Breastfeeding Duration and Its Effective Factors in Mothers with Children Aged 30-36 Months in Kerman in 2020

Introduction: Complete cessation of breastfeeding (CCB) at the right time is as important as starting breastfeeding, as well as identifying the factors that affect the duration of breastfeeding, so that breastfeeding promotion programs focus on these causes, to increase mothers' ability and desire to breastfeed. This study aimed to determine the time of CCB and its related factors. Methods: This study was a descriptive-analytical and cross-sectional type. A total of 802 urban and rural mothers with children aged from 30 to 36 months completed the questionnaire. The validity and reliability of the questionnaire were conrmed by Cronbach's alpha of 85%. Data were analyzed using SPSS software version 16. Results: The mean time of breastfeeding was 19.23±7.09 and the median was 22-month-year. About 41% of children were breastfed until 24-month-year. There was a signicant relationship between the time of cessation of breastfeeding with contraception, number of households, place of residence, and weight at 6-month-year at the level of 0.05. Conclusion: Duration of breastfeeding is inuenced by some demographic and cultural factors. The timing of the CCB differs from the suggestions of the World Health Organization (WHO) and religious teachings. Useful interventions are needed to increase the duration of breastfeeding.


Introduction
Shortening the duration of breastfeeding is a serious problem, especially in developing countries, as more than one million children under the 12-month-year die each year from not using breast milk. In Asia, an estimated 300,000-350,000 child deaths could be prevented with optimal breastfeeding and the majority would be under 12 months of age (1). Various studies have shown the effects of breastfeeding to reduce the incidence of various diseases in children. The prevalence of diarrhea and lower respiratory tract infections in breastfed infants is lower than in infants who are breastfed (1).
Various studies have suggested different reasons as barriers to breastfeeding, including not having a su cient amount of milk, maternal employment, stress, isolation, exhaustion, concern about the child's developmental disorder and time commitment to breastfeeding (2-7).
The US breastfeeding continuity index is problematic in the United States. Although the program target (healthy population by 2010) was 25% for continued breastfeeding until 12 months of age, and the 2020 target was 34.1%. Only 25.5% of US mothers report continuing breastfeeding for up to one year, and this gure is less than 10% for less than 18-month-year (8).
A Canadian study found that infants who were exclusively breastfed during hospitalization were breastfed longer than infants who received supplements (mean 11 Month vs. 7 months) (9). A study in Turkey found a correlation between demographic information and breastfeeding attitudes and duration of breastfeeding. There was an inverse relationship between maternal employment and breastfeeding duration (10).
Studies on the duration of breastfeeding and its related factors are limited in Iran, and the few studies that have been conducted differ in the duration of breastfeeding with the recommendations of the WHO. The results of a study conducted in Iran reported mothers with younger and higher education stopped breastfeeding earlier than others (11). In the study of Assarian et al. 50% of infants less than 4 months old and only 35% of infants less than 6 months old were exclusively breastfed (12). In another study, 87% breastfed their infants for 12 months, while only 36% were breastfed for up to 24 months (13).
The problems of malnutrition and growth retardation of children are seen in the two stages of exclusive cessation of feeding and the start of complementary foods and during the CCB. Therefore, this study was conducted for the rst time in Kerman with the aim to determine the time of CCB and its related factors.
The results of this study can be used to determine the pattern of breastfeeding that can help increase the duration of breastfeeding and improve the breastfeeding continuity index up to 2 years of age.

Design and setting
This cross-sectional-analytical study was conducted in Kerman with a population of about 800,000 and 83012 children aged under 5 years. This study was performed in all comprehensive health centers and health houses under the supervision of Kerman city health center from October 15 to Decemer 18, 2020.

Sample Size
In this study, there was a sample of both urban and rural communities. Since the volume of urban to rural population is 5 times, the required sample was selected in the same proportion from each of the rural and urban classes. Therefore, at least 654 samples of s 2 = 32.5 placement with 95% con dence interval and 80% power and d = 0.1, the minimum required sample volume was equal to:

Data Collection
A questionnaire used to collect data, which was designed and used in 2019 at Shiraz University. At the Shiraz university, the opinions of four specialists in pediatrics, nutrition, epidemiology, and social medicine were used to examine the validity, content, and structure of the questionnaire. The reliability of the questionnaire was con rmed by conducting a pilot study on 50 samples by two independent questionnaires, with an interval of one month, to an acceptable level (kappa between 75 to 85% and internal correlation coe cient, between 75 to 98%) (7). This questionnaire consists of 32 questions.
There are 14 questions about parental demographic information, 7 questions about children and 11 questions about time and method of CCB. Inclusion criteria included mothers with children aged 30-36 who were mentally healthy, had breastfed their child at least once and were Iranian nationals, and exclusion criteria included parents who did not have access to a telephone, problems such as deafness, mental retardation or any illness that prevented them from answering the questions correctly. The questionnaire was completed through a telephone interview or visiting the door. Five interviewers who were completely pro cient in the subject and had the necessary ability to communicate and conduct interviews collected data. The duration of each interview was between 20-25 minutes.

Statistical analysis
In this study, due to abnormal data distribution, non-parametric Mann-Whitney U tests were used to compare the means in the two groups and Kruskal-Wallis test was used to compare the means in more than two groups to examine different variables with complete cessation of breastfeeding. Chi-square test was also used to examine the relationship between demographic variables and CCB time. SPSS 16 software was used for data analysis. Signi cance level in the tests was considered 0.05.

Results
Of the 802 children surveyed, most were born at 38 weeks of gestation. 42.5% of the children were the rst child, the age range of mothers was between 18 to 47 years with an average of 31.41±5.50 and the age range of fathers was between 21 to 65 years with an average of 34.97±6.16 years. The demographic characteristics of the participants are given in Table 1.  The reasons for stopping breastfeeding before 24 months along with its descriptive results are presented in Table 3. According to Table 3 the decrease in infant desire was the most common cause of cessation of breastfeeding before 24-months. After CCB, only 359 (46.7%) mothers considered a program for psychological support of their child. Most of the parents who supported the child psychologically used methods such as shopping for toys, parking, cars, and motorcycles, traveling, playing with older siblings, going to grandparents, and buying favorite foods to gain the child's support and forget about the mother's breast.
The results of the study on the timing of CCB in the subgroups of demographic variables are presented in Table 4. According to Table 4, the time of CCB was signi cantly related to the type of contraception that this time in the other group with the group that used condoms (P = 0.006) or natural method (P = 0.032) for contraception, it was statistically different. The number of household members was also effective at the time of CCB. Thus, the time of CCB was different in families of 3 and 4 people (P <0.001). In addition to these variables, the time of CCB in urban and rural families was also different. There was no signi cant relationship between birth weight and the time of CCB. Among the weights of 6, 12, and 24 months, only the weight of the child at the age of 6 months was directly related to the time of CCB. The duration of breastfeeding also increases with weight increasing. For each unit that gained 0.382 month, the duration of breastfeeding was increased (Table 5). In a previous study in Iran, the mean CCB was 21 ± 5.7. The highest time of CCB was 24 months (36.8%) and complete cessation of breastfeeding occurred in 50% of children before 24 months (7). Another study conducted in Golestan of Iran was a median of 22 months and a mean of 20.44 months of CCB (14). The status of the present study is more unfavorable than the studies found. In a study conducted in Tehran, the average duration of breastfeeding was 11.75 months (15). In Haji Kazemi's study, the average duration of breastfeeding was 17.4 months (16). In another study conducted in Iran reported an average duration of breastfeeding of 17.31 months (11). The status of the present study is more favorable than the mentioned studies. Perhaps one of the reasons for the different duration of breastfeeding in different cities of Iran is cultural and social differences, because in this country there are different ethnic and racial groups with different cultures and customs regarding child nutrition.
The point of interest in literature reviewing in Iran is that the duration of breastfeeding seems to have improved in recent years, although there is still a gap of 2 years with the recommendations of the WHO. In Iran, breastfeeding is culturally and religiously important and valuable, and breastfeeding women are more supported in the family. According to studies, the duration of breastfeeding in other Middle Eastern countries is shorter than in Iran. In a study in Turkey, only 12.3% of mothers breastfeed their baby for at least a year, and the average duration of breastfeeding was 7.7 ± 3.3 months (17). In a study conducted in the UAE, the duration of breastfeeding was reported to be 8.6 months (18). Also the rate of breastfeeding up to 12 months in Qatari women has been reported to be 2.4% (19). Perhaps one of the reasons for this was Iran's efforts to establish a National Committee to Promote Breastfeeding, with about 80% of births taking place in Baby Friendly Initiative hospitals in 2008 (20,21). In 1992, "Ten Steps to Successful Breastfeeding" were approved by the World Health Assembly, since that time, foundation of infant nutrition policies at UNICEF and WHO in the form of Baby Friendly Hospital Initiative (BFHI). BFHI takes steps to successfully start breastfeeding infants after birth, as well as to continue breastfeeding in inpatient wards. One of the bene ts of BFHI is the exclusive feeding of infants with breast milk, which will lead to optimal development and health of the child (22).
In this study the most common reasons for mothers to wean their baby before 24 months of age are decreased baby desire, Insu cient milk supply and baby refusal to breastfeeding. In a study conducted in Shiraz province, one of the neighboring provinces of Kerman, Insu cient milk supply and infant refusal to breastfeed were reported as the main reasons for stopping breastfeeding, which is consistent with the present study (23). Another study conducted in Iran, 28% of mothers stated that the reason for stopping breastfeeding was insu cient milk (21). In a study conducted in Qatar, 44% of women mentioned lack of milk as a reason for stopping breastfeeding (19). Other studies have shown that mothers' perceptions of not having enough milk was a reason for stopping early breastfeeding (18, 24,25). Milk production is controlled by the number of breastfeeding times and the baby's demand (26). On the other hand, according to research, nutrition according to the plan may lead to insu cient milk production (27).
Therefore, mothers should be taught appropriate techniques to increase milk, because, even in societies where the diet is poor, most mothers are able to produce enough milk for the proper growth of their babies.
In the present study, a signi cant relationship was found between the time of CCB and natural contraception and condoms. In a study conducted in Gilan, (one of the northern cities of Iran) there was a signi cant relationship between discontinuation of breastfeeding and taking birth control pills (15). The results of Radwan et al.'s study also showed that mothers who used non-hormonal contraceptive methods or had no contraceptive method breastfed their baby for 9-10 months, while mothers who used hormonal contraceptive methods 5.8 ± 7.1 months breastfed their baby(18). In this case, the evidence on the relationship between the type of contraception and cessation of breastfeeding is limited, and there is still insu cient evidence that hormonal methods of contraception have a negative effect on breast milk. In a systematic review of combined contraceptives and breastfeeding, 15 articles were reviewed, some of which considered the use of combined contraceptives to be effective in reducing breastfeeding duration while a number of articles did not show such an effect (28). It seems that more detailed studies are needed to determine the exact effect of hormonal methods of contraception on breastfeeding.
There was a signi cant relationship between place of residence (city or village) and the time of complete cessation of breastfeeding; rural households had a cessation of CCB later than urban. In a study conducted in India, the duration of breastfeeding in rural mothers was longer than in urban areas (29). This relationship was also observed in the researches of Lubala and Thulier (30,31), which are consistent with the present study. This can be due to cultural differences and lifestyles in urban and rural areas as well as rural women having more free time to breastfeed and are mostly housewives.
There was a signi cant relationship between the number of households and the time of CCB. Families of 4 people stopped breastfeeding later than 3 people. The results of a study conducted in the Congo showed that the duration of breastfeeding increases with the birth rate of the child in the family, and in fact the last child has the longest breastfeeding period in the family (32).This may be due to the mother's increased experience and skills compared to breastfeeding in previous children.
In the present study, there was no signi cant relationship between birth weight and CCB. Among the weights of 6, 12, and 24 months, only the weight of the child at the age of 6 months was directly related to the time of complete cessation of breastfeeding. Other studies have shown that babies who had a higher birth weight at the time of CCB were earlier (33,34). Unfortunately, there is not enough evidence to compare but perhaps the reason that six months' weight was associated with an increase in breastfeeding duration is that six months is the time to start complementary feeding for children, and it is believed that if the baby is not gaining weight well, it is a sign of breast milk de ciency and complementary feeding should start earlier. On the other hand, mothers whose six-month-old baby weighs well will realize the adequacy and effectiveness of their milk and are therefore more encouraged to continue breastfeeding for longer.
One of the strengths is that this issue is done for the rst time in Kerman and is one of the few studies that has been done with this volume of samples in Iran. Kerman is wide in terms of geographical distance and there are cultural, economic and social differences in different parts of the city. In order for our sample size to cover all economic and social groups, we selected the desired sample from all centers.
One of the limitations of this research is the limitation in interpreting the results. Also transferring the results of this study with other communities should be done with caution. Another limitation of this study was the timing of the Covid 19 crisis, which was a major challenge for face-to-face data collection, and this prolonged the study process. It was also a retrospective study, and it may be said that there is a gap in the information, but since breastfeeding is an unpleasant process in families, mothers and even fathers remember the whole process well.
One of the good practices that Kerman province has taken to improve the breastfeeding index in recent years is the establishment of a specialized breastfeeding counseling center as a single center, which in comparison with other provinces of the country seems to have had a good effect on increasing the duration of breastfeeding. Therefore, it is suggested that governments establish such centers in communities.

Conclusions
The time of CCB in the present study is relatively favorable. The duration of breastfeeding is in uenced by some demographic and cultural factors. The time to stop breastfeeding completely differs from the recommendations of the WHO and religious teachings, which is 2 full years (24 months), by about 5 months, and it is necessary to take useful interventions to increase the duration of breastfeeding. Also, considering the high importance of breastfeeding, the importance of monitoring and continuous monitoring of this matter and efforts to expand and maintain breastfeeding, as well as expressing the important role of breastfeeding on the health of mother and child is necessary. It can be concluded that parents need speci c and specialized education regarding the duration of breastfeeding and the time of CCB.
The authors state that this article is just a scienti c research and it has not any relationship to government issues and sanctions and we con rm that none of the authors listed on the manuscript are not employed by a government agency that has a primary function other than research and/or education. And None of the authors are not as an o cial representative or on behalf of the government.