Megan Hall_Breastfeeding in Peru

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Exclusive breastfeeding decreases as maternal educational attainment

increases in urban and rural Peru Megan Hall

Introduction

Exclusive breastfeeding (EBF) for the first

six months of life is recognized as the

optimal infant feeding practice worldwide.

EBF not only provides immune protection

for neonates but also provides the highest-

quality nutrition for infants. Furthermore, as

complementary foods are added to infant diet

at six months, it is recommended that infants

continue breastfeeding through the second

year of life (PAHO/WHO, 2004). The

negative short- and long-term effects of not

breastfeeding for the first six months are

well-documented. Better outcomes for

overweight/obesity, blood pressure, diabetes

and intelligence tests in childhood and

adolescence are associated with

breastfeeding during infancy (Horta and

Victoria, 2013a). Furthermore, breastfeeding

“substantially protects from morbidity/

mortality form diarrhea” (Horta and Victoria,

2013b, p 16) and EBF in the first six months

intensifies this protection. EBF offers

approximately 80-90% protection for

mortality and hospital admissions and

approximately 50% protection for morbidity.

Additionally, breastfeeding provides

protection from respiratory infection:

approximately 30%, 50% and 60% for

morbidity, hospital admission and mortality,

respectively, indicating that breastfeeding not

only affects incidence but also severity of

respiratory infections (Horta and Victoria,

2013b). Considering diarrhea and respiratory

infections are two of the leading causes of

neonatal mortality in the developing world

(WHO, 2014), the benefits of breastfeeding,

especially EBF for the first six months, is of

immense importance. Specifically in Peru,

exclusive breastfeeding of zero- to three-

month old infants could prevent an estimated

43% of deaths from respiratory infections.

Additionally, EBF of infants of this same age

could prevent an estimated 57% of deaths

from diarrheal disease (Betrán, et al, 2001).

However, 2011 data from Peru shows that

only 70% of infants were exclusively

breastfed for the first six months of life

(WHO, 2011). Mothers’ feeding practices in

the rural Peruvian highlands are influenced

by the local food culture, economic status

and available time to breastfeed. Formal

secondary education of mothers is also

associated with increased knowledge about

child feeding practices (Urke, et al, 2013).

However, in periurban Peruvian mothers,

higher maternal education is associated with

decreased probability of EBF at three

months, with only 35% of mothers

exclusively breastfeeding at six months

(Matias, et al 2012). The aim of the current

analysis is to assess whether or not

educational attainment has the same

relationship to exclusive breastfeeding for six

months between mothers living in urban and

rural Peru.

Method

In order to assess this relationship, the

Demographic and Health Survey 2004 of

Peru was used, retrieved from Tulane

University’s resources for courses. Analysis

was completed using PASW Statistics 18.0,

commonly known as SPSS. The sample used

in this analysis included all respondents in

the DHS who breastfed for at least six

months. To identify these respondents, a

breastfeeding duration variable was coded

using DHS variable “months of

breastfeeding.” Respondents were grouped

into the following groups of breastfeeding

duration: <6 months, 6-11 months, 12-17

months, 18-23 months, and >23 months.

Socio-demographic characteristics of the

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sample were reviewed using frequency and

descriptive tables and can be found in Table

1. The dependent variable in this analysis

was breastfeeding practices; respondents

were categorized into three groups: exclusive

breastfeeding, breastfeeding and formula and

breastfeeding and other fluid(s) using 16

DHS variables of “liquids given before milk

began to flow.” Nineteen respondents were

missing responses for breastfeeding

practices, resulting in a final sample size of

2,122. Independent variables of interest were

educational attainment of mothers and type

of place of residence of mothers (see Table 1

for the categories within the independent

variables). The relationship between the

dependent and independent variables was

analyzed using crosstabs. See Appendix for

all coding of new variables and coding of

analysis.

Results

Exclusive breastfeeding for at least six

months was inversely associated with

educational attainment, with 93.1% of

mothers with no education reporting EBF,

compared to 62.8% of mothers with higher

education reporting EBF. Use of formula in

addition to breastfeeding for at least six

months was positively associated with

educational attainment; zero mothers with no

education reported using formula whereas

23.5% of mothers with higher education

reported using formula. Mothers with some

primary education reported the greatest use

of other fluid(s) in addition to breastfeeding

for at least six months (18.8%). See Table 2

for comparison of educational attainment to

breastfeeding practices. When stratified by

type of place of residence, the relationships

of EBF and breastfeeding and formula to

educational attainment were maintained—

although less linear—in both urban and rural

mothers. However, the prevalence of EBF

was much higher in rural versus urban

mothers across all levels of educational

attainment (see Table 3). Furthermore, the

prevalence of breastfeeding and other fluid(s)

is overall higher among urban mothers across

all levels of educational attainment except

incomplete secondary (see Table 3).

Discussion

As Matias, et al (2012) found, higher

maternal educational attainment has a

negative impact on the likelihood of

exclusively breastfeeding for at least six

months. This analysis found this relationship

to be true in both urban and rural settings, but

with urban mothers reporting overall lower

EBF and greater feeding of other fluids.

These results are important for guiding the

development of breastfeeding campaigns and

interventions targeting Peruvian mothers.

Campaigns and interventions must not only

target urban mothers, but mothers of higher

educational attainment, with messages

focusing on increasing EBF, as well as

decreasing use of other fluids. Urban mothers

may report a higher use of other fluids

compared to rural mothers because they have

greater access to these fluids, such as juices

and milk other than breast milk. However,

economic status of mothers may be a

confounding factor in this association; future

analyses must examine the relationship

between economic status of urban and rural

mothers and use of other fluids. Because

children of poorly educated mothers,

compared to children of higher educated

mothers, who are not optimally breastfed

face an increased risk of death to infectious

disease (WHO, 2000), the relationship

between other factors that affect infectious

disease incidence and maternal educational

attainment must also be analyzed. The use of

the DHS variable “liquids given before milk

began to flow” as the dependent variable was

a limitation because it may not accurately

reflect the feeding of fluids other than breast

milk throughout the entire first six months of

life.

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References

Betrán, A. P., de Onís, M., Lauer, J. A., and Villar, J. (2001). Ecological study of effect of breast

feeding on infant mortality in Latin America. BMJ, 323: 1-5.

Horta, B. L. and Victoria, C. G. (2013a). Long-term effects of breastfeeding: A systematic

review. World Health Organization: Geneva, Switzerland.

Horta, B. L. and Victoria, C. G. (2013b). Short-term effects of breastfeeding: A systematic

review on the benefits of breastfeeding on diarrhea and pneumonia mortality. World

Health Organization: Geneva, Switzerland.

Matias, S.L., Nommsen-Rivers, L.A., and Dewey, K.G. (2002). Determinants of exclusive

breastfeeding in a cohort of primiparous periurban Peruvian mothers. Journal of Human

Lactation, 28 (1), 45-54.

PAHO/WHO (Pan American Health Organization/World Health Organization) (2004). Guiding

Principles for Complementary Feeding of the Breastfed Child. Division of Health

Promotion and Protection, PAHO/WHO: Washington, DC.

Urke, H.B., Bull, T., and Mittelmark, M.B. (2013). Child diet and healthy growth in the context

of rural poverty in the Peruvian Andes: What influences primary caregivers’

opportunities and choices? Global Health Promotion, 20 (5), 5-13.

WHO (World Health Organization) (2000). Effect of breastfeeding on infant and child mortality

due to infectious disease in less developed countries: a pooled analysis. The Lancet, 355:

451-455.

WHO (World Health Organization) (2011). Global health observatory data repository [Data

file]. Retrieved from http://apps.who.int/gho/data/node.main.

WHO (World Health Organization) (2014). Children: reducing mortality. [Fact sheet]. Retrieved

from: http://www.who.int/mediacentre/factsheets/fs178/en/#.

http://apps.who.int/gho/data/node.main.1100?lang=en

http://www.who.int/mediacentre/factsheets/fs178/en/

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Table 1 Socio-demographic characteristics of Peruvian mothers

who breastfed for at least six months (n = 2141)a

Characteristic mean SD

Current age (in years) 29.65 7.1

Number of living children 3.1 2.0

Characteristic n %

Ethnicity

Castellano 1688 77.9

Quechua 379 17.7

Aymara 37 1.7

Otra lengua aborigen 57 2.7

Marital status

Never married 103 4.8

Married 778 36.3

Living together 1101 51.4

Widowed 8 .4

Not living together 180 7.1

Educational attainment

No education 144 6.7

Incomplete primary 583 27.2

Complete primary 282 13.2

Incomplete secondary 388 18.1

Complete secondary 372 17.4

Higher 372 17.4

Type of place of residence

Urban 1022 47.7

Rural 1119 52.3 aDemographic and Health Survey, Peru, 2004

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Table 2 Breastfeeding practices by educational attainment in Peruvian mothers who

breastfed for at least six months (n = 2122)a

Exclusive

breastfeeding

Breastfeeding and

formula

Breastfeeding and

other fluid(s)

n % n % n %

No education 134 93.1 0 .0 10 6.9

Incomplete primary 452 78.1 18 3.1 109 18.8

Complete primary 230 82.7 7 2.5 41 14.7

Incomplete secondary 295 76.6 27 7.0 63 16.4

Complete secondary 257 70.4 64 17.5 44 12.1

Higher 233 62.8 87 23.5 51 13.7

aDemographic and Health Survey, Peru, 2004

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Table 3 Breastfeeding practices by type of place of residence and educational attainment in

Peruvian mothers who breastfed for at least six months (n = 2122)a

Exclusive

breastfeeding

Breastfeeding and

formula

Breastfeeding and

other fluid(s)

n % n % n %

Urban

No education 7 77.8 0 .0 2 22.2





Higher 196 59.6 87 26.4 46 14.0

Rural

No education 127 94.1 0 .0 8 5.9





Higher 37 88.1 0 .0 5 11.9 aDemographic and Health Survey, Peru, 2004

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Appendix

RECODE M5 (SYSMIS=SYSMIS) (98=SYSMIS) (97=SYSMIS) (94=0) (Lowest thru 5=1) (6

thru 11=2) (12 thru 17=3) (18 thru 23=4) (24 thru 55=5) INTO BFDuration.

VARIABLE LABELS BFDuration 'Breastfeeding duration'.

EXECUTE.

FREQUENCIES VARIABLES=BFDuration

/ORDER=ANALYSIS.

BFDuration

Frequency Percent Valid Percent

Cumulative

Percent

Valid Never breastfed 45 1.8 1.8 1.8

<= 5 months 349 13.8 13.8 15.5

6-11 months 467 18.4 18.4 34.0

12-17 months 759 29.9 29.9 63.9

18-23 months 456 18.0 18.0 81.9

> 23 months 459 18.1 18.1 100.0

Total 2535 99.9 100.0

Missing System 2 .1

Total 2537 100.0

USE ALL.

COMPUTE filter_$=(BFDuration > 1).

VARIABLE LABEL filter_$ 'BFDuration > 1 (FILTER)'.

VALUE LABELS filter_$ 0 'Not Selected' 1 'Selected'.

FORMAT filter_$ (f1.0).

FILTER BY filter_$.

EXECUTE.

DESCRIPTIVES VARIABLES=CurrentAge NumberLivingChild

/STATISTICS=MEAN STDDEV MIN MAX.

FREQUENCIES VARIABLES=Ethnicity CurrentMarital EducAttain TypePlaceResidence

/ORDER=ANALYSIS.

IF (M55Z = 1) BFPractices=1.

EXECUTE.

IF (M55G = 1) BFPractices=2.

EXECUTE.

IF (M55A = 1 or M55B = 1 or M55C = 1 or M55D = 1 or M55E = 1 or M55F = 1 or M55H = 1

or M55I = 1 or M55J = 1 or M55K = 1 or M55L = 1 or M55M = 1 or M55N = 1 or M55X = 1)

and M55G = 0 and M55Z = 0 BFPractices=3.

EXECUTE.

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CROSSTABS

/TABLES=M55G M55A M55B M55C M55D M55E M55F M55H M55I M55J M55K M55L

M55M M55N M55X M55Z BY BFPractices

/FORMAT=AVALUE TABLES

/CELLS=COUNT

/COUNT ROUND CELL.

FREQUENCIES VARIABLES= BFPractices

/ORDER=ANALYSIS.

Exclusive and non-exclusive breastfeeding

Frequency Percent Valid Percent

Cumulative

Percent

Valid Exclusive breastfeeding 1601 74.8 75.4 75.4

Breastfeeding and

formula

190 8.9 9.0 84.4

Breastfeeding and other

fluid(s)

331 15.5 15.6 100.0

Total 2122 99.1 100.0

Missing System 19 .9

Total 2141 100.0

CROSSTABS

/TABLES=EducAttain BY BFPractices


/CELLS=COUNT ROW

/COUNT ROUND CELL.

CROSSTABS

/TABLES=TypePlaceResidence BY BFPractices


/CELLS=COUNT ROW

/COUNT ROUND CELL.

CROSSTABS

/TABLES=EducAttain BY BFPractices BY TypePlaceResidence


/CELLS=COUNT ROW

/COUNT ROUND CELL.

Megan Hall_Breastfeeding in Peru

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