Breastfeeding & Body image

By

Nanor Aghjian
Cynthia Zanazanian
Shant Leblebjian

Research Proposal
FHSC288

Faculty of Health Sciences

University of Balamand

August 2009

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 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

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 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.

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 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 body 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

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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 formula-

feeding 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 infant-

feeding chosen. Those women who care about other’s judgments of their bodies tend to

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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, 2000). 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 pre-

pregnancy 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

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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 body

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 purposes 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

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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 women 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 on 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.

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  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.

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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 of 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.

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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 of

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 would 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

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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

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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
Prenatal class attendance: Yes No
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  Disagree  Neutral  Agree  Strongly agree

Breastfeeding is beneficial for the mother’s health.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

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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  Neutral  Agree  Strongly agree

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

You have difficulty losing weight after pregnancy.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You follow strict diet to lose weight quickly after pregnancy.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You feel badly about yourself because you don’t like your body because of breastfeeding.
Strongly disagree  Disagree  Neutral  Agree  Strongly agree

Breastfeeding disturbs body image.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You pay more attention to physical image than to breastfeeding.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You think that breasts are viewed as sexual objects.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You avoid breastfeeding because breasts are viewed as sexual objects.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

Breastfeeding disturbs the shape of your breasts.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

Breasts should be used for erotic purposes rather than for infant feeding.
Strongly disagree  Disagree  Neutral  Agree  Strongly agree

Breastfeeding is compatible with my occupation.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

You are being hospitalized in baby friendly hospital.

Strongly disagree  Disagree  Neutral  Agree  Strongly agree

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Health professionals should actively encourage all mothers in their practices to try
breastfeeding.
Strongly disagree  Disagree  Neutral  Agree  Strongly agree

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 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

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Nanor Aghjian, Cynthia Zanazanian and Shant Leblebjian
Faculty of Health Sciences, University of Balamand
Beirut Lebanon

Read by respondent ( ) Assessor ( )

Agreed ( ) 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

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