Breastfeeding Prevalence and Factors Affecting Breastfeeding Duration Among Urban Multi-ethnic Malaysian Mothers: A Single-Center University Hospital Study

Abstract

Breastfeeding rates in urban Malaysian mothers are below World Health Organization (WHO) targets. Our prospective survey identified breastfeeding prevalences at 3, 6, and 12 months of 85.5%, 77%, and 60%, respectively. Combined (direct and expressed) breastfeeding significantly sustained longer-term breastfeeding. Efforts should be focused on mothers of Indian ethnicity and on expression after one month postpartum.

Keywords

maternal and child health public health prospective study breastfeeding breastmilk expression prevalence urban working mothers

What We Already Know

Following the implementation of the WHO Baby-Friendly Hospital Initiative in Malaysia, the prevalence of exclusive breastfeeding among urban and rural mothers has increased.

However, the rate of exclusive breastfeeding remains below WHO global targets.

More women are working out-of-home, and this may lead to an earlier than intended cessation of breastfeeding. Thus, understanding breastfeeding behavior and practices is crucial.

What This Article Adds

Expression of breastmilk is common among urban working mothers; about one-half of mothers started doing so within one-month post-partum.

Direct breaastfeeding combined with expressed breastmilk at three months is a strong predictor of sustaining breastfeeding at 6 and 12 months compared to either method alone.

Exclusive breastfeeding at 3-months post-partum is a strong predictor of still breastfeeding at 6 and 12 months.

Introduction

The benefits of exclusive breastfeeding last long after its duration for both child and mother.¹ World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, with continued breastfeeding up to two years and beyond.² The 6-month exclusive breastfeeding prevalence among Malaysian urban mothers was 48.3% in 2016,³ below the WHO 2030 global target of 70%.⁴ Understanding breastfeeding behavior and practices is crucial.

We conducted a prospective survey of postnatal breastfeeding practices among urban mothers to determine the prevalence and factors associated with breastfeeding outcomes at 3, 6, and 12 months.

Methods

We enrolled consecutive mother-infant pairs from the vaccination clinic in University Malaya Medical Centre (UMMC), Malaysia, from July to December 2016. Inclusion criteria were mothers aged above 18 years, without gestational or postnatal complications, and infants aged up to 3 months. The exclusion criteria were preterm or multiple births. Following consent, a face-to-face interview was conducted by trained researchers, using a pre-tested questionnaire.⁵ Data obtained at enrolment included socio-demographic variables and infant feeding practices (exclusive/non-exclusive breastfeeding [as per WHO definitions²] and direct, or expressed, or combined breastfeeding [direct and expressed⁶]). Breastfeeding outcomes at 6 and 12 months were obtained during clinic visits or by telephone. The study was approved by the Medical Research Ethics Committee of UMMC, MREC Number: 20161-2019 and NMRR-17-3535-38512 and carried out in accordance with the Declaration of Helsinki.

All data were coded and analyzed using IBM SPSS Statistics (version 29). Variables were examined for association with still breastfeeding at 3, 6, and 12 months using univariate and multivariate logistic regression analyses. For the multivariate model, variables significant on the univariate analysis were included. Crude odds ratio (OR) adjusted odds ratio (aOR), and their 95% confidence intervals (CIs) are reported. Statistical significance was P < .05.

Results

Altogether, 312 mothers were enrolled, 25 still breastfeeding mothers (8.0%) were lost to follow-up, while the remaining 287 had outcomes recorded at 6 and 12 months (see Figure 1).

Figure 1.

Mothers’ breastfeeding outcomes at 3, 6, and 12 months; total numbers analyzed were 312, 287, and 287, respectively.

Breastfeeding prevalence at 3, 6, and 12 months was 85.6%, 77.0%, and 60.3%, respectively.

Univariate and multivariate analyses results are shown in Tables 1 and 2, respectively. Ethnicity was significantly associated with breastfeeding duration. The odds of a Malay mother still breastfeeding at 3 and 12 months are 4.3 and 7.7 times higher than an Indian mother (aOR = 0.23, 95% CI [0.08, 0.65]; aOR = 0.13, 95% CI [0.05, 0.35], respectively). Other independent factors associated with sustained breastfeeding at 6 and 12 months were tertiary education (aOR = 3.23, 95% CI [1.17, 9.13]; aOR = 2.95, 95% CI [1.37, 6.32], respectively) and prior breastfeeding (aOR = 57.32, 95% CI [5.04, 652.32]; aOR = 1.98, 95% CI [1.02, 3.84], respectively). Expression of breast milk after the first month enabled breastfeeding at 3 months (aOR = 4.75, 95% CI [1.11, 20.35]) compared with those who had not expressed at 3 months. Mothers who expressed within the first month were 5.3 times less likely to continue breastfeeding at 12 months compared with those who did not express by 3 months (aOR = 0.19, 95% CI [0.06, 0.62]). The strongest predictors of breastfeeding at 6 and 12 months were the practices of exclusive breastfeeding at 3 months (aOR = 18.33, 95% CI [6.38, 52.68]; aOR = 9.99, 95% CI [4.69, 21.29], respectively) and combined breastfeeding (aOR = 15.91, 95% CI [5.47, 46.23]; aOR = 2.72, 95% CI [1.17, 6.32], respectively). Bed-sharing showed significance for breastfeeding at 3 months (aOR = 2.58, 95% CI [1.10, 6.05]).

Table 1.

Univariate Analysis of Breastfeeding Practices at 3 Months and Outcomes at Aged 3, 6, and 12 Months.

Variables	Still breastfeeding at 3 months		Univariate at 3 months old			N = 287	Still breastfeeding at 6 months	Univariate at 6 months old			Still breastfeeding at 12 months	Univariate at 12 months old
Variables	N = 312	Yes (%)267 (85.5)	OR	95% CI	P value	N = 287	Yes	OR	95% CI	P value	Yes	OR	95% CI	P value
Mother’s age, years
<35	243	211 (86.8)	1.00	—	—	226	178 (78.8)	1.00	—	—	138 (61.1)	1.00	—	—
≥35	69	56 (81.2)	0.65	[0.32, 1.33]	.239	61	43 (70.5)	0.644	[0.34, 1.22]	.175	35 (57.4)	0.86	[0.48, 1.52]	.602
Ethnicity
Malay	181	170 (93.9)	1.00	—	—	166	150 (90.4)	1.00	—	—	130 (78.3)	1.00	—	—
Chinese	63	47 (74.6)	0.19	[0.08, 0.44]	< .001	62	36 (58.1)	0.15	[0.07, 0.30]	.001	24 (38.7)	0.18	[0.09, 0.33]	< .001
Indian	49	36 (73.5)	0.18	[0.07, 0.43]	< .001	43	25 (58.1)	0.15	[0.07, 0.33]	.001	11 (25.6)	0.10	[0.04, 0.21]	< .001
Others	19	14 (73.7)	0.18	[0.06, 0.60]	.005	16	10 (62.5)	0.18	[0.06, 0.55]	.003	8 (50.0)	0.28	[0.10, 0.79]	.016
Educational level
Below tertiary	108	88 (81.5)	1.00	—	—	95	63 (66.3)	1.00	—	—	47 (49.5)	1.00	—	—
Tertiary	204	179 (87.7)	1.63	[0.86, 3.09]	.137	192	158 (82.3)	2.36	[1.34, 4.15]	.003	126 (65.6)	1.95	[1.18, 3.22]	.009
Sector of working
Public	108	101 (93.5)	1.00	—	—	98	88 (89.8)	1.00	—	—	75 (76.5)	1.00	—	—
Private	146	117 (80.1)	0.28	[0.12, 0.67]	.004	138	95 (68.8)	0.25	[0.12, 0.53]	< .001	66 (47.8)	0.28	[0.16, 0.50]	.001
Housewife	58	49 (84.5)	0.38	[0.13, 1.07]	.068	51	38 (74.5)	0.33	[0.13, 0.82]	.017	32 (62.7)	0.52	[0.25, 1.08]	.078
Maternity leave, days (n = 232)
< 60	12	9 (75)	1.00	—	—	11	6 (54.5)	1.00	—	—	6 (54.5)	1.00	—	—
> 60	237	205 (86.5)	2.14	[0.55, 8.31]	.274	221	175 (79.2)	3.17	[0.93, 10.85]	.066	133 (60.2)	1.26	[0.37, 4.25]	.710
Income
B40	81	63 (77.8)	1.00	—	—	72	47 (65.3)	1.00	—	—	38 (52.8)	1.00	—	—
Above B40	231	204 (88.3)	2.16	[1.12, 4.18]	.022	215	174 (80.9)	2.26	[1.25, 4.08]	.007	135 (62.8)	1.51	[0.88, 2.59]	.134
Parity
Primipara	113	86 (76.1)	1.00	—	—	108	69 (63.9)	1.00	—	—	47 (43.5)	1.00	—	—
Multipara	199	181 (91.0)	3.16	[1.65, 6.04]	< .001	179	152 (84.9)	3.18	[1.81, 5.61]	< .001	126 (70.4)	3.09	[1.88, 5.08]	< .001
Breastfeeding experience
First-time breastfeed	121	91 (75.2)	1.00	—	—	116	71 (61.2)	1.00	—	—	49 (42.2)	1.00	—	—
Breastfeed before	191	176 (92.1)	3.87	[1.98, 7.56]	< .001	171	150 (87.7)	4.53	[2.51, 8.17]	< .001	124 (72.5)	3.61	[2.19, 5.94]	< .001
Breast feeding practice variables
Expressed breastmilk
No expression by 3 months	58	47 (81.0)	1.00	—	—	51	35 (68.6)	1.00	—	—	33 (64.7)	1.00	—	—
EBM within first month	165	135 (81.8)	1.05	[0.49, 2.27]	.895	154	113 (73.4)	1.26	[0.63, 2.52]	.512	82 (53.2)	0.62	[0.32, 1.20]	.155
EBM after first Month	89	85 (95.5)	4.97	[1.50, 16.49]	.009	82	73 (89.0)	3.71	[1.49, 9.22]	.005	58 (70.7)	1.32	[0.63, 2.78]	.468
Exclusive breastfeeding at 3-month old
No	112	67 (59.8)	1.00	—	—	103	49 (47.6)	1.00	—	—	28 (27.2)	1.00	—	—
Yes	200	200 (100)	—	—	—	184	172 (93.5)	15.80	]7.83, 31.86]	.001	145 (78.8)	9.96	[5.69, 17.43]	< .001
Both direct and EBM at 3-month old
No	116	71 (61.2)	1.00	—	—	107	55 (51.4)	1.00	—	—	47 (43.9)	1.00	—	—
Yes	196	196 (100)	—	—	—	180	166 (92.2)	11.21	[5.77, 21.78]	.001	126 (70.0)	2.98	[1.81, 4.90]	< .001
Support
No	—	—	1.00	—	—	—	—	1.00	—	—	—	1.00	—	—
Parents	266	231 (78.3)	1.833	[0.84, 4.02]	.130	248	197 (79.4)	2.41	[1.18, 4.93]	.016	157 (63.3)	2.48	[1.25, 4.94]	.010
Husbands	283	247 (87.3)	3.09	[1.31, 7.30]	.010	261	205 (78.5)	2.29	[0.98, 5.32]	.054	160 (61.3)	1.58	[0.71, 3.55]	.265
In laws	247	213 (86.2)	1.28	[0.61, -2.68]	.520	231	180 (77.9)	1.29	[0.66, 2.52]	.453	143 (61.9)	1.41	[0.78, 2.54]	.254
Friends	262	230 (87.8)	2.53	[1.21, 5.25]	.013	240	192 (80.0)	2.48	[1.27, 4.84]	.008	152 (63.3)	2.14	[1.14, 4.02]	.018
Information
No	—	—	1.00	—	—	—	—	1.00	—	—	—	1.00	—	—
Doctor	275	237 (82.2)	1.46	[0.60, 3.55]	.409	252	197 (78.2)	1.64	[0.76, 3.56]	.209	154 (61.1)	1.32	[0.65, 2.70]	.440
Nurse	292	252 (86.3)	2.10	[0.72, 6.10]	.172	267	208 (77.9)	1.90	[0.72, 4.97]	.192	162 (60.7)	1.26	[0.51, 3.15]	.618
Confinement Lady	173	153 (88.4)	1.68	[0.89, 3.17]	.111	157	128 (81.5)	1.76	[1.01, 3.06]	.047	101 (64.3)	1.45	[0.90, 2.34]	.124
Friends	238	211 (88.7)	2.51	[1.29, 4.89]	.007	216	178 (82.4)	3.05	[1.69, 5.51]	.001	140 (64.8)	2.12	[1.23, 3.65]	.007
Internet	271	238 (87.8)	2.98	[1.39, 6.41]	.005	249	201 (80.7)	3.77	[1.85, 7.67]	.001	158 (63.5)	2.66	[1.32, 5.36]	.006
Breastfeeding course	225	199 (88.4)	2.14	[1.11, 4.11]	.022	206	167 (81.1)	2.14	[1.20, 3.82]	.010	134 (65.0)	2.00	[1.19, 3.38]	.009
Breastfeeding technique checked
No	78	63 (80.8)	1.00	—	—	69	46 (66.7)	1.00	—	—	35 (50.7)	1.00	—	—
Yes	234	204 (87.2)	1.62	[0.82, 3.20]	.166	218	175 (80.3)	2.04	[1.12, 3.71]	.021	138 (63.3)	1.68	[0.97, 2.89]	.064
Bed-sharing with mother
Not sharing bed	66	49 (74.2)	1.00	—	—	60	38 (63.3)	1.00	—	—	28 (46.7)	1.00	—	—
Sharing bed	246	218 (88.6)	2.70	[1.37, 5.32]	.004	227	183 (80.6)	2.41	[1.30, 4.48]	.005	145 (63.9)	2.02	[1.14, 3.59]	.016
Baby’s pacifier practice
Yes	77	59 (76.6)	1.00	—	—	70	46 (65.7)	1.00	—	—	31 (44.3)	1.00	—	—
No	235	208 (88.5)	2.35	[1.21, 4.56]	.012	217	175 (80.6)	2.17	[1.20, 3.95]	.011	142 (65.4)	2.38	[1.38, 4.12]	.002

Abbreviations: B40, bottom 40% of income earners; CI, confidence interval; EBM, expressed breastmilk; OR, odds ratios.

Statistical significance p < 0.05 are in bold.

Table 2.

Breastfeeding Outcomes and Independent Associations From Multivariate Analysis Aged 3, 6, and 12 Months.

Variables	Age 3 months (N = 312)			Age 6 months (N = 287)			Age 12 months (N = 287)
Variables	aOR	95% CI	P value	aOR	95% CI	P value	aOR	95% CI	P value
Ethnicity
Malay	1.00	—	—	1.00	—	—	1.00	—	—
Chinese	0.74	[0.23, 2.36]	.613	0.40	[0.12, 0.94]	.183	0.43	[0.16, 1.12]	.082
Indian	0.23	[0.08, 0.65]	.006	0.40	[0.12, 1.23]	.164	0.13	[0.05, 0.35]	< .001
Others	0.21	[0.08, 1.28]	.106	0.94	[0.15, 3.56]	.946	0.63	[0.16, 2.61]	.531
Educational level
Below tertiary	1.00	—	—	1.00	—	—	1.00	—	—
Tertiary	1.17	[0.51, 2.69]	.714	3.23	[1.17, 9.13]	.024	2.95	[1.37, 6.32]	.005
Breastfeeding experience
First time	1.00	—	—	1.00	—	—	1.00	—	—
Breastfed before	3.79	[0.66, 21.8]	.135	57.32	[5.04, 652.32]	.001	1.98	[1.02, 3.84]	.042
Parity
Primipara	1.00	—	—	1.00	—	—	1.00	—	—
Multipara	0.64	[0.12, 3.46]	.602	0.05	[0.01, 0.57]	.015	0.37	[0.05, 2.94]	.141
EBM
None by 3 months	1.00	—	—	1.00	—	—	1.00	—	—
EBM within first month	0.70	[0.25, 1.97]	.499	0.28	[0.08, 1.00]	.049	0.19	[0.06, 0.62]	.005
EBM after first month	4.75	[1.11, 20.35]	.036	0.42	[0.11, 1.68]	.221	0.34	[0.10, 1.16]	.084
Exclusive breastfeeding at 3-month old
No	—	—	—	1.00	—	—	1.00	—	—
Yes	—	—	—	18.33	[6.38, 52.68]	< .001	9.99	[4.69, 21.29]	< .001
Both direct and EBM at 3-month old
No	—	—	—	1.00	—	—	1.00	—	—
Yes	—	—	—	15.91	[5.47, 46.23]	< .001	2.72	[1.17, 6.32]	.020
Bed-sharing with mother
No	1.00	—	—	1.00	—	—	1.00	—	—
Yes	2.58	[1.10, 6.05]	.03	1.37	[0.48, 3.93]	.562	1.14	[0.51, 2.55]	.748

Abbreviations: CI, confidence interval; EBM, expressed breastmilk; aOR, adjusted odds ratio.

Discussion

In our cohort of urban Malaysian mothers, the rate of exclusive breastfeeding at 3 months postpartum was 64.1% and of ever breastfeeding at 3, 6, and 12 months was 85.5%, 77%, and 60%, respectively; the 2030 WHO global prevalence target at 12 months is 80%.⁴

Among ethnicities, Malay mothers had the highest breastfeeding prevalence at all time points, while Indian mothers were significantly less likely to breastfeed at 3 and 12 months, in agreement with local research.^5,7 Prior breastfeeding experience was a positive predictor of breastfeeding at 6 and 12 months; research shows these mothers have more self-efficacy and confidence for breastfeeding.⁸

We observed significantly positive relationships between maternal tertiary education and prevalence and duration of breastfeeding, similar to high-income countries.⁹ Previous research attributes this to increased awareness of breastmilk benefits,⁹ greater intention to breastfeed,⁸ and wider availability of milk expression,¹⁰ allowing mothers to be away from home while continuing to feed their infants breastmilk.⁶ Expression of breastmilk was high, 81.4% of mothers expressed by three months, compared with 56.6% in Singapore.⁶ Compared with no expression at all, milk expression after the first month was an enabler of ever breastfeeding at three months, whereas expression within the first month was significantly associated with breastfeeding cessation by 12 months.

Combined breastfeeding at three months was a strong predictor of sustaining breastfeeding at 6 and 12 months compared with either direct or expressed breastfeeding alone, as seen elsewhere.^6,10 Combined breastfeeding may be the most sustainable feeding strategy for working mothers to maintain mother-infant bonding and milk supply through direct feeding. Another strong predictor of still breastfeeding at 6 and 12 months was exclusive breastfeeding at three months postpartum, also found elsewhere.⁶ Infant-mother bed-sharing practice was observed in 78.8%, comparable with a previous Malaysian study⁵; this showed significance with breastfeeding at three months only.

This study is one of a few to describe the prevalence of breastfeeding and associated factors at three time-points up to 12 months among urban mothers in Malaysia. Our small sized, single-center study, limits generalizability. Nevertheless, the ethnic profile was representative of Malaysia. We did not explore the reasons why more than half of mothers expressed within one-month postpartum, long before returning to work.

Conclusion

For urban Malaysian mothers, ever breastfeeding prevalence at 3, 6, and 12 months was 85.5%, 77%, and 60%, respectively. Combined direct and expressed breastmilk helped sustain breastfeeding, though milk expression should only be encouraged after 1 month. To reach global targets, attention must be given to Indian mothers, those without tertiary education, and encouraging combined breastfeeding.

Supplemental Material

sj-docx-1-aph-10.1177_10105395231211978 – Supplemental material for Breastfeeding Prevalence and Factors Affecting Breastfeeding Duration Among Urban Multi-ethnic Malaysian Mothers: A Single-Center University Hospital Study

Supplemental material, sj-docx-1-aph-10.1177_10105395231211978 for Breastfeeding Prevalence and Factors Affecting Breastfeeding Duration Among Urban Multi-ethnic Malaysian Mothers: A Single-Center University Hospital Study by Kai Voon Heng, Lucy Chai See Lum, Emer Breen, Chuan Way Lye, Wai Chee Kuan, Saw Huan Goh, Ling Hang Tan and Kar Mun Yip in Asia Pacific Journal of Public Health

Footnotes

Acknowledgements

The authors acknowledge the contributions of the following individuals who assisted in patient enrollment and data curation: Pheng Hian Tan, Hui Ling Leong, Kai Wei Lim, and Yien Thung Loke.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Lucy Chai See Lum

Kar Mun Yip

Data Availability Statement

Data are available upon request and subject to approval by MREC UMMC.

Supplemental Material

Supplemental material for this article is available online.

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