This paper analyses breastfeeding patterns in different settings in Ecuador, where the diverse geographical, socioeconomic, and cultural milieu strongly influences local health- and nutrition- related behaviour. While the variables discussed here may be specific to Ecuador, a similar analysis can be applied elsewhere. This study was designed to understand the degree to which breastfeeding indicators, which are generally reported at the national level, may limit the ability to obtain accurate estimators for specific age groups and to translate those data into locally appropriate breastfeeding promotion and policies that reflect social, economic, and cultural specificities.
Study sites
Located in Ecuador’s northern highlands, 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 [12], representing a 10-year growth rate of 33%. Although Cumbayá is classified as a rural parish, due to 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, Cumbayá in many respects resembles North American and 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% [13]. 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 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 [13]. This province is similar to other parts of the country where social change and economic development have proceeded more slowly and where access to health care and other services is limited.
The province of Galapagos is renowned for its endogenous animal and plant species but was also home to 25,124 residents in 2010 and 25,244 in 2015. 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 promulgated 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 [13,14]. Galapagos is similar to other tropical parts of Ecuador in terms of climate, but is also a place of more rapid, specialized development because of its status as a global tourist attraction. At the same time, while the urban population has access to basic public and private health care, the province is isolated from the rest of the country and lacks specialized health care services.
Data and collection and management
Surveys were conducted independently in Cumbayá, urban and rural Morona Santiago, and Galapagos between August 2017 and August 2018. Data collection was conducted by different research groups, and datasets were subsequently standardized and merged through data pooling for this analysis. While different sampling methods were employed, each dataset was representative of the respective subregion. The surveys included mothers of infants between 0 and 59 months of age, who did not suffer from acute or chronic illnesses, and who provided informed consent. The questionnaire was adopted from an instrument designed by WHO [15,16], which collected information on household composition and indicators to assess infant feeding practices for evaluating breastfeeding practices worldwide. Socioeconomic information and birthing history included in the questionnaire provided data on informants’ age, marital status, employment, educational level, number of childbirths, and type of delivery.
Our analysis was conducted using indicators established by WHO [15,16], which we divide into four groups. The first group of two indicators are linked because the probability of age-appropriate breastfeeding practices is closely associated with successful early initiation.
1. Early initiation of breastfeeding: 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.
3. Exclusive breastfeeding (< 6 months): percentage of infants 0-5 months of age who
were fed exclusively with breastmilk during the previous day.
4. Continued breastfeeding: proportion of children 12-15 months who are fed breast milk.
5. Infants ever breastfed: percentage of children born in the past 24 months who were ever breastfed.
6. Continued breastfeeding to 24 months: percentage of children 20-23 months of age who are fed breast milk.
7. Predominant breastfeeding (< 6 months): percentage of infants 0-5 months of age previous day.
The third group is composed of five indicators that reflect different aspects of complementary feeding.
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 non-breastfed 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 0 to 24 months of age in each subregion: 0.5 in Galapagos and 0.48 in Cumbayá and Morona Santiago, using calculations from the national health and nutrition survey [17] and a 5% margin of error [18]. Additional adjustments for finite population size and non-response rates of 5% in urban areas and 2% in rural areas were applied for each subregion [19]. In the case of Galapagos, children above 24 months were not part of study. See Table 1.
Trained personnel conducted face-to-face interviews with eligible mothers in Cumbayá, urban and rural Morona Santiago, and Galapagos. Participants in Cumbayá were recruited opportunistically, identified, and selected through random sampling among women who attended either of two public health centres. Participation was solicited when women entered the health centres and a description of the study was provided along with the informed consent procedure. This process continued until the calculated sample size was reached.
In Morona Santiago, a representative sample of rural and urban residents was employed using national census tract definitions. As in Cumbayá, participants were recruited for voluntary participation and informed consent upon entering public health centres.
In Galapagos, a preliminary list of children from 0 to 24 months of age was obtained from government-operated day care centres. To reach the required
number of children, snowball sampling was applied to obtain additional participants in order to arrive at the required sample size. A total of 279 women were surveyed and 247 valid interviews were included in the analysis.
Data analysis
Indicators for feeding practices are reported using weighted data and calculated using the Demographic and Health Survey (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. The Cumbayá dataset required no adjustment after the field survey. In order to calculate differences in indicators between Cumbayá, Galapagos, and urban and rural Morona Santiago, the Tukey Contrast test was used to assess 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 [20]. The test compares the difference between each pair of means with appropriate adjustments for multiple testing to account for bias between surveys.