Article

Duration of exclusive breastfeeding: validity of retrospective assessment at nine months of age

Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.
BMC Pediatrics (Impact Factor: 1.93). 09/2011; 11(1):80. DOI: 10.1186/1471-2431-11-80
Source: PubMed

ABSTRACT

In cross sectional, case control and retrospective cohort studies, duration of Exclusive Breastfeeding (EBF) usually depends on maternal recall. Retrospective data are often subjected to recall bias and could lead to a potential for exposure misclassification. The purpose of the present paper is to assess the validity of maternal recall of EBF duration during infancy, after cessation of EBF and to evaluate the two methods to collect retrospective data on EBF.
A cohort study was carried out in Naula Medical Officer of Health (MOH) area. Study cohort included all infants born during the months of February to April 2008 and currently residing in Naula MOH area. Baseline data collection was carried out using the pregnancy record, the child health development record and by using an interviewer administered structured questionnaire. Data extraction from the pregnancy record and the child health development record were carried out by public health midwives. The interviewer administered structured questionnaire was administered by the MOH during the follow-up visits. Duration of EBF was assessed in three ways; based on prospective data since birth: Retrospective data based on an event calendar: and the Mother reported EBF duration.
A total of 114 mother-infant pairs were recruited and followed up. Proportion of infants receiving EBF up to the completion of the sixth month by the three methods were; data since birth (actual EBF rate) - 23.9%; mother reported data - 77.7% and event calendar method - 41.3%. Median duration of EBF reported in the three methods was 5, 6, and 5 respectively. A statistically significant difference was observed in these differences from Kaplan-Meire Survival analysis (Log rank test - Chi square-63.4, p < 0.001). Validity of retrospective methods was analysed using data since birth as the gold standard. Sensitivity of both methods to detect exclusively breastfed babies were 100.0%. Specificity of mother recall data was 26.2% (95%CI-17.9, 36.8%) compared to 75.0% (95% CI-64.5, 83.2%) in the event calendar method.
Retrospective evaluation methods systematically overestimate the duration of EBF. Maternal recall data provide highly unspecific data whereas use of an event calendar provided more valid data. Reporting of data accrual methods in breastfeeding studies will allow the readers to interpret findings accurately and the use of event calendars rather than direct questioning as a valid method of determining EBF is recommended.

Full-text

Available from: Suneth Buddhika Agampodi
RESEARCH ARTICLE Open Access
Duration of exclusive breastfeeding; validity of
retrospective assessment at nine months of age
Suneth B Agampodi
1*
, Suranga Fernando
2
, Samath D Dharmaratne
3
and Thilini C Agampodi
1
Abstract
Background: In cross sectional, case control and retrospective cohort studies, duration of Exclusive Breastfeeding (EBF)
usually depends on maternal recall. Retrospective data are often subjected to recall bias and could lead to a potential
for exposure misclassification. The purpose of the present paper is to assess the validity of maternal recall of EBF
duration during infancy, after cessation of EBF and to evaluate the two methods to collect retrospective data on EBF.
Methods: A cohort study was carried out in Naula Medical Officer of Health (MOH) area. Study cohort included all
infants born during the months of Februar y to April 2008 and currently residing in Naula MOH area. Baseline data
collection was carried out using the pregnancy record, the child health development record and by using an
interviewer administered structured questionnaire. Data extraction from the pregnancy record and the child health
development record were carried out by public health midwives. The interviewer administered structured
questionnaire was administered by the MOH during the follow-up visits. Duration of EBF was assessed in three
ways; based on prospective data since birth: Retrospective data ba sed on an event calendar: and the Mother
reported EBF duration.
Results: A total of 114 mother-infant pairs were recruited and followed up. Proportion of infants receiving EBF up
to the completion of the sixth month by the three methods were; data since birth (actual EBF rate) - 23.9%;
mother reported data - 77.7% and event calendar method - 41.3%. Median duration of EBF reported in the three
methods was 5, 6, and 5 respectively. A statistically significant difference was observed in these differences from
Kaplan-Meire Survival analysis (Log rank test - Chi square-63.4, p < 0.001). Validity of retrospective methods was
analysed using data since birth as the gold standard. Sensitivity of both methods to detect exclusively breastfed
babies were 100.0%. Specificity of mother recall dat a was 26.2% (95%CI-17.9, 36.8%) compared to 75.0% (95% CI-
64.5, 83.2%) in the event calendar method.
Conclusions: Retrospective evaluation method s systematically overestimate the dur ation of EBF. Maternal recall
data provide highly unspecific data whereas use of an event calendar provided more valid data. Reporting of data
accrual methods in breastfeeding studies will allow the readers to interpret findin gs accurately and the use of
event calendars rather than direct questioning as a valid method of determining EBF is recommended.
Background
Breastfeeding is one of the most cost effective interven-
tions for reducing the global burden of childhood mor-
tality and morbidity. More than 13% of under five
deaths can be averte d globally e ach year by promoting
exclusive breastfeeding [1]. Studies on breastfeeding
continue to play a m ajor role in world literature due to
its importance in promoting child health.
Breastfeeding recommendations are subjected to
change with the accumulation of new evidence. Global
health authorities recommend exclusive breastfeeding
up to the completion of the sixth month [2,3]. Studies
on the effects of exclusive breastfeeding depend heavily
upon the definitions used and the data accrual methods.
For cross sectional studies, among infants less than 6
months of age, World Health Organization (WHO)
recommends the 24-hour recall method to assess the
breastfeeding situation in communities [4] whereas
some authors challenge the validity of this WHO
* Correspondence: sunethagampodi@yahoo.com
1
Department of Community Medicine, Faculty of Medicine and Allied
Sciences, Rajarata University of Sri Lanka. Saliyapura, Sri Lanka
Full list of author information is available at the end of the article
Agampodi et al. BMC Pediatrics 2011, 11:80
http://www.biomedcentral.com/1471-2431/11/80
© 2011 Agampodi et al; lice nsee BioMed Central Ltd. This is an O pen 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 1
recommended met hod compared to exclusive breast-
feeding since birth [5-7] method.
When the age o f the child is more than six months,
there are no consensuses about the data accrual method
to obtain the duration of EBF. Further, duration o f EBF
in a community co uld be ideally determined only af ter
the ces sation of EBF (after six months). Hence, in c ross
sectional, case control and retrospective cohort studies
on childhood illnesses where breastfeeding is a major
determinant, duration of EBF is usually determined
based on maternal recall. This retrospective evaluation
is often used because it is much more efficient than pro-
spective studies for this purpose. Retrospective data are
often subjected to recall bias which could lead to a
potential for expo sure misclassification thus resulting in
biased measures of association. Previously, several stu-
dies elsewhere have shown the problem of reliability of
maternal recall data on estimating the duration of EBF
[8-12]. Prev iously, we showed the low validity of the 24-
hour recall data as a method of measuring current sta-
tus of breastfeeding [5]. The purpose of the present
paper is to assess the validity of maternal recall of EBF
duration at nine months and to evaluate the validity of
two methods to collect retrospective data to estimate
the duration of EBF.
Methods
The present study was carried out from February 2008
to April 2009 in Naula Medical Officer of Health
(MOH) area in the Matale district of the Central Sri
Lanka. Data for this study was obtained from a cohort
study c onducted in Naula (Naula breastfeeding cohort).
All infa nts born during the months of February to April
2008 and residing in Naula MOH area at the time of
data collection were the study population. All eligible
mother-infant pairs were selected from the Birth and
Immunization (BI) registers of Public Health Midwives
(PHM). Infants registered in BI registers, but planning
to move out from the area before completing the first
year of life were excluded from the study. PHMs
explained the study to care givers and informed verbal
consent was obtained prior to data collection. Baseline
data collection was carried out using the pregnancy
record, the child health development record and by
using an interv iewer a dministered structured question-
naire. All infan ts were followed up by PHMs monthly at
weighing clinics, starting from the first month after
birth. MOH Naula followed this cohort during routing
immunization clinics at completion of 2
nd
,4
th
,6
th
,9
th
and 12
th
months after b irth. Data ext raction from preg-
nancy records and child health development records
were carried out by PHMs. In terviewer administered
structured questionnaire was administered by the MOH
during the follow-up visits.
The EBF was defined according to the WHO recom-
mendation; Infant should receive only breast milk from
his/her mother or wet nurse or expressed breast milk
and no other liquid or solids with exception of drops or
syrups consisting of vitamins mineral supplements or
medicines
Duration of exclusive breastfeeding was assessed in
the following ways.
Firstly based on data since birth: this definition was
based on the prospective assessment of breastfeeding
status obtained during follow-up visits. Feeding practices
was assessed in each follow-up visit by the MOH during
the first six months and the duration of exclusive
breastfeeding was determined using an interviewer
administered struc tured questionnaire. The question-
naire included a list of locally prevalent breast milk sup-
plements, complementary feeds, and water based infant
foods/drinks used in Matale area. This list included 13
major items categorized in groups including water. Use
of food/liquid items in the list, date of introduction of
specific food items, frequency of the use and the quan-
tity were also recorded (an event calendar). Recall period
for the follow-up was two months at each visit. During
monthly follow-ups PHM assessed the feeding status
verbally and reported any significant finding to the
MOH as a supplement to two months recall period.
Once a mother reported tha t they introduced an item
from the list or other food or li quid item, duration of
exclusive breastfeeding was calculated to the date of
introduction of the specific food item and data collec-
tion with regard to EBF duration using data since birth
was discontinued.
Secondly using retrospective data based on an event
calendar: EBF was retrospec tively evaluated after com-
pletion of the ninth month using the event calendar
method described above. In this evaluation respondents
were asked whether they have provided the items indi-
cated in the list, if so the date of introduction of the
food item and the frequency of administration and
quantity.
Last ly, using the Mother reported EBF duratio n: After
completion of the 9
th
month, respondents were asked
about the duration of EBF using one single question (at
what age did you discontinue EBF?).
The main outcome variables were the proportion of
infants breastfed exclusively at the completion of sixth
months, and the duration of EBF. Data analysis was car-
ried out to evaluate the validity of reported duration of
EBF data. Validity of each method to determine the pro-
portion of mothers practising EBF for six months was
evaluated using sensitivity and specificity, considering
data since birth as the gold standard.
Ethical clearance for the study was obtained from
Ethical review committee, Faculty of Medicine,
Agampodi et al. BMC Pediatrics 2011, 11:80
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University of Peradeniya. Administrative clearance for
the study was obtained from the Medical officer of
health, Naula.
Results
A total of 114 mother-infant pairs w ere recruited and
were followe d up. The mean age of the moth ers was 27
years and standard deviation 5.3 years. Only six mothers
were employed while the remaining 108 mothers were
housewives. All 114 mothers had completed primary
education. However, only one mother had studied
beyond secondary education. The mean birth weight of
infants was 2.85 kg (SD 0.47 kg). Study sample consisted
of 61 (53.5%) male and 53 (46.5%) fema le infants. Five
(4.4%) infants were reported as premature (< 37 weeks)
deliveries and two (1.8%) were admitted to the Special
Care Baby Unit (SBU) immediately after birth. First-
born babies accounted for 49.1% (n = 56) of the study
sample.
According to baseline data, the breastfeeding initiation
rate was 100% at the time of discharge and 109 (95.6%)
infants received the first feed within an hour of delivery.
All 114 mother-infant pairs were followed up for 6
months. F rom sixth to ninth months, 11 participants
were lost to follow-up and only 103 w ere available for
the final analysis.
As evaluated by data since birth, obt ained during pro-
spective follow-up visits, only 23.9% (n = 27) practiced
EBF up to the completion of the sixth month. At this
age, 41 (36%) has started complementa ry fee ding and 45
(39.5%) were practising predominant breastfeeding. The
median duration of exclusive breastfeeding was 5
months with an inter-quartile range of 4 to 5 months.
Of the 87 mothers who discontinued EBF before com-
pleti on of the sixth month, 60 (52.6%) gave water as the
first food. Howeve r, 21 (18.4%) mothers gave only water
in addition to breast milk till the completion of the
sixth month.
At completion of nine months, 77.7% were reported as
exclusively breastfed for six months and the median
duration o f EBF was six months. Based on the data col-
lected through the event calendar method, at the com-
pletion of the ninth months, this proportion was 41.3%
and the median duration was five mon ths. Durati on of
EBF reported in maternal re call data and event calendar
data were compared with the data since birth using
Kaplan-Meire survival analysis (please see Figure 1). It
showed statistically significant differences in the three
Figure 1 Survival curves of duration of exclusive breastfeeding by assessment method.
Agampodi et al. BMC Pediatrics 2011, 11:80
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survival curves representing the three methods of data
collection on duration of EBF (Log rank test - Chi
square-63.4, p < 0.001)
Mother reported data and data collected through
event calendar method was validated against data sinc e
birth to evaluate the ability of the above two methods to
estimate EBF for six months. Table 1 shows the distri-
bution of exclusively breastfed and non-exclusively
breastfed babies at completion of sixth month.
Test parameters were calculated to assess s ensitivity,
specificity, and predictive values. Each method correctly
identified all those infants received only breast milk dur-
ing first six months of l ife (sensitivity-100%). However,
specificity varied widely. According to the maternal
recall method EBF w as only 26.2% while in the event
calendar method it was 64.5%. Table 2 shows the sensi-
tivity, specificity and predictive values of the two
methods.
Discussion
The present study showed that in the study population,
both maternal recall method data as well as data retro-
spectively obtained using an event calendar method sys-
tematically overestimates the duration of EBF. Maternal
recall data does not see m to be valid at all in estimating
the duration of EBF. Use of an event calendar provided
much more valid data.
Several previous studies also showed disagreement
between data since birth and recall data. However, most
of those studies reporte d better agreement than the pre-
sent study. Very few studies have specifically studied the
time of introduction of wate r or other liquids which the
present study collected data as the date when EBF
ended [11]. Bland et al in their study showed t hat at
nine months, specificity of reported EBF ranged from 40
to 82%. In their study the sensitivity was high, ranging
around 80%. However, previous studies have shown that
when the recall period was longer the misclassification
of EBF period was also large. For shorter recall periods,
it has been shown that maternal recall data are compar-
able with data since birth. The present study found l ow
validity of respondent reported data in determining EBF
retrospectively. A reason for th is difference could be the
way the questions were framed in maternal recall. Ask-
ing the duration of EBF (as in this study) will provide
different results to asking the time of onset of comple-
mentary feeding.
Recal l bias is a well- known phenomenon in epidemio-
logical studies. However, the low validity found in this
study cannot be directly attributed to recall bias. The
reported data depends mainly on formulating of appro-
priate questionnaires and methods. In a country like Sri
Lanka with high literacy rate, especially among females
(89.7%) [13], where people are aware of the recom-
mended duration of EBF, mothers tend to provide
answers that reflect the desired duration rather than
what ar e practised. This social d esirability bias could
have affected the present study, because data collectors
were their service providers. The main reason for
obtaining acceptable results in the event calendar
method may be due to the authors not mentioning EBF
during the particular assessme nt, making mothers not
obligatory to report the actual situation. However, in
large population based studies, event calendar method
could be difficult to administer with large number of
other variables. At least a list of common supplementary
foods including water and other juices could be used to
probe into the duration of EBF.
There were several limitations in the present study.
This sample was not a probability sample and the gen-
eralization of results is limited. Data collection was
carried out by the service providers who knew about
the study hypothesis, which could lead to probable
interviewer bias. Wording of recall questionnaire at
what age you discontinued EBF? could provide
Table 2 Test parameters of event calendar method and maternal recall method, in comparison to data since birth to
correctly identified EBF for six months
Event calendar EBF Mother reported EBF
Estimate 95% CI Estimate 95% CI
Sensitivity 100.0 85.7, 100 100.0 85.69, 100.0
Specificity 75.0 64.5, 83.2 26.2 17.86, 36.82
Positive Predictive Value 53.5 38.9, 67.5 28.1 19.48, 38.59
Negative Predictive Value 100.0 90.0, 100.0 100.0 84.54, 100.0
EBF -Exclusive Breast Feeding
Table 1 Comparison of event calendar and maternal
recall data on 6 months EBF with data since birth
Event calendar Mother reported EBF
Data since birth EBF N-EBF Total EBF N-EBF Total
EBF 23 0 23 23 0 23
N-EBF 20 60 60 59 21 80
Total 43 60 103 82 21 103
EBF- Exclusive Breast Feeding, N-EBF- non - exclusive breast feeding
Agampodi et al. BMC Pediatrics 2011, 11:80
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Page 4
different re sults than the othe r popular method of ask-
ing at what age you started complementary feeding.
However, within the given limitations results of this
study could be used to improve the quality of data in
studies where breastfeeding is a major determinant.
We pro pose reporting data accrual methods in brea st-
feeding studies as an essential requirement in its
methods section. Use of event calendars rather than
direct questioning is recommended to evaluate the
EBF duration.
Conclusions
Retrospective e valuation met hods systematically overes-
timate the duration of EBF. Reporting of data accrual
methods in breastfeeding studies will allo w the reader s
to interpret finding accurately and the use of event
calendars rather than direct questioning as a valid
method of determining EBF is recommended.
This study was partially funded by Rajarata University
Research Grant 200 9 (Grant No-RJT/R&P/2009/Med/
R.03)
Acknowledgements
All public health midwives in Naula MOH area are acknowledged.
Author details
1
Department of Community Medicine, Faculty of Medicine and Allied
Sciences, Rajarata University of Sri Lanka. Saliyapura, Sri Lanka.
2
MOH Office,
Naula, Sri Lanka.
3
Department of Community Medicine, Faculty of Medicine,
University of Peradeniya, Peradeniya, Sri Lanka.
Authors contributions
ASB designed the study, analyzed and interpreted data, and prepared the
manuscript.
SF involved in the design, data collection and manuscript preparation. DSD
and TCA helped in analysis and interpretation of data and in the preparation
of the manuscript.
All authors read and approved the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 November 2010 Accepted: 14 September 2011
Published: 14 September 2011
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Cite this article as: Agampodi et al.: Duration of exclusive breastfeeding;
validity of retrospective assessment at nine months of age. BMC
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    • "Accuracy in self-reports of mothers who participated in population-based household surveys have been assessed [14,15] and recommendations made to improve measurement and reporting of coverage estimates [8]. Accuracy of survey data can depend on a number of factors including the length of recall period161718 , demographic characteristics of respondents [11] inter-or intra-observer varia- tions [19,20], social desirability i.e. reporting about own practice based on socially acceptable norms212223 and approaches to data collection21222324 In this study, we have revealed variations in how data collectors interviewed and probed mothers to explain time-dependent questions about newborn bathing and breastfeeding initiation. "
    [Show abstract] [Hide abstract] ABSTRACT: Delayed bathing and early initiation of breastfeeding are among the essential interventions recommended to save newborn lives. Although survey coverage reports are key to monitoring these interventions, few studies investigated whether such reports accurately reflect the proportion of mothers and children who received these interventions. In order to gather accurate data, guidance on how to interview and probe mothers is provided. In this study, we investigated experiences of data collectors when asking mothers survey questions that assessed delayed bathing and early initiation of breastfeeding. In November 2013, using a self-administered semi-structured questionnaire, we interviewed data collectors who had taken part in a population-based newborn health household survey in Ethiopia during October-November 2013. A total of 130 out of 160 invited data collectors completed and returned the self-administered questionnaire. Descriptive statistics were used to analyse quantitative data using SPSS software version 19. Qualitative data showing the variety of probes used by data collectors was analysed by listing, screening to identify common themes, and grouping by category. Most data collectors reported that, in their opinion, mothers were able to understand the meaning of the question about newborn bathing (n = 102, 79%) and breastfeeding initiation (n = 106, 82%) without the need for probes. However, fewer mothers were able to recall the event for either newborn behaviours and describe it in minutes, hours or days without the need for probes. Overall, only 26% (n = 34) and 34 % (n = 44) of all data collectors reported that they did not need any probing for the questions related to newborn bathing and breastfeeding initiation questions, respectively. We identified a variety of probes used by data collectors and present examples. Considerable probing was necessary to facilitate maternal recall of the events and approximate their responses of time regardless of mothers’ age, level of education and parity. This could potentially lead to inaccurate coverage reports due to subjective and inconsistent interpretation of the indicators. Therefore, we recommend inclusion of standard probes or follow-on questions to the existing survey tools assessing the two indicators. Data collectors also require further guidance in using appropriate probes to gather accurate maternal responses.
    Full-text · Article · Apr 2015 · BMC Pediatrics
  • [Show abstract] [Hide abstract] ABSTRACT: Complementary food is needed when human milk (or infant formula) alone is no longer sufficient for nutritional reasons. The timing of introduction needs to be determined on an individual basis although 6 months of exclusive breastfeeding can be recommended for most healthy term infants. Solid foods are intended to 'complement' ongoing breastfeeding with those dietary items whose intake has become marginal or insufficient. Both breastfeeding and complementary feeding can have direct or later consequences on health. Possible short-term health effects concern growth velocity and infections while possible long-term effects may relate to obesity, cardiovascular disease, autoimmunity (celiac disease and type 1 diabetes) and atopic disorders. For most of these it is impossible on the basis of the available evidence to conclude on the age when risks related to the start of complementary feeding are lowest or highest, with the possible exception of infections and early growth velocity. For undesirable health consequences, whilst potential mechanisms are recognized, the evidence from mostly observational studies is insufficient and requires more and prospective research. While the 6-month goal is desirable, introduction of suitable complementary food after 4 completed months with ongoing breastfeeding can be considered without adverse health consequences for infants living in affluent countries. Even less evidence on the consequences of the timing of complementary food introduction is available for formula-fed infants.
    No preview · Article · Sep 2013 · World review of nutrition and dietetics
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    [Show abstract] [Hide abstract] ABSTRACT: We aimed to examine the association between breast-feeding and maternal risk of type 2 diabetes and to investigate whether this association is mediated by anthropometric and biochemical factors. A case-cohort study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study between 1994 and 2005 including 1,262 childbearing women (1,059 in a random sub-cohort and 203 incident cases) mainly aged between 35 and 64 years at baseline was applied. Self-reported lifetime duration of breast-feeding was assessed by questionnaire. Blood samples were used for biomarker measurement (HDL-cholesterol, triacylglycerols, C-reactive protein, fetuin-A, γ-glutamyltransferase, adiponectin). A systematic literature search and meta-analysis was conducted of prospective cohort studies investigating breast-feeding and risk of type 2 diabetes. The HR for each additional 6 months of breast-feeding was 0.73 (95% CI 0.56, 0.94) in EPIC-Potsdam. Meta-analysis of three previous prospective studies and the current study revealed an inverse association between breast-feeding duration and risk of diabetes (pooled HR for lifetime breast-feeding duration of 6-11 months compared with no breast-feeding 0.89; 95% CI 0.82, 0.97). Adjustment for BMI and waist circumference attenuated the association (HR per six additional months in EPIC-Potsdam 0.80; 95% CI 0.61, 1.04). Further controlling for potentially mediating biomarkers largely explained this association (HR 0.89; 95% CI 0.68, 1.16). Longer duration of breast-feeding may be related to a lower risk of diabetes. This potentially protective effect seems to be reflected by a more favourable metabolic profile; however, the role of body weight as a mediator or confounder remains uncertain.
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