The changing patterns of infant feeding in Scotland – exclusive or

mixed messages?

‘Tomi Ajetunmobi, Bruce Whyte

Glasgow Centre for Population Health/

ISD Scotland

10th November, 2011

Outline

• Introduction/Background

• Aims and objectives

• Definitions

• Results

• Conclusions

Introduction

• The WHO recommends exclusive breastfeeding for the first 6 months.

• The benefits of breastfeeding to both mother and infant are well established.

• In Scotland, although there have been programs and policies set up to improve and monitor breastfeeding, the proportion of exclusively breastfed infants remains one of the lowest in Europe and has remained relatively stable over the past 10 years.

Background: GCPH Breastfeeding Project

• 2 main aims:– To carry out analysis using a new using linked

dataset in order to investigate breastfeeding trends nationally and locally and to inform future monitoring

– To investigate the unexpected increase in breastfeeding in selected deprived neighbourhoods within Greater Glasgow and Clyde

Overview of data schemes

Predictor Variables Outcome Variables

Geography (NHS Board, CHP, Neighbourhood area, hospital)

Maternal characteristics (e.g. maternal age, marital status, ethnicity, socioeconomic characteristics, deprivation, smoking status)

Pregnancy/Delivery characteristics (e.g. gestation, previous pregnancies, parity, length of stay, mode of delivery, outcome, multiple birth, caesarean section,)

Infant characteristics (e.g. APGAR score, birth weight, congenital anomaly, neonatal/infant admission, length of stay)

Infant feeding – initiation (first feed, feed on hospital discharge)

Infant feeding - duration(feed on hospital discharge, feed at community discharge, feed at first visit, 6 to 8 week review, 8-9 month review)

NRS(GROS)

SMR02

CHSP-PS

SBR/SMR11

SSBID

NRS(GROS) – Births; SMR02 – Maternal hospital records ; CHSP-PS - Child Health Surveillance (pre-school); SBR/SMR11 - Scottish Birth Record/Neonatal and infant health; SSBID - Scottish Still Birth and Infant Death Records

Infant feeding definitions

• Exclusive breastfeeding

• Bottle (Formula) feeding

• Mixed formula and breastfeeding – Complementary/supplementary – Flexible, partial or minimal*

*Morse JM & Harrison MJ (1988) Patterns of mixed feeding. Midwifery 4:19-28

Infant feeding trends

Scotland: Exclusive breastfeeding trends

Scotland: Exclusive breastfeeding trends 2001- 2009 Source: CHSP, NRS/ISD Scotland linked extract

51% 54% 54% 53% 54% 54% 55% 55% 55%

45%45%43% 44% 45% 44% 45% 45% 45%

36%37%37%37%38%38%39%37% 38%

26% 27% 27% 26% 28% 26% 26% 26% 26%

0%

10%

20%

30%

40%

50%

60%

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year of birth

Infa

nts

(%)

Birth Hospital discharge First visit 6 to 8 week review

Scotland: Mixed feeding trends

Scotland: Mixed feeding trends 2001 - 2009Source: CHSP, NRS/ISD Scotland linked extract

3% 4% 4% 4%4%5% 5% 6%

6% 6% 7%8%

9% 9% 9% 9% 9% 9% 9% 10%

3% 3% 3% 3%4% 4% 4%

4%5%5%5% 5%

6%7%

8%9%

0%

2%

4%

6%

8%

10%

12%

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year of birth

Infa

nts

(%)

Birth Hospital discharge First visit 6 to 8 w eek review

Infant feeding amongst first time mothers

Scotland: Mixed feeding trends amongst first-time mothers

Scotland: First-time mothers mixed feeding trends 2001 - 2009Source: CHSP-PS, NRS/ISD Scotland linked extract

0%2%4%6%8%

10%12%

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year of birth

Infa

nts

(%)

Birth Hospital discharge First visit 6 to 8 w eek review

First-time mothers: Infant feeding trends 2001 and 2009

2001 2009Scotland: First time mothers

Infant feeding trends at hospital discharge 2001Source: CHSP-PS, NRS/ISD Scotland linked extract

MIXED3%

BOTTLE50%

BREAST47%

Scotland: First time mothers Infant feeding trends at hospital discharge 2009

Source: CHSP-PS/ISD Scotland linked extract

MIXED7%

BOTTLE45%

BREAST48%

Scotland: First time mothersInfant feeding trends at first visit 2001

Source: CHSP-PS, NRS/ISD Scotland linked extract

BOTTLE56%

BREAST40%

MIXED4%

Scotland: First time mothers Infant feeding trends at first visit 2009

Source: CHSP-PS, NRS/ISD Scotland linked extract

MIXED10%

BOTTLE52%

BREAST38%

First-time mothers: Mixed feeding and maternal age 2001 and 2009

Scotland first time mothers: Mixed feeding at first visit by maternal age2001 and 2009

Source: SMR02, CHSP-PS/ISD Scotland linked extract

2% 3% 4% 5%8% 9%

4%7%

10%13%

14%16%

0%

5%

10%

15%

20%

Less than20years

20 - 24years 25 - 29 years 30 - 34 years 35 - 39 years 40 + years

Maternal age

Infa

nts

(%)

2001 2009

First-time mothers: mixed feeding as a proportion of any breastfeeding by

maternal ageScotland first time mothers: Mixed feeding at first visit as a proportion of any

breastfeeding by maternal age 2001 and 2009 Source: SMR02/CHSP-PS/ISD Scotland linked extract

15%11% 9% 9%

13% 14%

28%

22%19% 20%

22% 24%

0%

5%

10%

15%

20%

25%

30%

Less than20years

20 - 24years 25 - 29 years 30 - 34 years 35 - 39 years 40 + years

Maternal age

Infa

nts

(%)

2001 2009

First-time mothers: mixed feeding as a proportion of any breastfeeding by area

deprivationFirst time mothers: Mixed feeding at first visit as a proportion of any

breastfeeding by area deprivation 2001 and 2009Source: SIMD 2006, NRS, CHSP-PS/ISD Scotland linked extract

9%11% 11% 10%

9%

25%22%

20%18% 18%

0%

5%

10%

15%

20%

25%

30%

SIMD 1_Mostdeprived

SIMD 2 SIMD 3 SIMD 4 SIMD 5_Leastdeprived

SIMD 2006 Quintile

Infa

nts

(%

)

2001 2009

First-time mothers: infant feeding trends by neonatal admission

Scotland first-time mothers: Infant feeding trends at first visit by neonatal admission 2001 - 2009

Source: SMR02, CHSP-PS/ISD Scotland linked extract

53%59%

55%

39%32% 31%

6% 6%9%

0%

10%

20%

30%

40%

50%

60%

70%

Not admitted Admitted for up to 48 hours Admitted for more than 48 hours

Neonatal indicator

Infa

nts

(%

)

BOTTLE BREAST MIXED

Mixed feeding as a proportion of any breastfeeding by neonatal admission

Scotland first-time mothers: Mixed feeding as a proportion of any breastfeeding by neonatal indicator 2001 - 2009

Source: SMR02, CHSP-PS/ISD Scotland linked extract

14%16%

23%

0%

5%

10%

15%

20%

25%

Not admitted Admitted for up to 48 hours Admitted for more than 48 hours

Neonatal indicator

Infa

nts

(%

)

Factors that increased the likelihood of mixed feeding compared to exclusive

breastfeeding at the first visitDemographic – Parents of Non-British origin/birth

– Mothers aged 40 years or older– Mothers of lower socio-economic class– Unemployed fathers– Residence in a more deprived area

Maternity care and health behaviour

– Instrumental delivery or caesarean section– Maternal post-natal hospital stay >2 days – Maternal smoking

Infant health – Infants with ill health/a neonatal event– Small weight for gestational age

In other studies…

Mixed feeding is associated with:

• (Further) reduced milk supply

• Infants separated from mothers due to ill health, work/child care arrangements

• Flexibility/social contexts

• Commencing weaning/early weaning practices

Conclusion • Exclusive breastfeeding rates have remained

relatively static while mixed feeding rates are increasing.

• Mixed fed infants are similar to exclusively breastfed infants. However compared to exclusively breastfed infants mixed feeding is associated with:– Infant ill-health/admission to neonatal ward – Maternal health care/delivery characteristics– Demographic background of parents (e.g. place of

birth, deprivation)

• Further research will be required to understand the patterns of mixed feeding and its influence on infant health.

Acknowledgements• GCPH Breastfeeding project is jointly funded by the

Scottish Centre for Public Health Research and Policy (SCPHRP) and GCPH.

• The project is being managed by Bruce Whyte (GCPH)• With support from an advisory group:

– James Egan (Public Health Programme Manager, GCPH) – Jim Chalmers (Public Health Consultant, ISD Scotland)– Rachel Woods (Public Health Consultant, ISD Scotland)– Diane Stockton (Public Health Specialist, ISD Scotland)– Judith Tait (Child Health Information Team Leader, ISD Scotland)– Linda Wolfson (Infant Feeding Advisor, NHS GG&C),– Jill Muirie (Public Health Advisor, NHS Health Scotland)– Ruth Campbell (Consultant Dietitian, NHS Ayrshire & Arran)– Helen Yewdell (Scottish Government)– David Tappin (Senior Clinical Lecturer, PEACH unit, Royal Hospital for

Sick Children, Glasgow)

Thank you!