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 identified themselves as indigenous, compared to the national figure of 7.0% [8]. In sum, this parish is similar to other places characterized by relatively rapid social change and economic development and where access to health care is favourable.
The province of Morona Santiago, located in the southern part of Ecuador’s tropical Amazon region, had a population of 147,940 in 2010, one third of whom lived in urban areas (mostly in the provincial capital of Macas) and two thirds in rural areas. Nearly half (48.4%) of the province’s residents identified themselves as indigenous [8]. This province is similar to other parts of the country where social change and economic development have proceeded more slowly and where vulnerability to adverse health conditions is greater.
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