Health Promotion International Advance Access originally published online on April 6, 2005
Health Promotion International 2005 20(3):229-237; doi:10.1093/heapro/dai002
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Breastfeeding prevalence and practices among Singaporean Chinese, Malay and Indian mothers
1Research and Information Management and 2Nutrition Department, Health Promotion Board, 3 Second Hospital Avenue, Singapore 168937, Republic of Singapore
Address for correspondence: L. L. Foo, Research and Information Management, Health Promotion Board, 3 Second Hospital Avenue, Singapore 168937, Republic of Singapore E-mail: Foo_Ling_Li{at}hpb.gov.sg
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The National Breastfeeding Survey 2001 was the first comprehensive study on breastfeeding conducted on a national level in Singapore. It aimed to establish the prevalence of breastfeeding among Chinese, Malay and Indian mothers and to identify factors influencing breastfeeding. A total of 2098 mothers were interviewed in this two-phase study, with the first interview conducted 2 months after delivery and the second interview 6 months after birth among mothers who were still breastfeeding at 2 months. Frequency distributions of breastfeeding prevalence and types of breastfeeding practices at different time intervals (from birth to 6 months) were produced. Multivariate logistic regression was carried out to construct a model with predictive information on factors which influence continued breastfeeding till 2 months and 6 months after delivery respectively. The study found that about 94.5% of the mothers attempted breastfeeding. At 1 month, 71.6% were still breastfeeding, 49.6% continued to do so at 2 months, and 29.8% persisted till 4 months. By 6 months, the breastfeeding prevalence rate fell to 21.1%. The results of this study show higher breastfeeding prevalence rates compared to past studies in Singapore. Despite this, exclusive breastfeeding is still not a common practice. Various factors were found to be significant in influencing mothers' decision to breastfeed. Factors such as ethnicity, age, educational attainment, religion and baby's sex are non-modifiable in the short term or at an individual level. However, factors such as awareness of breastfeeding benefits, advice from health professionals and previous breastfeeding experience are potentially modifiable. Efforts aimed at promoting breastfeeding in Singapore need to take these modifiable factors into consideration so as to better tailor health promotion efforts on breastfeeding to women.
Key words: breastfeeding; prevalence; Singapore
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend breastfeeding as the appropriate method of infant feeding (WHO, 1989
, 1990; American Academy of Pediatrics, 1997). The advantages of breastfeeding are well documented (Kelleher and Duggan, 1999; Booth, 2001; WHO, 1996, 1999, 2002). Extensive research in various countries provides evidence that breastfeeding has clear health benefits for infants while reducing their risk for a large number of diseases such as gastrointestinal and respiratory infections, diabetes mellitus, lymphoma, and Crohn's disease (Howie et al., 1990; Wang and Yu, 1996; American Academy of Pediatrics, 1997; Clemens et al., 1997; Cushing et al., 1998; Hylander et al., 1998; Wright et al., 1998; Kelleher and Duggan, 1999). Breastfeeding has also been related to the enhancement of cognitive development and educational ability in toddlers and children of preschool ages (WHO, 1989; Rogan and Gladen, 1993; Campbell and Jones, 1996; Wang and Wu, 1996; Horwood and Fergusson, 1998; Morrow-Tlucak et al., 1988; Wigg et al., 1998). The available information has urged the WHO to recommend exclusive breastfeeding for 6 months (WHO, 2002).
There is also evidence of health benefits from breastfeeding for mothers. Short-term benefits to mothers include a more rapid weight loss after delivery and a delayed resumption of ovulation resulting in increased child spacing (Lawrence, 1989; Gray et al., 1990; Kennedy and Visness, 1992; Dewey et al., 1993). In addition, breastfeeding appears to be protective against ovarian cancer (Rosenblatt and Thomas, 1993; Siskind et al., 1997) and pre-menopausal breast cancer (Newcomb et al., 1994; Michels et al., 1996). Breastfeeding has also been associated with reduction in hip fractures in the post-menopausal period (Cumming and Klineberg, 1993; Melton et al., 1993).
Despite the demonstrated benefits of breastfeeding, breastfeeding prevalence and duration in many countries are still lower than the international recommendation of exclusive breastfeeding for the first six months of life (WHO, 2002). Past studies on breastfeeding conducted in Singapore revealed a downward trend in the prevalence and duration of breastfeeding over the years as compared to the situation in the 1950s when the figures on breastfeeding were more encouraging (Millis, 1955; Wong, 1961; Chen, 1981; Counsilman and Viegas, 1985; Counsilman et al., 1986a, 1986b; Chua et al., 1989). Most of these studies were conducted by individual hospitals in Singapore, their samples were confined to patients within their own institutions and the sample sizes were relatively small. In addition, different definitions and indicators for breastfeeding were used in these studies.
In view of these considerations, the Health Promotion Board conducted the National Breastfeeding Survey in 2001, the first comprehensive study on breastfeeding conducted on a national level in Singapore. This study was designed to establish the prevalence of breastfeeding among Chinese, Malay and Indian mothers in Singapore and to identify the factors influencing breastfeeding.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The study was conducted among Chinese, Malay and Indian mothers, aged 15–47 years. Of the 6197 mothers who gave birth in April and May 2001, 2250 (36.3%) were recruited by hospital staff after delivery. Informed consent was obtained from mothers who agreed to participate in the study. In order to minimize bias, the mothers were informed that the study was on infant feeding practices instead of breastfeeding practices. The study was conducted in two phases via telephone interviewing by specially trained nurses. Of all the mothers who had consented to participate in the study, 2098 (93.2%) mothers were involved in the first interview which was conducted 2 months after delivery. The main reasons for non-participation by the remaining mothers were non-contactability and refusal to participate. The second interview was conducted 6 months after delivery among the 1049 mothers who were still breastfeeding at 2 months. The response rate for the second interview was 100% (Figure 1).
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The questionnaire used in this study was developed after focus group discussions with mothers to find out the motivating and inhibiting factors associated with breastfeeding. The questionnaire collected information on the demographic profile and socio-economic status of the mothers and their families, their obstetric histories and information on infant feeding practices. Breastfeeding was defined into four categories following closely the recommendations by WHO (1996)
: exclusive breastfeeding, mostly breastfeeding, partial breastfeeding and no breastfeeding. Special attention was given to reasons for initiation of breastfeeding, motivation for continued breastfeeding and reasons for termination of breastfeeding before 2 and 6 months.
Data were analysed using SPSS for Windows (SPSS, 2001). Frequency distributions of breastfeeding prevalence and types of breastfeeding practices at different time intervals (from birth to 6 months) were produced. The nominal coded variables were used in univariate analyses to identify factors that may affect initiation and continuation of breastfeeding. To determine any possible relationship, the significance level for univariate analyses was set at p < 0.25. Based on results of the univariate analyses, multivariate logistic regression (p < 0.05) was carried out in order to construct a model with predictive information on factors influencing continued breastfeeding till 2 months and 6 months after delivery respectively. The Hosmer and Lemeshow Goodness-of-Fit test was carried out to assess how well the model fitted the data.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The demographic profile of the mothers is given in Table 1. Of the 2098 mothers, 65.0% were Chinese, 27.5% were Malays and 7.5% were Indians. The mean age of the mothers was 32 years (range 13–47 years). About two-thirds of the respondents were working.
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About 94.5% of the mothers attempted breastfeeding. At 1 month, 71.6% were still breastfeeding, 49.6% continued to do so at 2 months, and 29.8% persisted till 4 months. By 6 months, the breastfeeding prevalence rate fell to 21.1%.
The median duration of breastfeeding was 7.0 weeks and the mean duration was 12.7 weeks. The median duration of breastfeeding was shorter than the mean duration as the proportion of mothers who continued breastfeeding was smaller than that of mothers who stopped breastfeeding; and among those who persisted, their average duration were longer. Among the mothers who attempted breastfeeding, the shortest duration was 0.5 weeks, while 21.1% were still doing so at the end of 6 months.
The data showed that exclusive breastfeeding at any time between delivery and 6 months is not a common practice in Singapore (Figure 2). For most mothers, breastfeeding was combined with supplementary feeds of powdered milk.
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Univariate analysis showed that ethnicity, age, educational attainment, religion, household income, working status, household living arrangement, total number of children, previous breastfeeding experience, number of babies delivered, length of mother's stay in hospital after delivery, length of baby's stay in hospital after delivery, baby's sex, whether baby had jaundice, perception of breastfeeding, ability to cite benefits of breastfeeding and advice on breastfeeding received from health professionals during pregnancy were factors related to breastfeeding 2 months after delivery. As some of these factors were inter-related, multivariate analysis was performed using continued breastfeeding as a dependent variable. The results of the multivariate analyses for predicting breastfeeding at 2 months are shown in Table 2. Interaction effects were investigated and were not included in the analyses as they did not result in a significant improvement of the model.
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The results of the multivariate analyses for predicting breastfeeding at 6 months are shown in Table 3. The inclusion of any interaction term did not result in a significant improvement over the ‘main effects’ model and hence were not included in the final multivariate model for breastfeeding at 6 months. Unlike the earlier model for breastfeeding at 2 months, ethnicity and age ceased to be significant in the current model for predicting continued breastfeeding at 6 months. Instead variables such as baby's sex, whether baby had jaundice and mother's perception of breastfeeding were found to provide significant predictive information about continued breastfeeding at 6 months.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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In 2001, a total of 37 183 mothers delivered in Singapore. Assuming that 6197 mothers delivered in April and May 2001, this study yielded a 1/3 response rate. The low response rate could be due to the heavy workload of nurses which may in turn affect recruitment of participants for the study and tiredness of mothers as they had just delivered. While the age profile of the survey respondents is similar to the total population of mothers, a slight difference is observed in terms of religion and education. Buddhist/Taoist mothers were under-represented while mothers with at least post-secondary education tended to be over-represented in the current study. However, as there are no reasons to assume any selection bias, the breastfeeding prevalence rate reported in the current study is likely to be reflective of the actual breastfeeding prevalence rate in Singapore.
The results of this study show a higher breastfeeding prevalence rate compared to past studies in Singapore (Millis, 1955; Wong, 1961; Chen, 1981; Ng et al., 1998). The number of mothers who initiated breastfeeding had risen from 76% as reported in a study conducted in the 1960s (Wong, 1961) to 95% in the present study. At 4 months, 30% of mothers were still breastfeeding compared to only 6% of mothers about 4 years ago (Ng et al., 1998). In Hong Kong, an equally affluent Asian country, the breastfeeding initiation rate in 1997 was estimated to be only 34% (Leung et al., 2002).
Despite a higher breastfeeding prevalence rate compared to past years, exclusive breastfeeding is not a common practice in Singapore. For most mothers, breastfeeding is combined with supplementary feeds of powdered milk. Only 7% of the mothers breastfed exclusively at 4 months, and this rate fell to near zero at 6 months (Figure 2). The exclusive breastfeeding rates under 4 months of age in Europe, Africa, Southeast Asia, the Western Pacific, Eastern Mediterranean and the Americas are substantially higher. In the Southeast Asia region for instance, the rate is estimated to be 49% (WHO, 1996).
The positive association between the level of maternal education and breastfeeding duration is consistent with other studies (Ford and Labbok, 1990; Michaelsen et al., 1994; Nolan and Goel, 1995; Clements et al., 1997; Scott, 2001).
The survey revealed different associations between certain religions and breastfeeding duration. Muslim mothers were 6.7 times more likely to breastfeed their babies at 2 months compared to Buddhist/Taoist mothers. This might be related to Islam's favourable stance towards breastfeeding—for example, the Quran (Chapter 2, Verse 233) decrees that ‘mothers shall give suck to their offspring for two whole years’ (Counsilman and Viegas, 1985). Christian mothers were also more likely to breastfeed their babies longer compared to Buddhist/Taoist mothers.
It is noteworthy that while the model for predicting continued breastfeeding at 2 months shows that Muslim mothers were more likely to breastfeed their babies compared to Buddhist/Taoist mothers, Malay mothers were less likely to breastfeed their babies compared to Chinese mothers. This apparent contradiction could be explained by the differing influences of ethnicity and religion on breastfeeding among different subgroups of respondents. Among the Malay mothers, all were Muslims—their ethnic and religious identities are thus closely intertwined. Among the Chinese mothers, their religious affiliations were more diverse—about half were Buddhist/Taoists, about a quarter were Christians, and another quarter had no religion. In addition, the shift towards Christianity in Singapore is most pronounced among the better educated Chinese (Singapore Department of Statistics, 2000), and better educated mothers tend to breastfeed their babies longer.
Non-working mothers were more likely to breastfeed their babies for a longer duration. The positive association between returning to work and terminating breastfeeding became more pronounced at 2 months and beyond as working mothers tend to return to the workforce at that time as the maternity entitlement is 8 weeks in Singapore. The difficulty of balancing the demands of work and breastfeeding may discourage mothers from continuing to breastfeed (Cronenwett et al., 1992; Piper and Parks, 1996; Visness and Kennedy, 1997; Fein and Roe, 1998; Abada et al., 2000).
Previous breastfeeding experience was associated with longer breastfeeding duration in some studies (Mclnnes et al., 2001). In the current survey, mothers who did not breastfeed their previous children were less likely to continue breastfeeding at 2 and 6 months than those who had breastfed their children. This finding emphasized the importance of encouraging and supporting breastfeeding in first-time mothers.
The survey found that 54.5% of the mothers did not receive advice on breastfeeding from health professionals during their pregnancy. However, this did not have a negative impact on breastfeeding duration in the current study. On the contrary, women who did not receive advice on breastfeeding from health professionals during pregnancy were more likely to breastfeed for a longer duration. Among the women in the survey who had not received advice on breastfeeding, the three mostly commonly cited sources of information were family members, friends and books. This suggests that family support and maternal knowledge are important. Not discounting the important role of health professionals in promoting breastfeeding, it might still be useful to provide women with credible information on breastfeeding as soon as possible as studies have shown that infant feeding decisions are made prior to delivery and such decision would influence the initiation and duration of breastfeeding (Lawson and Tulloch, 1995; Piper and Parks, 1996; Pande et al., 1997).
Awareness of the benefits of breastfeeding was found to be related to breastfeeding duration. At 2 and 6 months of age, the ability to cite at least one benefit of breastfeeding was found to be one of the more significant predictors of continued breastfeeding.
The survey found that while some factors were consistently predictive of breastfeeding at both 2 and 6 months, some were significant at only one time point. Ethnicity and age provided predictive information about continued breastfeeding at 2 months—Indian women and older mothers were more likely to breastfeed their babies. However, ethnicity and age ceased to be significant predictors at 6 months in the current survey. Other studies have also found variations in infant feeding patterns among different ethnic groups in their populations (Wiemann et al., 1998; Novotny et al., 2000; Li and Grummer-Strawn, 2002).
The finding that mothers who viewed breastfeeding as the best infant feeding method were more likely to continue breastfeeding their babies till 6 months is consistent with other studies (Wambach, 1997). Surprisingly, male babies were less likely to be breastfed at 6 months compared to female babies. However, this finding is in line with some previous studies although the association has not been consistently reported (Ford et al., 1994; Michaelsen et al., 1994; Perez-Escamilla et al., 1995; Pande et al., 1997; Scott et al., 2001). A possible explanation offered by Perez-Escamilla et al. (Perez-Escamilla et al., 1995) is that male infants may be weaned earlier than female babies due to the perception of mothers and/or health professionals that breast milk alone might not meet the higher nutritional needs of male babies. Unexpectedly, our survey found that babies without jaundice were less likely to be breastfed at 6 months compared to the other infants. This finding differs from a study that showed that most mothers stopped breastfeeding because of jaundice (Fok, 1996). A plausible explanation in the current survey could be mothers continued breastfeeding their babies despite jaundice in the early stage, with hopes that the nutritive and immunological benefits of breastfeeding would strengthen their babies.
In summary, the results of this study show higher breastfeeding prevalence rates compared to past studies in Singapore. Despite this, exclusive breastfeeding is still not a common practice. Various factors were found to be significant in influencing mothers' decision to breastfeed. Factors such as ethnicity, age, educational attainment, religion and baby's sex are non-modifiable in the short term or at an individual level. However, factors such as awareness of breastfeeding benefits, advice from health professionals, previous breastfeeding experience, and worksite policies are potentially modifiable. Future efforts aimed at promoting breastfeeding in Singapore would therefore need to take these modifiable factors into consideration so as to better tailor interventions to promote breastfeeding. Close cooperation with support groups such as the Association for Breastfeeding Advocacy (Singapore) would also be necessary to enhance these efforts. The association, which comprises representatives from hospitals, government bodies, the academia and professional groups is working towards creating breastfeeding awareness through relevant public and medical events and through developing a workplace policy to facilitate continuation of breastfeeding in workplaces, just to name a few.
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ACKNOWLEDGEMENTS |
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The collaboration with the Breastfeeding Mothers’ Support Group is acknowledged. In particular, we would like to express appreciation to Dr Chong Yap Seng and Mrs Wan Siew Kwun for their advice and assistance. We are grateful to the KK Women's and Children's Hospital, National University Hospital, Singapore General Hospital, East Shore Hospital, Gleneagles Hospital Singapore, Mount Alvernia Hospital, Mount Elizabeth Hospital and Thomson Medical Centre for supporting the study. We would also like to thank our team of interviewers for carrying out the fieldwork. Most of all, we are indebted to all the mothers who volunteered to participate in the study. Dr Paul Deurenberg guided us in drafting the manuscript.
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