Investigation of observed increases in breastfeeding rates in deprived areas

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Chief Scientist Office Form 4

Final report

form

CSO reference number:

Please complete this form in Verdana 10 point font size

Project title: Investigation of observed increases in breastfeeding rates in

deprived areas

Start date: 1 July 2010 Finish date: 30th June 2011

Investigators:

Mr Bruce Whyte Glasgow Centre for Population Health

Dr Pauline M Craig NHS Health Scotland (formerly Glasgow

Centre for Population Health)

Dr James Chalmers Information Services, NHS National

Services Scotland

Structure of final report:

1. Summary

This study had two aims. It sought to explain increases in breastfeeding in selected

neighbourhoods in Glasgow and, it aimed to provide new analyses of breastfeeding

trends across Scotland through the creation of a new child and maternal linked dataset.

A contextual analysis of the Glasgow neighbourhoods identified important compositional

changes in the population of each area that are likely to have affected trends in

breastfeeding. However, in two of the areas, Greater Gorbals and Govanhill, there were

rises in breastfeeding among British born mothers and mid-aged and older mothers that,

additionally, may reflect the potential positive influence of a ten year ‘peer support’

breastfeeding initiative.

Through this study a new child and maternal linked dataset has been created. The

analysis of this resource has highlighted the influence of a range of demographic, socio-

economic, lifestyle-related, birth and neo-natal related factors on types and duration of

infant feeding. Older mothers, mothers living in less deprived areas, those in higher

status jobs, those married or living with a partner, mothers who did not smoke, mothers

who were not obese or underweight and those born outside the British Isles or with a

non-British ethnic origin had higher levels of exclusive breastfeeding.

Many of the factors that predict likelihood of breastfeeding are known from the existing

literature, but have not been described before for a Scottish population. This new linked

dataset is a rich resource that could be developed and analysed further to improve

understanding of infant feeding in Scotland and, for example, its likely impact on infant

health.

2. Original aims

Our aims were to:

explain increases in breastfeeding rates observed between 1997 and 2009i in fiveii

selected neighbourhoods within NHS Greater Glasgow and Clyde.

i The period of analysis has been extended from 1997-2006 proposed in the original SCPHP application to

1997-2009 due to access to more recent linked and administrative data. ii Originally there were 4 selected neighbourhoods. However to bring greater clarity to the contextual analysis

Greater Gorbals and Govanhill, which were previously combined, were split and analysed separately.

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investigate new ways of analysing breastfeeding trends across Scotland making

use of linked data.

We have attempted to answer four specific research questions.

Q1 Has the population composition of the neighbourhoods changed between 1997 and

2009 in ways that might impact on breastfeeding rates, such as changes in

deprivation, household structure, housing tenure and population movement?

Q2 What are the best data sources and analytical methods to use to understand

breastfeeding trends in Greater Glasgow and Clyde?

Q3 What is the impact of maternal age, previous breastfeeding history, deprivation and

ethnic background on likelihood to breastfeed and length of breastfeeding in these

neighbourhoods and in Scotland as a whole?

Q4 Can we improve on the current Scottish measures of breastfeeding trends by

employing alternative sources such as those used in this project?

3. Methodology

In order to answer the first research question we undertook a contextual analysis of

selected neighbourhoods in Greater Glasgowiii by gathering a range of demographic,

housing and socioeconomic data from national and local sources. Trends and patterns in

these data were analysed for the period 1997-2009 and related to changes in patterns of

infant feeding over the same period. A draft report of this work has been completed and

a summary of the findings is included in the results section of this report.

To address the second research question we initially undertook a detailed quality

assurance of a child health surveillance dataset iv. This identified strengths, weaknesses

and gaps in this data source prior to linkage and subsequent analysis. A draft report of

this work has been written and will be published on the GCPH website.

Our next step was to plan and undertake a linkage to create a new child and maternal

linked dataset for Scotland. An application was made to NHS National Services

Scotland’s Privacy Advisory Committee requesting a linkage of child and maternal data

schemes in February 2010. This was approved in May 2010.

Working in collaboration with ISD Scotland, a record linkage applying probability

matching techniques (Gill and Baldwin (1987), Newcombe et al. (1989), Kendrick and

Clarke (1993), Kendrick (1997), Blakely and Salmond (2002), Mason and Tu (2008))

was undertaken to create a new child/maternal linked dataset . This new dataset

combines General Registrar of Scotland (GROSv) birth records, maternal obstetric

discharge records (SMR02), Neonatal discharge records (SMR11), Scottish Birth Records

(SBR), Scottish Still Birth and Infant Death Survey (SSBID) records and Child Health

Surveillance Programme – Pre-school System (CHSP-PS) records. The dataset covers all

Additionally, initially only South Lenzie was to be included, but during data collection it was decided to widen

the study area to the whole of Lenzie, by including North Lenzie – which is similar socio-economically and had

high rates of breastfeeding, although no notable upward trend - in order to provide more robust figures for a

larger population. iii The neighbourhoods were Govanhill, Greater Gorbals (both in South East Glasgow), Sighthill, Roystonhill &

Germiston (in North Glasgow), Lenzie (in East Dunbartonshire) and, Temple & Anniesland (in West Glasgow)

These neighbourhoods were selected because health profiles (Whyte B, 2008, GCPH) had identified increases in

rates of any breastfeeding in these areas between 1997-99 and 2004-06. iv CHSP-PS - Child Health Surveillance Programme Pre-School System v Now National Records of Scotland (NRS)

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births in Scotland in the period 1997-2009. Figure 1 provides a summary of the

linkagevi.

Figure 1 Linkage Summary

Additional variables were appended to the new child and maternal linked dataset after

linkage:

a name classification algorithm, Onomap (Mateos, Webber and Longley (2007)) was

applied to the dataset to create a marker of maternal and paternal ethnic and

cultural background

geographical and deprivation variables were added

the dataset provided to the research team was anonymised and a random ID number was created for every child

The quality assurance and linkage, alongside the analyses described in the next section,

help to answer the question we have posed regarding the best data sources and

methods for understanding breastfeeding trends in Greater Glasgow and Clyde.

The third research question was aimed at discovering the impact of a range of factors on

likelihood and duration of breastfeeding. There were several parts to our approach.

vi

Further details of the linkage methodology are available in a separate report which will be published on the

GCPH website.

613,900

Child Health Records

SMR11 records

GRO birth records

SBR

SSBID

GRO SBID

CHI database

Each child health record is linked against the maternal and neonatal database and can find a best match against any record type. The vertical arrow shows that once a best match is found to any record type, the record can indirectly link to all other record types within that mother/baby patient group

All record types within a mother/baby group are permanently linked together in the maternal and neonatal linked file

Initial linkage of GRO birth records to CHI database allows CHI number to be added to each birth record in the linked maternity file.

Maternal & Neonatal

Linked Database

SMR02 records

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A detailed literature review was undertaken. The review looked at the policy context

relating to infant feeding internationally and in Scotland, investigated issues of

measurement and sought evidence from the literature on factors that could influence

breastfeeding.

The main analytic phase of the project involved using the newly created child and

maternal linked dataset to undertake a series of analyses of infant feeding trends in

relation to a range of socio-economic, child-related and maternal factors (or predictive

variables). Analyses were initially carried out on a univariate basis to quantify the

relationship between predictive variables and different types of infant feeding - exclusive

breastfeeding, mixed feeding and bottle feeding. The main source of information on

infant feeding has been CHSP-PS data, which has allowed analysis of infant feeding at

different stages from birth through to the 6 to 8 week review.

Subsequently, these demographic, maternal and infant health variables were input into a

multivariate model and used to predict breastfeeding using manual and step-wise

(forwards) logistic regression (STATA v11).

An answer to research question 4 – ‘Can we improve on the current Scottish measures of

breastfeeding trends by employing alternative sources such as those used in this

project?’ – is given in the discussion and conclusions based on the overall findings from

the project.

4. Results

Contextual analysis

In this analysis we have examined both contextual factors (e.g. house building,

deprivation) and compositional factors (e.g. ethnicity, age of mothers) in the study

neighbourhoods and how these have changed over the period 1997-2009. Breast-

feeding rates are likely to be affected by a range of factors, including ethnicity, culture,

age, education, health, economic status, social networks, etc. Our methods do not

establish causation but do allow explanations of trends to be postulated that are firmly

rooted in relevant data.

Four areas included in this study were included in a Glasgow Breastfeeding Initiativevii

which was initiated via GP services between 1997 and 2000 and continued until 2007viii.

The project aimed to increase the duration and level of breastfeeding at 6 to 8 weeks in

participating localities. All of the selected neighbourhoods had been identified from

GCPH’s health profiles (Whyte B, 2008) as showing increases in breastfeeding at 6 to 8

weeks over the last decade; with the largest and most sustained increases occurring in

Greater Gorbals and Govanhill.

From the evidence gathered within the contextual analysis, summarised in Appendix 1, it

seems likely that in Govanhill changes in population composition – more mothers born

outside Britain and more births to older mothers – possibly coupled with the impact of

the peer support initiative on some maternal groups (e.g. British born mothers), have

contributed to increases in breastfeeding.

In Greater Gorbals, it is possible that breastfeeding trends have been influenced by a

combination of compositional changes and other factors – such as the Greater Glasgow

‘peer support’ breastfeeding initiative. For example, breastfeeding at birth among British

born mothers rose from 38% in 2001/2003 to 42% in 2007/2009, and at first visit

increased from 27% in 1997/1999 to 43% in 2007/2009ix. There was also evidence of a

vii The Glasgow Breastfeeding initiative was set up in parts of Greater Glasgow – mainly Gorbals, Govanhill and the Riverside LHCC. The initiative was set up in Greater Gorbals/Govanhill in 1997, in Sighthill/Roystonhill (but only for mothers registered with a Townhead GP) in 1997 and in Temple and Anniesland in 2000 as part of the Riverside LHCC. Linda Wolfson (Infant Feeding Coordinator, NHS Greater Glasgow and Clyde) personal correspondence viii Information provided by Marion McPhillips, Gorbals Health Centre ix 3 year rolling rates used to adjust for small numbers

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sustained increase in levels of breastfeeding among mid-aged mothers (25-34 year old)

and older mothers (35 years and over) at birth – see Figure 2 - and at first visit.

Figure 2 Breastfeeding trends at birth by maternal age, Greater Gorbals

Greater Gorbals: Any breastfeeding (exclusive and mixed) at birth by maternal age

2001/2003 - 2007/2009 Source: CHSP-PS, SMR02, GROS/ISD Scotland linked extract

37% 38%30%

37%47%

59% 64% 60%

77% 74%

46%45%45%

64%66%65%65%60%58%

69%64%

0%

20%

40%

60%

80%

100%

2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009

Year of birth

Infa

nts

(%

)

Less than 24 years 25 - 34 years 35 years +

In the three other neighbourhoods, a variety of socio-economic and breastfeeding trends

were identified. In Sighthill, Roystonhill and Germiston, it is likely that increasing

population diversity, older mothers and a less deprived population have contributed to

the rise in breastfeeding in the last decade. There has also been a notable increase in

mixed feeding, particularly among non-British born mothers.

In Temple and Anniesland, population composition has remained relatively stable,

albeit the population has become slightly more ethnically diverse. Exclusive

breastfeeding and mixed feeding have increased, but only marginally. There have been

increases in any breastfeeding among older mothers.

In Lenzie, the most affluent of the selected neighbourhoods, breastfeeding levels have

remained high and have not changed greatly in the last ten years. The population,

which is largely of British origin, has remained relatively stable.

Linkage

The child and maternal linked dataset created for this study was the key resource for

analysing infant feeding both nationally and locally.

The final child and maternal linked dataset contained 731,611 records relating to

children born in Scotland between 1997 and 2009, including 613,900 child health

records with links to other records. This difference is because the child health data set

does not have national coverage (currently 85%)x.

Figure 3 provides a diagrammatic summary of the main outcome and predictor variables

that have been analysed from the final linked dataset.

x There are currently 12 participating Boards in the Child Health Surveillance Programme Pre -School System covering 85% of Scotland’s pre-school population.

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Figure 3 Overview of data schemes

Literature Reviewxi

There is considerable evidence and policy support for breastfeeding as the main source

of nutrition in the first 6 months of life. The practice of infant feeding is greatly affected

by the socio-cultural and demographic characteristics of the mother. Influential factors

include age, education, deprivation, maternal physical and psychological health,

maternal and societal beliefs/ attitudes, social networks and experience of health care.

Evidence specific to the Scottish context is relatively sparse, although some research has

been carried out using the Infant Feeding Survey (Bolling K et al (2007)), Growing Up in

Scotland (Bradshaw P at al (2008)) and various ISD held datasets.

It was noted that there are still information gaps (particularly in Scotland) on the feeding

practices and effective interventions in deprived areas; the role of supportive

environments; media campaigns and non – health sector interventions in promoting

breastfeeding.

Univariate analyses

Our analysis has highlighted the influence of a range of demographic, socio-economic,

lifestyle-related, birth and neo-natal related factors on types and duration of infant

feeding. Across Scotland, older mothers, mothers living in less deprived areas, those in

higher status jobs, those married or living with a partner, mothers who did not smoke,

mothers who were not obese or underweight and those born outside the British Isles or

with a non-British ethnic origin had higher levels of exclusive breastfeeding.

In contrast, bottle feeding correlates with almost the polar opposite of these

characteristics. Additionally, mode of delivery, parity, length of maternal stay in hospital,

gestation and infant health also clearly influenced type and duration of infant feeding.

xi The literature review is being reviewed and will be published on the GCPH website as a working paper

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The following graphs illustrate a sample of these findings in relation to ethnic origin,

marital status and maternal weight.

Figure 4, based on Scottish data, illustrates an expected decline in exclusive

breastfeeding with time from birth but also that levels of exclusive breastfeeding were

higher among non-British born and non-British originxii mothers and in contrast were

lowest among mothers who were British born and of British origin.

Figure 4 Breastfeeding trends by ethnicity

Scotland: Breastfeeding trends (exclusive) and maternal ethnicity and place of

birth

2001 - 2009 Source: GROS Births, ONOMAP, CHSP-PS/ISD Scotland linked extract

79% 76%

59%51%

63%70% 67%

47%42%

54%63% 60%

39%35%

47%48% 46%

27% 24%34%

0%

20%

40%

60%

80%

100%

Non-British birth and

Non-British origin

Non-British birth and

British origin

British birth and Non-

British origin

British birth and British

origin

Unknow n birth or

origin

Maternal background

Infa

nts

(%

)

Birth Hospital discharge First visit 6 to8 week visit

Figure 5 illustrates two trends: the reduction in exclusive breastfeeding (in Greater

Glasgow and Clyde) with time from birth and also a gradient in levels of exclusive

feeding - from married mothers who have the highest levels of exclusive feeding to

single mothers (sole registrations) with the lowest.

Figure 5 Breastfeeding by marital status

NHS GG&C: Breastfeeding (exclusive) trends and

marital indicator 2001 - 2009 Source: GROS, CHSP-PS/ ISD Scotland linked extract

66%

43%27% 28%

17% 18%13% 15%7% 9%

55%

32%47%

26%35%17%

0%

20%

40%

60%

80%

100%

Married - to each other Joint registration - Same

address

Joint registration -

Different address

Sole registration

Marital indicator

Infa

nt

reco

rds

(%)

Birth Hospital discharge First visit 6 to 8 w eek review

Figure 6, based on Scottish data, illustrates that levels of exclusive breastfeeding were

higher among infants of mothers of normal weight and overweight mothers compared to mothers

who were obese or underweight mothers.

xii

This description is derived from applying, ONOMAP, a programme which uses a ‘name clustering technique’

to classify mothers into common cultural, ethnic and linguistic groups using a combination of forename and

surname. The combination of ONOMAP and country of birth data from the GROS allows potential first and

second (or third) generation immigrants to be identified

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Figure 6 Breastfeeding by maternal BMI

Scotland: Breastfeeding (exclusive) trends and maternal body mass index 2003-2009Source: SMR02, CHSP-PS, GROS/ ISD Scotland linked extract

42%

55% 55%48%

34%

46%

36%27% 28%

19%27% 25%

19%

45%39%

37%

0%

20%

40%

60%

80%

100%

Underw eight Normal w eight Overw eight Obese

Maternal BMI range

Infa

nt

reco

rds (

%)

Birth Hosptial discharge First visit 6 to 8 w eek review

The univariate analyses were undertaken at a Scottish level and repeated for Greater

Glasgow and Clyde and in the main the same associations were found. For example,

while exclusive breastfeeding trends were relatively stable over the main period of study

(2001-2009), the trend toward a higher prevalence of mixed feeding was notable

nationally and for the Glasgow region.

The findings of the univariate analyses, while useful in providing an overview of patterns

of association in relation to infant feeding, are limited as there has been no adjustment

for potential confounding factors.

Multivariate analyses

The results of the multivariate analysis described here should be considered provisional

at this stage as refinements are still being made to the models.

Multivariate analysisxiii was undertaken of infant feeding at birth, first review and 6 to 8

weeks of singleton births to primapara mothers in the period 2003-2009xiv. Singleton

birthsxv were determined from the GROS birth records and first time mothers were

selected from the SMR02 maternity recordsxvi. Infant feeding was defined as a

dichotomous variable i.e. either ‘breast/mixed’ or ‘bottle fed’. All maternal and infant

characteristics identified as being significant (p <0.05) were retained in the model.

The detailed results presented in this report focus on an analysis of infant feeding at

birth for a Scottish cohort – see Table 1 - although brief comparative comments are

included on the results of modelling at other review points.

At birth, several factors were independently associated with any breastfeeding. T he

odds of any breastfeeding increased with increasing age of parents (mother and father),

less deprivation, mothers of Non-British birth, increased length of stay following delivery

or due to neonatal admission in hospital and delivery in a baby friendly institution.

In contrast, the odds of any breastfeeding decreased with increasingly disjointed

parental relationships (higher odds in married couples compared to cohabiting or

disjointed/single parent families), more complicated deliveries (instrumental or

caesarean sections) or maternal diagnosis of ill health at delivery, a low birth weight for

gestational age baby, maternal smoking at first visit, at extremes of maternal BMI

xiii

Manual and step wise (forwards) logistic regression (STATA v11) using demographic, maternal and infant

health variables was used to predict breastfeeding. xiv

The period 2003-2009 was selected to allow the inclusion of maternal BMI, which was not available prior to

2003. xv

142,687 singleton births to first time mothers. xvi

Parity = 0.

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(underweight or obese mothers) and decreasing social class. The odds of any

breastfeeding also appeared to increase slight ly (1-2%) between 2003 and 2009.

Similar maternal and infant characteristics predicted any breastfeeding at first visitxvii

e.g. increased odds of any breastfeeding in older parents, of Non-British birth, of married

parents, normal/delivery. In addition, the odds of any breastfeeding increased in infants

exclusively breastfed at birth in contrast to bottle or mixed feeding and if the father was

a student. The model for any breastfeeding at the 6 to 8 week reviewxviii produced

similar results to those observed at birth and the first visit, but additionally the likelihood

of breastfeeding appeared to increase with the type of maternal employment – self

employed or unemployed mothers (compared to mothers in paid employment) and in

fathers who were students.

Further analyses conducted for Greater Glasgow and Clyde and for the study

neighbourhoods have identified similar predictive factors.

Table 1: Multivariate Step-wise (forwards) logistic regression, Scotland:

Factors associated with any breastfeeding at birth 2003 – 2009

Demographic/maternal/infant factors % n Odds ratio (95% CI)

Maternal age

Less than 20 years 14% 20,372 1.00

20 - 24 years 24% 33,758 1.37(1.31-1.43)

25 - 29 years 26% 36,879 1.71(1.63-1.81)

30 - 34 years 24% 33,681 2.02(1.91-2.14)

35 - 39 years 11% 15,347 2.13(1.99-2.28)

40+ 2% 2,650 2.39(2.12-2.69)

Deprivation

SIMD 1_Most deprived 27% 38,100 1.00

SIMD 2 22% 31,331 1.27 (1.23-1.31)

SIMD 3 18% 25,667 1.56 (1.50-1.62)

SIMD 4 17% 24,874 1.88 (1.81-1.96)

SIMD 5 _ Least deprived 16% 22,696 2.11(2.02-2.21)

Marital status

Married 44% 63,270 1.00

Cohabiting 35% 49,539 0.84 (0.81-0.87)

Disjointed families/single 21% 29,878 0.57 (0.55-0.60)

Father's country of birth

British birth 83% 118,844 1.00

Non-British birth 9% 13,279 1.66 (1.55-1.79)

Unknown country of birth 7% 10,564 0.80 (0.69-0.93)

Mother's country of birth

British birth 90% 128,072 1.00

Non-British birth 10% 14,615 3.06 (2.85-3.28)

Mode of delivery

Normal/spontaneous delivery 54% 77,231 1.00

Instrumental delivery 20% 29,004 0.84 (0.81-0.86)

Breech deliveries 0% 259 1.38 (1.02-1.86)

Caesarean section (elective) 5% 6,651 0.66 (0.62-0.70)

Caesarean section (emergency) 21% 29,496 0.71 (0.68-0.74)

Maternal Body mass index

Normal BMI/Overweight 18.5 - 29.9 kg/m2) 40% 57,067 1.00

Underweight (BMI <18.5 kg/m2) 2% 2,395 0.78 (0.71-0.86)

Obese (BMI >30.0 kg/m2) 9% 12,544 0.87(0.83 -0.91)

xvii First visit limited to infants reviewed within 6 to 30 days from birth between 2003 and 2009 xviii 6 to 8 week review limited to infants reviewed within 35 – 70 days from birth between 2003 and 2009

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Demographic/maternal/infant factors % n Odds ratio (95% CI)

Length of stay (post natal) xix

Less than 2 days (mean 1.5 days) 60% 86,007 1.00

3 – 20 days (mean 4 days) 40% 56,474 1.61(1.56 -1.66)

Greater than 20 days (50 days) 0% 206 3.00 (2.08-4.70)

Mother's health at deliveryxx

No ill health 90% 128,566 1.00

Ill health 10% 14,121 0.92 (0.88-0.96)

Maternal smoking status

Non smoker 78% 110,938 1.00

Smoker 18% 26,349 0.62 (0.60-0.64)

Unknown status 4% 5,400 0.81(0.76-0.86)

Baby friendly facility

Non-baby friendly/partial accreditation 42% 59,514 1.00

Baby friendly facility (fully accredited) 58% 83,173 1.14 (1.12-1.17)

Neonatal admission

Not admitted 88% 124,863 1.00

Admitted for up to 48 hours 3% 4,461 0.65 (0.61-0.70)

Admitted for 48 hours or more 5% 6,944 0.92 (0.87-0.98)

Unknown admission status 4% 6,419 1.09 (1.02-1.15)

Parental origin

Both parents of British origin 80% 114,532 1.00

Mother of British origin/father Non-British

origin 3% 3,640 1.30 (1.18-1.43)

Mother of Non-British origin/father of Non-

British origin 3% 4,522 1.41 (1.30-1.54)

Both parents of Non-British origin 5% 7,159 1.59 (1.43-1.77)

Either parent of unknown origin 9% 12,834 1.42 (1.25-1.60)

Year of birth (2003 – 2009) 100% 142,687 1.02 (1.01-1.02)

Estimated gestation

Normal gestation 90% 127,937 1.00

Post-gestation >42 weeks 4% 5,813 1.15 (1.08-1.23)

Mother's socioeconomic status

Higher managerial/professional 31% 44,544 1.00

Intermediate 24% 34,393 0.58 (0.56-0.61)

Semi routine/routine 27% 38,912 0.50 (0.48-0.52)

Students 4% 5,243 0.72 (0.67-0.78)

Unknown status 14% 19,595 0.46 (0.44-0.48)

5. Discussion

This research programme has been taken forward to fulfil a number of different but

complimentary aims. Initially, we set out to gain a better understanding of the

contextual factors that may have influenced changes in infant feeding in five

neighbourhoods in Glasgow. In tandem we have developed a sophisticated linkage of

national child and maternal data recording schemes and carried out univariate and

multivariate analyses on the new dataset, both nationally, for Greater Glasgow and

Clyde and for 5 study neighbourhoods.

The contextual analysis has examined the extent of impact of compositional changes

versus a specific local intervention (Greater Glasgow ‘peer support’ breastfeeding

initiative) on infant feeding. The value of analysing administrative data to build up a

picture of the pattern of population compositional changes in relation to infant feeding

trends has been demonstrated. Understanding changes in population structure,

xix Length of stay (post delivery) – Stays of greater than 20 days includes 110 records defined as non

institution events. xx Mother’s ill health based on health status on delivery – diagnosis codes as advised by Dr J Chalmers, ISD

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ethnicity, housing, economic participation and levels of deprivation is crucial to providing

a fuller understanding of any observed changes in infant feeding in local communities.

The creation of the child and maternal linked dataset from routinely collected

administrative data has provided a new national resource which provides the potential

for a much more nuanced understanding of the factors influencing infant feeding, both

nationally and locally. Many of the factors that predict likelihood of breastfeeding are

known from literature, but have not been described before for a Scottish population.

The linked dataset is a rich resource that could (and should) be developed and analysed

further to improve not only understanding of infant feeding within Scotland, but of

related issues, such as how different types of infant feeding associate with health in

early childhood.

6. Conclusions

The contextual analysis of five local areas in Glasgow has identified important

compositional changes in the populations of each area that are likely to have affected

trends in breastfeeding. In two of the areas, Greater Gorbals and Govanhill, while it is

likely that compositional changes have had the greatest influence, some trends hint at

the potential positive influence of a ‘peer support’ breastfeeding initiative on British born

mothers and mid-aged and older mothers.

Our analysis of the child and maternal linked dataset has highlighted the influence of a

range of demographic, socio-economic, lifestyle-related, birth and neo-natal related

factors on types and duration of infant feeding. Across Scotland, older mothers, mothers

living in less deprived areas, those in higher status jobs, those married or living with a

partner, mothers who did not smoke, mothers who were not obese or underweight and

those born outside the British Isles or with a non-British ethnic origin had higher levels

of exclusive breastfeeding.

This study has contributed new knowledge on infant feeding specific to the Scottish

context based on routinely collected data confirming findings of other published studies.

This study has shown that contextual analysis, using a range of existing administrative

data, and a new child and maternal linked data resource c an provide new detailed

intelligence that can be employed to improve the understanding and monitoring of

breastfeeding trends in Scotland.

7. Importance to NHS and possible implementation

Increasing breastfeeding has been a national priority and focus of policy initiatives for a

number of years: the Breastfeeding etc (Scotland) Act (2005); the Baby Friendly

Initiative designed by WHO/UNICEF; the Scottish Government Healthy Eating Ac tive

Living Action plan; national monitoring via the HEAT target; CEL 36 funding; the

Scottish’s Government’s Maternal and Infant Nutrition Framework (January 2011).

However, despite this policy focus, improvements in breastfeeding rates have been

modest.

The Scottish Government is committed to reducing inequalities, as exemplified by its

Equally Well programme. This study provides clear evidence for the positive and

negative influences of a range of socio-economic, child-related and maternal factors on

breastfeeding. The evidence from this study should help to target support and

interventions to enable higher levels of breastfeeding to be achieved in maternal groups

that are most in need of support.

The linked dataset provides a valuable resource for developing policy and interventions

and monitoring implementation across Scotland. Some specific trends are of particular

importance in terms of developing policy and interventions. The nation-wide increase in

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mixed feeding is one, for example. Another is the influence of parental backgroundxxi

and, particularly, the evidence of an 'aculturalisation effect' whereby the high levels of

breast feeding among first generation migrants reduces among second generation

migrants.

8. Future research

We intend to develop and extend the current phase of work by investigating the

relationship between parental background, particularly ethnic and culturally-related

factors, and infant feeding choices and exploring the influence of breastfeeding on future

child health, via linkage to child hospitalisation and child health surveillance records at

the Primary 1 school review.

9. Dissemination

The emerging findings from this first phase of work have already been presented to

SCPHRP’s Early Years Working group and to the SIFAN network. We plan to present our

findings at the 2011 PHINS seminar, the National Maternal and Infant Nutrition

conference and at the FPH’s Annual Scottish conference. Health Scotland has also

offered to facilitate a workshop for SIFAN members to explore how the research can be

used to inform service developments.

Project reports and briefing papers will be published on the GCPH website. We intend to

submit one or more papers to academic journals.

10. Research workers

‘Tomi Ajetunmobi has been employed as the project researcher on secondment from ISD

Scotland to GCPH. Bruce Whyte has supervised and managed the research.xxii

11. Financial statement

Table 2 below summarises the costs related to this project.

Costs

1 F/T Seconded Member of Staff £46,797

Travel (details) £500

ISD (for linkage) £4,550

License to use Onomap software £4,000

SUB-TOTAL £55,847

The majority of the costs (£46,347) were paid through a seed-funding grant provided by

SCPHRP. The remainder were met by GCPH.

xxi Parental background: refers to marital status, employment, social status and ethnic background of both mother and father.

xxii In addition to the principal investigators and researcher, the project has had an active and engaged

advisory group, including: Linda Wolfson (Maternal and Infant Feeding Coordinator, NHS Greater Glasgow and

Clyde); Judith Tait (Child Health Information Team Leader, ISD Scotland), Rachael Wood (Public Health

Consultant, ISD Scotland), Jill Muirie (Public Health Advisor, NHS Health Scotland), Ruth Campbell (Consultant

Dietician, NHS Ayrshire & Arran), Helen Yewdell (Scottish Government), David Tappin (Professor, PEACH unit,

Royal Hospital for Sick Children, Glasgow), James Egan (Public Health Programme Manager, GCPH).

13

12. Executive summary (Focus on Research)

Investigation of observed increases in breastfeeding rates in deprived areas Researchers ‘Tomi Ajetunmobi, Bruce Whyte, Pauline Craig, James Chalmers

Aim The studies aims were to:

explain increases in breastfeeding rates observed between 1997 and 2009 in four

selected neighbourhoods within NHS Greater Glasgow and Clyde.

investigate new ways of analysing breastfeeding trends across Scotland making

use of linked data.

Project Outline/Methodology A contextual analysis of the Glasgow neighbourhoods using a range of administrative

data was undertaken to try to understand the relationship between trends in infant

feeding and changes in population composition.

To fulfil the second aim, a new national child and maternal linked dataset was created

using probability matching record linkage. Infant feeding, and specifically breastfeeding,

was analysed in relation to a range of different predictor variables.

Key Results

The contextual analysis of Glasgow neighbourhoods identified important compositional

changes in the population of each area that are likely to have affected trends in

breastfeeding. However, in two of the areas, Greater Gorbals and Govanhill, there were

rising breastfeeding trends among British born mothers and mid-aged and older mothers

that, additionally, may reflect the potential positive influence of a ten year ‘peer support’

breastfeeding initiative.

Through this study a new child and maternal linked dataset has been created for

Scotland. The analysis of this resource has highlighted the influence of a range of

demographic, socio-economic, lifestyle-related, birth and neo-natal related factors on

types and duration of infant feeding. Older mothers, mothers living in less deprived

areas, those in higher status jobs, those married or living with a partner, mothers who

did not smoke, mothers who were not obese or underweight and those born outside the

British Isles or with a non-British ethnic origin had higher levels of exclusive

breastfeeding. In contrast, bottle feeding correlates with almost the polar opposite of

these characteristics. Additionally, mode of delivery, parity, length of maternal stay in

hospital, gestation and infant health also clearly influenced type and duration of infant

feeding.

Conclusions This study has shown that contextual analysis of a range of existing administrative data,

and the creation of a new child and maternal linked data resource, can provide detailed

new intelligence that can be employed to improve the understanding and monitoring of

breastfeeding trends in Scotland.

What does this study add to the field? Many of the factors that predict more or less likelihood of breastfeeding are known from

literature, but have not been described before for a Scottish population. This study has

also begun to assess the relative importance of different predictive factors on likelihood

to breastfeed.

14

Implications for Practice or Policy Specific trends will be particularly important to understand in terms of developing policy

and interventions. The nation-wide increase in mixed feeding is one. Another is the

evidence we have shown of an ‘aculturalisation’ effect whereby the high levels of breast

feeding among first generation migrants reduces among second generation migrants.

Where to next? We intend to develop and extend the current phase of work by investigating the

relationship between parental background, particularly ethnic and culturally-related

factors, and infant feeding choices and exploring the influence of breastfeeding on future

child health.

Further details from: Bruce Whyte

Public Health Programme Manager

Glasgow Centre for Population Health

1s t Floor, House 6,

94 Elmbank Street, Glasgow, G2 4DL

tel: 0141 287 6875

email: [email protected]

web: www.gcph.co.uk & www.understandingglasgow.com

facebook: facebook.com/theGCPH

twitter: @theGCPH

mailto:[email protected]

http://www.gcph.co.uk/

http://www.understandingglasgow.com/

http://www.facebook.com/theGCPH

http://twitter.com/theGCPH

15

References

Blakely T. and Salmond C. Probabilistic record linkage and a method to calculate the

positive predictive value. (2002) International Journal of Epidemiology 31(6)1246-

1252.

Bolling K, Grant C, Hamyln B, Thornton A (2007). Infant feeding survey report 2005.

The Information Centre.

(http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feeding%20Surve

y%20%28final%20version%29.pdf - accessed 4/08/ 2010) .

Bradshaw P, Martin C, Cunningham S (2008). Growing up in Scotland: Exploring the

experience and outcomes for advantaged and disadvantaged families

http://www.scotland.gov.uk/Publications/2008/03/12101843/3 (accessed 19th August

2008)

Gill L.E. and Baldwin J.A. (1987) Methods and technology of record linkage: Some

practical considerations. In: Baldwin J.A., Acheson E.D. and Graham W.J. (Eds) (1987)

Textbook of Medical Record Linkage. Oxford: Oxford University Press, 39-54

Kendrick S. (1997) The development of record linkage in Scotland: The responsive

application of probability matching. Available from:

http://www.fcsm.gov/working-papers/skendrick.pdf [accessed 31 March 2011]

Kendrick S.W. and Clarke J. A. (1993) The Scottish medical record linkage system.

Health Bulletin (Edinburgh), 51 72-79

Mateos, Webber and Longley (2007) The Cultural, Ethnic and Linguistic Classification of

Populations and Neighbourhoods using Personal Names , CASA Working Paper 116,

Centre for Advanced Spatial Analysis, University College London

Newcombe H.B., Fair M.E. and Lalonde P. (1989) Discriminating powers of partial

agreements of names for linking personal records. Methods of Information in Medicine,

28 86-91

Mason C.A. and Tu S. (2008) Data linkage using probabilistic decision rules: A primer.

Birth Defects Research Part A: Clinical and Molecular Teratology 82(11) 812-821.

Whyte B, Community Health and Wellbeing Profiles for Grerater Glasgow and Clyde

GCPH, 2008 http://www.gcph.co.uk/communityprofiles

http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feeding%20Survey%20%28final%20version%29.pdf

http://www.ic.nhs.uk/webfiles/publications/ifs06/2005%20Infant%20Feeding%20Survey%20%28final%20version%29.pdf

http://www.scotland.gov.uk/Publications/2008/03/12101843/3

http://www.fcsm.gov/working-papers/skendrick.pdf

http://www.gcph.co.uk/communityprofiles

16

Appendix 1

Summary findings from contextual analysis of selected neighbourhoods in

Greater Glasgow

In the contextual analysis demographic, socio-economic, housing and infant feeding

trends were investigated in five neighbourhoodsxxiii in Greater Glasgow - Govanhill,

Greater Gorbals (both in South East Glasgow), Sighthill, Roystonhill & Germiston (in

North Glasgow), Lenzie (in East Dunbartonshire) and, Temple & Anniesland (in West

Glasgow).

Data from a variety of administrative sources were accessed for this analysis: small area

population estimates (Scottish Government); births, including mothers’ country of birth

(GROS Birth Record); housing completions/demolitions, tenure and type, household

structure and ethnicity of children in education (Glasgow City Council); worklessness

(DWP); deprivation (SIMD); house prices (SNS); and asylum seekers (CoSLA).

Trends and patterns in these data were analysed over the period 1997-2009 and related

to changes in patterns of infant feeding over the same period. Trends were analysed

using annualised data. Not all of the data were available across the full period and this

is noted in the text and footnotes. In this regard it is to worth noting that the CHSP_PS

system only began to record infant feeding at birth from 2000 and data are only valid

from 2001. However, infant feeding data reported for the first review and 6 to 8 week

review are available back to 1997.

It is also relevant to note that four of the study areas - Govanhill, Greater Gorbals,

Sighthill, Roystonhill & Germiston and Temple & Anniesland - were included within a

Greater Glasgow Breastfeeding Initiativexxiv implemented between 1997 and 2000 and

continued until 2007xxv. The aim of the initiative was to increase the duration and level

of breastfeeding at 6 to 8 weeks in the participat ing localities. The strategy focused on

providing appropriate training and resources and monitoring progress for staff and

recruited volunteers supporting women ante-natally and postpartum. A key aim of the

contextual analysis has been to assess the potential impact of this scheme on

breastfeeding.

This summary is drawn from a longer report which will be published on the GCPH

website in the summer of 2011.

Govanhill

Overview of the area

Situated in south east Glasgow, Govanhill has a population of 15,839 (2009) and is

made up of 18 datazones. It has a rich multicultural identity with a history of migration

from Ireland, Pakistan and more recently, Poland and Slovakiaxxvi. In 2008, the

xxiii

These neighbourhoods were selected because health profiles (Whyte B, 2008, GCPH) had identified

increases in rates of any breastfeeding in these areas between 1997-99 and 2004-06. NB Initially only South

Lenzie was included, but during data collection it was decided to widen the study area to the whole of Lenzie,

by including North Lenzie – which is similar socio-economically and had high rates of breastfeeding, although

no notable upward trend - in order to provide more robust figures for a larger population.

xxiv The Glasgow Breastfeeding initiative was set up in parts of Greater Glasgow – mainly Gorbals, Govanhill and

the Riverside LHCC. The initiative was set up in Greater Gorbals/Govanhill in 1997, in Sighthill/Roystonhill (but

only for mothers registered with a Townhead GP) in 1997 and in Temple and Anniesland in 2000 as part of the

Riverside LHCC. Linda Wolfson (Infant Feeding Coordinator, NHS Greater Glasgow and Clyde) personal

correspondence

xxv Information provided by Marion McPhillips, Gorbals Health Centre xxvihttp://library.nhsggc.org.uk/mediaAssets/CHP%20South%20East%20Glasgow/SE%20Glasgow %20Health%20Improvement

%20Plan%202009-2012%20Public%20Summary.pdf

17

minority ethnic population was estimated to comprise about a third of the Govahill

neighbourhood (29%). In 2010, an estimated 272 asylum seekersxxvii lived in the area.

Residents of Govanhill have a lower life expectancy (males: 71 years; females 77 years)

compared to the overall Glasgow/Scottish average (72 years/74.5years and 78

years/79.5 years respectively)xxviii. It is relatively deprived with 46% of the population

living within the most deprived quintile – SIMD 1 (SIMD,2009).

Demographic, socio-economic and housing trends

Over the period from 1997-2009, Govanhill’s population rose by 12% to 15,839, due to

inward migration and natural increase. Govanhill had a birth rate of 16 births per 1000

population in 2009 (Scotland – 11 births per 1000 population). Births to teenage

mothers decreased from 56 births to 28 births per 1000 between 1997 and 2009 and

births to older mothers increased (e.g. the birth rates in mothers aged between 30 and

34 years rose from 66 births to 93 births per 1000 between 1997 and 2009. About half

of the births were to mothers living within the most deprived quintile.

Overall, 13% of the mothers in Govanhill smoked at first visit between 2001 and 2009,

compared to 21% across Scotland and the proportion mothers smoking declined over the

study period, similar to the trends observed in Greater Glasgow and Clyde and Scotland.

The proportion of the population from an ethnic minority population was estimated to

have risen to 29% by 2008 (from 19% in 2001). The proportion of mothers of non-

British birth increased from 26% in 1997 to 57% in 2009. While Govanhill has remained

relatively deprived, there was a drop in employment deprivation but a slight increase in

income deprivation. There was an increase in the proportion of the population privately

renting and a decrease in owner-occupation. Average house prices more than doubled

between 1997 and 2008 and house sales increased by 50%.

Breastfeeding trends

The pattern of infant feeding in Govanhill changed subtly between 2001 and 2009 at

different points after birth. While there was no overall change in any breastfeeding at

birth (~73%), mixed feeding increased to over 10% by the end of the period. Exclusive

and mixed feeding rose over the period both at the first review (7-10 days after birth)

and the 6 to 8 week review. Overall, exclusive and mixed feeding represented 16% and

32% of infant feeding, respectively, at the 6 to 8 week review.

As in all the other areas and in line with the evidence from national data, levels of any

breastfeeding were higher among non-British mothers and older mothers. Analysis of

breastfeeding by country of birth within the neighbourhood showed no change in breast

feeding among non-British born mothers. There were fluctuations in breastfeeding levels

among British born mothers at birth and at 6 to 8 weeks but a slight increase in any

breastfeeding at first visit, rising from 43% in 1997 to 65% in 2009.

There was an overall increase in breastfeeding among the maternal age groups over the

study period. Between 1997/1999 and 2007/2009, any breastfeeding increased from

54% to 64% in mothers aged less than 25 years; 59% to 72% in mothers aged between

25 and 34 years and 58% to 68% in mothers aged 35 years or older.

Conclusions in relation to breastfeeding and other social trends

The influence on breastfeeding trends of compositional change in the neighbourhood’s

population is clearly important. The overall population and the proportion of people from

a non-British origin has increased to nearly 30% of the total population. Perhaps most

significantly the proportion of mothers of non-British birth has increased from a quarter

to nearly 60%. The age profile of mothers has also risen. The area remains deprived but

the income and employment deprivation indicators have contrasting trends.

While the Greater Glasgow ‘peer support’ breastfeeding initiative may have had some

influence on infant feeding levels - there is evidence at first visit of an increase in

xxvii Source: recent f igures as at April 2010 from COSLA xxviii

Estimates 2001-2005, GCPH community health profiles http://w w w .gcph.co.uk/communityprofiles

http://www.gcph.co.uk/communityprofiles

18

breastfeeding among mothers born in Britain and an increase among younger and older

mothers – it is difficult to give a definitive answer based on this limited evidence. On

balance, it is likely that changes in population composition – more mothers born outside

Britain and more births to older mothers – possibly coupled with the impact of the peer

support initiative on some maternal groups, have contributed to increases in

breastfeeding.

Greater Gorbals


Greater Gorbals, situated in south east Glasgow adjacent to Govanhill, has a population

of 8,607 (2009) and consists of 9 datazones. It has high levels of deprivation with over

80% of its population described as living in the most deprived quintile – SIMD1 (SIMD

2009). Life expectancy is poorer than the Glasgow/Scottish average especially for males

(63 years). There are high proportions of lone and single parent households (over 50%

of all households with children in 2005)xxix and higher rates of crime and drug offending

compared to the Scottish average.


Over the period from 1997-2009 Greater Gorbals population rose by 10%. There were

consistently more deaths than births in the area, leading to a natural decrease in the

population but this has been counteracted by high net inward migration, peaking in

2005/06 (309 persons per 10,000 population). By 2008 the estimated ethnic minority

population had doubled to 6% (from 3% in 2001). Asylum seekers made up 2% of the

population in 2007 but the proportion within the population has since dropped to less

than 0.5% in 2010.

There was an increase in birth rates between 2001 and 2009. Greater Gorbals had a

high proportion of births to teenage mothers in 1997 (85 births per 1000) which declined

to 57 births per 1000 in 2009. There was also an increase in births to older mothers. In

the period 1997-2009, about 20% of the mothers in Great Gorbals were born in

countries outside the British Isles compared to 10% in Scotland as a whole and this had

increased from 4% in 1997 to 29% in 2009.

Greater Gorbals is an area of relative socioeconomic disadvantage – the 2nd most

deprived among the selected areas – but which showed improvement between 2001 and

2009, both in terms of income and employment deprivation. Housing stock and house

prices increased due to developments. While over 60% of housing is in the soc ial rented

sector, this has reduced as owner-occupation has risen to 27% and private rented

housing more modestly to 10% by 2009 (owner occupier: 20%; private rented housing:

3% in 2001).

Of the project neighbourhoods, Greater Gorbals had the highest proportion of mothers

who smoked at first visit but this declined significantly declined from 43% in 2001 to

21% in 2009.


There was an upward trend in both exclusive breastfeeding rates over the period at the

various review points, increasing at birth from 33% in 2001 to 54% in 2009, from 14%

(in 1997) at first visit to 33% in 2009 and from 26% in 1997 to 35% in 2009 at the 6 to

8 week review. There was little change in mixed feeding rates at birth over the period

but mixed feeding at the first review increased from 1% in 1997 to 14% in 2009 and at

the 6 to 8 week review from 16% in 1997 to 30% in 2009.

Levels of any breastfeeding were consistently higher among non-British mothers and

older mothers. Analysis of breastfeeding by country of birth showed some evidence of an

increase in breastfeeding among British born mothers at birth, rising from 38% in

2001/2003 to 42% in 2007/2009 and at first visit, increasing from 27% in 2001/2003 to

xxixFigures from 2005. Source: DRS, Glasgow City council as cited in GCPH (2008) A Community health and w ellbeing profile

for South East Glasgow

19

43% in 2007/2009. There was evidence of a sustained increase in levels of

breastfeeding among mid-aged mothers (25-34 year old) and older mothers (35 years

and over) at birth and at first visit. For example, any breastfeeding at birth among mid-

aged mothers increased from 47% in 2001/2003 to 64% in 2007/2009 and among older

mothers from 59% to 74%.


While still relatively deprived Greater Gorbals has become significantly less deprived and

more ethnically diverse. Coupled with housing developments and changes in housing

tenure, it is at least plausible to suggest that a new more affluent/less deprived

population has moved into the area significantly changing the composition of the

population. The age profile of mothers has increased also. This type of change,

coupled with large increase in mothers born outside the UK who tend to have higher

rates of breastfeeding, could partly explain the improvement in breastfeeding trends.

However, Greater Gorbals remains relatively deprived and yet rates of breastfeeding

have caught up and exceed those in Greater Glasgow and Clyde as a whole. It is notable

also that levels of breastfeeding have increased among mid-aged and older mothers. In

conclusion, it is possible that breastfeeding trends in the area have been influenced by a

combination of compositional changes and other factors – such as the Greater Glasgow

‘peer support’ breastfeeding initiative.

Sighthill, Roystonhill and Germiston


This area, located in the north of Glasgow, has a population of 12,741 (2009) and is

made up of 13 datazones. It has a relatively young population. Life expectancy is

slightly below the Scottish average (males: 66 years; females: 73 years). It is ethnically

diverse comprising a high proportion of immigrants (17% of population in 2008). It also

had a large proportion of lone/single parent households (51% of all households with

children (2005). Most of the residents live in deprived areas - 70% within SIMD 1 and 2

(SIMD 2009). High rates of violent crime and domestic abuse were reported compared

to the Scottish average (100% greater than the Scottish average)xxx.


The population of the Sighthill, Roystonhill and Germiston neighbourhoods increased by

13% from 1997 to 2001. Ethnic minorities made up 11% of he population in 2001 and

this rose to 17% in 2008; 6% of the population were estimated to be asylum seekers in

2007, although this has reduced now. The proportion of births to mothers of Non-British

birth increased dramatically from 17% in 1997 to 63% in 2009. Over the period 1997-

2009, the rate of teenage births halved while births to older mothers increased. There

was a significant decrease in the proportion of mothers who smoked between 2001 and

2009 (36% to 12%).

The area was and remains the most deprived of the selected areas, although both

income and employment deprivation have reduced significantly. The majority of housing

is in the social rented sector although there have been modest increases in owner

occupied dwellings (up to 19%) and private rented housing (up to 5%). House sales and

house prices have increased. Overall 10% of the births were to teenage mothers

(compared to 8% nationally) and there were relatively few births to older mothers (12%

to mothers aged 35 years or older).


Exclusive breastfeeding and mixed feeding rates increased over the period at the various

review points. There were rises in rates at birth (from 49% in 2001 to 52% in 2009), at

the first review (from 17% in 1997 to 37% in 2009) and at the 6 to 8 weeks review

(from 11% in 1997 to 28% in 2009). Mixed feeding rates increased at birth (from 3%

in 1997 to 15% in 2009), at first review (from 2% in 2001 to 25% in 2009) and at the 6

to 8 weeks review (from 6% in 1997 to 28% by 2009).

xxx GCPH (2008) A Community and w ellbeing profile for North Glasgow pg 39: Rates presented over the period 2004 - 2006

20


older mothers. Analysis of breastfeeding by country of birth showed no significant

change in levels of any breastfeeding over the period among non-British born and British

born mothers at birth or at 6 to 8 weeks, except that mixed feeding became more

prevalent among non-British born mothers. It is also notable that levels of breastfeeding

were as much three times higher among the non-British mothers compared to British

born mothers e.g. 89% vs. 29% at birth in 2009

There was evidence of a modest increase in levels of any breastfeeding among mid-aged

mothers (25-34 year old) at birth and at 6 to 8 weeks (e.g. 6 to 8 weeks: 45% in

1997/1999 to 57% in 2007/2009). There was also an overall increase, interspersed with

fluctuations, in breastfeeding among younger mothers (under 25) at birth, first visit and

at 6 to 8 week review (e.g. 6 to 8 weeks: 30% in 1997/99 to 46% in 2007/2009).


This area has remained one of the most deprived in Glasgow, although levels of

deprivation have reduced. It is clear also that the population has become more

ethnically diverse, that the average age of mothers has risen and that births to mothers

from outside the British Isles have risen. It is likely that the increasing diversity of the

population, older mothers and a less deprived population have all contributed to the rise

in breastfeeding in this area in the last decade. There has also been a notable increase

in mixed feeding, particularly among non-British born mothers.

Lenzie


Lenzie, which lies within East Dunbartonshire just to the north of Glasgow, has a

population of 9,566 (2009) and comprises 11 datazones. It has a small ethnic minority

population, small proportion of lone and single parent households (less than 1% - 2001

Census). It is an area of relative social advantage having no residents who may be

described as ‘deprived’ (100% of residents live within the ‘least deprived area’ – SIMD5

– based on SIMD 2009).


Because Lenzie is outside Glasgow we could not access all the contextual data we

gathered in other areas. However, it is clear that Lenzie has remained relatively affluent

and with a low proportion of ethnic minorities in the population – between 2001 and

2009, most of the births in Lenzie were to mothers born within the British Isles (92%)

and within the least deprived area (SIMD 5: 71%).

Mothers in the area tended to be older with about a third of the mothers aged 35 years

or older. Teenage births were very low and declined over the period 1997-2009 while

the proportion of births to older mothers rose e.g. the birth rate among mothers aged

35-39 years almost doubling. In line with national trends, there was a decrease in

mothers who smoked from 12% in 2001 to 2% in 2009.


Rates of any breastfeeding (mixed and exclusive) were high in Lenzie between 2001 and

2009 and the highest of the selected areas; 74% at birth and 51% at the 6 to 8 week

review. Mixed feeding was low overall, only accounting for 2% of feeding at birth and

11% by the 6 to 8 week review. There were fluctuations in the breastfeeding rates over

the period but no clear trend was evident.


older mothers. Analysis of breastfeeding by country of birth showed no evidence of a

significant change in levels of any breastfeeding over the period among British born

mothers or non-British born mothers or among mothers of different ages.


21

Lenzie is an affluent area to the north of Glasgow, with a relatively stable population of

largely British origin. Breastfeeding trends, while high, have not changed greatly in the

last ten years.

Temple & Anniesland


Temple and Anniesland, situated in the west of Glasgow, has a population of 11,146

(2009) and is made up of 14 datazones. It has a relatively older population and smaller

proportion of single adult and lone parent households (36% of all households with

children in 2005xxxi compared to Scotland overall). It may be described as an area of

moderate deprivation with about 30% of its residents living within ‘most deprived’ areas

– SIMD1 (SIMD 2009). Compared to Scotland, it had relatively lower rates of domestic

abuse incidents and drug offendingxxxii.


The population of the area increased marginally (by 3% between 1997 and 2009). In

2008, 4% of the population were estimated to be from an ethnic minority origin a slight

increase from 2001. Overall, 50% of the mothers were aged 30 or over and nine out of

ten mothers were born within the British Isles. As in the other areas, the average age of

mothers increased. There was a notable decrease in the proportion of mothers who

smoked at first visit from 33% to 14%.

Levels of worklessness and employment deprivation have reduced (employment dep.

reduced from 25% (SIMD 2004) to 19% (SIMD 2009)). There was considerable house

building in the period 2001-2009 (over 600 houses completed) and the proportion of

owner occupiers (56% – 58%) and private rented housing (5% – 14%) increased.


Rates of exclusive feeding in Temple and Anniesland increased at birth (from 53% in

2001 to 59% in 2009), were relatively stable at the first visit and increased at the 6 to 8

weeks review from 24% in 1997 to 29% in 2009. Mixed feeding rates increased at birth

from 2% in 2001 to 7% in 2009 and at the 6 to 8 weeks review from 7% in 2001 to 11%

in 2009.


older mothers. Analysis of breastfeeding by country of birth showed no significant

change in levels of any breastfeeding at any of the review points over the period among

non-British born and British born mothers. Rates of breastfeeding among older mothers

(aged 35 or over) increased both at birth - rising from 45% in 2001/2003 to 74% in

2007/2009 - and to a lesser extent at the 6 to 8 week review.


There has been considerable house building within the area in the last ten years and so

presumably a level of population turnover. However, population composition has

remained relatively stable, albeit becoming slightly more ethnically diverse and with

more people in work. Exclusive breastfeeding and mixed feeding have increased, but

only marginally. There have been increases in any breastfeeding among older mothers.

Glossary

CHSP_PS - Child Health Surveillance Programme Pre-School System

CosLA – Convention of Scottish Local Authorities

DWP – Department of Work and Pensions

GROS – General Register Office for Scotland (now NRS - National Records of Scotland)

xxxi Figures from 2005. Source: DRS, Glasgow City council as cited in GCPH (2008) A Community health and w ellbeing profile

for South East Glasgow xxxii Source: VRU, Strathclyde Police as cited in GCPH Community health and w ellbeing profiles. Figures as an average

number of incidents betw een 2004 -2006.

Documents

Investigation of observed increases in breastfeeding rates in deprived areas