Continuing breastfeeding for at least two years after birth in rural Vietnam: prevalence and psychosocial characteristics

Breastfeeding is a cost-effective source of nutrition that is essential in reducing morbidity and mortality as it confers many health benefits to both mothers [1] and children [2]. The World Health Organization (WHO) recommends that infants are fed only breastmilk for the first 6 months of life after which breastfeeding should be continued up to or beyond 2 years of age alongside nutritious complementary foods [3]. Meeting these recommendations is critical in preventing more than 800,000 child deaths per year [2].

Globally, less than half of children are breastfed for two or more years [4]. The prevalence of breastfeeding has been shown to vary based on the gross domestic product (GDP) of the country with low- and middle-income countries (LMICs) having longer breastfeeding durations than high-income countries [2]. In most high-income countries, less than 20% of women continue to breastfeed for 1 year [2]. In contrast, more than 70% of women are reported to continue breastfeeding for two or more years in certain LMICs such as Bangladesh, India and Nepal [5].

Breastfeeding practices are determined by characteristics at the community, household and individual level [6]. At the community level, social and cultural attitudes towards breastfeeding affect the duration of continued breastfeeding [6]. Breastfeeding can be viewed negatively especially when it occurs in public spaces and workplaces [7]. Healthcare providers play an important role in the maintenance of breastfeeding as they can influence mothers to opt for breastmilk substitutes as opposed to breastmilk [8]. This may in part be explained by gaps in knowledge about the importance of breastfeeding amongst healthcare providers [8, 9]. At the household level, factors such as the attitudes of some fathers and other relatives are influential in maintaining breastfeeding where some may support breastfeeding for a longer duration [10, 11]. Household wealth has also been shown to influence continued breastfeeding at 2 years in LMICs such as India and Pakistan, with those more disadvantaged found to breastfeed for longer periods [5].

At an individual level, employment type and education level can be associated with the early cessation of breastfeeding [6]. The intensity and practicality of employment can contribute to the decision to stop breastfeeding [12]. Additionally, the sex of the child can affect breastfeeding duration [13]. In some countries such as India, mothers prefer to breastfeed their boys longer than girls [14]. This preference may be due to mothers in India wanting to try again for a son therefore weaning their daughters earlier [14]. The relationship a mother has with her child in terms of controlling and settling their child can also cause a mother to cease breastfeeding [15]. They may assume that they do not have enough milk which may lead to the introduction of breastmilk substitutes [15]. Evidence also suggests that psychosocial characteristics such as depression throughout pregnancy [16, 17] and prenatal exposure to intimate partner violence [18] can predict early cessation of breastfeeding.

In Vietnam, 22% of women continued breastfeeding for at least 2 years [19] where breastfeeding practices are influenced by cultural and traditional beliefs of close relatives. For example, a woman’s husband may encourage breastfeeding for longer [20, 21]. Characteristics that have been proposed to be associated with breastfeeding cessation include lower maternal education level, women returning to work early or working further away from home, and inadequate support from negative influences of the breastmilk substitute market [21]. However, the possible influence of both sociodemographic and psychosocial characteristics on breastfeeding duration among women in Vietnam is not well known and understood [22]. Vietnam is a rapidly changing country shifting from lower-middle income to upper-middle income with a rate of the Gross Domestic Product per capital growth is among the highest in the world [23]. Important factors such as women’s participation in the workforce which is gradually changing from farming to the industrial sector, may affect their breastfeeding habits [24]. This study aims to examine the sociodemographic and psychosocial characteristics that can contribute to duration of breastfeeding for 24 months or more after birth among women in the rural province of Ha Nam, Vietnam.

In this study, we examined the relationships between sociodemographic and psychosocial characteristics and continued breastfeeding for 24 months or more in a sample of women residing in rural Vietnam. Of the characteristics analysed, sex of child was found to be significantly associated with sustained breastfeeding. Mothers with daughters were less likely to be breastfeeding at 24 months postpartum than mothers with sons. Similar observations have been made in India where girls were breastfed for a shorter duration than boys [14]. In India, girls had a lower consumption of breastmilk by 21% than boys [33]. Furthermore, exclusive breastfeeding of boys was significantly higher at 70.8% than 61.5% of girls [34].

A possible reason for this observation could be related to the preference of sons over daughters similar to that observed in India and Pakistan. In India, a reason for breastfeeding girls significantly less than boys was attributed to mothers increasing their chance of having another child with the hopes of the child being a boy [14]. In Pakistan, the difference in breastfeeding duration between boys and girls is twice as high as in India which may be due to a stronger preference in sons than daughters [35]. This is consistent with Arnold [36] who states that the preference for sons is ten times greater than daughters in Pakistan but five times greater in India [36]. In Vietnam, the preference for sons is engrained in tradition. Particularly in North Vietnam, sons hold a central position in the family as they continue the patrilineal family line [37]. As a result, the process of family building is often planned around the need for sons. The birth of a son may then legitimise a woman’s position in her in-law’s family and the community [37]. Therefore, it may be the case that if a mother has a daughter, she may feel pressured to have a son. She may wean her daughter earlier in order to try to conceive a son. Mothers may also earn a higher status in the family if they have a son. Therefore, they may be able to allocate more time to taking care of their son as they may have less housework.

We also found that older women were more likely to continue breastfeeding for two or more years than younger women. In prior studies, higher maternal age has been associated with increased breastfeeding duration [38]. Similarly, younger mothers have been found to cease breastfeeding earlier than older mothers [13, 39‐41]. A possible reason for such observations is that younger mothers may be more influenced by the breastmilk substitute industry [24]. Increase in intake of breastmilk substitutes has been associated with a decline in breastfeeding [42].

Breastmilk substitutes are still commonly used in Vietnam despite the implementation of policies such as the Decree on Trading In and Use of Nutritious Products for Infants (No. 21/2006/ND-CP) which prohibits advertising of complementary foods and breastmilk substitutes for children under six months and one year, respectively, to promote breastfeeding practices whilst regulating the baby formula marketing [43, 44]. Approximately half of newborn babies are fed formula within the first 3 days of life [45]. It is possible that older women are more discerning and may be more likely to exercise better judgement in breastfeeding practices including formula use. They may also have a stronger attachment to traditional practices and ways of infant feeding such as continued breastfeeding [46]. In contrast, younger mothers may have less insight and, therefore be more easily influenced by baby formula advertising and marketing.

Another reason young mothers may cease breastfeeding and opt for breastmilk substitutes could be a result of young mothers spending more time away from home. In rural Vietnam, younger women may have more opportunities to further their education compared to older women. This may result in higher paying occupations further away from home in cities like Hanoi [20]. Consequently, they may spend less time with their children which may influence them to opt for breastmilk substitutes [24]. Older mothers may have less access to highly skilled employment. Therefore, they may have more time to spend with their children and continue breastfeeding for a longer duration [24]. Older mothers may also require less support in breastfeeding than younger mothers. Lack of ongoing breastfeeding support especially in rural regions may negatively impact younger mothers’ decision continuing breastfeeding their children [47].

We also found that mothers who gave birth in commune health centres or at another location were more likely to continue breastfeeding for two or more years than mothers who gave birth in provincial or district hospitals evening after adjusting for socioeconomic status (other factors such as mother’s age, education and occupation; and father’s education and occupation); and sex of child. Women in Bangladesh were significantly more likely to initiate breastfeeding within the first hour of birth if they gave birth at home than if they gave birth in a facility [48]. In a hospital in Ho Chi Minh City, the prevalence of exclusive breastfeeding was lower than the national prevalence in Vietnam [49].

A reason for this observation could be the use of breastmilk substitutes in hospitals despite the introduction of policies aimed at reducing marketing of breastmilk substitutes [24]. Violations of breastfeeding policies aimed at reducing use of breastmilk substitutes are more prevalent in hospitals than commune health centres [50]. In a study of women in 11 provinces in Vietnam, 67% of families purchased breastmilk substitutes near the hospital or brought it from home compared to 39% of families who gave birth in a commune health centre [47]. Another reason for this observation could be health workers’ inadequate breastfeeding knowledge and skills especially regarding the WHO guidelines on infant and young child feeding practices [21, 51]. In this study, the education levels of both the women and their partners were not statistically significantly associated with continued breastfeeding when controlling for age and other characteristics. A previous study in Vietnam reported that woman’s education level was not associated with their uptake of information on breastfeeding practices and benefits [52]. This might suggest that the effectiveness of the current promotion strategies of breastfeeding in Vietnam is in the same level for the whole community. It could be both positive as effective for even the low educated women and negative as not effective for even high educated women.

Finally, we found the prevalence of continued breastfeeding in this rural province to be close to the national prevalence in Vietnam where approximately 22% of mothers continue to breastfeed for 24 months or more in Vietnam [25]. According to region, 24% of mothers breastfeed for 24 months or more in rural areas compared to 18% in urban areas [25]. The prevalence of continued breastfeeding for two or more years observed in Ha Nam is more closely reflective of the prevalence of continued breastfeeding for 24 months or more in rural areas of Vietnam [25].

From this study, we have been able to demonstrate that younger women, women who give birth to girls, and women who give birth in provincial and district hospitals were less likely to breastfeed for 24 months or more which does not meet the WHO guidelines stating that breastfeeding should be continued for at least two years postpartum to achieve optimal growth and development for infants [3]. These pieces of evidence may assist policymakers in targeting policies towards younger women and women who have girls to increase breastfeeding duration. It may also assist policymakers in reviewing the healthcare that is provided to women in hospitals and emphasise the adherence to WHO guidelines on infant and young child feeding practices.