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Health Bulletin (59)2 March 2001

Breastfeeding rates are increasing in Scotland

David M. Tappin, clinical senior lecturer, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Royal Hospital for Sick Children, Glasgow
Joan M. Mackenzie, biomedical scientist, Scottish Inborn Errors Screening Laboratory, Stobhill General Hospital, Glasgow
Arlene J. Brown, senior medical laboratory services officer, Scottish Inborn Errors Screening Laboratory, Stobhill General Hospital, Glasgow
Robert W. A. Girdwood, consultant microbiologist, Scottish Inborn Errors Screening Laboratory, Stobhill General Hospital, Glasgow
Jane Britten, research fellow, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Royal Hospital for Sick Children, Glasgow
Mary Broadfoot, information officer, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Royal Hospital for Sick Children, Glasgow
Jenny Warren, national breastfeeding adviser, Paediatric Epidemiology and Community Health (PEACH) Unit, Department of Child Health, Royal Hospital for Sick Children, Glasgow

Abstract

Objective: To measure the change in prevalence of breastfeeding between 1990/1991 and 1997/1998 in Scotland, using information collected on Guthrie cards when newborn infants are about seven days old.

Design: Analysis, by geographic postcode area, health board and maternity unit, for babies born in 1990/1991 and 1997/1998. For 1997, maternity unit and health board breastfeeding rates were also compared after standardisation for maternal age, deprivation and age of infant.

Setting: Scotland.

Subjects: 131,759 babies born in 1990/1991 and 118,055 in 1997/1998.

Results: In 1990/1991, 46,949 (35.6%) were breastfed as were 49,615 (42.0%) in 1997/1998, an increase of 6.4% (95% CI 6.0, 6.8) over eight years. A 3.8% increase remained after adjustment for change in maternal age. Maternity units with the Baby Friendly award improved 8.1% (95% CI 7.0, 9.2) compared with those with a certificate of commitment 6.1% (95% CI 5.2, 7.0). Other units improved 2.2% (95%C1 1.6, 2.8) no more than estimates due to increase in maternal age. Standardised rates were higher on the East Coast of Scotland 111 (109, 112) than the West or Central Regions 97 (96, 99).

Conclusion: Breastfeeding has increased over eight years in Scotland. Less than half can be explained by demographic change in maternal age. However present breastfeeding targets are unlikely to be met. Maternity units should be urged to participate fully in the UNICEF U.K. Baby Friendly Initiative. Effective interventions prior to pregnancy are required so that more young men and women want their babies to be breastfed.

Key words

Breastfeeding, Bottle feeding; Epidemiologic methods; Scotland; Metabolism, Inborn Errors; Infant, Newborn.

Introduction

In 1994, the Standing Committee on Nutrition of the British Paediatric Association reported that breastfeeding has health benefits for mothers and babies in industrialised countries.¹ Further studies have accumulated even more evidence of both short and long term benefits.^2-7 The potential savings in health service costs associated with increased rates of breastfeeding have also been calculated.^8,9 In 1994 the Committee on Medical Aspects of Food Policy recommended that mothers should be encouraged and supported in breastfeeding for at least four months and this has been adopted as policy in Scotland.¹⁰

The breastfeeding rate in Scotland is the second lowest in Europe, with 55% of women breastfeeding at birth.^11,12 In 1994, the Scottish Office set a target rate for breastfeeding in Scotland of 50% of mothers still to be breastfeeding their babies at six weeks of life by 2005.¹³

In 1994¹⁴ we reported an accurate method of measuring breastfeeding rates in order to audit promotion strategies, using information available from Inborn Errors Screening (Guthrie) cards taken usually at home by community midwives when infants are six to seven days of age. This method is likely to be unbiased since it involves the whole population-99.8% screened,¹⁵ and data are collected for another purpose.

The present report describes changes in breastfeeding rates at six to seven days postnatal age in Scotland from 1990/91 to 1997/98 by geographic postcode area and maternity unit and examines the effect of deprivation and demographic changes in maternal age. It also looks at the UNICEF U.K. Baby Friendly status of individual maternity units to assess if this framework¹⁶ has improved breastfeeding rates in Scotland.

Methods

This report compares information from 131,759 babies born in Scotland during 1990 and 1991¹⁴ and 118,055 babies in 1997 (60,321) and 1998 (57,734). A total of 118,647 babies were born in Scotland during 1997 (60,593) and 1998 (58,054) (ISD Scotland, Common Services Agency, Edinburgh). The number of infants for each mode of feeding were determined for each postcode area and each maternity unit with greater than 900 deliveries to the year ending 31/3/98 (ISD Scotland). Confidence intervals were calculated for the difference in proportions of breastfeeders between the two time periods. Dr Gray's (a new hospital) was excluded as no comparable figures were available for 1990/91. Hospitals were then split into three groups depending on level of participation in the UNICEF U.K. Baby Friendly Initiative by the beginning of 1999.¹⁶ These groups were: those with a Baby Friendly award, a certificate of commitment, neither of these. Confidence intervals were calculated around the summed improvement in breastfeeding rates from 1990/91 to 1997/98 for each of these groups. For 1997, all addresses without a sector postcode (10%) were re-postcoded from the full address. Then deprivation category (DEPCAT) was assigned.¹⁷ Breastfeeding rates were calculated for each maternity unit and health board area by combining sector postcodes (ISD Scotland). Direct standardisation was performed using Scotland as the standard population. Guthrie card information on: maternal age (four categories: <20 years, 20-24, 25-29, >30), DEPCAT (seven categories: 1-7), and infant age when tested (two categories: <7 days, >6 days) were used to create a table of 56 strata with specific breastfeeding rates for the standard population. Expected number of breastfeeders were then calculated for individual health boards and maternity units. A standardised rate and 95% confidence intervals were calculated by dividing the observed number of breastfeeders by those expected and multiplying by 100.¹⁸ Scotland the standard population has a rate of 100. To be sure that DEPCAT seven and one had not biased standardised rates, a further calculation was made using 40 strata excluding the most affluent (DEPCAT 1) and most deprived (DEPCAT 7) postcode sectors.

Results

Breastfeeding has increased from 35.6% in 1990/91 to 42.0% in 1997/98 (Table 1). The largest increase (11.5%) was seen in Edinburgh and the largest decrease in Aberdeen (-5.5%). The biggest change -bottle to breast- was seen in Perth where nearly 20% of the proportion of women who bottle fed in 1990/91 breastfed in 1997/98.

Table 1. Numbers and percentages of babies born in each postcode area of Scotland in 1990/91 and 1997/98 who were breastfed according to information recorded on Guthrie cards

* and surrounding areas.

Figure 1a shows breastfeeding rate is related to infant age at the time of Guthrie testing. The older the infant the lower the rate of breastfeeding. Figure 1 b indicates that infants were younger when having a Guthrie test in 1997/98 than 1990/91. However if rates of breastfeeding from 1997/98 are assigned to the infant age distribution from 1990/91, the rate of breastfeeding for 1997/98 would be 41.4% compared to the measured value of 42.0%. Thus little of the change in breastfeeding can be explained by change in the timing of the Guthrie test. Figure 2a shows that affluent women in DEPCAT 1 are more than three times as likely to breastfeed than those in DEPCAT 7. However figure 2b shows the 'deprivation distribution' to be unchanged therefore it is not an explanation for an increase in breastfeeding. Figure 3a shows that older women are more likely to breastfeed. There has been an increase in maternal age from a mean of 26 in 1990 to 29 in 1998 (Figure 2b).¹⁹ By using the maternal age distribution from 1990/91 and rates for 1997/98, the breastfeeding rate for Scotland would be 39.4% in 1997/98 compared with the actual value of 42.0%. Therefore 2.6% of the observed 6.4% rise may be explained by a demographic increase in maternal age.

Standardised rates for 1997 (Table 2 and Figure 4 & 5) indicate that East Coast health boards occupied seven of the top eight positions, with only Grampian in the lower half. This pattern remained unchanged when DEPCAT 7 and 1 were removed (Table 2).

Table 2. Breastfeeding rates at 7 days by Health Board for babies who had Inborn Errors Screening during 1997

Table 3 displays standardised breastfeeding rates for 1997 and the increase from 1990/91 to 1997/98 for individual maternity hospitals. Of hospitals in Table 3, Perth Royal Infirmary, the Queen Mothers Glasgow and Ayrshire Central Hospital had achieved the Baby Friendly award. Their combined increase in breastfeeding from 1990/91 to 1997/98 was 8.1% (95% CI 7.0, 9.2). For hospitals which had achieved a certificate of commitment but not the full Baby Friendly award, Forth Park Maternity, Inverclyde Royal, Vale of Leven, Royal Alexandra Paisley, Ninewells Dundee, and Stirling Royal Infirmary, combined increase was 6.1% (95% CI 5.2, 7.0). For hospitals which had not yet reached a certificate of commitment increase was 2.2% (95% CI 1.6, 2.8).

Table 3. Standardised Breastfeeding Rates 1997 and change in breastfeeding rates 1990/91 to 1997/98 from Guthrie cards by hospital of birth*

* - Hospitals with greater than 900 births for year ending 31 March 1998 (ISD Scotland), excluding Dr Gray's Hospital, which had no comparative data for 1990/1991.

Discussion

The prevalence of breastfeeding in Scotland is rising slowly and reached 42% at six to seven days postnatal age by 1997/98. Less than half (2.6%) of the 6.4% rise since 1990/91 can be explained by an increase in maternal age and the change is not due to increased affluence or an artefact of earlier Guthrie testing. The increase is likely to be real and is heartening to all those working to promote breastfeeding in Scotland. It is encouraging to see that babies tested later (10 to 100 days postnatal age, Figure 1) retained a breastfeeding rate of 35%.

Some areas had a large increase and one area, Aberdeen, showed a significant decrease. When looking at standardised rates aimed at overcoming confounding from maternal deprivation, East Coast health boards are doing better than those in the West and Central Regions. This points towards a cultural difference in attitudes towards breastfeeding. Grampian does not adhere to this pattern. Population influx associated with the oil industry may be an explanation.

Some maternity hospitals have shown spectacular improvements, while others have not. Reasons for this disparity are likely to be complex and will depend on both the maternity hospitals and their staff as well as mothers, families and friends. Level of participation in the UNICEF U.K. Baby Friendly Initiative was associated with a significant increase in breastfeeding rates from 1990/91 to 1997/98. This adheres to a dose response with hospitals who achieved the award having greater improvements than those who reached a certificate of commitment who in turn had significantly better improvements than those who had not reached this level. The latter group achieved no better improvement than may have been due to demographic increase in maternal age. All maternity units should be urged to use the Baby Friendly framework¹⁶ as a means to foster breastfeeding.

The Glasgow infant Feeding Audit (1995-1997)²⁰ showed that only 43% of women who booked at Glasgow Royal Maternity Hospital wanted to breastfeed when asked at maternity booking. In 1997/98, (Table 3) 28.5% breastfed to seven days, so 65% (28.5/43) achieved their aim. Sixty percent of women who booked at the Queen Mother's Maternity Hospital wanted to breastfeed and 75% (45/60) achieved their aim. Although a difference in achievement is seen between the two hospitals, it does not reflect the large difference in the standardised breastfeeding rates (115 and 85). This emphasises a cultural difference in attitude towards breastfeeding probably instilled at an early age, which is unlikely to change during pregnancy.²⁰ Interventions prior to pregnancy perhaps at school and within the media need to be developed to change these attitudes. Asking each woman their feeding intention at booking or delivery would assess change in cultural attitudes towards breastfeeding.

Measuring breastfeeding at seven days remains a useful measure of women who have seriously started to breastfeed. Since 1990, this information has been fed back to individual maternity units in Scotland on an annual basis. Women should be encouraged to exclusively breastfeed to four months.¹⁰ The national child health surveillance record is beginning to provide information at six weeks and eight months to measure duration of breastfeeding.²¹

In the eight years, from 1990/91 to 1997/98, the breastfeeding rate in Scotland has increased by 6.4% from 35.6% to 42.0% at seven days postnatal age. Some of this increase (estimate 2.6%) may be due to increase in maternal age. In the eight years to the end of 2005, it seems unlikely that the breastfeeding rate at seven days will reach 50%, it may only reach 45.8% without further demographic changes in maternal age (42.0% + (6.4%-2.6%)). From seven days to six weeks the breastfeeding rate falls.¹² Unless further health promotion measures are implemented quickly, the breastfeeding target for Scotland set by the Scottish Office in 1994 (50% still breastfed at six weeks postnatal age by 2005),¹³ will not be met.

Breastfeeding rates in Scotland are increasing. Maternity units and health boards should be congratulated on their achievements and encouraged to fully engage in the UNICEF U.K. Baby Friendly Initiative as an effective framework to help mothers who want to breastfeed their infants. The Chief Scientist Office, the Medical Research Council and the NHS Research and Development should call for research to find effective ways to change cultural attitudes towards breastfeeding, so that more young men and women want their future offspring to be breastfed.

Figure 1a. Breastfeeding rate (%) by infant age at inborn errors screening in Scotland 1997/98

Figure 1b. Births in Scotland by infant age at inborn errors screening comparing 1990/91 with 1997/98

Guthrie Inborn Errors Screening Card blood tests are taken by Community Midwives in the infant home usually between four and eight days of age. It can be seen that the proportion of tests performed by eight days of age has increased from 89% in 1990/91 to 97% in 1997/98 (Figure 1b). As breastfeeding rate falls with infant age (Figure 1a), earlier sample collection may produce a false increase in breastfeeding rate. By using the proportions of infants tested at different ages in 1990/91 and the breastfeeding rates from 1997/98, the breastfeeding rate for Scotland would be 41.4% compared with the actual value of 42.0%. So little of the observed increase in breastfeeding can be explained by the change in the timing of sample collection. It is encouraging to note that the breastfeeding 'rate remained high in 1997/98 whatever age the infant was tested and was 12% higher (36%) for infants greater than ten days old.

Figure 2a. breastfeeding rate (%) by deprivation category in Scotland 1997 from inborn errors screening cards
Breastfeeding is strongly associated with deprivation. Deprivation Categories¹⁷ are based on data collected in the 1991 Census.

Figure 2b. births in Scotland by deprivation category comparing 1990/91 with 1997/98
There has been no change in deprivation status of births in Scotland between 1990/91 and 1997/98. This information supplied by ISD (Information and Statistics Department, Scotland, Common Services Agency, Edinburgh). Therefore the change in breastfeeding rate between 1990/91 and 1997/98 is not due to change in deprivation status of births in Scotland.

Figure 3a. Breastfeeding rate (%) by maternal age in Scotland 1997/98 from inborn errors screening cards
Breastfeeding increases with maternal age.

Figure 3b. births in Scotland by maternal age comparing 1990/91 with 1997/98
Maternal age has increased from a mean of about 26 years in 1990 to 29 years in 1998. This may explain some of the increase in breastfeeding observed. By using the maternal age distribution from 1990/91 and the breastfeeding rates for maternal ages from 1997/98, the breastfeeding rate for Scotland would be 39.4% compared with the actual value of 42.0%. Therefore 2.6% of the observed 6.4% rise in breastfeeding rate may be explained by the increase in maternal age from 1990 to 1998.

Figure 4. standardised breastfeeding rates for the 15 health boards in Scotland from inborn errors screening cards collected at 7 days postnatal age during 1997
Direct standardisation has been used with the whole population of infants who had an Inborn Errors Screening test during 1997 (n=60,321) used as the standard population. Rates were calculated for three variables: Maternal age, <20 years, 20-24 years, 25-29 years and >30 years; Deprivation category of home address: 1,2,3,4,5,6 or 7; Infant age when tested, <7 days, seven days and above. Fifty-six breastfeeding rates were calculated, and the populations of each Health Board area categorised into the 56 strata. This allowed the expected number of breastfeeders to be calculated. Observed numbers were then divided by the calculated expected numbers and multiplied by 100 to give a standardised breastfeeding rate (SBR). Approximate 95% confidence intervals were calculated using the formula: plus or minus 1.96 x SBR/(Square root of the observed number of breastfeeders).¹⁸

Figure 5. This map displays the health board areas in Scotland with those in the East and North having standardised breastfeeding rates above 100 and those in the West and Central Regions having rates less than 100 (Table 2). Grampian is an exception to this pattern. Glasgow has a rate of 102, better than Scotland as a whole which will be a boost to workers in Glasgow who are actively promoting breastfeeding.

References

1. Standing Committee on Nutrition of the British Paediatric Association. Is breast feeding beneficial in the UK? Arch Dis Child 1994;71:376-80.

2. Paradise JL, Rockette HE, Colborn DK, Bernard BS, Smith CG, Kurs-Lasky M, Janosky JE. Otitis media in 2253 Pittsburgh-area infants: prevalence and risk factors during the first two years of life. Pediatrics 1997;99:318-33.

3. Baker D, Taylor H, Henderson J. Inequality in infant morbidity: Causes and consequences in England in the 1990s. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. J Epidemiol Community Health 1998;52:451-8.

4. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. Relation of infant diet to childhood health: Seven year follow-up of cohort of children in Dundee Infant Feeding Study. BMJ 1998;316:21-5.

5. Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, Kendall GE, Burton PR. Association between breast feeding and asthma in 6 year old children: Findings of a prospective birth cohort study. BMJ 1999;319:815-9.

6. Breastfeeding and obesity: cross-sectional study. von Kries R, Koletzko B, Sauerwald T, von Mutius E, Barnert D, Grunert V, von Voss H. BMJ 1999;319:14750.

7. Fergusson DM, Woodward U. Breastfeeding and later psychological adjustment. Paediatr Perinat Epidemiol 1999;13:144-57.

8. Ball TM, Wright AL. Health care costs of formula feeding in the first year of life. Pediatrics 1999;103:870-6.

9. Riordan JM. The cost of not breastfeeding: A commentary. J Hum Lactation 1997; 13: 93-7.

10. Working Group on the Weaning Diet of the Committee on Medical Aspects of Food Policy. Weaning and the Weaning Diet. London: HMSO, 1994:49.

11. Saadeh R, Betran AP. Global Data Bank on Breast-feeding. Geneva: Nutrition Unit, World Health Organisation, 1996.

12. Foster K, Lader D, Cheesbrough S. Infant Feeding 1995. Results from a survey carried out by the Social Survey Division of ONS on behalf of the UK health departments. London: The Stationery Office, 1997.

13. Management Executive. Local breastfeeding targets. Edinburgh: Scottish Office, MEL (1994) 110:1

14. Ferguson AE, Tappin DM, Girdwood RWA, Kennedy R, Cockburn F. Breastfeeding in Scotland. BMJ 1994;308:824-5.

15. Tappin DM, Girdwood RWA, Kennedy R, Tolland J, Johnstone K, Cowan T, et al. An audit of infants "unscreened" by the neonatal screening system in Scotland during 1991. Screening 1995;3:201-7.

16. Warren J. Progress of support for breastfeeding in Scottish maternity hospitals. MIDIRS Midwifery Digest 1999;9(2):212-4.

17. Carstairs V, Morris R. Deprivation and Health in Scotland. Aberdeen University Press; Aberdeen, 1991.

18. Campbell MJ, Machin D. Medical Statistics: A common sense approach. John Wiley and Sons Ltd, Chichester, 1993.

19. Registrar General for Scotland. Live births and age of mother. Annual Report. 1998.

20. Britten J, Tappin DM, Elton RA. Monitoring breastfeeding rates and setting local targets: the Glasgow experience. Health Bulletin (Edin) 2001;59:29-36

21. Mcinnes RJ, Love JG, Stone DH. Evaluation of a community-based intervention to increase breastfeeding prevalence. J Public Health Med 2000;22(2):138-45.

22. Britten &Broadfoot M. Breastfeeding in Scotland - Statistical Sources. Health Bul (Edinb) 2000;58:11-9.

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