Breastfeeding is the ultimate social leveller in terms of health. I hope, that by the end of this article, you will understand what I mean by this, and hopefully agree! My experiences as a woman, and as a doctor, have led me to research this subject more and more. Everyone seems to be aware of, and accept, the very low rates of breastfeeding in Ireland. 

Now since starting work in general practice in north inner-city Dublin, an area of social deprivation, I have come to realise that a breastfeeding mother coming to the surgery is the exception, not the norm. Breastfeeding is an important health issue related to social inequality, and a very under-researched area at that. I wanted to find out just how related were breastfeeding rates to socio-economic status (SES).

Is breastfeeding really all that good?

The ‘First 1,000 Days’ campaign in Ireland has been emphasising the importance of breastfeeding.¹ Evidence has repeatedly shown the benefits for both infant and mother. Infants have lower rates of infectious diseases, childhood obesity (leading to adult obesity), leukaemia, diabetes, allergies and SIDS and higher IQ (even when maternal IQ is controlled for). Mothers have lower rates of breast and ovarian cancers, postmenopausal fractures and postpartum obesity, to name a few. Economically it makes sense, as one large UK study found that 53% of diarrhoea hospitalisations and 27% of lower respiratory tract infection hospitalisations could have been prevented each month by exclusive breastfeeding. Breastfeeding helps to reduce the infant mortality rate, often an indicator of the socio-economic status of a region. It helps to break the cycle of deprivation. And it is free! 

The WHO recommends exclusive breastfeeding for six months, ie. no solids or formula, and preferably to continue on breast milk up until the age of two years. These recommendations do not just apply to developing countries. Obviously we, as health professionals, emphasise that any amount of breastfeeding is beneficial for the infant and mother. The intention to breastfeed is not only of importance to the individual, but is also an indicator of social behaviour in that community/city/country. As is, for example, exercising regularly and eating healthily. 

The WHO describes breastfeeding as a complex, multifaceted act. It is the cumulation of biological, psychological, social, cultural and economic factors. Dahlgren and Whitehead (1991) discussed a socio-ecological theory to health, known as the ‘layers of influence’. There are multiple spheres, or layers, that surround a mother and baby. The first is personal behaviour, ie. the individual lifestyle factors, which are affected by the norms of the community. The next layer includes the social and community influences, ie. the partner, family, friends, and co-workers, and predominantly, the mothers in each category. Other mothers in the neighbourhood make up the breastfeeding peers. 

As part of the community, GPs are within this layer, which just demonstrates our potential for influence. The third layer includes a broad range of socio-economic, cultural and environmental issues, ie. living conditions, education and employment. It also encompasses provision of, and access to, healthcare facilities. I recently commended a young local woman on breastfeeding her newborn, with little peer support, only to discover that she had never heard of breastfeeding groups, let alone attended one, which was likely to be her main support in the community.

What are the rates of breastfeeding?

Ireland has the lowest breastfeeding rates in Europe. Sad, but true. Data recording of rates is inconsistent nationally, and in the capital. One of the fundamental elements of health promotion is not recorded adequately in this city. Crude figures of breastfeeding initiation rates are recorded in Ireland on the NPRS (National Perinatal Reporting System), this is from the hospital discharge letter, but this is not accurate. There is no official recording system beyond this, unlike in other countries. 

Approximately three-quarters of women in the UK initiate breastfeeding, but half of these women have ceased to breastfeed by two months. Half of women initiate breastfeeding here in Ireland. One large national survey here showed that more than half of breastfeeding mothers stop after one month, and by four months, the rate was only 19%. Rates of initiation are famously more than 95% now in the Nordic countries, but surprisingly, it was not always this way, and breastfeeding there was hit with the same detrimental Nestle promotional campaign in the 1960s as in the rest of the world. However, Norway’s four-month rates are now higher than our initiation rates!

What is the evidence linking socio-economic status and rates of breastfeeding?

Numerous studies have shown that older mothers, in professional jobs, with higher education are more likely to breastfeed.

International evidence

One large Swedish study in 2007 specifically looked at the independent impact of socio-economic status (SES) on breastfeeding duration and rates of weaning.² They referred to breastfeeding as an indicator of social behaviour, and like most social behaviours, it is related to the social conditions that people live in. They observed that low SEG (socio-economic group) was directly related to shorter duration of breastfeeding. Scandinavian evidence has previously shown high breastfeeding rates to be inversely proportional to low rates of unemployment.

In contrast, in developing countries where there would be traditionally based infant feeding, an increase in women in employment has been shown to have a negative impact on breastfeeding.

Another interesting Swedish study described the impact of various perinatal complications on breastfeeding duration, while also looking at SES.³ Even taking into account prematurity of the infant, its size or various neonatal disorders, being adversely exposed to low SES factors was significantly associated with earlier weaning from the breast. 

A large study was carried out in 2006 in California, which looked at SES and breastfeeding initiation.⁴ They noted a marked socio-economic gradient in breastfeeding. They observed that a higher education was more related to higher breastfeeding rates than a higher income.

The UK Infant Feeding Survey is carried out every five years and recorded data is analysed and reported on.⁵ In the UK, people are classified into social groupings based on their (or their partner’s) occupation. In the most recent survey in 2010, over 10,000 women completed questionnaires based on infant feeding. 

Women from social class IV and V had lower initiation and duration rates of breastfeeding. The highest incidences of breastfeeding were found among mothers aged 30 or over (89%); those who left education aged over 18 (92%); those in managerial and professional occupations (91%); and those living in the least deprived areas (89%). In the UK summary rates, they stated that the differences in breastfeeding rates between mothers living in the most and least deprived areas were between 25-30%. 

In the survey, they asked about additional drinks and solids that were given to the babies. There was an interesting correlation. The WHO recommends delaying additional drinks or solids until six months of age. Babies born to mothers in lower SEGs were given drinks and solids at a much earlier age, and this was found to be related to the higher rates of formula feeding in these groups. So the knock-on effect of breastfeeding spans across all aspects of infant nutrition.

National evidence

The Department of Health and Children published ‘Breastfeeding in Ireland: A Five Year Strategic Action Plan for Breastfeeding’ in 2005 with an aim to improve the nation’s health and wellbeing.⁶ Two key targets were to raise the breastfeeding initiation and duration rates by 2% per year, and to increase the breastfeeding rate by 4% per year for the lowest socio-economic families.

In Ireland, there is no comprehensive, reliable source of infant feeding data following discharge, which makes it difficult to monitor trends and measure progress against targets for the duration of breastfeeding. In the Perinatal Statistics Report in 2011, which obtained its figures from the NPRS, breastfeeding was most common among mothers in ‘higher professional’ occupations (63%) and least common among ‘unemployed mothers’ (27.8%), which would be in line with other evidence. 

There is little published data regarding breastfeeding rates in the north inner-city Dublin. One reference was made to a small study by the Rotunda Hospital in 1996, (n = 76) which looked at rates in Ballymun – the initiation rate was found to be just 16%,⁸ while in the socio-economically thriving areas of Millmount and Larkhill, all mothers were reported to have initiated breastfeeding. This study does highlight the geographical divide in breastfeeding rates even within north Dublin. Another study in 1992 reported rates to be lower in the inner city (22%) compared with those living in the outer suburbs (56%). This is clearly an area in need of more reporting and research.

Breastfeeding is more complex than simply making an ‘informed decision’, so what factors influence breastfeeding in areas of social deprivation? The answer is: many of the same determinants that influence other mothers.

One study looked at the opinions of breastfeeding in low-income mothers.⁹ Reluctance to breastfeed was related to the fact that their mother did not breastfeed; they did not know anyone who had breastfed; embarrassment; and their partner’s negative attitudes toward it, which were mainly related to feeding in public and potential exposure. 

Culture is at the core, but I do not refer to ethnicity per se. Breastfeeding is a learned behaviour. It is learned from those around the mother. Culture has multiple dimensions, in terms of attitudes, peers, roles, norms, beliefs and values. Among these lies self-efficacy. 

Self-efficacy is paramount. This is a term I would not have come across much before, but it essentially embodies the psychological aspect from an individual point of view. To have self-efficacy means that the individual has the self-belief, and self-confidence, that they are capable of trying something. And that they have the ability, and confidence, to access resources if they require help. These factors are key in breastfeeding. An individual would need to be highly motivated without peer support. 

Inequalities in nutrition

An article in the British Medical Journal reflected on the overall picture of deprivation and nutrition.¹⁰ Lower SEGs have a higher incidence of premature and low birthweight babies, as well as other health problems, eg. heart disease, stroke and some cancers. Risk factors including lack of breastfeeding, smoking, physical inactivity and obesity can be found clustered in the lower SEGs.

Breastfeeding is increasingly recognised as fundamental for long-term health. However, as in the case of many health issues, those that need it most tend not to receive. The Tudor-Hart inverse care law: “The availability of good medical care tends to vary inversely with the need for it in the population served.”

Numerous studies show that infants born in areas of urban social deprivation have increased rates of illness and mortality and low birthweight. These are inversely proportional to the rates of breastfeeding in these areas. So the socially deprived infants, who need even more protection, are not receiving breast milk. So this is the situation, even with breastfeeding being a free intervention.

Recently, evidence has come from the ‘Growing Up in Ireland’ study, which showed concerning rates of childhood obesity, on a national level, and even more worrying rates in areas of social deprivation.¹¹ One of the major factors that this was related to was low breastfeeding rates in these areas. 

Conclusion

A review of breastfeeding practices was carried out in 2008 looking at a cross-sectional study of 561 women who attended a Dublin maternity hospital.⁸ Only 24% were giving ‘any’ breast milk at six weeks postpartum. Antenatal intention to breastfeed was one of the most important independent determinants of breastfeeding initiation, indicating that the antenatal period should be targeted as an effective time to influence mother’s attitudes and beliefs relating to breastfeeding.

It is ironic to note that Ireland has Europe’s highest birth rate, but the lowest breastfeeding rate. While Scandinavia is demographically different, it is important to note that in the 1970s, their breastfeeding rates were as low as ours.¹² They banned all advertising of artificial formula milk completely, offered one year’s maternity leave with 80% of pay, and on return to work, one hour of a breastfeeding break every day. 

Public and government policies can work! Research has been done into how to influence women of socially disadvantaged areas, and two main points were raised – peer influence and support, and the encouragement, support, and consistent advice of healthcare professionals.

We can aim to ensure that all infants get the same start in life, irrespective of where they are born. It is time to go back to basics. 

References

1. First 1000 days
2. Flacking, Nyqvist, Ewald. Effects of Socioeconomic status on Breastfeeding duration in mothers of preterm and term infants. European Journal of Public Health, 2007;17(6): 579-584 
3. Flacking, Wallin, Ewald. Perinatal and Socioeconomic determinants of Breastfeeding duration in very preterm infants Acta Paediatrica, 2007; 96(8)
4. Socioeconomic Status and Breastfeeding Initiation Among California Mothers, Public Health Rep. 2006; 121(1): 51–59
5. Hamlyn et al, Infant Feeding Survey UK 2000
6. Breastfeeding in Ireland: A five-year Strategic action plan, National Committee on Breastfeeding. (October 2005)
7. Perinatal Statistics Report 2011, Health Research and Information Division 
8. Roslyn, Tarrant, Kearney. Public health nutrition: Breast-feeding practices in Ireland, School of Biological Sciences, Dublin Institute of Technology, Proceedings of the Nutrition Society, 2008; 67: 371-380
9. Interim Report on the National Committee on Breastfeeding, May 2003
10. Socioeconomic determinants of Health: the contribution of Nutrition to inequalities oh Health, BMJ 2007; 314(7093): 1545-1549
11. Growing up in Ireland report 2012, The Department of Children and Youth Affairs
12. The effectiveness of public health interventions to promote the duration of breastfeeding:  A Systematic review, NICE 2005