An-Najah National University 
Faculty of Graduate Studies          

The Impact of Exclusive Breastfeeding on Infant 
Morbidity in the First Six Months of Infant s life 

in Nablus s Refugee Camps        

By 
Shaden Hamdi Shakeb Qanadelo      

Supervised by 
Dr-Samar Ghazal / Musmar       

Submitted in Partial Fulfillments of the Requirements for the 
Degree of Master in Public Health, Faculty of Graduate Studies, 
at An- Najah National University, Nablus, Palestine. 

2010 





 
iii 

Dedication  

To my parents, to every one deprived from education, and to 

those who know the value of learning and knowledge.              



 
iv

Acknowledgement 

ALLAH, Subhanahu wa ta'ala said in holy Quraan:- 

     

And Allah's grace on you is very great.                  (Surah An-Nisaa, 113) 

Firstly I must thank God for his graces and blessing on me to 

complete this study, which helped me to overcome all obstacles and hard 

times I met throughout my study years.  

I would like to extend my sincere gratitude to my thesis supervisor 

Dr-Samar Ghazal\ Musmar, MD; without her this research would never 

have been achieved. I would like to thank her deeply for her invaluable 

expert scientific guidance, support, and advises 

My sincere thanks to Dr-Motasim Al-Masri, and Dr- Suhail Salha for 

their scientific advises and continuous support.  

From bottom of my heart I would like to thank my parents who 

taught me the value of learning, especial thanks for my mother who's been 

always supporting, advising, and ensuring me that by believing, hope, and 

hard work all hard targets would be possible.    



 
v

        
: 

The Impact of Exclusive Breastfeeding on Infant Morbidity in the 

First Six Months of Infant s life in Nablus s Refugee Camps 

              

  

                               

. 

Declaration 

The work provided in this thesis, unless otherwise referenced, is the 

researcher s own work, and has not been submitted elsewhere for any other 

degree or qualification.  

:  Student's name: 

:    Signature: 

:             Date:  



 
vi

List of Acronyms 

Abbreviation

 
Explanation 

AAFP The American Academy of Family Physicians. 
AAP The American Academy of Pediatrics. 

ACOG 
The American College of Obstetricians and 
Gynecologist. 

ALRI Acute Lower Respiratory Infection 
AOM Acute Otitis Media 
ARI Acute Respiratory Infections. 
BF Breastfeeding. 

EBF Exclusive breastfeeding. 
EFF Exclusive Formula milk Feeding. 
IgA Immunoglobulin A. 
IgD Immunoglobulin D. 
IgE Immunoglobulin E. 
IgG Immunoglobulin G. 
IgM Immunoglobulin M. 
LRTI Lower Respiratory Tract Infection. 
MCH Maternal and Child Health 
OM Otitis Media. 

Adj-OR Adjusted Odds Ratio 
PBF Partial Breastfeeding. 

PCBS Palestinian Central Bureau of Statistics. 
PMOH Palestinian Ministry of Health.  

PSC Palestinian Satellite Channel 
ROM Recurrent Otitis Media. 
S-IgA Secretory Immunoglobulin A. 
SPSS Statistical Package for Social Sciences. 

Type I DM Type I Diabetes Mellitus. 
UNICEF The United Nations Children s Fund.  

UNRWA 
United Nations and Works Agency For Palestine 
Refugees in the Near East. 

URTI Upper Respiratory Tract Infection. 
USA The United States of America. 
UTI Urinary Tract Infection. 

WHO World Health Organization. 

 



 
vii

Table of Contents. 

No. Subject Page 

 
Dedication iii 

 
Acknowledgement iv 

 
Declaration v 

 

List of Acronyms vi 

 

Table of contents vii 

 

List of tables x 

 

List of Appendix xi 

 

Abstract xii 

 

Chapter One: Introduction 1 
1.1 Study background 2 
1.2 Types and importance of breastfeeding 3 
1.3 Types, composition, and benefits of Breast milk 5 
1.3.1 Biological and chemical composition of breast milk 6 
1.3.2 Breast milk role in fighting infection 8 
1.3.3 Other benefits of breast milk 10 
1.4 Formula feeding 10 
1.5 The problem of the study 11 
1.6 Significance of the study 13 
1.7 Goal and objectives of study 14 
1.8 Study questions 15 
1.9 Important definitions for this study 17 

 

Summary 18 

 

Chapter Two: Literature review  19 

2.1 
Relationship of breastfeeding and infections studies at 
international level  

20 

2.2 Regional studies  23 
2.3 Breastfeeding studies at national level 25 

 

Summary 26 

 

Chapter Three: Methodology and procedure 27 
3.1 Study population 28 
3.2 Study design and sampling method 30 
3.3 Sample of the study 30 
3.3.1 Inclusion criteria 31 
3.3.2 Exclusion criteria 32 
3.4 Operational definition of the study variables 33 
3.5 Instrument of data collection 37 
3.5.1 Questionnair 37 
3.5.2 Reliability and Validity of the tool 38 
3.5.3 Data collection 39 



 
viii

No. Subject Page 
3.6 Potential confounders 39 
3.7 Data analysis 39 
3.8 Ethical issues 41 
3.9 Study limitations 41 

 

Summary 42 

 

Chapter four: Results 43 

4.1 
Sample distribution according to mother's and infant's 
sociodemo-graphic profile 

44 

4.2 
Sample distribution according to infant s history of 
morbidity in the first six months 

46 

4.3 
Sample distribution according to type of infant feeding  
in the first six months of life 

48 

4.4 Results related to study hypotheses 48 

4.4.1 

Results related to the specific hypotheses; relationship 
between selected mother s and infant s 
sociodemographic profiles and type of feeding in the 
first six months of life in Nablus refugee camps  

48 

4.4.2 Results related to the hypotheses of morbidity 54 

4.4.2.1

 

Results related to the first specific hypothesis; 
relationship between type of feeding and frequency of 
disease visits in the first six months of life in Nablus 
refugee camps   

54 

4.4.2.2

 

Results related to the main hypothesis; relationship 
between type of infant feeding and morbidity in the first 
six months of infant s life in Nablus refugee camps 

55 

4.4.3 
Relationship between type of infant feeding and 
morbidity after adjustment for mother and infant 
confounding factors 

59 

 

Summary 61 

 

Chapter five: Discussion 62 

5.1 
Discussion related to sample distribution according to 
mother s and infant s sociodemographic profile 

63 

5.2 
Discussion related to sample distribution according to 
infant history of morbidity in the first six months 

65 

5.3 
Discussion related to sample distribution according to 
type of infant feeding  in the first six months of life 

66 

5.4 Discussion related to study hypotheses  67 

5.4.1 

Discussion related to the specific hypotheses; 
relationship between selected mother s and infant s 
sociodemographic profiles and type of feeding in the 
first six months of life in Nablus refugee camps 

67 



 
ix

No. Subject Page 
5.4.2 Discussion related to the hypotheses of morbidity 72 

5.4.2.1

 
Discussion related to the first specific hypothesis; 
relationship between type of feeding and frequency of 
disease visits in the first six months of life in Nablus 
refugee camps   

72 

5.4.2.2

 

Discussion related to the main hypothesis before and 
after adjustment for confounding factors; relationship 
between type of infant feeding and morbidity in the first 
six months of infant s life in Nablus refugee camps 

73 

 

Summary 81 

 

Chapter Six: Conclusions and Recommendations 82 
6.1 Conclusions 83 
6.2 Recommendations 84 

 

Summary 86 

 

References 87 

 

Appendix 100 

      

                               



 
x

List of Tables 

No. Table Page 

Table (1) 
Sample distribution according to the place of 
resident  

31 

Table (2) 
The sociodemographic profile of the study sample 
for both mothers and infants  

45 

Table (3) 
Sample distribution according to infant s history of 
morbidity in the first six months of life  

46 

Table (4) 
Sample distribution according to infant s morbidity 
with different diseases visits in the first six months 
of life  

47 

Table (5) 
Type of feeding in the first six month of life in the 
study sample  

48 

Table (6) 
Relationship between different mother's and infant's 
sociodemographic variables and type of feeding in 
the first six months of life 

50 

Table (7) 
Relationship between type of feeding in the first six 
months of life and infant s frequency of disease 
visits in the same period of age 

55 

Table (8) 
Relationship between type of infant feeding in the 
first six months of life and  morbidity according to 
different diseases in the same age 

56 

Table (9) 
Adjusted Odds ratio, Confidence Intervals and 
Significance levels for diseases affected by type of 
feeding 

60 

   



 
xi

List of Appendix 

No. Appendix Page 
Appendix (1)

 
Questionnaire 101 

Appendix (2)

 
Commitments for UNRWA and agreement from 
them to conduct the study 

104 

Appendix (3)

 

Child health record girls 0-3 years  105 

           



 
xii

The Impact of Exclusive Breastfeeding on Infant Morbidity in the First 
Six Months of Infant s life in Nablus s Refugee Camps 

By 
Shaden Hamdi Shakeb Qanadelo 

Supervised by 
Dr: Samar Ghazal / Musmar 

Abstract 

Throughout infancy it is important to receive the appropriate and the 

adequate nutrition, to ensure the utmost extreme biological growth and 

mental development for the child. 

World wide, many studies on infants provided evidences that 

breastfeeding is the ideal method; it can decrease the incidence and severity 

of many infectious conditions, such studies in our country are lacking. 

This study aimed to explore the effects of the different infant feeding 

patterns on infant s morbidity in the first six months of age in Nablus 

refugee camps (Balata, Askar, and Ein Beit el Ma). The research also 

aimed to explore the relationship between selected mother s and infant s 

sociodemographic factors, and the choice for the infant's patterns of feeding 

during the first six months of life in Nablus refugee camps. 

The study was cross-sectional retrospective analytical survey, 

included 690 files of infant\mother pair s, born in 2007, reside in Nablus 

refugee camps, and receive health care in one of three UNRWA's clinics in 

Nablus refugee camps. Secondary data obtained from infants clinical files, 

then analyzed by SPSS program, version 11; frequencies and percentages, 

Pearson Chi-square, and multiple logistic regression methods were used. 



 
xiii

The study results indicated; that percentage of Excusive 

Breastfeeding (EBF) for the first six months of life was 70%, whereas 

Partial Breastfeeding (PBF) was 16%, and Exclusive Formula Feeding 

(EFF) was 14%. Which reflected the good efforts regarding promoting 

exclusive breastfeeding in the UNRWA's clinics. 

Mother and infant sociodemographic factors (mothers aged 22-28 

years olds, mother aged 15-22 years olds at marriage, mother aged 22-28 

years old at delivery, those with high parity >4, mothers with basic and 

secondary level of education, not educated fathers, vaginal delivery, and 

female infants) were positively related to EBF significantly at 0.05.. 

On the other hand, EBF in the first six months of infant s life was 

negatively related to mothers aged > 36 years olds, mother aged > 29 years 

olds at marriage, mother aged > 36 years old at delivery, and those with 

low parity 1-2, high educated mothers and fathers, cesarean delivery, and 

male infants. 

This study confirmed that exclusive breastfeeding during the first six 

months of life protects against, lower respiratory tract infection, otitis 

media, gastroenteritis, diarrhea, wheezing, and allergies. The effect of 

protection continued to be statistically significant (except for diarrhea) even 

after adjusting for mother and infant sociodemographic factors. 

In conclusion, this study confirms that type of infant feeding in the 

first six months of infant's life is affected by mothers and infant's 



 
xiv

sociodemographic variables. And that exclusive breastfeeding in the first 

six months of life is important element in preventing and decreasing many 

diseases during the same period of age. 

The study results recommend that health agencies must give more 

concern for breastfeeding in general and exclusive breastfeeding in 

particular, especially during planning for fighting against infectious 

diseases. Further studies regarding this subject must be conducted within 

the Palestinian health agencies. 



 
1   

Chapter one 

Introduction   



 
2

Chapter one 

Introduction 

Breastfeeding has received significant attention in the past twenty 

years. Exclusive breastfeeding and its impact on infant's health has been a 

field of medical and public health research world wide. 

UNRWA's services at Palestinian Refugee camps are keeping 

excellent health records for infants and their mothers suitable to this type of 

study.  

In this chapter, the study background, the research problem, 

significance of the study, goal and objectives, study questions, hypotheses, 

and important definitions for what will be presented. 

1.1.Study background 

Having the appropriate and the adequate nutrition during infancy, 

and early childhood are fundamentals to the development of each child s 

full human potential 1. It is well recognized that the first two years of age is 

a critical window for the promotion of optimal growth, health, and 

behavioral development 1. This is due to the fact that this age is the peak for 

growth faltering, deficiencies of certain micronutrients, and common 

childhood illnesses such as diarrhea 1. 

Numerous factors affect the mother's choice to breastfeed, including 

socioeconomic status, cultural beliefs, level of social support, level of 

education, maternal work demands, range of care interventions provided 



 
3

during pregnancy, childbirth and the early postpartum period (medical 

advice), family pressures and commercial advertising 2,3. Biological factors 

including infant size, sex, development, interest/desire, growth rate, 

appetite, physical activity, and maternal lactational capacity may influence 

the decision about the type of feeding for infant, supplementation, and also 

determine the need and timing of complementary feeding 2,3.  

1.2.Types and importance of breastfeeding  

Breastfeeding (BF) is the ideal method of providing young infants 

with the optimum form of nutrients they require for healthy growth and 

development 4. By receiving accurate information, and the needed support 

of their families and the health care system; virtually all mothers can 

breastfeed 4.  

The World Health Assembly, endorsed a resolution in May 2001 

advocating the need to encourage Exclusive Breast Feeding (EBF) up to the 

age 6 months taking into account the findings of the World Health 

Organization (WHO) expert consultation on optimal duration of EBF; 

WHO s public health and infant feeding recommendations is that infants 

should be exclusively breastfed during the first six months of life and that 

they should continue to receive breast milk throughout the remainder of the 

first year and during the second year of life or beyond, and unrestricted 

exclusive breastfeeding results in ample milk production.  5, 6,7, 8,9.    

To enable mothers to establish and sustain EBF for 6 months, WHO 

and the United Nations Children s Fund (UNICEF) recommend 8: 



 
4

Within the first hour of life, mother can initiate breastfeeding. 

Exclusive breastfeeding. 

Breastfeeding on demand according to the child need, day and night. 

No use of bottles, teats or pacifiers. 

According to WHO report in the year 2002, and the American 

Academy of Pediatrics (AAP) in the year 2005, the definition of Exclusive 

Breastfeeding (EBF) is that the infant only receives breastmilk, and no 

water, other fluids (juice, non-human milk), or foods should be 

administered 7, 8, 10.  

EBF definition also comprises that the infant receives no 

pacifiers/dummies or artificial teats, at least 8-12 breastfeeding times in 24 

hours, including the night ones especially for newborn babies 11. It must be 

clear that any limitations placed on the number and /or duration of 

breastfeeding will interfere with the meaning of EBF 11.   

When infant receives breast milk plus infant formula, this pattern of  

feeding is called mixed feeding 10.                                                                  

Both the American Dietetic Association and the AAP (2005) 

recommended EBF for the infant's first 6 months of life, and to continue 

breastfeeding in conjunction with other foods for the first year 2, 10.  

Breastfeeding has been promoted and\ or recommended also by the 

United States Department of Health and Human Services, the American 



 
5

Public Health Association, the American Academy of Family Physicians 

(AAFP), the American College of Obstetricians and Gynecologists 

(ACOG), and numerous other institutions and organizations 12, 13. 

Islam as a religion strongly promotes breastfeeding. In the following 

ayah (verse) from the Holly Quran, ALLAH, Subhanahu WA ta'ala 

recommends the mother to suckle her offspring for 2 years if possible 14. 

The mothers shall suckle their offspring for two whole years, (that 

is) for those (parents) who desire to complete the term of suckling (Al-

Baqarah: 233)   

At national level, the Palestinian Ministry of Health (PMOH) 

coordinated with Palestine television and Palestinian Satellite Channel 

(PSC) through production of many programs to promote awareness for 

breastfeeding 15.  PMOH also plays a role through implementation of many 

programs on the importance of breastfeeding targeting women inside 

women unions, institutions, and health clinics, in addition to offering 

training courses in breastfeeding for participants from health organizations, 

and distribution of booklets and posters to targeted groups 16.  

1.3.Types, composition, and benefits of breast milk  

According to WHO In almost all situations, breastfeeding remains 

the simplest, healthiest and the least expensive, natural first food for 

babies 7, 8. Human milk provides easily tolerated, digestible, readily 

available at any time and everywhere (requires no preparation), sterile 



 
6

formula, at proper temperature, and with no artificial colorings, flavorings, 

or preservatives 2, 11. 

Sometimes breastmilk called the white blood, since it is considered 

similar to the placental blood of intrauterine life, in addition it is similar to 

unstructured living tissue like blood, plus its capability of transporting 

nutrients, affecting biochemical systems, enhancing immunity, and 

destroying pathogens 17. 

Like all other animal milks; human breastmilk is species-specific, its 

own ideal composition makes it different from that of other mammals 

types regarding ingredients and their concentrations 17, 18, 19. This 

composition is not constant and varies with stage of lactation, breastfeeding 

pattern, season, and parity, and differs also among individuals (mother s 

milk is especially suited for her own baby) and communities, and are 

adapted to gestational age 11,18. Mature breastmilk changes from month to 

month, day to day, feed to feed which makes it the superior milk that meets 

each particular baby s needs, plus that human breastmilk adapted 

throughout human existence to meet nutritional and anti-infective 

requirements of the human infant to ensure optimal growth, development, 

and survival11, 17, 18. 

1.3.1. Biological and chemical composition of breast milk 

The chemical composition of breast milk changes dramatically over 

time in the postpartum period. The stages of lactation correspond roughly 



 
7

to the postpartum time: colostrum (0 5 days), transitional milk (6 14 

days), and mature milk (15 30 days) 2,20 

As a complex fluid; breastmilk contains all the energy and nutrients 

needed by the newborn baby to promote infant s health, growth, and 

development during the first six months of life 7,8,18. It continues to provide 

up to half or more of a child s nutritional needs during the second half of 

the first year, and up to one-third during the second year of life 7,8 . 

Nutrients include metabolic fuel (fat, protein, and carbohydrates), 

water, and the raw materials essential for tissue growth and development, 

such as fatty acids, amino acids, adequate minerals, vitamins, and trace 

elements 18. 

It is important to know that the presence of some proteins in human 

milk are not for nutritional purpose to the infant; it serves immunological 

role instead 17. For example breastmilk as a white blood contains 

(leukocytes, immunoglobulins, and enzymes) in abundance, and the 

nonantibody factors  (Lactoferrin, the bifidus factors, and oligosaccharides) 

which offer the newborn protection against disease; this benefit in addition 

to other benefits has been recognized for hundreds of years and makes it a 

peerless substance for feeding the human infant 17. 

As a white blood there are two types of leukocytes in human milk; 

phagocytes (90%) and lymphocytes (10%) and their concentrations vary 

with the duration of lactation; where after birth these cells are higher than 

at any other time 17.  



 
8

Macrophages are the dominant phagocytes 17. They engulf and 

absorb pathogens, release Immunoglobulin A (IgA), and produce 

lactoferrin and lysozyme also 17. Neutrophils are other phagocytic 

leukocytes in breast milk and the first to arrive to the inflamed site 17. 

Lymphocytes in breast milk include T-cells (83%) and B-cells provide 

helpful immunity important in the destruction of viruses 17, 21.  

1.3.2. Breast milk's role in fighting infections 

Antibodies (immunoglobulins) are proteins produced by plasma cells 

in response to an immunogen 17. All types of immunoglobulins (IgG, IgA, 

IgM, IgE, and IgD) are found in human milk; however, both IgA and IgE, 

play a critical role in biological specificity of human milk on the recipient 

infant17, 22. 

Secretory IgA (S-IgA) a compound that is the primary disease fighter 

in the human immune system, reflects mother's exposure to mucosal 

infection, attaches to the lining of the nose, mouth, and throat, and fights 

the attachment of specific infecting agents 17,18,19,22.  

S-IgA is a couple of two IgA molecules, so-called secretory 

component seems to shield the antibody molecules from being degraded by 

the gastric acid and digestive enzymes in the stomach and intestines, this 

characteristic helps it to reach the intestine in undamaged condition, where 

it acts on pathogenic organisms and inhibit their multiplication 19,22,23 .  

The immunization process begins at birth by passive immunity, 

because mother s milk has antibodies to protect babies against diseases to 



 
9

which they might exposed to 2,11. Infant s own immune system may also 

produce S-IgA, but under the age of two years infant has immature immune 

response that is sometimes incapable of preventing disease 19. The 

consumption of the mother's S-IgA not only provides resistance to disease, 

but it also stimulates the production of additional S-IgA in the infant 19. As 

a result; breastfed children exhibit greater resistance to infectious diseases 

and stronger immune systems than their formula fed peers 19. Breastmilk 

also supplies smaller amount of IgM and IgG 24. 

Lysozyme; a major component of human milk enzymes (a potent 

digestive ingredient), has both bacteriocidal and anti-inflammatory action, 

and is much more abundant in human milk than in bovine type 17.   

Nonantibody factors in human milk comprise an elegant and intricate 

system that protects the infant against bacterial infection; the most 

important ones of these factors are Lcatoferrin, the bifidus factors, and 

oligosaccharides 17. 

Lactoferrin; is a potent iron-binding protein which absorbs enteric 

iron upon reaching intestine, leading to reduction of the amount of free iron 

below the level necessary for the growth of iron-dependent bacteria 24,17, 22. 

The intestinal flora of breastfed infants is dominated by gram-

positive helpful bacteria called Lactobacillus bifidus; with a level in breast-

fed infants that is typically ten times greater than that of formula-fed 

infants17, 22. The bifidus factor in human milk promotes growth of these 

beneficial bacteria17. The buffering capacities of milk (bifidus factor) 



 
10

together with the lactobacillus, contribute to the low pH (5-6) of stool 17, 24. 

This acid environment will discourage the replication of many pathogens17. 

Oligosaccharides (carbohydrates composed of a few 

monosaccharides) in human milk help to block antigens from attaching to 

the epithelium of the gastrointestinal tract17. 

1.3.3. Other benefits of breastfeeding  

Breastmilk in general provides many benefits for the baby's health; 

for example, it promotes optimal mother-infant bonding, and if the 

breastfeeding is exclusive will reduce spending on infant formulas and the 

benefits will increase to its highest; healthier mother and infant, reduce the 

need for the different types of medical services 2,11,19. The choice to 

breastfeed has a potential for decreasing annual health costs in The United 

States of America (USA) by $3.6 billion and decreasing parental employee 

absenteeism, the environmental burden for disposal of formula cans and 

bottles, and energy demands for production and transport of formula 10. So, 

in general breastfeeding is economic element for society 11. 

1.4.Formula feeding 

Infant formula is an artificial substitute for human breast milk, 

designed for infant consumption 25.Today, most infant formulas are based 

on either cow milk or soy milk, and some other types for infants with 

special dietary needs, are highly modified and may contain neither cow 

milk nor soy 25. 



 
11

Breastmilk substitutes increase the risk of contamination either 

during manufacturing or home preparation; for example, water used for 

washing bottle or mixing infant formula may be contaminated. Some 

families may dilute it to make it last longer or fall in errors during mixing11.  

1.5.The problem of the study 

Worldwide, diarrhea and respiratory infections are major causes of 

death of children, especially young ones 26. Acute gastroenteritis is one of 

the leading causes of illness and death in infants and children throughout 

the world, especially in developing countries; an estimated 2.5 million 

gastroenteritis deaths occur each year in children less than 5 years of 

age26,27. In Palestine, diarrhea is one of the main causes of outpatient visits 

and hospitalizations28. In the Palestinian Territory, deaths related to 

respiratory diseases are the second cause of infant death (21.8%) for the 

year 2005 29.  

Breastfeeding benefits were investigated by many studies which 

concluded that breastfed children exhibit greater resistance to infectious 

diseases and stronger immune system, with a lower rate of chronic diseases 

when compared with those fed by formula 19. Moreover, according to 

WHO report (2002); EBF during the first months of life is considered as a 

significant element that reduces infant morbidity and mortality, and aids in 

a quicker recovery during illness, especially those related to diarrheal 

disease and acute respiratory infections 7. 



 
12

The evidence of this protection was studied worldwide, and 

demonstrated that these effects are even more important in resource-poor, 

mal-nourished, and heavily populated societies 8, 17.  Consequently the very 

cramped, poor sanitation, and overcrowd Palestine refugee camps in 

general are considered the ideal site for such an important study lacking in 

Palestine. 

In Nablus there are three refugee camps suitable to conduct this 

study; Balata, Askar, and Ein Beit el Ma.  

However, no previous studies were found to detect for the 

relationship between type of feeding in the first six months of infant life, 

and infant morbidity regarding different and important diseases in the same 

period of infant's age in Palestine at all. Examples are; upper respiratory 

tract infection, lower respiratory tract infection, otitis media, asthma, 

wheezing, gastroenteritis, diarrhea, urinary tract infections, and allergies. 

In addition, there is a lacking in the studies that investigated in 

details the relationship between mother s and infant's sociodemographic 

factors and choice of infant s patterns of feeding during the first six months 

of life in Palestine. Examples are; mother s age, mother s age at marriage, 

mother s age at baby s birth, mother s level of education, mode of delivery, 

parity, and infant s gender. 

This study also tried to search for the role of father in affecting the 

mother's decision of type of feeding their infants in the first six months of 

life, especially father's level of education.  



 
13

Throughout this research, the researcher wants to investigate for the 

importance of exclusive breastfeeding as a simple and cheap method that 

fight the infectious diseases which increase the economic and medical 

burdens, especially in a developing society like Palestine refugee camps.  

And the researcher will try to detect the sociodemographic factors 

that negatively affect the exclusive breastfeeding to focus the promoting 

efforts on mothers with low tendency to exclusively breastfeed.  

1.6. Significance of the study 

This research is considered as the first study in Palestine refugee 

camps, particularly Nablus ones that aimed to investigate the relationship 

between type of feeding in the first six months of infant life, and infant 

morbidity in the same period of infant's age.  

It focuses on different diseases that affect many infants inspite it 

could be preventable by very simple and cheap methods. Examples are; 

upper respiratory tract infection, lower respiratory tract infection, otitis 

media, asthma, wheezing, gastroenteritis, diarrhea, urinary tract infections, 

and allergies. 

This research also aimed to find any relationship between selected 

mother's and infant's sociodemographic variables and the mother's choice 

of infant's feeding in the first six months of infant life.  

Many previous studies improved the presence and in some times the 

absence of a possible statistical relationship, between mother's and infant's 



 
14

sociodemographic variables and the choice for the type of infant's feeding 

in the first six months of life. Examples are mother s age, mother s age at 

marriage, mother s age at baby s birth, mother s level of education, mode 

of delivery, parity, and infant s gender.  

In addition, some studies investigated for the role of the father in 

affecting the mother choice on their infant feeding especially regarding a 

variable like father's level of education. 

It is expected that this study will play an important role in 

highlighting the importance of exclusive breastfeeding in the first six 

months of infant's life on infant morbidity. It also is expected to highlight 

factors affecting breastfeeding in Palestinian refugee camps' societies. 

1.7. Goal and objectives of study 

 

Study goal  

This research aims to explore the effect of the different types of 

feeding (exclusive breastfeeding, partial breastfeeding, and exclusive 

formula feeding) on infant morbidity in the first six months of age in 

Nablus refugee camps. 

 

Specific objectives  

In order to reach the main study goal, the following objectives are set 

to be measured. 



 
15

1. To explore the relationship between type of feeding and frequency of 

disease visits in the first six months of life in Nablus refugee camps 

(examples are; upper respiratory tract infection, lower respiratory tract 

infection, otitis media, asthma, wheezing, gastroenteritis, diarrhea, 

urinary tract infections, and allergies). 

2. To explore possible relationship between selected mother s 

demographic factors and choice of infant s patterns of feeding during 

the first six months of life in Nablus refugee camps (examples are 

mother s age, mother s age at marriage, mother s age at baby s birth, 

mother s level of education, mode of delivery, and parity). 

3. To explore possible relationship between infant s gender and choice of 

infant s pattern of feeding during the first six months of life in Nablus 

refugee camps.  

4. To identify possible relationship between father's level of education and 

type of infant feeding during the first six months of life in Nablus 

refugee camps. 

1.8. Hypotheses 

 

Main hypothesis 

There is no significant relationship, at the significance level p 0.05, 

between type of infant feeding and morbidity in the first six months of 

infant s life in Nablus refugee camps. 



 
16

 
Specific hypotheses 

1. There is no significant relationship, at the significance level p  0.05, 

between type of feeding and frequency of disease visits in the first six 

months of life in Nablus refugee camps (examples are; upper 

respiratory tract infection, lower respiratory tract infection, otitis 

media, asthma, wheezing, gastroenteritis, diarrhea, urinary tract 

infections, and allergies). 

2. There is no significant relationship, at the significance level p  0.05, 

between mother s age and type of feeding in the first six months of life 

in Nablus refugee camps. 

3. There is no significant relationship, at the significance level p  0.05, 

between mother s age at marriage and type of feeding in the first six 

months of life in Nablus refugee camps. 

4. There is no significant relationship, at the significance level p  0.05, 

between mother s age at the time of infant s birth and type of feeding 

in the first six months of life in Nablus refugee camps in Nablus 

refugee camps. 

5. There is no significant relationship, at the significance level p  0.05, 

between parity and type of feeding in the first six months of life. 

6. There is no significant relationship, at the significance level p  0.05, 

between mother s level of education and type of feeding in the first six 

months of life in Nablus refugee camps. 



 
17

7. There is no significant relationship, at the significance level p  0.05, 

between father s level of education and type of feeding in the first six 

months of life in Nablus refugee camps. 

8. There is no significant relationship, at the significance level p  0.05, 

between mode of delivery for the infant who participated in the current 

study and type of feeding in the first six months of life in Nablus 

refugee camps. 

9. There is no significant relationship, at the significance level p  0.05, 

between infant s gender and type of feeding in the first six months of 

life in Nablus refugee camps. 

1.9.  Important definitions for this study:  

United Nations Relief and Works Agency for Palestine Refugees in 

the Near East (UNRWA) is a relief and human development agency, 

providing aids to Palestine refugees living in Jordan, Lebanon and Syria, as 

well as in the West Bank and the Gaza Strip 30. 

Palestinian refugees or Palestine refugees are the people and their 

descendants, predominantly Palestinian Arabic-speakers, who fled or were 

expelled from their homes during and after the 1948 Palestine War 31. 

Exclusively breastfed infants (EBF); infants who receive only 

Breastmilk and no water or other fluids (juice, non-human milk) or 

foods7,8,10.  



 
18

Partially breastfed (PBF); Combination of breast feeding with 

formula milk 10. 

Infant formula; is an artificial substitute for human breast milk, 

designed for infant consumption 25. According to this study, feeding the 

infant by formulas only during the first six months of life is defined as 

Exclusive Formula Fed (EFF). 

According to this study, definition of disease visit was actual clinic's 

visit or request for medical prescription for any treatment in other places. 

Odds ratio; is the ratio of the probability of the two possible states of 

a binary variable in two groups of subject 32. 

Summary  

Breastfeeding is considered and recommended as the ideal way of 

infant feeding by many health agencies and Islam. Exclusive breastfeeding 

in the first six months of life is found to be an important element in 

reducing health and economic burdens of infectious diseases especially 

those related to diarrheal and respiratory infections. Consequently, 

breastfeeding in general and exclusive type in particular deserves to be 

studied and focused on especially when we plan for development of child 

health especially in our developing country (Palestine). 



 
19   

Chapter Two 

Literature review  



 
20

Chapter Two 

Literature review 

This chapter, briefly presents important scholarly work which 

investigated breastfeeding. Benefits and role in decreasing morbidity, 

important statistics of breastfeeding at international, and regional, and 

national levels are presented within this chapter.  

2.1. Relationship of breastfeeding and infections studies at 

international level  

Exclusive breastfeeding for 6 months is not a common practice in 

developed countries, and is still rarer in the developing ones 8. 

In its Healthy People 2010 statement; the United States has 

established federal goals for breastfeeding, including that for initiation in 

the early postpartum period, the percentage is 75%, continuing to 6 months 

postpartum is 50%, and of all women breastfeeding 25% which must 

continue to 1 year, exclusive breastfeeding for 3 months is 60% and for 6 

months is 25% 33.  

According to UNICEF statistics about EBF in different regions in the 

world for the years 1995 to 2000, and the year 2006, less than half were 

EBF < 4 months in most countries 34, 35. 

Several studies in different western countries explored protective 

effect of breastfeeding against infections in the first six months of infant s 

life. Howie et al designed a prospective observational study in Dundee 



 
21

(Scotland) published in 1990, and concluded that breast feeding when 

compared with bottle-feeding, confers protection against gastrointestinal 

illness; that persists beyond the period of breast feeding itself 36. 

Quigly et al (1990) conducted a case control study in England and 

found that: after adjustment for confounders; breast feeding protects against 

diarrheal disease in infants aged 6 months 37.  

Chantry et al study (1988-1994) documented the importance of full 

breastfeeding for 6 months (Full\BF 6) in providing greater protection 

against respiratory tract infection than does full breastfeeding for >4 but <6 

months in the USA 38. In addition, infants exclusively breastfed for one to 

three months Full\BF1-3 group had the first episode of OM before 1 year of 

age and Recurrent Otitis Media (ROM) more than the Full\BF 6 group 38.  

Levine et al carried out a case-control study in North America (1995-

1996) and found that; among infants  2-11 months old, current 

breastfeeding was associated with a decreased likelihood of invasive 

pneumococcal disease (Streptococcus pneumoniae) 39.  

Galton Bachrach et al (2003) conducted a meta-analysis of 33 studies 

on infants in developed nations to investigate the relation between 

breastfeeding and the risk of hospitalization for lower respiratory tract 

disease (LRTD) 40. They concluded that among generally healthy infants, 

those who were not breastfed had developed severe respiratory tract 

illnesses resulting in hospitalization three times more compared to those 

who were exclusively breastfed for 4 months 40. 



 
22

Similar findings in New Mexico, USA was illustrated by Cushing et 

al (1988-1992) who found that full breastfeeding was associated with a 

reduction in lower respiratory illness, and that breastfeeding reduces the 

severity of infant respiratory illnesses during the first 6 months of life 41.  

Several studies concentrated on the duration of breastfeeding and its 

relationship with infection. Sassen et al study carried out (1987-1988) in 

Leiden (Holland) revealed that the risk of Acute Otitis Media (AOM) 

depends on the number of months an infant is breast-fed and the number of 

months that pass after breast-feeding is discontinued 42. 

Duncan et al study in Tucson, USA (1993) suggests that EBF for 4 

or more months protects infants from OM and ROM 43. 

A study in Mexico City carried out by L pez-Alarc n et al (1997) 

showed that the likelihood of having a larger percentage of days ill was 

higher for the formula-fed than for the fully breast-fed infants during the 

entire follow-up. It concluded that human milk has a protective effect for 

Acute Respiratory Infection (ARI), as it does for diarrhea 44. 

Two Brazilian studies explored breastfeeding and infection 

relationship. César et al study (1993) found that breastfeeding protects 

young Brazilian children against pneumonia, especially in the first months 

of life (under 3 months old)  45.  

Romieu et al study (2000) confirmed that the low prevalence of 

asthma and wheezing observed among Brazilian school children (7-14) 

years of age may be partly related to the high level of breastfeeding 46. 



 
23

In the Philippines, Yoon et al (1988-1991) found that children who 

were not breastfed during the first 6 months of life, compared with those 

who were breastfed, were more likely to die of diarrhea 47. He also found a 

six times increase in mortality associated with both acute lower respiratory 

infection (ALRI) and diarrhea combined by not breastfeeding in the first 6 

months of life. Unfortunately, the data also suggested that after age 6 

months, the protective effects of breastfeeding dropped dramatically 47.  

2.2. Regional studies  

The effect of breastfeeding on infant mortality and morbidity has 

been studied in some regional countries. 

In Bangladesh, Arifeen et al cohort study (1993- 1995) showed that 

infants who were either partially or not breastfed had a higher risk of post 

neonatal (29 days-11 months) death than infants who were breastfed 

exclusively for the first 4 months of life 48.  

Another study in Bangladesh carried out by Mihrshahi et al (2003), 

showed that children aged 0-3 month(s) who are EBF, were less likely to 

have suffered from diarrhea and ARI than infants who were not EBF 49. 

In Saudi Arabia, a retrospective study carried out by Abdulmoneim I 

et al (2001) found that during the first 2 years of life; attack rates of all 

respiratory tract infections was significantly related to duration of 

lactation50.  



 
24

Another study in Egypt (1995-1997) carried out by Clements et al 

found that, relative to infants who were not breastfed, those who were 

breastfed exclusively, or partially breastfed had a 33% and 28% lower rate 

of diarrhea respectively 51.  

Some of studies in the region explored effect of sociodemographic 

factors on breastfeeding pattern and choices. For example, Khassawneh et 

al study (2003) in Irbid, Jordan, found that the type of feeding was 

independent of mother's age, father's education level, child's gender 52. 

Women with higher education (more than high school) were less likely to 

breastfeed, similarly employed mothers, mothers delivered by caesarian, 

and those with lower number of children (<3) were less likely to fully 

breastfeed 52. The study concluded that a high proportion of Jordanian 

women did breastfeed for more than one year 52. 

In Israel, a study conducted by Ever-Hadani et al on Jewish women 

(1974-1976) in the Jerusalem district found that women aged 24 years or 

younger and those aged 40 years or more were most likely to choose to 

breast feed. Birth order, maternal education, social class, age at marriage, 

and work outside the home did not significantly influence the decision to 

begin breast feeding 53. Delivering by caesarean section was significantly 

associated with a tendency to formula feed 53. Primipara and 

grandmultipara (parity > 4) were significantly more likely to breastfeed for 

three months or more. Mothers with the fewest years of schooling on the 

one hand, and those with the highest level education on the other, were 

most likely to breast feed for extended periods 53.  



 
25

2.3. Breastfeeding studies at national level. 

Although there are very few studies done on the breastfeeding 

subject in Palestine, a study carried out in Gaza Strip (2007) found that the 

level of mother's knowledge in regard to breastfeeding doesn t guarantee 

the full implementation of breastfeeding, therefore; a need for further 

training to health care providers on the infant feeding strategies and more 

ministerial commitments toward the implementation of BF strategies is 

needed 54. 

According to the Demographic and Health survey conducted in 

Palestinian Territory in the year 2004, one noticed that the percentage of 

breastfed children who were born 3 years before the study was 95.6% 55. 

Also in the report of Palestinian family health survey for the year 

2006, which was published by the Palestinian Central Bureau of Statistics 

(PCBS) in the year 2007, the results showed that breastfeeding practice is 

common in the Palestinian Territory, since 97.5% of children under five 

years of age were breastfed 55. It is good to know that the variation in 

breastfeeding across regions and districts was minimal, and the average 

duration of breastfeeding was 10.9 months in the year 2004, while in the 

year 2006 results showed that the average duration of breastfeeding 

increased to 12 months 29,55. 

But one will be surprised when he knows that inspite of the high 

breastfeeding percentage in the year 2006, the percentage of the exclusive 

breastfeeding the same year in Palestinian Territory was only 24.8% 55. 



 
26

The UNRWA study (2001) that assessed the prevalence and duration 

of EBF among Palestinian refugee infants utilizing UNRWA services in the 

five Fields of the Agency s area of operation (Jordan, Lebanon, Syrian 

Arab Republic, Gaza Strip, and the West Bank) found that the prevalence 

rates of EBF up to 4 months were (24.0%, 30.2%, 40.3%, 33.3%, 34.5%) 

respectively, with average 32.7% 5. And the mean duration of EBF agency-

wide based on data collected at the date of the interview was 2.7 months 

with no significant variations between Fields 5. 

Summary 

Most of international and regional studies concentrated on 

importance of breastfeeding in general and exclusive type in particular. 

At the national level all of the studies concentrated on prevalence and 

sociodemographic characteristics, but did not explore a possible 

relationship between breastfeeding and morbidity in children, especially 

infectious diseases in infancy. 

The researcher s literature review showed no previous published 

study at the national level directed towards the impact of exclusive 

breastfeeding on infant morbidity in the first six months of life in Nablus 

refugee camps. It is expected that such a study is going to lead to important 

results in this subject.  



 
27   

Chapter Three 

Methodology  



 
28

Chapter Three 

Methodology 

The main aim of this study is to explore the immediate effect of the 

different types of feeding (exclusive breastfeeding, partial breastfeeding, 

and exclusive formula feeding) on infant morbidity in the first six months 

of age in Nablus refugee camps 

In this chapter the research design and steps utilized to reach this 

important goal include; study population, study design and sampling 

method, operational definition of the study variables, instrument of data 

collection, potential confounders, data analysis, ethical issues, and study 

limitations. 

3.1.Study population 

The study population was chosen to include infants born in 2007, 

and registered to get their health care at the maternal and child health 

departments, in all the UNRWA's clinics included at Nablus area. 

There are 27 refugee camps in the occupied Palestinian territory (19 

in West Bank) 56. Approximately one third of Palestinian refugees still live 

in refugee camps; making up 25.4% of all refugees in the West Bank 56. 

Population density (inhabitants/km2) is high throughout the occupied 

Palestinian territory, it increased from 481 in 1997 to 626 in 2007 (416 in 

the West Bank) 57. According to WHO agenda (2008), the occupied 

Palestinian territory has a young population 57. The proportion of 



 
29

individuals below 15 years of age is slightly higher among refugees 

(45.8%) than non-refugees (45.3%) 57. The broad unemployment rate in 

West Bank refugees rose from (24.5%) in 2007 to (25.3%) in 2008 57. 

Nablus is a big city located in the north of West Bank, Palestine with 

(320,830) population according to the PCBS (2007) 55. 

In Nablus there are three refugee camps, Balata camp (in the eastern 

side of Nablus city) is one of the most densely populated locations on Earth 

since 30,000 people in its concrete block houses on less than two square 

kilometers in size 58. In Askar (located in eastern side of Nablus) the camps' 

registered population is 14,629 live on 299 dunums of land 59, and Ein Beit 

el Ma camp (located in western part of Nablus) had a population of 

approximately 5,036 inhabitants on 45 dunums in mid-year 2006 60.  

Since 1948, UNRWA established 3 clinics in Nablus, providing 

health and preventive care in the main 3 refugee camps (Balata, Askar, and 

Ein Beit el Ma) in Nablus area. 

According to the three clinic records for infants born in the year 

2007, and registered at MCH in each one of these clinics; it was found that 

there are 1738 active files for infants and their mothers in the three refugee 

camps clinics (756 infants at Balata, 560 at Askar, and 422 at Ein Beit el 

Ma clinic). 



 
30

3.2.Study design and sampling method 

This study is a cross-sectional retrospective analytical survey. 

Only those who met inclusion criteria were included in the study. A 

total of (690) infant\ mother files from the 3 clinics at refugee camps met 

the criteria to be included in the study, while 1048 infants were excluded. 

The time needed for collecting data was 2 months from November 2008 till 

January 2009. The clinical filling system used by UNRWA contains 

enough information related to the study concepts in addition to the 

variables for both mother and infant. Each infant was followed through 

his\her clinical file for the first six months of life. Data in the files used to 

fill the questionnaires to obtain information regarding mother's and infant's 

sociodemographic profile in addition to the infant history of type of feeding 

and morbidity during the first six months of life. 

UNRWA's clinics were used as a place to get the sample for this 

study because most of refugee camps residents receive their medical care 

especially MCH free of charge; population utilization of these services is 

very high due to its location inside refugee camp, and finally patients also 

visit clinics to obtain medication even if they get medical advice outside 

these clinics.  

3.3.Sample of the study 

The study sample consisted of clinical records for 690 mother \ 

infant pairs. The infants were from both genders, reside in one of Nablus 



 
31

refugee camps (Balata, Askar, and Ein Beit el Ma), were born in the year 

2007, registered at MCH departments in one of the three clinics included in 

the study, and met all the study criteria. Mothers of those infants also were 

included for the study purpose. Files of all infants born between 1\1\2007 

to 31\12\2007 were followed for the following 6 months of their birth date. 

Table (1) below shows the sample distribution according to the place of 

resident.  

Table (1): Sample distribution according to the place of resident 
(n=690) 

Camp No. of subjects % 
Askar 284 41.2 
Ein Beit el Ma 74 10.7 
Balata 332 48.1 

From table (1) above we notice that 48.1% of our sample was from 

Balata camp, while 41.2% and 10.7% were from Askar and Ein Beit el Ma 

clinics respectively. 

3.3.1.Inclusion criteria 

All inclusion and exclusion criteria were setup to include only 

healthy term infants, getting their care at the UNRWA clinics as the 

following:- 

 

Infants:  

i. All infants born in the year 2007. 

ii.  Reside in one of the refugee camps included in the study. 



 
32

iii.  Registered at the MCH departments in the clinics.  

 
Mothers: 

All mothers of the study sample infants. 

3.3.2. Exclusion criteria 

 

For infants 

i. Infants with low birth weight which is  2500 grams. 

ii. Premature and preterm infants i.e. infants born before 37 gestational 

weeks. 

iii. Those who were born in multiple gestation; twins, triple, etc. 

iv. Infants with any congenital malformation, chronic disease, or genetic 

diseases that might affect the study results. 

v. Infants diagnosed with anemia as been defined by WHO, and utilized 

by UNRWA s clinics: 

 

Mild anemia for Hb < 10 mg\dl. 

 

Moderate anemia for Hb 9-9.5 mg\dl. 

 

Severe anemia if Hb < 9 mg\dl. 

vi. Babies diagnosed with immunologic problems. 



 
33

vii. Infants who live outside the camp, because this increase the 

probability to visit other clinics in Nablus city, or Nablus rural area s 

rather than the UNRWA's clinics. 

viii. Infants born after complicated pregnancy such as preeclampsia\ 

eclampsia and gestational diabetes. 

ix. Infants with incomplete information in their clinical record files. 

 

For mother 

i. Those with incomplete files. 

ii. Divorced and widows to ensure that mothers and infants are living in 

the refugee camp and utilizing its services exclusively. 

3.4.Operational definition of the study variables 

The expected study outcome is focused on the relationship between 

patterns of infant feeding during the first six months of age and morbidity 

during the same period of life. At the same time it measures relationship 

between selected mother s and infant's sociodemographic variables and the 

choice of different patterns of feeding in the first six months of infant life. 

 

Dependent variables:  

A dependent variable: is what measured in the experiment and what 

is affected and responds to the independent variable 61. 

According to the above definition, the followings were considered 

dependent variables of this study: 



 
34

1. Type of feeding in the first six months of infant life, and according to 

our study criteria, we defined different methods of feeding for infants 

in their first six months of life as follow: 

i. Exclusively breastfed infants (EBF); infants who receive only 

Breast milk and no water or other fluids (juice, non-human milk) or 

foods. Only prescribed medicines will be allowed if present. 

ii. Partially breastfed (PBF); Combination of breast feeding with 

formula milk, the combination must be started at least from the first 

week of life, and percentage of breast milk to formula milk will not 

be taken in consideration in this study because it was not 

mentioned in the clinical records. 

iii. Exclusively formula fed infants (EFF); infants receive non-human 

milk without breast milk. 

2. Infant morbidity in the first six months of life, which helps to 

compare the effects of different types of feeding, especially EBF on 

infant morbidity in this period of infancy.  

Morbidity in this study was identified as clinic disease visits which 

was defined in chapter one. 

Diseases included were:- upper respiratory tract infection, lower 

respiratory tract infection, otitis media, asthma, wheezing, gastroenteritis, 

diarrhea, urinary tract infections, and allergies. 



 
35

Regarding different diseases and diagnosis, the researcher used the 

entered diagnosis by clinic physicians in the infant files. 

3. Frequency of disease visits in the first six months of life in Nablus 

refugee camps (examples are upper respiratory tract infection, lower 

respiratory tract infection, otitis media, asthma, wheezing, 

gastroenteritis, diarrhea, urinary tract infections, and allergies). 

 

Independent variables:  

Independent variable is defined as: The manipulated variable in an 

experiment or study whose presence or degree determines the change in the 

dependent variable 62. 

According to the above definition, the following were considered 

independent variables. 

1. For mother; sociodemographic characteristics regarding each mother in 

the mother\infant pairs who met selection criteria:  

i.  Mother s age: (15-21 years, 22-28 years, 39-35 years. 36 years and 

more). 

ii.  Mother s age at marriage: (15-21 years, 22-28 years, 29 years and 

more). 

iii.  Mother s age when the baby who participated in the study was born: 

(15-21 years, 22-28 years, 39-35 years. 36 years and more). 

iv. Parity: (1-2 children, 3-4 children,  >4 children) 



 
36

v. Mother s level of education: (not educated, basic, Secondary, high 

education). 

vi. Father s (husband) level of education: (not educated, basic, Secondary, 

high education).  This item was added because it was expected that the 

father also may have a role in promoting the mother decision, 

especially for those with high level of education.  

vii. Type of delivery for the infant who participated in the current study: 

(caesarean, vaginal).  

2. For infant; sociodemographic and feeding patterns information for 

every infant in the mother\infant pair:  

i.  Infant s gender: (male, female). 

ii.  Type of feeding in the first six months of life: (Exclusive Breastfed- 

EBF, Exclusive Formula Feeding-EFF, or mixture of both \partial 

breastfeeding-PBF).  

Notes:  During the testing for the specific hypotheses (relationship between 

the selected mother's and infant's sociodemographic profiles and type of  

feeding) type of feeding in the first six months of life was considered as a 

dependent variable to measure the effect of sociodemographic variables on 

it. While in the first specific hypothesis (relationship between type of 

feeding and frequency of disease visits) and the main hypothesis 

(relationship between type of infant feeding and morbidity) it was 



 
37

considered as independent variable to measure how much it affects the 

morbidity of infant in the first six months of infant s life. 

3.5.Instrument of data collection 

The researcher conducted several visits to the three UNRWA s 

clinics included in the study. During these visits a comprehensive review 

of infant\mother files was done to select the suitable ones according to the 

study criteria. 

3.5.1.Questionnaire 

The researcher developed a three section questionnaire, where 

important information from each infants\mother file was filled by the 

researcher herself. 

a. Section one: contained general information including (Residence, 

Ration number). 

b. Section two: contained mother sociodemographic profile including (date 

of birth, mother s age, mother s age at marriage, mother s age when the 

infant included in the study was born, parity, mother s and father s 

levels of education, mother s occupation, mode of delivery for the infant 

included in the study). 

c. Section three contained: infant s information including (date of birth, 

infant s gender, type of feeding in the first six months of life, if the 

infant has any illness during the first six months of his \ her life, if so, 

frequency of disease visits, and table for  infant s morbidity with 



 
38

different diseases visits in the first six months of life (diseases that was 

investigated in the study). 

All mother and infant sociodempographic variables and consequently 

the questions in the questionnaire were selected according to the study goal 

and objectives, and according to the literature review.  

3.5.2.Reliability and Validity of the tool 

Reliability is the consistency of the measurement, or the degree to 

which an instrument measures the same way each time it is used under the 

same condition with the same subjects 63. Simply reliability is usually 

estimated by test/retest is that one should get the same score on test 1 as he 

do on test 2, and internal consistency commonly is by using Cronbach's 

Alpha 63. 

Validity refers to whether the questionnaire or survey measures what 

it intends to measure 64. 

The study questionnaire developed by the researcher; was based on 

revision of the literature, and according to study objectives. It was reviewed 

by the supervisor, and experts, who suggested changes in some items, then 

all the recommended modifications were done. The researcher her self 

filled all the questionnaires, and most of the questionnaire s items are 

social demographic variables and infant morbidity data obtained from 

mother\infant files. A pilot test was felt to be unnecessary since all data 

were secondary. 



 
39

3.5.3.Data collection 

After obtaining a formal approval from UNRWA s director, the 

researcher herself collected information from clinical files of the three 

selected UNRWA s clinics between November 2008 to January 2009. 

The process of data collection went smoothly with very good 

cooperation of the three clinics staff.  

3.6.Potential confounders 

The economic status might be a confounder, and to adjust for this 

factor, study sample was chosen exclusively from the three Palestinian 

refugee camps in Nablus, in which the economic status of families is 

considered nearly at the same level.  

However, getting accurate information about income from families 

at refugee camps is difficult because families will not disclose their actual 

income for fear of possibility to loose monthly UNRWA s aid. 

To avoid the effect of confounding factors during analysis, the 

analysis for the table of the effect of infant feeding on his\her morbidity 

during the first six months of life was re-examined after applying 

adjustment for all statistically significant sociodemographic variables. 

3.7.Data analysis  

After collection of data, all information was entered and analyzed 

using the statistical Microsoft program SPSS version 11 (Statistical 

Package for Social Sciences). 



 
40

The following statistical formulas were used:- 

1. Frequencies and percentages. 

2. Crosstab table. 

3. Pearson Chi square: is a statistical test used to compare observed data 

with expected data (data we would expect to obtain according to a 

specific hypothesis). Our study depends on numbers and frequencies 

between variables, and examines the relationship between those pairs of 

variables, therefore; Pearson Chi-square test is thought to be a suitable 

test. It was used in our study to examine the significance of the 

relationship between mother and infant demographic variables and type 

of feeding in the first six months of age. It was also used to study the 

relationship between type of feeding and morbidity regarding different 

diseases in the first six months of life. Significance of the relationship is 

determined when p-value < 0.05. 

4. Multiple logistic regression: is used to predict a dependent variable on 

the basis of continuous and/or categorical independents and to 

determine the percent of variance in the dependent variable explained 

by the independents 32. In our study we have some confounding factors 

like mother s age, infant gender, etc, which must be adjusted to re-

examine the relation ship between type of feeding and morbidity in the 

first six  months of infant life again, so the suggested test here is the 

multiple logistic regression. 



 
41  

Accordingly, it was used in our study to re-examine the significance 

of the relationship between type of feeding and morbidity but after 

adjusting for mother and infant confounding factors. P-value and adjusted 

Odds Ratio (adj-OR) determined our result. 

3.8.Ethical issues 

Since this research did not include any meeting with mothers, but 

collecting secondary data from files by the researcher herself, there is no 

need to have consents from mothers to conduct the study. Consequently all 

information was obtained from patient s files after signing an agreement 

with the UNRWA s administration office. According to this agreement, the 

researcher abided to all UNRWA's regulations for conducting research and 

obtaining information including protecting privacy of families records used 

in this study. Also the researcher obtained the public health department 

committee's approval from An-najah National university including the 

ethical consideration. 

3.9.Study limitations 

Although there were no significant obstacles in performing this 

study, there were some limitations worth mentioning. Limited time of the 

study, small budget, and the high work load in UNRWA s clinics made it 

difficult to do face to face or telephone interview. 

At the same time lack of some other important information in 

UNRWA s files like family income, mother's smoking, and mother's 

occupation puts limitation on sociodemographic variables used. 



 
42

Other clinics in Nablus area providing health care to infants (for 

example ministry of health clinics) are so diverse in term of population, it 

was difficult to find complete records and follow up for specific infants 

which made this study unsuitable to be conducted at other clinics than 

UNRWA s . Therefore, infants from the city and rural areas were not 

included in the study. 

Finally, because this study depends on secondary data obtained from 

clinical files and not face to face meeting, it is expected that the 

information accuracy may not reach 100%.       

Summary: 

This cross-sectional study was conducted in the UNRWA's clinics in 

Nablus refugee camps; the sample was 690 infant\mother pairs files. A 

questionnaire was filled by information regarding mother's and infant's 

socio demographic profile, in addition to information about method of 

infant feeding and morbidity regarding different types of diseases in the 

first six month of infant life, data were analyzed using SPSS version 11. 

Different statistical methods to find frequencies, percentages, and 

relationships applying Chi-square and multiple logistic regression were 

used.  



 
43   

Chapter Four 

Results  



 
44

Chapter Four 

Results 

This chapter presents in details the results of the study in accordance 

with its hypotheses. It includes sample distribution according to mother's 

and infant's sociodemographic profile, sample distribution according to 

infant s history of morbidity in the first six months. Also it includes sample 

distribution according to type of infant feeding in the first six months of 

life, results related to the specific hypotheses, and results related to the 

main hypothesis before and after adjustment for confounding factors.  

4.1. Sample distribution according to mother s and infant s 

sociodemographic profile 

Table (2) below shows the sociodemographic profile of the study 

sample for both mothers and infants. Most of mothers were within the age 

group (22-28) and (29-35) (39.4% and 33.2%) respectively. For infants, 

both males and females were equally included in the sample, and majority 

of them were outcome of vaginal delivery (73.2%). Regarding parity it is 

noticed that (38.2%) and (36.9%) of mothers in the study sample have (1-

2), and (3-4) children, respectively. Results also indicate that most of the 

mothers and fathers in our sample had basic and secondary level of 

education.  



 
45

Table (2): The sociodemographic profile of the study sample for both 
mothers and infants. (n=690) 

Variables No. of subjects % 

Mother's age 

  

(15-21) 77 11.2 

(22-28) 272 39.4 

(29-35) 229 33.2 

36 and more 112 16.2 

Mother's age at Marriage 

  

(15-21) 458 66.4 

(22-28) 149 21.6 

(29-and more) 83 12.0 

Mother's age at baby s birth 

  

(15-21) 78 11.4 

(22-28) 268 38.8 

(29-35) 232 33.6 

36 and more 112 16.2  

Parity 

  

1-2 264 38.2 
3-4 254 36.9 

 

4 172 24.9  

Mother's level of education 

  

Not educated 42 6.10 
Basic 256 37.1 
Secondary 270 39.1 

High edu  cation 122 17.7  

Father's level of education(husband)

   

Not educated 44 6.40 
Basic 272 39.4 



 
46

Variables No. of subjects % 
Secondary 261 37.8 

High edu  cation 113 16.4  

 Mode of delivery 

  

Caesarean 185 26.8 
Vaginal 505 73.2  

 

Infant s Gender 

  

Male 343 49.7 
Female 347 50.3  

4.2. Sample distribution according to infant s history of morbidity in 

the first six months 

History of morbidity in the first six months of life for all infants 

included in the study was explored in tables (3), (4). 

Table (3): Sample distribution according to infant s history of 
morbidity in the first six months of life (n=690) 

Variables No. of subjects % 

Infant have any diseases during the 
first six months of his \ her life 

  

Yes 407 59.0 
No 283 41.0 
frequency of disease visits   

None 283 41.0 
1 137 19.8 
2-4 224 32.5 

 

4 46 6.70 

 

Table (3) shows that out of study sample (690), about 2/3 of infants 

407 had documented disease visits during the first six months of life. While 

283 (41%) infants did not have any disease during the same period of life.  



 
47

The table also shows that about a third of the study sample (32.5%) 

had average rate of recurrent visits for disease\s to the clinic (2-4) times. 

Only (6.7%) of study sample had more than 4 visits for illnesses to the 

clinic in their first six months of life. 

Table (4): Sample distribution according to infant s morbidity with 
different diseases visits in the first six months of life (n = 407) 

Diseases No. of subjects % 

Upper respiratory tract infection   
No 84 20.7 
Yes 322  79.3 

Lower Respiratory Tract Infection   

No 370 90.9 

Yes 37 9.10 

Otitis Media   

No 352 86.5 

Yes 55 13.5 

Wheezing   

No 370 90.9 

Yes 37 9.10 

Gastroenteritis   

No 329 80.8 
Yes 78 19.2 

Diarrhea   

No 328 80.6 

Yes 79 19.6 

Urinary tract infection   

No 401 98.5 
Yes 6 1.50 
Allergies   

No 363 89.9 

Yes 44 10.1 



 
48

Table (4) shows sample distribution for infants whose files showed a 

visit for one or more of diseases investigated in the study.  

It is evident from the table that URTI had the highest frequency 

(79.3%). On the other hand the lowest was 1.5% of files with diseases for 

UTI. 

4.3. Sample distribution according to type of infant feeding in the first 

six months of life (n=690) 

Table (5): Type of feeding in the first six month of life in the study 
sample (n=690) 

Type of feeding No. of subjects % 

Exclusive breastfeeding 481 69.7 
Partial breastfeeding 110 15.9 
Exclusive formula feeding 99 14.3 

Total 690 100% 

Table (5) shows that in the study sample, most of mothers (69.7%) 

provided exclusive breastfeeding to the infants in their first six months of 

life. Partial breastfeeding is less frequently used (15.9%), and exclusive 

formula feeding is only provided to (14.3%) of infants in the study sample. 

4.4. Results related to study hypotheses 

4.4.1. Results related to the specific hypotheses relationship between 

the selected mother's and infant's sociodemographic profiles and type of  

feeding in the first six months of life in Nablus refugee camps

 

A statistical relationship applying Pearson Chi-Square test (P  0.05) 

was used to test the different hypotheses between the selected mother's and 



 
49

infant's sociodemographic factors and the type of feeding in the first six 

months of life. The specific hypothesis stated that "there is no significant 

relationship, at the significance level p  0.05, between the selected 

mother s and infant's sociodemographic factors according to (mother's age, 

mother's age at marriage, mother's age at her baby's birth, parity, mother's 

level of education, father's level of education, mode of delivery, and 

infant's gender) and type of feeding in the first six months of life in Nablus 

refugee camps. 

Table (6) shows that there was statistically significant relationship 

between (mother's age, mother's age at marriage, mother's age at her baby's 

birth,  parity, mother's level of education, father's level of education, mode 

of delivery, and infant's gender) and type of feeding in the first six months 

of life in Nablus refugee camps. Detailed results for each variable are the 

followings:- 



 
50

Table (6): Relationship between different mother's and infant's 
sociodemographic variables and type of feeding in the first six months 
of life (n=690) 

Feeding in the first six months of life Correlation 
EBF PBF EFF Variables 

No. % No. % No. % 

Chi-
Square 
Value 

P-Value 

 

56 72.7

 

11 14.3

 

10 13.0

 

213 .378

 

47 .317

 

12 4.40

 

144 62.9

 

36 15.7

 

49 21.4

 

Mother's age 
15-21 
22-28 
29-35 
36 and more 68 60.7

 

16 14.3

 

28 .025

 

46.4 0.00001* 

 

362 .079

 

75 16.4

 

21 4.60

 

104 69.8

 

29 .519

 

16 10.7

 

Mother's age at marriage 
15-21 
22-28 
29 and more  15 18.1

 

6 7.20

 

62 .774 

285.1 0.00001* 

 

57 73.1

 

11 14.1

 

10 12.8

 

210 .478

 

46 .217

 

12 4.50

 

146 62.9

 

37 15.9

 

49 21.1

 

Mother's age at baby s birth  
15-21 
22-28 
29-35 
36 and more   68 60.7

 

16 14.3

 

28 .025

 

45.2 0.00001* 

 

166 62.9

 

45 17.0

 

53 .120 
181 71.3

 

35 13.8

 

38 15.0

 

Parity 
1-2 
3-4 

 

4 134 .977

 

30 .417 8 4.70

 

22.1 0.001* 

 

25 59.5

 

13 .031

 

4 9.50

 

192 .075

 

34 13.3

 

30 11.7

 

199 .773

 

39 14.4

 

32 11.9

 

Mother's level of education 
Not educated 
Basic 
Secondary 
High education   65 53.3

 

24 19.7

 

33 .027

 

28.8 0.0001* 

 

35 .579

 

4 9.1 5 11.4

 

190 69.9

 

43 15.8

 

39 14.3

 

192 73.6

 

42 16.1

 

27 10.3

 

Father's level of education  
Not educated 
Basic 
Secondary 
High education 64 56.6

 

21 .618

 

28 .824

 

16.7 0.011* 

 

96 51.9

 

34 .418

 

55 .729

 

Type of delivery 
Caesarean 
Vaginal 385 .276

 

76 15.0

 

44 8.70

 

49.4 0.0001* 

 

226 65.9

 

54 15.7

 

63 .418

 

Infant s gender 
Male 
Female 255 .573

 

56 .116

 

36 10.4

 

9.2 0.010* 

* Statically significant at ( = 0.05) 



 
51

A. Mother's age: 

Regarding mother's age we found that (78.3%) of the mothers at the 

age (22-28) years breastfed their infant exclusively in the first six months 

of age, and (17.3%) tends to partially breastfed their infants at the same 

interval of mother's age, while we found that for the age group 36 years and 

more the high percentage (25.0%) is for formula feeding (P-value is < 

0.05). This means there is a significant correlation between mother s age 

and type of feeding in the first six months of life. So we reject the 

hypothesis and say that: There exists a significant relationship, at the level 

of p  0.05, between mother's age and type of feeding in the first six 

months of life.

 

B. Mother's age at marriage: 

For the mother's age at marriage we found that (79.0%) of mothers in 

the age (15-21) years exclusively breastfed their infants, (19.5%) of the age 

group (22-28) years partially breastfed their infants, and (74.7%) of the age 

group 29 years and more were fed their infants by formulas (P-value is < 

0.05). This means there is a significant correlation between mother s age at 

marriage and type of feeding in the first six months of life. So we reject the 

hypothesis and say that: There exists a significant relationship, at the level 

of p  0.05, between mother s age at marriage and type of feeding in the 

first six months of life.

 



 
52

C. Mother's age at baby s birth:  

For this variable, results showed that the high percentage is for the 

age interval (22-28) years for EBF (78.4%). However it is noticed that age 

group  36 years tends to have the highest percentage (25%) for EFF 

infants (P-value is < 0.05). This means there is a significant correlation 

between mother s age at baby s birth and type of feeding in the first six 

months of life. So we reject the hypothesis and say that: There exists a 

significant relationship, at the level of p  0.05, between mother s age at 

baby s birth and type of feeding in the first six months of life.

 

D. Parity:  

Regarding this factor the highest percentage (77.9%) is for  mothers 

with parity > 4, compared with mothers with low parity (1-2) children who 

tended to have highest level for and EFF (20.1%)  (P-value is < 0.05). This 

means there is a significant correlation between parity and type of feeding 

in the first six months of life. So we reject the hypothesis and say that: 

There exists a significant relationship, at the level of p  0.05, between 

parity and type of feeding in the first six months of life.

 

E. Mother's level of education:  

Study findings show that women with basic and secondary education 

(75.0%, and 73.0%) tend to have high percentage for EBF compared to 

non-educated ones and women with high level of education. Women with 

high education had the highest percent in using EFF (27.0%). which means 



 
53

there is a significant correlation between mother's level of education and 

type of feeding in the first six months of life (P-value is < 0.05). So we 

reject the hypothesis and say that: There exists a significant relationship, 

at the level of p  0.05, between mother's level of education and type of 

feeding in the first six months of life.

 

F. Father's level of education (husband):  

Study results indicated that infants born to non-educated fathers tend 

to have highest percent in receiving exclusive breastfeeding (79.5%), 

compared to other levels of education. On the other hand infants born to 

fathers with high education had the highest percent of EFF (24.8%) (P-

value is < 0.05). which means there is a significant correlation between 

father's level of education and type of feeding in the first six months of life 

(P-value is < 0.05).Therefore, we reject the hypothesis and say that: There 

exists a significant relationship, at the level of p  0.05, between father's 

level of education and type of feeding in the first six months of life.

 

G. Type of delivery:  

Investigation for type of delivery in our research indicated that 

women who delivered vaginally tended to provide EBF more frequently 

than those delivered by C-section (76.2% vs 51.9%). EFF was much higher 

in infants born to mothers through C-section compared to vaginal delivery 

(P-value is < 0.05). This means there is a significant correlation between 

type of delivery and type of feeding in the first six months of life. So we 



 
54

reject the hypothesis and say that: There exists a significant relationship, 

at the level of p  0.05, between type of delivery and type of feeding in the 

first six months of life.

 

H. Infant's gender:  

Regarding infant gender, female infants were fed by EBF in higher 

percent (73.5%) compared to males (65.9%). Higher percent of male 

infants (18.4%) were given EFF compared to females (P-value is < 0.05). 

This means there is a significant correlation between infant's gender and 

type of feeding in the first six months of life. So we reject the hypothesis 

and say that: There exists a significant relationship, at the level of p  

0.05, between infant's gender and type of feeding in the first six months of 

life.

 

4.4.2. Results related to the hypotheses of morbidity 

4.4.2.1. Results related to the first specific hypothesis relationship 

between type of feeding and frequency of disease visits in the first six 

months of life in Nablus refugee camps

 

In order to test the main hypothesis," There exists no significant 

relationship, at the level of p  0.05, between type of feeding and frequency 

of disease visits in the first six months of life in Nablus refugee camps 

(examples are upper respiratory tract infection, lower respiratory tract 

infection, otitis media, asthma, wheezing, gastroenteritis, diarrhea, urinary 

tract infections, and allergies) , Pearson Chi-Square test was applied. 



 
55

Tables (7) below shows the frequencies and percentage of the two variables 

(frequency of disease visits and type of feeding in the first six months of 

life). 

Table (7) Relationship between type of feeding in the first six months 
of life and infant s frequency of disease visits in the same period of age 
(n=690) 

Feeding in the first six months of life Correlation 

EBF PBF EFF 
Frequency 
of disease 

visits  No. % No. % No. % 
Chi-Square 

Value P-Value 

 

251 .788

 

16 5.70

 

16 5.70 
111 81.0

 

19 13.9

 

7 5.10 
112 50.0

 

56 25.0

 

56 25.0 

 

None 
1 
2-4 

 

4   7 15.2

 

19 41.3

 

20 43.5 

168.9 0.00001* 

* Statically significant at ( = 0.05) 

Table (7) shows that (88.7 %) of infants with no disease visits to the 

clinic were fed by EBF. At the same time those who had high frequent 

disease visits (> 4) were mainly fed by either PBF (41.3%) or EFF (43.5%). 

The difference was statistically significant (P 0.05). So we reject the 

hypothesis and say that there is a significant relationship, at the level of p  

0.05, between type of feeding and frequency of disease visits in the first six 

months of life in Nablus refugee camps. 

4.4.2.2. Results related to the main hypothesis relationship between 

type of infant feeding and morbidity in the first six months of infant s life 

in Nablus refugee camps

 

In order to test the main hypothesis," There is no significant 

relationship, at the significance level p 0.05, between type of infant 



 
56

feeding and morbidity in the first six months of infant s life in Nablus 

refugee camps . Pearson Chi-Square test was applied. Table (8) below 

shows the relationship between type of infant feeding in the first six 

months of infant s life and morbidity regarding different diseases in the 

same age. 

Table (8): Relationship between type of infant feeding in the first six 
months of life and   morbidity according to different diseases in the 
same age (n=407) 

Feeding in the first six months of life Correlation 
EBF PBF EFF Diseases 

No. % No. % No. % 
Chi-Square 

Value P-Value 

  

47 56.0 16 19.0

 

21 25.0

 

Upper respiratory  
tract infection 
No 
Yes 183 56.8

 

77 23.9 62 19.3 

1.8 0.416 

  

221 .759 86 .223 63 .017 

Lower respiratory  
tract infection 
No 
Yes 9 24.3

 

8 21.6

 

20 54.1 

25.6 0.00001* 

 

229 .165 71 .220 52 .817 
Otitis Media  
No 
Yes 1 1.80

 

23 41.8

 

31 56.4

 

95.2 0.00001* 

 

220 .559 83 .422 67 .118 
Wheezing  
No 
Yes 10 27.0

 

11 29.7

 

16 43.2

 

16.5 0.00001* 

 

213 .764 58 .617 58 .617 
Gastroenteritis 
No 
Yes 17 21.8

 

36 46.2

 

25 32.1

 

49.8 0.00001* 

 

206 .862 74 .622 48 .614 
Diarrhea 
No 
Yes 24 30.4

 

20 25.3

 

35 44.3

 

36.4 0.00001* 

 

217 .895 80 .022 66 .218 
Allergies  
No 
Yes 13 29.5

 

14 31.8

 

17 38.6 
15.6 0.00001* 

*Statically significant at ( = 0.05) 

Table (8) shows a statistically significant relationship for 

development of most types of diseases with type of feeding in the first six 

months of life as follows. 



 
57

A. Upper respiratory tract infection: 

Regarding this disease we found that P-value was >0.05, which 

means there is no significant correlation between the type of feeding in the 

first six months of life and possibility to develop URTI during the same 

period of age. 

B. Lower respiratory tract infection: 

According to findings in table (8), we notice that highest percent for 

those who did not develop LRTI was for infants fed by EBF (59.7%). On 

the other hand the highest percentage (54.1%) for those who were 

diagnosed with LRTI were EFF (P < 0.05). This means that there is a 

significant correlation between type of feeding and developing LRTI in 

infants in the first six months of life. 

C. Otitis media: 

Numbers show that for infants who did not have OM in the first six 

months of life EBF was the highest percentage (65.1%). Only (1.8%) of 

those who developed OM had EBF (P-value is < 0.05). This means that 

there is a significant correlation between type of feeding and developing 

otitis media in the first six months of life. 

D. Wheezing: 

Regarding wheezing the results found that among infants who had 

wheezing episode, EFF was the most frequent method of feeding (43.2%). 



 
58

Infants with EBF were the most frequent (59.5%) among those who never 

wheezed in the first six months of their lives (P < 0.05). Therefore, we can 

conclude there is a significant correlation between type of feeding and 

wheezing in the first six months of life. 

E. Gastroenteritis: 

For this disease, the study results showed that (64.7%) of infants 

who did not develop gastroenteritis had EBF, in comparison to (17.6%) for 

both PBF and EFF (P< 0.05). This means there is a significant correlation 

between type of feeding and gastroenteritis in the first six months of life. 

F. Diarrhea: 

Numbers show that infants who were fed by EFF had the highest 

percentage in developing diarrhea (44.3%). Infants who did not develop 

diarrhea were mainly from the EBF group (62.8%) (P-value is < 0.05). This 

means there is a significant correlation between type of feeding and 

diarrhea in the first six months of life. 

G. Allergies: 

We notice that infants who were breastfed exclusively were the 

highest to not develop allergies in the first six months of life (59.8%), 

compared to PBF and EFF (22.0%) and (18.0%) respectively (P-value is < 

0.05). This means there is a significant correlation between type of feeding 

and developing allergies in the first six months of life. 



 
59

In general, the statistical relationship between type of feeding and all 

diseases in table (8) was significant at P<0.05, except for URTI. Therefore, 

we reject the hypothesis and say that: There exists a significant 

relationship, at the level of p  0.05, between type of feeding and morbidity 

regarding (LRTI, OM, wheezing, gastroenteritis, diarrhea, and allergies) in 

the first six months of infant s life.

 

Regarding UTI, there were only six reported cases among the study sample 

(a very small number to apply any statistical association).  

4.4.3. Relationship between type of feeding and infant morbidity after 

adjustment for mother and infant confounding factors 

After adjustment for mother and infant confounding factors, analysis 

for morbidity was re-examined, by using multiple logistic regression 

method. Adjusted Odds Ratio (Adj-OR), 95% confidence intervals, and P-

value for significance levels for diseases were investigated. Table (9) below 

shows the result of analysis, EBF was treated as the referent group. 



 
60

Table (9) Adjusted Odds ratio, Confidence Intervals and Significance 
levels for diseases affected by type of feeding (n=407) 

Type of feeding 
EBF  PBF EFF 

 
P-
value 

Adj-OR, CI P-
value 

Adj-OR, CI Disease 

Referent

 

0.246 
1.467 (0.768, 
2.801) 

0.004*

 

3.724 (1.528, 
9.074) 

Upper 
respiratory tract 
infection 

Referent

 

0.421 
1.558 (0.530, 
4.585) 

0.005*

 

5.110 (1.621, 
16.106) 

Lower 
respiratory tract 
infection 

Referent

 

0.066 
2.506 (0.940, 
6.667) 

0.006*

 

4.950 (1.572, 
15.625) 

Wheezing 

Referent

 

0.001*

 

5.525 (2.724, 
11.364) 

0.050* 
2.584 (0.998, 
6.711) 

Gastroenteritis 

Referent

 

0.935 
1.032 (0.484, 
2.202) 

0.115 
2.033 (0.841, 
4.926) 

Diarrhea 

Referent

 

0.019* 
2.793 (1.181, 
6.624) 

0.003* 
4.926 (1.704, 
14.286) 

Allergies 

Adj-OR: adjusted Odds Ratio. 

CI: Confidence Intervals. 

* P 0.05, significant 

From table (9), we notice that after adjusting for mothers' and infants' 

demographic variables, there is a significant increment in the adjusted odds 

ratio of EFF and PBF groups for allergies and gastroenteritis. While for 

URTI, LRTI, and wheezing the increment in adjusted odds ratio reach the 

significant level only for EFF group. Regarding diarrhea the increased 

adjusted OR did not reach statistical significance for both EFF and PBF. 



 
61 

We omitted OM from analysis after adjustment for confounding 

factors due to presence of a very small cell in the statistical analysis, which 

makes relation if present theoretical not practical. 

Summary 

The study results show that majority of infants in Nablus refugee 

camps are fed by EBF ( 70%) in their first six months of life.  

There exists a significant relationship, at the level of p  0.05, 

between type of feeding in the first six months of life and mother's and 

infant's demographic profiles (mother's age, mother's age at marriage, 

mother's age at her baby's birth, parity, mother's level of education, father's 

level of education, mode of delivery, and infant's gender). 

There is also a significant relationship, at the level of p 

 

0.05, 

between type of feeding and morbidity regarding (LRTI, OM, wheezing, 

gastroenteritis, diarrhea, and allergies.) in the first six months of infant s 

life. 

Even after adjustment for confounding factors this relationship is still 

significant for (LRTI, wheezing, gastroenteritis, and allergies), in addition 

to URTI. 



 
62   

Chapter Five 

Discussion 



 
63

Chapter Five 

Discussion 

In this chapter, the study result will be discussed in terms of sample 

distribution, sociodemographic profile of infants and mothers, and the 

results of tested hypotheses. The study results will be compared by similar 

studies done globally and regionally. 

5.1. Discussion related to sample distribution according to mother s 

and infant s sociodemographic profile 

The study sample showed a good distribution of mother s age where 

it ranged from being very young mothers to older mothers, with the highest 

percentage was for (22-28) age group (39.4%). Mother s age at marriage 

shows that early marriage is still a pattern of Palestinian societies in 

refugee camps. Age of marriage at (15-21) in the sample was (66.4%). It is 

clear that the trend of early marriage increased in the year 2007, when one 

noticed in the results of PCBS survey for the year (2006) that the median 

age at first marriage of ever-married women between the ages (20-54 

years) in Palestine refugee camps was for the age 19 years 55.   

Mother s age at baby s birth showed that the highest percentages 

were for age groups (22-28) years (38%), then (29-35) years (33.6%). The 

result agrees with PCBS results of survey (2006); fertility rate per 1000 

women by age in Palestine refugee camps, showed that the highest was 

among the age group (25-29) years (272.3), followed by (20-24)years 

(229.3) 55. 



 
64

Regarding parity, low parity (1-2) and intermediate (3-4) combined 

formed around 75% of our sample, leaving high parity group (>4) to be 

around (25%). According to WHO agenda (2009), parity has stabilized in 

the last five years, the mean parity among Palestinian refugee women 

accessing UNRWA services was found to be 4.5 in the West Bank 56. 

Mother s level of education shows that only (6%) of mothers did not 

get education and that (17.7%) of mothers received high education. The 

result goes with PCBS survey (2006), the highest percentages of female 

(age 10 and above) by educational level in refugee camps were for 

elementary and preparatory combined (49.8%), and secondary level of 

education (19.8%) 55. 

Regarding father s level of education the pattern in this study is 

similar to mothers level of education; even mothers have slightly higher 

level of education reflecting that Palestinian society encourages education 

for both males and females. This results are similar to that of the PCBS 

survey (2006); the highest percentages distribution of males (age  10 

years) by educational level in Palestine refuge camps elementary (22%), 

then preparatory (30.2%), and finally secondary (17.1%) 55. 

Regarding type of delivery, about a quarter of study sample had their 

babies by C-section. This percentage is some what higher than findings in 

PCBS survey (2006) which pointed that rate of C-section in Nablus was 

18.3% 55.  However, the annual report of UNRWA (2007); found that the 



 
65

C-section rate among women in West Bank was (27%) 65, a rate close to 

our findings.  

For infant gender, males and females were included in equal 

percentage (49.7% males, 50.3% females) in order to decrease gender bias.  

This result is highly consistent with PCBS survey (2006), that from 

population pyramid for the Palestinian Territory we noticed that male and 

female ratios were (50.7%) and (49.3%) respectively 55. More males are 

born than females, but males have higher mortality rates than females 55.  

5.2.  Discussion related to sample distribution according to infant s 

history of morbidity in the first six months of life 

Table (3) shows that only (41%) of study sample had no visits for 

diseases to the clinic. Despite that only (6.7%) had high frequent visits to 

the clinic (>4). This is usual in the first years of infants life. According to 

the UNRWA s annual report (2007); attendance  for preventive care  at 

UNRWA primary health care facilities (medical examination,  

immunization, and identification of children with special needs ) during the 

first year of life was estimated at (90%) of all infants registered agency-

wide with the highest percentage (100%) among Palestinian refugees in 

Lebanon and Gaza fields 65. While the attendance rate agency-wide were 

(75% and 49%) during the second and third years of infant s life 

respectively 65. 

Table (4) shows that URTI was the most frequent for disease visits 

(79.3%). For healthy infants; this is the mean characteristic of the study 



 
66

sample, URTI is the usual frequent acute illness in infant s life. According 

to the UNRWA s annual report (2007),  respiratory infections is the third 

main cause of mortality among children aged (1-3) years (14.7%), after 

congenital malformation and accidents during the year (2006) 65. 

The least frequent cause for disease visits was UTI and again this is 

expected for healthy term babies. 

5.3.  Discussion related to sample distribution according to type of 

infant feeding in the first six months of life 

Table (5) shows that around (70%) of the study sample were fed by 

EBF, and only (14%) were provided EFF. Study results show that 

Palestinian women in refugee camps tend to provide breastfeeding in a very 

good percent to their infants. According to the researcher observation, 

UNRWA s clinics in Nablus refugee camps ( including Balata, Askar, and 

Ein Beit el Ma) has important and extensive efforts in promoting 

breastfeeding through the information presented to mothers by nurses in 

MCH departments, and\or through booklets and pamphlets. This may 

interpret the large difference in patterns of feeding percentages especially 

EBF that noticed between this study and PCBS survey (2006); which found 

that exclusive breastfeeding in the first six months of life in Palestine 

refugee camps was 24.8% 55.  

Another explanation for this difference is the poor economic 

conditions among Palestine refugee camps which may prevent them from 

getting infant formulas. 



 
67

5.4. Discussion related to study hypotheses 

5.4.1. Discussion related to the specific hypotheses relationship between 

the selected mother's and infant's sociodemographic profiles and type of 

feeding in the first six months of life in Nablus refugee camps

 

A. Mother's age: 

This research found that in a society like the Palestinian refugee 

camps there is a statistically significant association between type of feeding 

in the first six months of life and mother s age. As noticed in table (6), 

women aged 22-28 years old were the highest to breastfeed either 

exclusively (78.3%) or partially (17.3%), while the group aged  36 years 

old tends to formula feed their infants. These results are in contrary to the 

results of Irbid study (2003); a semi-urban community in Jordan which 

found that type of feeding in the first six months of age was independent of 

mother s age 52, but this study result is similar to that conducted by 

Sachdev and Mehrptra in New-Delhi; urban city in India (1993-1994), 

which found that younger mothers were positively related to exclusive 

breastfeeding 66. On the other hand Ever-Hadani et al study on Jewish 

women in Jerusalem (1974-1976) found that maternal age < 24 or >40 

years old were positively associated with the decision to breastfeed 53. 

B. Mother's age at marriage: 

The study results point to the presence of significant relationship 

between type of feeding in the first six months of infant life and mother s 



 
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age at marriage (table 6); the younger the mother the higher the tendency to 

exclusively breastfeed. This result is different from Ever-Hadani et al on 

Jewish women from Jerusalem (1974-1976), which found that age at 

marriage did not significantly influence the decision to breastfeed 53. 

C. Mother's age at baby s birth: 

In this study (table 6), result point that mother s age at baby s birth 

correlates significantly with mother s choice about infant type of feeding in 

the first six months of infant life; mothers aged 22-28 years old were the 

highest to breastfeed either exclusively or partially, while the group aged 

36 years old tend to formula feed their infants. Unfortunately, no previous 

study was found related to such association. 

Suggested explanation for the previous three items (mother s age, 

mother s age at marriage, mother age at baby s birth) may be that marriage 

and delivery at relatively young age puts high responsibility on mothers to 

increase their knowledge about maternal and child health in general, and 

the most suitable way of feeding method for her baby in particular. 

Therefore, they respond positively to doctors and nurses advice about their 

infant health more than older mothers. 

D. Parity: 

Regarding parity, the result found a statistically significant relation 

with infant feeding pattern in the fist six months of life (table 6); the higher 

the parity ( >4 children) the higher the tendency to breastfeed exclusively; 



 
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and the lower the parity (1-2), the higher the tendency to feed by using 

formula-milk exclusively. This can be explained by the effect of economic 

factors to save expenditures on formulas. And may be that practicing 

breastfeeding is considered as contraceptive method especially for those 

with high number of children. According to PCBS survey during the year 

(2004), the percentage of refugee camp women aged (15-49) years who 

practice breastfeeding as a contraceptive method was 3.7% 29. Another 

explanation for tendency of mother s of high parity to breastfeed is that 

high number of children leads to increased experience for mother in 

breastfeeding. The study findings are consistent with Khassawneh et al 

study (2003) in Jordan which found that mothers with lower number of 

children  3 were less likely to exclusively breastfed, and Berger-Achituv 

study et al in Tel Aviv district which found that grand multiparas ( 5 

children) had a significantly higher rate of breast-feeding than women with 

one to four children 52, 67. While Ever- Hadani et al study in Jerusalem 

(1974-1976) found that mothers with primipara and grandmultipara >4 

breastfeed their infants for longer ( 3 months) 53. 

E. Mother's level of education: 

In this study, the results revealed that type of infant s feeding in the