Pediatric Assessment of an Infant

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Social Science & Medicine 74 (2012) 1754e1764

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Social Science & Medicine

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Feeding her children, but risking her health: The intersection of gender,
household food insecurity and obesity

Molly A. Martin*, Adam M. Lippert
Pennsylvania State University, 211 Oswald Tower, University Park, PA 16802, United States

a r t i c l e i n f o

Article history:
Available online 20 December 2011

Keywords:
Overweight
Obesity
Gender
Food insecurity
Parenting
Income
USA

* Corresponding author. Tel.: þ1 814 863 5508.
E-mail address: mmartin@pop.psu.edu (M.A. Mart

0277-9536/$ e see front matter � 2012 Elsevier Ltd.
doi:10.1016/j.socscimed.2011.11.013

a b s t r a c t

This paper investigates one explanation for the consistent observation of a strong, negative correlation in the
United States between income and obesity among women, but not men. We argue that a key factor is the
gendered expectation that mothers are responsible for feeding their children. When income is limited and
households face food shortages, we predict that an enactment of these gendered norms places mothers at
greater risk for obesity relative to child-free women and all men. We adopt an indirect approach to study
these complex dynamics using data on men and women of childrearing age and who are household heads or
partners in the 1999e2003 waves of the Panel Study of Income Dynamics (PSID). We find support for our
prediction: Food insecure mothers are more likely than child-free men and women and food insecure fathers
to be overweight or obese and to gain more weight over four years. The risks are greater for single mothers
relative to mothers in married or cohabiting relationships. Supplemental models demonstrate that this
pattern cannot be attributed topost-pregnancy biological changes thatpredispose mothers toweight gain or
an evolutionary bias toward biological children. Further, results are unchanged with the inclusion of physical
activity, smoking, drinking, receipt of food stamps, or Women, Infants and Children (WIC) nutritional
program participation. Obesity, thus, offers a physical expression of the vulnerabilities that arise from the
intersection of gendered childcare expectations and poverty.

� 2012 Elsevier Ltd. All rights reserved.

Scholars argue that it takes money to maintain a healthy weight
in America’s obesogenic environment (Poston & Foreyt, 1999)
because healthy food is relatively expensive and calorie-dense,
nutrient-poor food is cheap (Drewnowski & Specter, 2004).
Although weight is a function of both caloric intake and expendi-
ture, materialist arguments focus on the costs of food and predict
greater caloric intake and consequent body fat among low versus
high income people (Glass & McAtee, 2006). In the U.S., there is
a strong, negative correlation between income and the likelihood of
being overweight or obese, but only among women; this is not
observed among men (for reviews, see McLaren, 2007; Sobal &
Stunkard, 1989). This sex difference is puzzling, particularly to
scholars who look beyond individual explanations to consider the
role of shared environments for health because the majority of men
and women live together (Casper & Bianchi, 2002) and share
socioeconomic resources and weight-related behaviors (French,
Story, & Jeffery, 2001; Mitchell et al., 2003). Given these common-
alities, one would expect greater similarity between the sexes.

We hypothesize that the key distinction is not between all
women and all men, but between mothers and non-mothers. We

in).

All rights reserved.

argue that the confluence of two factors e the experience of food
insecurity and the gendered nature of childcare e intersect and
contribute to the observed sex differences in the association of
income and body weight. Food insecurity is highly correlated with
poverty (Sarlio-Lähteenkorva & Lahelma, 2001) and occurs when
a household faces budgetary constraints that limit the quantity or
quality of food they can purchase (Wunderlich & Norwood, 2006).
Yet food insecurity is a “managed process” (Radimer, 1990),
meaning that families strategize and diligently work to avoid
hunger. That responsibility, however, falls more heavily on women
given traditional discourses about family life and “women’s work”
that place greater expectations on women for feeding and
nurturing their family, especially when children are present
(DeVault, 1991). Given that food insecurity is correlated with poor
dietary behavior and obesity (for a review, see Institute of Medicine,
2011), we assert that food insecurity mediates the association
between income and weight, but that the management of food
insecurity intersects with gender to create differential risks for
obesity between mothers and non-mothers.

To investigate these dynamics, we study men and women of
childrearing ages (i.e., 18e55) who are heads or partners of U.S.
households in the 1999, 2001 and 2003 waves of the Panel Study of
Income Dynamics (PSID). We test whether the association between

M.A. Martin, A.M. Lippert / Social Science & Medicine 74 (2012) 1754e1764 1755

household food insecurity and the likelihood of being overweight
or obese differs across groups defined by sex and parenthood in
cross-sectional models of weight status and longitudinal models of
weight change. We also examine how partner co-residence further
moderates these processes due to the gendered norms about
parental custody (Coltrane & Adams, 2003) and the greater prev-
alence of food insecurity among single parents (Rose, Gundersen, &
Oliveira, 1998).

Food insecurity and weight

Household food security exists along a continuum but can be
categorized into a four-point ordered scale: food secure, food
insufficiency, low food security, and very low food security (Bickel,
Nord, Price, Hamilton, & Cook, 2000; Wunderlich & Norwood,
2006). Most Americans are food secure, but some face food insuf-
ficiency, meaning, they worry about having enough money to buy
food for the month, but actually make no or few changes to their
diet (Wunderlich & Norwood, 2006). Food insecurity occurs when
those fears become a reality. Low food security, or not having the
means to buy the kinds of food desired, reduces the quality and
variety of people’s diets (Wunderlich & Norwood, 2006). Very low
food security occurs when people do not have the means to buy the
quantity of food needed and leads people to skip meals and reduce
their food intake (Wunderlich & Norwood, 2006). Those with either
“low food security” or “very low food security” are considered “food
insecure” (Wunderlich & Norwood, 2006). In 2009, 14.7% of U.S.
households were food insecure (Nord, Coleman-Jensen, Andrews, &
Carlson, 2010), while in 2003, the year corresponding to our study,
the prevalence was 11.2% (Nord, Andrews, & Carlson, 2004).

Because poverty predicts food insecurity (Sarlio-Lähteenkorva &
Lahelma, 2001), there are several parallels found in research on the
roleof food security for body weight. Keyamong them are consistent
sex differences, such that low food security is linked to being over-
weight (Adams, Grummer-Strawn, & Chavez, 2003; Dinour, Bergen,
& Yeh, 2007; Lyons, Park, & Nelson, 2008; Townsend, Peerson, Love,
Achterberg, & Murphy, 2001) and gaining 5 pounds or more in one
year (Wilde & Peterman, 2006), but only among women. Very low
food security is associated with being underweight, but again only
for women (Wilde & Peterman, 2006).

Several studies suggest that food insecurity is linked to over-
weight and obesity due to management strategies people adopt in
the face of economic constraints. Food insecure individuals are
more likely to consume high-calorie but nutritionally-poor food to
avoid feelings of hunger (Dixon, Winkleby, & Radimer, 2001;
Drewnowski & Specter, 2004; Kirkpatrick & Tarasuk, 2008), eat
irregular meals or skip breakfast (Kempson, Keenan, Sadani, Ridlen,
& Rosato, 2002; Ma et al., 2003), and consume less milk, fruit and
vegetables, especially later in the month (Tarasuk, McIntyre, & Li,
2007). According to public health and nutrition research, these
dietary practices are associated with being overweight (Ledikwe
et al., 2006; Ma et al., 2003) and weight gain (Berkey, Rockett,
Gillman, Field, & Colditz, 2003). In the next section, we detail
how the management of food insecurity is gendered.

Gender, childcare, and food insecurity management

Traditional discourses about “family” life and “women’s work”
since the industrial revolution include expectations that women
are responsible for caring for their family members and managing
household tasks (Rothman, 1978; Sokoloff, 1980). When children
are present in the home, those responsibilities multiply (Hays,
1998) and the gendered division of household labor becomes
more unequal (Coltrane, 2000). For example, there is greater
gender equity in the total number of hours spent on housework in

child-free cohabiting and married couples than among similar
couples with children (Sanchez & Thomson, 1997; South & Spitze,
1994). Therefore, mothers are more likely to be subjected to,
internalize, and reflect traditional gender expectations about their
roles and responsibilities than child-free women.

A key feminine responsibility is “feeding the family,” which
requires a series of tasks: meal planning, monitoring the supply of
household provisions, shopping, cooking, and cleaning (DeVault,
1991). Beyond the practical goals, “feeding the family” also
sustains children’s emotional needs for love, support and security
(DeVault, 1991).

In food insecure homes, mothers work hard to prevent hunger
amongst their children. In a qualitative study with frequently food
insecure young mothers, all insisted that their children only expe-
rienced food insufficiency because they adopted several strategies
to protect them (Stevens, 2010), including prioritizing their chil-
dren’s needs over their own (McIntyre et al., 2003; Stevens, 2010). As
DeVault notes “[t]hese women seem to be expressing a heightened
sense of the more widespread notion that’s women’s own food is
less important than that prepared for others” (1991, p.199). As one
woman in a cash-strapped household noted: “If it gets down to it, we
buy to feed the kids” (DeVault, 1991, p.191).

To manage food insecurity, mothers adopt a variety of strategies.
Some strategies focus on grocery shopping, like buying in bulk,
shopping at different stores to get the best prices, or using coupons
(DeVault, 1991; Wiig & Smith, 2008). Other strategies involve
mothers’ food intake. Food insecure mothers skip meals, wait to eat
until later in the day, or eat less to spare their children from hunger
and nutritional deprivation (Badun, Evers, & Hooper,1995; DeVault,
1991; McIntyre, Connor, & Warren, 2000; McIntyre et al., 2003). As
a result, women in food insecure households are at risk of nutrient
deficiencies in Vitamin A, folate, iron, and magnesium (Tarasuk &
Beaton, 1999). We suspect that these behavioral patterns under-
gird the unexplained sex differences in the association between
food insecurity and weight (Adams et al., 2003; Dinour et al., 2007;
Lyons et al., 2008; Olson, 1999; Townsend et al., 2001; Wilde &
Peterman, 2006) and why food insecurity is typically not corre-
lated with children’s weight (Gundersen, Garasky, & Lohman, 2009;
Martin & Ferris, 2007), but for an exception see Gundersen and
Kreider (2009). Unfortunately we do not have direct measures on
people’s dietary behavior or food insecurity management practices
to fully explore this sequence, but we do have the requisite data to
test our primary hypothesis:

H1. There is a statistically significant association between food
insecurity and being overweight or obese for mothers, but not
child-free women or all men.

We know of only one paper about food insecurity and obesity
that emphasizes parenthood. With a sample of parents (65% of
whom were single mothers), Martin and Ferris (2007) found
a positive association between food insecurity and obesity, but they
did not explore whether there was a differential association
between mothers and fathers. Therefore, the current analysis
makes a significant contribution by offering an initial test of this
hypothesis.

The role of marriage and cohabitation

We predict that the living arrangements of heterosexual men
and women further condition the differences between mothers and
non-mothers. Prior research demonstrates that caretaking duties
among separated parents are largely performed by the custodial
parent, typically the mother (Furstenberg & Cherlin, 1994;
Marsiglio, Amato, Day, & Lamb, 2000). Therefore, the risks of
overweight due to food insecurity should be exacerbated among

M.A. Martin, A.M. Lippert / Social Science & Medicine 74 (2012) 1754e17641756

single mothers and relatively lower for mothers in co-residential
couple households. Likewise, single fathers should be at greater
risk of obesity when they are food insecure. Unfortunately, we have
too few single fathers in our data to fully explore this possibility
because most single parents are single mothers (Casper & Bianchi,
2002), reflecting a “community division of labor” (DeVault, 1991,
p.193) whereby women routinely have custody after parents
separate. Our second hypothesis is:

H2. The association between food insecurity and being over-
weight or obese is stronger for single mothers versus married or
cohabiting mothers.

It is important to note, however, that the causal relationships
between overweight, family formation, union dissolution, and
household food security are complex. In fact, the causal process
could work in the opposite direction: Overweight women may be
less likely to form unions and bear children given feminine beauty
ideals emphasizing thinness (Allon, 1982).

Alternative explanations

We predict that food insecurity and its management increases
the risks of overweight and obesity for mothers given the gendered
expectations of childrearing. We recognize, however, that there are
competing explanations and we do our best to address them.

First, one may agree with our prediction but disagree with our
interpretation. One may consider any observed risks for mothers as
reflecting, not childrearing, but biological risks of childbearing. If
metabolic changes related to pregnancy predispose birth mothers
to gain weight, then food insecure biological mothers would be at
greater risk of overweight and obesity than “social” mothers. Such
differences could also arise if, due to evolutionary pressures,
mothers are more protective of their biological children (Daly &
Wilson, 1980). To test whether the experience of pregnancy or
biological kinship creates unique risks, we conduct two supple-
mental analyses. First, we restrict our sample to only women living
with children (50% of the sample) and compare whether the risk of
obesity for food insecure mothers is lower among women living
with children they did not give birth to (i.e., they are adoptive, step,
or foster mothers), controlling for the number of children present.
Because most women live only with biological children, statistical
power issues may limit our ability to detect a significant difference.
Second, we restrict our sample to women who have ever given birth
by 2003 and examine whether the risks of household food inse-
curity increase as parity increases, regardless of whether their
children currently live with her and controlling for her age and
other demographic characteristics. Because 89% of the women in
our sample have given birth by 2003, power is less of a problem in
these analyses. If metabolic changes associated with pregnancy
undergird our findings, then one would expect those risks to
accumulate with each birth and, thus, translate into a statistically
significant interaction between parity and food insecurity among
biological mothers.

Second, one might argue that the statistical association between
food insecurity and overweight is a function of other sociodemo-
graphic factors besides income. Thus, we control for status char-
acteristics, like age, education and race/ethnicity in all models.

Third, one might expect that other mediating factors explain
these patterns, especially given that we do not have self-reported
measures of energy intake or, even better, data from doubly-
labeled water tests to measure their energy intake (Schoeller,
1990). We test several alternative mechanisms. Because food
insecure mothers may have fewer opportunities for recreational
physical activity, we test whether differences in self-reported
physical activity reduce the association between food insecurity

and weight among mothers. We also test whether the consumption
of alcohol or smoking cigarettes explains the observed patterns.
Because of the stresses associated with poverty and food insecurity
(Huddleston-Casas, Charnigo, & Simmons, 2009), which would
likely feel more threatening to parents, food insecure parents could
be more likely to self-soothe themselves with alcohol and nicotine.
Yet these behaviors are associated with being overweight (Mokdad
et al., 2003; Slattery et al., 1992). Lastly, given the longstanding
debate about whether receiving food stamps (now officially the
Supplemental Nutrition Assistance Program) increases the risks for
overweight and obesity (Borjas, 2004; Gibson, 2003; Institute of
Medicine, 2011), we test whether our results change with the
inclusion of food stamps receipt. We also include a measure of
participation in the Women, Infants and Children (WIC) nutritional
program.

In sum, we bridge several empirical literatures to develop a new
theoretical model about how gendered patterns of childcare
intersect with household economics to increase the risk of over-
weight among poor, food insecure mothers. We recognize that
there are several alternative explanations and, thus, do our best to
test them with the available data. Our aim is to provide an initial
examination of whether overweight and obesity are physical
expressions of the vulnerabilities that arise from the intersection of
gender, parenthood, and poverty.

Data and methods

Data

We use data from the Panel Study of Income Dynamics (PSID)
because it is the only study that collects data on individuals’ weight,
income, household food insecurity, and household composition.
Unfortunately, PSID does not have information about individual’s
energy intake and food insecurity management.

PSID is a longitudinal household-based study that began col-
lecting data in 1968 for a nationally representative sample and an
oversample of low-income, Southern households (Hill, 1992). The
PSID contains longitudinal data for all individuals who were ever in
a PSID household, even if they move out (Hill, 1992). Interviews
since 1997 are conducted biennially. Given that the PSID has been
fielded for almost 50 years, sample attrition could pose a problem,
but several studies have found that attrition has not affected PSID’s
representativeness (Becketti, Gould, Lillard, & Welch, 1988;
Fitzgerald, Gottschalk, & Moffitt, 1998). PSID is not representative,
however, of immigrant groups arriving in the U.S. after 1968.

We make several restrictions to arrive at our analytic sample.
First, we must rely on data collected in 1999, 2001, and 2003, the
years in which PSID collected data on both weight and food inse-
curity. Second, we restrict our analysis to those who were either the
head of a PSID household or their marital or cohabiting partner in
1999, 2001, and 2003 (n ¼ 9935) because PSID only collects data on
body weight for those individuals. While this provides for
a consistent sample across the various models, it makes the sample
more selective with regard to family structure stability. Our
substantive findings are unchanged, however, in analyses where
the data are multiply imputed to include anyone who meets the
restrictions listed below and was ever in the PSID between 1999
and 2003, regardless of their relationship to the household head.
Third, we restrict the analysis to heads and partners between the
ages of 18 and 55 in 1999 (n ¼ 8151) to focus on adults most at risk
for living with minor children and, thus, the hypothesized patterns.
The next two restrictions eliminate outlier cases that would chal-
lenge the statistical homogeneity of our analysis. Fourth, we drop
those who report being foreign born (n ¼ 82) or who can be
reasonably assumed to be foreign born because they have five or

M.A. Martin, A.M. Lippert / Social Science & Medicine 74 (2012) 1754e1764 1757

fewer years of completed schooling (and the minimum age of
compulsory schooling in the United States is 16) (n ¼ 51). These
individuals are unique in both unobserved and observed ways (i.e.,
their means and correlations for food insecurity, number of chil-
dren, marital status and weight differ significantly) because the
PSID is not representative of immigrants. The absence of immi-
grants reduces the prevalence of food insecurity in the study
(Borjas, 2004). Fifth, we omit women who are pregnant at the time
of the 2003 interview (n ¼ 85). Specifically, we omit women
reporting a live birth in the PSID’s Childbirth and Adoption History
File within 9 months following their 2003 interview date. After
these restrictions, our sample is 7931 adults.

Missingdata dueto item non-response is relatively minor in these
data. There are actually no missing data for people’s sex, age, part-
nership status, the number of co-residential children, urbanicity, and
household income (because the PSID has imputed it). There is minor
item non-response on food insecurity (n1999 ¼ 9, n2001 ¼ 11,
n2003 ¼ 20), self-rated health (n2003 ¼ 86), race (n ¼ 129), and
women’s fertility histories (n ¼ 36). The items with the most missing
data are body mass index (n1999 ¼ 379 [4% of the original 9935
sample], n2001 ¼ 257 [3%], n2003 ¼ 305 [3%]) and education
(n2003 ¼ 596 [6%]). We utilize multiple imputation handle item non-
response, which replaces missing values with predictions from
information observed in the sample (Rubin, 1987). We use the
supplemental program “ice” within STATA 11.0 (Royston, 2005a,b) to
create five imputed data sets. The imputation models include all of
the variables and their interactions that are used in the empirical
models, as well as the respondent’s work status, occupation, and
region (all in 2003), the number of adults in the household (in 1999,
2001, 2003), whethertheylivewithayoungchild(ages0e5;in 2003)
and whether PSID imputed their income. We estimate the empirical
models for each imputed data set and then combine the results,
accounting for the variance within and between the imputed
samples to calculate the coefficients’ standard errors (Rubin, 1987).

Measures

Body weight
We determine people’s weight classification in three steps. First,

because PSID only has self-reported weight and because self-
reported weight is generally biased downward among women and
upward among men (Cawley & Burkhauser, 2006), we use the
Cawley (2004; Cawley & Burkhauser, 2006) adjustments to improve
the accuracy of our dependent variable. Specifically, we multiply
respondents’ self-reported weight by race- and sex-specific coeffi-
cients from Cawley’s regressions of measured weight on self-
reported weight. Second, we calculate their body mass index
(BMI) [weight (kg)/height2 (m2)] from their self-reported height and
their Cawley-adjusted self-reported weight. Third, we follow World
Health Organization (2000) guidelines to classify BMI into the
following weight categories: underweight (BMI < 18.5), normal
weight (18.5 � BMI < 25), overweight (25 � BMI < 30) and obese
(BMI � 30). In the cross-sectional models, we predict whether
a person is (1) normal weight or underweight, (2) overweight, or (3)
obese in 2003. Because less than 2% of the sample is underweight,
we cannot model underweight as a separate category. For the
longitudinal models, we predict their weight change (in pounds)
between 1999 and 2003, simply calculated as their Cawley-adjusted
2003 weight minus their Cawley-adjusted 1999 weight.

Household food insecurity
We use the U.S. Department of Agriculture’s Food Security Scale

(Bickel et al., 2000). Respondents were asked a sequential series of
18 questions if they live with children and 10 questions if they do
not. The different series are made equivalent (and thus orthogonal

to the presence of children) in the final 10-point scale and cate-
gorical measure of food security. Following the USDA’s guidelines,
households are classified as food insecure (¼1) if they score a 2.2 or
higher on the Food Security Scale (Bickel et al., 2000). We measure
their household food insecurity in 2003 and create a longitudinal
measure that counts the survey years with reported household
food insecurity between 1999 and 2003 (values: 0, 1, 2, or 3).

Sex
Sex is a dichotomous indicator for whether the person is female

(1 ¼ yes) or male.

Children
PSID participants report the number of children between the

ages of zero and 17 years currently in the household, regardless of
their biological relationship to the household head or their partner.
We create a dichotomous measure indicating children are present
(¼1) and a count of children present.

We use the PSID’s Childbirth and Adoption History (1985e2007)
data to create two variables. First, among those living with children
in 2003, we determine whether the woman gave birth to every
child present and create a dichotomous variable equal to one if she
did not. Because very few women live with a mix of biological and
non-biological children (N ¼ 14), the results primarily reflect
whether women who did not give birth to any of the children
present (N ¼ 307) are different. Second, we calculate the total
number of children a woman has ever borne.

In the longitudinal models, we use a variable that equals the
differencebetween thenumberofchildrenpresentin2003and 1999.

Partner co-residence
To compare adults in different residential relationships, we

estimate models separately for those who are single and those who
are who are living with a romantic partner, whether married or
cohabiting.

Alternative mediating variables
Supplemental models include the following variables, reported

in 2003: being a “current smoker” (¼1), the number of alcoholic
drinks consumed per day (0 ¼ none,1 ¼ less than one a day, 2 ¼ 1 to
2 per day, 3 ¼ 3 to 4 a day, and 4 ¼ 5 or more a day), bouts of
“heavy” physical activity during the last month (PSID-provided
examples include aerobics, running, swimming, strenuous house-
work), bouts of “light” physical activity during the last month
(PSID-provided examples include walking, golfing, gardening,
bowling), receipt of food stamps in 2001 (¼1), and receipt of WIC in
2002 (¼1).

Control variables
To control for confounding variables, we include age (in years),

education (in years of completed schooling), poor self-rated health
(0 ¼ “good,” “very good,” or “excellent,” 1 ¼ “poor” or “fair”),
disability status (1 ¼ at least one limitation in the Activities of Daily
Living Scale, 0 ¼ none), and metropolitan residence (0 ¼ non-
metropolitan area, 1 ¼ metropolitan area). Race is measured with
three dichotomous variables to compare (1) non-Hispanic African
Americans, (2) Hispanics, and (3) non-Hispanic other racial groups
to non-Hispanic Whites (the reference category).

Analysis

For the cross-sectional analysis, we estimate several ordinal
logistic regression models in STATA (v. 11) to predict 2003 weight
categories. The results are substantively similar to those from
multinomial logistic regression models. (Results available upon

M.A. Martin, A.M. Lippert / Social Science & Medicine 74 (2012) 1754e17641758

request.) For the longitudinal models, we make an additional data
restriction. We omit people who report gaining (n ¼ 73 [averaged
across imputations]) or losing (n ¼ 50 [consistent across imputa-
tions]) at least 75 pounds in between 1999 and 2003 because such
dramatic changes likely reflect a reporting error in either year or
very unique weight-related experiences. We then use an OLS
regression to predict their change in weight (in pounds) between
1999 and 2003.

All models include PSID 2003 sampling weights to account for
the PSID’s attrition and oversampling of low-income Southern
households and, thereby, make the findings generalizable to the
2003 U.S.-born population. For ease of presentation, we present
results stratified by sex, but we estimate supplemental models
using a pooled sample of men and women to directly test whether
the interaction between food insecurity and the presence of chil-
dren is significantly different by sex.

Results

Table 1 presents weighted descriptive statistics for our full
analytic sample and for men and women separately. Key among
these is that over 60% of the sample is overweight or obese in both
1999 and 2003. On average, women are more likely to be over-
weight or obese in both years and women gain more weight
between 1999 and 2003 (p < .01). In 1999, 6.8% of the sample was
food insecure, while only 4.8% of the sample was food insecure in
2003. These estimates are lower than the national averages for
these years, reflecting our restriction to U.S.-born individuals. As
such, our tests rely on the comparison of small subpopulations.
There are 174 food insecure men (101 are fathers) and 293 food
insecure women (196 are mothers). In 2003, the average sample
member was 39 years old, which partially accounts for the
observed decline in the proportion living with children between

Table 1
Sample means and percentages, weighted and adjusted for sampling design.

Full sample (N ¼ 7931)
1999 2003

Weight, Cawley-adjusted self-report
Body mass index 28.3 29.2
Weight classification
Underweight 1.1% 1.0%
Normal weight (reference) 34.7% 30.1%
Overweight 33.6% 33.6%
Obese 30.6% 35.3%

Weight change (in pounds), 1999e2003 5.3
Household food insecurity 6.8% 4.8%
Household income (in $1000s) e 79,892
Female (¼1) e 53.1%
Children
Co-reside with children (¼1) 55.0% 49.9%
Number of children present 1.0 0.9
Relationship to co-residential children (among those living with children)
All borne by her e e
Some or all not borne by her e e

Number of children ever borne e e
Age (range: 18e55 in 1999) e 39.4
Education in years (range: 6e17) e 13.5
Married or cohabiting (¼1) e 73.3%
Poor or fair self-rated health (¼1) e 11.1%
Disabled (¼1) e 6.2%
Race/ethnicity
non-Hispanic White (reference) e 80.1%
non-Hispanic African American e 9.9%
Hispanic e 6.1%
non-Hispanic other racial group e 3.9%

Metropolitan residence (¼1) e 76.0%
Note: Two-tailed tests of a significant difference between men and women are noted as

1999 and 2003. Half the sample lives with children in 2003 and
women are slightly more likely than men to live with children
(p < .05).

Prior research has consis

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Replacement Feeding Experiences of
HIV-Positive Mothers in Ethiopia
Bogale Abera Woldegiyorgis a & James L. Scherrer b
a Hawassa College of Teacher Education, Hawassa, Ethiopia
b Graduate School of Social Work, Dominican University, River
Forest, Illinois, USA
Version of record first published: 12 Mar 2012.

To cite this article: Bogale Abera Woldegiyorgis & James L. Scherrer (2012): Replacement Feeding
Experiences of HIV-Positive Mothers in Ethiopia, Journal of Community Practice, 20:1-2, 69-88

To link to this article: http://dx.doi.org/10.1080/10705422.2012.648123

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Journal of Community Practice, 20:69–88, 2012
Copyright © Taylor & Francis Group, LLC
ISSN: 1070-5422 print/1543-3706 online
DOI: 10.1080/10705422.2012.648123

PART 2: POLICY

Replacement Feeding Experiences
of HIV-Positive Mothers in Ethiopia

BOGALE ABERA WOLDEGIYORGIS
Hawassa College of Teacher Education, Hawassa, Ethiopia

JAMES L. SCHERRER
Graduate School of Social Work, Dominican University, River Forest, Illinois, USA

The World Health Organization most recent guidelines recom-
mend that HIV-positive mothers exclusively breastfeed unless
replacement foods meet the criteria of acceptability, feasibility,
affordability, sustainability, and safety (AFASS). However, the
fear of HIV transmission through breastfeeding has pressured
these mothers into choosing replacement feeding whether they
meet AFASS criteria or not. This choice has subjected infants
to malnutrition and related deaths. This qualitative study is
based on Scheper-Hughes and Lock’s (1987) Three Bodies Model.
Discussions were carried out in a Prevention of Mother-to-Child
Transmission Program (PMTCT) in Hawassa, Ethiopia using
in-depth interviews, key informant interviews and focus groups.
The study focused on the challenges that HIV positive mothers face
due to inadequate counseling services, poor economic situations,
and lack of support and follow up. The Three Bodies Model exposes
the deficits in the comprehensive delivery of services by PMTCT pro-
grams. Implications for social work practice and funding policies
are discussed.

KEYWORDS replacement feeding, social meanings, PMTCT,
HIV/AIDS, breastfeeding, mothers

We acknowledge Haile Michael Tesfahun, Addis Ababa University, School of Social Work,
for his critical comments on the original thesis. The research was funded through Addis Ababa
University, School of Social Work.

Address correspondence to Bogale Abera Woldegiyorgis, Hawassa College of Teacher
Education, P.O. Box 115, SNNPR, Hawassa, Ethiopia. E-mail: bogale.abera@gmail.com

69

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70 B. A. Woldegiyorgis and J. L. Scherrer

The emergence of the human immunodeficiency virus (HIV) epidemic in
the past few decades threatened breastfeeding as a safe and healthy method
of feeding infants in economically distressed parts of the world. The World
Health Organization (WHO) Update (2007b) recommended that HIV-positive
mothers exclusively breastfeed their infants unless replacement feeding,
which does not include breast milk, meets the criteria of accessibility, feasi-
bility, affordability, sustainability, and safety (AFASS). However, HIV-positive
mothers often choose replacement feeding whether or not AFASS criteria are
met, because they fear transmitting the HIV virus to their infants through
their breast milk. When AFASS criteria are not met, infants are subjected to
malnutrition, infections, and diseases that may result in death. The purpose
of this study is to assess the difficulties in replacement feeding experiences
faced by HIV-positive mothers enrolled in the prevention of mother-to-child
transmission (PMTCT) program in Hawassa, Ethiopia. The study aims to
know the challenges HIV-positive mothers faced in their infant feeding
experience, how community infant feeding practices and social meanings
influence feeding choice, and how replacement-feeding mothers feel about
the support and services they receive.

This qualitative study uses the Three Bodies Model (Scheper-Hughes
& Lock, 1987) to set up in-depth interviews with HIV-positive moth-
ers, breastfeeding counselors, and members of the HIV community. The
interviews were transcribed and analyzed to discover common influences
on HIV-positive mothers’ decisions to breastfeed, replacement feed, or
mix feed their infants. In addition, common themes about support and
information provided to them were explored. The implications for future
social work community practice are examined and courses of action
recommended.

PMTCT OF HIV

Feeding options for infants of HIV-positive mothers are either exclusive
replacement feeding or exclusive breastfeeding (Koniz-Booher, Burkhalter,
de Wagt, Iliff, & Willumsen, 2004). However, both feeding options involve
risks to child health and survival. Although exclusive breastfeeding is more
practical, it has a 5% to 15% chance of transmitting HIV to infants (Israel
& Kroeger, 2003). This incident rate of mother-to-child transmission could
be reduced through drug intervention, and an awareness of precautions
such as minimizing the duration of breastfeeding (WHO, 2003). Exclusive
replacement feeding is an ideal option, because there is no chance of HIV
transmission. However, it is difficult to apply in resource-limited nations,
where exclusively replacement fed infants have a six-fold increased risk of
dying in the first 2 months of life, compared with those who were breastfed
(WHO, 2008).

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Replacement Feeding Experiences in Ethiopia 71

Over 530,000 new cases of pediatric HIV infection occur each year
throughout the world, primarily due to mother-to-child transmission of HIV
(WHO, 2007a). In resource-rich settings, prenatal transmission rates of 2%
or less are achieved with the use of a combination of antiretroviral, obstet-
rical interventions and avoidance of breastfeeding. HIV-positive mothers in
such settings can safely provide formula to their infants so that they can
avoid breastfeeding. In resource-limited settings, however, alternatives to
breastfeeding do not usually meet the requirements of AFASS for many HIV-
infected women. HIV-positive mothers tend to overestimate that all breastfed
babies will be HIV-infected. As a result, they exclusively replacement feed
their infants, even though AFASS criteria are not met (Koniz-Booher et al.,
2004). A study in Tanzania showed that replacement feeding is rare in a
breastfeeding culture, because the community believes that infants cannot
survive without breast milk (Leshabari, Blystad, & Moland, 2007). Thus,
exclusive replacement feeding in early infancy violates the rules of good
motherhood. Those who practice it are considered failures as mothers. As a
result, the community pressures HIV-positive mothers to mix breastfeeding
with replacement feeding.

Replacement feeding also has some negative socially constructed mean-
ings (Leshabari et al., 2007). Replacement-feeding mothers are thought to
be concerned more about their body shape than child rearing, and to
engage in extramarital affairs, or to be HIV positive. Njunga’s (2008) study in
Malawi recommended that PMTCT programs should take into consideration
the spectrum of such cultural factors that influence experiences, behav-
ior, and attitudes (Sevelius, 2011). Partners and/or family members of the
replacement-feeding mothers may attempt to exert control over her feeding
method (Koniz-Booher et al., 2004). Unless partners and family members are
involved in the infant feeding decision, adherence to replacement feeding
will be challenging (Aubel, 2011). These mothers also face the challenge pre-
sented to them by rapidly changing recommendations from WHO (Moland
et al., 2010). The WHO (2001) guidelines recommend that mothers meet
AFASS criteria before choosing replacement feeding as the form of nutri-
tion for their infants (Koniz-Booher et al., 2004; Koricho, Moland, & Blystad,
2010). If AFASS criteria cannot be met, these mothers should exclusively
breastfeed their infants. These guidelines were in effect until 2007, when
WHO shifted the focus to breastfeeding first and AFASS criteria second.
They were changed again in 2009, and still again in 2010, to reflect ongo-
ing research in what would keep infants of HIV-positive mothers, and the
mothers themselves, healthy. Current guidelines differ significantly from
those of 2001, yet many postnatal counselors have been trained only to
the 2001guidelines (Moland et al., 2010; WHO, 2010).

AFASS criteria may impose significant economic challenges for moth-
ers choosing to replacement feed in Ethiopia (Koricho, 2008). Health care
centers may provide formula for replacement feeding of infants, but often

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72 B. A. Woldegiyorgis and J. L. Scherrer

it is not enough. Mothers are then forced to use replacement feeding meth-
ods that do not meet AFASS criteria. The issue is further complicated by
the fact that health service counselors only examine the affordability por-
tion of AFASS and nothing else. Even the availability of free formula may
not ensure that the decision to replacement feed translated into successful
practice (Koniz-Booher et al., 2004). Besides knowing their HIV status and
having access to free or subsidized formula, these mothers needed proper
advice from counselors, partner or family involvement, better educational
level, assistance with being the primary income provider, and participation
in structured PMTCT programs. Instead, HIV-positive mothers were often
exposed to conflicting messages from the local mission hospital, family
members, and traditional healers (Bond, Chase, & Aggleton, 2002).

Mothers using replacement feeding in a breastfeeding culture faced
criticism from the community and were given some negative social mean-
ings, which PMTCT programs overlooked. However, a study of HIV-positive
mothers in Botswana (Nyblade, Kidd, & Field, 2000) indicated that moth-
ers were able to override any traditional norms by prioritizing their infants’
health. This, coupled with the benefits of follow-up counseling (Matovu,
Bukenya, Musoka, Kikonyogo, & Guay, 2002), was hampered by a slow
and crippled program beginning that has limited access to HIV/AIDS-related
services. As a result, replacement-feeding mothers were trapped between
the demand of the health care system wanting mothers to either exclusively
breastfeed or exclusively replacement feed and the community cultural prac-
tice demanding them to mix feed. They also struggled with the control efforts
from their partner and in the home environment (Aubel, 2011; Bland, Rollins,
Coutsoudis, & Coovadia, 2002).

Mulugeta’s (2008) study of economic and social adaptations of women
in Addis Ababa, Ethiopia, found that HIV-positive mothers using replace-
ment feeding methods employed various strategies to cope with the
challenges facing them. They entered formal and informal employment sec-
tors, diversified survival strategies, went on informal migration, minimized
household expenditures, changed dietary habits, and sought the support of
family members, friends, and other kin. Informal associations also provided
crucial supportive roles. Generally, replacement feeding in resource-poor
settings caused more harm than good to infant survival and became a source
of fear and challenge for mothers in Africa who could not afford to buy even
their own meals. This was supported by Sethuraman et al.’s (2011) study of
rural Vietnamese HIV-positive mothers. They found that replacement feed-
ing occurred early out of necessity and social pressure even though AFASS
criteria were not met.

PMTCT of HIV services are being rendered in all hospitals in regional
towns and in satellite health centers in Ethiopia (Amare & Deneke, 2003).
According to the Ethiopian Federal Ministry of Health (2007), the preven-
tion of HIV transmission from infected women to their infants is one of

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Replacement Feeding Experiences in Ethiopia 73

the strategies of PMTCT. A behavior surveillance survey in Ethiopia found
that HIV/AIDS-prevention programs have some impact on knowledge about
HIV/AIDS (Federal Ministry of Health, et al., 2006). However, neither the
increase in knowledge of HIV/AIDS nor the WHO Update (2007b) rec-
ommendation that infant feeding counseling and support for HIV-positive
women be provided during pregnancy and for 2 years after the infant’s birth
have led to corresponding behavior change (Federal Ministry of Health,
2009). According to a World Bank (2008) report, to date only 2% of HIV-
positive pregnant women needing PMTCT have benefited from the service
in Ethiopia. In 2006, only 2,028 pregnant women received Nevirapine, of
whom only 1,341 took a complete course for themselves and their infants.
Although 1,400 sites are planned to have PMTCT services by the end of
2007, only 184 sites provided the services.

THE THREE BODIES MODEL

The results of these studies can be synthesized using Scheper-Hughes
and Lock’s (1987) conceptual framework, The Three Bodies Model
(see Figure 1). The framework analyzes the body using three different
approaches, representing three levels of analysis. The first level is the indi-
vidual body, which is the lived experiences of the body self and the meaning
attached to these experiences. The second level is the social body, which
refers to the body as a natural symbol with which to think about nature,
society, and culture. The social body is developed through being a member
of a particular social or cultural group. The third level is the body politic,
referring to the regulation, surveillance, and control of bodies.

Social Body:
Infant feeding

culture and
social

meanings

Coping Strategies

Exclusive
Replacement
Feeding (ERF)

Politic Body:

Control in
home and

health care
systems

Individual Body:

Feeding
challenges,

perceptions, and
fears

FIGURE 1 The three bodies and exclusive replacement feeding. Source. Developed by the
authors from the concepts presented in Scheper-Hughes and Lock (1987)

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74 B. A. Woldegiyorgis and J. L. Scherrer

Incorporated in this framework are feeding-related challenges that HIV-
positive mothers face: fears regarding feeding choice, influences and social
meanings of community infant feeding practices, and controls exerted over
the HIV-positive mother in the home environment and by the health care
system. HIV-positive mothers are faced with the infant feeding dilemma of
exposing their infants to HIV infection through breastfeeding, or replace-
ment feeding which, although HIV-free, exposed infants to malnutrition
and infectious diseases. In addition, because breastfeeding is socially con-
structed as being an essential feature of motherhood, replacement feeding
reflects negatively on the mother’s commitment to motherhood and her chil-
dren. Husbands, mothers, mother-in laws, friends, and communities apply
pressure to the HIV-positive mother at least to mix breastfeeding with
replacement feeding. Finally, the HIV-positive mother is faced with chal-
lenges in implementing the requirements of the health care system with
limited resources. According to Leshabari (2007), the interconnectedness
and dynamics of these influences and challenges are well illustrated by this
framework.

RESEARCH METHODS

The study was conducted in 2009 in Hawassa, Ethiopia, a small city of
about 157,879 residents (Federal Democratic Republic of Ethiopia, Office of
Population Census Commission, Central Statistics Agency, 2010). Participants
in the study were drawn from Hawassa Referral Hospital (HRH), Tilla
Association of Women Living with HIV/AIDS (Tilla), and key informants
from the community. HRH is the only government hospital in the city and it
provides free PMTCT services to Tilla members, most of whom replacement
feed their infants. An ethnographic research design was used, to obtain
a holistic picture of the infant feeding practices of HIV-positive mothers.
Selection of participants sought to obtain respondents representing each of
the Three Bodies. Seven exclusive-replacement-feeding mothers who used
varied methods of replacement feeding such as formula, cow’s milk, and
gruel represented the individual body. The respondents were selected using
maximum variation sampling, a technique that purposefully selects a wide
range of variations on a dimension of interest (WHO, 1994). None of these
mothers completed high school. Their family income is less than $20 US per
month. Their average age was 27 years. All were married except one. Their
family size ranged between three and 10 children. Four counselors in HRH
and Tilla represented the body politic and were selected by intensity sam-
pling, a sampling technique that focuses on excellent, but not necessarily
extreme, examples of the phenomenon (Ulin, Robinson, Tolloy, & McNeill,
2002). Their experience in infant feeding counseling ranged from 1 year to
6 years. Three female Infant Feeding Counselors, who have a diploma in

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Replacement Feeding Experiences in Ethiopia 75

nursing, from HRH and one male nurse, who has a Bachelor of Science in
nursing, from Tilla participated in this part of the study.

Key community members, selected by homogenous sampling (Ulin
et al., 2002) and divided into two focus groups of seven members, rep-
resented the social body. This sampling technique is typically used to select
people with similar characteristics and a common identity to discuss and
share their experiences in focus groups. One focus group consisted of older
(ages 30–40) HIV-positive women from Tilla who did not participate in
the individual interviews. The other focus group consisted of older (ages
45–65) HIV-positive men from the Union of Iddirs of People Living With
HIV/AIDS. Iddirs are community-based organizations set up for arranging
burial ceremonies of a deceased member, comfort the family on the loss
of the beloved one, and support one another during problematic situations.
Currently, the government has started to include them in efforts to solve
community problems like helping orphans and other development activities.

Data collection instruments consisted of open-ended questions to
guide interviews and focus group discussions. These instruments were
produced from WHO standard questionnaires, reports, and readings on
HIV-positive mothers’ infant feeding experiences. The concepts included
were: HIV-positive mothers’ replacement feeding experiences and their per-
ceptions of these; community infant feeding culture and meaning attached
to feeding practices; the influence on mothers’ choice of feeding by her
family and relatives and by the health facility; and the coping strategies
exclusive-replacement-feeding mothers used to manage these environmental
demands. The instruments were pretested at HRH and Tilla with respon-
dents who did not participate in the actual study, and modified based on
the pretest results. Written consent was obtained from all of the participants.
Participation was voluntary and the participants were told of their right to
withdraw without giving a reason at any time and to request that their data
be excluded. The rights of participants to refuse answers for a few or all
interview questions were respected. Each participant was given $1.75 US for
his or her time spent in the study.

There were some potential risks to the study participants. HIV-positive
infant-feeding mothers who have not disclosed their status could have been
rejected by their husbands, physically abused, or divorced. The community
members could have breached confidentiality of information discussed in
the focus group. Their participation in the study could have affected the
services they receive from HRH. The nurse counselors’ job might be endan-
gered for revealing actions of their health facilities that compromised the
quality of infant feeding follow-up visits. These risks were discussed with
the participants, as well as an explanation of how they would be minimized.
To reduce these potential risks, the names of participants were coded to
protect identifying information. Written commitments were obtained from
the participants to respect the confidentiality of the interviews. Interviews

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76 B. A. Woldegiyorgis and J. L. Scherrer

and focus group discussions were conducted in Amharic and tape recorded.
Participants were told they could speak without being tape-recorded
whenever they chose. In addition, field notes recording environmental
setting and verbal and nonverbal information during the interviews were
taken.

Data analysis involved first transcribing the tape recordings of the inter-
views and discussions. The Amharic transcripts were then translated into
English and the English translations were analyzed. When the information
from different data sources did not agree, the original Amharic transcripts
were consulted either to reconcile contradictions or to present divergent
interpretations. The data were analyzed in five steps as suggested by Ulin
et al. (2002). The translated transcripts and field notes were read and reread
carefully to become familiar with the text. Emerging themes were coded
using informant and researcher concepts. Principal themes and subthemes
were identified through data display. The most essential concepts and rela-
tionships were made visible through condensation of the data. Finally,
interpretations were made by identifying and explaining core meanings of
the data, communicating the essential ideas of the participants, and remain-
ing faithful to their perspectives. All information obtained in the study was
maintained on a secure computer that was password protected.

FINDINGS

The Individual Body: Mothers and Replacement Feeding

Three themes around replacement feeding challenges were evident in the
interviews with the mothers. The first theme was that replacement-feeding
mothers do not get proper infant feeding counseling. Neglecting other
AFASS criteria, counselors only asked mothers if they could afford to buy
the replacement foods. The counseling focused on scaring mothers about
the possibility of infecting their infants and favoring the choice of formula
feeding. The mothers were sometimes exposed to conflicting counseling
messages as noted by a mother of three:

A home-care provider advised me to exclusively breastfeed the child for
6 months. I began exclusive breastfeeding as per her advice. However,
when I went to Referral Hospital, the doctor told me that the infant
had been fed the virus. I was shocked and planned to immediately stop
breastfeeding. In the hospital, the child spent 24 hours without having
any food until the virus he had been sucking was “removed.” After all the
virus is removed from his stomach, I began cow’s milk. (Selam, personal
communication, March 26, 2009)

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Replacement Feeding Experiences in Ethiopia 77

The mothers were orally informed about replacement feeding but they
were given no demonstration during the counseling. Fathers were not
involved in infant feeding counseling because they did not accompany the
mothers and their infants to the counseling room. HIV-positive mothers were
not instructed on preparing for the delivery of their child, by bringing for-
mula or cow’s milk and a feeding bottle to replacement feed their infants
after delivery, resulting in infants waiting long hours until the replacement
food was found in the town. There were no follow-up visits by HRH on
how well, or even if, the replacement-feeding mothers were implementing
the instructions they had been given on replacement feeding.

The second theme that evolved was on the challenges in maintaining
replacement feeding that met AFASS criteria. Economics presented the major
challenge. Most of the mothers began with formula, but changed to cow’s
milk and then to mitin, a gruel-type of substance made from different types
of grains, because that was what they could afford. Other common replace-
ment foods identified by the mothers are raw milk, boiled cow’s milk, abish
or fenugreek, a soup made from a local plant, and atmit, a gruel made from
one kind of grain. Only one mother was able to feed her infant formula
for 6 months. The others all stopped much sooner, some after only 1 week.
An infant feeding counselor noted:

I don’t think mothers sustainably adhere to their feeding choice. Market
situation and their income do not match. Lots of replacement-fed children
are malnourished and admitted to the hospital. They get balanced diet
in the hospital and recover. When these children go home, mothers
cannot properly feed them and you see the same child in the therapeutic
feeding center next month. There is a cycle of malnutrition. They go
to hospital, get better, go home, and are malnourished and admitted to
hospital again. This shows that the mother couldn’t sustainably provide
replacement feeds. (Tibebu, personal communication, April 7, 2009)

Some of the reasons for this lack of sustainability include mothers who
stayed at home to care for their children and could not go out to earn addi-
tional income. Most of the fathers have no regular income to contribute
toward purchasing replacement food. As a result, the nutrition of other fam-
ily members was neglected because the family’s economic resources went
for purchasing the replacement food. In addition, sustainability was threat-
ened by a policy of providing mothers with infant nutritional support for
only a week or a month at a time at most. A mother of triplets described her
dilemma in sustaining her feeding choice:

The counselors told me to exclusively replacement-feed the infants or
exclusively breastfeed them. When I and my husband examine it, this
is very useful for one child. However, ours are three and neither of the

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78 B. A. Woldegiyorgis and J. L. Scherrer

choices was feasible for us. My breast milk will not suffice for three of
them. We could not afford to buy replacement feed for them. I haven’t
thought they will survive. One of them died after 2 months. I suspect
it could be due to starvation. Then I was worried about the survival of
the other two and feed them everything thought to be good for infants.
(Tarikua, personal communication, April 3, 2009)

Most of the study mothers overcame these challenges in their replacement
feeding by shifting the nutritional support that they received for themselves
from a nongovernmental organization (NGO) to their infants, which resulted
in compromising their own health. They also coped by cutting back family
expenditures, creating additional income sources, and immediately taking
infants to health institutions whenever they became ill.

The third theme that became evident was the mothers’ fears of replace-
ment feeding their infants. They have doubts about the nutritional adequacy
of their replacement feeding method. Most of the study mothers (5/7) feared
the possibility that other nursing mothers who could breastfeed their infants
would be HIV-positive, thus exposing their infants to the virus. Almost all
mothers (6/7) feared that they did not show love to their infants because
they replacement fed rather than breastfed them. A mother of one child
noted:

I think I missed a lot due to replacement feeding. I began to worry just
as I got pregnant. One day I was exploring my breast and milk began to
flow. When I thought that I couldn’t breastfeed my child, I wept for the
whole night. I feel that my child would not love me because I have not
breastfed her. I often ask, “How do I make her know I love her? How do
I express my love to my child?” Though I devoted my full time t

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