Growing Up in Scotland - Birth Cohort 2. Infant Feeding: Breastfeeding and weaning amongst mothers in Scotland

This document presents key findings on infant feeding from the second birth cohort (BC2) of the Growing Up in Scotland (GUS) study, surveyed for the first time during 2011 when children were aged 10 months. The cohort is representative of all children born in Scotland in 2010/11. It considers findings on breastfeeding initiation, duration and support, and on the introduction of solids, exploring variations in these experiences according to key demographic and socio-economic characteristics such as maternal age and household income. Where possible, comparisons were made with data on infant feeding from families in the first birth cohort (BC1) collected during 2005/6 when the cohort child was also 10 months old.

Main Findings

• 36% of children were exclusively breastfed for six or more weeks and 11% until six months or more. Comparable data on exclusive breastfeeding is not available from BC1.
• Breastfeeding outcomes are strongly associated with multiple socio-demographic factors. In particular, breastfeeding is more likely to occur, and continue to six weeks, if: either parent has a degree or "other" educational qualification; the mother has a resident partner, is of a minority ethnicity, or is older; and if the family live in a rural area, or a less deprived area.
• The proportion of children who were breastfed at all (but not necessarily exclusively) for six weeks or more was unchanged between BC1 and BC2 (42%). However, after controlling for socio-demographic factors, the rate was actually found to be lower in BC2.
• 75% of mothers recalled having received breastfeeding advice "at the time of birth" from any source. It is possible mothers also received such advice outside of the period they defined as "at the time of birth".
• Initiation of breastfeeding was higher amongst those mothers who recalled receiving breastfeeding advice, from any source, "at the time of birth", but particularly amongst those who recalled receiving advice from a midwife.
• Among those who had initiated breastfeeding, recall of breastfeeding advice from a health visitor or other health professional was associated with continuation of breastfeeding to six weeks or more.
• 42% of parents delayed introduction of solids until 21 weeks (five months) and 14% delayed until 26 weeks (six months).
• Introduction of solids at six months was more likely amongst parents who had breastfed for at least six weeks, and even more amongst those who continued breastfeeding to six months.

Breastfeeding - initiation and duration

63% of mothers initiated breastfeeding (that is, breastfed for any length of time), but only about two-thirds of those initiating were still breastfeeding at six weeks (42% of all mothers), and even fewer were breastfeeding exclusively at that point (36%).^[1]

Data on duration of breastfeeding showed that the early decrease happens mainly in the first two weeks after the child's birth. It also shows that the exclusive breastfeeding rate begins to fall more sharply after 17 weeks of age (four months). By six months of age, 25% of babies are breastfed at all, and fewer than half of these are exclusively breastfed (11%).

A range of socio-demographic factors were found to be associated with exclusive breastfeeding to six weeks or more. After controlling for all factors together, the key characteristics were found to be:

• Maternal education: 60% of degree-educated mothers breastfed exclusively for six weeks or more compared with 18% of those with Standard Grades.
• Area deprivation: 53% of mothers living in the least deprived areas breastfed exclusively to six weeks compared with 21% in the most deprived areas.
• Maternal age at child's birth: 45% of mothers in their thirties at the child's birth and 41% of those aged 40 or older did so compared with 35% of mothers in their twenties and 12% of teenage mothers.
• Family type: exclusive breastfeeding for six weeks was higher amongst mothers in couple families than for single parents.
• Ethnicity: more likely for mothers with minority ethnic backgrounds than white mothers.

Ignoring any socio-demographic changes between the cohorts, the overall percentage of mothers who initiated breastfeeding increased marginally between the cohorts, from 60% to 63%. The proportions breastfeeding for six weeks or more, and for six months or more, have remained virtually unchanged.

However, after adjustment for changes in the distribution of key socio-demographic factors over the six years between cohorts, mothers in BC2 were found to be slightly less likely to have breastfed for at least six weeks, counter to policy aims.

Reasons for not breastfeeding, or for stopping

Personal preference or past negative experience were the most commonly cited reasons for not breastfeeding. For example, of those who did not breastfeed, 29% simply said they "didn't want to", 12% said they had a previous bad experience and 7% said they were embarrassed or uncomfortable about it.

However, the most common reason for not breastfeeding was "other" which represents a complex mixture of many additional personal and specific reasons (33%).

Similarly, the group of many specific "other" reasons formed one of the largest given for stopping breastfeeding (31% of those who had breastfed and stopped by the time of the interview gave an "other" reason). This was followed by "not enough milk" (31%), "baby not interested" (12%) and "returned to work" (9%).

Information and advice about breastfeeding

Mothers were asked whether they received any help or advice about breastfeeding at the time of the child's birth^[2]. Among all women, 75% recalled receiving advice about breastfeeding from any source "at the time of birth" and 65% recalled having received advice from a midwife.

In general, midwives have earlier, individual opportunities (that is, earlier than the time of birth) to raise the issue of breastfeeding with a pregnant woman, and a key medium for doing so is during ante-natal classes. Advice could have also been received from breastfeeding support workers or peer supporters working in hospitals and in the community very early on in the breastfeeding journey. It could also include advice from health visitors or within breastfeeding support groups in the community. However, it is unclear whether respondents considered such provision of advice as falling under the remit of the "at the time of birth" question asked.

This may account for some of the negative responses.

Significantly more women who initiated breastfeeding than those who did not, recalled receiving any breastfeeding advice at the time of birth (85% compared with 60%). However, there was little relationship between having received "any" advice and succeeding in breastfeeding to six weeks.

Weaning (starting solid foods)

Weaning guidance changed between the births of children in BC1 and BC2. Whereas for BC1, weaning was recommended at between four and six months of age, for BC2 it had changed to six months or older.

The median age for starting solids was 20 weeks. 25% of babies had started solid foods by one week short of four months of age (16 weeks), 50% by one week short of five months of age (20 weeks) and 75% by two weeks short of six months (24 weeks).

In terms of policy guidance, only 14% had waited until six months of age before weaning, but 42% waited until at least five months of age.

A wide range of ages for starting solids were reported from as young as 10 weeks to as old as seven months.

There was a key relationship between extent of breastfeeding and age at starting solids. In general, the youngest weaning ages were reported by mothers who had not breastfed at all and the highest by those who breastfed for six months or more. This relationship remained evident after controlling for area deprivation. Thus, even amongst mothers living in the most deprived areas, weaning age was higher for those who had breastfed than for those who had not.

After controlling for socio-demographic variables, alongside breastfeeding, the following factors were associated with waiting until five months before weaning:

• Mother having a degree or "other" educational qualification;^[3]
• Older maternal age
• Living in a less deprived area
• Living in a large urban or remote rural area.

A switch in measurement units (from months to weeks) for this item makes it difficult to undertake a reliable comparison between BC1 and BC2.

However, assuming that BC2 respondents obtained the child's "age in weeks" at weaning by a simple multiplication of "age in months" by four, the data show an improvement over BC1. Fewer babies started solids as early as four months (40% in BC2 compared with 59% in BC1) and as early as five months (69% in BC2 compared with 81% in BC1). This means more have waited until six months, in line with the refreshed recommendations.

Summary

With regard to breastfeeding rates, the HEAT targets aimed at increasing the proportion of infants being exclusively breastfed at six-eight weeks to 32.7% (Scottish Government, 2007; 2008) was exceeded by mothers in 2011 (36%). However, the prior target of increasing the proportion of mothers breastfeeding (not necessarily exclusively) for six weeks to 50% (Scottish Executive, 2000) was not met (42%), and was unchanged from six years previously.

In terms of exclusive breastfeeding, only 11% of BC2 continued this to six months of age, but this rate is substantially higher than the rate reported by the 2005 infant feeding survey (<1%).

Breastfeeding (initiation and continuation to six weeks/six months) is strongly associated with socio-demographic factors. Some are of particular note.

For example, despite many mothers of minority ethnicity potentially having difficulties of language and access to information, advice and support, they are more likely to breastfeed. This suggests that attitude, cultural experience and expectation as to how a mother should feed her baby are important.

Higher breastfeeding amongst mothers living in rural areas, over and above the well-known effects of education, deprivation and young age, is also notable. It may, therefore, be fruitful to reflect why/how a woman with all the risk factors for not breastfeeding, but who lives in a remote/rural location, succeeds with breastfeeding when a similar mother living in an urban environment does not, and what lessons can be learned.

Efforts to improve infant feeding outcomes focus on information, advice and support. The latest Off to a Good Start booklet (a written resource providing breastfeeding information to new mothers), provides parents with information as well as contact details for a vast array of networks and resources, many of which are web-based, to which mothers can turn to for additional advice on breastfeeding (NHS Health Scotland, 2012). There is some evidence in the GUS data that this is helpful.

The two most common reasons for stopping breastfeeding - "not enough milk" and "other" (stated reasons that could not be categorised into any of the main themes) may be fruitful areas for further research and development of initiatives.

References

NHS Health Scotland (2012) Off to a good start: all you need to know about breastfeeding your baby. Edinburgh: NHS Health Scotland

Scottish Executive (2000) Our national health a plan for action, a plan for change. Edinburgh: Scottish Executive

Scottish Government (2007) Better health, better care: action plan. Edinburgh: Scottish Government

Scottish Government (2008) Healthy eating, active living: an action plan to improve diet, increase physical activity and tackle obesity (2008-2011). Edinburgh: Scottish Government

Further information on the Growing Up in Scotland study can be found at: www.growingupinscotland.org.uk

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