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Breast- or bottle-feeding: Who decides?

In the case of rural mothers, the high and protracted prevalence of lactation implies that such a decision was made from a very limited set of options. The decision process in the case of urban mothers is more complicated. They often have a weaker tradition of breastfeeding. In addition, formula is readily available, and one day's average salary of a low-income worker can buy three cans of formula. Further, about 60% of those workers are entitled to the Social Security benefit of a free supply of formula.

We first asked, "Who decides the feeding mode of a given infant?" The vast majority of a cohort of breastfeeding mothers interviewed two weeks after parturition claimed they themselves made the decision to breastfeed. They claimed that the decision to use formula was the responsibility of a family member or of members of the health-care team [10].

During a follow-up visit at about four months, after infants were switched to formula, the mothers were asked who procured the first can of formula. In almost 40% of the cases, the mother obtained the first can of formula without any professional advice. In 20% of the cases, the first formula was provided or prescribed by a physician or nurse. Overall, deci sions were taken by mothers in 64% of the cases and by health-care professionals in 31 % of the cases. These results support the idea that in this group mothers play the leading role in deciding whether the infant is breastfed or bottle-fed.

TABLE 3. Prevalence of breastfeeding according to residence and age of child

Age (mo) Rural (n = 216) Urban (n = 346)
% predom. breasta % breast + formula Total % predom. breasta % breast + formula Total
0.5 99 0 99 75 18 93
1 98 0 98 67 21 88
2       49 29 78
3 98 0 98 40 31 71
4       38 26 64
5       30 27 57
6 94 0 94 25 27 52

a. Predominantly breast: no other milk but solid food and other liquids provided.

In response to a questionnaire, 60% of women who discontinued breastfeeding gave "insufficient milk" as the reason. Thirteen per cent stated that the infant refused to suckle. Surprisingly, only 9% indicated that the free supply of formula was the reason to stop breastfeeding. These results suggest that in most cases mothers switched to formula spontaneously because they perceived their lactation performance as inadequate.

Other social factors influencing the estabilshment of lactation

For this part of the study, four weeks of continuous breastfeeding was defined as the successful establishment of breastfeeding. The success rate tended to be higher in better-educated mothers, but the trend was not statistically significant. Working mothers were as successful as those staying at home, probably because labour regulations allow mothers a postpartum leave of absence of 90 days. The level of family income was positively correlated with success. It is important to note that family income covaried with years of education and level of knowledge of breastfeeding. Women living in the same house with their partners were more successful in establishing

TABLE 4. Relation between maternal socio-economic factors and the establishment of breastfeeding in the urban cohort lactation than single mothers. None of the women in the last category lived alone; they almost always lived with relatives (table 4 ).


% successful breastfeeding


Years of education
0-6 65  
7-12 81  
>12 72 NS
Employment status
outside home    
employed 81  
not employed 68 NS
Monthly household income (US$105)
1 65  
2 71  
3 85 p < .05
Marital status
married 83  
single 55 p < .02

NS, Not significant.

Pérez-Escamilla et al. [10] found no relationship between returning to work and successful breastfeeding, usually because mothers had already discontinued lactation. As in our study, the advice of close friends was one of the most frequent reasons given for introducing formula. Poor socioeconomic level and the presence of a partner negatively influenced breastfeeding.


Biological determinants of lactation establishment

The evaluation of lactation performance is critical, because data presented above suggest that concerns about lactation performance may induce mothers to stop breastfeeding. The following data come from a study of 30 mother-infant pairs. Ten were recruited in the rural community of San Mateo Capulhuac, and 20 in the urban community of Iztapalapa. Exclusively breastfed infants weighing more than 2,500 g at birth were followed for the first month of life. The growth of the infants and the output and composition of the milk were recorded.

Growth of Infants

Urban newborns were 100 g heavier than rural newborns on the average, but the difference was not significant. Both rural and urban infants lost weight within 48 hours after birth; urban infants lost significantly more weight than rural infants (197 + 74 g vs 122 + 30 g; p < .01). By 74 hours after birth, all had regained their birthweight. This recovery was followed by a period of fast growth (45 g/day) up to day 30. The mean body weight of both groups was comparable at day 30 to the mean body weight of breastfed infants in the United States.

Maternal milk production and dally nutrient Intake of Infants

At day 3 milk production (a little more than 360 ml/ day) and energy (65 kcal [272 kJ]/kg/day) and lipid (3.4 g/kg/day) intakes of infants per kilogram body weight were similar in the rural and urban groups (table 5). The energy intake was below the energy requirements determined by Lucas [26], using the double-labelled water technique in infants of similar age.

By day 15 milk production had increased to almost 550 ml/day in both groups and energy intake to 97 kcal (406 kJ)/kg/day for urban infants and 88 kcal (369 kJ)/kg/day for rural infants. The differences between groups were not significant, and the absolute values were closer to the values published by Lucas [26]. The daily energy and protein intakes at day 3 were negatively correlated with the magnitude of weight loss within the first few days. Such a loss likely indicates a negative energy balance because of insufficient energy intake. We speculate that the infant's hunger might be expressed as insistent suckling and uneasiness during the first stages of lactation. Mothers may have interpreted this as an inability to meet the nutritional demands of infants and therefore discontinued lactation.

On days 3 and 15, the number of suckling episodes per day was similar in both groups. On day 3 the average time the baby spent attached to the breast was about 198 minutes in both rural and urban groups. On day 15, however, rural infants suckled almost 30 minutes per day longer than urban infants. This finding suggests that a stronger stimulus was necessary to maintain milk production.

Although the maternal nutritional status was different in the two groups, the milk volume and energy output were similar. This finding suggests that maternal nutritional status had little impact on the lactation performance at these planes of nutrition.

TABLE 5. Energy and macronutrient intakes (mean ± SD) in relation to age and residence of infants

Age/ residence

Energy (kcal/kg/d)

Protein (g/kg/d)

Lactose (g/kg/d)

Lipid (g/kg/d)

Day 3
rural 65.3 ± 16.7 1.5 ± 0.4 7.1 ± 1.7 3.4 ± 1.4
urban 65.7 ± 23.2 1.8 ± 0.7 6.9 ± 2.5 3.4 ± 1.3
Day 15
rural 87.9 ± 20.3 1.4 ± 0.4 9.8 ± 2.6 4.3 ± 17
urban 97.3 ± 29.7 1.5 ± 0.4 9.9 ± 2.1 5.7 ± 2.6



We have presented evidence that before the Baby-Friendly Hospital Initiative was implemented in Mexico, the proportion of urban mothers commencing breastfeeding was low, exclusive breastfeeding was rare, and the average total duration of breastfeeding was three months. In addition, the marketing practices of formula manufacturers and the practices and policies of both public and private hospitals were detrimental to breastfeeding. All of these measures improved after the Baby-Friendly Hospital Initiative was introduced. This substantial improvement is seen as a consequence of national and international efforts.

Mothers are the chief decision makers in choosing the mode of infant feeding. A lack of adequate support and appropriate advice seems to be responsible, in part, for the short duration of breastfeeding. The energy intake of exclusively breastfed infants is below reported requirements during the first days postpartum. It is associated with a loss of body weight, which might be misinterpreted by mothers as an inability to fulfil their infants' needs, leading them to stop lactation or to introduce some formula feedings.



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