Determinants of breastfeeding practices in Ecuador: implications for localized applications of breastfeeding promotion and policies

Background Best practices in breastfeeding are often not followed in spite of appropriate levels of knowledge and positive attitudes regarding the many benefits of human milk. For a variety of reasons, particular, women do not initiate breastfeeding, suspend breastfeeding early, or initiate complementary feeding earlier than recommended. This paper analyzes breastfeeding patterns in three settings in Ecuador: a suburban parish near Quito, the nation’s capital, urban and rural parts of a province in the Amazonian lowlands, and the province of Galapagos. Methods We analyse data produced by surveys conducted in the three locations, each of which included mothers of infants between 0 and 24 months of age. The surveys collected demographic information and data based on breastfeeding indicators established by WHO. Results Significant differences were found in breastfeeding practices, particularly between the suburban parish near Quito and Galapagos, on one hand, and urban and rural parts of the Amazonian province, on the other. Conclusions Differences among population segments reflect specific opportunities and barriers to practices related to promoting optimal infant health and nutrition. Consequently, regional or local conditions that often are not apparent in national-level data should orient policies and promotion activities in specific populations.


Abstract
Background Best practices in breastfeeding are often not followed in spite of appropriate levels of knowledge and positive attitudes regarding the many benefits of human milk. For a variety of reasons, particular, women do not initiate breastfeeding, suspend breastfeeding early, or initiate complementary feeding earlier than recommended. This paper analyzes breastfeeding patterns in three settings in Ecuador: a suburban parish near Quito, the nation's capital, urban and rural parts of a province in the Amazonian lowlands, and the province of Galapagos.
Methods We analyse data produced by surveys conducted in the three locations, each of which included mothers of infants between 0 and 24 months of age. The surveys collected demographic information and data based on breastfeeding indicators established by WHO. Results Significant differences were found in breastfeeding practices, particularly between the suburban parish near Quito and Galapagos, on one hand, and urban and rural parts of the Amazonian province, on the other.
Conclusions Differences among population segments reflect specific opportunities and barriers to practices related to promoting optimal infant health and nutrition. Consequently, regional or local conditions that often are not apparent in national-level data should orient policies and promotion activities in specific populations.

Background
Many mothers throughout the world do not breastfeed, suspend breastfeeding early, or initiate complementary feeding earlier than recommended by international organizations and most national public health authorities. The World Health Organization [1] recommends that newborns initiate breastfeeding (BF) in the first hour after birth and continue exclusive breastfeeding (EBF) for six months and complementary feeding (CF) for an additional 18 months. The benefits of BF and correct timing of EBF and CF are well established. Human milk is a nutritious and safe food that is easily absorbed and provides appropriate levels of vitamins, minerals, and proteins. Health benefits that accrue to infants include improved nutritional status and survival rates, prevention of infectious disease in infancy and of chronic disease (including diabetes) and obesity in adulthood. Breastfeeding also provides for extension of post-pregnancy amenorrhea and enhanced infant-maternal affective relationships. In social terms, one of the greatest benefits is that BF is free and safe-critical advantages in poor populations [2,3]. Most mothers can and should breastfeed; only in exceptional circumstances is breastmilk contraindicated [4].
Despite these manifold benefits, reported rates of BF are generally lower than would be expected.
Initiation of BF in the first hour after birth occurs in only 44 percent of cases worldwide and appropriate EBF occurs in only 43 percent of cases. Factors associated with less-than-optimal BF, EBF, and CF practices include maternal age, educational level, socioeconomic status, urban residence, characteristics of institutionalized health care, perceived insufficiency of breast milk supply, maternal or infant illness, discomfort or injury, previous BF experience, lack of social support, emotional stress, and the pressure of advertising that touts what are purported to be the advantages of milk substitutes. Maternal employment represents an important barrier to appropriate BF practices when women are obliged (often for economic reasons) to return to work without appropriate conditions for continuation of BF [2,5,6]. This paper analyzes BF patterns in three settings in Ecuador, where the diverse geographical, socioeconomic, and cultural milieu strongly influences health-and nutrition-related behavior in general. This study shows that there are significant regional differences in BF practices related to geographic, socioeconomic, and cultural conditions. While the determinants discussed here may be specific to Ecuador, a similar analysis can be applied elsewhere. This approach is important because we suggest that a subnational approach to BF promotion and policy is necessary in order to effectively address gaps between knowledge, attitudes, and practices that are specific to local contexts. This is an essential point because BF indicators are generally reported at the national level, which limits the ability to obtain accurate estimators for specific age groups and to translate those data into locally appropriate strategies. In contrast, results presented here support the relevance of regional data that can be useful in the design of appropriate BF promotion and policies that reflect social, economic, and cultural specificities. This paper discusses breastfeeding patterns in a suburban parish near the capital city of Quito in the Andean highlands, urban and rural parts of a province located in Ecuador's Amazonian basin, and the island province of Galapagos. First, located in northern highland region, Cumbayá parish is home to a heterogeneous population of long-time residents who maintain rural lifestyles alongside newer, often wealthier residents, many of whom commute 10 km. to Quito, the nation's capital. According to the most recent census, Cumbayá had 31,463 residents in 2010 compared to a total of 21,078 in the previous (2001) census [7], representing a 10-year growth rate of 33%. Although Cumbayá is classified as a rural parish, its close geographical, economic, and social proximity to Quito and the rapid development of office buildings, shopping centres, and residential clusters referred to as urbanizaciones, so that Cumbayá is similar in many respects to North American or European suburbs in terms of access to goods and services, including health care. In 2010, 3.4% of Cumbayá's residents The province of Galapagos is a renowned for its endogenous animal and plant species, but was also home to 25,124 residents in 2010 and 25,244 in 2015 [8,9]. In all, 82.5% of residents live in urban areas, mostly in the two largest cities of Puerto Ayora and San Cristobal. Before regulations were instituted to limit permanent settlement, immigration was rapid, especially from the coastal mainland, although a community of highland indigenous residents also developed, such that 7.0% of Galapageños identified themselves as indigenous in 2010. Galapagos is similar to other tropical parts of Ecuador in terms of climate, but is also place of more rapid, specialized development because of its status as a global tourist attraction. At the same time most of the population lives in the three major urban centers so that the province is relatively isolated in geographic terms and with regard to specialized health care Methods Surveys were conducted in the three locations between August 2017 and August 2018 and included mothers of infants between 0 and 24 months of age, who did not suffer from acute or chronic illnesses, and who volunteered to participate. The questionnaire was adopted from an instrument designed by WHO [1, 10]. Demographic information included the informants' age, marital status, employment, educational level, number of childbirths, and type of delivery. The analysis was conducted using indicators established by WHO [10], which we divide into four groups.
The first group of two indicators are linked because the probability of age-appropriate BF practices is closely associated with successful early initiation.
1. Early initiation of BF: percentage of children born in the past 24 months who were put to the breast within one hour of birth.
2. Age-appropriate breastfeeding: percentage of infants 0-5 months of age who receive only breast milk and of children 6-23 months of age who received breast milk as well as solid, semi-solid, or soft foods during the previous day.
The second group of five indicators reflect appropriate breastfeeding practices during different stages of infancy and early childhood. The third group is composed of five indicators that reflect different aspects of CF.

8.
Introduction of solid, semi-solid, or soft foods (6-8 months): percentage of infants 6-8 months of age who were fed with solid, semi-solid, or soft foods during the previous day.

9.
Minimum dietary diversity (6-23 months): percentage of children 6-23 months of age who received foods from at least 5 out of 8 defined food groups during the previous day.

10.
Minimum meal frequency (6-23 months): percentage of children 6-23 months of age who received solid, semi-solid, or soft foods (but also including milk feeds for nonbreastfed children) the minimum number of times or more during the previous day.

11.
Minimum acceptable diet (6-23 months): percentage of children 6-23 months of age who received a minimum acceptable diet during the previous day.

12.
Bottle feeding (0-23 months): proportion of children 0-23 months of age who were fed with a bottle during the previous day.
The final indicator refers to children who were not breastfed.

13.
Milk feeding frequency for non-breastfed children: proportion of non-breastfed children 6-23 months of age who received a least two milk feedings during the previous day.
The questionnaire was applied in Spanish in Cumbayá and Galapagos, while in some cases, it was applied in indigenous languages in Morona Santiago after validation by trained bilingual interviewers. Sample sizes were calculated considering a standard normal deviation of 1.96, adjusted by expected prevalence of appropriate breastfeeding prevalence for children of 0 -24 months in the regions (e.g. 0.5 in Galapagos [11] and a 5% margin of error [12]. Additional adjustments including finite population size, and non-response rate of 5% in urban areas and 2% in rural areas were applied for each region [13]. These calculations produced a minimum sample size of 256. See Table 1.

Data collection
Trained personnel conducted face-to-face interviews with eligible mothers in Cumbayá, urban and rural Morona Santiago, and Galapagos. Participants in Cumbayá were identified and selected through non-random sampling among women who attended either of two public health centres. For Morona Santiago, a representative sample of rural and urban residents was employed using national census tracks definitions. For Galapagos, a preliminary list of children from 0 to 24 months of age was obtained from government-operated day care centres. In order to reach the required number of children, snowball sampling was applied to obtain additional participants on the Galapagos islands of San Cristobal and Santa Cruz. A total of 279 women were surveyed and 269 valid interviews were included in the analysis.

Data analysis
Indicators for feeding practices are reported using weighted data and calculated using the DHS approach to handling missing data [10]. Data cleaning and post-stratification were performed for the Galapagos and Morona surveys using additional demographic data and a ranking algorithm. To assess differences in indicators between Cumbayá, Galapagos, and urban and rural Morona Santiago, the Tukey Contrast test was used to assesses multiple comparisons of means (MCT) for each pair of surveys in order to determine which means among a set of means differ from the others [14]. The test compares the difference between each pair of means with appropriate adjustments for multiple testing.
Results Table 2  Caesarean sections was high compared to WHO guidelines [15], while in the latter, few women had delivered via Caesarean section.  proportionately, more than half of infants <6 months are breastfed, and that again, the practice is most evident in rural Morona Santiago. Table 3 reports on data related to CF practices. It can be seen that there are no significant differences between Cumbayá and Galapagos, but that there are with urban and rural Morona Santiago, reflecting less appropriate practices in the latter. Finally, panel D reports on milk feeding frequency for non-breastfed infants from 6 to 23 months of age. These data, collected only in Cumbayá and Galapagos, show no significant differences between those two study sites, in that in both places, a large proportion of infants received at least two portions of milk the day before the survey. are not heterogeneous and BF practices may be declining, they may still be protected by the lower rates of Caesareans although conversely, CF practices may be less appropriate due to poorer socioeconomic conditions [16][17][18]. Conversely, while women in Cumbayá and Galapagos have more advantageous access to health services in general, they are more likely to give birth through

Panel C of
Caesarean and in addition, have greater access industrialized milk substitutes and to mass-media advertising.
This analysis provides an understanding of regional or even local conditions that may be obfuscated by national-level data. For example, the proportion of infants who benefitted from timely initiation of BF is quite high in Morona Santiago but surprisingly low in Cumbayá, where mothers can receive prenatal care and give birth in well-equipped private or public hospitals. Ready access to quality health care is clearly advantageous, but at the same time it is contradictory that the rates of Caesarean sections are high, so that early initiation of BF is nearly impossible, which in turn can affect other age-appropriate BF practices. Conversely, CF practices are less adequate in Morona Santiago, where rural mothers, many of them very young, are likely to be poor and hence, may not have access to nutritious complementary foods or to appropriate nutrition and health information.
Optimal BF practices are undermined in many parts of the world by early introduction of industrialized milk substitutes to the detriment of new-borns' health and wellbeing [19]. WHO BF indicators are widely used in a variety of settings, but they are not sensitive enough to provide information on the variability and quality of the diet that children consume at the local level.
Therefore, it may be necessary to investigate more thoroughly the determinants that influence the period of transition from EBF to CF in many settings, when it is essential to introduce appropriate foods that not only guarantee adequate nutrients, but also generate healthy eating practices that will last throughout the life cycle, because even moderately poor nutrition during infancy can lead to irreversible damage [21,22].
The adequacy of CF depends not only on the availability of a variety of foods in the household, but also on the feeding practices of caregivers. Appropriate feeding of infants and young children requires active care and stimulation, where the caregiver is responsive to infants' clues regarding hunger, but also active or responsive feeding. Conversely, inappropriate feeding practices during infancy can lead to inadequate food intake, so it is essential that those responsible for infant care and feeding possess the appropriate skills to promote and stimulate appropriate complementary feeding [13,23]. Many determinants are related to this aspect, including level of mothers' education [24][25][26]. Similarly, it is increasingly clear that behavioural sciences can contribute significantly to positive change among those responsible for CF, using, for example, innovative tools including social media platforms such as Facebook, Twitter, and Messenger to promote appropriate BF behaviours [27]. Finally, the importance of appropriate health services provided by trained personnel in BF protection and promotion cannot be over-emphasized [28].