TO BREASTFEED OR NOT TO BREASTFEED ? THAT IS THE QUESTION . JACQUI MÝBURGH SUSAN PRICE

Die skrywer het die hipotese dat meer kleurling as blanke vroue op ses weke post-partum nog borsvoed in ’n navorsingsprojek getoets. Daar is bevind dat kieurlinge wel meer suksesvol is met borsvoeding as blankes. Maatskaplike faktore soos ouderdom, huwelikstaat en pariëteit het nie ’n betekenisvolle invloed op bors­ voeding gehad nie. Die skrywers maak ’n aantal voorstelle wat verpleegkun­ diges in gedagte moet hou om borsvoe­ ding effektief te bevorder.


INTRODUCTION
The following research was carried out during the eight weeks of A ugust and S eptem ber 1982.It in volved coloured and white patients.O ur interest, was to determ ine how successful coloureds and whites in Johannesburg were at breastfeeding at the tim e of their six week post natal check-up.

PURPOSE OF STUDY
O ur reason for doing the study was that during our midwifery training we noticed that many m others had given up breastfeeding within six weeks despite educational pro gramm es held at the Hospital.As our dealings were prim arily with whites we w ondered w hether this was also the case with other sectors of the population and w hether their educational program m es in prom ot ing breastfeeding were better or worse.
This article is based on research con ducted as part of the authors' final year requirements for the degree BSc (Nursing) at the University of the Witwatersrand, 1982.The research project won the 1983 Juta Nursing Research Prize in the category for students on a course for a basic degree or diploma in Nursing.

METHOD
We were limited to the coloured sector of the population because of unforseen circum stances and re fusal to conduct a survey from chosen black hospitals.The hospi tals we used were registered as uni versity training centres for degree and non-degree nurses and other m em bers of the health team .
Initially a pilot study was con ducted on 20 coloured m others.The necessary m odifications were m ade to the instrum ent which, in this case, was a questionnaire and interview.
The following sample sizes were obtained: 62 C oloured m others answered the questionnaire of which twelve were considered spoilt, as they had not been checked by us im medi ately after being answered and many items had been overlooked.Therefore we had a usable sample of 50.
Exactly 50 white m others were interview ed and there was a 100 % return.

DEFINITIONS
A specific explanation of term ino logy used is necessary.A white person is one who:(a) in appearance obviously is a white person and who is not generally accepted as a coloured person; O R(b) is generally ac cepted as a white person and is not in appearance obviously a white person.
• By the term s successful or better breastfeeders it is implied that there are m ore people in one group breastfeeding than in the other.T here is no reference to the actual technique of breast feeding.

HYPOTHESIS
Coloureds are m ore successful breastfeeders than whites at six weeks post partum .-Young adults (above the age of 21) are better breastfeeders than teenagers (13-20).M ultigravidas are better and m ore successful breastfeeders than prim i-paras.

CULTURAL ASPECTS OF BREASTFEEDING
In an article entitled H um an M ilk in the M odern W orld reasons are listed for a decline in breastfeeding.The authors say it is due to a variable blend of interacting sociological fac tors.These are summarised below as a m odification of th e classification of D w yer & M eyer (1975), V alquist (1975) and others.
• -R apid urbanisation, indus trialisation and change in status of fem ales leads to in creased num bers o f wom en w orking.-A ltered family structure (sm all, nuclear, two gener ation family).
-A lleged convenience of bottle feeding.-W estern urb an attitude to fem ale breasts (privacy for breast-feeding -clothes in crease difficulties).
• Insufficient action by the G o v e r n m e n t to e n c o u r a g e breastfeeding.
-F ailure to provide creches for w orking m others.-In ad eq u ate attention to ap p ro p ria te legislation to support lactation.
-N utrition w elfare program m e th at tends to dim inish b reast feeding.-Lack of atten tio n to hum an m ilk as a national food re source.-M inim al or absent effective health education especially via m ass m edia.
• N egative effect o f health and nu tritional professionals.
-Increasing hospital deliveries w ith indifferent or disruptive regim es, and confusing advice in m aternity units.-Lactation-inhibiting contra ceptive pills.-Lack of em phasis on diet of p r e g n a n t a n d l a c t a t i n g w om en.
• M arketing, advertising and p ro m otion of form ulae.
-Influencing o f health person nel, such as giving of free sam ples.

RESULTS AND INTERPRETATION OF STUDY
A fter correlating the data it was found th at the sam ple of 50

Breastfeeding rates
The coloureds had a higher inci dence of breastfeeding than the whites (see table 4) and this was sig nificant at p =0,00.T herefore this can be generalised to the total coloured and white population, that is coloureds have a higher incidence of breastfeeding than whites and are m ore successful.

Influence of social factors.
Taking the total sam ple, age does affect breastfeeding rates and the highest ra te of breastfeeders in var ious age groups differed betw een coloureds and whites.C oloureds had the bulk of breastfeeding m others in the age group 16-25, due to there being m ore single m others among the coloureds.In w hites the highest percentage of breastfeeding m others w ere over 21 years of age.M arital status had no effect on the rate of breastfeeding at th e 0,05 significance level.Parity in general was also independant of the success ra te o f b r e a s tfe e d in g b e tw e e n coloureds and whites.
C oloured m others had a higher incidence of breastfeeding despite working status.It was felt th at this may have been due to their lower socio-econom ic status as com pared to whites.M ore coloured m others need to w ork to possibly im prove the family incom e and m ore m ay be breastfeeding because it is cheaper.

Effect of guidance
In the sam ple studied, it seem s that whites received m ore guidance on the whole than coloureds (see table 5).H ow ever coloureds in the sample w ere m ore successful des pite guidance given.This m ay m ean that the guidance given to the whites m ay no t be effective or ex tensive enough and is not necessar ily the only factor influencing suc cessful breastfeeding.M others were not aware of the advantages and disadvantages of b re a s tfe e d in g .T h e r e fo r e h e a lth education program m es are either ineffective or not extensive enough.The latter was found to be more true.
It was also found that husband encouragem ent does not play an im portant role in breastfeeding.
The level of education does not necessarily affect the success rate of breastfeeding but increases aw are ness of advantages.

ROLE OF THE NURSE AS PROMOTER OF BREAST FEEDING
Listed below are a num ber of facts that the educator (nurse, doctor, param edic) should bear in mind if they are to perform an effective role as a teacher.
-Spend time with the patient and allow for questions and answers.-Never be so busy that you cannot be interupted with ques tions.-W hen unavoidable reasons on the part of the m other or baby are apparent for not breastfeed ing, they must be recognised.The midwife should then advise the m other on the best possible alternative for feeding using a bottle and a substitute milk for mula.

LIMITATIONS
As with any study of this kind, cer tain limitations are im posed -by circum stance, by those directing and by those researching.
The most severe limitation of this study was the time factor, due to the authors still being student nurses.They still had a full quota of ward hours to com plete and as degree students had lectures to attend and studying to do.The topic was extrem ely wide for two students to cope with.U nanticipated factors were the length of tim e it took hospitals to reply and refusal to conduct sur veys.As a result the topic had to be modified.
The inter-racial nature of the po pulation was a limiting factor as some of the wording used in the questionnaire was not understood by the coloured m others.This was corrected on adm inistration of the instrum ent).T here is a limited am ount of literature available on breastfeeding success rates in the different population groups and thus the form ulation of the ques tionnaire was based partly on the literary review and partly on trial and error.

RECOMMENDATIONS FOR FURTHER STUDY
• Does the economic status of coloureds and whites affect the rate of breastfeeding in m arried m others?
• M otivating factors in influencing prim iparas and m ultiparas to breastfeed (parity was found to not necessarily influence rates of breast-feeding).
• Investigate reasons for m others wanting to return to w ork, or reasons for working and corre late it with their econom ic status, such as income.
• Find the working and breastfeed ing status in larger samples of white and coloured wom en and do significance levels.
• Have m others who want to work stopped breastfeeding so they can return to work; or is the desire to want to work an excuse for not breastfeeding?
• D eterm ine the significance of education levels and success rate of breastfeeding.

CONCLUSION
It was found that the success rate of the two population groups differed significantly in the Johannesburg area at six weeks post-partum .
T here is still a high rate of unneces sary bottle feeding and the increase of bottle feeding is a phenom enon of urbanisation.As a result of this, it is the m oral and legal duty (ac cording to South A frican Nursing Council Rules and Regulations) for registered midwives to prom ote breastfeeding.This must be ac com panied by constant re-assess m ent and revaluation of our health education program m e for im prove m ents to be m ade.
It was felt that this study was im portant in nursing research to make nurses aware of the ratio of bottlefeeding and breastfeeding in all the population groups for the reasons given below.
• It may aid us to learn from the achievem ents of nurses in other population groups in the prom o tion of breastfeeding.• By com paring race groups, we may learn why one group is m ore successful than another.• By assessing rates of breastfeed ing and comparing them to educa tional program m es, it may be used as a form of evaluating the health educational program m es.• It is interesting and enlightening.
• By studying m ore than one race group, nurses learn about the cultural and ethnic aspects of these race groups so that she may care for all hum anity with under standing of differences between the various race groups and cul tures.
w hite m others at tending their post-natal check-ups had the social characteristics as in dicated in tables 1-3.
-Spend time reading over litera ture with patient and answering queries.-Supply the m other with assur ance and encouragem ent.-Intensive counselling to m others ante-and post-natally.-E m p h a s i s e a d v a n t a g e s o f breastfeeding in a language that can be understood.-O bstetricians and paediatricians should work together and p ro m ote breastfeeding.-Medical personnel should be up to date with current concepts in breastfeeding -achieved by reading journals, periodicals and attending sem inars.-Base education on the cultural and economic environm ent of the community.-As midwives we should have a positive attitude tow ard breast feeding and therefore create a socially acceptable situation.W e must not project our own personal feelings and attitudes.-We must aim to gain the confi dence of the m others and be good listeners.-B reastfeeding should be ad vertised by m eans of radio, tele vision, new spapers and posters.