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Jornal de Pediatria - Vol. 76, Nº1, 2000 65
0021-7557/00/76-01/65
Jornal de Pediatria
Copyright © 2000 by Sociedade Brasileira de Pediatria
ORIGINAL ARTICLE
Breastfeeding in Montes Claros, Minas Gerais:
a representative sample study
Antônio P. Caldeira,1 Eugênio M.A. Goulart2
Abstract
Objective: to evaluate the situation of breast-feeding in the city of Montes Claros, state of Minas
Gerais, Brazil, among children under 2 years of age, and to determine variables associated to major risks
for early weaning.
Methods: in this cross-sectional study, interviews were carried out by trained personnel with 602
mothers randomly selected in the urban area of Montes Claros from September to November 1996. Survival
analysis was the method used to calculate the prevalence and the median duration of breast-feeding. The
chi-square test was performed to compare the proportions; significance level was set at 5%. Prevalence
odds ratio was used to measure the significance of associations, with a 95% confidence interval. Logistic
regression analysis was used to identify the risk factors for early weaning.
Results: the average length of breast-feeding was 8.7 months; however, the median length of exclusive
breast-feeding was only 27 days. Risk factors for early weaning were low birth weight (odds ratio=2.65;
confidence interval 95%=1.10-6.40), mothers with difficulties to breastfeed in the first days (OR=1.86; CI
95%=1.21-2.85), and lack of postnatal medical incentive to breastfeed (OR=1.75; CI 95%=1.15-2.66).
Conclusions: in general, breast-feeding is in a better situation than that showed by other national
reports, although the numbers are still below what is recommended by the World Health Organization.
There is a critical exclusive breast-feeding pattern. The factors related to early weaning denote a weak
breast-feeding support given by maternal and infant health services.
J Pediatr (Rio J) 2000; 76(1):65-72: breast-feeding, infant feeding, weaning, lactation, human milk,
nutritional survey.
Introduction
Mother’s milk undoubtedly represents the best
nourishment for the child during the first months of life.
Several studies emphasize the advantages of breast-feeding
in the promotion of infant health.1-3 Although breast-feeding
was considered natural in the beginning of this century,
today it is the result of a maternal option that involves a
complex interaction of factors.
National studies recently published point out an
improvement in breast-feeding rates4,5 in relation to the
past years.6,7 This fact reflects a world trend, and leads to
1. Assistant Professor Woman and Child Health, Universidade Estadual de
Montes Claros (UNIMONTES) School of Medicine.
2. Associate Professor, Department of Pediatrics, School of Medicine,
Universidade Federal de Minas Gerais (UFMG).
65
66 Jornal de Pediatria - Vol. 76, Nº1, 2000
an expressive repercussion in the health of Brazilian children
in general. However, the present situation is far from ideal,
and several works have aimed at presenting/testing strategies
to increase breast-feeding rates.8,9
Several studies intended to define the determinant
variables in the success or failure of breast-feeding,10-12
which could ease the organization of promotional strategies.
Nevertheless, it is always prudent to consider that, as an
eating habit, breast-feeding is intrinsically related to the
development and the cultural patterns of a given population.
This fact justifies the need for regional studies that allow a
more efficient action in regard to intervention measures,
based on knowledge of the local reality.
Some authors study the local status of breast-feeding
based on restricted samples, or on the clientele of inpatient
and outpatient units. Despite the importance of these works,
the population samples are not representative. Other studies
do not define the different patterns of breast-feeding, or
present an imprecise terminology. In this work, we tried to
clearly define the terminology used in the study of a local
representative population sample.
The present study aimed at establishing knowledge
about the reality of breast-feeding in the urban area of
Montes Claros, state of Minas Gerais, Brazil. We also
aimed at identifying the demographic and socioeconomic
variables related to maternal and infant assistance that may
be negatively interfering in breast-feeding practices.
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
During the interviews, we used forms with direct, easyto-answer questions. Most of these questions, already tested
in previous studies,13 did not open many answering
possibilities, requiring short answers. Questions included
information on demographic and socioeconomic variables
of the mothers and on local maternal and infant assistance,
in addition to the children’s eating habits. The mothers were
also questioned about the reasons for early weaning. The
studied variables were divided in four groups:
Demographic variables: parity, type of delivery,
birthweight, maternal age, and presence of the father in the
family structure.
Socioeconomic variables: family income (assessed in
minimum wages), maternal education, paternal education,
and the father’s type of job (specialized or not).
Variables related to prenatal assistance: number of
prenatal appointments, prenatal incentive to breast-feeding
(mothers were questioned whether they had been oriented
and motivated to breastfeed during their prenatal
appointments), previous willingness and planning to
breastfeed (the mothers were questioned whether they were
willing to breastfeed their children and for how long they
planned to breastfeed in case they were willing to do so),
and previous experience with breast-feeding (for mothers
who had already breastfed).
Methods
The city of Montes Claros is located in the northern area
of the state of Minas Gerais, Brazil, and it represents the
main urban center of the region. Total population is
approximately 270,000 inhabitants. The city presents indices
of a predominantly poor population.
Variables related to postnatal assistance: stay in conjoin
lodgings, hospital incentive to breastfeed (mothers were
questioned whether or not they had received orientation and
incentive to breastfeed during their stay in the hospital/
maternity), time elapsed between birth and first breastfeeding, initial difficulties (mothers were questioned about
the difficulties with mammary ingurgitation, fissures,
problems with the nipple, and mastitis on the first days), and
incentive during postnatal appointments (mothers who
controlled the postnatal development of their children were
asked whether they had been oriented and motivated by the
pediatricians in relation to breast-feeding).
In this research, we sought to study a representative
sample of infants under the age of 2 (about 4.5% of the total
population). The sample size suggested by Barros & Víctora
for similar studies is approximately 450 children.13 The
EPI-Info software14 suggests a sample of 564 children, with
25% of weaning before the 6th month, 5% of standard error,
and design factor equal to 2 (it constituted a conglomerate
sample).
A previous pilot study was performed in order to test the
questionnaire and the team of interviewers. All data were
collected in the months of September and October 1996. In
the beginning of November, 5% of the interviews were
checked for a better control of the information quality. We
considered as losses the mothers who refused and those who
were absent or unavailable for an interview after at least
three visits (total of 17 mothers).
A random sample of 602 mothers of children under 2
year of age was selected for an interview at their own homes
by a team of 28 especially trained interviewers. The sampling
process occurred in two different stages: initially, we drew
some censual sectors to be included in our study. Later, we
randomly selected a starting point (a city block) in each
sector, from where the whole area began to be visited
(homes were alternated). We used the maps provided by
Fundação IBGE for demographic and territorial divisions,
according to the latest census.
The EPI-Info software (version 6.0)14 was used for
processing and analyzing data. The chi-square test was
applied for comparing proportions when we evaluated
factors associated with early weaning; a 5% alpha error was
admitted. We also calculated odds ratio for each studied
variable, with a 95% confidence interval. This is usually
applied in crossover studies, in which the prevalence instead of the incidence - is assessed according to the
significance of the association. Its calculation is similar to
the relative risk, which is the odds ratio.15
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
Logistic regression was performed with the Multlr16
software, in order to identify the variables that in a
simultaneous mathematical analysis presented an
independent explanatory effect on higher risk for early
weaning. For this stage of the investigation, we selected the
variables that showed P<0.20 in the bivariate analysis.
For analyzing the length of breast-feeding, we applied
the life table technique using an electronic spreadsheet. We
considered the fact of receiving mother’s milk an assessment
criterion. The introduction of water, tea, or juices was
considered the final event in cases of exclusive breastfeeding; the introduction of any other food was considered
the final event in cases of predominant breast-feeding.
When analyzing length, the final event was usually the
definitive interruption of breast-feeding.
The terminology here used is proposed by the World
Health Organization.17 Thus, isolated, the term breastfeeding does not define a specific behavior of giving suck.
Exclusive breast-feeding refers to the use of human milk as
the only source of nourishment to the child. Predominant
breast-feeding is used when human milk is consumed as the
main source of nutrition, allowing the consumption of other
liquids (water, juices, or teas). Complementary feeding
applies to the use of human milk associated with other food,
either lactic or not, solid or liquid.
Early weaning, in this text, refers to the introduction of
complementary feeding prior to 4 months of life, with the
interruption of exclusive or predominant breast-feeding
before this period. Thus, for obvious reasons, only children
older than 4 months of age participated in the analysis we
present here. This subgroup was composed by 494 children.
Jornal de Pediatria - Vol. 76, Nº1, 2000 67
The performance of this project was approved by the
Department of Woman and Child Health, Medical School,
Universidade Estadual de Montes Claros, and by the ethics
committee of the Hospital Aroldo Tourinho.
Results
In our observed group, we identified a homogeneous
distribution in relation to the children’s sex. The majority of
the interviewed mothers was primiparous (45.7%), and
only 10.4% of them had more than three children. Around
72% of the children were born by normal deliveries, and
among these, 7.3% presented birthweight lower than 2,500
g. The proportion of mothers under 20 years of age was
approximately 20%. In 24% of the visited homes, there was
no father living with the family.
Around 43% of the families had a monthly income
inferior to two minimum wages, and 30.4% of the interviewed
mothers informed an income between two and five minimum
wages. Maternal education was evaluated: 5% of the mothers
were illiterate, 25.4% had up to the 4th grade of elementary
school, and less than 5% had completed college. Similar
indices were observed in relation to paternal education:
7.1% of the fathers were illiterate, 23.9% had studied up to
the 4th grade of elementary school, and 6.8% had completed
a college program.
Based on the life tables, it was possible to establish the
graphic here presented (Figure 1) using the patterns of
breast-feeding considered. The life table technique allows
us to consider children who are still being breastfed in the
moment of the interview, and also to know the proportion of
Figure 1 - Survival curve for the several patterns of breast-feeding (Montes Claros,
Minas Gerais, Brazil, 1996)
68 Jornal de Pediatria - Vol. 76, Nº1, 2000
children that remain being breastfed by the end of each
month. So, it allows a longitudinal approach to the crosssectional data collected.
In relation to exclusive breast-feeding, we observed that
this is no longer a universal practice immediately after birth.
By the end of the 1st month of life, only 48% of the children
are being exclusively breastfed. In the following months,
we noticed a continuous decline: by the end of the 2nd
month of life, only 28% of the children remain being
exclusively breastfed, and at 4 months, this percentage is
approximately 8%. The median length of exclusive breastfeeding (age in which half of the children are receiving only
the mother’s milk) was inferior to 1 month (27 days).
The survival curve for exclusive breast-feeding +
predominant breast-feeding reveals an early introduction of
water or teas/juices. By the end of the 1st month of life, 88%
of the children are included in this category. At 2 months of
age, this proportion was 81%, and at 4 months of age, it was
50%. The average length observed was thus 4 months. From
this age on, we observed significant frequency falls, with
proportions of 27%, 18%, and 3% to 5, 6, and 7 months of
age, respectively.
The survival curve for general breast-feeding is also
presented in the figure. We noticed that starting breastfeeding at birth is almost a universal practice among the
interviewed mothers: around 96% of the children were still
breastfed at the end of the 1st month, regardless of other
sources of nutrition. However, weaning is frequent in the
first months. At 2 months of age, the proportion of children
who still receive mother’s milk is 91%; at 4 months of age,
this rate falls to 76%. At 6 months of age, the proportion of
children who still receive mother’s milk is 65%, and by the
end of the 1st year, it goes down to 41%. The median length
of breast-feeding was 8.7 months. During the 2nd year of
life, breast-feeding rates remain decreasing: at 18 months,
22% of the children still use the mother’s milk, and by the
end of the 2nd year, this rate is approximately 10%.
The analysis of factors associated with early weaning
refers to the study of the association between exclusive
breast-feeding + predominant breast-feeding and some
demographic and socioeconomic variables, in addition to
data regarding maternal and infant care (pre and postnatal).
It was not possible to evaluate determinants of the exclusive
breast-feeding pattern due to the small number of children
in this group; the early introduction of water or teas/juices
is very usual among the studied population.
Tables 1, 2, 3, and 4 present the studied variables and
their association with early weaning. Among the variables
chosen for the logistic regression (Table 5), low birthweight
(odds ratio=2.65; confidence interval 95%=1.10-6.40) and
lack of incentive to breastfeed during postnatal care
(OR=1.75; CI 95%=1.15-2.66) were the factors associated
with higher risks for early weaning. The variables concerning
presence of father in the family structure and length of
breast-feeding experience were not selected for the logistic
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
Table 1 -
Demographic variables and association with early
weaning (Montes Claros, Minas Gerais, Brazil, 1996)
Variable
Weaning
Yes No
χ2
P
RP
CI 95%
Parity
Primiparous
102
Nonprimiparous 133
123
136
0.67
0.4121
0.92 0.76-1.11
Interdelivery interval
<24 months
35
> 24 months
98
36
100
0.01
0.9128
1.00 0.76-1.31
Mode of delivery
Operative
71
Normal
164
67
192
0.95
0.3299
1.12 0.92-1.36
Birthweight
<2500 g
>2500 g
25
208
10
248
7.68
0.0056
1.57 1.24-1.98
Maternal age
<20 years
>20 years
62
173
51
208
2.76
0.0967
1.21 0.99-1.48
Presence of the father
No
61
Yes
174
52
207
2.09
0.1480
1.18 0.97-1.45
regression so that the lack of complete information would
not affect the analysis.
The main reason (31.8%) presented by the mothers for
the introduction of other food in their children’s diet was the
belief that the isolated mother’s milk was not sufficient (that
“it didn’t sustain” the children). When asked about what led
them to believe in this, the most frequent answers were:
excessive crying (54.0%), little milk (22.0%), stable weight
(9.0%), and “thinned milk” (7.5%).
Table 2 -
Socioeconomic variables and their association with
early weaning (Montes Claros, Minas Gerais, Brazil,
1996)
Variable
Family income
<1 m.w.*
>1 m.w.*
Weaning
Yes No
χ2
P
RP
CI 95%
32
196
25
228
1.60
0.2055
1.21 0.94-1.56
Maternal education
<4 years
85
>4 years
150
70
189
4.37
0.0366
1.24 1.03-1.49
Paternal education
<4 years
64
>4 years
108
62
144
1.83
0.1766
1.19 0.95-1.48
Father’s job
Unspecialized
Specialized
142
65
5.65
0.0174
1.41 1.06-1.89
* minimum wage
139
35
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
Table 3 -
Variable
Variables related to prenatal care and their association
with early weaning (Montes Claros, Minas Gerais,
Brazil, 1996)
Weaning
Yes No
χ2
P
RP
CI 95%
Prenatal care
<4 appointments 44
>4 appointments 191
31
228
3.86
0.0496
1.29 1.04-1.60
Prenatal incentive
No
88
Yes
147
78
181
2.65
0.1037
1.18 0.98-1.43
Will to breastfeed
No/Indifferent 26
Yes
209
19
240
1.64
0.2000
1.24 0.95-1.62
Breast-feeding planning
<6 months
82
66
>6 months
153 193
4.76
0.0291
1.25 1.04-1.51
Previous experience
<4 months
35
>4 months
86
4.10
0.0429
1.37 1.05-1.78
23
109
The second reason (11.1%) presented by the mothers
for early weaning was that the milk had dried out. Mothers
who gave this answer were asked whether they knew the
reason for such thing to have happened. Around 46% said
they did not know why. The rest of the mothers presented
reasons such as the use of medication (20%), emotional
reasons (11%), physical reasons (6%), and others (17%).
Other reasons presented for early weaning were: medical
indication (10.7%), return to work (9.6%), and lack of
interest on the child’s part (5.8%). Other reasons presented
summed up 31.0%.
Jornal de Pediatria - Vol. 76, Nº1, 2000 69
A fact that may justify the critical situation of exclusive
breast-feeding, in spite of the general improvement in
general breast-feeding, is the relevant rural influence
observed in the city. Due to its geographic and developmental
situation, the studied area presents an important migratory
flow from the countryside to the city and its surrounding
communities. It is well known that rural communities have
more traditional habits: although they frequently start breastfeeding and sustain it for longer periods, they usually
introduce other foods very early.7,20
Another factor that may be contributing to an early
interruption of exclusive breast-feeding is the weak
performance of maternal and infant services. The indices
closest to the ideal ones were found, for example, in the city
of Guarujá, São Paulo, as the result of an intense work of the
lactation centers.21 Another example that must be mentioned
is the town of Feira de Santana, state of Bahia, where very
high indices can also be found due to a strong work developed
by the healthcare units.22
In relation to the variables involved in breast-feeding,
this study assessed, for the first time, the factors associated
with a higher risk for early weaning, here understood as the
introduction of foods other than water or tea/juices prior to
4 months of life. This approach took into consideration the
fact that the introduction of water and tea in the studied
population is a widely spread habit. Probably, the mothers
who gave their children water or tea were not concerned
with the nutritional aspect, but did so out of ignorance, or
because they believed it could be helpful in solving their
infants’ colic. Doctors are also commonly tolerant with
such conduct.23
Table 4 -
Discussion
This study showed a relatively better situation for the
urban area of Montes Claros when compared to general
breast-feeding in other regions of Brazil.4,5 Almost all
mothers started to breastfeed (98%), and the average length
observed (8.7 months) was higher than the length found in
previous studies. However, we identified a critical situation
in regard to exclusive breast-feeding, which presented an
average length inferior to 1 month (27 days). These data are
compatible with the recent national literature: the National
Research on Demography and Health,4 carried out in several
regions of the country, showed a 92.3% rate for initial
breast-feeding, with an average length of 7.0 months for
breast-feeding, and 1.1 month for exclusive breast-feeding.
So, a return to the breast-feeding practice has been seen in
our country over the last years, especially after the creation
of the Programa Nacional de Incentivo ao Aleitamento
Materno; this has been registered in previous studies.18,19
Variable
Variables related to postnatal care and their
association with early weaning (Montes Claros, Minas
Gerais, Brazil, 1996)
Weaning
Yes No
χ2
P
RP
CI 95%
Conjoin lodging
No
142
Yes
93
147
112
0.54
0.4623
1.08 0.90-1.31
Hospital incentive
No
78
Yes
157
72
187
1.45
0.2287
1.14 0.94-1.38
First breast-feeding
>6 hours
164
<6 hours
62
161
97
5.19
0.0227
1.29 1.04-1.62
Initial difficulties
Yes
119
No
116
89
170
12.73 0.0004
1.41 1.17-1.69
Postnatal incentive
No
138
Yes
97
127
132
4.27
1.23 1.02-1.49
0.0388
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
70 Jornal de Pediatria - Vol. 76, Nº1, 2000
The majority of studies that deal with factors associated
with breast-feeding establish associations with the breastfeeding total length, and do not take into consideration the
different patterns of suckling.10 This fact incurs the mistake
of considering extreme situations in one only category, such
as the child who receives exclusively mother’s milk, and
one who receives it only now and then. Naturally, the ideal
approach to this matter would be a survey with the mothers
who exclusively breastfeed their infants. However, as
previously mentioned, the introduction of water and teas in
the newborns’ diet is very usual, thus reducing the number
of children classified in the exclusive breast-feeding
category.
Generally, demographic variables (Table 1) are not very
likely to be relevant to the breast-feeding pattern. A review
performed by Losch et al.11 points out several works with
different results in relation to these variables. The present
study showed low birthweight as a risk factor for early
weaning, even after the logistic regression. This result is in
agreement with other national study,24 although the literature
stresses diverging results.25 These unmatched results can
possibly be justified by the complexity of factors involved
in the birth of an underweight child.
The bivariate analysis of socioeconomic factors (Table
2) showed that the return of the breast-feeding practice has
been more common among socially privileged families
(greater maternal education and “specialized” paternal
work). Nevertheless, this observation was not confirmed by
the logistic regression. Other studies are necessary in order
to better define the role of socioeconomic variables,
considering that there are some studies remarking a positive
association between early weaning and low maternal
education, for instance.12 On the other hand, we can not
forget that different studies set different cutoff points; as an
Table 5 -
Tables 3 and 4 emphasize (already in the bivariate
analysis) the lack of association between the studied breastfeeding pattern and variables classically considered as
supportive of breast-feeding: prenatal incentive, stay in
conjoin lodging, and incentive during postnatal care, for
instance. Two hypotheses were raised to justify such
situation. The first was the existence in the town of a
reference center for breast-feeding: the Banco de Leite
Humano, of Hospital Aroldo Tourinho, recently certified as
Hospital Amigo da Criança. Such fact could have been
acting as homogenizing factor, since the studied population
was not divided according to the place of prenatal or
postnatal care. Another justification for such findings would
be a generally unsatisfactory performance of maternal and
infant care in health services concerning the promotion of
breast-feeding. This hypothesis should not be disregarded,
since after the logistic regression (Table 5), the variables
that remained able to predict a higher risk for early weaning
(low weight, initial difficulties in breast-feeding, and lack
of incentive in postnatal care) were directly or indirectly
associated with the quality of maternal and infant care.
Breast-feeding is a maternal option that involves a
complex interaction of socioeconomic, cultural and
psychological factors, among others. However, as a “socially
recreated” habit, the role of maternal and infant services in
the promotion of breast-feeding should by no means be
disregarded. The proportion of mothers who did not stay in
conjoin lodgings and presented late first suckling, or that
mentioned not having received any information about breastfeeding in prenatal appointments or during their stay in the
hospital/maternity is noteworthy.
Logistic regression analysis for some variables related to higher risk for early
weaning (Montes Claros, Minas Gerais, Brazil, 1996)
Variable
Birthweight
Maternal age
Maternal education
Paternal education
Father’s job (status)
Prenatal appointments
Prenatal incentive
Breast-feeding planning
Late first breast-feeding
Initial difficulties
Postnatal incentive
* P< 0.05
example, in our approach, we established early weaning as
the introduction of other foods prior to 4 months of life.
Coefficient
(ß)
Standard
deviation
Odds Ratio
CI 95%
0.9749
- 0.1229
0.2423
- 0.0695
0.4655
0.3466
- 0.1068
0.4808
0.3695
0.6201
0.5608
0.4497
0.2967
0.3045
0.2985
0.2793
0.3391
0.2504
0.2590
0.2313
0.2181
0.2143
2.651*
0.884
1.274
0.933
1.593
1.414
0.899
1.617
1.447
1.859*
1.752*
1.098-6.400
0.499-1.582
0.702-2.314
0.520-1.675
0.921-2.754
0.728-2.749
0.550-1.468
0.979-2.686
0.920-2.277
1.212-2.851
1.151-2.667
Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
Certainly, there is a complex relationship between the
determinants of a well-succeeded breast-feeding practice,
and this work did not aim at discussing it deeply. The
authors believe that when defining the breast-feeding pattern
in a certain region, it is important that all intervening
variables be considered, allowing a global knowledge of the
situation, and ensuring a greater potential for interventions.
The main reasons presented by the mothers for the early
introduction of other foods are similar to those already
presented in previous studies, and denote insecurity and
absence of knowledge.26 The considerable rate of mothers
who informed early weaning as a medical indication is a
reason for concern: 10.7%!
This work demonstrated that, despite the return of the
breast-feeding practice, permanent incentive and support
are necessary, since we still observe an unsatisfactory
behavior, particularly in relation to exclusive breast-feeding.
The results here presented stress the need for prioritizing
activities for the promotion and improvement of maternal
and infant services. The variables here studied naturally
present a complex interaction with others not yet studied.
Future studies are necessary to approach the interrelations
among these several variables and also other psychological
and anthropological questions (not covered by this study)
that certainly interfere in the breast-feeding practice.
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Breastfeeding in Montes Claros, Minas Gerais:... - Caldeira AP et alii
Correspondence:
Dr. Antônio Prates Caldeira
Rua Santa Helena, 136
CEP 39400-369 – Montes Claros, MG, Brazil
Phone: + 55 38 222.3879
E-mail: [email protected]