Breastfeeding & Body image
By Nanor Aghjian Cynthia Zanazanian Shant Leblebjian
Research Proposal FHSC288
Faculty of Health Sciences University of Balamand
August 2009
1
Table of Contents Acknowlegements________________________________________________________3 Introduction_____________________________________________________________4 Literature review_____________________________________________________________ 4 Ratinale and Hypotheses_______________________________________________________ 8 Research Question___________________________________________________________________ 8 Hypotheses________________________________________________________________________ 8 Objective__________________________________________________________________________ 8
Methodology____________________________________________________________9 Study Design_________________________________________________________________ 9 Target Population____________________________________________________________ 9 Attainable population________________________________________________________ 9 Data Collection_____________________________________________________________ 10 Ethical Issues_______________________________________________________________ 10 Variables___________________________________________________________________ 10 Limitations_________________________________________________________________ 11 Plan of Analysis_____________________________________________________________ 11
Conclusion_____________________________________________________________11 References_____________________________________________________________12 Appendices_____________________________________________________________13 Questionnaire_____________________________________________________________ 13 Informed Consent___________________________________________________________ 15
2
Acknowledgements
We would like to thank our mentor Dr. Sani Hleis for his support and advice, guidance about the ethical issues, and for his insight and valuable input along the semester.
3
Literature Review Women are identified in society by their appearance. Because of this cultural standard, women pay too much attention to their look and measure their value according to their physical appearance. Nowadays, a woman’s power has been related to her beauty and not her brain. Women themselves have socialized this concept in their lives, because they worry a lot about their prettiness. That’s why many females are obsessed with their bod y image and this affects their lifestyles leading to many health problems such as eating disorders, depression, nervousness, anxiety. Also, the rate of cosmetic surgeries is continuously increasing worldwide and most women pay billions of dollars to maintain their youth (Giddens, 2006). “Body image can basically be defined as the mind’s picture of the personal body and accompanying thoughts, feelings, and perceptions” (Roth, 2006). Body image can be classified into 3 major categories: body esteem which states whether the person feels positive or negative about her body, body satisfaction and body distortion (Roth, 2006). The way in which a woman perceives her body constitutes an important part of her personality: Does her shape make her self-confident? Does she appreciate her body more than anything else? Is she ashamed of her shape? According to WHO, breastfeeding is defined as: “The ideal way of providing young infants with the nutrients they need for healthy growth and development”. The breast milk has many benefits for both the infant and the mother. For the infant it causes less allergic reactions, the antibodies found in this milk protect the body against infectious diseases, it is easily digested because it is composed of well-balanced amino
4
acids, sugars and fats, it improves the mental development of the child, especially the IQ. As for the mother, breastfeeding helps her to resist different types of cancers, especially breast cancer, increases maternal and fetal attachment, it is inexpensive and aids in losing weight. Research has shown that “breastfeeding is an easy way to burn an extra 500-600 calories a day” (Zahorick, Il, and Webber, 2000). Moreover, according to The Breastfeeding Answer Book, mothers who breastfeed till three to six months after delivery lose more weight than formula-feeding mothers who consume fewer calories. A study done on one month postpartum women had shown that the hips of the breastfeeding mothers were slimmer and they had lower weights than those who relied on formulafeeding methods. It may be surprising to some women that lactation can even burn the fat accumulated before pregnancy (Zahorick, Il, and Webber, 2000). Many factors can influence a woman’s decision about breastfeeding such as cultural standards, traditional family practices, religious teachings, and most importantly, the feminine body image. There are many psychological and physiological changes that take place during pregnancy. For instance, the size of the abdomen and body weight increase. Most women desire to return to their pregnancy shape as soon as possible. According to a research done previously, the progression of pregnancy leads to the feeling of having negative body image and this emotion peaks after delivery (Huang, Wang, and Chen, 2004). For this reason, they might choose not to breastfeed thinking that such a feeding causes “sagging” of the breasts, which is a common misconception (Battersby). There has been a correlation between body satisfaction and the method of infantfeeding chosen. Those women who care about other’s judgments of their bodies tend to
5
bottle-feed their infants, because they can’t imagine themselves “as a vessel of infant nourishment” (Roth, 2006). Thus, a woman’s satisfaction with her body can be influenced by societal standards. Moreover, some mothers believe that the act of breastfeeding might damage their breasts. During pregnancy and breastfeeding, fat is stored in women’s bodies for the purpose of infant nourishment. This fact has been proved by a new research which has affirmed that fat cells do not form only during infancy and puberty, but also during the last trimester of pregnancy (Zahorick, Il, and Webber, 2 000). That’s why many mothers don’t lose their weight easily after pregnancy, even if they were able to control their weight before. This can be a real problem, because “fat cells are always ready and eager to store energy” (Zahorick, Il, and Webber, 2000). However, through diet and exercise we can shrink but not completely remove them. This issue of fat accumulation during pregnancy can become a big concern specifically for obese females, where statistics has shown that those with higher body mass index before pregnancy lean towards more negative body image during pregnancy (Huang, Wang, and Chen, 2004). Hence, such women are more inclined towards choosing bottle-feeding, because they think that breastfeeding will increase their weight. Since obese mothers are dissatisfied with their bodies they are more prone to post-partum depression and stress. According to general body image research, a positive correlation has been noted between body dissatisfaction and stress. In addition, these women make their lives miserable by putting themselves on strict diet to lose weight quickly since they put a high priority on regaining their prepregnancy weight and shape, thus avoiding breastfeeding. As a matter of fact, stressful women might find it difficult to breastfeed, since stress impairs the onset of lactation. On
6
the other hand, many women do not know the fact that breastfeeding decreases stress and facilitates adaptation to life with the infant (Roth, 2006). Moreover, it is important to mention that women who breastfeed tend to lose weight more in the first postpartum year. Also, stopping breastfeeding is not a solution for loosing weight because if a mother follows a well-balanced diet during nursing her child will be able to maintain her weight (Zahorick, Il, and Webber, 2000). Researchers who have conducted many studies of body image have proved that “women without body image disturbance were 1.25 times [CI: 1.09, 1.42] more likely to breastfeed than women who had marked concerns about their body shape” (Roth, 2006). According to the advocates of breastfeeding, such a method can help to elevate the woman’s self-esteem; thus it may be a crucial mediating factor for body satisfaction in the postpartum period. Body image is also linked with sexuality. Certain societies define some bod y shapes as fashionable where the shape and the size of the breast are highly emphasized. Women’s breasts are increasingly sexualized specifically in western societies. In addition, one of the indicators of female attractiveness in these cultures has been the size of the breasts. That’s why the breasts are viewed primarily as sexual objects and both genders perceive breastfeeding as “primitive and crude” (Battersby). Furthermore, it is more likely for females in these societies to use their breasts for erotic p urposes rather than for feeding an infant since the breasts are regularly viewed as sexual items, then this can lead to feelings of disgust and embarrassment when breastfeeding is thought of (Battersby). Hence, even if these women decide to breastfeed, there is high probability of stopping nursing and shifting their focus on themselves due to their encounter of negative sexual messages about their bodies (Roth, 2006). According to Breastfeeding and Human
7
Lactation, breasts are described as “part of a woman’s internalized body image… representing a woman’s deepest sense of woman hood. Any change in her breasts… threatens this feminine internal view of self” (Roth, 2006). It should be mentioned that that the changes that come with lactation modify how women view their body attractiveness (Roth, 2006). However, what these wo men do not know is that during breastfeeding the woman’s nipples will be less sensitive to sexual arousal; Thus, the breasts can not be regarded as sexual stimuli during nursing. In addition, since no research has proved that breastfeeding withdrawal can reduce the breast size and since breastfeeding has many benefits than any other method of feeding, then it is more favorable to continue nursing a baby. Hypothesis:
An interesting research question could be raised o n this issue; Is breastfeeding affected by woman’s conception about her body image? Many studies have shown a very high association between body image and the method of infant feeding chosen (Zahorick, Il, and Webber, 2000). In this research we are going to test the following hypothesis: “Breastfeeding does not disturb a woman’s body image”. Objectives:
Estimate if there is an association between breastfeeding and body image.
Estimate if there is an association between breastfeeding and sexuality.
Indicate whether Lebanese women pay more attention to breastfeeding or to physical image.
8
Assess whether other different variables like: education, parity, occupation, socioeconomic status, and prenatal class attendance also affect women’s decision in breastfeeding.
Methodology Study design: We will conduct a descriptive cross sectional study on a representative sample of population because it allows us to assess the relationship between breastfeeding and body image and other factors of interest as they exist in the specified population at a particular time. Moreover, it can be used to gather information about the prevalence of breastfeeding in Lebanon and assess mothers’ knowledge, attitudes and practices regarding this issue. Target population: Our sample will include post-partum women who gave birth in 2 Lebanese hospitals in Beirut (Lebanon) in November through clustered sampling. The inclusion criteria of the study will be only those women who are multi-parous and have the ability to read and write Arabic. Attainable population: We will recruit all women presenting for delivery from the list of hospitals and fitting the eligibility criteria until the sample size is satisfied. All women participating in the study will have to complete a fifteen minute questionnaire, assessing their misconception about breastfeeding.
9
Data collection: We will collect our data through self administered questionnaire (survey) of 15 minutes each. The data will be collected in the year 2010 in November. Ethical issues: The informed consent prepared should be clearly read and signed by the participants to avoid any misunderstanding. The answers should be respected and protected whereby no one should have access to them and to any other private or contact information without the approval of the principle investigator. All results and conclusions should be disseminated with complete objectivity and regardless o f any research advantages. The assessors will be ready to answer any question related to the topic and any women having concerns will be provided by a contact number. There must be confidentiality, anonymity and privacy whereby each woman should complete the questionnaire alone. The woman has the freedom not to answer any question that she finds disturbing or disrespectful and to stop the questionnaire at any time. Variables: Our dependent variable is the breastfeeding and the independent variable is the body image. Both variables will be assessed by a questionnaire which is composed of 2 parts. The first part gathers demographic data about the participants where it also integrates an item that indicates the choice for infant feeding method. This closed question offers three response alternatives: breastfeeding, bottle-feeding, and mixed (breast and bottle) feeding. The second part includes questions that assess mothers’ attitude towards breastfeeding, body image, sexuality and other factors of interest.
10
Responses were based on a 5-point Likert scale, with 1= strongly disagree, 2= disagree, 3= neutral, 4= agree, 5= strongly agree. High scores indicate a more positive body image and higher level of tendency to breastfeed. Our confounders will be the education level, parity, occupation (housewife or employed outside home, socioeconomic status (low, middle, high), and prenatal class attendance. Limitations: A limitation of this study is that it would be difficult to establish causal relationships, that is, it cannot identify why women think that breastfeeding disturbs body image. Another drawback of our study is that changes and trends over time cannot be drawn from a cross-sectional study such as this investigation. Plan of analysis: A univariate analysis will be performed where the mean and standard deviation will be used to assess the quantitative variables. A multivariate logistic regression will be performed to examine the level o f association between breastfeeding and body image controlling for confounders. SPSS 130 will be used to perform these analyses. Conclusion:
An interesting question that would emerge from our study wou ld concern whether or not factors such as emotional and physical support at birth and rooming-in affect women’s perception of their baby and change their attitude about breastfeeding. A follow-up investigation of how many women change their intended feeding method also
11
would be of interest after 1 month by use of telephone interview. We suggest that both issues should undergo further research.
Reference List
Abdul Khalek, F & Madi, H.. (2009). Misconceptions about the use and effects of Contraceptive pills among women planning to get married in Lebanon. Unpublished manuscript. University of Balamand.
Battersby, S. Exploring attitudes towards infant feeding. Retrieved from Academic Search Premier Database.
Giddens, A. (2006). Sociology. (5th ed.). Cambridge: Polity Press.
Huang, H.C., Wang, S.Y., & Chen, C.H. (2004). Body Image, Maternal-Fetal Attachment, and Choice of Infant Feeding Method: A Study in Taiwan. Birth: Issues in Perinatal Care, 31(3), 183-188. doi: 10.1111/j.0730-7659.2004.00303. Retrieved from Academic Search Premier Database.
Roth, M. (2006). Could Body Image Be a Barrier to Breastfeeding? A Review of the Literature. Leaven, 42, 4-7. Retrieved from http://www.llli.org/llleaderweb/LV/LVFebMar06p4.html
12
Zahorick, M, Il, R. & Webber, V. (2000). Postpartum Body Image and Weight Loss. New Beginnings, 17, 156-59. Retrieved from http://www.llli.org/NB/NBSepOct00p156.html
Appendices
Questionnaire about Breastfeeding and body image Assessor: _______________
Questionnaire No ____ Date of interview: ___________ We are nursing students from the University of Balamand and we will conduct this study for our research course in order to estimate the number of women who breastfeed their infants. We also want to see whether body image and sexuality interfere with breastfeeding along with other confounders. To note, we will maintain confidentiality and anonymity of the participants.
Age: ___ years Weight: ___ Kg Height: ___ cm Education level: Primary Intermediate Secondary University Occupation: Health profession Non-Health profession Socioeconomic status: No of family members: ___ No of rooms: ___ Marital status: Married Single Divorced Widow No Prenatal class attendance: Yes Number of children: ___ Number If any, a) How many were breastfed exclusively?
b) How many were mixed fed? c) How many were formula fed exclusively? You are planning to breastfeed. Strongly disagree
Neutral
Agree
Strongly agree
Breastfeeding is beneficial for the mother’s health. Strongly disagree Disagree Neutral
Agree
Strongly agree
Disagree
13
Breastfeeding is beneficial for the child’s health. Strongly disagree Disagree Neutral
Agree
Strongly agree
Breast milk is the ideal food for babies. Strongly disagree Disagree
Agree
Strongly agree
Neutral
WHO recommends that infants should be breastfed for 2 years. My attitude regarding this issue is: Strongly disagree Disagree Neutral Agree Strongly agree
Your body shape was more acceptable before pregnancy. Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Agree
Strongly agree
Strongly agree
You have difficulty losing weight after pregnancy. Strongly disagree
Disagree
Neutral
You follow strict diet to lose weight quickly after pregnancy. Strongly disagree
Disagree
Neutral
Agree
You feel badly about yourself because you don’t like your body because of breastfeeding. Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Neutral
Agree
Strongly agree
Breastfeeding disturbs body image. Strongly disagree
Disagree
You pay more attention to physical image than to breastfeeding. Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Agree
Strongly agree
You think that breasts are viewed as sexual objects. Strongly disagree
Disagree
Neutral
You avoid breastfeeding because breasts are viewed as sexual objects. Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Agree
Strongly agree
Breastfeeding disturbs the shape of your breasts. Strongly disagree
Disagree
Neutral
Breasts should be used for erotic purposes rather than for infant feeding. Strongly disagree
Neutral
Agree
Strongly agree
Breastfeeding is compatible with m y occupation. Strongly disagree Disagree Neutral
Agree
Strongly agree
Agree
Strongly agree
Disagree
You are being hospitalized in baby friendly hospital. Strongly disagree Disagree Neutral
14
Health professionals should actively encourage all mothers in their p ractices to try breastfeeding. Strongly disagree
Disagree
Neutral
Agree
Strongly agree
15
UNIVERSITY OF BALAMAND Faculty of Health Sciences June 2009
CONSENT FORM
Dear Participant, You are invited to participate in a study that will examine misconceptions about breastfeeding. We hope to understand better the benefits of breastfeeding and some issues that stop women from breastfeeding. You were selected as a possible participant in this study because we would like to assess your knowledge about breastfeeding and understand better your concerns and decisions about whether to breastfeed or not. This is why we would like you to fill this questionnaire. This study is conducted by the Faculty of Health Sciences at the University of Balamand. The interview will take approximately 15 minutes. We will ask you questions about: Your decision to breastfeed or not. • Your preferred/favored method of infant feeding. • Your knowledge about the benefits and concerns in relation to breastfeeding. • Any personal information provided by you will remain totally confidential and will be disclosed only with your permission. The information provided will be used only for research purposes. Your name, address, and other personal information will be removed from the questionnaire, and only a code will be used to connect your name and your answers without identifying you. Your decision whether or not to participate is voluntary. If you decide to participate, you are free to discontinue participation at any time without prejudice. If you have any questions, please do not hesitate to contact us at any time. If you have any additional questions later, please contact Ms. Nanor Aghjian, Ms. Cynthia Zanazanian or Mr. Shant Leblebjian at 03-074288 who will be happy to answer them. You will be offered a copy of this form to keep.
Thank you
16
Nanor Aghjian, Cynthia Zanazanian and Shant Leblebjian Faculty of Health Sciences, University of Balamand Beirut Lebanon
Read by respondent ( Agreed (
)
)
Assessor ( Refused (
) )
_____________________________________________________________________ You are making a decision whether or not to participate. Your signature indicates that you have read the information provided above and have decided to participate. You may withdraw at any time without penalty or loss of benefits to which you may be entitled after signing this form should you choose to discontinue participation in this study.
____________________________________ Signature of Participant _____________________________________ ___________________________ Signature of Assessor Date
17