1. Rurality and Breastfeeding: What is the Relationship? Lucy Denvir StR Public Health NHS Dumfries and Galloway November 2011

2. Background Evidence for positive health benefits of breastfeeding Local interest in urban / rural health issues National priority agenda (has been HEAT target) Local priority – Breastfeeding Strategy

5. Aims Explore and appraise current knowledge in this area Analyse available relevant local data Assess implications and provide any recommendations for policy, practice and future research

6. Literature Search Ovid Medline database via ‘The Knowledge Network’ English language articles 1999-2010 Search terms: ‘breastfeeding and (urban or rural*)’ 59 initial articles, 4 left after inclusion and exclusion criteria applied

7. Findings Very limited transferable knowledge in this area - most studies based outside UK in developing countries Whether urban or rural, important factors are: -Access to information, services and support -Targeting of areas with lowest rates -Whole community approach Relationship with deprivation unclear

8. Data Methodology Data from Child Health Systems Programme Pre-School System via ISD. 3 years 07-08, 08-09, 09-10. Dumfries and Galloway - 4463 cases. Individual level data: 6-fold urban/rural indicator, SIMD 09 quintile, maternal age, feeding method first visit, feeding method 6-8 week review. Analysis using SPSS.

9. Results 6-Fold Urban/Rural Classification can be condensed into 2-Fold Categories 1-4 = Urban, 5 and 6 = Rural. There are no areas in Urban/Rural category 1 (large urban) in D+G Cross-tabulation and chi-square test for difference in proportions: Chi-square test results all had P-value <0.001 ie probability that these results due to chance is less than 1/1000

10. UrbanRural

13. UrbanRural

14. UrbanRural

15. Results so far! Relationship between urban-rural indicator and feeding method at first visit and 6-8 week review – rural mothers more likely to breastfeed. Relationship between deprivation and feeding method – most deprived SIMD 09 quintiles 1 and 2 least likely to breastfeed. Relationship between maternal age and feeding method – mothers age >30 more likely to breastfeed.

16. Results contd BUT: More rural mothers aged >40 and fewer aged <25. Deprivation relationship less clear, biggest difference between SIMD 09 quintiles 2 and 3. So urban-rural mothers have a different age and deprivation profile – further analysis required!

17. Multiple Logistic Regression: Cases with missing data excluded leaving 4030 for analysis Reference categories: Youngest age group (<20 years) SIMD 09 Quintile 1 (most deprived) Urban/Rural category 2 (other urban areas)

18. Variable = Maternal age Breastfeeding at first visitBreastfeeding at 6-8 week review P-valueOR (95% CI) P-valueOR (95% CI) 20-24<0.001 2.00 (1.37 – 2.93)<0.001 2.65 (1.58 – 4.43) 25-29<0.001 3.40 (2.36 – 4.91)<0.001 4.35 (2.64 – 7.15) 30-34<0.001 5.26 (3.63 – 7.61)<0.001 6.60 (4.00 – 10.86) 35-39<0.001 4.99 (3.39 – 7.34)<0.001 6.96 (4.17 – 11.62) >40<0.001 4.40 (2.69 – 7.20)<0.001 6.46 (3.53 – 11.80)

19. Variable = Deprivation Breastfeeding at first visit Breastfeeding at 6-8 week review P-value OR (95% CI) P-value OR (95% CI) SIMD09 2<0.001 1.68 (1.29 – 2.20) <0.001 1.83 (1.32 – 2.52) SIMD09 3<0.001 2.26 (1.72 – 2.96) <0.0012.56 (1.86 – 3.53) SIMD09 4<0.001 2.55 (1.92 – 3.37) <0.0012.79 (2.00 – 3.89) SIMD09 5<0.0012.47 (1.70 – 3.59) <0.0012.56 (1.67 – 3.91)

20. Variable = Urban/Rural Breastfeeding at first visitBreastfeeding at 6-8 week review P-valueOR (95% CI) P-valueOR (95% CI) 3 Accessible Small Town 0.0020.70 (0.56 – 0.88) 0.0030.67 (0.52 – 0.88) 4 Remote Small Town 0.0270.70 (0.51 – 0.96) 0.1810.79 (0.55 – 1.12) 5 Accessible Rural 0.0241.26 (1.03 – 1.53) 0.0731.22 (0.98 – 1.52) 6 Remote Rural 0.0031.38 (1.11 – 1.70) 0.0021.44 (1.14 – 1.82)

21. Results Maternal age and deprivation are significant and independent predictors of breastfeeding at first visit and 6-8 week review Most marked increase in odds of breastfeeding in mothers age >30 and mothers in SIMD 09 quintile 4 Odds of breastfeeding increased in rural category areas 5/6 in relation to urban areas Some evidence of rurality as an independent and significant predictor of breastfeeding but this is less certain particularly at 6-8 week review

22. Conclusions Good sample size, relatively accurate and complete data Does not include other important variables eg educational attainment, parity Some evidence that rurality may be an important predictor of breastfeeding independent of maternal age and deprivation Breastfeeding determinants are complex and multifactorial and issues such as rural deprivation contribute to the difficulty in identifying vulnerable communities and individuals

23. Recommendations Target areas with lowest rates Flexible and individualised but whole community approach Replicate study in other areas Include analysis of other variables More research on cultural, attitudinal and behavioural differences between urban and rural areas

24. Acknowledgements: Carolyn Hunter-Rowe (Snr Health Intelligence Analyst) Dr Andrew Carnon (CPHM) Claire Nolan (Information Analyst ISD) Thanks for listening! Any comments / questions? ☺