Social Science and Medicine 52 (2001) 71–81

Determinants of breastfeeding in the Philippines: a survival

analysis
Teresa S.J. Abada*, Frank Trovato, Nirannanilathu Lalu
Department of Sociology and Population Research Laboratory, The University of Alberta, Edmonton, Alberta, Canada T6G 2H4

Abstract

This study examines modern and traditional factors that may lengthen or shorten the duration of breastfeeding.
Specifically, health sector, socio-economic, demographic, and supplementary food variables are analysed among a large
representative sample of women in the Philippines. It is proposed that while modernisation can lead to the adoption of
western behaviours, traditional cultural values can also prevail, resulting in the rejection of certain aspects of
modernity. The Cox Proportional Hazards model is employed for the analysis of breastfeeding. The results show that
traditional factors associated with breastfeeding (use of solid foods such as porridge and applesauce, and prenatal care
by a traditional nurse/midwife) do not play a significant role in the mother’s decision to continue breastfeeding. Factors
associated with modernity are significant in explaining early termination of breastfeeding (respondent’s education,
prenatal care by a medical doctor, delivery in a hospital and use of infant formula). The findings of this study suggest
that health institutions and medical professionals can play a significant role in promoting breastfeeding in the
Philippines; and educational campaigns that stress the benefits of lactation are important strategies for encouraging
mothers to breastfeed longer. # 2000 Elsevier Science Ltd. All rights reserved.

Keywords: Breastfeeding; Promotion of breastfeeding; Philippines

Introduction The decline in the initiation and duration of

Breastfeeding plays a particularly important role in
child survival in developing countries: it contributes to
the child’s immunologic defense system, and increases its
resistance to disease. Breastfeeding also facilitates child
survival through postpartum annovulation and post-
partum abstinence as these increase the intervals
between births (Huffman & Lamphere, 1984). According
to Williamson (1986), both the incidence and duration
of breastfeeding in the Philippines are on the decline.
This trend is of major concern to officials because family
income is generally low, child nutrition is often
inadequate, and there is little use made of modern
family planning methods. To the extent that breastfeed-
ing becomes less prevalent among mothers, fertility will
remain high and child survival probabilities will not rise
as much as they could.
*Corresponding author.
breastfeeding is an inevitable consequence of the
modernisation process (Adair, Popkin & Guilkey,
1993; Akin, Bilsborrow, Guilkey & Popkin, 1986;
Guilkey, Popkin, Akin & Wong, 1989; Guthrie, Guthrie,
Fernandez & Estrera, 1983; Kent, 1981). In a broad
sense, modernisation entails a rapid abandonment of
traditional approaches to childrearing, and the adoption
of modern practices, including the use of modern health
services and the use of supplementary foods for infants,
in favour of breastfeeding or prolonged lactation.
Notwithstanding this generalisation, modernisation is
seldom a process that involves a sudden change in
behaviours from traditional to modern. This is particu-
larly true during the early stages of modernisation
(Romaniuk, 1980). As such, some aspects of breast-
feeding behaviour can take on both modern and tradi-
tional features simultaneously. In this study, we examine
both modern and traditional factors that may affect the
duration of breastfeeding. Socio-economic, demographic,
supplementary food and health sector variables will be

0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved.
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72 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81
analysed among a large representative sample of women in
the Philippines. An understanding of these factors should
prove useful in formulating policies that seek to promote
breastfeeding in developing countries.
Socio-economic and demographic factors
Urbanisation is usually associated with lower incidence
and a shorter duration of breastfeeding (Castle, Solimano,
Winikoff, Samper de Paredes, Romero & Morales de
Look, 1988; Akin et al., 1986; Huffman & Lamphere,
1984; Ferry & Smith, 1983). The adoption of bottle-
feeding in the urban areas is widespread both because it is
considered to be more modern, sophisticated and
convenient (especially if the mother works outside the
home), and because there are fewer breastfeeding role
models for urban women to emulate (Trussell, Grummer-
Strawn, Rodriguez & Vanlandingham, 1992). In the rural
environment, however, breastfeeding calls for little change
in lifestyle. The presence of additional family members in
the household, in particular mothers-in-law, provides
positive support for breastfeeding practices, encouraging
mothers to breastfeed for a longer period of time (Stewart,
Popkin, Guilkey, Akin, Adair & Fleiger, 1991; Butz,
Habicht & De Vanzo, 1981).
One of the key determinants of the decline in
breastfeeding in the Philippines is the increasing level
of education among women, a factor which plays a role
in the adoption of modern ideas, and which usually
leads to the abandonment of traditional practices
regarding child care. This shift in the balance of family
relations can manifest itself in the abandonment of
traditional sources of influence, namely extended family
members, which can often result in breastfeeding of a
shorter duration (Caldwell, 1979).
The amount of time a mother has to breastfeed is
determined by her occupation. Women involved in
modern work, such as clerical, factory and professional
jobs in the urban centres are often required to work away
from home, thus reducing a mother’s access to her child.
On the other hand, women who are involved in traditional
or informal work (agricultural activities, cottage indus-
tries and small scale marketing (especially in the rural
areas)), have more flexible schedules and this allows them
to nurse their infants more often, thus maintaining longer
periods of lactation (Huffman, 1984; Ho, 1979).
The transition from traditional to modern societies
has prompted a move away from breastfeeding of long
duration, particularly among younger generations of
women. For older women, a strong attachment to
traditional customs and the experience of raising many
children usually means a more rigid view of infant
feeding patterns. Such women are more likely to reject
modern breast milk substitutes and to rely on traditional
forms of infant feeding, including prolonged breastfeed-
ing (Kent, 1981).
On the other hand, increasing maternal age and high
parity can also lead to breastfeeding of a shorter
duration. Higher parity leads to shorter birth intervals
and hence shorter times available for breastfeeding. It is
also well established that parity is closely related to
maternal age (Smith & Ferry, 1984). An older woman is
more likely to have a greater number of children; hence
the demands on her time are considerable which may
lead to early termination of breastfeeding. Indeed, a
large family size may not be compatible with the modern
lifestyle in the city, leading to a shorter duration of
breastfeeding. The demands of childcare coupled with
the demands of a highly structured employment only
increases the conflict between the maternal role and the
work role, which in turn reduces the duration of
breastfeeding. High parity also leads to breastfeeding
of a shorter duration among rural women. Poor
nutritional status, particularly among older women can
diminish the volume as well as the fat and vitamin
content of breast milk (Jelliffe & Jelliffe, 1978). The
result is that not enough adequate breast milk will be
provided to the infant, thus hastening the early
termination of breastfeeding.
Supplementary food variables
In the Philippines, certain supplementary foods, such
as rice water, are considered culturally important and
can affect the timing of the weaning process. For
example, rice water, apple juice and tea brews are used
as folk remedies for infant diarrhoea (Simpson-Hebert &
Makil, 1985). Such beliefs strongly influence the timing
of the introduction of supplemental foods, which in turn
affects the duration of breastfeeding. The early intro-
duction of milk supplements results in the reduction in
frequency of breastfeeding; this in turn may lead to a
decrease in the mother’s breast milk, which ultimately
hastens the termination of breastfeeding. Moreover, the
marketing activities of the infant formula industry have
played an important role in providing alternative infant
foods, especially in the urban areas, where the use of
such substitutes alleviates the time constraints prompted
by the changes in maternal lifestyle (Guthrie et al., 1983).
Other solid supplements such as rice porridge, or
applesauce may promote breastfeeding of longer dura-
tion. The infant’s weight is often a sign of successful
breastfeeding and if such supplements are used early on
the infant’s diet, then the improved overall health of the
infant can encourage mothers to breastfeed for a longer
period of time (Adair et al., 1993).
The role of the health sector
The type of advice provided by medical practitioners
to mothers regarding breastfeeding is often conditioned
by the marketing activities of the infant formula
 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81 73

industry. Health professionals who are involved in the doctor have a greater probability of early termination
prenatal care and the delivery of babies are often of breastfeeding.
provided with advertising materials as well as free 2. Women who deliver in a hospital as opposed to their
samples of infant formula to be distributed to new own home have a greater probability of early
mothers (Adair et al., 1993; Stewart et al., 1991). Health termination of breastfeeding.
professionals who consider infant formula to be better
than breast milk can influence their patients to adopt
Data and methods of analysis
infant formula over breastfeeding. Studies have shown
that prenatal care from a medical doctor and institu-
Data
tional delivery often results in breastfeeding of a shorter
duration. This suggests that the movement away from
This study is based on data from the Individual
breastfeeding is also a consequence of the replacement
Women’s Questionnaire in the 1993 Philippines Na-
of traditional health care systems by the modern
tional Demographic Health Survey, conducted between
medical establishment (Mock, Franklin, Bertrand &
April and June 1993. Information was collected on
O’Gara, 1985; Popkin, Yamamoto & Griffin, 1985;
topics that included background characteristics (educa-
Solimano, Winikoff & Laukaran, 1984; Adair et al.,
tion, age), reproductive behaviour and intentions,
1993).
availability of family planning supplies and services,
breast-feeding, child health and maternal mortality. The
maternity history contains a maximum number of six
Hypotheses
entries relating to births in the 5 years preceding the
interview.1
A number of hypotheses are outlined in relation to
The Integrated Survey of Households (ISH) devel-
each of the factors discussed in the preceding section.
oped in 1980, comprised samples of primary sampling
(A) Socio-economic and demographic factors }
units (PSU) and was employed to generate information
Wife’s Education, Husband’s Education, Wife’s Occu-
on employment and socio-economic characteristics
pation, Husband’s Occupation, Maternal Age, Parity.
among a nationally representative sample of women
aged 15–49 years. A total of 2100 PSU was system-
1. The higher the level of education the greater the
atically selected for the ISH, 750 of which were selected
probability of early termination of breastfeeding.
for the 1993 DHS, with a probability of selection
2. Involvement in professional/administrative jobs de-
inversely proportional to the size of the barangay.2 The
notes a greater probability of early termination of
PSU selection, which was self-weighted in each of the 14
breast-feeding, whereas involvement in agricultural/
regions, was carried out separately for the rural and
domestic household services denotes a lower prob-
urban areas, using a two stage sampling design. The first
ability of early termination of breastfeeding.
selection consisted of barangays and the second selection
3. The older the mother, the earlier the cessation of
consisted of households within the barangay. A total of
breastfeeding.
1659 valid cases were obtained for the study.
4. High parity women have a greater probability of
early termination of breastfeeding.
Measurement of variables
(B) Supplementary foods } Other Liquids, Infant
Formulas, Solid Foods:
Dependent variable
1. The earlier the introduction of other liquids and
In this study, duration of breastfeeding is the
infant formulas into the infant’s diet, the greater the
dependent variable and is based on information pertain-
probability of early termination of breastfeeding.
ing to the last child of the respondent.3 The variable is
2. The earlier the introduction of solid foods, the lower
the probability of early termination of breastfeeding.
1
If the respondent had more than six births in the last 5
(C) Health Sector Variables } Prenatal Care received years, then only the last six are included in the maternity
from Traditional Nurse/Midwife, Prenatal Care from history.
2
Barangays are considered to be the smallest political
Medical Doctor, Delivery in a Hospital.
subdivision that corresponds to a census enumeration area.
3
Potential errors may arise in the data, particularly for
1. Women who receive prenatal care advice from a respondents who breastfed for a short time only, and may have
traditional nurse/midwife have a lower probability of failed to report this. But the study minimises the recall error
early termination of breastfeeding, whereas women regarding this concern since it focuses on the last child born in
who receive prenatal care advice from a medical the last five years.
74 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81
calculated as the number of months that the mother
reports having breastfed the child. The maximum
number of months recorded in the survey was 40 months.
Independent variables
Socio-economic and Demographic Variables } Age,
Parity, Highest Level of Education (Respondent’s and
Husband’s), Occupation (Respondent’s and Husband’s).
The age of the mother is measured as a continuous
variable, in single years of age from 15 to 49 years. Parity
is measured as the total number of children. Since the
study focuses on women who have had at least one child,
the lowest possible value assigned to parity is one. The
education of both respondent and spouse is the highest
level of schooling attained, measured as no education,
primary, secondary, and post-secondary. The respondent’s
and husband’s occupation is also measured as a catego-
rical variable: not working, agricultural job, self-em-
ployed, and household/domestic comprise one category,
and professional/administrative, clerical/sales the other.
Supplementary Food Variables } Age for Infant
Formula, Age for Solids and Age for Liquids.
These three variables represent the last child’s age in
months when the mother started to use food supple-
ments on a regular basis. The maximum number of
months is 30 months.
Health Sector Variables } Prenatal Care } Doctor,
Prenatal Care } Traditional Nurse/Midwife and Place
of Delivery.
Categories relating to prenatal care are dichotomous:
no prenatal care from a doctor, and prenatal care from a
medical doctor; no prenatal care from a traditional
nurse/midwife, and prenatal care from a traditional
nurse/midwife. The place of delivery is measured as
either in a home, or in a hospital.
Methods
Survival analysis has been used in the analysis of
breastfeeding. The 1993 Philippines DHS is a retro-
spective cross-sectional survey that provides maternity
histories completed up to the time of the survey. It is
expected, therefore, that the period between the start
and the end of breastfeeding would vary significantly
among women. The survival analysis technique adjusts
for truncation bias by incorporating both complete and
incomplete segments of histories in the breastfeeding
analysis (some women may be continuing to breastfeed
at the time of the survey). The Cox proportional hazards
(PH) model may be viewed as a multivariate life table,
but unlike other regression techniques, this method uses
censored data, and thus controls for truncation bias
(Allison, 1984). This model allows one to stratify across
factors that do not meet the proportionality assumption.
In the present case, it was discovered that rural-urban
residence did not meet this assumption4 (SPSS, 1997;
Kleinbaum, 1996). For this study, rural-urban residence
is used as stratification variable (i.e. urban, rural) rather
than as a covariate. Each stratum has a different baseline
hazard function, resulting in hazard functions for the
rural and the urban models.
Descriptive statistics and the individual effects of the
Cox regression analysis for each variable are given to
provide a general overview of the covariates in the
analysis. The Cox regression analysis is set in two stages.
First, the various predictors are grouped into separate
models. Model I consists of the socio-economic and
demographic variables (education, occupation, age, and
parity); Model II consists of the supplementary food
variables; Model III consists only of the health sector
variables. Next, all the predictors found to be statisti-
cally significant from the previous three models are
grouped into Model IV and analysed accordingly. The
hazard function5 is expressed as:
hðt; zÞ ¼ h0 ðtÞeðbzÞ
where h(t,z) is the hazard rate at time t, h0(t) is the
baseline hazard function of t, b is a vector of coefficients
and z is a vector of covariates. It is assumed in this
model that: (1) there is a hazard or risk of occurrence of
the event of interest (in this case, the termination of
breastfeeding) at each time t, and this is applicable to all
members of the population; (2) at each time t, the
respondents at one level of a given sub-group experience
a hazard proportional to the reference category; the
models are a function of time and regressor variables; (3)
even though there will only be one set of coefficients, the
model is partitioned into two strata, one for rural
residence, and the other for urban residence (Klein-
baum, 1996). The different baseline hazards for each
rural and urban residence yields different estimated
survival curves (see Fig. 1).
Results
Fig. 1 shows the respective survival curves for rural
and urban women. The survival curves represent the
4
The proportionality of hazards was checked via inspection
of the plots of the log minus log survival function [hi(ti, Zi)] for
strata defined by variables suspected of having a non-
proportional effect on the hazard function. Results indicated
that among all the predictors, rural–urban residence did not
meet the assumption of proportionality of hazards.
5
A likelihood ratio test was also carried out to compare the
log-likelihood statistics for the interaction model (rural–urban
residence  predictor variables) and the non-interaction model.
The difference in the LR statistic of the two models was
295.529ÿ291.616=3.913, which is not significant at the 0.05
level. Therefore, we can conclude for these data that the non-
interaction model is acceptable (at least at the 0.05 level).
 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81
Fig. 1. Survival curves for duration of breastfeeding in the Philippines: rural and urban samples, 1993.
probability of women who continue to breastfeed at any
given time. The survival curve for rural women is
consistently above that of urban women. At each point
of duration, urban women have a lower probability
surviving (continuing to breastfeed) relative to rural
women. For example, at duration one, the probability of
continuing to breastfeed for among urban women is
only 0.650, whereas for rural women, the probability of
continuing to breastfeed is approx. 0.825.
Table 1 presents means and standard deviations of
covariates. The average duration of breastfeeding is 7.5
months. The mean age of the mother for the sample is 33
years, while the average number of children born is 3.9.
The following categorical variables are expressed in
percentage values. About one half of respondents only
attained up to a primary education, and only 22.1%
have attained a post-secondary education. Only 16.1%
are involved in professional and administrative work,
whereas about 83.4% are involved in agricultural work,
indicating that the majority of mothers still work close
to home. The husband’s education shows a similar
pattern to the wife’s education. Only 21.6% have
achieved a post-secondary education. Unlike the re-
spondent’s occupation, a greater percentage of husbands
(50.1%) are involved in professional and administrative
work. The mean age of the child at the time of the
introduction of infant formula and other liquids on a
regular basis is 9.4 months and 8.7 months respectively.
Infants are weaned to solid foods earlier around 7.5
months of age, denoting the importance of certain
cultural foods (rice porridge) as a means of promoting
the infant’s health (Simpson-Hebert & Makil, 1985).
Table 2 presents the individual effects of each of the
variables on the duration of breastfeeding. Maternal age
75
is not statistically significant. Women with a post-
secondary education and those involved in professional/
administrative work and women with high parity are
associated with early termination of breastfeeding. The
husband’s education and occupation were not statisti-
cally significant. Women who had prenatal consultation
with a medical doctor had a risk of ceasing to breastfeed
that was 25% higher than women who did not consult a
medical doctor. Those who delivered in a hospital were
also associated with breastfeeding of shorter duration.
Women who consulted a midwife had a risk ceasing to
breastfeed that was 11% lower than their counterparts
who sought prenatal care advice elsewhere. As hypothe-
sised, those women who used infant formula and other
liquids (such as rice water) early had a higher probability
of ceasing to breastfeed. The effect for solid foods was
not statistically significant.
The next three tables show the changes in the effects of
the predictors once we control for other variables. Three
separate Cox regression analyses were computed for the
three models.
Model I: socio-economic and demographic variables
Table 3 shows that among the socio-economic and
demographic variables, the respondent’s education,
occupation, and parity are the only predictors that
remain statistically significant. For women with post-
secondary education, the risk of ceasing to breastfeed is
1.52 times greater than in women without post-
secondary education. Women who are involved in
professional/managerial positions have a higher prob-
ability of ceasing to breastfeed than women involved in
low skilled/agricultural positions. This finding is con-
76 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81

Table 1
Means/percentages and standard deviations of covariatesa

Variable Mean/percentages Standard deviation

Duration of breastfeeding 7.5 7.21

Maternal age 33 7.93
Respondent’s education
No education 3.3%
Primary education 41.8%
Secondary education 32.8%
Post-secondary and higher 22.1%
Respondent’s occupation
Household/domestic/agricultural work 83.4%
Professional/administrative/clerical 16.1%
Total number of children born 3.9 2.47
Husband’s education
No education 2.7%
Primary 42.9%
Secondary 32.8%
Post-secondary and higher 21.6%
Husband’s occupation
Household/domestic/agricultural 49.9%
Professional/administrative/clerical 50.1%
Prenatal-care doctor 49.6%
Prenatal-care nurse/midwife 54.2%
Place of delivery (home) 59.0%
Place of delivery (hospital) 41.1%
Age for infant formula 9.43 11.86
Age for other liquids 8.74 9.93
Age for solids 7.59 8.14
a
Source: in this and subsequent tables, figures, computed using data from 1993 Philippines National Demographic Health Survey.

sistent with other studies regarding maternal work and
compatibility with childrearing, suggesting that the rigid
hours associated with such types of employment can
encourage the mother to use infant formula early,
resulting in a shorter duration of breastfeeding (Van
Esterick & Grenier, 1981; Butz et al., 1981; Ho, 1979).
The relative risk for parity (as represented by total
number of children born) is 1.4923 and is highly
significant at the 0.0001 level. It appears that the
presence of additional children in the household
would place more constraints on the mother’s time
thereby increasing the conflict between work and
motherhood.
Model II: supplementary food variables
Table 4 shows the effects of the supplementary food
variables on the probability of termination of breast-
feeding. Contrary to the hypothesis, the age for solids
was in the negative direction, whereas the age for liquids
was in the expected negative direction. Both effects were
not significant. The older the age at which infant
formula is introduced into the infant’s diet, the lower
the hazard rate. The relative risk is 0.9735, indicating
that the hazard is reduced by 0.03% for each additional
month of infant’s age at which the introduction of infant
formula is delayed. This finding is consistent with other
studies in which the introduction of breast milk
substitutes is associated with a relatively rapid cessation
of breastfeeding (Winikoff, Durongdej & Cerf, 1988;
Castle et al., 1988).
Model III: health sector variables
Table 5 presents the estimated coefficients and the
relative risks for the health sector variables. The only
predictor that was not statistically significant is the
prenatal care advice } traditional nurse/midwife. The
estimated risk of ceasing to breastfeed is 1.1964 times
greater for women who sought prenatal care advice from
a medical doctor, in comparison to women who did not
consult a medical practitioner. Women who delivered in
a hospital had an estimated risk of stopping breastfeed-
ing that was 15% higher than women who gave birth at
home. Our study also shows that the movement away
from breastfeeding is a function of the practices of
medical practitioners in those facilities. These factors
can affect the mother’s attitudes towards breastfeeding
negatively, which in turn encourage early use of infant
formula, leading to early termination of breastfeeding.
 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81 77

Table 2
Proportional hazards (gross effects) of duration of breastfeeding: socio-economic, demographic, health sector and supplementary food
variablesa

Variable Coefficients Standard error Relative risk

Maternal age 0.0100 0.0056 1.0101

h0(0)rural=0.0262; h0(0)urban=0.0631 Education
No education (Ref)
Primary ÿ0.0820 0.0671 0.9213
Secondary 0.0779 0.0636 1.0810
Post secondary 0.4973 0.0669 1.6443
h0(0)rural=0.0301; h0(0)urban=0.0652
Respondent’s occupation
Not working (ref)
Agricultural ÿ0.1086 0.0444 0.8971
Professional/administrative 0.2196 0.0428 1.2456
h0(0)rural=0.0339; h0(0)urban=0.0806
Parity 0.3456 0.0385 1.4129
h0(0)rural=0.0186; h0(0)urban=0.0459
Husband’s education
No educ (ref)
Primary ÿ0.0748 0.0698 0.9282
Secondary 0.0526 0.0681 1.0537
Post-secondary 0.3673 0.0726 1.4438
h0(0)rural=0.0318; h0(0)urban=0.0691
Husband’s occupation
Not working (ref)
Agricultural ÿ0.2776 0.3351 0.7577
Professional/clerical/administrative ÿ0.0400 0.3367 0.9612
h0(0)rural=0.0438; h0(0)urban=0.0983
No doctor (ref)
Prenatal Care } Doctor 0.2284 0.0406 1.2566
h0(0)rural=0.0420; h0(0)urban=0.0755
No Nurse/midwife(ref)
Prenatal Care-Nurse ÿ0.1194 0.0387 0.8874
h0(0)rural=0.0297; h0(0)urban=0.0807
Delivery-home (ref)
Place of delivery-hospital 0.1733 0.0297 1.1892
h0(0)rural=0.0364; h0(0)urban=0.0801
Age for infant formula ÿ0.0235 0.0027 0.9768
h0(0)rural=0.0452; h0(0)urban=0.0991
Age for other liquids ÿ0.0116 0.0037 0.9884
h0(0)rural=0.0374; h0(0)urban=0.0871
Age for solids ÿ0.0108 0.0064 0.9893
h0(0)rural=0.0363; h0(0)urban=0.0878
a
L2 (Baseline) 15099.7550; P40.05; 
4P 0.01; In these and the next tables, h0(0) represent the hazard at time 0.

Model IV: socio-economic, demographic, supplementary
food and health sector variables
Table 6 presents the results of the proportionality
hazards model for the duration of breastfeeding. In this
analysis, the socio-economic and demographic, health
sector, and supplementary food variables that were
found to statistically significant from Models 1, 2 and 3
are entered together in one model. Education is used as a
categorical variable. As education increases at the post-
secondary level, the hazard rate is increased, suggesting
a greater probability of ceasing to breastfeed. The
estimated risk of ceasing to breastfeed is 1.53 times that
of women with no education. Women with post-
secondary education are more likely to be involved in
modern work requiring them to be away from their
infants during the day, thus encouraging the early use of
breast milk substitutes. The results also show that
involvement in professional or administrative jobs
increases the likelihood of ceasing to breastfeed by 15%.
High parity, as represented by the total number of
children born, is also associated with breastfeeding of
78 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81

Table 3
Proportional hazards model of duration of breastfeeding: socio-economic and demographic variables effectsa

Variable Coefficients Standard error Relative risk

Maternal age ÿ0.0047 0.0064 0.9953

Respondent’s education
no educ (ref)
primary education ÿ0.0958 0.0812 0.9086
secondary education 0.0967 0.0795 1.1015
post-secondary and higher 0.4271 0.0892 1.5327
Respondent’s occupation
not working (ref)
agricultural/domestic/home services 0.0014 0.0480 1.0014
professional/administrative/clerical/sales 0.1177 0.0491 1.1249
Husband’s education
no educ (ref)
primary education ÿ0.0838 0.0840 0.9196
secondary education ÿ0.0484 0.0838 0.9528
post-secondary and higher 0.1013 0.0931 1.1066
Husband’s occupation
not working (ref)
agricultural/domestic/low skilled ÿ0.1216 0.3367 0.8929
agricultural/domestic/manual ÿ0.1158 0.3378 0.8906
professional/administrative 0.4003 0.0406 1.4923
Parity
a
h0(0)rural=0.0197; h0(0)urban=0.0410. L2 (Baseline) 14045.0110; ÿ2 Log Likelihood 13874.4420 (14 d.f.); model w2 improvement
170.5690; P40.05; P40.01.

shorter duration.6 Its relative risk is 1.47, indicating that
an increase in parity by one child increases the hazard
rate by 47%. This suggests that additional children place
more constraints on the mother’s time, thereby increas-
ing the time costs involved with children, resulting in
early termination of breastfeeding.7
For the health sector variables, ‘‘prenatal care }
medical doctor’’ and ‘‘delivery in a hospital’’ remain
statistically significant. Consistent with the findings in
Model 3, prenatal care advice from a medical doctor and
delivery in a private hospital are associated of breast-
feeding of shorter duration. The relative risk for women
who sought prenatal care from a medical doctor is
1.3319 while the estimated risk for women who delivered
6
The non-significant effect of age in the previous models can
be explained by the close relationship of age to parity. Since
older women also have high parity, the effect of parity in this
case masks the effects of maternal age. As such, parity has a
more significant effect than maternal age on the duration of
breast-feeding. If age was included in this model, the ÿ2 Log
Likelihood was computed to be 14869.212 with a model w2
improvement of 280.590 and 10 degrees of freedom. When age
was dropped from the analyses, the ÿ2 Log Likelihood was
14609.388 with a model w2 improvement of 275.497 and 9
degrees of freedom. Since there has not been a huge difference
in the w2 improvement between the two models, dropping age
from the analyses does not change the improvement in the
model as much.
in a hospital is 15% higher relative to women who did
not deliver in a hospital. It should also be noted that
women who are more likely to consult with medical
doctors are more likely to use a hospital for place of
delivery. The weak effect of place of delivery can be
explained by the close relationship between this pre-
dictor and ‘‘prenatal care } doctor’’; i.e. ‘‘prenatal care-
doctor’’ masks the effect of place of delivery on the
duration of breastfeeding.
The later infant formula is introduced in the infant’s
diet the longer the duration of breastfeeding. The
relative risk for age for infant formula is 0.98, indicating
that an increase in the infant’s age as the time at which
infant formula is used on a regular basis reduced the
hazard of terminating breastfeeding by 3%. As previous
studies also show, it would appear that ‘‘for most
children, milkfeeding involves either breast milk or
7
The effect of parity on breast-feeding also depends on who
substitutes for the mother’s childcare time (Uyanga, 1986). If
the responsibility of childcare is allocated to older siblings and
adult relatives then the mother may have less constraints in
terms of balancing work and family which may encourage her
to breastfeed for a longer duration. In rural areas, such support
is more readily available. Unfortunately however, the data does
not allow one to determine who is responsible for the child
when the mother works, which then makes it difficult to
establish a causal relation between substitutes for the mother’s
childcare time and the duration of breast-feeding.
 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81 79

Table 4 breast milk substitutes together. When mixed feeding is

Proportional hazards model of duration of breastfeeding: seen, it is likely part of a transitional phase leading to the
supplementary food variables effectsa cessation of breastfeeding’’ (Castle et al., 1988, p. 23).
Variable Coefficients Standard Relative
error risk
Conclusions
Age for infant formula ÿ0.0268 0.0026 0.9735
Age for solids ÿ0.0027 0.0067 0.9973 This analysis examined both traditional and modern
Age for other liquids ÿ0.0061 0.0039 0.9939
determinants of lactation in the Philippines during 1993.
a
h0(0)rural=0.0485; h0(0)urban=0.1032. Initial L2 (baseline) The results indicated that traditional factors associated
15020.8620; 2 Log Likelihood ÿ14894.1970 (3 d.f.); Model with breastfeeding (age for liquids, age for solids,
improvement 126.6650; P40.01. prenatal care traditional nurse/midwife) did not play a
significant role in the mother’s decision to continue
breastfeeding. Factors associated with modernity were
significant in terms of early termination of breastfeeding.
Table 5
Proportional hazards model of duration of breastfeeding:
These include the respondent’s education, prenatal care
health sector variables effectsa with a medical doctor, place of delivery and the age at
which infant formula is introduced. High parity was
Variable Coefficients Standard Relative associated with shorter breastfeeding of shorter dura-
error risk tion, indicating that the presence of additional children
Prenatal care in the household can incur greater costs to the mother’s
No doctor (ref) time, thus resulting in early termination of breastfeeding
Medical doctor 0.1793 0.0491 1.1964 (Becker, 1981). The time constraints imposed by work
No nurse/midwife (ref) and motherhood, particularly among women with a
Traditional nurse/midwife 0.0071 0.0457 1.0072 post-secondary education and those involved in the
Place of delivery wage sector, encourage early use of breast milk
Home delivery (ref) substitutes, which then leads to early termination of
Hospital 0.1363 0.0312 1.146
breastfeeding. The implications for labour force and
a 2
h0(0)rural=0.0431; h0(0)urban=0.0756. Initial L (baseline) educational policies points in the direction of the
15100.4910; 2 Log Likelihood 15049.6590; Model w2 improve- promotion of timesaving methods that can increase the
ment 50.8320 (3 d.f.); P40.05; P40.01. likelihood of breastfeeding for a longer duration. These

Table 6
Proportional hazards model of duration of breastfeeding: socio-economic, demographic, health sector and supplementary food
variables effectsa

Variable Coefficients Standard error Relative risk

Education
No educ (ref)
Primary 0.0485 0.2146 1.0497
Secondary 0.1765 0.2149 1.1930
Post Secondary 0.4282 0.2225 1.5345
Parity 0.3871 0.0382 1.4726
Respondent’s occupation
Not working (ref)
Agricultural/Domestic 0.1111 0.0710 1.1175
Professional/administrative 0.1438 0.0724 1.1547
Prenatal care
No doctor (ref)
Prenatal care } doctor 0.2866 0.0863 1.3319
Place of delivery
Home (ref)
Place of delivery } hospital 0.1414 0.0669 1.1518
Age for infant formula ÿ0.0230 0.0027 0.9773
a
h0(0)rural=0.0162; h0(0)urban=0.0274. Initial L2 (Baseline) 14882.3890; 2 Log Likelihood 14609.3880 (9 d.f.); Model w2
improvement 275.4970; P40.05; P40.01.
80 T.S.J. Abada et al. / Social Science and Medicine 52 (2001) 71–81
include improving the transportation that takes women
to and from their barrios to their place of employment,
provision of nursing breaks, flexible working hours, and
the availability of creches (Huffman, 1984).
The results for the health sector variables showed that
having prenatal care under the care of a medical doctor
and delivery in a hospital was associated with breast-
feeding of a shorter duration. This reveals that medical
institutions and associated professionals are important
sources of social influence. The attitudes and practices of
medical personnel can affect the reproductive and
childcare practices. In addition, a hospital environment
that encourages breastfeeding practices can affect the
mother’s decision to breastfeed for a longer time. For
example, rooming-in policies, in which the infant is near
the mother night and day and not kept separately in a
nursery, allow the infant to be fed whenever he demands
feeding rather than being fed according to a hospital
schedule (Huffman, 1984).
Increasing urbanisation, a key structural determinant
of breastfeeding behaviour in many developing societies,
will most likely limit the ability of policymakers to
promote an increased awareness of lactation. The rise in
education and labour force participation among women
may enhance their economic status, but it will also likely
lead to the abandonment of traditional values or
practices regarding infant feeding. Lifestyle changes as
influenced by the mass media, the modern health sector,
and the increased availability of modern consumer
goods, will continue to affect the mother’s decision to
initiate, continue or terminate breastfeeding in moder-
nising societies.
Acknowledgements
A note of thanks is extended to the anonymous
reviewers of this journal for having provided insightful
comments and suggestions for revision. Of course, any
errors or omissions are the sole responsibility of the
authors.
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