Indicators of ‘good’ feeding,breastfeeding latch,and feeding experiences among healthy women with healthy infants: A qualitative pathway analysis using Grounded Theory

BackgroundBreastfeeding behaviour remains a public health priority worldwide. Despite evidence-based guidelines, healthy women who give birth to healthy, term infants continue to face barriers to breastfeeding. Understanding women’s experiences of feeding in the early postnatal period is crucial to identify how support may be better tailored to improve breastfeeding outcomes, including women’s experiences.QuestionTo understand women’s experiences of infant feeding amongst healthy women who give birth to healthy, average-weight, term infants.MethodsGrounded Theory methodology was used to analyse data from a nested qualitative interview study. Twelve women between four and twelve months postpartum were recruited from a longitudinal cohort study and public advertisements. Semi-structured face-to-face interviews were audio-recorded and transcribed for analysis.FindingsThree distinct themes were found, subsuming identified super-categories: Perceived indicators of ‘good’ feeding (infant ‘output’; infant crying; weight gain; feeding frequency and duration); Women’s experiences of breastfeeding latch (‘good’ latch; ‘bad’ latch with pain and discomfort); and Overall breastfeeding experience (positive; negative; and uncertain). Data suggest women give precedence to their latch experiences over indicators of ‘good’ feeding, highlighting breastfeeding latch as a possible mediating factor to the overall breastfeeding experience. Feeding experience can be achieved through four distinct pathways.DiscussionThe physical and psychological impacts of latch pain were pronounced. Even amongst healthy women with healthy infants, a positive breastfeeding experience overall was uncommon, highlighting the difficulties women continue to encounter. Understanding women’s perceptions of ‘good’ feeding, and ensuring a pain-free latch, may better support women to have a positive breastfeeding experience.     

Women’s experiences of infant feeding support: Findings from a cross-sectional survey in Victoria,Australia

ObjectiveTo evaluate new mothers’ experiences of infant feeding support.DesignA postal survey developed for this study was sent to all new mothers in ten local government areas in Victoria, Australia when their baby was six months of age. Questions explored infant feeding methods, feeding support services, and experiences of infant feeding support. This survey made up one component of the Supporting breastfeeding In Local Communities (SILC) cluster randomised controlled trial.Findings997/4127 women (24%) completed the survey between 15 April 2013 and 31 July 2013. Women received infant feeding support from multiple sources, including professionals, family members, and peers. Overall, 88% reported receiving adequate infant feeding support. Women who reported not receiving adequate infant feeding support were less likely to be giving any breast milk at six months compared to those reporting adequate support (OR = 0.59; 95% CI 0.40, 0.88). Adjusting for breastfeeding intention and parity did not alter the association (Adj. OR = 0.60; 95% CI 0.40, 0.90). Women were most satisfied when they received accessible, available, consistent professional infant feeding support provided in a non-judgemental and reassuring way. Women were dissatisfied when there were barriers restricting access to support, or when they received conflicting advice or support that made them feel guilty, pressured or judged.Key conclusionsRegardless of infant feeding method, women wanted accessible, non-judgemental support. Given that receiving adequate support was associated with more breast milk feeding at six months, care providers should ensure accessible infant feeding support is available to all new mothers.     

The experiences of breastfeeding mothers returning to work as hospital nurses in Pakistan: A qualitative study

Background

Pakistan has a higher infant mortality rate than countries with comparable economies, with around half of all under-5 deaths occurring in the first month of life. Breastfeeding is known to improve infant morbidity and mortality, but rates of formula feeding in Pakistan are increasing. Maternal employment is recognised globally as a major barrier to the continuation of breastfeeding.

“It Makes My Skin Crawl”: Women’s experience of breastfeeding aversion response (BAR)

ProblemSome women who intend to breastfeed experience a breastfeeding aversion response (BAR) while breastfeeding.BackgroundLittle is known about the experience of those who have feelings of aversion while breastfeeding.AimThis study aimed to investigate the experiences of women who have an aversion response to breastfeeding while their infant is latched at the breast. This is the first study that aims to understand this breastfeeding aversion response (BAR) as described by women who experience this phenomenon.MethodsInterpretative phenomenological analysis (IPA) was used to conduct and analyse ten semi-structured in-depth interviews with women who self-identified as experiencing BAR.FindingsFour overarching themes were identified: (1) Involuntary, strong sensations of aversion in response to the act of breastfeeding, (2) Internal conflict and effects on maternal identity, (3) The connection between BAR and relationships with others, and (4) Reflections on coping with BAR and building resilience.DiscussionSome women who intend to breastfeed can experience BAR, and this negative sensation conflicts with their desire to breastfeed. BAR can impact on maternal wellbeing. Those who experience BAR may benefit from person-centred support that directly addresses the challenges associated with BAR to achieve their personal breastfeeding goals.ConclusionThe experience of BAR is unexpected and difficult for mothers. If support is not available, BAR can have detrimental effects on maternal identity, mother–child bonds, and intimate family relationships.     

Factors influencing Aboriginal and Torres Strait Islander women’s breastfeeding practice: A scoping narrative review

BackgroundThe nutritional and health benefits of breastfeeding for infants and young children are well-established however rates of breastfeeding initiation and duration for Aboriginal and Torres Strait Islander children are lower than non-Indigenous children.AimTo describe factors influencing breastfeeding practice amongst Aboriginal and Torres Strait Islander women.MethodsA scoping narrative review was conducted using the Joanna Briggs Institute framework. A search was conducted in four online databases (PubMed, Scopus, ANU SuperSearch, and Science Direct). Findings were analysed using [30] narrative synthesis.FindingsThis review included 9 journal articles, a conference summary and a book. This review identified four factors influencing women’s breastfeeding practice; sources of support, culturally appropriate care, intention to breastfeed and social determinants.ConclusionMultiple social determinants resulting from colonization have interrupted traditional infant feeding practices and women’s sources of support. Although Aboriginal and Torres Strait Islander women have strong intention to breastfeed, their breastfeeding outcomes are impacted by lack of pro-breastfeeding support when encountering breastfeeding challenges as well as norms surrounding the use of infant formula milk. Culturally appropriate care is essential for identifying women’s needs and avoiding stereotyping. Further research is needed to investigate the effectiveness of breastfeeding interventions for this group of women.     

Mothers’ attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa

BackgroundIn American Samoa, initiation of breastfeeding is almost universal but exclusive breastfeeding, a promising target for obesity prevention, is short in duration.Aims(1) To examine American Samoan mothers’ feeding experiences and attitudes and beliefs about infant feeding and (2) to identify potential barriers to exclusive breastfeeding.MethodsEighteen semi-structured interviews were conducted with American Samoan mothers at 16–32 days postpartum. Interviews focused on mother's knowledge and beliefs about infant feeding, how their infants were fed, why the mother had chosen this mode of infant feeding, and how decisions about feeding were made within her social surroundings. A thematic qualitative analysis was conducted to identify salient themes in the data.FindingsIntention to exclusively breastfeed did not predict practice; most women supplemented with formula despite intending to exclusively breastfeed. The benefits of breastfeeding were well-recognized, but the importance of exclusivity was missed. Formula-use was not preferred but considered an innocuous “back-up option” where breastfeeding was not possible or not sufficient for infant satiety. Identified barriers to exclusive breastfeeding included: the convenience of formula; perceptions among mothers that they were not producing enough breast milk; and pain while breastfeeding. The important support role of family for infant feeding could be utilized in intervention design.ConclusionThis study identified barriers to exclusive breastfeeding that can be immediately addressed by providers of breastfeeding support services. Further research is needed to address the common perception of insufficient milk in this setting.     

Breastfeeding and emerging motherhood identity: An interpretative phenomenological analysis of first time Chinese Australian mothers’ breastfeeding experiences

BackgroundChinese Australian mothers are more likely than the general Australian mothers to introduce formula in the first month of age. A better understanding of the context of formula introduction in the early weeks of birth can provide a deeper insight into how Chinese Australian mothers can be supported to continue exclusive breastfeeding.MethodsAn interpretative phenomenological analysis approach was used to examine the lived breastfeeding experiences of 11 first time Chinese mothers in Australia. The experiences of those who breastfed exclusively were compared to those who introduced formula in the first month after birth.FindingsAn overarching theme across all participants’ narratives was the meaning ascribed to breastfeeding in their emerging motherhood identity. Breastfeeding could be a pragmatic and a socially desirable method to nourish an infant but lacking personal identification to the mother. These mothers were more vulnerable to the early introduction of formula, especially when the support environment was lacking. Maternal identity conflict was common and negatively impacted exclusive breastfeeding and mothers’ mental health. In contrast, mothers who identified closely with breastfeeding showed greater persistence and enjoyment in breastfeeding and were more likely to continue breastfeeding exclusively. Health professionals were perceived to have an important influence in strengthening maternal breastfeeding motivation and self-efficacy.ConclusionBreastfeeding support to Chinese Australian mothers needs to consider how breastfeeding can be better integrated with their motherhood identity. Health professionals are well-positioned to facilitate this process through a better understanding of mothers’ cultural and social contexts around breastfeeding.     

Factors associated with breastfeeding initiation and maintenance for Aboriginal and Torres Strait Islander women in Australia: A systematic review and narrative analysis.

BackgroundAustralian Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) women breastfeed at lower rates than non-Aboriginal women. Little is known about factors associated with breastfeeding specific to Aboriginal women and infants.AimDetermine the protective and risk factors associated with breastfeeding for Aboriginal women in Australia.MethodsCINAHL, Medline, EMBASE, SCOPUS, PsycINFO, and the Cochrane library were searched for peer-reviewed literature published between 1995 and 2021. Quantitative studies written in English reporting protective and risk factors associated with breastfeeding for Aboriginal women or women having an Aboriginal infant were included. Ten percent of papers were co-screened, and two reviewers completed data extraction. Narrative data synthesis was used.FindingsThe initial search identified 12,091 records, with 31 full text studies retrieved, and 17 reports from 14 studies met inclusion criteria. Protective factors included living in a remote area, attending an Aboriginal-specific service, attending a regional service, higher levels of education attainment, increased maternal age, living in larger households, being partnered, and having a higher reported number of stressful events and social health issues. The identified risk factors were smoking in pregnancy, admission to SCN or NICU, and being multiparous.ConclusionThis review identified factors associated with breastfeeding for Aboriginal women. Government focus, support, and consistent funding are required to plan and implement evidence-based interventions and services for Aboriginal women and infants in urban, rural, remote, and very remote locations. Rigorous research is required to understand the Aboriginal-specific factors associated with breastfeeding to improve rates and health outcomes for Aboriginal women and infants.     

Breastfeeding experiences and perspectives among women with postnatal depression: A qualitative evidence synthesis

BackgroundStudies show that postnatal depression affects around 10–16% of women globally. It is associated with earlier cessation of breast feeding, which can negatively impact infants’ long-term development. Mechanisms underpinning associations between mental health and women’s decision to commence and continue to breastfeed are complex and poorly understood.AimThe aim of this review was to investigate breastfeeding experiences, perspectives, and support needs of women with postnatal depression. No previous reviews were identified which had addressed this aim.MethodA systematic search was conducted of six databases to identify relevant qualitative studies. Six included studies were critically appraised and synthesised using thematic synthesis.FindingsFive themes were identified: (1) desire to breastfeed and be a ‘good mother’, (2) struggles with breastfeeding, (3) mixed experiences of support from healthcare professionals, (4) importance of practical and social support, (5) support for mental health and breastfeeding. Most women with postnatal depression expressed strong intentions to breastfeed, although some perceived ‘failure’ to breastfeed triggered their mental health problems. Practical and non-judgemental support for their mental health needs and for successful breastfeeding from healthcare professionals, family and friends are needed.ConclusionMost women with postnatal depression desired to breastfeed but experienced breastfeeding difficulties that could impact on their mental health. By offering women with postnatal depression tailored and timely support, healthcare professionals could help women minimize breastfeeding problems which could consequently impact on their mental well-being and ensure they and their infants have opportunity to benefit from the advantages that breastfeeding offers.     

Factors that positively influence in-hospital exclusive breastfeeding among women with gestational diabetes: An integrative review

ProblemWomen with gestational diabetes have higher rates of introducing infant formula before leaving hospital.BackgroundDespite health professional support, less women with gestational diabetes exclusively breastfeed in hospital.AimTo find factors that positively influence in-hospital exclusive breastfeeding practices among women with gestational diabetes.MethodsAn online search was performed in Medline, Scopus, Pubmed, CINAHL and Cochrane databases. Studies containing the keywords gestational diabetes and breastfeeding were retrieved.FindingsAuthors identified 1935 papers from search criteria. Twenty-six papers with no restrictions on research design met inclusion criteria and were included in the review. Factors were divided into personal, antenatal, intrapartum and postnatal factors. The main modifiable factors that were associated with improved in-hospital exclusive breastfeeding rates were having a strong intention to breastfeed, being confident, feeling supported and having continuity of education and support. Women’s main reasons to introduce formula were related to baby’s hypoglycaemia, delayed lactogenesis II and perceived low milk supply. Skin-to-skin contact after birth combined with frequent breastfeeds were effective ways to improve in-hospital exclusive breastfeeding rates.ConclusionInfluencing factors such as women’s breastfeeding intention, confidence and ongoing support are no different to the general population of women. However, promoting skin-to-skin contact after birth combined with frequent feeds are crucial for women with gestational diabetes who are more likely to introduce formula due to delayed lactogenesis II and fear of neonatal hypoglycaemia. There is a need for developing educational and supportive interventions that are tailored specifically for women who have gestational diabetes.     

Aboriginal women in rural Australia; a small study of infant feeding behaviour

BackgroundAboriginal women in rural areas have lower rates of breastfeeding than Australian averages. The reasons for this are poorly understood. Aboriginal people experience higher morbidity and increased rates of chronic disease throughout the life cycle. The protective effects of sustained breastfeeding could benefit rural Aboriginal communities.ObjectiveTo explore the factors impacting upon infant feeding choices in a rural Aboriginal Community.MethodsSemi-structured interviews were conducted with eight Aboriginal rural dwelling first time mothers. These women received a continuity of midwife and Aboriginal Health Worker model of care. Interviews were also undertaken with five Aboriginal Health Workers and two Aboriginal community breastfeeding champions. The analysis was integrated with a conventional literature review and was further developed and illustrated with historical literature. Indigenist methodology guided the study design, analysis and the dissemination of results.ResultsThree key themes were identified. These were “I’m doing the best thing for…” which encompasses the motivations underpinning infant feeding decisions; “this is what I know…” which explores individual and community knowledge regarding infant feeding; and “a safe place to feed” identifying the barriers that negative societal messages pose for women as they make infant feeding decisions. It appears loss of family and community breastfeeding knowledge resulting from colonisation still influences the Aboriginal women of today.DiscussionAboriginal women value and trust knowledge which is passed to them from extended family members and women within their Community. Cultural, historical and socioeconomic factors all strongly influence the infant feeding decisions of individuals in this study.ConclusionsEfforts to normalise breastfeeding in the culture of rural dwelling Aboriginal women and their supporting community appear to be necessary and may promote breastfeeding more effectively than optimal professional care of individuals can do.     

Postpartum women’s experiences of social and healthcare professional support during the COVID-19 pandemic: A recurrent cross-sectional thematic analysis

ProblemDisrupted access to social and healthcare professional support during the COVID-19 pandemic have had an adverse effect on maternal mental health.BackgroundMotherhood is a key life transition which increases vulnerability to experience negative affect.AimExplore UK women’s postnatal experiences of social and healthcare professional support during the COVID-19 pandemic.MethodsSemi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed (T1), and a separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (T2). Recurrent cross-sectional thematic analysis was conducted in NVivo 12.FindingsT1 themes were, ‘Motherhood has been an isolating experience’ (exacerbated loneliness due to diminished support accessibility) and ‘Everything is under lock and key’ (confusion, alienation, and anxiety regarding disrupted face-to-face healthcare checks). T2 themes were, ‘Disrupted healthcare professional support’ (feeling burdensome, abandoned, and frustrated by virtual healthcare) and ‘Easing restrictions are bittersweet’ (conflict between enhanced emotional wellbeing, and sadness regarding lost postnatal time).DiscussionRespondents at both timepoints were adversely affected by restricted access to informal (family and friends) and formal (healthcare professional) support, which were not sufficiently bridged virtually. Additionally, the prospect of attending face-to-face appointments was anxiety-provoking and perceived as being contradictory to social distancing guidance. Prohibition of family from maternity wards was also salient and distressing for T2, but not T1 respondents.ConclusionHealthcare professionals should encourage maternal help-seeking and provide timely access to mental health services. Improving access to informal and formal face-to-face support are essential in protecting maternal and infant wellbeing.     

Factors that influence women’s decision on infant feeding: An integrative review

BackgroundMany women stop breastfeeding earlier than what they intended prior to birth. Although there are many studies that focus on the factors that influence women’s antenatal breastfeeding decisions, the factors that influence women’s decisions during the continuum of antenatal and postnatal period are less known.AimTo understand and synthesise the contemporary factors that influence women’s decisions on infant feeding from the antenatal period and across the breastfeeding continuum.MethodFive online databases (CINAHL, Medline, PubMed, Scopus and Web of Science) were searched. We included original search articles that were published since 2015 to August 2021 and were available in English. The framework of Whittemore and Knafl was used to guide this integrative literature review. Out of the 872 articles identified, 14 studies met the inclusion criteria of our study. We used theory of birth territory and midwifery guardianship to synthesise the interactions between the themes.FindingsFive main themes were identified: (a) Women’s own views, (b) Family and friend’s preferences and advice, (c) Health professional’s preference, advice and practice, (d) Sociocultural norms, and (e) Media representation. The interaction between the themes was explained based on women’s intrinsic and extrinsic power outlined in the birth territory and midwifery guardianship theory.ConclusionThe factors that influence women’s decisions towards infant feeding methods are complex and multi-dimensional. Promoting and supporting women towards breastfeeding need to focus on the factors that are tailored for a woman within her social network where she can feel safe about her breastfeeding decisions.     

Socio-economic Differentials in Infant and Child Mortality during Mortality Decline: England and Wales, 1890–1911

In this paper data from the 1911 Census of the Fertility of Marriage of England and Wales are used to study patterns of mortality decline by socio-economic characteristics, principally the occupation of husband. That census reported data on number of wives, children ever born, and children dead by marriage-duration cohorts for 190 non-overlapping occupations of husband. These results, along with those on number of rooms in the dwelling of the family are used to make indirect estimates of childhood mortality using the techniques described in United Nations, Manual X. These procedures produce values of q(a), the probability of dying before reaching some exact age ‘a’. Estimates for q(2), q(3), q(5), q(10), q(15), and q(20) are derived from data on women married 0–4, 5–9, 10–14, 15–19, 20–24, and 25–29 years, respectively. These estimates can also be dated to a point in the past. These values can also be converted to a corresponding level of a Model West life table, which describes the ‘average’ mortality regime which the children of those women experienced. This furnishes a basis to look at mortality decline for various social classes and occupational groups. Ordinary least squares regressions of the levels of Model West life tables implied by the 1(a) values on time give one measure of mortality decline. Another is the absolute amount of the increase in the level of the Model West life tables from marriage-duration cohort 20–24 years to 0–4 years. The aggregate results indicate that social class in England and Wales during the 1890s and 1900s tended to be related to the speed of mortality decline: childhood mortality declined more rapidly in the higher and more privileged social class groups. But the results were neither nearly as strong nor as regular as those which predicted the level of mortality within any marriage-duration cohort. These outcomes are not particularly sensitive to the three different social-class stratification schemes used: the 1911 English Registrar General's classification; the 1951 English Registrar General's classification; and the 1950 U.S. Census classification. There was also a fairly regular and predictable gradient for the number of rooms in the home: child mortality was higher in families who lived in larger dwellings. Analysis of 190 detailed male occupational groups revealed that considerably more of the variation in mortality levels than of trends could be explained by social-class categories. Between 20 and 40 per cent of variation in mortality trend could be accounted for by social class alone, as opposed to 50 to 80 per cent of mortality levels for different marriage-duration cohorts. Results for a more restricted sample of 116 occupations for which income estimates could be made revealed a similar pattern. In addition, income was virtually unrelated to the pattern of mortality decline, and improvement was more rapid in groups who were more urban. This reflects the role of rapidly improving urban sanitation in the late nineteenth and early twentieth centuries in England. In contrast, income was significantly related to childhood morality levels for various marriage-duration cohorts (with higher income associated with lower mortality), while urbanization was inversely correlated with mortality levels (more urban groups experienced higher mortality). Overall, social class (or occupation group), income, and urbanization were more successful in explaining mortality levels than time trends across occupations, although social class and the extent of urbanization did reasonably well in accounting for trends. Over a longer period, the transition in child mortality was under way by the 1890s, but its pace and timing varied in different occupations and social class groupings. Although absolute differences in infant mortality were reduced after about 1911, relative inequality persisted even as infant and child survival improved for all groups.     

Theory and social practice of agency in combining breastfeeding and employment: A qualitative study among health workers in New Delhi,India

BackgroundWomen's agency, or intentional actions, in combining breastfeeding and employment is significant for health and labour productivity. Previous research in India showed that mothers use various collaborative strategies to ensure a “good enough” combination of breastfeeding and employment. Bandura's theoretical agency constructs previously applied in various realms could facilitate the exploration of agency in an Indian context.AimTo explore manifestations of agency in combining breastfeeding and employment amongst Indian health workers using Bandura's theoretical constructs of agency and women's experiences.MethodsQualitative semi-structured interviews were conducted with ten women employees within the governmental health sector in New Delhi, India. Both deductive and inductive qualitative content analyses were used.FindingsBandura's features and modes of agency revealed that intentionality is underpinned by knowledge, forethought means being prepared, self-reactiveness includes collaboration and that self-reflectiveness gives perspective. Women's interviews revealed four approaches to agency entitled: ‘All within my stride or the knowledgeable navigator’; ‘Much harder than expected, but ok overall’; This is a very lonely job’; and ‘Out of my control’.ConclusionsAgency features and their elements are complex, dynamic and involve family members. Bandura's theoretical agency constructs are partially useful in this context, but additional social practice constructs of family structure and relationship quality are needed for better correspondence with women's experiences of agency. The variation in individual approaches to agency has implications for supportive health and workplace services.     

Partner behaviours improving breastfeeding outcomes: An integrative review

ProblemThe impact of specific supportive behaviours of a woman’s partner on breastfeeding outcomes is unclear.BackgroundBreastfeeding is beneficial for the infant, mother, and society. Partner support plays a significant role in promoting breastfeeding. Strategies to improve breastfeeding rates have had limited success with rates worldwide remaining well below World Health Organization recommendations, contributing to significant morbidity, mortality, and economic burden globally.AimTo determine what specific supportive behaviours of a breastfeeding woman’s partner increase breastfeeding initiation, exclusivity, and duration rates in Western-culture settings.MethodsA Population-Interest-Context framework-based search strategy was applied to the Cumulative Index to Nursing Allied Health Literature Plus with full-text, Web of Science, Scopus, and PubMed databases, limited to primary research published January 2008–December 2018 in English conducted in Western-culture settings.FindingsFrom 652 articles, after critical appraisal seven articles (eight studies) satisfied the requirements of this integrative review. Supportive behaviours were categorised as knowledge, help, encouragement, and responsiveness. Help and encouragement behaviours were associated with increased initiation. Results were mixed regarding behaviours affecting exclusivity and duration; however, responsiveness was found to ameliorate otherwise generally negative effects of knowledge, help, and encouragement on these outcomes.DiscussionConsistent with wider social support research, awareness of receiving support is associated with negative health consequences. However, where partner support is provided in a responsive manner as part of a ‘breastfeeding team’, thereby promoting the woman’s sense of autonomy and self-efficacy, breastfeeding outcomes improve.ConclusionResponsive partner behaviours improved breastfeeding outcomes in Western-culture settings. Further primary research is needed.     

The effect of child mortality experience on subsequent fertility: in Pakistan and Bangladesh

Summary This paper presents an empirical analysis of the effects, behavioural and biological, of child mortality experience on subsequent fertility in two South Asian Islamic nations. Data for the investigation came from retrospective pregnancy histories of 2,910 currently married women interviewed in the Pakistan National Impact Survey (1968-69) and from longitudinal vital registration data (1966-2070) of 5,236 women residing in a rural area of Bangladesh collected by the Cholera Research Laboratory. The aim of this study was to assess the importance of the child-replacement motivational response to child death experience after biological effects have been controlled adequately. A common approach employed previously has been to examine cumulative fertility according to child death experience. In Pakistan and Bangladesh, a consistently positive relationship was demonstrated between the number of children ever born and the number of child deaths. This method, however, did not exclude the inverse relationship, the influence of fertility on mortality, nor did it dissect out behavioural from biological effects. Utilizing a measure of subsequent fertility, live-birth-to-live-birth intervals, the study further illustrated another common pitfall. Since the risk of infant death, which leads to shorter birth intervals, is associated with the mother's reproductive history, women with child mortality experience are more likely to experience shorter intervals because of the biological effect of subsequent infant death. Behavioural influences may, therefore, be observed by considering only those birth intervals in which the first-born child survives to the end of the interval. With these limitations controlled, very few, if any, behavioural influences were noted in the Pakistan and Bangladesh data. Median birth intervals in Pakistan varied between 35-43 and 41-42 months, increasing with parity. Within each parity group, no consistent difference was observed between women with and without previous child loss. In Bangladesh, the median birth interval for all women with a surviving infant was 37-2 months. This was shortened to 24-31 months by an infant death. When intervals with infant deaths were excluded, little or no behavioural influence was detected among women of the same parity, but with varying levels of previous child loss. Even without behavioural effects, elimination of infant mortality in Bangladesh would reduce fertility by prolonging the average period of post-partum sterility. In the Bangladesh setting, however, the size of the effect was only about four per cent. This modest effect, more-over, was counterbalanced by an overall increase of net reproduction by seven per cent due to better survivorship of infants.