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Abstract
Background: We have previously shown that in Iran, only 28% of infants were exclusively breastfed at six months,
despite a high prevalence of breastfeeding at two years of age. The primary aim of this study was to investigate the
reasons women discontinued exclusive breastfeeding.
Method: This retrospective study was based on questionnaires and interviews with 63,071 mothers of infants up to
24 months of age, divided into two populations: infants younger than six months and six months or older. The data
were collected in 20052006 from all 30 provinces of Iran.
Results: Only 5.3% of infants less than six months of age stopped breastfeeding (mean age of 3.2 months); more
commonly in urban than rural areas. The most frequently cited reasons mothers gave for discontinuing exclusive
breastfeeding were physicians recommendation (54%) and insufficient breast milk (self-perceived or true, 28%).
Breastfeeding was common after six months of age: only 11% of infants discontinued breastfeeding, at a mean of
13.8 months. The most common reason for discontinuation at this age was insufficient breast milk (self-perceived or
true, 45%). Maternal illness or medication (10%), infant illness (6%), and return to work (3%) were uncommon causes.
Use of a pacifier was correlated with breastfeeding discontinuation. Maternal age and education was not associated
with duration of breastfeeding. Multivariate analysis showed that using a pacifier and formula or other bottle
feeding increased the risk of early cessation of breastfeeding.
Conclusions: Physicians and other health professionals have an important role to play in encouraging and
supporting mothers to maintain breastfeeding.
Keywords: Family, Doctor advice, Pacifier, Infant feeding
Background
Breastfeeding provides ideal nourishment for the growth
and development of infants and has a unique biological
and emotional influence on the health of both mother
and child [1,2]. The World Health Organization (WHO)
has recommended that exclusive breastfeeding, defined
as giving breast milk without any food or liquid until six
months of age, confers benefits to mothers and infants [3].
We have previously shown that in 2006, only 57% of
Iranian babies were exclusively breastfed at four, and
28% at six, months of age [4]. These figures were low in
comparison to the WHO recommendation. However, the
Methods
* Correspondence: Beheshteh.Olang@ki.se
1
Unit for Public Health Nutrition, Department of Biosciences and Nutrition,
Karolinska Institutet, Stockholm, Sweden
2
Department of Health, Nutrition and Management, Oslo and Akershus
University College of Applied Sciences, Oslo, Norway
Full list of author information is available at the end of the article
Definitions
2012 Olang et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Page 2 of 7
IMES data were analyzed using Stata version 8.0 and Survey
Analysis commands by using each medical university as a
separate stratum and each data collection area as primary
sampling unit (PSU) and the proportion of sampled persons
to the population of under two years of age as weight. The
rates of discontinuation in different age groups were calculated with 95% confidence interval (CI). Multivariate analysis using Stata 8.0 and XT logistic regression models in
survey analysis mode were used. The same PSUs were used
for analyzing association between discontinuation rate of
breastfeeding and background variables.
Ethical approval
12
10
Percentage
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an
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or
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a s des
an ta
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az
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an z
a
ba and n
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oc an
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or
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ou n
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h ka
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ai
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n
Fa
r
Te s
hr
a
Ar n
da
Bu bil
sh
eh
G r
Kh uila
uz n
es
ta
n
Provinces
Figure 1 The percentage of discontinuation of breastfeeding before 6 months. Data from IMES.
Page 3 of 7
Results
Physicians recommendation
54 (53, 55)
28 (27, 29)
Family recommendation
20 (19, 21)
Crying baby
17(16, 18)
Non-specific reason
17(16, 18)
household were not significantly correlated with breastfeeding discontinuation in the first six months.
Infants over 6 months of age (n = 52,637)
3.5
Age (month)
2.5
1.5
0.5
So
ut
h
Kh
or
a
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am n
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rm eda
an n
s
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st Ma az
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lo a r
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h
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or
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ga
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es
n
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za azd
rb
ai
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n
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Te rs
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rd n
es
t
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rm
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ou
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nt
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ry
or
o
as les
an ta
n
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hk zav
ilo i
uy
e
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ui
la
Is n
f
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uz n
es
Se tan
m
n
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ar
ka
N
z
or
th Ard i
Kh ab
or il
as
Ea
a
st Za n
Az n ja
ar n
ba
ija
n
Ila
m
Q
om
Provinces
Figure 2 Mean age in months of discontinuation of breastfeeding before 6 months. Data from IMES.
Page 4 of 7
Table 2 Multivariate analysis for discontinuing breastfeeding in two population groups (< and 6 months of age)
<6 months of age Adjusted
Odds Ratio (95% CI)
Variable
Living in urban areas (Reference group: rural areas)
16 (7.45, 30.65)
Using formula or other bottle feeding (Reference group: did not bottle feed)
12 (5.02, 20.84)
Discussion
Our findings indicated that the rate of early discontinuation of breastfeeding (before six months of age) was low
18
16
14
Percentage
12
10
So
ut
h
K Ila
or ho m
th ra
Kh sa
or n
as
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az ha
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or
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es
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uy
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o r ra
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za lan
rb
Si
ai
st
ja
an
K
ba er n
lo ma
oc
he n
s
Bu tan
sh
eh
r
Provinces
Figure 3 The percentage of discontinuation of breastfeeding after 6 months of age. Data from IMES.
Page 5 of 7
18
16
14
Age (month)
12
10
Fa
rs
Ko Qom
rd
es
ta
Te n
hr
an
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st Gu
W Az ilan
e s a rb
tA a
za ijan
rb
ai
ja
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az
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n
I
Ko sfah
hk an
ilo
uy
Kh
e
or Co h
as
u
an ntr
R y
az
av
i
Y
Kh a z
uz d
es
ta
Ar n
da
M bil
ar
ka
N
or Ke zi
th
rm
Kh an
or
Si
as
st
a
a
C n b Lor n
ha
es
al
r m oo ta
ah ch n
al est
ba an
kh
H tiar
am y
ed
So
B an
ut us
h
h
Kh eh
or r
as
an
Ila
m
Za
n
Se jan
m
M
az na
an n
da
G ran
o
H les
or
t
m an
Ke oz
g
rm
a
an n
sh
ah
Provinces
Figure 4 Mean age in months of discontinuation of breastfeeding after 6 months of age. Data from IMES.
It can not be excluded that mothers reported that advice was given by physicians or health professionals
even though it was the mothers own decision, as this
might be more socially acceptable than saying they
decided themselves.
Taveras et al. reported in multicultural study groups that
mothers will not usually discontinue breastfeeding within
the first three months after delivery if they are encouraged
by physicians to continue [9]. The American Academy of
Pediatricians recommends physicians to advise mothers on
initiation and continuation of breastfeeding and to be
Table 3 Percentage distributions of reasons for
discontinuing breastfeeding after 6 months of age in
52,637 infants in Iran
Reasons for discontinuation of
breastfeeding 6 months of age
45 (43, 47)
11 (10, 12)
Return to work
3 (2, 4)
Time to stop
6 (5, 7)
Breast refusal
27 (26, 29)
Infant illness
Non-specific reason
*Mothers could give more than one reason.
6 (5, 7)
25 (24, 27)
Conclusion
The cause of early discontinuation of exclusive breastfeeding during infancy, as given by the mother, was
mainly physicians recommendation and/or insufficient
breast milk. Specific reasons, such as maternal or infant
illness were rare, indicating that by support and education, the prevalence of exclusive breastfeeding to six
months could be increased. The results suggest an important role for physicians and other health professionals
to encourage breastfeeding.
Competing interests
The authors declare that they have no competing interests.
Acknowledgements
Special thanks go to the Deputy Minister of Health in the MOH in Iran, the
head of the Population and Family Health Office in the MOH and the head
and staff at the breastfeeding office in the MOH.
Page 6 of 7
Author details
1
Unit for Public Health Nutrition, Department of Biosciences and Nutrition,
Karolinska Institutet, Stockholm, Sweden. 2Department of Health, Nutrition
and Management, Oslo and Akershus University College of Applied Sciences,
Oslo, Norway. 3Kermanshah University of Medical Sciences, Kermanshah, Iran.
4
Breastfeeding Research Center, Tehran University of Medical Sciences,
Tehran, Iran. 5Guilan University of Medical Sciences, Rasht, Iran.
Authors contributions
BO drafted the manuscript and coordinated the project between the MOH in
Iran and Karolinska Institutet in Sweden. AB was responsible for IMES data
and performed statistical analysis. BS helped to developing the study and
writing the manuscript. AY participated in design of the study. All authors
approved the final manuscript.
Received: 05 January 2011 Accepted: 6 May 2012
Published: 6 May 2012
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