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6C Breastfeeding Initiation and Duration

Description | Specific Indicators | Corresponding Mandatory Objectives | Corresponding National Indicators | Data Sources |  Alternative Data Sources | ICD Codes | Analysis Check List | Method of Calculation |  Basic Categories | Indicator Comments | Cross-References to Other Sections | References  
 

Description


Initiation: Proportion of mothers aged 15-49 years who breastfed their last baby
(born within last five years)
Duration: Proportion of mothers aged 15-49 years who breastfed their last baby (born within last five years) by duration

 

 

Specific Indicators

  • Breastfeeding initiation
  • Breastfeeding duration of four months or more
  • Exclusive breastfeeding duration of four months or more
  • Breastfeeding duration of six months or more
  • Exclusive breastfeeding duration of six months or more
  • Breastfeeding duration at twelve months

Corresponding Mandatory Objectives

http://www.health.gov.on.ca/english/providers/pub/pubhealth/manprog/manprog.html

  • To increase to 50 per cent the percentage of infants breast-fed up to six months by the year 2010.

Corresponding National Indicators

Data Sources (see Resources: Data Sources)


Numerator & Denominator: Canadian Community Health Survey (CCHS)
Original source: Statistics Canada
Distributed by:
1.       Health Planning Branch, Ontario MOHLTC
2.       Statistics Canada
Suggested citation (see Data Citation Notes):
1.       Canadian Community Health Survey [year], Statistics Canada, Share File, Health Planning Branch, Ontario MOHLTC
2.       Canadian Community Health Survey [year], Statistics Canada, Public Use Microdata File, Statistics Canada

 

Survey Questions


2003 Canadian Community Health Survey (Cycle 2.1):
Question MEX_Q03 (For your last baby), did you breastfeed or try to breastfeed your child, even if only for a short time?  1) Yes, 2) No 

Question MEX_Q02 “Are you still breastfeeding?  1) Yes, 2) No 

Question MEX_Q06 How long did you breastfeed (your last child)?  1) Less than 1 week, 2) 1 to 2 weeks, 3) 3 to 4 weeks, 4) 5 to 8 weeks, 5) 9 to less than 12 weeks, 6) 3 months (12 weeks to less than 16 weeks), 7) 4 months (16 weeks to less than 20 weeks), 8) 5 months (20 weeks to less than 24 weeks), 9) 6 months (24 weeks to less than 28 weeks), 10) 7 to 9 months, 11) 10 to 12 months, 12) More than 1 year

Question MEX_Q06 “How old was your (last) baby when you first added any other liquids (e.g.milk, formula, water, teas, herbal mixtures) or solid foods to the baby’s feeds?  1) Less than 1 week, 2) 1 to 2 weeks, 3) 3 to 4 weeks, 4) 5 to 8 weeks, 5) 9 weeks to less than, 12 weeks, 6) 3 months (12 weeks to less than 16 weeks), 7) 4 months (16 weeks to less than 20 weeks), 8) 5 months (20 weeks to less than 24 weeks), 9) 6 months (24 weeks to less than 28 weeks), 10) 7 to 9 months, 11) 10 to 12 months, 12) More than 1 year, 13) Have not added liquids or solids

 

Alternative Data Sources


Breastfeeding initiation and duration (does not consider exclusivity):

2000/01 Canadian Community Health Survey (Cycle 1.1):
Question BF_Q02 “(For your last baby), did you breast-feed or try to breast-feed your child, even if only for a short time? 1) Yes, 2) No” 
Variable Name: BRFA_02

Question BF_Q03 “Are you still breast-feeding? 1) Yes, 2) No” 
Variable Name: BRFA_03

Question BF_Q04 “How long did you breastfeed (your last child)? 1) Less than 1 week, 2) 1 to 2 weeks, 3) 3 to 4 weeks, 4) 5 to 8 weeks, 5) 9 to less than 12 weeks, 6) 3 to 6 months, 7) 7 to 9 months, 8) 10 to 12 months, 9) More than 1 year
Variable Name: BRFA_04

1990 Ontario Health Survey
Provides data on breastfeeding initiation from women aged 16-44 years who had given birth in the last 15 years.
Variable F5Q85A: “Did you breast-feed your last child?” 
Variable F5Q85B: “How long did you breast-feed your last child? 1) Less than 1 month, 2) 1-3 months, 3) 4-6 months, 4) More than 6 months” 

Rapid Risk Factor Surveillance System (RRFSS) - Optional module
The breastfeeding module provides data on breastfeeding initiation and duration from women aged 18-49 years who have given birth in the last 5 years.
Question rh8: “(For your last baby), did you breastfeed or try to breastfeed your child, even if only for a short time?” 1) Yes, 5) No, d) don't know, r) refused
Question rh9: “Are you still breastfeeding?” 1) Yes, 5) No, d) don't know, r) refused
Question rh10: “How long did you breastfeed (your last child)?” @day Enter number of DAYS, @week Enter number of WEEKS, @month Enter number of MONTHS, @year Enter number of YEARS.

Breastfeeding initiation only:

1996/97 Ontario Health Survey
Provides data on breastfeeding initiation from women aged 15-49 years who had given birth in the last 2 years (since the last interview in 1994/95).
Question SGH2-Q4 “(For your last baby), did you breast-feed or try to breast-feed your child, even if only for a short time? 1) Yes, 2) No”
Variable Name: ghs6_24

Niday Perinatal Database
Breastfeeding – indicates whether the woman intended to breastfeed on admission (regardless of whether any feeding occurred). Response options: yes, no, unknown.
Other related indicators in the Niday Perinatal Database that are to be added to the database:
Infant feeding in hospital: unknown; breastmilk only; combination of formula and breastmilk; formula only; other.
Infant feeding – reason for substitute: none; breast reconstruction/surgery; clinical evidence of severe dehydration; hypoglycemia unresponsive to feeding; inborn errors of metabolism; infant unable to feed at breast; mom taking contraindicated medication; separation of mom and baby; severely ill mother; other.
Infant feeding – on discharge: unknown; not applicable; breastmilk only; combination of formula and breastmilk; formula only; other.

Integrated Services for Children Information System (ISCIS)
Available from the ISCIS extract, for both ISCIS 1.0 and ISCIS 2.0: Infant feeding at discharge.

 

Analysis Check List

  • Because only women who gave birth in the past five years are asked questions about breastfeeding, there are a large number of respondents who are not applicable. Check cell sizes carefully since results may not be reportable.

  • The 2003 CCHS asks women aged 15-15 years whether they gave birth in the past year. Include only women aged 15-49 years.

  • Analysis of breastfeeding duration requires collapsing many categories. 
    - For breastfeeding duration of four months or more, using the CCHS 2003, collapse categories 7 thru 12, with categories 1 thru 6 being “less than four months”. For breastfeeding duration six months or more, collapse categories 9 thru 12, with categories 1 thru 8 indicating breastfeeding duration of “less than 6 months”. Since women who are still breastfeeding are excluded from the duration question, and their duration cannot be determined, they can either be excluded (not applicable) or, if there is sufficient cell size, included as their own category of “still breastfeeding”. Clearly document.
    - For exclusive breastfeeding, include Question MEX_Q06.

  • Before releasing and/or publishing CCHS or OHS 1996/97 data, users should ensure that the number of sampled respondents who contributed to the estimate is at least 10 (when bootstrapping) or 30 (when using C.V. tables), regardless of the estimate’s coefficient of variation. For estimates based on sufficient sample size, determine the coefficient of variation of the rounded weighted estimate and follow the guidelines below: 

  • Acceptable (0.0 - 16.5) Estimates can be considered for general unrestricted release. Requires no special notation. 

  • Marginal (16.6 - 33.3) Estimates can be considered for general unrestricted release but should be accompanied by a warning cautioning of high sampling variability. 

  • Unacceptable (greater than 33.3) Statistics Canada recommends not releasing estimates of unacceptable quality. However, if the user chooses to do so then estimates should be flagged and the following warning should accompany the estimates: “The user is advised that . . .(specify the data) . . . do not meet Statistics Canada’s quality standards for this statistical program. Conclusions based on these data will be unreliable and most likely invalid”. These data and any consequent findings should not be published. If the user chooses to publish these data or findings, then this disclaimer must be published with the data.

  • The release guidelines for the 1990 OHS are slightly different: No qualification (C.V. less than 16.6), Qualified estimate (C.V. of 16.6 – 25.0), Suppress estimate (C.V. greater than 25.0).

Method of Calculation


Breastfeeding initiation: 

Total weighted number of women aged 15-49 years who gave birth in the past five years who breastfed or tried to breastfeed their child

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 Breastfeeding duration of four months or more: 

Total weighted number of women aged 15-49 years who gave birth in the past five years and who breastfed their child for at least four months

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 Exclusive breastfeeding duration of four months or more: 

Total weighted number of women aged 15-49 years who gave birth in the past five years and who breastfed their child for at least four months and who did not add any other liquids or solid foods to the baby’s feeds until at least four months

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 Breastfeeding duration of six months or more: 

Total weighted number of women aged 15-49 years who gave birth in the past five years and who breastfed their child for at least six months

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 Exclusive breastfeeding duration of six months or more: 

Total weighted number of women aged 15-49 years who gave birth in the past five years and who breastfed their child for at least six months and who did not add any other liquids or solid foods to the baby’s feeds until at least six months

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 Breastfeeding duration of twelve months or more: 

Total weighted number of women aged 15-49 years who gave birth in the past five years and who breastfed their child for at least twelve months

* 100

Total weighted number of women aged 15-49 years who gave birth in the past five years

 

Basic Categories

  • Breastfeeding duration from CCHS 2003: four months or more, six months or more.

  • Exclusive breastfeeding, non-exclusive breastfeeding.

  • Geographic areas for: CCHS – all 37 Public Health Units and16 District Health Councils in Ontario; 1996/97 OHS – 23 health areas; 1990 OHS – all 42 Public Health Units and 32 District Health Councils that existed at the time.

Indicator Comments

  • As stated by the World Health Organization (see: http://www.who.int/child-adolescent-health/NUTRITION/infant_exclusive.htm), breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. A review of the evidence1 has shown that, on a population basis, exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond.

  • The Breastfeeding Committee for Canada endorses exclusive breastfeeding to the age of six months and provision of safe, appropriate, and locally available complementary foods, with continued breastfeeding for up to two years of age and beyond. This is consistent with recommendations of the World Health Organization.2

  • Similarly, The Canadian Paediatric Society, Dieticians of Canada and Health Canada recommend exclusive breastfeeding for at least the first four months of life, and continuing breastfeeding and complementary foods for up to two years of age and beyond.3 

  • The primary data source for this indicator is the CCHS because data are available for all public health units, with Ontario data available for comparison. Some health units conduct their own surveys to assess breastfeeding in their local area but would not be able to compare their results with other areas and the province. On the other hand, the number of women who are asked about breastfeeding in the CCHS may be too small to assess at the local level, particularly for breastfeeding duration. Other data sources, if available, may be more useful.

  • Although the CCHS directed its breastfeeding questions to women aged 15-55 years, this indicator only includes women aged 15-49 years to maintain consistency with other  indicators. Very few women aged 50-55 have had a baby in the last five years.

  • The CCHS asked breastfeeding questions of women aged 15-55 years who had given birth within the past 5 years, whereas the 1996/97 OHS asked women aged 15-49 who had given birth in the past two years and the 1990 OHS asked women between 16-44 who had given birth to their last child within the past 15 years. The 1996/97 OHS did not assess breastfeeding duration, only initiation. Because of differences in age groups and questions, comparisons between surveys should be done with caution.

  • The categories for breastfeeding duration differ in the 2000/01 CCHS and 2003 CCHS. Because of the way duration categories were divided in the CCHS 2000/01 with category 6 being “3 to 6 months” and category 7 being “7 to 9 months”, it is difficult to determine the percentage breastfeeding four months or more, and six months or more. It is also not clear in which response category women who breastfeed 6 ½ months would fall. As a result, two indicators are used: breastfeeding duration of at least three months, and breastfeeding over six months. The CCHS 2003 was improved to include more categories with “3 months”, “4 months”, “5 months” and “6 months” all separate. These categories are more appropriate for determining breastfeeding at four months and six months. It is not clear how these differences may affect the comparability of the two surveys. It is recommended that CCHS 2003 data be used, rather than CCHS 2000/01. 

  • The CCHS 2003 has an additional question that allows exclusivity of breastfeeding to be assessed.

  • The draft Mandatory Health Programs and Services Guidelines (January 2003 version) has the following objectives:
    1. The breastfeeding initiation rate will be increased to 90%.
    2. The rate of exclusive breastfeeding at 4 and 6 months will be increased.
    3. The rate of breastfeeding at 12 months will be increased.

  • The indicators match these objectives; however, the sample size for the last objective related to breastfeeding at 12 months would be too small to report at the local level.

  • Definitions of breastfeeding initiation vary. Initiation may entail “trying” to breastfeed or may require successful breastfeeding initiation.

  • The CCHS asks about breastfeeding rather than feeding breast milk. Some women may pump breast milk to feed their baby if they are having difficulty getting the baby to feed from the breast. It is not clear how these women would answer the questions.

  • Prior to being asked about breastfeeding duration, the CCHS asked women whether they were still breastfeeding. It is not possible to calculate duration for these women because only the year of birth of the child is available (see Analysis Check-List). 

  • In the CCHS, only one child per woman is considered. The denominator is the number of women who gave birth in the past 5 years, not the number of children born. A woman could have more than one child in that time but specifying the most recent child helps to determine which child is considered. Presumably, the youngest child is also considered in the case of multiple births.

Cross-References to Other Sections

  • None

 

References

  1. Kramer MS, Kakuma R. The Optimal Duration of Exclusive Breastfeeding: A Systematic Review. World Health Organization, 2002.

  2. The Breastfeeding Committee for Canada – The National Authority for the WHO/Unicef Baby Friendly™ Hospital Initiative (BFHI) in Canada.
    See: http://www.breastfeedingcanada.ca/html/contents.html

  3. Canadian Paediatric Society, Dieticians of Canada and Health Canada. Nutrition for Healthy Term Infants. Minister of Public Works and Government Services, Ottawa, 1998. (Reaffirmed March 2004).
    Available at: http://www.cps.ca/english/statements/n/breastfeedingmar05.htm

Date of Last Revision:  July 30, 2004

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