VIVE. Revista
de Investigación en Salud
https://revistavive.org
Volumen 7 No.
20, mayo-agosto 2024
ISSN: 2664-3243
ISSN-L: 2664-3243
pp. 617 – 627
Análisis
de factores maternos que afectan la lactancia materna exclusiva en Ecuador
Analysis of maternal factors affecting exclusive breastfeeding in Ecuador
Análise dos factores maternos que afectam o aleitamento materno
exclusivo no Equador
Katherine
Oleas Nieto
https://orcid.org/0009-0007-6673-0128
Universidad Politécnica
Salesiana. Ecuador, Quito
Artículo
recibido 13 de marzo 2024 / Aceptado 22 de abril 2024 / Publicado 10 de mayo
2024
Escanea en tu
dispositivo móvil o revisa este artículo en:
https://doi.org/10.33996/revistavive.v7i20.327
RESUMEN
La
lactancia materna exclusiva (LME) ha sido considerada por varios organismos
internacionales como la solución para combatir la desnutrición infantil, la
cual es considerada como un problema de salud pública. Bajo este contexto, la
presente investigación busca encontrar cuáles son los determinantes de la LME
en el Ecuador, y mostrar cómo influye el nivel educativo de la madre sobre la
duración de la lactancia materna exclusiva. Para cumplir dicho objetivo se
emplea un modelo probabilístico obteniendo como resultado que el nivel de
instrucción de la madre, la etnia, el quintil de ingresos, el género del recién
del bebé y la edad de la madre juegan un papel importante sobre la duración de
la lactancia materna en el Ecuador. En el caso del nivel de instrucción se
encuentra que las mujeres con una educación superior tienen menos probabilidad
de dar LME, por seis meses o más, que las madres sin un nivel de educación.
Palabras clave: Lactancia
materna exclusiva; Nivel socioeconómico; Nivel Educativo; Etnia; Género
ABSTRACT
Exclusive breastfeeding (EBF) has been considered by several
international organizations
as the solution to combat child
malnutrition, which is considered a public health problem.
In this context, the present research
seeks to find the determinants
of EBF in Ecuador, and to
show how the mother's educational level influences the duration of
exclusive breastfeeding. In order
to fulfill this objective, a probabilistic model was used, obtaining
as a result that the mother's level
of education, ethnicity, income quintile, gender of the newborn
and the mother's age play an
important role in the duration of breastfeeding
in Ecuador. In the case of educational level, it is found
that women with higher education
are less likely to breastfeed for
six months or more than mothers
with no education.
Key words: Exclusive breastfeeding;
Socioeconomic status; Educational
Level; Ethnicity; Gender
RESUMO
O aleitamento materno exclusivo (AME) tem
sido considerado por várias organizações
internacionais como a solução
para combater a desnutrição
infantil, que é considerada um problema de saúde pública. Neste contexto,
esta investigação tem como
objetivo encontrar os determinantes do AME no Equador,
e mostrar como o nível
educacional da mãe influencia a duração
do aleitamento materno exclusivo. Para cumprir este objetivo, é utilizado um
modelo probabilístico, com o resultado de que o nível de educação da mãe, a etnia, o quintil de rendimentos,
o sexo do recém-nascido e a idade
da mãe desempenham um papel importante na duração do aleitamento materno no
Equador. No caso do nível
de educação, verifica-se
que as mulheres com educação superior têm menos
probabilidades de amamentar durante seis meses ou mais do que as mães sem educação.
Palavras-chave: Aleitamento materno exclusivo; Nível
socioeconómico; Nível de escolaridade;
Etnia; Género
INTRODUCTION
The Food and Agriculture Organization of the United
Nations FAO (1), estimates that by 2020, only
43.8% of children worldwide between birth and six months
will be exclusively breastfed. For Latin American and Caribbean countries, the prevalence of exclusive breastfeeding is 37.8%, below the world
average. Complementing the above, Walters et al. (2),
note that, globally, lack of breastfeeding
causes 595 379 infant deaths
(in children aged 6-59 months) per year due to diseases
such as diarrhea and pneumonia. In addition, it contributes to 98,243 maternal deaths due to diseases
such as breast cancer, ovarian cancer and type 2 diabetes. Lack of breastfeeding
also causes significant economic losses, estimated at US$341.3 billion per
year. These losses are due to increased healthcare
costs, premature mortality
and lost productivity.
For these reasons, the objective
of the present
study is to investigate the influence of
various maternal factors on exclusive breastfeeding in
Ecuador. Some of the factors to
be reviewed are the mother's level of education, ethnicity,
income quintile, gender of the
newborn and the mother's age. In this line, the hypothesis proposed is that women
with higher educational levels tend to practice
exclusive breastfeeding for
shorter periods compared to mothers
with lower educational levels; a logistic econometric model is used
to test this hypothesis.
The structure of this research
consists of six sections. First,
the theoretical and empirical part is shown, where
the causes and consequences
of exclusive breastfeeding
are discussed. In addition,
an analysis of the situation
of EML in Ecuador is made. The following
section analyzes the data used in the model. This
is followed by a specification of the methodology.
In the last two sections, the
results are analyzed and conclusions are presented.
Exclusive breastfeeding (EBF) is
considered a way to protect the
newborn from infectious diseases by providing necessary
nutrients. Breastfed babies are less likely to suffer
from dental malocclusion problems and are protected against mortality and morbidity. Similarly, there are numerous benefits for the
mother, as it reduces the risk of
ovarian and breast cancer, hypertension and
cardiovascular disease (3).
According to
the United Nations Children's Fund (UNICEF) and the World Health Organization
(WHO), exclusive breastfeeding is
a type of feeding in which the newborn receives
only breast milk and no other food, whether solid
or liquid, except rehydration solutions, minerals, vitamins or medications
(4). This type of exclusive breastfeeding should be maintained for the first
6 months of life and continued until two years
of age.
In
2000, the United Nations established the Millennium Development Goals (MDGs) to
address major global challenges. These goals include reducing
extreme poverty, promoting gender equality, ensuring universal education and reducing child mortality. To achieve
the Millennium Development Goal of reducing
child mortality, exclusive breastfeeding has been identified as one of the main
areas of intervention at both global and national levels (5,6).
International research has provided
strong evidence of the clear
health benefits of breastfeeding for both infants
and mothers. Optimally breastfed infants have been shown
to have a lower risk of
common childhood illnesses such as
gastrointestinal and respiratory infections,
otitis media, atopic eczema, and allergies
during infancy (7,8).
According to
Paramashanti et al. (9), the
low practice of exclusive breastfeeding (EBF)
in most developing countries is due
to a variety of maternal and infant factors. These factors include geographic location, sex and age of the
child, maternal employment
status, maternal age and educational
level, access to mass media, and economic status. The conceptual model of Rollins et al. (10) points out that
breastfeeding decisions and
practices are influenced by several factors
operating both at the individual level and in the sociocultural environment. For example, in some cultures, exclusive breastfeeding
is considered not only a way
to feed the
baby, but also a powerful way to
establish and strengthen the bond between mother and child.
For Oblitas et al. (11), low milk production,
congenital malformations
and morbid nutritional
status represent risk factors for mothers
to stop breastfeeding their children. While for Rahman et al. (12),
non-practice of EML is associated with
mothers with secondary (OR 0.65) and higher
(0R 0.52) education. One of the explanations
supporting these results is related
to the fact
that some women with high
educational levels sometimes cannot breastfeed their children due to
lack of time (they work) or
because of an aesthetic issue.
This is consistent
with the study conducted by Gayatri (8) in Indonesia in
2017, where working women with higher
educational levels are more
likely not to breastfeed.
Perspective of
exclusive breastfeeding in the
Ecuadorian context
In
Ecuador, by 2023, 51% of children under 6 months will be exclusively breastfed, according to figures published by the
National Institute of Statistics and Census (INEC) through the National Survey
of Child Malnutrition
(ENDI). In rural areas, a higher
percentage (57%) of infants are exclusively breastfed compared to urban areas
(47%).
From a territorial approach,
the highest number of mothers
who breastfeed for six months
is found in the provinces of
Pastaza (82%), Cotopaxi (77%) and Imbabura (77%). The
provinces below the national average
are Cañar (46%), Santa Elena (40%), El Oro (36%), Guayas (33%) and Los Ríos
(21%) Figure 1.
Figura 1. Prevalence of
exclusive breastfeeding by province. Source: ENDI (13).
The data reveal significant differences in the practice of
exclusive breastfeeding among
the different ethnic communities in Ecuador. Thus, the highest
percentage is observed in white, AfroEcuadorian and mestizo infants,
with 60%, 56% and 51%, respectively.
In contrast, Montubio children
show the lowest percentage (18%) of exclusive breastfeeding (EBF) compared to the other
ethnic communities mentioned.
MATERIALS AND
METHODS
The information used in this study
was obtained from the National
Health and Nutrition Survey (ENSANUT), conducted in
2018 by the National Institute of Statistics and Census (INEC). The ENSANUT is a probability sampling survey that provides data on the health
and nutrition status of the Ecuadorian population INEC (14). Thus, the survey consists
of five questionnaires,
each of which
addresses various significant aspects of societal behavior. These aspects cover
the reproductive health of mothers, fertility,
development and nutritional
status of newborns, household characteristics, among other relevant
topics.
The ENSANUT covers
the 24 provinces of Ecuador and has as its target population all household members. The information collected is stored
in nine databases, each of which
has a unique identifier for individuals, households and dwellings. These identifiers allow the databases
to be combined, which makes it
possible to conduct the study
of interest, (14).
Four different databases were used in this study,
covering maternal, household,
socioeconomic status, and exclusive breastfeeding characteristics. The integration of these databases
was achieved using the household
and individual (mother) identifier.
As a result, the database has a total of 11,293 observations.
To test the hypothesis that women with higher
levels of education tend to breastfeed exclusively
for shorter periods compared to mothers with
lower levels of education, a dichotomous variable is generated that takes the value
1 if the mother exclusively breastfed her child
for 6 months or more, and the value 0 if the
breastfeeding period was less than
6 months (dependent
variable). Likewise, the mother's educational level is considered
as an independent variable,
which is divided into three
categories: mothers with no formal education, mothers with secondary
or high school
education, and mothers with higher education.
In
addition, the model includes the following control variables: mother's ethnicity, marital
status, mother's age, income quintile, sex of the newborn
and unmet basic needs. A summary table of the variables used in the estimation
is shown below Table 1.
Tabla 1. Descriptive analysis of variables.
This section
describes the empirical strategy used to
examine the hypothesis that more educated women tend to
practice exclusive breastfeeding
for shorter periods compared to less educated
mothers. Since the dependent variable (EBF) is dichotomous, a binary response model is chosen, specifically
a probit model, which fits this
case adequately. This model uses as estimation method the Maximum
Likelihood Method, whose objective is to find
the joint density function (or likelihood) that best fits
the distribution of the data (15).
The probit regression model is a binary response model that estimates
the probability that our dependent
variable "y" takes a value
equal to 1 using a standard cumulative normal distribution
function (1), evaluated at
z=β_0+β_1 X (a critical value
that depends d the set of control variables).
The probit model is widely
used for its ability to
ensure that the probability is in the interval
from 0 to 1 and that the conditional
probability of Y=1 given a set of explanatory variables "X" is
increasing for β_1>0. This requires a nonlinear functional form for the
probability, such as an "S-shaped curve". It is important
to note that in probit models, the resulting coefficients
are not directly
interpretable and only provide
information on sign and statistical significance. Therefore, if one wishes
to know the
real effect, it is necessary to
obtain the marginal effects, which indicate the change
in probability due to changes in an
explanatory variable. In other
words, it is a matter of
obtaining the partial derivative. The equation to be estimated is shown
below:
Where:
EBF:
Dichotomous dependent
variable that takes the value of
1 if the mother breastfed exclusively for 6 months or more, and 0 if the breastfeeding
period was less than 6 months.
: The categorical
variable assigning the value of 1 to
mothers with no education, 2 to mothers with a medium level of
education and 3 to mothers with higher
education.
: Categorical variable for mother's ethnicity.
1 indigenous, 2 Afro-Ecuadorian,
3 mestizo and 4 monotubo.
: The
dichotomous variable takes the value of
1 when the mother is married
or single and 0 otherwise.
: The
variable that captures the mother's age.
: Categorical
variable for income quintile.
: Dichotomous
variable that corresponds to the sex of
the baby (1 female 0 male).
: The variable that reflects the
unsatisfied basic needs of the
household.
: Error term.
RESULTS
The results obtained confirm the hypothesis, that is, women
with higher educational levels tend to practice
exclusive breastfeeding for
shorter periods compared to mothers
with lower educational levels. Thus, Ecuadorian mothers with a higher educational level are 2.2% less likely to give
EML (for six months or more) than mothers with
no education Table 2. Similar results
are found in the study by Rahman et al. (12) in
Bangladesh, where it is concluded that
mothers with secondary and higher education tend not to give
EML to their children. One of
the reasons supporting these results is related
to the fact
that sometimes women with higher
levels of education may find
it difficult to breastfeed their
infants due to lack of
time because of their work or
because of aesthetic considerations.
Tabla 2. Results from
the application of the probabilistic
model.
As
for the mother's
age, a negative marginal effect
of 0.001 was found. This means
that, for each additional year of mother's
age, the probability of giving SCI, for six months or
more, is reduced by 0.1%. Regarding the variable that captures the mother's ethnicity,
we find that
mothers selfidentified as
Afro-Ecuadorian are 3.2% less
likely to give SBI, for six
months or more, than mothers self-identified
as indigenous. For the group of
Montubio mothers, the probability of giving SBI, for six months or
more, compared to indigenous mothers is 4.6%. Finally, mestizo mothers are 2.5% less likely to exclusively
breastfeed for 6 months or more than indigenous mothers Table 2. On the other hand,
the variable that records the sex of the infant
reveals that the probability of a mother providing
EML to her child for 6 months
or more increases by 1.4% when the
newborn is a girl, compared to boys.
According to
the results obtained, it can be observed that mothers
located in quintiles 2, 4 and 5 have
a lower probability of giving SCI than
quintile 1, with 1.8%, 2%
and 2.5%, respectively. For
example, if the mother is
in quintile 5 of the population, she has a 2.5% lower probability of giving SCI, for six months or
more, compared to quintile 1, where the probability is positive. Similar results are found in studies conducted in underdeveloped countries such as Peru and Costa Rica (16,17). Both
studies conclude that the lower
the socioeconomic level, the higher
the probability of giving SCI compared
to the higher
quintiles. The argument of these studies
suggests that a better economic level allows mothers
to forgo breastfeeding and seek breast milk substitutes.
DISCUSSION
To ensure the robustness of the results
, a series of post-estimation
tests are performed, such as the confusion
matrix and the Receiver Operating Characteristic (ROC)
curve. The calculation of the confusion
matrix is intended to identify
the number of hits that the
model had when classifying true positives
and negatives. Oleas K. 625 Volumen 7 No. 20 mayo-agosto 2024,
https://revistavive.org, ISSN: 2664-3243, ISSN-L: 2664-3243 Thus,
the confusion matrix is structured
as follows: on the main diagonal is the number
of classifications made correctly by the estimation,
and at the extremes are the
type 1 and 2 errors. Thus, it can be seen that the
model was able to classify
91.54% of the total as
positive (sensitivity), and 13.19% of the total as true negative (specificity). Finally, the confusion matrix
shows that the model was able
to predict 85.65% between true positives and negatives Table 3.
Tabla 3. Confusion matrix.
On the other hand, the
ROC curve can be used to analyze the predictive power of the
model. The further the ROC curve deviates from the
slope, the greater the predictive power of the
model. In this case, the area under
the curve is 0.58, i.e., the model has a predictive power of approximately
58% Figure 2.
Figura 2. ROC curve of the
probabilistic model.
ed on what was previously
reviewed, women with higher levels
of education tend to practice
exclusive breastfeeding (EBF) for
shorter periods compared to mothers
with lower levels of education.
Specifically, Ecuadorian mothers with higher
levels of education are 2.2% less likely to practice
EBF for six months or more compared to mothers
with no education. The trend observed
in Ecuador may not be an isolated phenomenon,
but part of a broader pattern
that manifests itself in different socioeconomic and cultural contexts.
One possible explanation for these results lies
in the additional difficulties faced by women with
higher levels of education. These
difficulties are often related to work
demands and the pressures of the
professional environment, which may limit
the time and flexibility needed for breastfeeding.
Mothers with higher levels of
education tend to hold job
positions that demand more
time and commitment, making
it difficult to practice EML for extended periods. In addition, some women may choose
not to practice
EML because of aesthetic considerations or the perception
that breastfeeding may interfere with
their professional image.
These findings have important implications for public health policies
and breastfeeding support strategies. It is crucial that breastfeeding promotion programs consider the specific barriers
faced by more educated women. For example, implementing
workplace policies that allow for
more flexible hours, creating
breastfeedingfriendly spaces
in workplaces, and educational
campaigns that address and demystify aesthetic concerns could be effective in increasing SBI rates in this demographic.
Although more educated
women have more access to information
and resources about the benefits of
breastfeeding, they face significant barriers that may
limit their ability to practice
EBF for extended periods. Addressing these barriers through targeted policies and programs can help improve SBI rates and, ultimately, the health and well-being of children in Ecuador.
CONCLUSIÓN
We found significant evidence that mothers with
higher educational attainment tend to practice exclusive breastfeeding for shorter periods compared to mothers
with lower educational attainment. That is, mothers
with a higher educational level are 2.2% less likely to
practice exclusive breastfeeding
for six months
or more compared to mothers with
no education. This result may be related
to the fact
that mothers with a higher level
of education are unable to breastfeed
for longer due to their
work. In this line, it is recommended
to implement labor policies that help
to increase the mother's breastfeeding
time, i.e., to extend the maternity period.
On the other hand, the
type of ethnicity
of the mother
was found to play an
important role in the duration of exclusive breastfeeding in Ecuadorian mothers. For example,
mothers selfidentified as
Montubias are 4.6% less likely
to breastfeed for six months
or more than indigenous mothers. By income quintile,
mothers located in the highest socioeconomic
quintiles are less likely to breastfeed exclusively
for the first
6 months or more than those located
in the lowest economic levels. Finally, the age
of the mother
and the sex of the infant are also important determinants of the duration of
exclusive breastfeeding in Ecuador
CONFLICT
OF INTEREST
The author
declares that there is no conflict of interest for
the publication of this scientific
article
FINANCING
The author
declares that he/she did receive funding
THANKS
The authors acknowledge the effort and contribution that people made
to the development
of this scientific
article.
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