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Determinants of breastfeeding in the Philippines: a survival analysis
Teresa S.J. Abada*, Frank Trovato, Nirannanilathu Lalu
Department of Sociology and Population Research Laboratory, The University of Alberta, Edmonton, Alberta, Canada T6G 2H4
Abstract This study examines modern and traditional factors that may lengthen or shorten the duration of breastfeeding. Speciﬁcally, health sector, socio-economic, demographic, and supplementary food variables are analysed among a large representative sample of women in the Philippines. It is proposed that while modernisation can lead to the adoption of western behaviours, traditional cultural values can also prevail, resulting in the rejection of certain aspects of modernity. The Cox Proportional Hazards model is employed for the analysis of breastfeeding. The results show that traditional factors associated with breastfeeding (use of solid foods such as porridge and applesauce, and prenatal care by a traditional nurse/midwife) do not play a signiﬁcant role in the mother’s decision to continue breastfeeding. Factors associated with modernity are signiﬁcant in explaining early termination of breastfeeding (respondent’s education, prenatal care by a medical doctor, delivery in a hospital and use of infant formula). The ﬁndings of this study suggest that health institutions and medical professionals can play a signiﬁcant role in promoting breastfeeding in the Philippines; and educational campaigns that stress the beneﬁts of lactation are important strategies for encouraging mothers to breastfeed longer. # 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Breastfeeding; Promotion of breastfeeding; Philippines
Introduction Breastfeeding plays a particularly important role in child survival in developing countries: it contributes to the child’s immunologic defense system, and increases its resistance to disease. Breastfeeding also facilitates child survival through postpartum annovulation and postpartum abstinence as these increase the intervals between births (Huﬀman & Lamphere, 1984). According to Williamson (1986), both the incidence and duration of breastfeeding in the Philippines are on the decline. This trend is of major concern to oﬃcials because family income is generally low, child nutrition is often inadequate, and there is little use made of modern family planning methods. To the extent that breastfeeding becomes less prevalent among mothers, fertility will remain high and child survival probabilities will not rise as much as they could.
The decline in the initiation and duration of breastfeeding is an inevitable consequence of the modernisation process (Adair, Popkin & Guilkey, 1993; Akin, Bilsborrow, Guilkey & Popkin, 1986; Guilkey, Popkin, Akin & Wong, 1989; Guthrie, Guthrie, Fernandez & Estrera, 1983; Kent, 1981). In a broad sense, modernisation entails a rapid abandonment of traditional approaches to childrearing, and the adoption of modern practices, including the use of modern health services and the use of supplementary foods for infants, in favour of breastfeeding or prolonged lactation. Notwithstanding this generalisation, modernisation is seldom a process that involves a sudden change in behaviours from traditional to modern. This is particularly true during the early stages of modernisation (Romaniuk, 1980). As such, some aspects of breastfeeding behaviour can take on both modern and traditional features simultaneously. In this study, we examine both modern and traditional factors that may aﬀect the duration of breastfeeding. Socio-economic, demographic, supplementary food and health sector variables will be
0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 1 2 3 - 4
1979). Ferry & Smith. which ultimately hastens the termination of breastfeeding. The result is that not enough adequate breast milk will be provided to the infant. Poor nutritional status. 1983). 1978). provides positive support for breastfeeding practices. For older women. rice water. certain supplementary foods. which in turn reduces the duration of breastfeeding. have more ﬂexible schedules and this allows them to nurse their infants more often. Supplementary food variables In the Philippines. factory and professional jobs in the urban centres are often required to work away from home. such as rice water. Romero & Morales de Look. The transition from traditional to modern societies has prompted a move away from breastfeeding of long duration. thus hastening the early termination of breastfeeding.. For example. Socio-economic and demographic factors Urbanisation is usually associated with lower incidence and a shorter duration of breastfeeding (Castle. The demands of childcare coupled with the demands of a highly structured employment only increases the conﬂict between the maternal role and the work role. / Social Science and Medicine 52 (2001) 71–81 analysed among a large representative sample of women in the Philippines. On the other hand. On the other hand. The role of the health sector The type of advice provided by medical practitioners to mothers regarding breastfeeding is often conditioned by the marketing activities of the infant formula . the marketing activities of the infant formula industry have played an important role in providing alternative infant foods. 1984.J. Such beliefs strongly inﬂuence the timing of the introduction of supplemental foods. particularly among younger generations of women. in particular mothers-in-law. including prolonged breastfeeding (Kent. 1993). which can often result in breastfeeding of a shorter duration (Caldwell. a large family size may not be compatible with the modern lifestyle in the city. Abada et al. 1988. Such women are more likely to reject modern breast milk substitutes and to rely on traditional forms of infant feeding. Akin et al.S. 1984). An older woman is more likely to have a greater number of children. sophisticated and convenient (especially if the mother works outside the home). then the improved overall health of the infant can encourage mothers to breastfeed for a longer period of time (Adair et al. this in turn may lead to a decrease in the mother’s breast milk. apple juice and tea brews are used as folk remedies for infant diarrhoea (Simpson-Hebert & Makil. particularly among older women can diminish the volume as well as the fat and vitamin content of breast milk (Jelliﬀe & Jelliﬀe. 1986. The presence of additional family members in the household. Other solid supplements such as rice porridge. especially in the urban areas. Solimano. Indeed. Habicht & De Vanzo. Moreover. 1983). This shift in the balance of family relations can manifest itself in the abandonment of traditional sources of inﬂuence. Butz. The early introduction of milk supplements results in the reduction in frequency of breastfeeding. Winikoﬀ. Higher parity leads to shorter birth intervals and hence shorter times available for breastfeeding. which in turn aﬀects the duration of breastfeeding. or applesauce may promote breastfeeding of longer duration. The adoption of bottlefeeding in the urban areas is widespread both because it is considered to be more modern. 1981). cottage industries and small scale marketing (especially in the rural areas)). and which usually leads to the abandonment of traditional practices regarding child care.. An understanding of these factors should prove useful in formulating policies that seek to promote breastfeeding in developing countries. leading to a shorter duration of breastfeeding. Ho. Guilkey. It is also well established that parity is closely related to maternal age (Smith & Ferry. increasing maternal age and high parity can also lead to breastfeeding of a shorter duration. women who are involved in traditional or informal work (agricultural activities. 1981). 1992). 1984. a strong attachment to traditional customs and the experience of raising many children usually means a more rigid view of infant feeding patterns. Women involved in modern work. 1979). Adair & Fleiger. High parity also leads to breastfeeding of a shorter duration among rural women. Popkin. Samper de Paredes.72 T. One of the key determinants of the decline in breastfeeding in the Philippines is the increasing level of education among women. a factor which plays a role in the adoption of modern ideas. and because there are fewer breastfeeding role models for urban women to emulate (Trussell. In the rural environment. The infant’s weight is often a sign of successful breastfeeding and if such supplements are used early on the infant’s diet. hence the demands on her time are considerable which may lead to early termination of breastfeeding. namely extended family members. are considered culturally important and can aﬀect the timing of the weaning process. 1991. thus maintaining longer periods of lactation (Huﬀman. breastfeeding calls for little change in lifestyle. thus reducing a mother’s access to her child. 1985). Akin. GrummerStrawn. encouraging mothers to breastfeed for a longer period of time (Stewart. such as clerical. where the use of such substitutes alleviates the time constraints prompted by the changes in maternal lifestyle (Guthrie et al. Huﬀman & Lamphere.. however. Rodriguez & Vanlandingham. The amount of time a mother has to breastfeed is determined by her occupation.
1. was carried out separately for the rural and urban areas. Stewart et al. 1993). The earlier the introduction of solid foods. conducted between April and June 1993. (C) Health Sector Variables } Prenatal Care received from Traditional Nurse/Midwife. 1984. 1985. 2. . A total of 1659 valid cases were obtained for the study. The maternity history contains a maximum number of six entries relating to births in the 5 years preceding the interview. Hypotheses A number of hypotheses are outlined in relation to each of the factors discussed in the preceding section. reproductive behaviour and intentions. 1991). (B) Supplementary foods } Other Liquids. Parity. particularly for respondents who breastfed for a short time only. Yamamoto & Griﬃn. the lower the probability of early termination of breastfeeding. Maternal Age.. Health professionals who are involved in the prenatal care and the delivery of babies are often provided with advertising materials as well as free samples of infant formula to be distributed to new mothers (Adair et al.3 The variable is 1 If the respondent had more than six births in the last 5 years. Bertrand & O’Gara. Franklin. 1993. (A) Socio-economic and demographic factors } Wife’s Education. the earlier the cessation of breastfeeding. 2. Studies have shown that prenatal care from a medical doctor and institutional delivery often results in breastfeeding of a shorter duration. Health professionals who consider infant formula to be better than breast milk can inﬂuence their patients to adopt infant formula over breastfeeding. with a probability of selection inversely proportional to the size of the barangay. Popkin. Data and methods of analysis Data This study is based on data from the Individual Women’s Questionnaire in the 1993 Philippines National Demographic Health Survey. 750 of which were selected for the 1993 DHS. doctor have a greater probability of early termination of breastfeeding. duration of breastfeeding is the dependent variable and is based on information pertaining to the last child of the respondent. Involvement in professional/administrative jobs denotes a greater probability of early termination of breast-feeding.2 The PSU selection. / Social Science and Medicine 52 (2001) 71–81 73 industry. 1985. This suggests that the movement away from breastfeeding is also a consequence of the replacement of traditional health care systems by the modern medical establishment (Mock.1 The Integrated Survey of Households (ISH) developed in 1980. Husband’s Occupation. whereas involvement in agricultural/ domestic household services denotes a lower probability of early termination of breastfeeding. Infant Formulas. Prenatal Care from Medical Doctor.S. 4. Winikoﬀ & Laukaran. A total of 2100 PSU was systematically selected for the ISH. the greater the probability of early termination of breastfeeding. Adair et al. Women who receive prenatal care advice from a traditional nurse/midwife have a lower probability of early termination of breastfeeding. age). Wife’s Occupation. comprised samples of primary sampling units (PSU) and was employed to generate information on employment and socio-economic characteristics among a nationally representative sample of women aged 15–49 years. High parity women have a greater probability of early termination of breastfeeding. using a two stage sampling design. The ﬁrst selection consisted of barangays and the second selection consisted of households within the barangay. and may have failed to report this. Abada et al. Women who deliver in a hospital as opposed to their own home have a greater probability of early termination of breastfeeding. Solimano. Information was collected on topics that included background characteristics (education. The earlier the introduction of other liquids and infant formulas into the infant’s diet. Husband’s Education.. breast-feeding. whereas women who receive prenatal care advice from a medical Measurement of variables Dependent variable In this study. Solid Foods: 1. child health and maternal mortality. 2 Barangays are considered to be the smallest political subdivision that corresponds to a census enumeration area. then only the last six are included in the maternity history.J. which was self-weighted in each of the 14 regions. availability of family planning supplies and services. The older the mother. 1. 3.T. 3 Potential errors may arise in the data. Delivery in a Hospital. The higher the level of education the greater the probability of early termination of breastfeeding. 2.. But the study minimises the recall error regarding this concern since it focuses on the last child born in the last ﬁve years.
or in a hospital. The 1993 Philippines DHS is a retrospective cross-sectional survey that provides maternity histories completed up to the time of the survey. 4 . The respondent’s and husband’s occupation is also measured as a categorical variable: not working. and parity). / Social Science and Medicine 52 (2001) 71–81 calculated as the number of months that the mother reports having breastfed the child. Categories relating to prenatal care are dichotomous: no prenatal care from a doctor. The education of both respondent and spouse is the highest level of schooling attained. Descriptive statistics and the individual eﬀects of the Cox regression analysis for each variable are given to provide a general overview of the covariates in the analysis. rural-urban residence is used as stratiﬁcation variable (i. secondary.J. Zi)] for strata deﬁned by variables suspected of having a nonproportional eﬀect on the hazard function. Therefore. the lowest possible value assigned to parity is one. resulting in hazard functions for the rural and the urban models. primary. no prenatal care from a traditional nurse/midwife. 1). The Cox proportional hazards (PH) model may be viewed as a multivariate life table. Highest Level of Education (Respondent’s and Husband’s).529À291. Abada et al. rural) rather than as a covariate. Results Fig. measured as no education. one for rural residence. in single years of age from 15 to 49 years. The survival curves represent the The proportionality of hazards was checked via inspection of the plots of the log minus log survival function [hi(ti. Kleinbaum. For this study. and prenatal care from a medical doctor. therefore. 1996). These three variables represent the last child’s age in months when the mother started to use food supplements on a regular basis. which is not signiﬁcant at the 0. occupation. and the other for urban residence (Kleinbaum. and prenatal care from a traditional nurse/midwife. 5 A likelihood ratio test was also carried out to compare the log-likelihood statistics for the interaction model (rural–urban residence Ã predictor variables) and the non-interaction model. and thus controls for truncation bias (Allison. the respondents at one level of a given sub-group experience a hazard proportional to the reference category. It is assumed in this model that: (1) there is a hazard or risk of occurrence of the event of interest (in this case.05 level). rural–urban residence did not meet the assumption of proportionality of hazards. Prenatal Care } Traditional Nurse/Midwife and Place of Delivery.z) is the hazard rate at time t. it was discovered that rural-urban residence did not meet this assumption4 (SPSS. Supplementary Food Variables } Age for Infant Formula.S. Methods Survival analysis has been used in the analysis of breastfeeding. The diﬀerence in the LR statistic of the two models was 295. the models are a function of time and regressor variables. this method uses censored data.913. self-employed. h0(t) is the baseline hazard function of t. Model III consists only of the health sector variables. First. the termination of breastfeeding) at each time t. the model is partitioned into two strata. Each stratum has a diﬀerent baseline hazard function. The survival analysis technique adjusts for truncation bias by incorporating both complete and incomplete segments of histories in the breastfeeding analysis (some women may be continuing to breastfeed at the time of the survey). The place of delivery is measured as either in a home. but unlike other regression techniques. that the period between the start and the end of breastfeeding would vary signiﬁcantly among women. agricultural job. the various predictors are grouped into separate models. The age of the mother is measured as a continuous variable. This model allows one to stratify across factors that do not meet the proportionality assumption. The Cox regression analysis is set in two stages. Independent variables Socio-economic and Demographic Variables } Age. Age for Solids and Age for Liquids. all the predictors found to be statistically signiﬁcant from the previous three models are grouped into Model IV and analysed accordingly. The hazard function5 is expressed as: hðt. zÞ ¼ h0 ðtÞeðbzÞ where h(t. Occupation (Respondent’s and Husband’s). clerical/sales the other. age.e.05 level. 1997. and this is applicable to all members of the population. we can conclude for these data that the noninteraction model is acceptable (at least at the 0. Health Sector Variables } Prenatal Care } Doctor. Results indicated that among all the predictors. 1984). In the present case. b is a vector of coeﬃcients and z is a vector of covariates. Parity is measured as the total number of children. Parity. 1 shows the respective survival curves for rural and urban women. It is expected. urban. Model I consists of the socio-economic and demographic variables (education.616=3. Since the study focuses on women who have had at least one child. The diﬀerent baseline hazards for each rural and urban residence yields diﬀerent estimated survival curves (see Fig. Next. (3) even though there will only be one set of coeﬃcients. and post-secondary. The maximum number of months recorded in the survey was 40 months.74 T. The maximum number of months is 30 months. Model II consists of the supplementary food variables. 1996). (2) at each time t. and household/domestic comprise one category. and professional/administrative.
About one half of respondents only attained up to a primary education.4% are involved in agricultural work. The eﬀect for solid foods was not statistically signiﬁcant. the probability of continuing to breastfeed is approx. Unlike the respondent’s occupation. 0. 1985). The mean age of the child at the time of the introduction of infant formula and other liquids on a regular basis is 9. occupation. the probability of continuing to breastfeed for among urban women is only 0.5 months. Table 1 presents means and standard deviations of covariates.J. The husband’s education shows a similar pattern to the wife’s education. Survival curves for duration of breastfeeding in the Philippines: rural and urban samples.825.1% are involved in professional and administrative work.650.S. For women with postsecondary education. Women who had prenatal consultation with a medical doctor had a risk of ceasing to breastfeed that was 25% higher than women who did not consult a medical doctor. Three separate Cox regression analyses were computed for the three models. 1. indicating that the majority of mothers still work close to home. whereas about 83. This ﬁnding is con- .7 months respectively. The mean age of the mother for the sample is 33 years. Table 2 presents the individual eﬀects of each of the variables on the duration of breastfeeding. Abada et al. / Social Science and Medicine 52 (2001) 71–81 75 Fig. The husband’s education and occupation were not statistically signiﬁcant. Infants are weaned to solid foods earlier around 7. The average duration of breastfeeding is 7. and parity are the only predictors that remain statistically signiﬁcant. Maternal age is not statistically signiﬁcant. At each point of duration. As hypothesised. The next three tables show the changes in the eﬀects of the predictors once we control for other variables.9. Model I: socio-economic and demographic variables Table 3 shows that among the socio-economic and demographic variables.5 months of age. while the average number of children born is 3. denoting the importance of certain cultural foods (rice porridge) as a means of promoting the infant’s health (Simpson-Hebert & Makil. 1993. The following categorical variables are expressed in percentage values.52 times greater than in women without postsecondary education. the risk of ceasing to breastfeed is 1. Only 16. Only 21. the respondent’s education. urban women have a lower probability surviving (continuing to breastfeed) relative to rural women. and only 22.4 months and 8. Women with a postsecondary education and those involved in professional/ administrative work and women with high parity are associated with early termination of breastfeeding. at duration one. The survival curve for rural women is consistently above that of urban women. probability of women who continue to breastfeed at any given time.1%) are involved in professional and administrative work. For example. Women who consulted a midwife had a risk ceasing to breastfeed that was 11% lower than their counterparts who sought prenatal care advice elsewhere. a greater percentage of husbands (50.1% have attained a post-secondary education. Those who delivered in a hospital were also associated with breastfeeding of shorter duration.T.6% have achieved a post-secondary education. those women who used infant formula and other liquids (such as rice water) early had a higher probability of ceasing to breastfeed. Women who are involved in professional/managerial positions have a higher probability of ceasing to breastfeed than women involved in low skilled/agricultural positions. whereas for rural women.
The older the age at which infant formula is introduced into the infant’s diet. whereas the age for liquids was in the expected negative direction. Durongdej & Cerf.2% 59. The estimated risk of ceasing to breastfeed is 1. 1981.43 8.3% 41.6% 49..4923 and is highly signiﬁcant at the 0. The only predictor that was not statistically signiﬁcant is the prenatal care advice } traditional nurse/midwife.8% 22. indicating that the hazard is reduced by 0.0% 41.S.. in comparison to women who did not consult a medical practitioner. the age for solids was in the negative direction.1% 3. Ho. Castle et al. Women who delivered in a hospital had an estimated risk of stopping breastfeeding that was 15% higher than women who gave birth at home.9735. leading to early termination of breastfeeding.1% 49. 1981.1964 times greater for women who sought prenatal care advice from a medical doctor. .8% 21.4% 16. This ﬁnding is consistent with other studies in which the introduction of breast milk substitutes is associated with a relatively rapid cessation of breastfeeding (Winikoﬀ.0001 level. the lower the hazard rate. These factors can aﬀect the mother’s attitudes towards breastfeeding negatively. Model III: health sector variables Table 5 presents the estimated coeﬃcients and the relative risks for the health sector variables.9% 50.76 T. It appears that the presence of additional children in the household would place more constraints on the mother’s time thereby increasing the conﬂict between work and motherhood. computed using data from 1993 Philippines National Demographic Health Survey. Contrary to the hypothesis.93 8. The relative risk for parity (as represented by total number of children born) is 1.93 2. Model II: supplementary food variables Table 4 shows the eﬀects of the supplementary food variables on the probability of termination of breastfeeding. sistent with other studies regarding maternal work and compatibility with childrearing.9 2. Our study also shows that the movement away from breastfeeding is a function of the practices of medical practitioners in those facilities.59 Standard deviation 7.5 33 3. Butz et al. 1988.21 7. Both eﬀects were not signiﬁcant.03% for each additional month of infant’s age at which the introduction of infant formula is delayed. resulting in a shorter duration of breastfeeding (Van Esterick & Grenier.74 7.9% 32. which in turn encourage early use of infant formula.J.86 9. / Social Science and Medicine 52 (2001) 71–81 Table 1 Means/percentages and standard deviations of covariatesa Variable Duration of breastfeeding Maternal age Respondent’s education No education Primary education Secondary education Post-secondary and higher Respondent’s occupation Household/domestic/agricultural work Professional/administrative/clerical Total number of children born Husband’s education No education Primary Secondary Post-secondary and higher Husband’s occupation Household/domestic/agricultural Professional/administrative/clerical Prenatal-care doctor Prenatal-care nurse/midwife Place of delivery (home) Place of delivery (hospital) Age for infant formula Age for other liquids Age for solids a Mean/percentages 7.6% 54. 1988).8% 32. 1979). suggesting that the rigid hours associated with such types of employment can encourage the mother to use infant formula early. The relative risk is 0.7% 42.47 11.1% 9.14 Source: in this and subsequent tables.1% 83. Abada et al. ﬁgures.
0537 1. Abada et al.0691 Husband’s occupation Not working (ref) Agricultural Professional/clerical/administrative h0(0)rural=0.0983 No doctor (ref) Prenatal Care } Doctor h0(0)rural=0.4438 À0.0438.0186.0810 1. is also associated with breastfeeding of . In this analysis.0755 No Nurse/midwife(ref) Prenatal Care-Nurse h0(0)rural=0.0027 0. as represented by the total number of children born.2456 1. suggesting a greater probability of ceasing to breastfeed.0318. h0(0)urban=0.0526 0.0991 Age for other liquids h0(0)rural=0.9213 1. h0(0)urban=0. h0(0)urban=0.0064 1.2196ÃÃ 0. supplementary food and health sector variables Table 6 presents the results of the proportionality hazards model for the duration of breastfeeding.0363.8874 0.01.0801 Age for infant formula h0(0)rural=0.3673 0.0100 Education À0. h0(0)urban=0. The estimated risk of ceasing to breastfeed is 1. h0(0)urban=0. As education increases at the postsecondary level.0806 Parity h0(0)rural=0.0101 0. Women with postsecondary education are more likely to be involved in modern work requiring them to be away from their infants during the day.8971 1.0108 ÃÃ 0.9768 0.0878 a Coeﬃcients 0.1194Ã 0.0428 0.4129 À0. In these and the next tables.2776 À0. demographic.0779 0.0459 Husband’s education No educ (ref) Primary Secondary Post-secondary h0(0)rural=0.2566 À0.05.3367 0.1892 0. High parity. 2 and 3 are entered together in one model.0669 0. thus encouraging the early use of breast milk substitutes.0871 Age for solids h0(0)rural=0.0652 Respondent’s occupation Not working (ref) Agricultural Professional/administrative h0(0)rural=0. ÃP40.9612 0. the socio-economic and demographic.S.7550.3351 0.0406 1. The results also show that involvement in professional or administrative jobs increases the likelihood of ceasing to breastfeed by 15%. Education is used as a categorical variable.0387 0. h0(0)urban=0.9893 L2 (Baseline) 15099.0820 0.0452.4973ÃÃ Standard error 0.0297 0.0444 0. and supplementary food variables that were found to statistically signiﬁcant from Models 1.0297. health sector.T.0698 0.1733ÃÃ À0.7577 0. h0(0)urban=0.0116Ã À0.0681 0.0420.0671 0. h0(0)urban=0. health sector and supplementary food variablesa Variable Maternal age h0(0)rural=0.0726ÃÃ 0. Model IV: socio-economic.6443 À0.0400 0.J.0748 0. demographic.0301.0235ÃÃ À0.53 times that of women with no education. h0(0)urban=0.3456ÃÃ 0.0385 0. the hazard rate is increased. h0(0)urban=0.0339. h0(0) represent the hazard at time 0.0364.9282 1.0636 0.0374. h0(0)urban=0.0037 0.2284ÃÃ 0. 4P 0.0631 No education (Ref) Primary Secondary Post secondary h0(0)rural=0.0056 Relative risk 1.1086 0.0262. h0(0)urban=0.9884 0. / Social Science and Medicine 52 (2001) 71–81 77 Table 2 Proportional hazards (gross eﬀects) of duration of breastfeeding: socio-economic.0807 Delivery-home (ref) Place of delivery-hospital h0(0)rural=0.
6 Its relative risk is 1.0795 0.9953 À0.0480 0.0491 1. resulting in early termination of breastfeeding.5327 0. in a hospital is 15% higher relative to women who did not deliver in a hospital.e. such support is more readily available.0892 0. i. indicating that an increase in the infant’s age as the time at which infant formula is used on a regular basis reduced the hazard of terminating breastfeeding by 3%. Since there has not been a huge diﬀerence in the w2 improvement between the two models. ÃP40. As such. If the responsibility of childcare is allocated to older siblings and adult relatives then the mother may have less constraints in terms of balancing work and family which may encourage her to breastfeed for a longer duration. model w2 improvement 170.9528 1.1158 0.212 with a model w2 improvement of 280.0047 Standard error 0.590 and 10 degrees of freedom.0410.01.1216 À0. If age was included in this model.497 and 9 degrees of freedom. which then makes it diﬃcult to establish a causal relation between substitutes for the mother’s childcare time and the duration of breast-feeding. the data does not allow one to determine who is responsible for the child when the mother works. dropping age from the analyses does not change the improvement in the model as much.1249 À0.78 T. 1986). It should also be noted that women who are more likely to consult with medical doctors are more likely to use a hospital for place of delivery. milkfeeding involves either breast milk or The eﬀect of parity on breast-feeding also depends on who substitutes for the mother’s childcare time (Uyanga.0812 0.0838 0.98.1015 1. L2 (Baseline) 14045.0931 0.7 For the health sector variables.47.0838 À0.9196 0.J. thereby increasing the time costs involved with children. ‘‘prenatal care } medical doctor’’ and ‘‘delivery in a hospital’’ remain statistically signiﬁcant. As previous studies also show. the À2 Log Likelihood was 14609. This suggests that additional children place more constraints on the mother’s time. shorter duration. it would appear that ‘‘for most children.8929 0. indicating that an increase in parity by one child increases the hazard rate by 47%. parity has a more signiﬁcant eﬀect than maternal age on the duration of breast-feeding.).3319 while the estimated risk for women who delivered 6 The non-signiﬁcant eﬀect of age in the previous models can be explained by the close relationship of age to parity. ‘‘prenatal caredoctor’’ masks the eﬀect of place of delivery on the duration of breastfeeding. 7 . ÃÃP40. The later infant formula is introduced in the infant’s diet the longer the duration of breastfeeding. The relative risk for age for infant formula is 0.3378 0. the À2 Log Likelihood was computed to be 14869.0406 0.1066 À0.4271Ã 0.S. Since older women also have high parity. prenatal care advice from a medical doctor and delivery in a private hospital are associated of breastfeeding of shorter duration.1177Ã 0. À2 Log Likelihood 13874.0064 Relative risk 0. In rural areas.4003ÃÃ 0. Unfortunately however.0484 0. / Social Science and Medicine 52 (2001) 71–81 Table 3 Proportional hazards model of duration of breastfeeding: socio-economic and demographic variables eﬀectsa Variable Maternal age Respondent’s education no educ (ref) primary education secondary education post-secondary and higher Respondent’s occupation not working (ref) agricultural/domestic/home services professional/administrative/clerical/sales Husband’s education no educ (ref) primary education secondary education post-secondary and higher Husband’s occupation not working (ref) agricultural/domestic/low skilled agricultural/domestic/manual professional/administrative Parity a Coeﬃcients À0.0840 0.388 with a model w2 improvement of 275.0014 0.0014 1.0967 0.0958 0.1013 0.f. The weak eﬀect of place of delivery can be explained by the close relationship between this predictor and ‘‘prenatal care } doctor’’. Abada et al. The relative risk for women who sought prenatal care from a medical doctor is 1. Consistent with the ﬁndings in Model 3.0197.4923 h0(0)rural=0.4420 (14 d.3367 0.9086 1.05. the eﬀect of parity in this case masks the eﬀects of maternal age.5690.8906 1.0110. h0(0)urban=0. When age was dropped from the analyses.
thus resulting in early termination of breastfeeding (Becker. Model w2 improvement 275.).1518 0. prenatal care traditional nurse/midwife) did not play a signiﬁcant role in the mother’s decision to continue breastfeeding. prenatal care with a medical doctor. demographic. These Table 6 Proportional hazards model of duration of breastfeeding: socio-economic..0072 0.9735 0.9939 h0(0)rural=0.01.1111 0. Initial L2 (Baseline) 14882.0061 Standard error 0. Table 5 Proportional hazards model of duration of breastfeeding: health sector variables eﬀectsa Variable Coeﬃcients Standard Relative error risk Prenatal care No doctor (ref) Medical doctor 0. 1981). Abada et al. h0(0)urban=0.8320 (3 d. which then leads to early termination of breastfeeding. Initial L (baseline) 15100. Factors associated with modernity were signiﬁcant in terms of early termination of breastfeeding.J.2146 0.S. The results indicated that traditional factors associated with breastfeeding (age for liquids.0162. ÃÃP40.0071 Place of delivery Home delivery (ref) Hospital 0. ÃÃP40.1032. When mixed feeding is seen.1438Ã 0.5345 1. / Social Science and Medicine 52 (2001) 71–81 Table 4 Proportional hazards model of duration of breastfeeding: supplementary food variables eﬀectsa Variable Age for infant formula Age for solids Age for other liquids a 79 breast milk substitutes together.9773 a h0(0)rural=0.0485 0.4970. h0(0)urban=0.0382 1.).0274. 23).1930 1.05. ÃP40.0497 1.1363ÃÃ a 0.f. The time constraints imposed by work and motherhood. age for solids.4910.1547 0. The implications for labour force and educational policies points in the direction of the promotion of timesaving methods that can increase the likelihood of breastfeeding for a longer duration.0669 0.0312 2 1.0026 0. These include the respondent’s education.8620.0724 1.1765 0. ÃP40. 2 Log Likelihood 14609. health sector and supplementary food variables eﬀectsa Variable Education No educ (ref) Primary Secondary Post Secondary Parity Respondent’s occupation Not working (ref) Agricultural/Domestic Professional/administrative Prenatal care No doctor (ref) Prenatal care } doctor Place of delivery Home (ref) Place of delivery } hospital Age for infant formula Coeﬃcients Standard error Relative risk 0.1793Ã No nurse/midwife (ref) Traditional nurse/midwife 0.0067 0. indicating that the presence of additional children in the household can incur greater costs to the mother’s time. encourage early use of breast milk substitutes. Model w2 improvement 50.f.3890.1414Ã À0. ÃÃP40.4282Ã 0.0756. High parity was associated with shorter breastfeeding of shorter duration.2149 0.0230ÃÃ 0.6590.0027 1.0710 0.2866ÃÃ 0. Model improvement 126. Initial L2 (baseline) 15020.).0431. 2 Log Likelihood À14894.0485. p.1970 (3 d. .146 h0(0)rural=0.0457 1.3880 (9 d. Coeﬃcients À0.2225 0.0268ÃÃ À0.0039 Relative risk Conclusions 0.01.T.0027 À0. place of delivery and the age at which infant formula is introduced.1964 1.01.f.0863 1.6650.05.4726 0. 1988. h0(0)urban=0. This analysis examined both traditional and modern determinants of lactation in the Philippines during 1993.1175 1.9973 0.0491 0.3871ÃÃ 0.3319 0. it is likely part of a transitional phase leading to the cessation of breastfeeding’’ (Castle et al. particularly among women with a post-secondary education and those involved in the wage sector. 2 Log Likelihood 15049.
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