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Implementation of a conceptual scheme for improving the nutritional status of the rural poor in Thailand

Sakorn Dhanamitta, M.D., D.Sc., Suwanee Virojailee, M.S., and Aree Valyasevi, M.D., D.Sc.
Institute of Nutrition, Mahidol University, Bangkok, Thailand

INTRODUCTION

Thailand is located in South-East Asia, and has a population of approximately 47 million (1). The population growth is 2.3 per cent a year, which ranks among the highest in the world. About 85 per cent of the population live in the rural areas, are in poor health, and have a low nutritional status, especially infants and pre-school children and pregnant and lactating mothers.

During the years covered by the past three national development plans, nutrition has not been emphasized and was left to the health sector, which showed minimal involvement in agricultural, educational, and community development. Therefore, nutrition programmes for the past twenty years have been rather discouraging. In our Fourth National Development Plan, however, priority has been given to improving health and nutrition, with programme implementation carried out through the health care network at the peripheral or village level. Nevertheless, an effective model for integration of nutrition into the health care service has not yet been established. At the same time, it has also been recognized that, in order to improve the nutritional status of the villagers, it is essential to integrate health care, agriculture, and income generation into the nutrition package.

In an attempt to improve the nutritional status of the rural poor in Thailand, the Institute of Nutrition, Mahidol University (INMU), implemented a pilot project during the years 19761980 in the village of Nong-Hai. This village is part of Ubon Province and is located in the northeast of Thailand. The project initially followed a conceptual framework, which was later developed into a conceptual model. Infant supplementary food formulas, which were formulated by the institute, played an essential role in the implementation of the project. (The formulation of the supplementary foods is further discussed in the article by Tontisirin et al. on p. 00 of this issue of the Food and Nutrition Bulletin. )

The objectives of the project were:

a. to establish an integrated nutrition improvement programme utilizing a community approach model;
b. to integrate the model into the existing health care network;
c. to look for a suitable model which can be replicated for nation-wide use.

CONCEPTUAL FRAMEWORK

The project was implemented on the basis of the concept that good health and good nutrition among the people of a community will help boost agriculture and food production; that proper vocational training will promote income generation; and that these together will lead to an improved economy and result in a more advanced level of development in the community as a whole. The schematic flow of this concept is shown in figure 1.

PROJECT PLANNING AND IMPLEMENTATION

The basic principle of the project lies in obtaining maximum community participation with existing available resources. Since this project integrated nutrition, health, and community development, co-ordination with the district health officer, agricultural officer, and the community development worker was necessary in order to plan and implement the intervention programme. The principal personnel required for this project were a field researcher and a field implementor. The field researcher performed such duties as data collection, constant evaluation of project outcome, and motivation and support of the villagers on programme activities. The field implementor, who carried out the major activities of the project, was a midwife or nurse already stationed in the village by the government. An established, good rapport with the village people was indispensable before any behavioural changes could be made. A village centre was built in the village for purposes of programme implementation and as a gathering place for nutrition activities.

Baseline data on socio-economic status, nutritional status, and health status were obtained from 236 households with a total population of 1,655. The average family size was six. Specific data were collected on income, land ownership, water sources, housing, hygiene in the home, latrine availability, and illnesses. Cases of malnutrition were identified on the basis of the modified Gomez classification (as described in the footnote to table 1).

Health Care

The community development projects previously conducted by the Institute of Nutrition had shown the need for medical care as the first priority area among services for the villagers. Hence, curative health care was used as the initial entry point in programme implementation. This involved first-aid services, simple medical care, and a referral system. The second step, preventive health care, involved immunization of children at regular intervals, maternal and child health, and development of a school health programme. The third step in health care involved promotion of family planning, sanitation and hygiene, and health education.

In the area of sanitation and hygiene, attention was paid to instruction in the use of latrines and proper waste disposals and construction of a number of wells and water pumps for adequate and clean water supply.

FIG. 1. Conceptual Framework of Project Implementation

Nutrition

In implementing nutrition as a major component of the programme, areas of concentration involved were nutrition surveillance, food production, processing, and distribution, food supplementation, nutrition education, and the promotion of breast-feeding (3, p. 527).

Before the programme was implemented, nutrition surveillance was done on a representative sample of 202 pre-school children. Surveillance data showed that 55 per cent of the children had protein-energy malnutrition (PEM). Twenty-four hour dietary recalls from the village mothers showed that the energy intake of pre-school children was only about 60 to 80 per cent of the requirement, with carbohydrate intake of about 80 to 85 per cent, fat 4 to 8 per cent, and protein 8 to 12 per cent of the total energy intake. The diet was bulky and very low in fat content. About two-thirds of the protein intake was derived from rice and vegetable sources. An important step toward improving the diet was to increase the intake of fat and to improve the quality of protein intake.

The institute formulated seven supplementary food mixtures, based on the Thai Standard for Infant Food. Each formula was proportionally prepared from a mixture of locally available carbohydrate, fat, and protein food sources. Preparation of these food mixtures was simple.

Recommended action for nutrition implementation on PEM children was given as follows:
- first degree: nutrition education;
-second degree: nutrition education plus supplementary feedings;
-third degree: nutrition education plus supplementary feeding plus therapy if required.

Mothers of second- and third-degree PEM children brought their children to be fed twice a week at the village centre. The food was prepared by these mothers, who took turns to cook the simple and nutritious food under the supervision of the field implementor. After feeding, the infant food packages were distributed to the second- and third degree PEM children, so the mothers could prepare the food and feed their children on other days of the week. Nutrition education was offered regularly at the village centre to everyone in the community. Nutrition education was also given on special accessions such as temple fairs and other village activities.

Aside from food processing and distribution, the village centre was also sometimes used for food demonstrations. Soybean milk, soybean chips, and other products were prepared and introduced to the community. Breast-feeding was promoted and advice on the subject given.

Agricultural and Food Production

The villagers were soon convinced of the beneficial effects on their children of the nutritious supplementary foods. A need was therefore seen for producing the raw ingredients of these foods. Using appropriate techniques in line with advice given by agricultural extension officers and project personnel, agricultural and food production in the village was greatly improved. Increased production of legumes and groundnuts was observed, and home gardening, poultry raising, and the use of fish ponds was initiated.

Vocational Training

Vocational training was another area included in the project. In an effort to promote home industries, short training sessions were offered to villagers to enable them to pick up some knowledge of those special skills in which they were interested. Silkworms were raised for the production of Thai silk. The villagers were shown how to use appropriate weaving equipment, and exhibitions were held to demonstrate and sell the finished products. As a result, the village's income-generating capacity was increased. Offering these training sessions also helped to encourage villagers to come to the village centre for nutrition education.

Increased agricultural production and the generation of more income through home industries ultimately resulted in an improvement in the local economy and, together with improved health and nutrition, led to the all-round development of the community.

PROJECT EVALUATION

The effectiveness of this project depended largely upon the strategies used in the integration of the four individual project components. The four components-health care, nutrition, agricultural and food production, and vocational training - played sequential roles in promoting the optimum nutritional status of the community

It was through the initial entry point of curative health care implementation that people began to gain trust in the project personnel. Certain dietary treatments on anaemic and beriberi patients had enabled the villagers to realize the importance of nutrition in relation to health and disease. People became more aware and concerned of their dietary habits, and this was when nutrition education could be implemented. The promotion of food supply through increased agricultural production, home gardening, and poultry raising provided the community with a steady supply of food. The introduction of appropriate technologies through vocational training in cloth weaving and other crafts enabled the community to generate more income. Finally, by processing supplementary infant foods from locally available sources at the village level, distribution and home delivery of the infant food packages reached second- and third-degree PEM children easily, hence improving their overall diet.

TABLE 1. Nutritional Status of Children before and after Food Supplementation in the Integrated Programme of Nong-Hai Village (1979-1980)

* Weight for age, using modified Gomez classification for protein-energy malnutrition (PEM) on the basis of body weight as a percentage of mean reference body weight (Harvard Standard), as follows: first-degree PEM, 75-85% of mean reference body weight; second-degree PEM, 60-70% of mean reference body weight; third-degree PEM, below 60% of mean reference body weight.
** Chi-square test, p < 0.01.
*'* Chi-square test, p < 0.001.

An evaluation of the project shows that following the initiation of curative health care, full community participation was achieved within six months of programme implementation. Nutrition education was found to be most effective when related to health and disease.

Supplementary food processing and distribution, the last aspect of the programme to be implemented, was undertaken during its final eighteen months. An evaluation of the effectiveness of the integrated programme over this period is shown in table 1. The nutritional status of the 202 infants and pre-school children, as measured by the modified Gomez classification, improved significantly. The proportion of normal healthy children increased from 45 to 79 per cent. The incidence of first-degree PEM decreased from 38 to 16 per cent. Second-degree PEM fell from 16 to 6 per cent, while third-degree PEM, which had an incidence of 1 per cent, disappeared altogether in eight months.

It can be hypothesized from the results that food assistance was required for the improvement of second- and third-degree malnutrition cases. The nutritional improvements in normal and first-degree PEM children were due largely to nutrition education and the other model components. Nutrition education played an important role in increasing the mothers' awareness of proper infant-feeding practices. Income generation alone did not necessarily improve the nutritional status of the rural poor, but when implemented with other components of the model, showed long term effectiveness.

FIG. 2 Conceptual Model Showing the Four Integrated Components of Health Care, Nutrition Education, Agricultural Production, and Income Generation

DEVELOPMENT OF THE MODEL AND ITS SIGNIFICANCE

From our experience with this integrated nutrition, health, and rural development project, we have learned that, by utilizing curative health care as the initial entry point of implementation along with preventive and promotive health care and continuous nutrition education, the nutritional status of the community can be improved. We have also found that other components to do with the availability of local food supplies and income generation play equally important roles in promoting the outcome.

This project has led us to develop our original conceptual framework into a model (figure 2), which consists of four major components elaborated as follows:
a. health care-curative, promotive, and preventive;
b. food consumption-promoting the quality and quantity of food consumed by modifying people's dietary habits through nutrition education;
c. food supply-promoting agricultural production which leads to effective supplementary food processing and distribution at the community level;
d. income generation -the promotion of appropriate technology and occupations.

The sequential integration of these four components has endowed our project in Nong-Hai with popularity. Training sessions and workshops have been given to provincial and district health care personnel, agricultural extension workers, and community development workers in an attempt to replicate the model in other parts of Thailand.

CONCLUSION

An integrated health, nutrition, and rural development project was implemented in the village of Nong-Hai in an attempt to improve the nutritional status of the rural poor. The project followed a conceptual framework involving the implementation of four components: health care, nutrition, agricultural and food production, and vocational training. Curative health care was used as the initial entry point of programme implementation.

Seven supplementary food mixtures were formulated and tested for safety, digestibility, and acceptability by the institute. These food mixtures were introduced, fed, and distributed to second- and third-degree PEM children. Nutrition education and other related activities were initiated. Agricultural production and income generation were promoted, which ultimately resulted in an improvement of the local economy and the all-round development of the community.

An evaluation of the programme showed significant improvements in the nutritional status of normal children and first-degree PEM children. Nutrition education played an important role in increasing the mothers' awareness of dietary habits. Food assistance was needed for the improvement of second- and third-degree PEM children.

The original conceptual framework of programme implementation has now been developed into a model with four major components: health care, food consumption, food supply, and income generation. The proper sequential integration of these components is essential if the project is to have a successful outcome. As a result of the Nong-Hai project, it is hoped that this programme model will become our national model and that our experience can be shared with the people of other developing countries.

REFERENCES

1. The Population Reference Bureau, Inc., 1980 World Population Data Sheet (Washington D.C., 1980).
2. F. Gomez, G.R. Ramos, J. Cravioto, and S. Frank, "Malnutrition in Infancy and Childhoods with Special Reference to Kwashiorkor," in S.Z. Levine, ed., Advance in Pediatrics, 7:131 (Year Book Publishers, Chicago, 1955).
3. A. Valyasevi, "Public Health Program to Promote Nutrition in Rural Areas-Thailand Experience," in W. Santos, N. Lopes, J. Barbosa, D. Chaves, and J. Valente, eds., Nutrition and Food Science (Plenum Press, New York, 1980).

Perspectives on infant feeding: decision-making and ecology

Gretel H. Pelto
Associate Professor, Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut, USA

INTRODUCTION

Near the end of the eighteenth century the conical glass infant feeding bottle was developed, fitted with a "tubular mouthpiece enclosed in an overlapping finger of linen, parchment or wash-leather" (1), This new low-cost device replaced earlier feeding devices such as perforated cow horns and various forms of pap spoons. Thus, concurrent with the beginning of the Industrial Revolution, technological developments for the first time made possible a widespread shift away from breast-feeding of human infants. Before the advent of this technological breakthrough, those women who wished to avoid some of the responsibilities of breast-feeding had resorted to the use of wet nurses- a practice that is of considerable antiquity in the western world.

Bottle-feeding did not, however, spread rapidly in the early nineteenth century, in part because both medical and lay opinion was against the practice. As the London obstetrician Underwood wrote in his Treatise on the Diseases of Children, "Every child should be suckled, and always by its own mother, where her health can safely admit of it." To this opinion, an editorial footnote was added:

I am convinced that the attempt to bring up children by hand proves fatal, in London, to at least seven out of eight .... In the country, the mortality among dry nursed children is not so great as in London, but it is abundantly greater than is generally imagined. [Quoted in ref. 1, p. 1141.]

These medical observations at the dawning of the "bottle-feeding era" set forth some of the outlines of the controversy that has become one of the most celebrated issues in contemporary nutrition. Despite the attention and debate-involving scientists as well as political, social, and commercial interests - our knowledge about the dynamic forces shaping current practices lacks coherence, and many critical questions remain unanswered.

An examination of the sizeable body of empirical studies on the social correlates of infant-feeding practices reveals that many investigations have proceeded without a systematic theoretical framework to guide the research.

Variables often appear to be selected on an ad hoc basis, without regard to the underlying dimensions they represent. Many potentially important factors have not been studied. For those that have, methodological problems in conceptualizing and operationalizing variables reduces the usefulness of the research.

The clouded state of data on infant-feeding practices has been discussed by Butz in a paper in which he offers a "conceptual model of breastfeeding behaviour," based on economic concepts of supply and demand. After setting out a series of hypotheses (to be discussed below) he notes:

It is a remarkable fact that not one of the above predictions has received testing adequate for making even a preliminary judgement as to support or refutation. Most of the predictions have not been tested at all. We are unfortunately in the position of looking around for empirical generalizations that seem consistent or inconsistent with particular predictions. [2, p.247]

In a similar fashion, Dugdale and Doessel have commented that "this inability to quantitate factors because of lack of data has allowed the current controversy on infant feeding to develop by emphasizing one or another factor while ignoring the remainder and has prevented a rational solution" (3, p. 1). Furthermore, a significant component of the literature consists of programmatic statements, opinions, and pronouncements that lack empirical documentation.

At present, a number of comprehensive research programmes on infant feeding are in various stages of planning and execution. The purpose of this paper is to contribute to the effort to understand infant-feeding behaviour by setting what is currently known about patterns of infant feeding in a framework of big-cultural and socio-cultural theory.

INFANT-FEEDING PRACTICES IN TRADITIONAL, NON-WESTERN SOCIETIES

As members of the class Mammalia, infants of Homo sapiens have been sustained on their mother's milk throughout the history of our species. Prior to the recent development of artificial feeding, almost ail traditional societies encouraged long-term breast-feeding, as is documented by Whiting and Child in a cross-cultural study of 75 societies undertaken nearly 30 years ago. The researchers reported:

There are 52 societies for which we have our judges' estimates of the age at which serious efforts at weaning are typically begun. For the median case, weaning is reported to begin at the age of two and a half years. Approximately this age is indeed typical of primitive societies in general, for the estimate for 33 out of the 52 societies falls between the ages of two years and three years.

At the upper extreme there are only two societies for which the usual age at weaning appears to be greater than three and a half years.... At the lower extreme there are only two primitive societies in our sample who attempt to wean their children before they are a year old. [4, pp. 70, 71 ]

Of interest here is not only the information about long breast-feeding but also the fact of variability from one society to another. Whiting and Child report differences in the intensity of breast-feeding-the degree of "oral indulgence" of the infant-and in maternal attitudes toward breast-feeding, as well as in duration of breast-feeding. According to their research, differences in infant-feeding practices are systematically related to other features of child training, as well as to differences in religious ideology and belief systems. In later research Whiting and colleagues demonstrated that cultural differences in infant and child feeding were also related to other social and cultural characteristics of those societies (5).

The duration of breast-feeding represents one aspect of infant feeding that varies from one non-western society to another. The timing of the introduction of supplemental foods and the degree of reliance on foods other than human milk also vary in systematic ways, as demonstrated by Nerlove. In a cross-cultural study that reviewed ethnographic reports on 83 societies, Nerlove found strong support for her hypothesis that societies in which women are involved to a greater degree in subsistence activities are statistically more likely to have patterns of early supplemental feeding (before one month of age) than societies where women play less important roles in food production. She reports that, while "the primary responsibility for child care is nowhere in the world left to men," there are "societies in which women do make a substantial contribution to subsistence food production activities" (6, p. 207). In such societies infant-feeding practices are apparently adjusted to fit with other demands on the lactating woman through early introduction of supplemental foods.

Anthropologists commonly classify societies on the basis of subsistence (economic/ecological) systems. These broad classifications distinguish between: a. hunting/gathering systems, in which crops are not grown and domestic animals are not used for food; b. intermediate cultivators, gardening societies such as those in Central Africa, the Amazon rainforest, and other tropical areas; c. pastoralist herders, including East African cattle herders and Lapland reindeer herders; d. complex agriculturalists, e.g., the rice cultivators of South and South-East Asia, the great civilizations of the New World and pre-industrial Europe.

There is evidence that child-training practices tend to be different in different types of subsistence systems (7), and, by extension, we can expect that infant-feeding practices are also patterned in relation to subsistence type, although this has been less systematically documented. Beyond the broad outlines of social organization associated with different types of subsistence systems, cross-cultural studies-such as those by Whiting and Child and Nerlove (4, 6)-as well as ethnographic studies of child rearing practices (5, 8, 9) provide ample evidence that in non-western, traditional societies, where human milk is the primary source of nutrients for infants, there are distinct variations in infant-feeding practices that are relatable to social and environmental conditions. One non-western culture, that of the Marquesans, sounds surprisingly like some industrial societies, for the Marquesans believe that nursing makes a child hard to raise and not properly submissive. There was probably a certain amount of nursing, dependent upon the will of the mother, but in any event the nursing period was very short. Women took great pride in the firmness and beautiful shape of their breasts, which were important in sexual play. They believed that prolonged nursing spoiled the breasts. [4, PP. 59-70]

At the other extreme in infant feeding are the ethnographic reports on the Chenchu people of India, who supposedly nurse children until five or six years of age (ibid., p. 71).

INFANT FEEDING IN THE WESTERN WORLD

Western societies in earlier centuries depended on mother's milk to feed infants, just as all other cultures have. However, both the employment of wet nurses and the use of bottles have a long history in western culture and appear to have been well-developed practices in ancient Greece and Rome not limited to situations of maternal lactation failure (1, 1013). In some respects, the controversies about artificial feeding are centuries old.

The eleventh-century physician Avicenna presented in his Canon of Medicine a medical opinion concerning the advantages of women nursing their own babies:

Whenever possible, the mother's milk should be given and by suckling. For that is the aliment of all others most like in substance to the nutrient material which the infant received while in the womb. [Quoted in ref. 1, p. 1141.]

It is implied in this statement that alternatives to mother's milk and suckling were options for some segments of the population. Avicenna goes on to outline the desirable characteristics of a wet nurse. He recommends that the woman be of medium build, between 25 and 35 years of age, "strong-necked and broad-cheated, the breasts firm, the nipples well-formed but not too large. Her character and personal habits must be good, her nature equable and slowly aroused by the bad passions of the mind" (ibid.). Moreover, the wet nurse should not engage in sexual intercourse because it would have a bad effect on the milk, he felt.

Michelangelo was wet-nursed by a stone cutter's wife-a circumstance he regarded as having affected his career: "With my mother's milk I sucked in the hammer and chisels I use for my statues" (12, p. 284).

There is a tragic and sympathetic document recording a mother's plaintive directive to future generations, after she herself had relied (unsuccessfully) on wet nurses:

Be not so unnatural as to thrust away your own children; be not so hardy as to venture accessory to that disorder of causing a poorer woman to banish her own infant for the entertaining of a richer woman's child, as it were, bidding her to unlove her own to love yours. [Quoted in ref. 12, from the original pamphlet of Elizabeth Clinton, Dowager Countess of Lincoln, 1662.]

In the seventeenth and eighteenth centuries, employment of a wet nurse was a standard practice in the upper classes of Europe and England (10), a feature of child training that was taken up in North American society as well. As late as the middle of the nineteenth century, well-to-do American women employed wet nurses. In a social history of a nineteenth century Pennsylvania mill town, Wallace reports that some of the educated, elite women "employed wet-nurses for their infants at birth, or shortly after, thus freeing themselves to move about, to work and to travel. This practice entailed the occasional inconvenience of losing some of the intimacies of motherhood; but the mothers took a practical view of the matter" (14, p. 24). Styles of infant care carried through to management of older children:

Nor were children . . . allowed to disrupt their mothers' lives at older ages.... Boarding school at ten or eleven ended the child's residential connection for several years during the teens, except for summer vacations.... It was a no-nonsense system, which functioned (and no doubt was designed! to protect the mother's role as hostess and household administrator and increasingly, her continued intellectual development and participation in evangelical and reform activities in the community. |Ibid.]

INFANT FEEDING IN THE TWENTIETH CENTURY

All cultures include provision for the feeding of babies who are orphaned or whose mothers experience lactation failure. In many cultures, especially those of the western tradition, there has been a minority of elite women who have delegated child-care responsibilities (including infant feeding! to others. Until the twentieth century, however, mother's milk was the major source of nutrition for the great majority of human infants. By the middle of the twentieth century this was no longer true. Large segments of the world's population of infants now receive their food in a bottle containing something other than human milk.

The trend forward bottle-feeding began in the industrialized, western world. Sweetened, condensed milk was commercially produced in the United States in the late 1850s, followed 30 years later by canned, evaporated milk; infant formulas became available in 1916 (15). Utilization of these new products developed rapidly. By the end of the Second World War only one mother in four in the northeastern United States left the hospital breast-feeding ( 16). Nationally, about 60 per cent of babies were bottle-fed at the time of discharge from the hospital. The percentage of women who chose bottle-feeding continued to increase rapidly throughout the 1950s, levelling off at more than 80 per cent. Trends in the industrialized countries of Europe were similar to in the United States, although the percentage of breast-feeding remained somewhat higher (171.

Recently, there has been some reversal of the trends toward bottle-feeding (171. By 1975, 30 per cent of US infants were breast-fed to some extent, and "by 1974 about one-half of babies born to women with some college education were breast fed" (18, p. 3). Other industrialized countries, especially in northern Europe, appear to be experiencing a similar tendency toward increased breast-feeding. As in the United States, the selection of breast-feeding in Europe is generally associated with higher socio-economic status and higher education (19).

In developing countries it has been more difficult to obtain statistics on infant-feeding practices. There have been a number of studies of specific subgroups in various countries, but data on a national level have not generally been available. Studies reveal great variability of practices, both within and between countries. For example, in Ghana 88 per cent of infants in the northern part of the country were fully breast-fed at six months of age, but in the south the corresponding figure was only 54 per cent (20). Considerable use of bottles is reported in some urban communities (for example, in Costa Rica and Chile), especially among upper income groups (ibid). The multinational collaborative study undertaken by WHO confirms the impression conveyed by earlier reports:

Marked urban/rural differences in patterns of breastfeeding . . . emerge in the majority of countries studied; mothers in urban areas seem less likely to breastfeed than rural mothers, or to breastfeed for as long as rural mothers.... In the Philippines, where the lowest prevalence of breastfeeding was documented, 33% of urban well-to-do mothers who were interviewed had not breastfed the youngest child; similarly 15% of all urban poor mothers interviewed had not breastfed the youngest child. In Guatemala, the corresponding percentages were 23% among the urban well-to-do and 9% among urban poor mothers. [Ibid., p. 21]

Interpretation of the statistics on modes of infant feeding is complicated by several methodological problems (171. First, there are the typical problems that characterize public health statistics, especially in countries that do not have adequate resources for statistical data gathering. Secondly, there are problems in the definitions of modes of infant feeding. Many studies report results simply as "breast-fed" and "bottle-fed." A further refinement includes the category "mixed feeding." The reality behind these labels, however, is a behavioural complex which exhibits great intra-group variability (21). The meaning of "mixed feeding" or even an affirmative response to the question, "Are you breast-feeding this infant?" is very broad, covering a wide range of behaviour.

The lack of specificity in the labels presents a problem for the investigator who wants to accurately describe the distribution of infant-feeding modes. It also creates a problem for interpreting the social dynamics that lie behind the statistics. In broad outline it is clear that large numbers of babies in the western world are bottle-fed and that a significant number of babies in developing countries are also bottle-fed, at least to some degree. Our concern here is not with the consequences of a particular mode of infant feeding but with understanding why and how selections of modes of feeding occur.

EXPLANATIONS FOR CHANGING INFANT-FEEDING PRACTICES

As the controversy over bottle-feeding has expanded, the changing patterns have become a social and political issue as well as a scientific concern. In reviewing suggested explanations of the phenomena, it may be useful to distinguish between positions that are essentially "social philosophies" and those that contain a more-or-less articulated theory of social and/or biological processes. In the first category, we can identify at least three orientations: the "women's rights/feminist" position, the "anticommercial" position, and the "biological determinist" position.

Women's Rights/Feminist Orientation

Interestingly, the contemporary social philosophy associated with the women's rights movement has been used to argue both for and against bottle-feeding. On the one hand, artificial feeding can be regarded as a boon to women, giving them the opportunity to engage freely in other activities without being tied to a schedule of infant feeding. The trend toward bottlefeeding can, therefore, be interpreted as a reflection of women's increasing expression of their right to control their own time and activities.

On the other hand, members of the women's movement have argued strongly for a woman's rights to fulfil her biological function as a nurturer of her infant without penalty (e.g., loss of job, pay) and without interference or coercion. From this perspective, the increase in bottle-feeding can be regarded in a negative light- a reflection of increased male dominance over women, caused, in part, by the increasing dominance of male physicians over female reproductive activities.

Anti-commercial Orientation

The significance of promotional activities by the corporations that manufacture infant formulas has been approached in several ways. On the one hand, questions about the role of advertising and promotion are being framed as testable hypotheses for which research data can be collected. Also, documentation of the nature and extent of these activities is being undertaken as a descriptive research task (Marchione, personal communication). On the other hand, the adoption of bottle-feeding by women in the third world is being incorporated into anti-capitalist philosophy as an example of contemporary world-wide economic processes. Often this philosophical position has been presented with little concern for establishing clear causal links between the commercial advertising and the supposed dependent variable-bottle-feeding behaviour. Discussion of the contradiction between feminist positions (which generally include an assumption that women are intelligent and make rational choices) and the anti-commercial rhetoric (which portrays women as gullible victims of multinational promotion efforts) is surprisingly absent from the literature (22).

Biological Determinist Position

In much of the popular writing concerning women's roles there has continued to be an underlying biological determinism, focused on concepts of women's "natural" biological qualities in relation to child care. From that perspective any deviations from long-established patterns of infant feeding are generally thought of as "deviance" or ' warping" of women's personalities and essential nature. As a writer in the sixteenth century put the matter, "Wherefore it is agreeing to nature so it is also necessary and comely for the own mother to nurse the own child . . . it shall be commendable and wholesome" (23).

In a recent expression of the "biological determinist" position, anthropologists Lionel Tiger and Robin Fox discuss breast-feeding in the context of "bonding," a concept that is central to their construction of human behaviour. They first suggest that "the reason behind the invariability of the mother-child bond in mammals- as compared with the extreme variability of the male female bond-is very simple: suckling" (24. p. 61). They go on to state:

The human mother is a splendid mammal-the epitome of her order. Her physiology is more highly developed for suckling behavior-with permanent breasts, for example-than any of her cousins, except domesticated ungulates bred specially for milk-giving. But more than this, she is, like any other mammal, emotionally programmed to be responsive to the growing child. [Ibid., p. 65]

However, Tiger and Fox urge their readers to understand that the dependence of the infant "does not hinge wholly on food, but on emotional security, of which food is but a part."

The biological determinist orientation is subtly at work in the new advertising gambit of the formula manufacturers, reflected in such phrases as, "When mother's milk fails . . . ," or "The best substitute when mothers can't nurse." The implication is that women's biological capacity is weak, requiring the benign assistance of industrial progress. The explanation, then, for the recent trends toward bottle-feeding is founded on abiological determinist orientation, in this case couched as "biological failure."

These three social orientations have appeared in both the popular and the scientific literature, sometimes presented with great eloquence, sometimes in strident, polemical fashion. They contain ideas about causes of infant-feeding trends, some of which can be transformed into scientifically testable hypotheses. They are also important for study as social phenomena in their own right. As Gerlach has suggested (25, 26), it is important to understand the impact of these social philosophies on selection of infant-feeding modes and on the institutions (commercial, governmental, educational, and medical) to which they are addressed.

In contrast to the preceding orientations, which can be characterized as social philosophies, there are a number of approaches to an explanation of infant-feeding trends which are either directly theoretical (i.e., presentation of a causal model) or imply a theory in the selection of variables for empirical study. These approaches can be characterized as follows: modernization models, economic models, and bio-cultural models.

Modernization Models

This is probably the most widely evoked of all theories, some formulation of "modernization" being frequently used to explain trends in infant feeding. In the context of discussing "the dramatic decline in breast feeding" in the developing world, Berg expresses this position in the following words:

Encroaching urbanization and modernization and new social values are significant influences. Breast feeding is often viewed as an old-fashioned or backward custom and, by some, as a vulgar peasant practice. Indeed, anthropologists, struck by the relationship of artificial feeding to societal change, have used the duration of nursing as an inverse measure of acculturation for some countries. In most developing countries, the greater the sophistication, the worse the lactation: the bottle has become a status symbol. [27, p. 99]

The influence of mass media, improvements in transportation and communication, and exposure to new ideas from health care personnel can be regarded as additional aspects of "modernization." The language is sometimes different but the underlying theme is the same in discussions about the spread of bottle-feeding in industrialized countries. For example, the following statements by sociologists C. Hirschman and J. Sweet in their analysis of the 1965 National Fertility Survey reflect a "modernization" model:

We know of no adequate theoretical perspective that can guide empirical research in this area. At most, the ideas from popular culture suggest that breast-feeding has declined as society moved from a traditional, rural-based, family-centered structure to the modern urban social milieu where traditional culture regarding childbirth and child-care was discarded. [28, p. 42]

The authors hypothesize that the resurgence of interest in traditional values may be associated with a renewed interest in breast-feeding:

Similarly, we might expect that resurgence of popular interest in natural foods, natural childbirth, bicycling to work, etc., represent attempts to recapture less modern or mechanized ways of dealing with the basic tasks of life. Thus, there might be some basis to believe that breastfeeding may have been making a comeback in recent years. Although we will not be able to test these speculations directly, our data will allow us to examine trends in breastfeeding behavior until 1965 [Ibid.]

In this study, as in a number of others carried out in both western and developing countries, the researchers look for associations with such variables as education, income, place of residence, region of origin, and other "social background" characteristics. In a sense, these may all be regarded as aspects of modernization, for they capture those features of modern life that depart from the types of social systems in which breast-feeding was the only mode of infant feeding. In these studies, investigators generally find significant correlations between feeding mode and a variety of social background characteristics (29-32). Generally, these associations can be regarded as support for "modernization hypotheses." However, since they are basically descriptive, merely documenting associations of infant-feeding modes with characteristics of contemporary life, they provide little insight into the causal factors. As Hirschman and Sweet say at the end of their article:

Although we think that this analysis has provided some conclusion on this subject where only speculation existed before, it has raised more questions than it answered. Why has the rate of breastfeeding been declining so rapidly over the past few decades? What is it about certain ethnic, religious and regional groups that causes differentials in breastfeeding behavior? Do the effects of educational attainment upon the rate of breastfeeding represent a true education "effect" or is it an indicator of some other socioeconomic factor that is correlated with education? Analysis of these and other questions will require further research.

Berg's comments quoted above (27, p. 99) and the preceding statement about "a true educational effect " suggest that one of the major components of modernization is adherence to a set of beliefs or values which provide guidelines for behaviour. That is, one may logically conclude that a belief that breast-feeding is vulgar would lead a woman to select bottle-feeding and, similarly, that the belief that breast milk is best for babies should be associated with a decision to breast-feed.

These statements reflect a long-standing theoretical position in anthropology and other social sciences. The premise on which this position is based is that behaviour results from an individual's attitudes and values. The prime source of these attitudes is generally "the culture." Women's ideas about proper infant feeding are transmitted from one generation to the next through the process of enculturation. Thus rural, peasant women breast-feed their infants for a year or more because it is the custom. When new ideas are introduced, either through outside cultural influences or through migration to new cultural settings, behaviour changes as well.

As a theoretical perspective, the "ideational" or "cultural norms" frame of reference has come under increasing criticism (32-34). When analysis is presented in the form of descriptive associations, we are left unenlightened about the causal relationship. To date, researchers have made little effort to design studies that would untangle the difficult questions about the role of beliefs and attitudes in affecting behavioural choices.

There is a paucity of studies directly addressed to questions of the relationships between attitudes on infant feeding and actual behaviour. The available information is ambiguous. Several studies have documented a disparity between belief and practice and have shown that many women who believe that breast milk is better for babies nonetheless choose to bottle-feed (35-371. On the other hand, there are also strong statistical associations between positive attitudes about breast-feeding and the selection of this mode of infant feeding. The same holds for associations between the expression of negative attitudes about breast-feeding and the selection of bottle-feeding (35, 36). In order to increase our understanding about the role of beliefs and attitudes in the selection of infant-feeding modes, we will need further studies in which beliefs and attitudes are carefully measured prospectively and are followed by a recording of actual behaviour with respect to infant feeding.

Economic Models of Infant-Feeding Practices

To date, serious analytic efforts to understand the factors that influence infant feeding have been limited mainly to economic variables. As noted above, Butz has developed a sophisticated theoretical model to explain the demand for breast-feeding:

in trying to explain and predict how a particular scarce resource is allocated among competing uses, economists generally find it helpful to investigate determinants of the supply of that resource and of the demand for it that arises out of each competing use . . . in this case the scarce resources . . . are a woman's time and her stock of nutrients. [2, p. 233]

After pointing out the variety of competing uses of a woman's time, Butz notes that "some values, like wages for market work, are relatively easily measured. Others, like the value of sleep or social activity are conceptually and empirically very difficult to evaluate."

After defining the main dimensions of the model, constructed to show the effects of alterations in the supply and demand curves, Butz describes a series of implications (hypotheses) derived from it. Several of the implications deal with the effect of changes in the market:

1. An increase in the market demand for female labor tends to reduce breast-feeding if the jobs are less than fully compatible with maternal child care.
2. An increase in the supply of female labor to the market. . . tends to reduce breast-feeding if many labor market jobs are less than fully compatible with breast-feeding.
3. An increase in the price of food staples consumed by adults tends to reduce breast-feeding in populations suffering mild to moderate or worse malnutrition.
4. An increase in the marginal value product schedule of a woman's time in home agriculture or cottage industry tends to reduce breast-feeding if these activities are less compatible with child care than alternative activities engaged in.
5. Factors that reduce the supply curve of a woman's breast-feeding . . . tend to reduce her actual breast-feeding more if alternative foods are available.... [Ibid.]

Butz goes on to consider a series of other factors that could have effects on his primary factors. These further items include the availability of modern contraceptives, infant-weaning foods, substitutes for the economic and non-economic benefits bestowed by children, and so on. His model therefore suggests a number of significant areas for further research.

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