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Istituto Superiore di Sanità - EpiCentro


Results of a Survey on Breastfeeding in Molise, 2001

T M Manfredi Selvaggi1, T Santilli2, A Vendemiati2, M L Di Nunzio2, E Palombi3, Monica Vichi4

1Food Hygiene and Nutrition Service, ASL n.3 Central Molise, 2Neonatology and Neonatal Intensive Care Unit, ASL n.3 Central Molise, 3Food Hygiene and Nutrition Service ASL Benevento 4Laboratory of Epidemiology and Biostatistics, ISS, Rome

 

To increase the number of infants who are breastfed and to extend the duration of breastfeeding to the sixth month of life as recommended by the World Health Organization, the Local Health Authority 3 “Central Molise” conducted a regional study to determine the effects of the activities that had been undertaken to encourage breastfeeding. Two previous studies conducted in the 1990s in the Molise region of central Italy, which were designed primarily to collect information on vaccine coverage but also collected data on the status of breastfeeding in various regions of Italy (1,2), demonstrated a breastfeeding coverage in Molise of approximately 80%, lower than the percentage of women who could actually breastfeed (3).

 

The current survey, which was conducted during October-December, 2001, had as its primary objective to measure the frequency and duration of breastfeeding and to identify which practices were most useful in encouraging initiation and continuation of breastfeeding in the region. The study population consisted of children under a year of age whose families were residents in the area served by the local health authorities of Molise. Information was collected during the infants’ visit for the second dose of mandatory vaccines, when maternal recall of breastfeeding practices in the first months of life was still likely to be good.

 

A total of 430 interviews were conducted among the estimated 630 children who would have been eligible for their second vaccine dose during the quarter; this estimate was based on ISTAT data, which showed that there were 2532 births in the region during 2001. Only 4 mothers refused to participate, although difficulties were encountered in finding the mothers since Molise is sparsely populated and in many places there are not vaccination centres with fixed clinic hours; instead in these sites vaccinations are provided on request by a local physician.

 

The questionnaire asked the mother to specify, for each week of life of the child, whether the child was receiving mother’s milk, artificial milk, or both. In addition, she was asked, where relevant, the reasons why breastfeeding was not initiated or was stopped, the advice she received, and breastfeeding promotion activities of the hospital where she delivered. In addition, information was collected on the educational level of the mother, the place and type of delivery, birth weight, birth order, and smoking behavior. EPIINFO was used to enter and analyze the data. Crude odds ratios (OR) were calculated with their 95% confidence intervals (95% CI), and the duration of breastfeeding was examined using the Kaplan-Meier technique and actuarial tables.

 

More than 90% of the babies were initially breastfed, and at the time of the interview, when the babies were 4-6 months of age, nearly 1 in 3 (129/430; 30%) were still being exclusively breastfed. The Figure shows levels of exclusive and partial breastfeeding at the time of the interview.

 

Overall, however, less than half of the babies (210/430, 48.8%) were still being breastfed at the time of the interview and of these, many were also receiving artificial milk. One in 7 of the mothers (54/430; 13%) had stopped breastfeeding by the time the infant was two months of age. Lack of milk was the reason most frequently cited for failure to initiate breastfeeding (38%), as well as for stopping breast feeding before the fifth month of life (68%).

The strongest risk factor for failure to initiate breastfeeding was not having breastfed the first child (OR 8.3 I.C. 95% 2.4-28.8), followed by birth weight < 2500 g (OR 5.9 I.C. 95% 2.2-16.0), Cesarean delivery (OR 2.8 I.C. 95% 1.3-6.2), lack of information (OR3.2 I.C. 95% 1.4-7.3), as well as the lack of advice both at home (OR 3.6 I.C. 95% 1.6-8.2) and in the hospital (OR 2.5 I.C. 95% 1.2-5.3).

The mothers included in our survey had a significantly higher level of education than those in the 1998 survey. No educational differences were found among the various local health authorities, and education did not appear to be correlated with initial breastfeeding or with duration of breastfeeding.

 

With respect to early interruption of breastfeeding, among the 13% of infants who breastfed for less than two months, risk factors included difficulties encountered on returning home (OR 5.9; 95% CI 2.3-15.3), not having breastfed their first infant (OR 3.6; 95% CI 1.1-11.1), having received milk samples (OR 3.3; 95% CI 1.5-7.2); lack of rooming in (2.6; 95% CI 1.3-5.1) and finally, smoking OR 4.2; 95% CI 1.9-9.3).

 

The analysis by hospital and by local health authority demonstrated that children born in the Campobasso hospital were significantly more likely to be exclusively breastfed at 4-6 months than those born elsewhere (OR 2.5; 95% CI 1.5-4.0); the same was true for residents of the Campobasso local health authority (OR 4.1; 95% CI 2.5-6.8).  Conversely, infants born in the hospitals of Larino and Termoli, both located in the “Lower Molise” local health authority, had a higher probability of early interruption of breastfeeding (OR 4.2; 95% CI 2.0-8.8); findings were similar when births among residents of the local health authority were examined (OR 4.7; 95% CI 2.4-9.2).

 

To further study the differences noted between the hospitals and local health authorities. the Campobasso hospital was more likely to have rooming in (OR 66.3; 95% CI 29.7-152.5); provide breastfeeding on request (OR 12.9; 95% CI 6.4-26.5); to initiate breastfeeding within 2 hours of birth (OR 5.5; 95% CI 3.4-8.9); to demonstrate how to breastfeed (OR 2.7; 95% CI 1.6-4.5). to distribute information materials (OR 1.9; 95% CI 1.1-3.0). They were also more likely to receive advice during hospitalization (OR 1.8; 95% CI 1.2-2.9) and to not have received milk samples (OR 0.31; 95% CI 0.17-0.59).

 

Editorial Note

Serena Donati e Michele Grandolfo. Laboratory of Epidemiology and Biostatistics, ISS, Rome

The importance of breastfeeding for the short-, medium-, and long-term health of newborns and mothers has been well-documented in the scientific literature and is widely accepted. Among the many benefits for the infant, the risk of infection and allergy is reduced; for mothers, there is less risk of post-partum hemorrhage when the infant is breastfed shortly after birth as well as a decreased risk of breast cancer later in life.

 

Studies conducted by the ISS have shown a universally positive attitude toward breastfeeding on the part of Italian women, despite the minimal support they receive both in terms of information and concrete assistance when problems develop either during the immediate post-natal period or later on.

 

This report on the prevalence of breastfeeding in Molise is therefore much appreciated. The study identifies reasons for the low prevalence of breastfeeding at 6 months (30%), ostensibly due to insufficient milk and to problems encountered in breastfeeding once the woman returns home, problems that might be solved if adequate support were available. Of particular concern are the inappropriate practices that delay the initiation of breastfeeding in the hospital setting and lessen the likelihood of prolonged breastfeeding. The results obtained in the Campobasso hospital are nonetheless encouraging and demonstrate that early initiation after delivery and good information and support can make a real difference.

 

A more complete and detailed analysis of the data would be useful. Such detailed information could be helpful in developing training and continuing education programs for health workers involved in pre- and post-natal care, and in the re-organization of procedures and services to better provide counselling and support during the birth process and thereafter, including initiation of breastfeeding shortly after birth and subsequent home visits to identify and resolve any problems or difficulties encountered after hospital discharge.

 

The ISS has recently completed a national survey in which approximately 7000 women were interviewed one year after deliver to evaluate the association between outcomes (one of which was exclusive breastfeeding) and exposure to services and procedures during pre- and post-natal care. Preliminary results confirm the findings of the Molise study. On the basis of these data, the ISS has been requested by the Ministry of Health to develop informational and training materials on breastfeeding and to implement demonstration projects designed to promote breastfeeding in interested local health authorities that are based on provision of adequate support and counselling for all women during the pre- and post-natal periods.

 

References

1.Manfredi Selvaggi TM. Tozzi AE. Carrieri MP. Binkin N. et al. Quanto è praticato oggi l’allattamento al seno in Italia. Minerva Pediatr 1995; 47: 451-455.

2.Istituto Superiore di Sanità. Gruppo di lavoro ICONA. ICONA: indagine nazionale sulla copertura vaccinale infantile. Rapporti ISTISAN 98/33; ISSN 1123-3117: 67.

3.Davanzo R. Orzatesi M. Allattamento al seno in Italia. Necessità di continuare a promuoverlo. Riv Ital Pediatr (IJP) 2000; 26: 45-46.