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Explaining Infant Feeding Style of Low-Income Black Women

Karen S. Corbett, PhD

Unstructured interviews were conducted with 10 low-income black women to explore infant feeding style. Formula-feeding with early introduction of cereal in the bottle was the most common pattern used by mothers in the first 3 months. By 6 months, formula-fed infants had a complex diet of a variety of foods. Half the women intended to breast-feed, but only one exclusively breast-fed. Beliefs about healthy infants and crying influenced feeding. There was a lack of knowledge about and support for breast-feeding in these women's environment. Support and advice about infant feeding from the health care system were uneven.

Copyright 2000 by W.B. Saunders Company

DEQUATE NUTRITION and early feeding patterns are important determinants of health during infancy (Institute of Medicine [IOM], 1991 ). The nutritional, health, and psychological benefits of breast-feeding are widely accepted (Lawrence, 1997). Breast-feeding is recommended for the first 12 months of life. It is also recommended that solid foods be introduced beginning at 6 months of age (American Academy of Pediatrics, 1997). Health promotion goals for the year 2000 include goals to increase to 75% the percentage of mothers who breast-feed their infants at hospital discharge and to 50% those who continue to breast-feed until 5 to 6 months of age. Low-income and black women are identified as special population targets because they have the lowest rates for both incidence and duration of breast-feeding and are a significant proportion of all new mothers (Department of Health and Human Services, 1991). The IOM recommends that "further research is needed to identify the determinants of the decision to both initiate and continue breastfeeding.., in particular, among adolescents, those with limited education, and black, Hispanic, and other minority women" (1991, p. 240). This study explored the infant feeding style of low-income black women. Infant feeding style includes practices as well as the values, attitudes, and beliefs associated with infant feeding (Van Esterik & Elliott, 1986). Feeding style combines actual behavior resulting from deliberate choices and the meaning of these practices. Infant feeding style is affected by both external and internal factors and reflects interaction among individuals and groups.
Journalof PediatricNursing,Vo115, No 2 (April), 2000

CONCEPTUAL ORIENTATION
Infant feeding is a composite of behaviors that exist in a complex environment and also a process that occurs over time and involves a range of behaviors including breast-feeding, formula-feeding, introduction of supplementary foods, and weaning (Raphael, 1984). Concepts from anthropology, child development, and human ecology have been synthesized to develop a cultural-ecological framework that guides the study of infant feeding. A cultural-ecological framework (Corbett, 1999) allows for the examination of context and moves beyond the infant-mother dyad to consider impact of the entire ecosystem on the individual. It recognizes that biological, psychological, social, cultural, and economic factors all affect a caregiver's actions and beliefs regarding infant feeding. McElroy and Townsend (1985) suggest a model of an ecosystem in which the environment consists of physical, biotic, and cultural elements. The cultural component is composed of social organization, technology, and ideology. An individual's cultural environment influences dietary practices, family life patterns, and beliefs and practices related to health and illness (Tripp-Reimer, 1984). LeVine (1977) developed a theory of child

From the Medical UniversiO, of South Carolina. College of N,trsing, Charleston. SC Address reprint requests to Karen S. Corbett, PhD, Medical Universi~ of South Calvlina, College of Nursing, 171 Ashley Ave, Charleston, SC 29425. Copyright 2000 by W.B. Saunders Company 0882-5963/00/1502-0003510.00/0 doi: 10.1053/jn.2000.5445 73

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rearing as cultural adaptation. As one aspect of childrearing, infant feeding is the result of cultural adaptation to particular environmental conditions. Infant feeding practices are imbedded in the context of cultural values and behaviors. Ogbu (1981) suggested that the native theory of child rearing contains a culture's beliefs about proper ways to raise children and their organization of childrearing tasks. This native theory of childrearing does not necessarily correspond to the "scientific" model of childrearing, but is a lay model that guides adults in their relationship to children. This study focused on the interrelationships between the infant feeding practices of individual caregivers and the cultural environment. The cultural environment is composed of both microsystems and macrosystems (Bronfenbrenner, 1977). The microsystem is a complex of relationships among various lifestyle factors and the household to which the infant belongs. At the microlevel, the household is the focus within which infant feeding practices are organized and enacted. External variables affect the options available and the choicemaking strategies of household members. The cultural environment influences the household structure and lifestyle factors that interact with and impact on the household. Lifestyle factors that influence infant feeding are occupation, education, income, religion, ethnicity, and folk beliefs. The macrosystem concept enables the investigator to identify and explore the impact of aspects of the larger society on the individual's microsystem. The health care system represented the macrosystern component examined in this study. The health care system impacts on lifestyle factors and in turn influences the microsystem containing the caregiver and the infant. Hospital practices, advice from health care professionals, and the Woman, Infants and Children (WIC) program were the specific aspects of the health care system that were studied.

LITERATURE REVIEW
A variety of demographic factors have been investigated in relationship to incidence and duration of breast-feeding. National estimates are available on education, income, employment, race, parity, age, and marital status (IOM, 1991; Ryan, 1997). Older mothers initiate breast-feeding and continue longer than younger mothers. Both initiation and duration of breast-feeding are positively associated with maternal education and family income. Married mothers are more likely than

unmarried mothers to breast-feed and experience a lower attrition rate at 5 to 6 months (IOM, 1991). In 1995, 59.7% of all women breast-fed in the hospital and 21.6% were still breast-feeding at 6 months. These rates vary by race, with white women having a higher incidence (64.3%) compared with black women (37%). By 6 months, these rates had decreased to 21.6% for whites and 11.2% for blacks (Ryan, 1997). Although we have seen a recent increase in both incidence and duration for blacks, they still have the lowest rates of breastfeeding and duration of breast-feeding. Blacks living in the South Atlantic region had an incidence of 35.3% in the hospital and a continued breastfeeding rate of 10% at 6 months. Early introduction of formula (Kurinij, Shiono, & Rhoads, 1988; Loughlin, Clapp-Channing, Gehlbach, Pollard, & McCutchen, 1985) and solids (Hawkins, Nichols, & Tanner, 1987) has been reported as risk factors for early termination of breast-feeding. Women who initiate partial breastfeeding in the hospital are usually employed and black and tend to have low-birth-weight babies (Ryan, Wysong, Martinez, & Simon, 1990). Black women have a higher incidence of supplemental formula use in the hospital than white women, which is the primary determinant of a shorter duration of breast-feeding (Kurinij et al., 1988). Many black women stop breast-feeding in the first few weeks postpartum before lactation is fully established (Bevan, Mosley, Lobach, & Solimano, 1984: Kurinij, Shiono, & Rhoads, 1988). Even the number of exclusively breast-fed infants decreased rapidly (20% at 3 weeks to 7% at 6 months) in a study of low-income black urban infants (Parraga, Weber, Engel, Reeb, & Lerner, 1988). Most studies of infant feeding focus on formulaversus breast-feeding, but information on supplementation patterns and trends is limited. Studies of feeding practices among low-income black mothers reveal patterns of early introduction of solids and the feeding of cereal and high sugar content beverages by bottle (Adair, 1983; Brogan, & Fox, 1984; Burki & Reis, 1985; Parraga et al., 1988; Solem, Norr, & Gallo, 1991). Several studies reported introduction of solids into the infant's diet during the first month of life, and the majority had started solids betbre the recommended age of 4 to 6 months (Burki & Reis, 1985; Doucet & Berry, 1988; Parraga et al., 1988). Feeding cereal by bottle is a common practice among blacks (Andrew, Clancy, & Katz, 1980; Burki, & Reis, 1985). Juices are also commonly fed to infants as early as 3 weeks (Doucet & Berry, 1988; Parraga et al.,

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1988). Thus there is a need for information on current patterns of infant feeding among lowincome black women. Two broad categories of determinants influence the choice of infant feeding method: infant feeding ideology and external constraints (IOM, 1991). Infant feeding ideology includes beliefs about perceived benefits of different feeding methods and values placed on breast- or formula-feeding. Infant feeding ideology results from past experience. It is used to guide infant feeding practices and is the result of prior cultural adaptation to particular environmental conditions or influences (Chibnik, 1982). Ethnic group membership influences health beliefs and knowledge and may also influence who will be the most influential person in terms of support and advice about various aspects of infant feeding (Baranowski, et al., 1983; Bryant, 1982; McClorg & Bryant, 1989). Kin, friend, and neighbor networks transmit information about the advantage of introducing solid foods at an early age, as well as values and beliefs about specific feeding practices (Black, Blair, Jones, & DuRant, 1990: Bryant, 1982; Burki & Reis, 1985). Health professionals were not a significant influence for low income women; but family, friends, and peers were identified as having the most influence (Bryant, Coreil, D'Angelo, Bailey, & Lazarov, 1992; Dix, 1991). Women of low income status were less likely td receive help from all sources in their infant feeding decision than women of middle and upper income status (Grossman, Fitzsimmons, Larsen-Alexander, Sachs, & Harter, 1990). Low-income women identified lack of role models in the community and lack of support as barriers to breast-feeding (Bryant et al., 1992). External constraints include separation from the infant resulting from demands of household and family responsibilities and commitments outside of the home such as work. Behaviors and lifestyles of blacks are different from those of other ethnic groups. The attitudes and patterns of behavior, as well as child rearing priorities, are the result of unique, economic, cultural, and racial circumstances in their environment (Peters, 1997). To develop data-based interventions, the beliefs, attitudes, and situational factors that affect childrearing of black low-income caregivers must be identified and described. Interventions to increase the incidence of breastfeeding among low-income and black women have been successful (Brent, Redd, Dworetz, D'Amico, & Greenberg, 1995; Healthy People 2000, 1995);

however, the duration of breast-feeding has not improved. The limited data available suggest that many women who are breast-feeding at the time of discharge from the hospital stop breast-feeding well before the desired 5 to 6 months of age. There is little information about the low-income black woman who initiates breast-feeding and even less about those who nurse for a prolonged period. Although we know that low-income black women have low rates of breast-feeding, there is little information about decisions made regarding not only breast-feeding and formula-feeding but introduction of solid foods and the beliefs that influence these practices. It is necessary to identify the factors that influence the decision to breast-feed or formula feed (Lawrence, 1988). More information about styles of infant feeding and the influence of the microenvironment and macroenvironment on black low-income women is needed to plan culturespecific and effective interventions to achieve the health promotion goal for 2000 and improve infant health status.

METHODS
An ethnographic field study design using intensive interviewing was used. Fieldwork is the process of studying phenomena first hand in the environments in which they naturally occur (Glaser & Strauss, 1967). Ethnography recognizes that behavior is context related and aims to capture that context in detail. Through the ethnographic method of intensive interviewing, the researcher "learns from informants the meanings they attach to their activities, events, behaviors, knowledge, rituals and other aspects of their life-style" (Germain, 1993, p. 239). Ethnography is appropriate for the study of phenomena of which we have little knowledge, particularly phenomena that involve implementation of processes over time such as infant feeding.

Settingand Sample
Criteria for sample selection were the following: black, age 18 or over, and low-income household. An additional criterion was that the informant was the mother of a healthy, full-term infant delivered by a nurse midwife. Three counties surrounding a metropolitan center in the southeastern United States provided the setting. The sample consisted of I0 mothers who delivered their infants at the county hospital and who ranged in age from 18 to 27 years. Eight informants were high school graduates; two had completed I 1 years of school. Seven of the informants were single parents who lived in extended family households. The other three were

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married and resided in nuclear households. Seven of the households were in urban areas, and three were rural. All infants were enrolled in Medicaid and WIC program. Half the informants were firsttime mothers and the rest had either one or two other children. There were seven female and three male infants, with birth weights ranging from 5.5 to 8.5 pounds. Six of the mothers were intending to breast-feed and four were intending to formula feed at the time of discharge from the hospital.

topical areas derived from the conceptual framework and the literature review were used as a guide for a more focused interview. Topical areas included infant feeding practices, sources of knowledge, views of "what is a healthy baby," lifestyle activities, such as work or other household responsibilities that influenced feeding decisions, and previous experiences feeding children. A variety of demographic data was collected to examine household structure and lifestyle factors.

Data Collection
Potential subjects were contacted by the investigator, in person, before discharge from the hospital. The first 13 subjects who agreed to participate in the study were enrolled, but the investigator was unable to contact three subjects after hospital discharge. Each of the subjects agreed to eight interviews during the infant's first year of life and was paid $10 per interview. In previous studies, informants often had difficulty remembering past patterns of feeding and reasons for making decisions related to feeding. Frequent intensive interviewing was done to gather more detailed and accurate data. Interviews were conducted throughout the infant's first year of life to gather data about the process of feeding as the child grew and developed. The initial interview took place when the infant was 2 weeks old, and interviews were done monthly thereafter until the infant was 6 months old. Interviews were scheduled more frequently in the first half of the year when the infant was growing and developing more rapidly. This allowed for gathering data on practices such as introduction of solid tbods and other fluids. The remaining interviews took place when the infants were 9 and 12 months old. All interviews were held in the mother's home. They were audiotaped and transcribed before the next interview. The sample was considered adequate when data saturation had occurred, that is, when no new themes or dimensions were identified that contributed to answering the research questions (Morse & Field, 1995). Data were collected using intensive interviews, a guided conversation whose goal was to "discover informants' experiences of a particular topic or situation" (Lofland & Lofland, 1984, p. 12). The conversation always started with the same "grand tour" question: "Tell me how you are feeding your baby." Interviews were fairly unstructured to allow for the informant to initiate topics. After the informant had answered the "grand tour" question,

Protection of Human Subjects


The privacy and confidentiality of informants were protected during the study. Confidentiality, goals of the study, and payment for participation were discussed with informants before beginning interviews. It was made clear that informants could refuse to answer any questions or discontinue participation at any time. The University Institutional Review Board granted exempt status to this study.

Data Analysis
Data analysis began in the field and guided further data collection. Interviews were transcribed verbatim and transcripts reviewed for accuracy. Methods derived from the work of Spradley (1979) and Loftand and Lofland (1984) were used to identify and analyze categories, patterns, and themes. Interview transcripts were first scanned to identify categories and relationships among various categories. Tentative coding categories were developed inductively and the interview was coded. This process was continued through all subsequent data collection. Subsequent interviews were also transcribed and coded. All previously collected data were reviewed as categories and their attributes refined. After all interviews were completed and coded, a code book listing codes, definitions, and attributes was developed for the final data analysis. Data analysis was guided by the aims of the study: to describe styles of infant feeding among lowincome black mothers and to describe the influence of household structure, lifestyle factors, and the health care system on infant feeding style.

FINDINGS Patterns of Breast-feeding


Six informants planned to breast-feed at the time of discharge from the hospital. At the initial interview (2 weeks of age), two women were exclusively breast-feeding, three were combining breastand formula-feeding, and one never breast-fed after discharge. Both of the mothers who were exclu-

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sively breast-feeding had tried to give formula to their infants, but reported that the infants "wouldn't take a bottle." How formula and breast-feeding were combined varied. One informant breast-fed at night and formula fed during the daytime. Another mother would use a bottle if she were "going out." A third mother combined breast- and formula-feeding in a random fashion that varied day to day. The three mothers who combined breast- and formulafeeding from birth had a short duration of breastfeeding (I, 2, and 3 months) and all where exclusively formula-feeding by 3 months of age. The two informants who were exclusively breastfeeding initially continued to breast-feed longer than mothers who combined breast- and formulafeeding. This finding is similar to that of a study showing longer duration of breast-feeding when mothers reported exclusive breast-feeding during the second month of life (Hill, Humenick, Brennan, & Woolley, 1997). One of the mothers breast fed her infant until he was 11 months old. She began solid foods when the infants was 4 months old. The other mother began combining breast- and formulafeeding when the infant was 2 months old and continued this pattern until the infant was weaned from the breast at 9 months.

breast-feeding such as the relationship between frequent feeding and increased breast milk supply. One mother quit breast feeding at 1 month because she "needed to loose weight" while another said that she stopped breast-feeding "because I wasn't eating fight, and I didn't want her to get sick." Informants were aware that they needed to eat "right" and that foods they ate could affect the infant. One informant stated "I don't eat that much stuff like I used to. Like sausage and stuff. Stuff with a lot of grease in it, I don't eat no more. I just decided not to do it, because then she would get gas, and then it won't go away."

Attitudes and Beliefs about Breast-feeding


None of the mothers who breast-fed were married, and each lived with her extended family who were not supportive of breast-feeding. Only one informant knew any one else who had successfully breast-fed. All informants reported negative attitudes toward breast-feeding such as it's "nasty." One informant was told by her mother who had briefly attempted breast-feeding that "girl that thing hurts" and "you are not going to like that." Breast-feeding mothers described both an attitude of revulsion and curiosity about breast-feeding. One informant's mother told her to "go in the bathroom and do that." Another told of curiosity of friends who were visiting and wanted to watch because they had never seen a woman breast feed. Even the breastfeeding mothers believed that breast-feeding was not something that should be done in public. One informant never breast-fed in front of the infant's father and another did not breast-feed in front of her 7- and 10-year-old children. Breast-fed infants were ted formula when mothers were going out in public. Half the mothers chose formula-feeding, although they had heard that breast-feeding was "best for the baby." Breast-feeding seemed to be an unfamiliar and undesirable activity as reflected in comments such as "that's not me" and "I can't see myself taking my breast out and givin' her." Another informant was told that it "hurt to breast feed" by her sister, who had tried and did not like it.

Deciding to Breast-feed
All mothers who choose breast-feeding did so because of information mad encouragement they received from health care providers during prenatal care. They wanted to breast-feed because "it was best for the baby" or because of "convenience." Mothers reported specific advantages of breastfeeding for the infant: "gain a lot of weight," "don't get sick as much," "easier to feed at night," "helps bowels," "baby will be closer to me," "makes (baby) more secure," and "don't spit as much." The mother who exclusively breast-fed stated " I ' m really the only one that can give him breast milk, and that makes me happy. He looks for me to feed him, I like that a lot."

Knowledge about Breast-feeding


Knowledge about breast-feeding was limited. None of the informants identified physiological benefits of breast-feeding for the mother, which is consistent with the view of breast milk as a product rather than breast-feeding as a process (Van Esterik & Elliott, 1986). It is also consistent with another study of low-income breast-feeding mothers (Coreil, Bryant, Westover, & Bailey, 1995). These women did not have much knowledge about the process of

Formula-Feeding
Of the 10 infants in this study, 9 were formula fed during infancy, and only t was exclusively breast fed. Five infants were exclusively fed formula by bottle from birth. Another four infants were formula fed in combination with breastfeeding from birth. Mothers often had a hard time

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recalling exact amounts and frequencies of feedings. The amounts and frequency of formula feedings were typical of what one would expect and varied by size and age of the infant. Informants fed infants on a "demand schedule," that is when they believed the infant was hungry. They let the infant determine the amount of a feeding. In addition to formula, water, cereal, Karo syrup, strained foods, and juice were all led by bottle. It was a common belief that infants must be fed water. One informant explained "Sometimes like if she get hungry and I know she hungry, then I give her a little bit of water first, so she can get used to it. She gotta have some water." Informants emphasized the importance of boiling water and sterilizing bottles as part of formula preparation and all warmed the formula before feeding.

vegetables. All formula-fed infants were still drinking from bottles at 1 year of age.

Influence of Family and Friends


All informants either lived with their mothers or within a few miles of their mothers' homes. Sisters, grandmothers, and cousins were also nearby. Informants learned about infants as they cared for younger siblings or infants of other relatives as they were growing up. Family and friends were more important sources of advice about infant feeding than the health care system. Informants had information about scientific recommendations such as " d o n ' t start solids early" and "feed cereal by spoon" but made the decision to start cereal and put it in the bottle. One informant, who lived with her parents, described the advice she received about feeding her 3-week-old infant: My grandmother, she tell me to give the baby cereal. She said she needed it and would sleep longer. She say "she hungry cause she just drinking milk and that milk can't fill her up that much." They come over and they see me giving her formulaand they say, "That's all she's drinking? Is that supposed to fill her up?" By 2V2 months this mother had started to feed her child cereal in the bottle. The father and his extended family often were involved with the infant even when the parents were not married and did not live in the same house. One infant would be sent to spend weekends or holidays at the father's family home when he was home from college. This infant, who was exclusively breast-fed by her mother, was fed formula and cereal (at 2 months) when she spent 3 days at her father's family home during the holidays. The one informant who exclusively breastfed was given gifts of strained foods and cereal when she would take the infant to visit the paternal grandparents. She reported that "His father's mother wanted me to start giving him food when he was like two months and I told her I didn't want to. But she would always buy him foods and send me home with it but I would just always stick it [away]."

Solid Food
Seven infants received cereal before 3 months of age, and the majority of mothers fed cereal in the bottle. There was no consistent pattern of how the cereal-formula mixture was prepared or how often it was given. Several informants put cereal in each bottle while others led cereal in one bottle a day. One mother told me that she would begin cereal soon because that's "what infants needed" and was "'how she fed her other two children." Her reason was because "milk couldn't be enough to satisfy the infant." A second mother put 2V2 teaspoons of cereal in each 4-oz bottle. She stated "When she just had the plain milk, she wouldn't sleep as long. If I feed her, she would wake up again like probably two or three, wanting another bottle. With the cereal she just eat, she get full, she don't worry if her bottle came." A third informant, who started cereal when her son was 3 weeks old, described how she made the decision. "At that time, he was hungry all the time, so I thought of putting cereal in his bottle, cause his little stomach would growl, so I just started giving him some cereal." She thought that adding the cereal "helped, because his sleep patterns were messed up cause he wouldn't sleep that long. But like right now he'll sleep like all morning long." These three infants had tripled their birth weights by 6 months of age and were considered overweight by the WIC program. By 6 months of age, all but one infant were eating a wide variety of commercial infant foods. Informants used a variety of fruits and vegetables and reported definite infant preferences for and refusal of certain foods. No mothers reported preparing table foods such as mashing a banana or

Interactional Style
A mother's response to and interpretation of crying, as well as beliefs and attitudes about cuddling and fondling an infant, all contributed to feeding style. Interpretation of crying as not being satisfied, contributed to cereal being added to the diet of infants. All mothers said that they decided that the infant was hungry if the baby cried. Some mothers reported that they knew that babies weren't

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satisfied after being fed a bottle because they cried or "smack on their hands." Informants reported a variety of responses to their infants' crying such as using pacifiers, picking infants up, walking with them, or at times letting them cry themselves to sleep. The belief "that infants can be spoiled" influenced interactional style and response to crying. Babies were often described as good or spoiled. A good baby didn't cry a lot. One informant said. "She is a good baby, she only cry if she is hungry or wet." A spoiled baby wants to be held all the time. If you picked up infants when they cried, they would always want to be held. Friends and family would warn mothers about spoiling the infant. When asked to explain what spoiled meant, one informant said "he wants to stay in my lap, my arm and he doesn't want to stay down. He cries to get in my lap. When he gets in my lap he's fine." Picking an infant up when she cried was believed to spoil the child and result in an infant always wanting to be held. Feeding was a frequent response to crying. It was a strategy to stop the crying without "spoiling" the infant.

1996). Some women also used videotapes, books, and pamphlets as sources of information. Health care for the infants was fragmented. All informants took their infants to public health clinics for well-child care, made separate visits to WIC clinics, and saw a private medical doctor or used the emergency room when the child was sick. The WIC program provided the most advice about infant feeding. Some health care providers gave advice that was not supportive of breast-feeding. One physician told an informant to "give a two week old breast fed infant one bottle of formula a day and start cereal at one month." Another mother was told by hospital staff "if she doesn't take to the breast don't force and give a bottle." Several informants were told that breast-fed infants needed water. Other studies have identified the lack of knowledge about breast-feeding in a variety of health care personnel (Coreil et al., 1995, Trado & Hughes, 1996).

DISCUSSION
The shared style of infant feeding practiced by women in this study is similar to previous studies of infant feeding in other regions of the country. Formula feeding with early introduction of cereal in the bottle is a way to feed infants. Cereal is initially fed in the bottle. Other solid foods and juice are introduced early so that by 6 months of age, infants have a complex diet of a variety of foods. The belief that milk alone could not satisfy an infant underlies the practice of feeding cereal. Feeding cereal in the bottle is a strategy mothers use to get the infant to sleep longer at night and decrease the frequency of feedings during the day. Results of feeding are judged by immediate and visible criteria such as appearance and behavior. Fear of spoiling the infant may contribute to feeding the infant as a response to crying rather than holding. A healthy baby is one that had a good appetite, is happy, growing well, and not sick. Breast-feeding is not a way to feed infants and is considered a "nasty" behavior by many. Mothers who breast fed were attempting to adopt a new style of infant feeding. They viewed breast milk as a product and tried to incorporate breastfeeding into the style of infant feeding that they knew. Breast- and formula-feeding from birth occurred because of a lack of knowledge about and support for breast-feeding. Breast-feeding was seen as a private behavior, and a bottle was often used when mothers needed to feed their infants in front of others. When these women stopped breastfeeding, they returned to the style of infant feeding

Influenceof the Health Care System


Practices at the hospital where all infants were born included those that are considered nonsupportive of breast-feeding including supplementing breast-fed infants with forn~ula and gluscose water, separating mother and infant, and distributing formula discharge kits. Infants were often described as sleepy or uninterested in breast-feeding while they were in the hospital. A lactation consultant from the WIC program saw some mothers in the hospital, and a peer counselor program was in place. However, some mothers in this study stopped breastfeeding before they were contacted by a counselor or were never contacted. Although informants had been given some information about breast-feeding, they did not have practical knowledge and lacked support or assistance once they were home. This lack of support between the hospital and the first postpartum visit was also identified by Coreil et al. (1995) in a study of low-income women who breast fed. Informants identified information given during the prenatal care, assistance in the hospital, and being able to call for information as helpful with breast-feeding. Support for the breast-feeding mother was consistently identified as helpful in another study of breast-feeding mothers who participated in the WIC program (Trado & Hughes,

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.that they learned about from family and friends. Informants breast-fed their infants in a context that was not supportive of breast-feeding. The women in their environment whom they turned to for advice were not knowledgeable about lactation and often had negative attitudes toward breast-feeding. Support from the health care system was uneven, and mothers who had a short duration of breastfeeding had the least support. Formula supplementation has been associated with shortened duration of breast-feeding. Morse, Harrison, and Prowse (1986) identified a pattern of minimal breastfeeding in which formula- and breast-feeding are combined, but only after a period of exclusive breast-feeding during which lactation has been established. Health promotion goals for the year 2000 include increasing both the incidence and duration of breast-feeding. Low-income and black women have been targeted for special attention because they have the lowest rates of breast-feeding. If we hope to increase breast-feeding among low-income black women, we need to invest in and support those who decide to breast-feed. Styles of infant feeding are

passed from older to younger women and are based on successfully feeding infants over centuries. If we can assist some low-income black women to have successful breast-feeding experiences, they in turn can be models for a new style of infant feeding.

Nursing Implications
All informants in this study had information about current feeding recommendations; however, knowledge, attitudes, and beliefs don't always lead to practice. Nurses need to broaden their assessment by eliciting a client's beliefs about ways of feeding infants and identify constraints and opportunities in the client's environment. Descriptions of feeding style and environmental factors that influence styles are necessary to design culture-specific and effective interventions to improve the health status of low-income black children. Examination of environmental influences on infant feeding style may provide a window to view how these same factors operate to influence other aspects of child rearing.

REFERENCES
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