|Food and Nutrition Bulletin Volume 02, Number 2, 1980 (UNU, 1980, 40 p.)|
|Food and nutrition policy|
Thomas J. Marchione
Department of Anthropology, Case Western Reserve University, Cleveland, Ohio, USA
Change in infant-feeding practices is often viewed from an oversimplified perspective: traditional mothers were happily practicing ideal feeding patterns until they became exposed to multi-national infant formula milk advertising; then their breast-feeding declined dramatically to the great detriment of their infants' health. Efforts to examine the true effects of food companies and to combat the harm they can do will best succeed if our investigations proceed from a more accurate knowledge of traditional feeding patterns and a more sophisticated understanding of changing socio-cultural systems This historical study of breast-feeding practices attempts to introduce such understanding for the English-speaking Caribbean.
This study primarily discusses the West Indian population of African heritage in the English-speaking Caribbean, the former British West Indies. In 1975 this population segment, usually classified as "black" and "mixed" or "coloured," comprised over 80 per cent of the estimated five million persons in the countries and territories of Jamaica, Trinidad and Tobago, Guyana, Barbados, Bahamas, Belize, St. Lucia, Grenada, St. Vincent, Antigua, Dominica, St. Kitts-Nevis, Montserrat, Cayman Islands, and Turks and Caicos Islands (1-4). The next largest ethnic group, East Indians, comprised around 15 per cent of the population. The latter group was brought to the area not under slavery but rather as indentured labour following the period of emancipation in the 1830s. The practices of this group are given limited attention in the historical account.
The data from this region strongly suggest that the mixed feeding patterns found in the Caribbean around 1970 represent patterns which have been changing over quite a long period. Historians record that West African slave women in the West Indies were steadfast breast-feeders (43, 44). A recent theory proposes that prolonged breast-feeding was responsible for wider spacing of births and lower fertility of Caribbean slave populations compared to US slave populations after over one hundred years of slavery (43). By 1811 plantation owners were not only conscious of the effects of lactation on maternal work output and fertility, they were offering each other advice on ways to curb "excessive suckling" (over 14 months) and ways to supplement infant diets in day-care nurseries (44,45). We know for certain that the use of dilute paps as breast-milk substitutes was seen to pose a serious health problem as early as 1905 in some territories (40). The introduction of herbal (bush) teas almost from birth is a con-neon West African practice and to a large extent continues to this day among the Afro-Caribbean population.
The relatively recent advent of multi-national infant formula promotion has undoubtedly affected the length of lactation, and the constituents of the supplementary and complementary foods offered to infants of all classes The nature of this influence, however, can be seen to be an acceleration of long-term trends in existing patterns. However, this paper does not disentangle the complex of influences which accompanied the increase of commercial promotion following 1940, such as accelerated industrialization, urbanization, use of hospital facilities and cultural "modernization." Taken in sum, these have resulted in the perpetuation of harsh living circumstances for a majority of women to the continuing benefit of a minority of political and economic interests. From the period of slavery to the present day, these interests have included food-producing enterprises. Modern multi-national agribusinesses and multi-national baby food industries both play a part, although somewhat different parts, in perpetuating this system. The decline in breast-feeding, though irrational from a nutritional point of view, does seem rational as an adaptation by women to these continuing material circumstances. However, the real causes for the decline of breast-feeding are an as-yet undiscovered combination of influences on women's activity patterns, access to substitute feeding, and perceptions of desirable feeding methods.
In this paper I trace the history of breast-feeding practices only back to 1900. A more detailed study of earlier centuries will be included in a later work (49). At each step further back into time in the study, the data depart further from standards of scientific reliability and empirical accuracy. Community surveys are often unrepresentative, their conclusions biased in favour of hospital pediatric ward admissions or hospital catchment populations, and at each step, there is a greater abundance of sweeping statements by "expert" observers. The information regarding the practices of breast-feeding and infant diet from the time of slavery to 1950 is almost totally based on personal and official accounts by elite white observers from the dominant class. During that entire period, only one quantitative study and not a single systematic population sample demonstrating breast-feeding practices was found. Much of what follows is not only a body of scientific assessments, but also a natural history of the cultural attitudes of dominant slave owners, colonists, and expatriates toward a subject and dependent people.
II. STATUS OF BREAST-FEEDING PRACTICES
The Caribbean has been classified within the "arid" world zone, along with North America, Western Europe, and Australasia. In this zone, it is claimed that only a minority of mothers are still breast-feeding their three-month-old infants, with the exception of those in a few unspecified "oases" (6). Cook sums up the situation in the English-speaking Caribbean in his recent review.
The decline of breast-feeding in this area deserves a prominent mention under the heading of social factors. The practice of exclusively breast-feeding the infant for the first 6 months of life, or longer, and prolonged lactation was very widespread until only 3 decades ago, but it has since declined to a level where in urban centres as few as 5 percent of mothers exclusively breast-feed their children even to the age of 3 months. One trusts that this is a nadir from which there can only be recovery, for along with the lack of relatively cheap, nutritious and compact weaning foods, the decline in breast-feeding, with the gastroenteritis and marasmus which accompany it, is one of the two major immediate causes of protein-energy malnutrition which in the Caribbean has its peak incidence in the age group 3-24 months. .
A similar statement is found in an expert committee report to the Caribbean Health Ministers Conference held in Dominica in February 1973. The health ministers called for an assessment of the situation because of their growing concern over the mental health ramifications of gastroenteritis and malnutrition in the region. The report, presented in response to a 1973 resolution, was prepared by the most highly regarded medical-nutritionist opinion in the English-speaking Caribbean countries, including the staff of the University of the West Indies teaching hospital, PAHO/WHO Zone I advisers, and the staff of the Caribbean Food and Nutrition Institute (CFN), who were also the organizers of the conference. The conference report states:
One of the principal causative factors at the root of early onset of malnutrition combined with recurrent gastroenteritis is the practice of bottle feeding. This practice has spread in the last 25 years to all classes in all the countries, to the extent that now in the largest cities of the region as little as five percent of babies are solely breast-fed up to the age of four months. Most are fed either with the bottle only or with mixed patterns of breast and bottle. The expensiveness of the powdered milk, ignorance of the right proportions to mix, unawareness of the necessity of virtual bacterial sterility in baby feeds, and lack of refrigeration, convenient stove, and a stock of bottles, all these combine to be a major cause of the malnutrition-gastroenteritis syndrome so often seen clinically. .
The accuracy of these summaries of current breast-feeding practices can be assessed through an examination of available survey results from nine of the 14 countries containing roughly 80 per cent of the population (see table 1). The quality of these data leaves much to be desired. Only the cross-sectional surveys done in Barbados and Guyana can be considered to be representative samples of national populations. The most careful longitudinal studies done in urban Kingston are samples of children born, often with complications such as prematurity, at the teaching hospital of the University of the West Indies.
Accepting these data limitations, a fairly consistent pattern emerges: one of mixed infant feeding. Generally, most infants are not entirely weaned until the second semester of life, except for Afro-Guyanese and the residual category in the Guyana survey, who are mostly of European and Chinese upper-class parentage. From two-thirds to nino tenths of infants were receiving a bottle before three months of age. However, it should not be assumed that the bottle given always contained formula milk or milk in any form. Although mothers used a variety of things in bottles, recently commercial infant formula has become the supplementary food of choice. After formula, cow's milk, sweetened condensed milk, and unsweetened evaporated milk were frequently mentioned. In a 1973 study by Marchione (9), 183 Jamaican mothers in a random sample were asked, not what was used most often, but rather what milks had been used for feeding their infant (0 - 12 months) in the preceding 24 hours. After breast milk (40 - 50 per cent), mothers named cow's milk, sweetened condensed milk, and formulas about equally. In most studies the daily use of bush teas was found in the diets of just under one-half of infants before they reached three months (see table 1). These tea supplements are often started at birth or in the first few weeks of life. In urban Kingston and Barbados, the use of fruit juices by the age of three months was practiced by mothers in over 75 per cent of cases (10, 11, 46). Also by three months the supplemental use of starchy or carbohydrate gruels, i.e., "paps," usually made from cereals such as cornmeal, fruits such as plantain, or substances such as arrowroot, was found to be as high as 73 per cent in St. Vincent, but less than 55 per cent in other studies. Frequent and early introduction of glucose water and cod-liver oil is also reported in these studies.
TABLE 1 Breast-Feeding Practices in the English-Speaking Caribbean (circa 1970)
|Country (region)||Sample size||Year||Weaning-month percentile||Supplementary feeding percent (under 3 months)|
|N||25 %||50 %||75 %||Bottle %||Bush tea %||Gruel%|
|Barbados2 *||284||1969||4||6||9||83* *||37 * *||-|
|East Indian||253||-||5 -8||-||54||-||-|
|Jamaica (urban)5***||290||1967 - 68||4||7-8||10-12||82||41||-|
|Jamaica (urban)6***||82||1972-73||4||5||6 - 8||94||42||48|
|Jamaica (rural)2||458||1969||6 - 9||9 - 12||9 -12||77||-||26**|
|Jamaica (rural)7||221||1971||1 - 5||6- 9||10 - 12||-||-||-|
|Jamaica8||91||1972||6 - 12||6 - 12||6-12||-||-||-|
|St Vincent 13||163||1967||5 -8||9 -12||9 - 12||-||-||-|
|St Vincent (rural)9||254||1967 - 69||4-6||7 -9||13 - 15||-||-||-|
|Grenada (rural)10||48||1972||5||9||12 - 16||75||50||20|
* National random sample surveys
** Under 4 months
*** Longitudinal studies
- Data lacking
1. R. Cook. Some Information about Feeding Practices in the Eastern Caribbean," West Indian Med. J.,20 (3): pp. 208 212,1971.
2. S.K. Reddy, "Artificial Feeding in Jamaica and Barbados," West Indian Med. J., 20 (3): pp. 198 - 207, 1971; also references 10 and 13.
3. F.A. Larkin, "Pattern of Weaning in Dominica," West Indian Med. J 20 (3): pp. 229 - 236, 1971.
4. Reference 12.
5. S.M Grantham-McGregor and E.H Back, "Breast Feeding in Kingston, Jamaica," Arch. Dis. Childh.. 45 (241) pp. 404 - 405, 1970; also reference 11.
6. J.P. Landman and V. Shaw-Lyon, "Breast-Feeding in Decline in Kingston, Jamaica," West Indian Med. J., XXV: pp. 43 - 57,1976
7. A.C.K. Antrobus, Programme Planning and Evaluation in Community Nutrition Education, Report on the Lambs River Project, Jamaica,1971 - 74 (Caribbean Food and Nutrition Institute. Kingston, Jamaica), 1975.
8. T. Greiner. "Infant Food Advertising and Malnutrition in St. Vincent, M.S. thesis, Cornell University, 1977, p. 141; also reference 6.
9. Reference 26.
10. Carribbean Food and Nutrition Institute, La Paterie Nutrition Survey, Grenada (CFNI, Kingston, Jamaica), 1972.
11. A longitudinal hospital population study of 418 Infants done in urban Trinidad in 1974 did not fit the table format. Gueri, Jutsum, and Hoyte, "Breast-Feeding Practices in Trinidad," Bull. PAHO,12: pp 316-322,1978, found 40 per cent weaned at four to five months, suggesting a median at perhaps five or six months of age Also, 88 per cent had other kinds of milk before three months, and 62.4 per cent were getting cereal by four to five months.
12. S. Almroth, "Breast-Feeding Practices in a Rural Area in Jamaica, M.S. thesis, Cornell University, 1976.
13. M. Beaudry, "An Ecological Study of Family Patterns of Food Consumption on the Island of St. Vincent.' M.S. thesis Cornell University, 1969.
Data from the Guyana National Nutrition Survey of 1971 illustrate the nature of some of these mixed feeding patterns (12). (See table 1 for basic survey data.) i he survey revealed that of 500 mothers, 79 per cent of the East Indian mothers and 83 per cent of African mothers had introduced milk in bottle or cup before their children reached five months of age. When asked what milk they used most often, 80 per cent of all mothers in the sample named a proprietary brand of formula milk. The survey questionnaire also examined the use of bush teas. Fifty-three per cent of all mothers said they used any one or a combination of over 28 different types of bush teas (herbal infusions); 68 per cent of these said they fed a whole bottle daily or several times per week, and 73 per cent started bush teas by the time the child was six months old. Furthermore, 86 per cent of the sample of mothers interviewed said they used pap or porridge in child feeding. These included, in order of frequency: plantain flour, oats, barley, sage, arrowroot, corn flour, cassava flour, and, to a much lesser degree, various proprietary cereals. Twenty-nine per cent of these mothers started using these preparations before their infant was four months of age; 63 per cent had started before the infant was six months old. Most mothers who used pap or porridge this early used both water and milk in the preparation, and 80 per cent fed the cereal by bottle because of its liquid consistency. Reddy (13) reports a similar practice at the other end of the Caribbean region in Jamaica: "Porridge is usually fed from bottles with teats having a larger hole than that used for milk feeds." I have found this practice very common in my own ethnographic observations in Jamaica; it was difficult to observe a distinction between bottles of milk, bottles of dilute pap, and bottles of dilute paps with milk added. Much more detailed research is needed to answer this question fully.
In contrast to the impression conveyed by the quoted summaries of the current situation, a majority rather than a minority of mothers are breast-feeding at three months, although they are also giving a wide range of supplementary milks, teas, juices, paps, and mixtures of these.
III. CONTEMPORARY TRENDS-POST-WORLD WAR II
This period in Caribbean history is characterized by the achievement of political independence from Great Britain by many states in the region. Economies tended to diversify; bauxite in Guyana, bauxite and tourism in Jamaica, and oil in Trinidad began to overshadow agricultural exports. However, agriculture has remained the largest employer sector in the economies of the region with the exception of Trinidad and Barbados (50). External trade and external economic influence have increasingly shifted away from England in favour of the United States (14). In addition, urbanization has accelerated. Urban growth rates were twice those of rural in the period 1950-1970 (50). For example, the Kingston metropolitan area had 16 per cent of Jamaica's population in 1943; by 1960 it had 23 per cent, and by 1970,26 per cent of the population (including the pert-urban areas and those who left the country from Kingston would much inflate this figure). Nevertheless, this reveals a change in the city's population from 203,000 in 1943 to 475,548 in 1970, a 234 per cent increase (2,15).
Sweetened condensed milk distribution was well established at the beginning of this period. Milk processing plants were built in Cuba in 1930 and in Jamaica in 1940 (16). By 1974, Jamaica imported 922 tons of finished milk products, from one multinational company, while the company's subsidiary increased milk production in Jamaica from 694 tons in 1940 to over 30,000 tons in 1974 (16). In the early 1970s, the Caribbean Food and Nutrition Institute reported that four local distributors for multinational milk firms were using a variety of advertising media and promotional methods to market infant formula milks in Jamaica. These included the distribution of free samples in hospitals, use of "mothercraft" nurses, and the use of the mass media (48). In St. Vincent, local health professionals claimed that bottle feeding was well established by the 1940s. Infant formula advertising was found in local newspapers as far back as 1935. By 1954 the number of advertisements appearing in one year had grown to 42 for six products (47).
The use of powdered milk for infant feeding was also encouraged in the 1950s and 1960s by the widespread distribution of powdered milk by UNICEF and USAID throughout the region (7).
Unfortunately there are apparently no survey data existing for the period 1945-1965 of comparable quality to those reported for 1970. The US-sponsored nutrition survey of the West Indies done in 1961 gathered data on lactation and infant feeding (A. Schaefer, personal communication), but they were not included in published reports (17). One must rely on indirect evidence of a shift in breast-feeding practice based mainly upon clinical pediatric studies. These studies show lower incidences of kwashiorkor relative to marasmus in children under 24 months, and higher incidences of malnutrition at younger ages. Aykroyd (18) described this shift in clinical aspects of malnutrition in south Trinidad between 1958 and 1963. Similarly, data from the Tropical Metabolism Research Unit of the University of the West Indies in Kingston-St. Andrew show that kwashiorkor admissions had declined from 32 per cent of all admissions of children with severe malnutrition in 1957-1959 to 20 per cent in 19721973. During the same period, marasmus admission increased from 20 per cent to 38 per cent of all admissions (19). The authors suggest that this change "may be associated with a change in infant feeding" specifically, earlier weaning and use of infant formula milk.
The economic growth of oil-rich Trinidad was well under way by 1958 when Jelliffe, Symonds, and Jelliffe (20) did their study at the San Fernando General Hospital and its catchment area. The survey examined the dietaries of 223 children in the community, and found that over 50 per cent were still breast-feeding during the second year of life in both East Indian and African ethnic groups. Bush teas were universally employed by the second semester, and by four months 54 per cent of East Indian and 67 per cent of African mothers were feeding their infants cow's milk, usually from various powdered formula preparations or condensed milk. The survey found that 7 per cent of African and 10 per cent of East Indian mothers were also feeding infants carbohydrate gruels by four months; these gruels consisted mainly of sago, arrowroot, and parched flour. However, dietary histories of children with PCM showed that most combined arrowroot flour with formula milk preparations. In the 14 of 15 instances of infantile kwashiorkor (mean age 8 months):
. . . infant feeding had consisted principally of mainly carbohydrate gruels and paps, such as sago, wheat flour, or, more usually, arrowroot (86%), sometimes associated with very small quantities of overdilute milk, usually one of a variety of dried products or occasionally a sweetened condensed preparation." [Italics added]
Of 69 cases of infantile marasmus and diarrhoea, weaning had occurred early (by two weeks) in 39 per cent of the cases, breast-feeding had not been initiated in 36 per cent, and in 18 per cent breast-feeding was supplemented with carbohydrate gruels. Infantile diarrhoea admissions were shown to be increasing dramatically (20).
Aykroyd (18) reports on a study tour to Jamaica, Puerto Rico, St. Thomas, Surinam, British Guiana, Grenada, Barbados, St. Lucia, Dominica, Antigua, St. Kitts, and Trinidad taken during the winter of 1963-64. In his travels he examined charts of children under treatment for malnutrition, and he reported impressionistic data about changing breast-feeding practices. High incidences of gastroenteritis and malnutrition were said to be associated with these changing practices. The information regarding feeding was obtained mainly by questioning doctors, health visitors, and nurses.
Visits to markets and shops provided useful information; for example, large displays of tinned milk products of many kinds, including expensive proprietary infant milk preparations, threw light on trends in child feeding, as did statements by shopkeepers such as, "We don't sell much arrowroot nowadays. " [18; italics added ]
The author goes on to state that the duration of breast-feeding in the Caribbean is relatively shorter than in other parts of the world.
Three to 6 months is usual and 9 months seems to be the limit except in a few communities, e.g., East Indians in British Guiana. This relates to the period during which the breast is offered to the child. A distinction must be made between breast-feeding as the sole or main source of the infant's nourishment, and partial breast-feeding which makes a smaller contribution to its needs. After 3 months or so, and often earlier, breast feeding, if it does not cease altogether, becomes partial. . . The mother usually needs to continue partial breast- feeding as long as possible in the hope of avoiding pregnancy. 
Aykroyd also concluded that at that time limited breast- feeding was changing in the direction of even less breast milk being given to the infant, and formula milks were replacing condensed milk (18). However, he acknowledges the superficial nature of the data on feeding and refers to the work of Jelliffe et al. in Trinidad (20), and Jelliffe in Jamaica (21, 22).
Jelliffe (21, 22) discusses the infant feeding patterns in Jamaica based entirely upon the work reported by Jelliffe, Williams, and Jelliffe (23), and Jelliffe, Bras, and Stuart (24). In both of these studies, community survey data are lacking, yet general descriptions of infant feeding are provided. One study presented data on clinical cases of malnutrition in children in one rural village (23). The other study was a report on 31 cases of kwashiorkor (in hospital? the study is unclear). Jelliffe states that mothers wean their children at about seven to nine months, although this is quite variable, one year being more common in rural areas. Earlier weaning is reported among working mothers, and those who have an early next pregnancy. Bush teas and starch gruels (usually cornmeal, degerminated maize starch) are said to be used throughout infancy (22). Jelliffe's general conclusions about the trends in breast-feeding in the Caribbean are pased upon the studies in Jamaica and Trinidad cited above, plus reference to the work of Aykroyd (18), which, in an interesting circularity, relies heavily on this same work by Jelliffe et al.
Some solid indication of the patterns of infant feeding in post-war rural Jamaica can be found in the intensive research work of social psychologist Madeline Kerr (25). Kerr investigated child-rearing patterns in three rural villages over the years 1947 - 1949. She reported that bush teas were used daily from birth by nearly all mothers and were considered to be a necessary supplement to breast milk. After ". . . about three or four months, pap made from starch, arrowroot, or cornmeal was given every day" (25). Mention is made of the bottle feeding of porridges or gruels. These were also used as weaning foods along with cow's and condensed milk. In a sample of 50 mothers, none reported weaning before infants were five months old, and the median weaning age was 12 months. This contrasts sharply with rural studies in Jamaica shown in table 1. Antrobus (26) in 1971 found weaning before five months in 25 per cent of the cases studied, and the median weaning age was between six and nine months. Yet bush teas were still used daily by half the mothers in 1971, and fresh and condensed cow's milk were chosen most often.
In summary, there are numerous indications, if not solid community survey data, that breast-feeding practices did change during the post-war years. Earlier weaning with all its negative health consequences began to be apparent by the 1950s. However, supplementation with bush teas from the neonatal period onward remained unchanged. In the late 1940s supplementation by the age of three or four months with dilute starchy gruels and porridges apparently was a common practice, and the use of the bottle was not unknown. Yet not until 1958 is there community survey data showing that supplementary milk feeding with powdered milk was practiced. Jelliffe et al. (20) have shown that in Trinidad early weaning both with and without supplementary milk feeding caused considerable problems. Traditional weaning foods which were nearly devoid of protein were given at such an early age that serious infantile kwashiorkor was prevalent. This evidence suggests that early weaning was occurring not only because formula milk powder was introduced. It is incorrect, in my view, to say the formula milk was "eked out" by adding starchy flours and water to the bottle. We see, instead, milk becoming a new ingredient in already existing preparations traditionally used as supplementary and weaning foods.
Based on this information and on that from earlier periods, the conclusion is justified that infants in the Caribbean 25 to 30 years prior to 1973 were not exclusively breas- fed until they were six months old. On the contrary, patterns of mixed feeding were already commonly practiced.
Conclusions as to the causes for these changing patterns during this period are certainly not very clear from these data. The rising rate of industrial production relative to agriculture, the growing internal migration to the cities, the rise of milk distribution through aid programmes, the use of modern hospital facilities, as well as the growing cultural influences which accompanied the tourist boom, all went hand in hand with commercial milk promotion. All were components of the unregulated development which has accompanied declines in breast-feeding in many parts of the world.