Rurality and Breastfeeding: What is the Relationship?
Lucy Denvir StR Public HealthNHS Dumfries and GallowayNovember 2011
Background Evidence for positive health benefits of breastfeeding Local interest in urban / rural health issues National priority agenda (has been HEAT target) Local priority – Breastfeeding Strategy
Aims
Explore and appraise current knowledge in this area
Analyse available relevant local dataAssess implications and provide any
recommendations for policy, practice and future research
Literature Search
Ovid Medline database via ‘The Knowledge Network’
English language articles 1999-2010Search terms: ‘breastfeeding and (urban
or rural*)’59 initial articles, 4 left after inclusion and
exclusion criteria applied
FindingsVery limited transferable knowledge in this
area - most studies based outside UK in developing countries
Whether urban or rural, important factors are:
-Access to information, services and support
-Targeting of areas with lowest rates
-Whole community approach
Relationship with deprivation unclear
Data Methodology
Data from Child Health Systems Programme Pre-School System via ISD.
3 years 07-08, 08-09, 09-10.Dumfries and Galloway - 4463 cases.Individual level data: 6-fold urban/rural
indicator, SIMD 09 quintile, maternal age, feeding method first visit, feeding method 6-8 week review.
Analysis using SPSS.
Results
6-Fold Urban/Rural Classification can be condensed into 2-FoldCategories 1-4 = Urban, 5 and 6 = Rural.
There are no areas in Urban/Rural category 1 (large urban) in D+G
Cross-tabulation and chi-square test for difference in proportions: Chi-square test results all had P-value <0.001 ie probability that these results due to chance is less than 1/1000
Feeding Method at First Visit and 6-8 Week Review by 6-fold Urban/Rural Indicator
0
10
20
30
40
50
60
70
80
2 Other UrbanAreas
3 AccessibleSmall Town
4 RemoteSmall Town
5 AccessibleRural
6 RemoteRural
Urban/Rural Indicator
% F
ee
din
g M
eth
od
Wit
hin
Ea
ch
In
dic
ato
r
Both (first visit)
Both (6-8 weeks)
Bottle (first visit)
Bottle (6-8 weeks)
Breast (first visit)
Breast (6-8 weeks)
Urban Rural
Feeding Method at First Visit and 6-8 Week Review by SIMD 09 Deprivation Category
0
10
20
30
40
50
60
70
80
90
1 MostDeprived
2 3 4 5 LeastDeprived
SIMD 09 Deprivation Category
% F
ee
din
g M
eth
od
Wit
hin
Ea
ch
C
ate
go
ry
Both (first visit)
Both (6-8 weeks)
Bottle (first visit)
Bottle (6-8 weeks)
Breast (first visit)
Breast (6-8 weeks)
Feeding Method at First Visit and 6-8 Week Review by Maternal Age
0
10
20
30
40
50
60
70
80
90
100
<20 20-24 25-29 30-34 35-39 >40
Maternal Age Group
% F
eed
ing
Met
ho
d W
ith
in E
ach
Ag
e G
rou
p
Both (first visit)
Both (6-8 weeks)
Bottle (first visit)
Bottle (6-8 weeks)
Breast (first visit)
Breast (6-8 weeks)
Maternal Age by 6-fold Urban/Rural Indicator
0
5
10
15
20
25
30
2 Other UrbanAreas
3 AccessibleSmall Town
4 RemoteSmall Town
5 AccessibleRural
6 RemoteRural
Urban/Rural Indicator
% A
ge
Gro
up
Wit
hin
Eac
h In
dic
ato
r <20
20-24
25-29
30-34
35-39
>40
Urban Rural
SIMD 09 Deprivation Category by 6-Fold Urban/Rural Indicator
0
5
10
15
20
25
30
35
40
45
50
2 Other UrbanAreas
3 AccessibleSmall Town
4 RemoteSmall Town
5 AccessibleRural
6 RemoteRural
Urban/Rural Indicator
% S
IMD
09
Dep
Cat
Wit
hin
Eac
h In
dic
ato
r 1 Most Deprived
2
3
4
5 Least Deprived
Urban Rural
Results so far!
Relationship between urban-rural indicator and feeding method at first visit and 6-8 week review – rural mothers more likely to breastfeed.
Relationship between deprivation and feeding method – most deprived SIMD 09 quintiles 1 and 2 least likely to breastfeed.
Relationship between maternal age and feeding method – mothers age >30 more likely to breastfeed.
Results contd
BUT:More rural mothers aged >40 and fewer
aged <25.Deprivation relationship less clear, biggest
difference between SIMD 09 quintiles 2 and 3.
So urban-rural mothers have a different age
and deprivation profile – further analysis
required!
Multiple Logistic Regression:
Cases with missing data excluded leaving 4030 for analysis
Reference categories:
Youngest age group (<20 years)
SIMD 09 Quintile 1 (most deprived)
Urban/Rural category 2 (other urban areas)
Variable =Maternal age
Breastfeeding at first visit Breastfeeding at 6-8 week review
P-value OR(95% CI)
P-value OR(95% CI)
20-24 <0.0012.00
(1.37 – 2.93) <0.0012.65
(1.58 – 4.43)
25-29 <0.0013.40
(2.36 – 4.91) <0.0014.35
(2.64 – 7.15)
30-34 <0.0015.26
(3.63 – 7.61) <0.0016.60
(4.00 – 10.86)
35-39 <0.0014.99
(3.39 – 7.34) <0.0016.96
(4.17 – 11.62)
>40 <0.0014.40
(2.69 – 7.20) <0.0016.46
(3.53 – 11.80)
Variable =Deprivation
Breastfeeding at first visit Breastfeeding at 6-8 week review
P-value OR(95% CI)
P-value OR(95% CI)
SIMD09 2 <0.001 1.68 (1.29 – 2.20)
<0.001 1.83(1.32 – 2.52)
SIMD09 3 <0.001 2.26 (1.72 – 2.96)
<0.001 2.56(1.86 – 3.53)
SIMD09 4 <0.001 2.55 (1.92 – 3.37)
<0.001 2.79 (2.00 – 3.89)
SIMD09 5 <0.001 2.47(1.70 – 3.59)
<0.001 2.56(1.67 – 3.91)
Variable =Urban/Rural
Breastfeeding at first visit Breastfeeding at 6-8 week review
P-value OR (95% CI)
P-value OR(95% CI)
3 AccessibleSmall Town
0.002 0.70(0.56 – 0.88)
0.003 0.67 (0.52 – 0.88)
4 Remote
Small Town
0.027 0.70(0.51 – 0.96)
0.181 0.79 (0.55 – 1.12)
5 Accessible
Rural
0.024 1.26(1.03 – 1.53)
0.073 1.22(0.98 – 1.52)
6 Remote
Rural
0.003 1.38(1.11 – 1.70)
0.002 1.44(1.14 – 1.82)
Results
Maternal age and deprivation are significant and independent predictors of breastfeeding at first visit and 6-8 week review
Most marked increase in odds of breastfeeding in mothers age >30 and mothers in SIMD 09 quintile 4
Odds of breastfeeding increased in rural category areas 5/6 in relation to urban areas
Some evidence of rurality as an independent and significant predictor of breastfeeding but this is less certain particularly at 6-8 week review
Conclusions
Good sample size, relatively accurate and complete data
Does not include other important variables eg educational attainment, parity
Some evidence that rurality may be an important predictor of breastfeeding independent of maternal age and deprivation
Breastfeeding determinants are complex and multifactorial and issues such as rural deprivation contribute to the difficulty in identifying vulnerable communities and individuals
Recommendations
Target areas with lowest ratesFlexible and individualised but whole
community approachReplicate study in other areasInclude analysis of other variablesMore research on cultural, attitudinal and
behavioural differences between urban and rural areas
Acknowledgements:
Carolyn Hunter-Rowe (Snr Health Intelligence Analyst)Dr Andrew Carnon (CPHM)Claire Nolan (Information Analyst ISD)
Thanks for listening! Any comments / questions?
☺