Community-based assessment of infant feeding practices within a programme for prevention of mother-to-child HIV transmission in rural Zimbabwe

OBJECTIVE: To describe the infant feeding practices and attitudes of women who used prevention of mother-to-child transmission of HIV (PMTCT) services in rural Zimbabwe. DESIGN: A cross-sectional study including structured interviews and focus group discussions was conducted between June 2003 and February 2004. SETTING: The study took place in Murambinda Mission Hospital (Buhera District, Manicaland Province), the first site offering PMTCT services in rural Zimbabwe. SUBJECTS: The interviews targeted HIV-infected and HIV-negative women who received prenatal HIV counselling and testing and minimal infant feeding counselling, and who delivered between 15 August 2001 and 15 February 2003. The focus groups were conducted among young and elderly men and women. RESULTS: Overall, 71 HIV-infected and 93 HIV-negative mothers were interviewed in clinics or at home. Most infants (97%) had ever been breast-fed. HIV-negative mothers introduced fluids/foods other than breast milk significantly sooner than HIV-infected mothers (median 4.0 vs. 6.0 months, P = 0.005). Infants born to HIV-negative mothers were weaned significantly later than HIV-exposed infants (median 19.0 vs. 6.0 months, P = 10(-5)). More than 90% of mothers reported that breast-feeding their infant was a personal decision, a third of whom also mentioned having taken into account health workers' messages. CONCLUSION: The HIV-infected mothers interviewed were gradually implementing infant feeding practices recommended in the context of HIV. Increased infant feeding support capacity in resource-limited rural populations is required, i.e. training of counselling staff, decentralised follow-up and weaning support.     

Breast-feeding in a UK urban context: who breast-feeds, for how long and does it matter?

OBJECTIVE: To investigate what factors relate most strongly to breast-feeding duration in order to successfully support breast-feeding mothers. DESIGN: Prospective birth cohort study using questionnaires, routinely collected weights and health check at age 13 months. SETTING: Gateshead, UK. SUBJECTS: Parents of 923 term infants born in a defined geographical area and recruited shortly after birth, 50% of whom were breast-feeding initially. RESULTS: Only 225 (24%) infants were still breast-fed at 6 weeks, although 136 (15%) continued beyond 4 months. Infants in the most affluent quintile were three times more likely to be initially breast-fed (P < 0.001) and five times more likely to still be feeding at 4 months (P = 0.001) compared with infants in the most deprived quintile. A third of breast-fed infants were given supplementary feeds in the maternity unit and this was associated with a 10-fold increase in odds of giving up breast-feeding by discharge (P = 0.001). Frequent feeding was reported as a reason for giving up in 70% of mothers at 6 weeks and 55% at 4 months. Those infants who stopped breast-feeding earliest showed the most rapid weight gain and were tallest at age 13 months. Non-breast-fed infants had 50% more family doctor contacts up to age 4 months (P = 0.005). CONCLUSIONS: Initiation of breast-feeding in urban Britain remains strongly determined by socio-economic background and early cessation seems to be related to frequent feeding and rapid growth as well as a continuing failure to eradicate health practices that undermine breast-feeding. Those infants not receiving breast milk suffered increased morbidity, but the apparent association between breast-feeding duration and growth probably reflects reverse causation.     

The cost of infant feeding in Liverpool, England

OBJECTIVE: To investigate feeding practices in infants under the age of 4 months in Liverpool, England with particular reference to the cost of infant feeding. DESIGN: A cross-sectional survey consisting of self-completion questionnaires and interviews. SETTING: Subjects' homes within Central and South Liverpool Primary Care Trust areas. SUBJECTS: One hundred and forty-nine women (aged 18 to 43 years) and their infants (mean age 13 weeks). RESULTS: The average weekly cost of breast-feeding was 11.58 pounds sterling compared with 9.60 pounds sterling for formula-feeding. Many breast- and formula-feeding women spent money however on items that were not needed or used only once or twice. This was especially true of first-time mothers. Characteristics significantly associated with higher spending were: feeding method - mothers that had or were partially breast-feeding (P=0.001), education - those educated to degree level (P=0.028), socio-economic status - those in social classes I and II (P=0.002) and age - those aged 30 years and over (P=0.003). CONCLUSIONS: This study demonstrates that while breast-feeding is often promoted as being free, this is not the case. Better information needs to be given to parents to avoid wasting money on items that are unnecessary, or where cheaper alternatives are available.     

Breast-feeding at 12 months of age and dietary habits among breast-fed and non-breast-fed infants

OBJECTIVE: To analyse factors associated with breast-feeding and use of sweetened drinks at 12 months, and to compare dietary habits among breast-fed and non-breast-fed infants. DESIGN: Data were collected by a semi-quantitative food-frequency questionnaire filled in by the parents. SETTING: National dietary survey in Norway. SUBJECTS: In total, 1932 12-month-old infants were included. RESULTS: At 12 months, 36% of the infants were breast-fed. The odds of breast-feeding at this age were more than doubled both for mothers > or =35 years compared with mothers <25 years and for mothers in the highest educational group compared with mothers in the lowest. A negative association was found for maternal smoking, and the odds of breast-feeding were 40% lower for mothers who smoked than for non-smokers. Some dietary differences were observed between breast-fed and non-breast-fed infants apart from intake of milk. In particular, breast-fed infants had a significantly lower daily intake of sweetened drinks than non-breast-fed infants and a 16% lower mean daily intake of added sugars (P<0.001). Furthermore, breast-fed infants had 30% higher odds of not receiving sweetened drinks daily, compared with non-breast-fed infants. CONCLUSIONS: Maternal age, education and smoking status were important factors for breast-feeding at 12 months. Breast-fed infants had lower intakes of sweetened drinks and added sugars than non-breast-fed infants. From a public health perspective, continued promotion of breast-feeding is needed to reduce inequalities in breast-feeding. Moreover, prevention of high intakes of sweetened drinks and added sugars should start in infancy.     

The infant feeding practices of mothers in the Maldives

OBJECTIVE: To document the infant feeding practices of Maldivian mothers. METHODS: A cross-sectional survey of 251 Maldivian mothers recruited in 2004 from the 'well baby' or 'well child' clinics on the island of Male' and including 75 mothers from three other islands, Hura, Himmafushi and Thulusdhoo. RESULTS: The full breast-feeding rate at hospital discharge was 93% but declined to 41% at 4 months. Any breast-feeding rates were high among Maldivian mothers: 100% at 1 month and 85% were still breast-feeding at 6 months. The median duration of breast-feeding was 24 months. CONCLUSION: Breast-feeding rates are high and the average duration of breast-feeding is more than 2 years in the Maldives. Health promotion activities should be directed towards maintaining the already high 'any breast-feeding' rates and increasing the proportion of infants exclusively breast-fed to 6 months.     

Do early infant feeding practices vary by maternal ethnic group?

OBJECTIVE: To examine UK country and ethnic variations in infant feeding practices. DESIGN: Cohort study. SETTING: Infants enrolled in the Millennium Cohort Study, born between September 2000 and January 2002. SUBJECTS: A total of 18 150 natural mothers (11 286 (8207 white) living in England) of singleton infants. OUTCOME MEASURES: Breast-feeding initiation, breast-feeding discontinuation and introduction of solid foods before 4 months. EXPLANATORY VARIABLES: Maternal ethnic group, education and social class. RESULTS: Seventy per cent of UK mothers started to breast-feed, of whom 62% stopped before 4 months. Median age at discontinuing breast-feeding was 14, 13, 10 and 6 weeks in Scotland, England, Wales and Northern Ireland, respectively. Thirty-six per cent of UK mothers (34% in England) introduced solids before 4 months. White mothers were more likely to discontinue breast-feeding (62%) and introduce solids early (37%) than most other ethnic minority groups; those stopping before 4 months were more likely to introduce solids early compared with those continuing to breast-feed beyond this age (adjusted rate ratio (95% confidence interval): 1.3 (1.1-1.2)). Educated mothers were less likely to stop breast-feeding before 4 months (white mothers, 0.8 (0.8-0.9); non-white mothers, 0.9 (0.8-1.0)) than those with no/minimal qualifications but, among ethnic minorities, were more likely to introduce solids early (1.3 (1.0-1.6)). Socio-economic status was positively associated with breast-feeding continuation among white women, and with age at introduction of solids among non-white women. CONCLUSIONS: We have identified important geographic, ethnic and social inequalities in breast-feeding continuation and introduction of solids within the UK, many of which have not been reported previously. The factors mediating these associations are complex and merit further study to ensure that interventions proposed to promote maternal adherence to current infant feeding recommendations are appropriate and effective.     

Full-term, peri-urban South African infants under 6 months of age are at risk for early-onset anaemia

OBJECTIVE: There is a paucity of data on the micronutrient status of low-income, lactating South African women and their infants under 6 months of age. The aim of this study was to elucidate the level of anaemia and vitamin A deficiency (VAD) in peri-urban breast-feeding women and their young infants. DESIGN: Cross-sectional study including anthropometric, biochemical and infant feeding data.Setting: Peri-urban settlement in Cape Town, South Africa. SUBJECTS: Breast-feeding women (n=113) and their infants (aged 1-6 months) attending a peri-urban clinic. RESULTS: Mean (standard deviation (SD)) haemoglobin (Hb) of the lactating mothers was 12.4 (1.3) g dl(-1), with 32% found to be anaemic (Hb<12 g dl(-1)). Maternal serum retinol was 49.8 (SD 13.3) microg dl(-1), with 4.5% VAD. Using breast milk, mean (SD) retinol concentration was found to be 70.6 (24.6) microg dl(-1) and 15.7 (8.3) microg/g milk fat, with 13% below the cut-off level of <8 microg/g fat. There was no correlation found between breast milk retinol and infant serum retinol. Z-scores (SD) of height-for-age, weight-for-age and weight-for-height were -0.69 (0.81), 0.89 (1.01) and 1.78 (0.83), respectively. Mean (SD) infant Hb was 10.9 (1.1) g dl(-1), with the prevalence of anaemia being 50%, 33% and 12% using Hb cut-offs below 11 g dl(-1), 10.5 g dl(-1) and 9.5 g dl(-1), respectively. Mean (SD) infant serum retinol was 26.9 (7.2) microg dl(-1), with 10% being VAD. None of the infants was exclusively breast-fed, 22% were predominantly breast-fed and 78% received complementary (mixed) breast-feeding. Thirty-two per cent of infants received weaning foods at an exceptionally young age (< or =1 month old). CONCLUSION: A high rate of anaemia is present in lactating women residing in resource-poor settings. Moreover, their seemingly healthy infants under 6 months of age are at an elevated risk of developing early-onset anaemia and at lower risk of VAD.     

Breast-feeding initiation and exclusive breast-feeding in rural Vietnam

OBJECTIVE: To investigate the initiation of breast-feeding and exclusive breast-feeding within the first week after delivery for women in rural Vietnam. DESIGN: An interviewer-administered survey was conducted on a sample of rural women who gave birth during August-October 2002. SETTING: Quang Xuong District, Thanh Hoa Province of Vietnam. SUBJECTS: Four hundred and sixty-three women participated in the study, of whom 181 delivered at the district hospital (39.1%), 229 at a commune health centre (49.5%) and 53 at home attended by a traditional birth attendant (11.4%). RESULTS: Although the initiation and exclusive breast-feeding rates were relatively high at 98.3% and 83.6% respectively, the premature introduction of complementary food was a great concern. Logistic regression analysis showed that, together with socio-cultural determinants such as feeding preferences of the husband and maternal grandmother, feeding practices of friends, factors relating to delivery methods, delivery locations and health problems could influence the initiation rate and breast-feeding patterns. CONCLUSIONS: To promote breast-feeding practices of rural mothers, health education on breast-feeding should take into account local socio-cultural features in addition to improving the counselling skills of health workers.     

Are infant feeding options that are recommended for mothers with HIV acceptable, feasible, affordable, sustainable and safe? Pregnant women's perspectives

OBJECTIVE: To investigate pregnant women's views on infant feeding options recommended for HIV-infected women. DESIGN: A structured interview survey complemented with focus group discussions. SETTING: Antenatal clinics in Moshi urban and rural districts of Tanzania. SUBJECTS: Five hundred pregnant women participated in the interview survey and 46 pregnant women participated in six focus group discussions. RESULTS: Participating women reported that they would change to an alternative infant feeding method if they were found to be HIV-infected and were advised to do so. Cow's milk was regarded as the most feasible infant feeding method for local HIV-infected mothers. Infant feeding formula was regarded as too costly, but if recommended by health workers and distributed free of charge, the majority of the women (82%) were confident that they would then choose this option. In the focus group discussions, women were less optimistic and expressed great concern for the social consequences of not breast-feeding. The safety of exclusive breast-feeding was questioned. Less common infant feeding methods, such as expressed heat-treated breast milk and wet-nursing, were not regarded as viable options. Several social barriers to replacement feeding were identified in the focus group discussions, including possible lack of support from partner and potential negative reactions from the community. CONCLUSION: Future research on infant feeding options should include the broader cultural context and the psychological stress that HIV-infected women face when choosing infant feeding methods.     

Maternal micronutrient status and decreased growth of Zambian infants born during and after the maize price increases resulting from the southern African drought of 2001-2002

OBJECTIVE: To investigate the effects on maternal micronutrient status and infant growth of the increased maize prices that resulted from the southern African drought of 2001-2002. DESIGN: Longitudinal cohort study. SETTING: A maternal and child health clinic in Lusaka, Zambia. SUBJECTS: Maternal and infant health and nutrition data and maternal plasma were being collected for a study of breast-feeding and postpartum health. Samples and data were analysed according to whether they were collected before (June to December 2001), during (January 2002 to April 2003) or after (May 2003 to January 2004) the period of increased maize price. Season and maternal HIV status were controlled for in analyses. RESULTS: Maize price increases were associated with decreased maternal plasma vitamin A during pregnancy (P = 0.028) and vitamin E postpartum (P = 0.042), with the lowest values among samples collected after May 2003 (vitamin A: 0.96 micromol l(-1), 95% confidence interval (CI) 0.84-1.09, n = 38; vitamin E: 30.8 micromol mmol(-1) triglycerides, 95% CI 27.2-34.8, n = 64) compared with before January 2002 (vitamin A: 1.03 micromol l(-1), 95% CI 0.93-1.12, n = 104; vitamin E: 38.9 micromol mmol(-1) triglycerides, 95% CI 34.5-43.8, n = 47). There were no significant effects of sampling date on maternal weight, haemoglobin or acute-phase proteins and only marginal effects on infant weight. Infant length at 6 and 16 weeks of age decreased progressively throughout the study (P-values for time of data collection were 0.51 at birth, 0.051 at 6 weeks and 0.026 at 16 weeks). CONCLUSIONS: The results show modest effects of the maize price increases on maternal micronutrient status. The most serious consequence of the price increases is likely to be the increased stunting among infants whose mothers experienced high maize prices while pregnant. During periods of food shortages it might be advisable to provide micronutrient supplements even to those who are less food-insecure.     

Breast-feeding initiation and exclusive duration at 6 months by social class--results from the Millennium Cohort Study

OBJECTIVES: To assess breast-feeding initiation and rates of exclusive breast-feeding for the first 6 months after birth, and to examine social class differences in breast-feeding rates. DESIGN: First sweep of a longitudinal population-based survey, the Millennium Cohort Study. SETTING: Four countries of the UK. SUBJECTS: Subjects were 18 125 singletons born over a 12-month period spanning 2000-01. Data were collected by parental interview on the initiation of breast-feeding and exclusivity at 1, 4 and 6 months after birth. RESULTS: Overall breast-feeding was initiated for 71% of babies, and by 1, 4 and 6 months of age the proportions being exclusively breast-fed were 34%, 3% and 0.3%, respectively. There were clear social class differences and mothers with routine jobs with the least favourable working conditions were more than four times less likely (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.18-0.29) to initiate breast-feeding compared with women in higher managerial and professional occupations. Women in routine jobs were less likely to exclusively breast-feed their infants at 1 month (OR 0.42, 95% CI 0.36-0.50) and 4 months (OR 0.5, 95% CI 0.31-0.77) compared with women in higher managerial and professional occupations. CONCLUSIONS: Clear social class differences in breast-feeding initiation and exclusivity for the first 4 months were apparent in this large UK sample. By 6 months, less than 1% of babies were being exclusively breast-fed. A co-ordinated multi-faceted strategy is required to promote breast-feeding, particularly among lower-income women.     

Breast-feeding mothers can exercise: results of a cohort study

OBJECTIVES: To study the relationship between exercise by the mother and breast-feeding initiation and duration, and its effect on infant growth. DESIGN: A cohort study of mothers and infants, recruited at birth. Infant feeding methods were recorded in detail and breast-feeding was categorised as 'any' or 'full'. Exercise levels were categorised using the metabolic equivalent tasks approach based on details of physical activity recorded in questionnaires. SETTING: Perth, Western Australia. SUBJECTS: A total of 587 mothers were interviewed on seven occasions over a period of 12 months. RESULTS: There was no difference in the means of infant weight and length changes, indicating that exercise appeared to have no significant influence on infant growth up to 52 weeks after birth (P=0.236 and 0.974, respectively). The mother's level of exercise was not significantly associated with breast-feeding to 6 or 12 months. This applied to 'full' and 'any' categories of breast-feeding. CONCLUSION: Exercise does not affect breast-feeding outcomes at the usual levels of activity undertaken by mothers. Breast-feeding and exercise are important for maintaining and promoting health, and this study provides reassurance to health professionals wishing to encourage mothers to continue both behaviours.     

Breast-feeding Performance Index: a composite index to describe overall breast-feeding performance among infants under 6 months of age

OBJECTIVES: To develop a composite index to describe the overall breast-feeding performance of infants<6 months of age; and, using this index, to identify the factors associated with poor breast-feeding practices and the association between breast-feeding and infant morbidity. DESIGN, SETTING AND SUBJECTS: The 2003 Demographic and Health Survey was a multi-stage cluster sample survey of 4320 households in Timor-Leste which covered 573 infants aged<6 months. Breast-feeding Performance Index (BPI) was constructed by allocating one point for each of seven infant feeding practices: first suckling within an hour of birth; absence of prelacteals; non-use of feeding bottles; current breast-feeding; not receiving liquids; not receiving formula or other milk; and not receiving solids in the last 24 hours. BPI was treated as the dependent variable in univariate and multivariate analyses to identify the factors associated with poor breast-feeding. RESULTS: Exclusive breast-feeding rate was 29.9%. The BPI (mean 4.4, standard deviation 1.77) was categorised as low, average and high according to tertiles. Multivariate analysis indicated that infants from the richest households were 1.70 (95% confidence interval (CI) 1.04-2.77) times more likely to have 'low BPI' than the poorest. Maternal BMI<18.5 kg m(-2) was predictive of poor breast-feeding (odds ratio=1.79; 95% CI 1.27-2.52). In the 'low' BPI group, the incidence of diarrhoea (13.4%) and acute respiratory infections (20.7%) during the previous two weeks was significantly higher than in 'average' (4.3 and 9.3%) and 'high' BPI groups (4.6 and 5.5%). CONCLUSIONS: Creating a composite index to assess the overall breast-feeding performance among infants<6 months of age is feasible. BPI can be effectively used to identify target groups for breast-feeding promotion interventions.     

Infant feeding practices in Xinjiang Uygur Autonomous Region, People's Republic of China

AIMS: To document infant feeding methods in the first six months of life in Xinjiang Uygur Autonomous Region, People's Republic of China, 2003-2004. Some problems with breast-feeding in the area are explained. METHODS: A longitudinal study of infant feeding practices was undertaken. A total of 1219 mothers who delivered babies during 2003 and 2004 were interviewed in five hospitals or institutes, and after discharge were contacted in person or by telephone at approximately monthly intervals to obtain details of infant feeding practices. Multivariate logistic regression analysis was used to explore factors associated with breast-feeding initiation. RESULTS: 'Any breast-feeding' rates at discharge and at 0.5, 1.5, 2.5, 3.5, 4.5 and 6 months were 92.2, 91.3, 89.9, 88.8, 87.7, 86.0 and 73.0%, respectively. 'Exclusive breast-feeding' rates at discharge and at 0.5, 1.5, 2.5, 3.5, 4.5 and 6 months were 66.2, 47.6, 30.1, 25.8, 22.1, 13.0 and 6.2%, respectively. The main problem of breast-feeding in Xinjiang was the early introduction of formula or water. The average duration of 'exclusive breast-feeding' was 1.8 months (95% confidence interval (CI) 1.7-2.0), of 'full breast-feeding' 2.8 months (95% CI 2.7-2.9) and of 'any breast-feeding' 5.3 months (95% CI 5.2-5.4). CONCLUSIONS: Infant feeding methods in Xinjiang were documented in this study and the main problems with infant feeding in Xinjiang are discussed. Further studies are needed to identify factors associated with 'exclusive breast-feeding' and duration.     

Unintended pregnancies are associated with less likelihood of prolonged breast-feeding: an analysis of 18 Demographic and Health Surveys

OBJECTIVE: To examine the relationship between unintended pregnancies and prolonged breast-feeding among 18 countries on an individual and aggregated level.DESIGN AND SETTING: Regional multivariate logistic regression analyses were conducted to examine this association based on 18 Demographic and Health Surveys conducted between 1995 and 2000.SUBJECTS: Women who had a live child between 13 and 36 months old were included in these analyses (n=41 353).RESULTS: Regression models were adjusted for 10 covariates including child age, maternal age, pregnancy status of mother at the time of interview and parity. In 11 out of the 18 countries the odds ratio (OR) of the association between unintended pregnancies and prolonged breast-feeding was <1.0, reaching statistical significance in three countries. Pooled analyses of all 18 countries detected a significant association between unintended pregnancies and less likelihood of prolonged breast-feeding (OR=0.90, 95% confidence interval=0.85-0.96).CONCLUSIONS: Prospective studies are needed to further understand if and how pregnancy intentions influence breast-feeding outcomes in different settings.     

Do mothers understand healthy eating principles for low-birth-weight infants?

OBJECTIVES: To describe feeding patterns and mothers' perceptions of desirable feeding practices in low-birth-weight (LBW) infants after hospital discharge in England and to test for the association of inappropriate practices/perceptions with identifiable demographics. DESIGN: Postal questionnaires from 198 mothers of LBW infants in London, Liverpool and Winchester were analysed regarding infant demographics, mothers' demographics, infant milks used, solid feeding practices and mothers' perceptions of infant feeding practices. RESULTS: At birth, the median weight, independent of gestational age, was 1.80 kg (range 0.6-2.50 kg) and 37.1% of infants received breast milk exclusively; 83.7% were breast-fed at some stage, a practice favoured more by first-time mothers (90.2%) than multiparous mothers (73.4%) (P = 0.004) as well as by mothers of higher social groups (P = 0.019). The median age of solid food introduction was 17 postnatal weeks (range 8-36 weeks); the timing correlated strongly with infant birth weight (P < 0.001). A high-fibre diet and a low-fat diet were incorrectly considered important for their infants by 67.1% and 51.6% of mothers, respectively. Regarding a high-fibre diet as important was associated with being a multiparous mother (P = 0.006), while regarding a low-fat diet as important was associated with low social group (P = 0.018). A quarter of mothers did not consider 'plenty of calories' to be important for their infants, reflecting similar attitudes in 1990 for mothers of term infants; this incorrect attitude exhibited an association with being a first-time mother (P = 0.047). CONCLUSIONS: Infant feeding practices were very variable, showing poor concordance with national and international recommendations for term infants. In selecting foods for their infants, many mothers appeared to be applying principles more appropriate to planning a healthy diet for adults. There is an urgent need to develop and implement evidence-based guidelines for feeding LBW infants after hospital discharge, with special attention given to multiparous mothers as well as mothers from lower social groups.     

Individual and contextual determinants of exclusive breast-feeding in São Paulo, Brazil: a multilevel analysis

OBJECTIVE: To identify individual and contextual factors associated with the practice of exclusive breast-feeding (EBF). METHODOLOGY: We analysed 34 435 children under 6 months of age living in 111 municipalities in the state of S?o Paulo, south-eastern Brazil, who participated in a survey investigating feeding practices during the first year of life, carried out during the 1999 national vaccination campaign. The questionnaire employed included questions on the consumption, in the last 24 h, of breast milk, water, tea, other types of milk and other foods, in addition to mother and child characteristics. Information on the pro-breast-feeding measures implemented in the municipalities was also collected. The effects of individual and contextual characteristics on EBF were analysed using multilevel models. RESULTS: The final model showed a greater chance of EBF in women with tertiary education (odds ratio (OR) = 1.91; 95% confidence interval (CI) 1.75-2.06); women aged between 25 and 29 years (OR = 1.52; 95% CI 1.41-1.63); multiparae (OR = 1.42; 95% CI 1.33-1.49); female babies (OR = 1.12; 95% CI 1.05-1.18); birth weight > or = 3000 g (OR = 1.73; 95% CI 1.49-1.97); child follow-up in the private health-care network (OR = 1.10; 95% CI 1.02-1.18); and municipalities with four or five pro-breast-feeding measures (OR = 2.4; 95% CI 2.19-2.88). An analysis of the interactions between individual and contextual variables showed that the presence of at least four pro-breast-feeding measures in the municipality attenuated the risk of early termination of EBF associated with low maternal schooling and low birth weight, and transformed child follow-up in the public network into a protective factor against the early termination of breast-feeding. CONCLUSIONS: The presence of measures aimed at protecting, promoting and supporting breast-feeding in the municipality had a positive influence on EBF and attenuated the impact of risk factors for the termination of breast-feeding.     

Breast-feeding and feeding practices of infants in a developing country: a national survey in Lebanon

OBJECTIVE: Breast-feeding (BF) provides the ideal food for the healthy growth and development of infants. The prevalence of BF in Lebanon shows mixed results. The present study was the first large-scale, extensive survey on BF parameters in Lebanon that aimed to explore demographic, socio-economic and other fundamental issues associated with the initiation and duration of BF by Lebanese mothers.DESIGN: The survey was cross-sectional in design and administered over 10 months.SETTING: Information on all variables was collected from mothers at health centres.SUBJECTS: Two-stage sampling was conducted to select participants. A total of 1,000 participants were randomly selected. A consent form was provided to each participant. Data were collected from 830 of these.RESULTS: Almost all mothers were Lebanese, married and had given birth in a hospital. About a third stated that breast milk was the first food introduced after birth. Although 55.9% started breast-feeding their newborns within a few hours after birth, and 18.3% within half an hour, 21.2% replied that they initiated BF a few days after birth. Only 4.6% of the mothers replied that they never breast-fed their infant. Timing of initiation of BF was associated with the type of delivery (vaginal/Caesarean section) and hospital-related factors (rooming-in, night feedings and frequency of mother-infant interaction). Of the mothers who breast-fed exclusively beyond 6 months, 86.7% had initiated BF a few hours following delivery, while only 13.3% had initiated BF a few days later. Compared with the exceptionally high proportion of BF initiation, exclusivity of BF was low, dropping to 52.4% at 1 month. Exclusivity of BF was also associated with place of residence (urban/rural) and negatively associated with educational level of the mother. Duration of BF was inversely associated with the use of pain killers during delivery and maternal education. Rural mothers and those who practised exclusive BF maintained BF for a longer duration.CONCLUSION: Initiation rates of BF are very high in Lebanon but rates of exclusive BF are low and duration of BF is short. Future research targeting the factors associated with BF, with particular emphasis on exclusivity, is needed. For the 95.4% of mothers who initiated BF, an ecological perspective on intervention aimed at women and their social support system is required to improve duration and exclusivity.     

Breast-feeding in South Korea: factors influencing its initiation and duration

OBJECTIVE: To investigate factors influencing the practices of partial breast-feeding (PBF) and exclusive breast-feeding (EBF). DESIGN: A national, cross-sectional survey was conducted among married women aged 15-49 years from May to August 2003. SETTING: South Korea. SUBJECTS: A total of 865 mothers answered questions regarding the feeding practices of their youngest baby, born between January 2001 and May 2003. RESULTS: The initiation rates of PBF and EBF were 81% and 63%, respectively. However, the median durations of PBF and EBF were very short: 12 and 8 weeks, respectively. According to stepwise logistic and Cox regression analyses, the more prenatal care women received, the more likely they were to initiate PBF and EBF but the less likely to continue EBF. Delivery by Caesarean section decreased the initiation of PBF and EBF. The mother's education level and employment status before marriage, the amount of prenatal care, delivery method and baby's status at birth affected breast-feeding initiation, whereas the amount of prenatal care influenced breast-feeding duration. CONCLUSION: To promote breast-feeding, education and campaigning on the importance of continued breast-feeding should be provided to the general public, particularly to health workers in maternity units.     

Motherhood meets epidemiology: measuring risk factors for breast-feeding cessation

OBJECTIVE: To examine statistical models that have been used to predict the cessation of breast-feeding. SETTING: In nutritional epidemiology, a knowledge of risk factors that lead to breast-feeding cessation is essential to promote optimal infant health by increasing or sustaining breast-feeding rates. However, a number of methodological issues complicate the measurement of such risk factors. It is important when building multivariate models that variables entered into the model are not intervening variables, factors on the causal pathway or surrogate outcomes. Inclusion of these types of variable can lead to inaccurate models and biased results. A factor often cited to predict breast-feeding is 'intention to breast-feed' prior to the birth of the infant, although this factor is directly on the causal decision-making pathway. Another factor often cited is the age of introduction of formula feeding, which is actually part of the outcome variable because formula feeding defines the difference between full, complementary and no breast-feeding. Rather than include these as risk factors in multivariate models, factors removed from the causal pathway such as influences of educational practices, including advice to complementary feed, and beliefs and attitudes of families and health-care practitioners should be measured. CONCLUSIONS: The accurate quantification of modifiable risk factors is essential for designing public health education campaigns that are effective in sustaining or increasing breast-feeding duration.