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Public health nutrition

Factors related to the duration of breast-feeding in Ankara, with special reference to sociocultural aspects - Benal Büyükgebiz, Necla Çevik, and Olcay Oran

Abstract

A questionnaire designed to elicit information on the relationship between certain sociocultural factors and the duration of breast-feeding was administered to 1,500 mothers. Giving colostrum, demand feeding, night feeding, feeding with both breasts, rooming-in, and planned pregnancy were factors found to have a positive effect on the duration of breast-feeding. Factors having a negative association included the use of prelacteal foods, mothers' educations, smoking, and maternal employment. For employed mothers, paid maternity leave before and after delivery did not affect the duration of breast-feeding, but unpaid maternity leave and milk leave had a positive effect.

Introduction

There is no doubt that breast-feeding is the best way to feed infants. Breast milk offers a balance of nutrients, growth stimulants, and anti-infective properties for healthy physical and mental development in the first four to six months of life [1-6].

Infant feeding practices vary with socio-economic level, however, and are influenced by a variety of factors such as ethnicity, urbanization, education, and modernization [7-14]. The effect of these factors on the duration of breastfeeding was investigated in Ankara, Turkey, where breastfeeding is an accepted and traditional practice which has declined with modernization and urbanization [15].

Materials and methods

A questionnaire was administered to 1,500 mothers attending the Hacettepe Children's Hospital well baby clinic between 1 September 1988 and 1 April 1989.

To be eligible for participation, the mothers had to be between 18 and 45 years old, well-nourished, delivered vaginally, and free from both acute and chronic illneses [16, 17], with infants either younger than 6 months or older than 12 months, born appropriately for gestational age at 38-42 weeks [12, 18].

The mothers were placed into two groups: group I consisting of mothers who had breast-fed for less than six months and had started bottle feeding, and group II of mothers with babies over 12 months old who were still partially breast-feeding. (The mean duration of breastfeeding in Turkey is 12 months [15].)

A variable for mode of feeding distinguished between scheduled feeding and demand feeding. Statistical analysis was done using chi-square and Student's t tests.

Results

Group I comprised 811 mothers (58.2%) and group II 583 (41.8%). One hundred six mothers were excluded because they had had Caesarean deliveries, their child's birth weight was under 2,500 grams, or they were under 18 years of age.

Factors that were significant and positively associated with duration of breast-feeding are listed in table 1.

All the mothers in group I had started breast-feeding following delivery but had stopped at or before six months. Insufficient milk was the most common reason they indicated for the cessation of nursing (76.7%), followed by reasons relating to work (17.0%), and nipple problems (1.5%) (table 2).

The delayed introduction of breast-milk substitutes or solids was found to be statistically important. In group I 97.8% of the women introduced solids or breast-milk substitutes before their infant reached six months of age as compared to only 54.2% in group II; this difference was statistically significant (t = 19.92, p < .01).

TABLE 1. Factors found to have a significant positive association with the duration of breast-feeding

All of the chi squares were significant at the p< .0001 Ievel.

TABLE 2. Reasons cited by mothers in group I for terminating breast-feeding

The use of prelacteal foods (table 3), the mother's education (table 4), and smoking were significantly negatively associated with the duration of breast-feeding.

Breast-feeding was longest among mothers who had only completed primary school (X2 = 82.76, p < .05) and shortest among those who had completed school at the tertiary level (X2 = 27.29, p < .05); i.e., the duration decreased as the mother's education level increased, giving a significant negative association (x2 = 82.76, p < .01).

Only 337 of the mothers (24.2%) worked, and maternal employment was found to have a negative effect on the duration of breast-feeding. Neither a 21-day paid maternity leave before delivery, used by 185 of the employed mothers (24.2%), nor a 45-day paid leave after delivery, used by all of them, significantly affected the duration. However, a six-month unpaid maternity leave and a six-month 1 2-hour daily milk leave were found to have positive effects. The employed mothers' use of paid/unpaid maternity leave and daily milk leave is shown in table 5.

There were no significant differences between the two groups in their time of initiation of breast-feeding or their reports of nipple problems.

Discussion

The factors that contributed most to the cessation of breastfeeding in the first six months of life were insufficient milk supply, work, and nipple problems.

It has been reported that insufficient breast milk is the most common reason given for the cessation of breastfeeding [11,12,19], but it has also been found that fewer than 5% of nursing mothers are physiologically incapable of producing sufficient milk because of inadequate glandular lactation tissue [20]. The perception of inadequate milk supply may be due to a misunderstanding of the infant's behaviour as indicating hunger. A decision to discontinue breast-feeding because of insufficient milk should not be made by the mother but by health personnel using a growth monitoring approach.

Health personnel should take an active role in supervising and improving the breast-feeding practices of mothers. The presence of a lactation nurse who can assist in establishing and maintaining successful breast-feeding in the hospital and at home increases the duration of breast-feeding [21], and this long-term breast-feeding goes hand in hand with late weaning [12, 22]. The delayed introduction of breast-milk substitutes or solids was found to be a statistically important factor in this study.

Certain cultures have strong beliefs against feeding colostrum [23, 24]. It is also common in many societies to give babies prelacteal feedings of formula, cow milk, or glucose-water before the mother's milk [24]. We found that mothers were giving glucose-water (64.6%) and colostrum (68.8%) at the same time. Colostrum is all that a normal baby needs at this time; prelacteal foods are not necessary and in this study were found to have a negative association with the duration of breast-feeding.

TABLE 3. Use of prelacteal foods

x2 = 134.46, p c .01.

TABLE 4. Distribution of mothers by education level

x² = 295.26, p < .01.

TABLE 5. Employed mothers' use of paid and unpaid maternity leave and daily milk leave

a. Percentages under ``Total employed mothers" are percentages of all the mothers in the study within each group. All other percentages in the table are percentages of the employed mothers.

The relationship found between the frequency and the duration of breast-feeding agreed with previous studies [24]. There were also positive correlations between ondemand feeding, night feeding, and feeding with both breasts and the duration of breast-feeding.

In the last decade, research has stressed the possibility of a positive relationship between early maternal/infant contact and breast-feeding capacity and duration [25-28]. Taylor et al. [24] showed that suckling during extra-early contact was associated with a greater incidence of breast-feeding. It has also been found that mothers who had rooming-in care developed a higher interest in breast-feeding than mothers cared for in the conventional way [29]. It is to be hoped that the number of baby-friendly hospitals and rooming-in projects increases in the future, but in this study only 52 (3.7%) of the 1,394 mothers had received rooming-in care, and none had experienced extra-early contact with their infant in the delivery room.

Although some studies have shown that the education level of the mother has a significant positive effect on the duration of breast-feeding (especially in the developed world) [12, 22, 30-331, we did not find this relationship: in Turkey, as in other developing countries, the education of the mother affects the duration of breast-feeding negatively. This is not because of a better awareness of the benefits of breast-feeding in women with less education but because in rural areas, where women are less educated, breast-feeding is a common and traditional practice, while in the cities the situation has changed [34, 35] and the knowledge and tradition that once were passed from one generation to the next have disappeared with urbanization and the fragmentation of the family [36].

Smoking was another factor found, in agreement with other studies [29, 13], to be negatively related to the duration of breast-feeding. This might not be a biological effect but rather simply because women who smoke may be more likely to be of higher educational status.

Findings reported in the literature on the relationship between maternal age and the duration of breast-feeding are conflicting [29, 37], but our data did not demonstrate a close relationship. The effects of nipple problems on the duration of breast-feeding, in agreement with other research [37], were insignificant.

The strong negative relationship between maternal employment and the duration of breast-feeding could be due to the shortness of the 45-day paid maternity leave in Turkey. In Finland, the 11month paid maternity leave together with the annual vacation of an employed person makes it possible for mothers to stay at home for the first year of their infant's life [13]. In contrast, Turkish mothers are allowed only 75 days of paid leave, including annual vacation In addition to the paid maternity leave, some employers allow mothers to take an unpaid maternity leave, which was found to have a positive effect on the duration of breast-feeding. Only 81 working mothers (24.0%) took an unpaid leave, and, out of the 256 working mothers who did not, 168 (65.6%) cited economic constraint as their reason for returning to work.

The difficulty of scheduling feedings when the mother returns to work definitely affects the duration of breast-feeding [37]. The ideal situation would be to have a day nursery at the mother's place of work [26], but unfortunately this is not very common in Turkey. However, other modifications can be made in the work environment to facilitate breast-feeding. Studies have shown that mothers who used breast pumps or hand-expressed their milk were more likely to nurse longer than women who did not pump their breast at times of missed feedings [38, 39]. In this study, the daily milk leave taken by 83 of the working mothers (24.6%) had a positive influence on the duration of breast-feeding.

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