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Women's Employment and the Feeding of Infants
At the outset it is important to note that "employment" is often far from being a simple variable in its effect on women's lives and roles. We tend to think of people in our society as either employed or "unemployed" in relation to "jobs" that earn wages or salaries. In much of the world (including major sectors of North American society) the gradations of "jobs" and "employment" (in and outside the home) can be complex indeed.
One of the few studies that directly addressed the interrelations of women's employment and infant feeding is the work of Popkin and Solon (38). Their study is focused on the Philippines, where they note first of all that women are more actively involved in trade, service, professional, industrial and other work which draws her [sic] outside the home for employment.... Nevertheless market related activities which take place in the home such as embroidery, basket weaving and sari-sari store management play a major role in her economic activities. [38, p. 197]
In their sample of women on the island of Cebu, they found that "26% of the urban and 31% of the rural women were engaged in some form of market employment." They note that some studies in the Philippines report infants nursed 7 to 8 times per day, with each feeding lasting 15 minutes to half an hour. This schedule of nursing could require from 3 to 4 hours, in addition to which one should allow for "travel time" if the mother is working somewhere and returns to her infant for breast-feeding. In any case, the scheduling of breast-feeding requires a very considerable time investment from the mother.
Dugdale (39) examined data on breast-feeding patterns for 2,009 infants in Kuala Lumpur, Malaysia, for the years 1960, 1962, and 1965. The information included family income (divided into high and low), number of children in the family (presumably of that particular mother), and ethnicity (Chinese, Malay, Indian). The data are interesting because they are roughly comparable to situations in many other developing nations, especially in Asia. Focusing on the data for families of two to four children (the modal category) in 1965, according to the different ethnicities, we find that the income variable is important in each of the ethnic groups, with the higher income (higher socio-economic status) women breast-feeding less often land for shorter duration) than the lower status mothers (table 1). Dugdale feels that there are two possible reasons for the differentials based on income:
The first is that the social and advertising pressures are all away from breastfeeding. The mother who has a higher income is probably more educated and is more able to afford artificial feeding. The second reason is that many families have a higher income because both parents work outside the home. Under these circumstances, breast-feeding is not possible. [39, P. 233]
TABLE 1. Percentage of Mothers Breast-feeding at 28 Weeks in Kuala Lumpur (1965) according to Income and Ethnicity
*n in parentheses. Source: Dugdale (39).
Also, as the author comments, "the extended family and the availability of domestic help both make possible the care of infants while the mother works." Further, among the Malays the mothers with children go out to work much less than do the Chinese, hence an overall higher incidence of breast-feeding among the Malay mothers (in the three years surveyed).
A comparison of the data for 1960 with the 1965 data shows a consistent decrease in breast-feeding in the Chinese sample, (n is 1020) and an increase in breast-feeding among the Malay women. The author does not comment on this difference in the trends but notes that the increase in breast-feeding is mainly among low income mothers with one child.
Marchione (40) has developed an economic model to explain infant-feeding patterns in the Caribbean. He emphasizes the relationship of women's work activities with the type of economy in which those activities take place as a significant factor in infant-feeding patterns. In a plantation economy-first under slavery, then as low-pay resident workers-women in the Caribbean have for centuries been under pressure to devote long hours to work and short hours to breast-feeding. Marchione's study suggests that, wherever we find the combination of a past or present plantation agricultural system and the presence of a variety of breast milk substitutes such as bush teas, starchy gruels, or paps, we can hypothesize on the existence of direct pressures on women to limit breast-feeding.
Another type of economic model also concentrates on structures outside the household, specifically on the economic motivations of the commercial interests that stand to gain from a large-scale shift to bottle-feeding- the infant food manufacturers, the advertising media, and, to a limited extent, health-care professionals. The research strategy that has been pursued to develop this model has focused primarily on describing the economic structures of the formula-manufacturing companies and the promotional strategies of corporation and advertising agencies (41, 42). There has been little linking of these structures and activities to maternal selection of feeding mode, perhaps largely because it presents serious methodological and ethical problems for investigators.
Bio-cultural Models of Infant Feeding
Another approach to explaining infant-feeding patterns examines issues from a biological perspective, seeking to understand the extent to which problems with lactation, as a socially mediated biological process, may be involved in current trends. It is important to note that this approach is more limited in that it applies only to one segment of the women who make up the statistics-those who attempt breast-feeding but shift rapidly to bottle-feeding. In any examination of infant-feeding practices it is necessary to separate exclusive bottle-feeders from those women who begin breast-feeding, even if they only breast-feed for a few days. The decision to bottle-feed an infant-if the decision is made before the infant is born-is conceptually a different kind of decision from the decision to try breast-feeding. Bio-cultural explanations which seek to understand "lactation failure" or "premature weaning" apply, of course, only to those women who attempt breast-feeding.
While a biological failure of the capacity to initiate lactation is rare, post partum problems in lactation are not (43). It has been hypothesized that separation of infants from their mothers at birth, which has been a common practice in western medicine, affects lactation success. Klaus and Kennell (44) have studied the relationship of early separation to problems in mother-infant bonding, which, in turn, appears to be implicated in lactation problems. Newton and Newton (45) and others have suggested that separation, which delays the onset and frequency of breast-feeding in the immediate post partum period, may be related to breast over-engorgement and sucking problems for the infant that lead to a "vicious cycle," resulting in early termination of breast-feeding.
Raphael has also proposed a big-cultural explanation of lactation failure, an explanation based on the of the "let down reflex" in the absence of supportive social networks for the newly delivered mother (46). The breakdown of social networks and social support is postulated as an urban phenomenon which, together with other stresses of urbanization and modernization, leads to psychophysiological stress inhibiting milk production (47, 48).
Recently Gussler and Briesemeister (43) have presented a big-cultural explanation for what they refer to as the "insufficient milk syndrome." Their discussion begins with a review of a significant finding in many studies, namely, that the most common reason mothers give for premature weaning or early termination of breast-feeding is "insufficient milk." From many different cultural and social settings in both industrialized and developing countries, mothers report that their milk was insufficient or inadequate to satisfy their infant's needs:
Anecdotal and research data suggest that, quite naturally, mothers become concerned about presumably unhappy or uncomfortable infants, and respond to their behavioral cues with an explanation of breast milk insufficiency, even though the explanation is not confirmed by poor weight gain.
These mothers are both right and wrong. They are probably correct in interpreting the behavior of their fussy infants as caused by hunger. They are incorrect that this necessarily indicates that something is inherently "wrong" with their milk or ability to lactate. [43, p. 6]
From this base the authors develop their theory. The primary source of the problem is what they call "non-biologic breast-feeding," the pattern of "scheduled, widely spaced feedings of breast milk." Scheduled, infrequent feeding leads, in turn, to a crying baby, to sucking difficulties, to maternal anxiety, to insufficient sucking and emptying of the breast, and hence through several neural and cognitive pathways to the interpretation of "insufficient milk." In many cases the interpretation becomes a biological self-fulfilling prophecy. The authors conclude their paper with a call for research on this important aspect of contemporary breast-feeding experiences.
Each of these approaches-socio-cultural (modernization), economic, and psycho-physiological-has much to offer to our understanding of contemporary infant-feeding practices. Of course, the significance of particular factors will vary in different contexts. To date, none of the theoretical approaches have been fully explored through systematic research, nor have efforts been made to integrate them. While the bio-cultural approach of Gussler and Briesemeister does present a theory that integrates social behaviour (frequency of feeding) with biological variables, it does not provide a full framework since it is focused specifically on milk insufficiency. The development of a full framework is probably best achieved through successive approximations based on feedback from empirical research. The remainder of this paper is devoted to outlining some of the features of a "first approximation," noting several key components of what can be regarded as a "cultural-ecology" approach.
THE CULTURAL-ECOLOGY FRAME OF REFERENCE
An ecological perspective directs attention to the specific features of the physical and social environments within which behaviour takes place. The question of how individuals and groups meet essential needs (for food, shelter, and so on) remains a central concern. Although people are seen as acting within a system of environmental constraints and opportunities land having available resources and technologies), they are considered to be making conscious choices about behaviour. The ecological approach thus emphasizes people's rational decision-making behaviour and calls attention to intra-community, intra-population variations in the specific choices, as related to situational (environmental) differences (34).
Anthropologist John Bennett has described the theoretical perspective of cultural ecology clearly:
A second meaning of the term ecology emphasizes adaptation or adaptive behavior. Here we refer to coping mechanisms or ways of dealing with people and resources in order to attain goals and solve problems. Our emphasis here is not on relationships between institutions, groups or aggregates of data, but on patterns of behavior: problem-solving, decision-making, consuming or not consuming, inventing, innovating, migrating, staying. [49, p. 11]
In the nutrition and public health field, the issue of infant feeding is often approached from a narrow viewpoint in which the infant is seen as a passive receiver of food and the mother as the giver of food. Problems arise when the mother fails to fulfil adequately her role as food-giver. However, the woman's behaviour with respect to feeding her infant is rarely examined in the total context of her life. While a new infant may seem to be a major focus of a mother's energy and attention, the fact is that a new mother can be said to have acquired an additional role- that of mother of her new-born-but she does not necessarily lose her other roles. In most circumstances she may continue to have the responsibilities of being a wife, a daughter-in-law, a mother to her other children, a farmer, a housekeeper, a lawyer, and so on.
While the extension of biologically oriented theory places primary emphasis on women's roles as child-bearers and child-rearers, an ecological approach would tend to focus on women's responsibilities in the economic subsistence system, as well as in maternal tasks. The contrast between the two approaches is evidenced in this statement from the study by Nerlove:
In her discussion of the division of labor by sex, Brown (1970) stated that the degree to which women participate in subsistence activities depends upon the compatibility of the latter with simultaneous child care responsibilities. The present study qualified this statement by showing that child care responsibilities may be adjusted to accomodate the mother's subsistence activities. [6, p. 212]
The ecological framework is not one of economic determinism, but a search for all the relevant factors (economic and others) affecting women's roles. Aside from direct food production practices and ways of making a living, many other factors must be taken into account in an ecological perspective, including such features as shelter, modes of travel, and environmental characteristics. Political organization and religious beliefs and other ideological components are also examined. Perhaps the major feature of the cultural-ecology approach is the attention to a multiplicity of factors affecting every aspect of human behaviour.
ECOLOGICAL THEORY AND WOMEN'S ROLES
The growing body of literature on women's situations in various cultures and diverse environmental contexts is beginning to provide a base for generalizations about women's roles. These studies point to some of the major variables and parameters that are necessary for a well-developed model of women's roles in the care and feeding of offspring. It would appear that throughout history women have played a very significant and primary role in child care, not least because of the nature of their biological relationship with their offspring. It is also clear that in many societies women have major responsibilities for food production and that, in these societies, their child-care roles are adjusted to these responsibilities.
The introduction of new crops into traditional societies can have various and diverse effects on women's roles. The economic position of Afikpo Ibo women of Nigeria is an interesting illustration. According to LeVine, when the new crop cassava, was introduced in the region, it was considered to be of very low prestige and value. Women were allowed (by the men) to grow the cassava as a marginal activity:
This despised crop eliminated the annual famine before the yam harvest and attained a high and stable market value. The Afikpo women became capable of supporting themselves and their children without aid from their husbands.... Afikpo husbands have found it increasingly difficult to keep their wives at home in their formerly subordinate position. [50, p. 178]
A different sort of example is provided by the Azande people in East Africa. Until recent times the Azande engaged in frequent warfare, and women were the main source of labour and symbols of wealth. Traditionally, women were "treated much like slaves and . . . barred from the main source of power." Increasing contacts with Europeans and the introduction of cash crops brought large-scale changes. "Women became emancipated, crops acquired cash value, war disappeared, hunting was reduced, and men were compelled to invest most of their efforts in agriculture" (51, p. 201). In contrast to the Afikpo situation, the Azande men placed high value on the major cash crops and controlled the access of women to this new sphere of activity. Although the women gained a new measure of freedom, they did not become anything like as economically powerful as the Afikpo women.
The growing number of studies of women's roles in different types of societies have underscored two major themes: a. Women's overall status and prestige and the degree they contribute to the basic economic system exhibit a very wide range of variations in non-modern societies. b. Degrees of participation in food production and other economic activities have strong effects on the patterning of child care activities.
Some of the other variables that have important effects on women's roles include the patterning and degree of warfare (52), kinship structure and household composition (53), and religious system (54). This is hardly an exhaustive list of the variables that may be important in affecting women's roles and infant-feeding practices, but it provides a starting point for an examination of individual cases and contexts.
THE SHAPING OF WOMEN'S ROLES
From an ecological perspective, women's roles in a social system can be seen as composed of a number of crucial dimensions that can take on a range of values. Following role theory we can conceptualize that an individual has a cluster of roles. Many of the roles an individual assumes are of long standing and taken to be stable over the generations. For example, the central roles of wife and mother are thought of as relatively unchanging in basic content from one generation to the next. Also, in a stable society the supposed rules of behaviour are sufficiently well established and pragmatic that regular expectations about conduct in the role of "wife" do not seriously conflict with the requirements of the role set to "mother." On the other hand, everyone is familiar with examples in which different aspects of role expectations come into sharp conflict. In such situations individuals have had to make agonizing choices: "Shall I give up my family ties to marry this man?" "Shall I protect my husband from this unwarranted demand by our son?"
The factors that shape the multiple-role behaviour of any given women in any particular society are variable and specific to the situation. At the same time, it can be argued that these factors have regular, patterned effects, so that generalizations can be made about the nature of role behaviour:
1. Although people do not always act in their own best
interests, in general individuals weigh alternatives and make
choices based on their perceptions of the relative merits and
shortcomings of particular actions. All persons seek to be
optimizers in their daily behaviour.
2. "Micro differences" in characteristics such as household composition, distance from resources, material wealth, etc., create differential behaviour within even the smallest and most traditional populations.
3. Therefore women within practically all communities will exhibit a range of variation in their tendencies toward particular types of role behaviour, including breast-feeding. Intra-community variation is a pervasive fact of life.
4. Individual choice behaviour is, of course, always constrained by knowledge of what other persons-kin and non-kin-expect as appropriate, right conduct.
5. For most categories of behaviour and activities there are alternatives that people can choose. Life is not a rigid prescription.
6. Recent decades have brout new dimensions of choice in practically all parts of the world. People have many more options to consider, even though poverty and lack of technical skills may in practice limit their selections from the theoretically available alternatives.
7. Although new options and alternatives have spread rapidly in recent decades, change and development occurred in most societies and communities in past centuries as well. Most people are used to the prospect of change.
INFANT FEEDING AND DECISION MAKING
The statistics on trends in both breast-feeding and bottle" feeding can be regarded as a reflection of multiple decisions by numerous women and their families. The concept of decision implies, of course, a choice among alternatives. With the advent of large-scale availability of bottles, it is apparent that many women perceive themselves as having an alternative. Seen against the whole of human history the decision to use a bottle appears to represent the exercise of choice, comparable to the choice involved in using contraceptives to regulate fertility.
However, just as with the use or non-use of contraceptives, we must be careful not to assume that choices are made in a vacuum, without constraints. It is apparent from the available literature that many factors influence and constrain a woman's decision to breast-feed or bottle-feed her infant. Among the factors that influence this decision are the views of significant other persons, particularly spouses, as the following illustrations make clear.
In an Egyptian village, anthropologist Soheir El Sukkary interviewed women concerning their views and decisions about infant feeding. One woman, the mother of seven, told her:
In our village all women have to breast-feed. I told my husband that I was tired of breast-feeding after seven children and I want to use cow's milk. You know what he said? He told me even if I break my neck I still have to breast-feed. We are no city girls. [El Sukkary, personal communication]
Contrast the constraints on this woman with those on a young Puerto Rican woman interviewed in Miami by anthropologist Carol Bryant:
The doctor said to breast-feed them, especially the boy. But I can't explain it, maybe it has a lot to do with my husband. He's sort of shy about that, too . . . You know, I think he's jealous. When I told him I wanted to breast-feed, he said, "You're going to breast-feed? Well, I don't know about that." And stuff like that. But if I had to do it again, I'd try it. 
In another cultural context, it is the in-laws who effectively control the decision-making concerning infant feeding. Johnston (55) has reported about the situation in West Indian households in Trinidad, where the low-status young wife is subordinate to her mother-in-law in an extended family household. According to Johnston, the young mother is expected to "entrust the daytime care and feeding of the infant to her in-laws and devote her attention to chores for the benefit of the whole family." The grandparents therefore give bottles, filled with a variety of substances from skim milk powder to sugar water and tea, while the mother works at other types of activities for the household. This Trinidad study is perhaps the clearest example Yet reported of bottle-feeding motivated by the work demands of a woman's extended household. The bottle-feeding regimen does not, however, eliminate breast-feeding. Moreover, Johnston reports that the ratio of breast-feeders to bottle-feeders has not changed substantially during the past decade.
In this Trinidad example, the significance of in-laws in the infant-feeding process lies in the fact that they are in the same economically integrated household. Clearly the variable of household size and structure may in this case be more significant than simply the "cultural attitudes" of in-laws per se. There are a few other cases, however, in which the in-laws appear to have some influence. In a small-scale study in New England, for example, the opinions of the subjects' in-laws appeared to be the only major anti-breastfeeding influence.
The doctor Avicenna's advice against any substitutions for natural (mother's) breast-feeding (1) reminds us that health professionals may be among the most important sources of influence on women's infant-feeding practices. Jelliffe and Jelliffe (48, 56), Cole (57), and others have noted the significance of health professionals in affecting infant feeding. Halpern et al., for example, reported that among 1,700 infants in Dallas, Texas, there was a strong correlation between breast-feeding and the paediatrician's attitudes (58). In developing countries, the role of western medical care may significantly influence women to adopt bottle-feeding (42), and lack of encouragement and assistance from medical and nursing staff has been identified as a factor in lactation failure among Asians recently migrated to Great Britain (59).
MULTIPLE SOURCES OF ADVICE
Many of the studies of infant feeding in both industrialized and developing societies have provided information on the effects of social ties, significant others, opinions of relatives, and other influences on women's decision-making. While these are undoubtedly important factors, they appear to assume significance mainly in relation to other variables.
In practically all situations where the opinions of significant others-kin and non skid-appear to be important, there is likely to be a considerable mixture of sources of information and opinion. Karkal reports that in a survey conducted in Bombay the following were identified as sources of advice regarding supplemental foods: tradition, 11 per cent; elders, 19.2 per cent; self, 17.1 per cent; doctor or nurse, 13 per cent; radio or reading, 4.7 per cent; and "cannot say," 34 per cent (60). An effective explanatory model must make sense of this mixture.
In the earlier discussion on big-cultural approaches, the role of birth practices, feeding schedule, and the absence of a supporting social network were mentioned as factors that affect infant-feeding practices. Additional features of maternal health and pregnancy experience, fatigue, maternal intake of fluids and calories, and other dietary variables must also be carefully considered. In pursuing a cultural-ecology approach, the problem will be to identify the ways in which biological variables enter into the complex calculus of decision-making of individuals.
The main features of a cultural-ecology framework as a guide to research and application of research for programme planning and development in infant feeding include the following:
1. The aggregate pattern of infant-feeding modes for any
particular population or identifiable social groups is a
composite result of a series of individual decisions
2. To understand these decisions, attention must be focused both on the individual decision-makers (mothers and their households) and on the characteristics of the environment in which the decisions are made.
3. In choosing among alternative strategies for feeding their infants, mothers may be influenced by a series of factors: economic conditions; health characteristics and concerns (their own and their baby's); requirements and desires related to allocation of their own time; the presence of alternative caretakers; beliefs and values related to the social acceptability of the choices; and advice from other people and media sources.
4. Selection from theoretically available alternatives is strongly conditioned by external [environmental) and internal (individual) constraints. Thus, such features as the availability of work, characteristics of the economic system, characteristics of the health care system, family and community structure, and organization may all exert powerful constraining influences on an individual mother's decisions about how to feed her infant.
5. Decisions on infant feeding, as with most other activities, are not made simply at a single point in time but should more properly be regarded as a process, in which the key actors (mothers, infants, families, and other significant participants) monitor and adjust their behaviour over time.
These points suggest that the reasons for particular patterns of feeding will differ from one social setting to another over time. It is fallacious to conclude that a common pattern is necessarily the result of common causes. The utilization of a cultural-ecology approach does not imply a simple eclecticism in which "all variables are equal." As conditions change, the "power" or significance of particular factors in the decision-making process may change.
Following a cultural-ecology framework, the next steps to improving our understanding of contemporary infant feeding patterns is to develop research that is holistic and multidisciplinary. Attention must be directed to include mother-infant pairs, the households in which they reside, the communities and environments in which the households exist, and the larger socio-political, cultural, and economic systems from which the new choices (e.g., bottles and formulas) and new constraints (e.g., wage employment) are ultimately derived.
There is no evidence, at present, that justifies eliminating any of the major domains of causal influence from investigation. The extent to which economic factors, household characteristics, the individual's beliefs, goals, desires, and values, and psycho-biological characteristics affect decisions about infant feeding is amenable to empirical investigation. Since the relative importance of these characteristics is likely to be different in different environments, future research must be cross-cultural and must be carried out in different regions and cultural conditions. This does not mean that research on infant feeding has to be undertaken in every community on the face of the earth before we can have a better understanding of the contemporary situation. But it does mean that we must be careful not to assume that the picture is the same in all urban centers of the industrialized world or that we can easily extrapolate findings from a rural Asian community to a plantation in Guatemala.
Direct interventions by policy-makers can bring about dramatic changes in the environment, changes which presumably will have powerful effects on individuals' decisions. It would seem logical to conclude, for example, that banning bottles from the market-place would create an environmental constraint of overwhelming proportions. However, alternative routes to utilization of artificial feeding may develop readily if the other factors that are influencing mothers to select bottle-feeding remain unchanged. We return to the basic premise: decision-making about infant care (including infant feeding) is a rational process in which the outcome reflects the "best choice" or the "best compromise" among competing demands, conditions, and values. When the "best choice" conflicts with "best" psycho-physiological and health outcomes (as judged from a big-medical perspective), health care professionals and other people are appropriately distressed. The problems, however, cannot begin to be resolved unless infant-feeding patterns are examined in the complex context in which they occur. Thus, research that is sensitive to differences in micro-ecological variations (for example, in the WHO research and action projects) is essential for progress in our understanding of these issues (61). A cultural-ecology approach contains the guidelines for beginning that process.
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