Rurality and Breastfeeding: What is the Relationship?

Lucy Denvir StR Public HealthNHS Dumfries and GallowayNovember 2011

Background Evidence for positive health benefits of breastfeeding Local interest in urban / rural health issues National priority agenda (has been HEAT target) Local priority – Breastfeeding Strategy

Aims

Explore and appraise current knowledge in this area

Analyse available relevant local dataAssess implications and provide any

recommendations for policy, practice and future research

Literature Search

Ovid Medline database via ‘The Knowledge Network’

English language articles 1999-2010Search terms: ‘breastfeeding and (urban

or rural*)’59 initial articles, 4 left after inclusion and

exclusion criteria applied

FindingsVery limited transferable knowledge in this

area - most studies based outside UK in developing countries

Whether urban or rural, important factors are:

-Access to information, services and support

-Targeting of areas with lowest rates

-Whole community approach

Relationship with deprivation unclear

Data Methodology

Data from Child Health Systems Programme Pre-School System via ISD.

3 years 07-08, 08-09, 09-10.Dumfries and Galloway - 4463 cases.Individual level data: 6-fold urban/rural

indicator, SIMD 09 quintile, maternal age, feeding method first visit, feeding method 6-8 week review.

Analysis using SPSS.

Results

6-Fold Urban/Rural Classification can be condensed into 2-FoldCategories 1-4 = Urban, 5 and 6 = Rural.

There are no areas in Urban/Rural category 1 (large urban) in D+G

Cross-tabulation and chi-square test for difference in proportions: Chi-square test results all had P-value <0.001 ie probability that these results due to chance is less than 1/1000

Feeding Method at First Visit and 6-8 Week Review by 6-fold Urban/Rural Indicator

0

10

20

30

40

50

60

70

80

2 Other UrbanAreas

3 AccessibleSmall Town

4 RemoteSmall Town

5 AccessibleRural

6 RemoteRural

Urban/Rural Indicator

% F

ee

din

g M

eth

od

Wit

hin

Ea

ch

In

dic

ato

r

Both (first visit)

Both (6-8 weeks)

Bottle (first visit)

Bottle (6-8 weeks)

Breast (first visit)

Breast (6-8 weeks)

Urban Rural

Feeding Method at First Visit and 6-8 Week Review by SIMD 09 Deprivation Category

0

10

20

30

40

50

60

70

80

90

1 MostDeprived

2 3 4 5 LeastDeprived

SIMD 09 Deprivation Category

% F

ee

din

g M

eth

od

Wit

hin

Ea

ch

C

ate

go

ry

Both (first visit)

Both (6-8 weeks)

Bottle (first visit)

Bottle (6-8 weeks)

Breast (first visit)

Breast (6-8 weeks)

Feeding Method at First Visit and 6-8 Week Review by Maternal Age

0

10

20

30

40

50

60

70

80

90

100

<20 20-24 25-29 30-34 35-39 >40

Maternal Age Group

% F

eed

ing

Met

ho

d W

ith

in E

ach

Ag

e G

rou

p

Both (first visit)

Both (6-8 weeks)

Bottle (first visit)

Bottle (6-8 weeks)

Breast (first visit)

Breast (6-8 weeks)

Maternal Age by 6-fold Urban/Rural Indicator

0

5

10

15

20

25

30

2 Other UrbanAreas

3 AccessibleSmall Town

4 RemoteSmall Town

5 AccessibleRural

6 RemoteRural

Urban/Rural Indicator

% A

ge

Gro

up

Wit

hin

Eac

h In

dic

ato

r <20

20-24

25-29

30-34

35-39

>40

Urban Rural

SIMD 09 Deprivation Category by 6-Fold Urban/Rural Indicator

0

5

10

15

20

25

30

35

40

45

50

2 Other UrbanAreas

3 AccessibleSmall Town

4 RemoteSmall Town

5 AccessibleRural

6 RemoteRural

Urban/Rural Indicator

% S

IMD

09

Dep

Cat

Wit

hin

Eac

h In

dic

ato

r 1 Most Deprived

2

3

4

5 Least Deprived

Urban Rural

Results so far!

Relationship between urban-rural indicator and feeding method at first visit and 6-8 week review – rural mothers more likely to breastfeed.

Relationship between deprivation and feeding method – most deprived SIMD 09 quintiles 1 and 2 least likely to breastfeed.

Relationship between maternal age and feeding method – mothers age >30 more likely to breastfeed.

Results contd

BUT:More rural mothers aged >40 and fewer

aged <25.Deprivation relationship less clear, biggest

difference between SIMD 09 quintiles 2 and 3.

So urban-rural mothers have a different age

and deprivation profile – further analysis

required!

Multiple Logistic Regression:

Cases with missing data excluded leaving 4030 for analysis

Reference categories:

Youngest age group (<20 years)

SIMD 09 Quintile 1 (most deprived)

Urban/Rural category 2 (other urban areas)

Variable =Maternal age

Breastfeeding at first visit Breastfeeding at 6-8 week review

P-value OR(95% CI)

P-value OR(95% CI)

20-24 <0.0012.00

(1.37 – 2.93) <0.0012.65

(1.58 – 4.43)

25-29 <0.0013.40

(2.36 – 4.91) <0.0014.35

(2.64 – 7.15)

30-34 <0.0015.26

(3.63 – 7.61) <0.0016.60

(4.00 – 10.86)

35-39 <0.0014.99

(3.39 – 7.34) <0.0016.96

(4.17 – 11.62)

>40 <0.0014.40

(2.69 – 7.20) <0.0016.46

(3.53 – 11.80)

Variable =Deprivation

Breastfeeding at first visit Breastfeeding at 6-8 week review

P-value OR(95% CI)

P-value OR(95% CI)

SIMD09 2 <0.001 1.68 (1.29 – 2.20)

<0.001 1.83(1.32 – 2.52)

SIMD09 3 <0.001 2.26 (1.72 – 2.96)

<0.001 2.56(1.86 – 3.53)

SIMD09 4 <0.001 2.55 (1.92 – 3.37)

<0.001 2.79 (2.00 – 3.89)

SIMD09 5 <0.001 2.47(1.70 – 3.59)

<0.001 2.56(1.67 – 3.91)

Variable =Urban/Rural

Breastfeeding at first visit Breastfeeding at 6-8 week review

P-value OR (95% CI)

P-value OR(95% CI)

3 AccessibleSmall Town

0.002 0.70(0.56 – 0.88)

0.003 0.67 (0.52 – 0.88)

4 Remote

Small Town

0.027 0.70(0.51 – 0.96)

0.181 0.79 (0.55 – 1.12)

5 Accessible

Rural

0.024 1.26(1.03 – 1.53)

0.073 1.22(0.98 – 1.52)

6 Remote

Rural

0.003 1.38(1.11 – 1.70)

0.002 1.44(1.14 – 1.82)

Results

Maternal age and deprivation are significant and independent predictors of breastfeeding at first visit and 6-8 week review

Most marked increase in odds of breastfeeding in mothers age >30 and mothers in SIMD 09 quintile 4

Odds of breastfeeding increased in rural category areas 5/6 in relation to urban areas

Some evidence of rurality as an independent and significant predictor of breastfeeding but this is less certain particularly at 6-8 week review

Conclusions

Good sample size, relatively accurate and complete data

Does not include other important variables eg educational attainment, parity

Some evidence that rurality may be an important predictor of breastfeeding independent of maternal age and deprivation

Breastfeeding determinants are complex and multifactorial and issues such as rural deprivation contribute to the difficulty in identifying vulnerable communities and individuals

Recommendations

Target areas with lowest ratesFlexible and individualised but whole

community approachReplicate study in other areasInclude analysis of other variablesMore research on cultural, attitudinal and

behavioural differences between urban and rural areas

Acknowledgements:

Carolyn Hunter-Rowe (Snr Health Intelligence Analyst)Dr Andrew Carnon (CPHM)Claire Nolan (Information Analyst ISD)

Thanks for listening! Any comments / questions?

☺