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Department of Nutritional Sciences, University of Connecticut, Storrs, CT
2To whom correspondence should be addressed. E-mail: rperez{at}canr.uconn.edu.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • Africa • breast-feeding • parity • pregnancy intention
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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and >40% in
developing countries are unexpected. Thus, the rate of unplanned
pregnancies continues to be high despite advocacy and promotion of
contraceptive use worldwide. In New York State, women (n
= 33,735) with mistimed [odds ratio
(OR)3
= 1.10] or unwanted pregnancies (OR = 1.35) were significantly
(P < 0.05) more likely not to plan to breast-feed
upon discharge from the maternity ward than women who planned their
pregnancies (2)
. The OR for not planning to
breast-feed exclusively were 1.26 and 1.41 for mistimed and
unwanted pregnancies, respectively (P < 0.05). LISREL
analyses based on the 1991 Peruvian Demographic and Health Survey (DHS)
(n = 6020) indicated that breast-feeding duration
among women with unplanned pregnancies was significantly shorter than
among women who planned their pregnancies (3)
.
To our knowledge, there is no published research attempting to
determine whether the association between unplanned pregnancies and
breast-feeding outcomes can also be detected in sub-Saharan
Africa and whether this relationship is modified by parity. Thus, the
objectives of this study were to examine the association between
pregnancy intentions and the likelihood of breast-feeding and
determine whether parity modifies this relationship in Ghana. This West
African nation is ideal for these analyses because it is a country with
a high infant mortality (76 per 1000 births in 1995) and has
on-going breast-feeding promotion campaigns and programs
(4)
.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Data set.
These cross-sectional analyses are based on data from the 1993
Ghanaian DHS, a self-weighted nationally representative survey
(5)
. DHS is a program funded by the U.S. Agency for
International Development, which provides assistance to developing
countries with the design and implementation of nationally
representative surveys, focusing on family planning, infant feeding
practices, and maternal and child health information. Data collection
followed all of the rigorous sampling designs and quality control
procedures established by DHS and was coordinated by the Ghana
Statistical Services from September 1993 to January 1994
(5)
. The survey instrument was divided into two major
sections, focusing on household- and individual-level information.
Data were obtained from 5822 households and 4562 women aged 15–49 y.
Information was collected on demographic and socioeconomic variables;
maternity, reproduction and contraceptive use; breast-feeding,
immunization and health; fertility preferences; and anthropometry. Most
of the infant feeding questions were limited to women with children
born during the last 3 y preceding the survey (n
= 2012).
Statistical analyses.
Data were downloaded from the DHS internet site and subsequently read and analyzed at the University of Connecticut using SPSS for Windows (version 8.0, Chicago, IL).
Because 97% of 12-mo-old children were still being breast-fed,
analyses were based on last-born children who were 13–36 mo old at
the time of the survey (n = 1101). Backwards
stepwise multivariate logistic regression was used to examine the
association between pregnancy intentions [planned vs. unplanned
(mistimed or unwanted) pregnancy] and the likelihood of
breast-feeding at the time of the survey (yes vs. no), and whether
this association was modified by parity. To assess pregnancy
intentions, women were asked: "At the time you became pregnant with
[this] child; did you want to become pregnant then; did you want to
wait until later; or did you want no more children at all?"
(5)
. In our analyses, no differences were found in the
outcome regardless of whether the pregnancy was mistimed or undesired.
For this reason we categorized pregnancies as either "planned" or
"unplanned."
The interaction between parity and pregnancy intentions was tested because we hypothesized that parity is likely to modify the association of pregnancy intentions with the likelihood of breast-feeding. Median breast-feeding durations were estimated by parity and pregnancy intention status on the basis of the predictive curves derived from the logistic regression equations. Curves were generated for multiparous and primiparous women by pregnancy intention status setting covariates at their mean values. Regression results are also presented as OR and their respective 95% confidence intervals (CI). Associations were determined to be significant if the 95% CI excluded the value of 1.
Covariates.
Because breast-feeding is a child age–dependent phenomenon, all
analyses were adjusted for child age and the square function of this
variable. Additional covariates were selected on the basis of
theoretical grounds and empirical data. Socioeconomic status is known
to affect duration of breast-feeding, with affluent mothers
breast-feeding for a shorter period (6
7
8)
. Better
hygienic conditions, higher education of mothers and paid employment
have also been associated with a shorter breast-feeding duration
(6
,7
,9
,10)
. Mothers working away from their infants have
been found to reduce the frequency and duration of breast-feeding,
and may be more likely to bottle feed (9
,11)
compared with
those who have their child in close proximity during work. Finally,
breast-feeding also varies according to region of residence of the
mother and child. Women living in urban areas tend to breast-feed
for a shorter period compared with their rural counterparts
(6
,11
12
13)
.
Sociodemographic and biocultural covariates were as follows: place of residence (urban vs. rural); education level attained (no education vs. primary vs. secondary/higher); child proximity (did not work/work at home vs. work away from home); child age (in months); place of delivery (home vs. hospital/clinic); type of delivery (cesarean vs. vaginal); time after birth at which breast-feeding was initiated (0–24 vs. >24 h postpartum); and total number of children ever born (primiparous vs. multiparous).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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).
|
. Multivariate analysis.
Unplanned pregnancies were significantly and inversely associated with
the likelihood of prolonged breast-feeding (i.e., >1 y of life),
but this relationship was modified by parity (Table 2
and Fig. 1
). Primiparous women with planned pregnancies had a significantly
greater median duration of breast-feeding than their counterparts
whose pregnancy was unintended (21.1 vs. 18.5 mo, respectively).
Among multiparous women, median breast-feeding duration was similar
in both groups (21.5 vs. 21 mo). The following covariates were also
identified as risk factors for not breast-feeding in both sets of
analyses: urban residence, higher formal education, hospital delivery
and older child age (Table 2
and Fig. 1
).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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. Others, however have found an
inverse association between prolonged breast-feeding and infant
anthropometric outcomes. This may occur as a result of reverse
causality because more undernourished infants appear to be selected by
their mothers to be breast-fed for longer (14)
. Risk
factors identified for less likelihood of breast-feeding (i.e.,
urban residence, higher maternal education and hospital delivery) are
consistent with other studies in African countries.
The finding that pregnancy intentions are associated with
breast-feeding outcomes appears to cut across cultures because it
is fully consistent with previous findings from Peru (3)
and New York (2)
. It is possible that women with unplanned
pregnancies may experience psychosocial pressures and stresses that
inhibit them from following desirable public health behaviors such as
timely prenatal care (15
,16)
and committing to
breast-feed for a prolonged period of time. In our study, the
association between pregnancy intentions and prolonged
breast-feeding was found only among primiparae. It is possible that
these women are more susceptible to psychosocial pressures than their
multiparous counterparts who have already had previous child feeding
and rearing experience.
Cross-sectional and retrospective findings from this and previous
studies (2
,3)
may have implications for breast-feeding
promotion programs because they suggest that women with mistimed or
unwanted pregnancies are likely to need additional breast-feeding
support. Longitudinal studies are required, however, to further
understand whether and how pregnancy intentions influence infant
feeding behaviors in different cultures.
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FOOTNOTES |
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3 Abbreviations used: CI, confidence interval; DHS, Demographic and Health Survey; OR, odds ratio.
Manuscript received September 5, 2000.
Initial review completed October 24, 2000.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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1. Grimes D. A. Unplanned pregnancies in the United States. Obstet. Gynecol. 1986;67:438-442[Medline]
2.
Dye T. D., Wojtowycz M. A., Aubry R. H., Quade J., Kilburn H. Unintended pregnancy and breastfeeding behavior. Am. J. Public Health 1997;87:1709-1711
3. Pérez-Escamilla R., Cobas J. A., Balcazar H., Benin M. A. Specifying the antecedents of breastfeeding duration in Peru through a structural equation model. Public Health Nutr 1999;2:461-467[Medline]
4. Academy for Educational Development Country programs: Ghana. Linkages-Annual Report and Work Plan: October 1 1997-September 30 1999 1999:27-30 Academy for Educational Development Washington, DC.
5. Ghana Statistical Service and Macro International, Inc Ghana Demographic and Health Survey: 1993 1994 Accra, Ghana and Calverton MD.
6.
Omondi L. O., Persson L. A., Staugard F. Determinants for breastfeeding and bottlefeeding in Botswana. J. Trop. Pediatr. 1990;36:28-33
7.
Fawzi W. W., Herrera M. G., Nestel P., El Amin A., Mohamed K. A. A longitudinal study of prolonged breastfeeding in relation to undernutrition. Int. J. Epidemiol. 1998;27:255-260
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9. Igbedioh S. O. Influence of mother’s occupation and education on breastfeeding and weaning in infants and children in Makurdi, Nigeria. Nutr. Health. 1994;9:289-302[Medline]
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11. Winikoff B., Laukaran V. H. Breastfeeding and bottle feeding controversies in the developing world: evidence from a study of four countries. Soc. Sci. Med. 1989;7:859-868
12. Osinusi K. A study of the pattern of breastfeeding in Ibadan, Nigeria. J. Trop. Med. Hyg. 1987;90:325-327[Medline]
13. Hinde P. R., Mturi A. J. Social and economic factors related to breastfeeding durations in Tanzania. J. Biosoc. Sci. 1996;28:347-354[Medline]
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Hellerstedt W. L., Pirie P. L., Lando H. A., Curry S. J., McBride C. M., Grothaus M. A., Clark Nelson J. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am. J. Public Health. 1998;88:663-666
16. Braveman P., Marchi K., Egerter S., Pearl M., Neuhaus J. Barriers to timely prenatal care among women with insurance: the importance of prepregnancy factors. Obstet. Gynecol. 2000;95:874-880[Medline]
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