional inform ation on theinfant's health status at birth, but w e ex plored thep ossib le role o f th e mo th er's p erce ptio ns an d sh ow e dth at c on tro llin g f or ac tu al LBW , a mo th er's p erc ep tio nthat her inf ant w as sm all tended to increase the lik elihood that she w ould not breast-f eed, ev en w hen sheintended to do so. In earlier w ork , w e show ed that the

duratio n o f b re ast-f ee din g is in cre ase d when th e in fan thas a high ponderal index or relativ e fatness. W e interpreted this as an ef fect of positiv e f eedback to themo th er. If sh e pe rc eiv ed th at he r in fan t w as do ing w e ll,she w as m o re lik ely to continue to breast-f eed (A d airet al. 1993). T his is also relev ant to our f inding thatm others w ho chose to breast-f eed a L BW inf ant w erem o re lik ely to breast-f eed that inf ant f ully . W e k nowthat L BW infants tend to undergo a period of catchup grow th in the f irst 2 m o of lif e, particularly if theyare f ully b reast-f ed an d th us w e ll n ou rish ed an d mo reprotected from inf ectious diseases (A d air 1989). Inother analy ses of grow th of infants w ith dif ferentf ee din g patte rn s, w e f ound th at f ully b re ast-f ed in fan tsw eighed m o re in the f irst 4 m o of lif e. T he good grow thperf orm ance of f ully breast-f ed inf ants m ay serv e tore in f orce the mo the r's b reas t- fe ed ing behav i or.T h e se co nd set o f clu es relates to h osp ital p olicie s.A lthough w e do not hav e specif ic inform ation on policie s re lated to p ossib le d if fe re ntial treatm e nt o f L BWinf ants, w e can show dram atic dif ferences in generalp olicie s that re late to f ee din g b y p lac e o f d eliv ery , an din tu rn , sig nif ic an t e ff ec ts o f p lace o f d eliv ery o n f ee ding. E arly m o ther-inf ant contact is one im p ortant aspect of postnatal care that af f ects the initiation andsuccess of breast-f eeding. W e f ound dram atic dif ferences in the percentage of w om en w ho had early contac t w i th in fan ts ac ro ss d eliv e ry se ttin gs, w i th p riv atef ac ilit ie s hav i ng the lowest p revalence o f early con tac t.W e did not f ind dif ferences in the percentage of L BWin fan ts w i th e arly c on tac t, n or d id w e f in d a sig nif ic an tinteraction of L BW w ith early contact in our m ultiv ariate m odels. T hus lack of early contact w as notshow n to be a f actor w hich can ex plain the decreasedlik elihood of breast-feeding am ong L BW inf ants inparticular.A sec on d p olic y th at v arie d su bstan tially across d eliv ery settin g is the p ro visio n o f f re e samp les o f in fan tform ula to m others. O nly 4% of m others w ho delive re d at h om e rece iv ed a f ree samp le , w h ereas 2 7% whodeliv ered in public hospitals and 68% w ho deliv ered

T ABL E 5P redicted probability of n ever in itiatin g breast-f eedin gam on g C LH P iS w om en 1

P lac e o feliveryHomePublicPrivateAllN EW 22.98.312.76.0LEW 4.813.019.49.5Lreterm4.112.918.98.7LEWerm4.714

1 N um bers represent predicted probability (% ) of m em bershipi n s pe cif ie d g ro up .2 N EW = norm al birth w eight; L EW = low birth w eight.


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FEEDING OF LOW B IRTH W EIGHT IN FA NTS 11 1T ABL E 6

Predicted probability of breast-f eedin g pattern s am on g CL HN S wom en 1Plac e o f d el iv e ry

Home Publicfacility PrivatefacilityN EW LBW NEW LEW NEW LEW

Feed ing pat te rnFully breast-fed 6 m o 16.3 2,0.3 30.2 38.4 1.5 1.6Fully b reast-fed for >2 but 2 but


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112 A DA IR A ND POPK INB allard,J. L , N ov ak , K .K ..& D riv er, M . (1979) A sim plif ied scoref or assessm ent of fetal m aturation in new ly born inf ants. J. Pe-d iat r. 9 5: 769 -774 .B arros, F. C., V ictora, C. G., V aughn, J. P. & S mith, P. G. (1986|B i rt h w e ig ht an d t he d urat io n o f b re as t-f ee di ng : are t he b en ef ic ialef fects of hum an m ilk being ov erestim ated? Pediatrics 78: 656-661.B riscoe, ]., A kin, J. S . & Guilk ey , D. K . (1990) People are notpassiv e acceptors of threats to health: endogeneity and its conseq ue nc es . In t. J. E pid em iol. 1 9: 1 47-1 53 .B utz , W . P. & D aV anz o, J. (1981) D eterm inants of B reastf eedingand W e aning Patterns in M alay sia. R and C orporation, S antaM onica, C A .C eb Study T eam (1991) U nderly ing and prox im ate determ inantso f ch ild h ealth : the C eb lo ng itu din al h ealth an d n utritio n stu dy .A m . J. E pidem iol. 133: 185-201.Churella, H. R ., B achhuber, W . L . & MacL ean,W . C. (1985) Surv ey : m ethods of f eeding low birth w eight inf ants. Pediatrics 76:243-249.de Chateau, P. & W iberg, B . (1977) L ong term ef fect on m other-inf ant behav ior of ex tra contact during the f irst hours post-par-tu m . A c ta Pae diatr. S can d. 6 6: 13 7-1 51.Fernandez , M a. E. & .Popk in, B . M . (1988) Prelacteal f eeding patterns in the Philippines. E col. Food N utr. 21: 303-314.Form an, M . R . (l984) R ev iew of research on the f actors associatedw ith choice and duration of inf ant f eeding in less-dev elopedc oun trie s. Ped iatric s 74 (su pp l p art 2): 6 67 -6 94 .H ausm an, J. A . (1978) S pecif ication tests in econom etrics. E conomet ri ca 4 6: 1 25 1- 12 71 .M adalla, G . S . (1988) Introduction to E conom etrics. M acm illan,N ew Y ork , N Y .N arayanan, I. (1986) Care of the low birth w eight infant in dev eloping countries. A n n. T rop. Pediatr. 6: 11-15.Pollitt, E., Gilm ore, M . & .V alcarcel, M . (1978) T he stability ofsuck ing behav ior and its relationship to intak e during the f irstm onth of lif e. Inf ant B ehav . D ev el. 1: 347-357.Popk in, B ., A k in, J. S ., B illsborrow , R . E. a Y am om oto, M . E . (1983)B reast-f eed ing p rac tice s in lo w in com e co un tries . M e d. A n th ro -p ol. 7: 1 -31 .

Popk in, B ., L ask y , T ., L itv in, J., S picer, D. & Y am am oto, M . E.( 198 6) T he In fan t Fee din g T riad : M o the r, In fan t an d H ou seh old.B reach S cience Publishers, N ew Y o rk , N Y .Popk in, B . M ., Y am am oto, M . & Grif f in, C. (1984) T raditionaland m odern health prof essionals and breast-f eeding in the Philip pine s. J. Pe diatr. G astroe nte ro l. N u tr. 3 : 7 65 -7 76 .R enquist, U . H., K usin, J. A . & Jansen, A . A . J. (1985) Feedingpattern, supplem entary f ood and grow th of low birth w eight andnorm al birth w eight inf ants in M achak os, K eny a. E ast A f r. M ed.J. 6 2: 299 -308 .S alariya, E. M ., Easton, P. M . & Cater, J. I. (1978) Duration ofb reast-f eed ing af ter early initiatio n an d f req uen t f ee din g. L an ce t2 : 1141-1143.S teichen, J. J., K rug-W ispe, S . K . & T sang, R . C. (1987) B reastf eeding the low birth w eight preterm inf ant. C lin. Perinatol. 14:131-171.

S tew art, J. F., Popk in, B . M ., Guilkey , D. K ., A k in, J. S ., A dair,L . S . & Flieger, W . (1991) Inf luences on the ex tent of breastf eeding: A prospectiv e study in the Philippines. D em ography28: 181 -199 .V erronen, P. (1985) B reast-feeding of low birth w eight infants.A c ta Pae diatr. S c an d. 7 4: 4 95 -4 99 .V illar, J. & B eliz an, J. (1982) T he relativ e contribution of pre

m aturity and fetal grow th retardation to low birth w eight indev eloping countries. A m . J. O bstet. G ynecol. 143: 793-798.W orld Health Organization (1981) Contem porary Patterns ofB reast-Feeding: R eport on the W H O Collaborativ e S tudy onB reast-Feeding. W o rld H ealth O rganiz ation, G enev a, S w itz erland.W orld Health Organization (1984) T he incidence of low birthw eight: an update. W e ek ly E pidem iol. R ecord 59: 205-212.W orld Health O rganiz ation (1992) Global Health S ituation andPro je ct io ns : Es timat es . D i vi si on o f Ep id em io lo gi cal S u rv e il lan ce ,W o rld H ealth O rg aniz atio n, G en ev a, S w itz erlan d.Z ohoori, N ., Popk in, B . M . & .Fernandez , M . (1993) B reast-f eedingp atte rns in th e Ph ilip pin es: a p ro sp ec tiv e analy sis. J. B io so c. S ci.2 5: 127 -138 .

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