Background
Optimal breastfeeding has both short- and long-term benefits for the mother-infant dyads [
1‐
4]. Breastfed infants are less likely to develop diarrhoea [
5,
6], otitis media and obesity as well as have a lower likelihood of mortality [
5]. Appropriate breastfeeding is also associated with a higher likelihood of better intellectual functioning [
7]. Mothers who engage in optimal breastfeeding practices have a lower risk of developing breast and ovarian cancers, and type 2 diabetes mellitus [
4]. The evidence as to why breast milk is the “best” food for the newborn continues to evolve notably. Recent studies have identified mechanisms as to why breast milk is important for the newborn, including stimulation of the immunological and epigenetic functions, and enhancement as well as maintenance of the microbial changes of the gut [
8‐
13]. The World Health Organization and United Nations Children’s Fund (WHO/UNICEF) recommend early initiation of breastfeeding within the first hour of birth and exclusive breastfeeding in the first six months followed by the introduction of safe, age-appropriate and nutritionally adequate complementary foods along with continued breastfeeding until the child is 2 years and beyond [
14].
Globally, approximately 38% of infants are exclusively breastfed until around the age of four months, indicating that early cessation of exclusive breastfeeding (EBF) is prevalent in many countries [
4]. In Australia, the prevalence of early or timely initiation of breastfeeding is high (96%) [
15]. However, EBF for infants aged less than 4 months is low (39%), and decreases even further by 6 months (15%) [
13]. The number of Indigenous infants who were exclusively breastfed post discharge from hospital after birth was even lower compared to non-Indigenous infants [
16]. Factors that limit optimal breastfeeding in Australian mothers have been elucidated. These included: low socio-economic status (SES) [
17], primiparity [
18,
19], caesarean delivery, lower maternal age (<25 years) [
19], cigarette smoking [
20,
21], a mother not having intention to breastfeeding [
20‐
22] and self-reported depressive symptoms [
20]. Additionally, anxiety about breastfeeding in public may also be a determinant for suboptimal breastfeeding practices in Australia [
23]. A recent study from Western Australia identified potential barriers as breastfeeding problems, poor community acceptability, and inconvenience; while the enablers included breastfeeding education, community support, family support and not having to work [
24].
In 2011, the Government of New South Wales (NSW), Australia introduced initiatives and policies (such as policy on promotion, protection and support for breastfeeding and establishment of Breastfeeding Support Clinics) to promote optimal breastfeeding [
25‐
27]. Despite these initiatives, the prevalence of EBF at discharge from health facilities remained unchanged in NSW (80% in 2010 and 79% in 2014) [
28], and whether continuing EBF in the early postnatal period has been influenced by these policies is uncertain. We aimed to investigate the prevalence and determinants of cessation of EBF in the early postnatal period in one of Australia’s most culturally and linguistically diverse (CALD) communities in Sydney, NSW, using routinely collected perinatal data. This is the first study in the period post-implementation of breastfeeding initiatives in NSW that examines early cessation of EBF in the postnatal period since the policies were introduced. We will also report on the main reasons why mothers do not initiate or continue EBF in the early postnatal period. It is important to focus on this period as it is considered a critical phase to establish and support appropriate breastfeeding, and when targeted initiatives would yield better outcomes [
29‐
31]. This paper provides breastfeeding information from a high-income country, contrary to a previous study on the importance of breastfeeding, which indicated that researchers and health authorities in developed countries appear to have overlooked breastfeeding [
4]. Evidence from this study will provide context-specific information to ensure targeted initiatives on a range of factors underpinning cessation of EBF at the early postnatal period in one of NSW most CALD populations.
Results
The study was based on a sample of 17,564 mothers of all live infants born in public facilities in SWSLHD and SLHD. Almost half of the mothers were born outside Australia (46%). Of these, many were from Middle Eastern countries (10%), South East Asia (8%) and Southern Asia (8%), with the cohort covering women from more than 25 countries. Most mothers intended to breastfeed their babies (92%). A large proportion of mothers (81%) practiced skin-to-skin contact (Table
1). EBF at delivery and discharge were high (90 and 89% respectively). In the early postnatal period, more than half of mothers exclusively breastfed their babies (62%), indicating a 27% decrease in EBF prevalence between one and four weeks of delivery. Twenty two percent of mothers provided breast milk and infant formula to their babies, and 16% provided only infant formula. The most common reasons cited for not commencing or continuing EBF in this cohort included: incorrect positioning and attachment, prematurity, low birth weight and jaundice.
Table 1
Prevalence of breastfeeding practices by socio-demographic and maternal health characteristics of infant’s mothers from South Western Sydney and Sydney Local Health Districts in 2014 (N = 17,564)
SES category | 14,752 | | | 15,668 | | | 14,260 | | | 16,073 | | | 8459 | | |
High | | 5487 | 40.6 | | 5095 | 40.3 | | 5059 | 39.5 | | 5791 | 40.7 | | 1301 | 15.4 |
Middle | | 6190 | 45.8 | | 5838 | 46.2 | | 5965 | 46.6 | | 6479 | 45.5 | | 4106 | 48.5 |
Low | | 1840 | 13.6 | | 1703 | 13.5 | | 1772 | 13.9 | | 1969 | 13.9 | | 3052 | 36.1 |
Australian born | 15,227 | | | 16,162 | | | 14,698 | | | 16,600 | | | 8755 | | |
No | | 6200 | 44.3 | | 6168 | 47.3 | | 6129 | 46.4 | | 6387 | 43.3 | | 3964 | 45.3 |
Yes | | 7779 | 55.7 | | 6874 | 52.7 | | 7084 | 53.6 | | 8357 | 56.7 | | 4791 | 54.7 |
Maternal age group | 15,232 | | | 16,169 | | | 14,699 | | | 16,604 | | | 8756 | | |
20–39 years | | 13,015 | 93.1 | | 12,129 | 93.0 | | 12,298 | 93.1 | | 13,707 | 92.9 | | 8195 | 93.6 |
> 40 years | | 187 | 1.3 | | 245 | 1.9 | | 214 | 1.6 | | 194 | 1.3 | | 477 | 5.5 |
< 20 years | | 782 | 5.6 | | 669 | 5.1 | | 703 | 5.3 | | 847 | 5.7 | | 84 | 1.0 |
BMI | 14,216 | | | 13,382 | | | 12,188 | | | 13,850 | | | 7442 | | |
Underweight | | 812 | 6.2 | | 720 | 6.6 | | 708 | 6.5 | | 767 | 6.2 | | 458 | 6.2 |
Normal weight | | 7415 | 56.9 | | 6282 | 57.9 | | 6340 | 57.7 | | 7172 | 58.1 | | 4512 | 60.6 |
Overweight | | 2900 | 22.2 | | 2357 | 21.7 | | 2416 | 22.0 | | 2704 | 21.9 | | 1606 | 21.6 |
Obese | | 1915 | 14.7 | | 1489 | 13.7 | | 1517 | 13.8 | | 1702 | 13.8 | | 866 | 11.6 |
Pre-existing maternal health problems | 13,838 | | | 14,976 | | | 13,550 | | | 15,250 | | | 8122 | | |
No | | 8815 | 69.4 | | 9076 | 74.5 | | 8872 | 72.9 | | 9777 | 72.2 | | 5898 | 72.6 |
Yes | | 3886 | 30.6 | | 3103 | 25.5 | | 3297 | 27.1 | | 3759 | 27.8 | | 2224 | 27.4 |
Intimate partner violence | 13,972 | | | 13,136 | | | 11,964 | | | 13,576 | | | 7280 | | |
No | | 12,634 | 98.6 | | 10,526 | 98.6 | | 10,628 | 98.8 | | 11,932 | 98.8 | | 7200 | 98.9 |
Yes | | 175 | 1.4 | | 147 | 1.4 | | 134 | 1.3 | | 146 | 1.2 | | 80 | 1.1 |
Type of delivery | 15,195 | | | 16,127 | | | 14,660 | | | 16,565 | | | 8732 | | |
Normal vaginal | | 8720 | 62.5 | | 10,017 | 77.0 | | 9111 | 69.2 | | 9301 | 63.2 | | 5640 | 64.6 |
Assisted vaginal | | 1516 | 10.9 | | 1472 | 11.3 | | 1450 | 11.0 | | 1604 | 10.9 | | 991 | 11.4 |
Caesarean section | | 3711 | 26.6 | | 1514 | 11.6 | | 2615 | 19.9 | | 3806 | 25.9 | | 2101 | 24.0 |
Alcohol consumption | 14,606 | | | 13,795 | | | 12,567 | | | 14,292 | | | 7668 | | |
No | | 13,186 | 98.5 | | 11,026 | 98.3 | | 11,160 | 98.5 | | 12,549 | 98.4 | | 7537 | 98.3 |
Yes | | 205 | 1.5 | | 189 | 1.7 | | 174 | 1.5 | | 203 | 1.6 | | 131 | 1.7 |
Smoking status | 15,226 | | | 14,538 | | | 13,239 | | | 15,097 | | | 8085 | | |
No | | 13,104 | 93.7 | | 10,948 | 92.5 | | 11,212 | 93.6 | | 12,727 | 94.2 | | 7769 | 96.1 |
Yes | | 874 | 6.3 | | 892 | 7.5 | | 764 | 6.4 | | 781 | 5.8 | | 316 | 3.9 |
Supportive partner | 13,952 | | | 13,104 | | | 11,941 | | | 13,550 | | | 7316 | | |
Yes | | 12,444 | 97.0 | | 10,308 | 96.8 | | 10,464 | 97.1 | | 11,735 | 97.1 | | 7132 | 97.5 |
Not sure | | 126 | 1.0 | | 107 | 1.0 | | 99 | 0.9 | | 122 | 1.0 | | 55 | 0.7 |
No | | 252 | 2.0 | | 230 | 2.2 | | 209 | 1.9 | | 235 | 1.9 | | 129 | 1.8 |
Antenatal depressive symptoms | 13,368 | | | 12,549 | | | 11,450 | | | 12,963 | | | 6976 | | |
EPDS <13 | | 11,524 | 94.0 | | 9586 | 94.3 | | 9702 | 94.3 | | 10,840 | 94.1 | | 6581 | 94.4 |
EPDS ≥13 | | 732 | 6.0 | | 576 | 5.7 | | 586 | 5.7 | | 682 | 5.9 | | 395 | 5.6 |
Younger mothers (<20 years) were significantly more likely to discontinue EBF in the early postnatal period compared to older mothers (20–39 years) [Adjusted Odds Ratio (AOR) =2.7, 95%CI 1.9–3.8,
P <0.001] (Table
2). Mothers from higher SES groups were significantly less likely to cease EBF in the early postnatal period compared to those from lower SES groups (AOR = 0.6, 95%CI 0.5–0.9,
P <0.001). Mothers who reported smoking cigarettes in pregnancy were significantly more likely to stop EBF in the early postnatal period compared to their counterparts (AOR = 2.5, 95%CI 2.1–3.0,
P = 0.042). The odds for ceasing EBF in the early postnatal period were higher among mothers who received interventions during delivery (AOR = 1.5, 95%CI 1.4–1.7,
P <0.001 for caesarean section and AOR = 1.3, 95%CI 1.1–1.5,
P <0.001 for assisted vaginal delivery) and, those who reported a history of intimate partner violence (AOR = 1.4, 95%CI 1.0–2.0,
P = 0.042). Mothers who reported not having partner support were significantly more likely to discontinue EBF in the early postnatal period compared to their counterparts (AOR = 1.7, 95%CI 1.2–2.1,
P = 0.003). The analysis showed no association between CALD population and early cessation of EBF in the postnatal period. Findings from multiple imputation analyses were not substantially different from the complete case analysis for most of the study factors (Table
2), suggesting that missing data did not considerably affect the observed findings.
Table 2
Associations between key study factors and early cessation of exclusive breastfeeding in the postnatal period of infant’s mothers from South Western Sydney and Sydney Local Health Districts in 2014 (N = 17,564)
Early cessation of EBF in early postnatal period |
Maternal age group |
20–39 years | 1.0 | | 1.0 | | 1.0 | | 1.0 | |
> 40 years | 1.1 (0.9–1.3) | 0.293 | 1.1 (0.9–1.4) | 0.236 | 1.1 (0.9–1.3) | 0.524 | 0.9 (0.7–1.2) | 0.225 |
< 20 years | 3.1 (2.4–4.1) | <0.001 | 2.7 (1.9–3.8) | <0.001 | 3.4 (2.4–4.7) | <0.001 | 2.9 (2.1–4.1) | <0.001 |
Socio-economic status |
Low | 1.0 | | 1.0 | | 1.00 | | 1.0 | |
Medium | 0.8 (0.6–0.7) | <0.001 | 0.7 (0.6–0.8) | <0.001 | 0.7 (0.6–0.7) | <0.001 | 0.7 (0.6–0.7) | <0.001 |
High | 0.5 (0.4–0.6) | <0.001 | 0.6 (0.5–0.9) | <0.001 | 0.5 (0.4–0.6) | <0.001 | 0.5 (0.5–0.6) | <0.001 |
Antenatal depressive symptoms |
EPDS <13 | 1.0 | | 1.0 | | 1.00 | | 1.0 | |
EPDS ≥13 | 1.2 (1.0–1.4) | 0.014 | 1.2 (1.1–1.5) | 0.068 | 1.2 (1.1–1.2) | 0.016 | 1.3 (1.1–1.5) | 0.056 |
Cigarette smoking |
No | 1.0 | | 1.0 | | 1.0 | | 1.0 | |
Yes | 3.2 (2.8–3.7) | <0.001 | 2.5 (2.1–3.0) | <0.001 | 2.9 (2.5–3.5) | <0.001 | 2.7 (2.3–3.2) | <0.001 |
Supportive Partner |
Yes | 1.0 | | 1.0 | | 1.0 | | 1.00 | |
Unsure | 1.9 (1.3–2.8) | <0.001 | 1.6 (1.1–2.4) | 0.026 | 1.8 (1.2–2.7) | 0.007 | 1.5 (1.0–2.3) | 0.078 |
No | 1.5 (1.2–2.0) | <0.001 | 1.7 (1.2–2.1) | 0.003 | 1.7 (1.3–2.3) | <0.001 | 1.4 (1.3–1.9) | 0.049 |
CALD |
No | 1.0 | | | | | | | |
Yes | 0.9 (0.8–1.0) | 0.107 | 0.9 (0.8–1.0) | 0.088 | 1.1 (0.9–1.2) | 0.0101 | 0.9 (0.7–1.0) | 0.075 |
Pre-existing maternal health problems |
No | 1.0 | | 1.0 | | 1.0 | | 1.0 | |
Yes | 1.1 (1.0.–1.2) | 0.207 | 1.2 (1.1–1.3) | 0.002 | 1.1 (1.1–1.2) | 0.095 | 1.0 (0.9–1.1) | 0.405 |
Intimate partner violence |
No | 1.0 | | 1.0 | | 1.0 | | 1.0 | |
Yes | 1.6 (1.2–2.2) | 0.004 | 1.4 (1.0–2.0) | 0.042 | 1.7 (1.2–2.5) | 0.005 | 1.2 (0.7–1.8) | 0.516 |
Type of delivery |
Normal vaginal | 1.0 | | | | | | | |
Assisted vaginal | 1.1 (1.0–1.2) | 0.119 | 1.3 (1.1–1.5) | <0.001 | 1.0 (0.9–1.1) | 0.898 | 1.1 (0.9–1.2) | 0.426 |
Caesarean section | 1.5 (1.4–1.6) | <0.001 | 1.5 (1.4–1.7) | <0.001 | 1.6 (1.3–1.6) | <0.001 | 1.5 (1.3–1.6) | <0.001 |
Discussion
In this study, most mothers intended to breastfeed, and most infants experienced skin-to-skin contact. EBF prevalence at delivery and at discharge from hospital after birth were high, but the prevalence of EBF in the early postnatal period declined by 27%, suggesting that many infants were introduced to complementary foods as early as the second month of birth, contrary to recommended practice. Younger mothers (<20 years) and those with no supportive partners were significantly more likely to discontinue EBF compared to older mothers (20–39 years) and those who reported having supportive partners, respectively. Mothers from higher SES groups were less likely to cease EBF compared to those from low SES groups. The odds for ceasing EBF in the early postnatal period were higher among mothers who received interventions during delivery, pregnant mothers who smoked cigarettes in pregnancy, and those who reported a history of intimate partner violence (IPV). The negative impact of antenatal depressive symptoms on cessation of EBF in this population has been reported elsewhere [
40].
EBF decreased in the early postnatal period, consistent with previous reports [
15,
21]. Previous Australian studies revealed that this steep decline in EBF may be due to early return to work [
46], inexperience in breastfeeding, a lack of partner’s support [
15], and Aboriginal heritage [
21]. Additionally, our study found that younger maternal age and smoking in pregnancy were the strongest determinants (in terms of effect sizes) for sub-optimal EBF in Sydney. This finding is consistent with a previous Australian study, which indicated that Indigenous status, young maternal age and smoking in pregnancy were associated with sub-optimal breastfeeding [
21]. Current interventions to promote breastfeeding in NSW include: policy on promotion, protection and support for breastfeeding [
27]; maternity leave policy; establishment of Breastfeeding Support Clinics; Breastfeeding Reference Groups [
26,
32,
47]; and a universal home visiting program [
48,
49]. Some aspects of these interventions specifically target vulnerable and at-risk mothers (such as low SES mothers) who may have limited information in appropriate breastfeeding [
49]. Our study provides further insight into challenges in maintaining EBF in the early postnatal period, and suggests that current and/or future interventions to promote EBF should target disadvantaged groups to maximise positive results.
Consistent with prior studies [
17,
19], we found that higher maternal SES was associated with EBF compared to mothers from lower SES groups, suggesting better uptake of health information in higher SES mothers. Mothers with higher educational attainment are more likely to be in employment as well as have a better propensity to take up health care messages compared to those with lower educational attainment [
50,
51]. Other plausible reasons for why mothers from lower SES groups engaged in suboptimal breastfeeding practices may include limited skills to negotiate working hours, stress and poor social interactions [
52,
53]. These discrepancies in breastfeeding practices across the socio-economic scale may also reflect aspects of health inequalities between higher SES and lower SES families in Australia [
51]. Legislators, social and health administrators must work together to improve infant feeding behaviours in all households to ensure improvement in household well-being and productivity.
The effective implementation of the Baby Friendly Hospital Initiative (BFHI) is an important strategy to increase optimal breastfeeding rates following caesarean delivery. BFHI was introduced in 1990 by WHO/UNICEF, and was implemented in Australia in 1993 to promote, protect and support breastfeeding in the hospital and community [
54]. Among Australian states and territories, and in comparison to other states such as Queensland (28%) and South Australia (18%), NSW has one of the lowest proportions of BFHI accredited facilities (14%) [
54]. This is particularly significant considering the fact that NSW is the most populous state in Australia [
55]. The current policy direction for breastfeeding promotion, protection and support in the state includes important priority areas for action such as health professionals’ education and training; support for breastfeeding in health care settings; breastfeeding support for priority groups; and continuity of care, referral pathways and support networks [
27]. Appropriate implementation and sustained monitoring of these key areas of optimal breastfeeding across different levels of cultural background, socio-economic and demographic measure is crucial to promote EBF in Sydney, Australia.
In Australia and internationally, previous studies [
56‐
61] have shown that family members (particularly partner or grandmother) do not only influence the decision to initiate and continue EBF, but they can also play a role in premature cessation of EBF. Our study indicated that mothers with no supportive partners were more likely to discontinue EBF in the early postnatal period. Evidence indicates that fathers want to help the mother to have a successful breastfeeding experience [
58,
62]. However, limited breastfeeding information for fathers and conflicting information from health professionals to fathers were reported as barriers to fathers’ participation in breastfeeding support. Providing fathers with appropriate breastfeeding information to become breastfeeding advocates will increase EBF duration in Sydney [
63]. Appropriate implementation of the BFHI will also address aspects of the inconsistency in breastfeeding information from health professionals. Our study also indicated that IPV and maternal cigarette smoking were associated with cessation of EBF in the early postnatal period. The Australian and NSW Government initiatives to stop IPV in communities [
64] and control tobacco smoking [
65] are strategies needed at the national and sub-national level to improve breastfeeding practices of mothers. These efforts, however, must be tailored to the socio-economic environment in which mothers raise their children to ensure better outcomes.
In comparison to many developing countries [
6,
66‐
68], the introduction of solid, semi-solid and soft foods to infants aged less than 6 months may not create the environment for Australian infants to experience diarrhoea associated with inappropriate infant feeding practices. Reasons for this observation may include better social amenities (like housing, access to potable water and good sanitary environment), and better availability and affordability of food storage systems, operational policies and vaccination programs in Australia. Although infants in Australia may have a lower likelihood of developing diarrhoea associated with suboptimal infant feeding, appropriate breastfeeding remains relevant in a developed country, such as Australia. For example, breastfeeding is relevant in reducing the risk for a number of non-communicable diseases in mother-infant pairs, including obesity [
69] diabetes [
70] and cancers [
71‐
73] in addition to facilitating optimal development and cognitive abilities for infants [
7]. Similarly, a recent randomised control trial among Australian children showed that optimal breastfeeding was associated with a reduced risk of childhood obesity [
74,
75]. Initiatives to improve mother and infant health in NSW must consider the important role of optimal breastfeeding to maximise outcomes.
An emerging threat to optimal breastfeeding in the 21
st century may be the continued “disapproval about breastfeeding in public”. In Australia, the law supports nursing mothers to breastfeed in public places [
76]. However, shop attendants and security guards [
77‐
80] in Australia have asked mothers to leave a public venue whilst breastfeeding, suggesting that a proportion of people are unaware of the mother’s right to breastfeed. Although our study did not examine the impact of disapproval about public breastfeeding, previous studies have indicated that anxiety associated with public breastfeeding was a major reason for suboptimal breastfeeding [
81‐
83]. Even though responses to public breastfeeding can be positive or negative in the community [
77,
84], interventions to promote breastfeeding in the wider community must not only focus on the importance of breastfeeding, but also on normalising public breastfeeding. Research into strategies to make public breastfeeding an acceptable norm in the community may also be warranted.
Study limitations and strengths
The study has a number of limitations. First, the outcome was measured based on self-report which may have led to a recall and/or measurement bias that may have underestimated or overestimated the association between early cessation of EBF and key study factors. Second, unmeasured confounding factors (such as culture, multi-parity or level of support services received postnatal) may also affect the study findings. Third, longitudinal data on EBF (from 4 weeks to 6 months postnatal) were unavailable, information that may have provided a broader pattern of EBF of mothers in Sydney. Finally, our analysis was unable to separate mothers who were assessed by the community health nurse in the first, second, third or fourth week postnatal. This information would have provided additional detail on early cessation of EBF in the postnatal period. Despite these limitations, the study provides information on EBF in the early period following delivery in one of the most diverse populations in Australia. We believe that any potential bias due to missing data is unlikely to have affected the observed findings since the study took this into consideration using a sensitivity analysis that imputed missing data. Our study also provides breastfeeding information from a high-income country, contrary to a proposition from a previous study, which indicated that researchers and health jurisdictions in high-income countries appear to have ignored breastfeeding [
4].
Acknowledgements
The authors are grateful to all the health professionals in South Western Sydney Local Health Districts and Sydney Local Health District who spent time entering the data, and also to personnel in the Information Management & Technology Division for the time spent on generating the data for this analysis.
Membership of the Early Years Research Group
Anne Dudley, Elizabeth Paz, Jacqueline Stack, Karen Sorensen, Mary Knopp, Alison Colley and Carissa Kleiman