Tan International Breastfeeding Journal 2011, 6:2

http://www.internationalbreastfeedingjournal.com/content/6/1/2

RESEARCH Open Access

Factors associated with exclusive breastfeeding

among infants under six months of age in
peninsular malaysia
Kok Leong Tan

Abstract
Background: Breastfeeding is accepted as the natural form of infant feeding. For mothers to be able to breastfeed
exclusively to the recommended six months, it is important to understand the factors that influence exclusive
breastfeeding. The aim of the study was to identify factors associated with exclusive breastfeeding in Peninsular
Malaysia.
Methods: This was a cross-sectional study involving 682 mother-infant pairs with infants up to six months
attending maternal and child health section of the government health clinics in Klang, Malaysia. Data were
collected by face-to-face interviews using a pre-tested structured questionnaire over 4 months in 2006. Data on
breastfeeding were based on practice in the previous one month period. Logistic regression was used to assess the
independent association between the independent variables and exclusive breastfeeding adjusting for infant age.
Results: The prevalence of exclusive breastfeeding among mothers with infants aged between one and six
months was 43.1% (95% CI: 39.4, 46.8). In the multivariate model exclusive breastfeeding was positively associated
with rural residence, Malay mothers, non-working and non-smoking mothers, multiparous mothers, term infants,
mothers with husbands who support breastfeeding and mothers who practice bed-sharing.
Conclusions: Interventions that seek to increase exclusive breastfeeding should focus on women who are at risk
of early discontinuation of breastfeeding.

Background was 94.7% (95% CI: 93.0, 95.9) [2]. The prevalence of
Over the past decade, the government of Malaysia has exclusive breastfeeding up to four months and six
recognized the significance of breastfeeding and infant months were 19.3% (95% CI: 15.5, 23.9) and 14.5% (95%
nutrition. The National Breastfeeding Policy was formu- CI: 11.7, 17.9) respectively [2].
lated in 1993 and revised in 2005 in accordance with Wide variations exist in breastfeeding and other infant
the World Health Assembly Resolution 54.2 (2001) feeding practices between countries and among sub-
whereby exclusive breastfeeding was recommended for groups of populations. For mothers to be able to breast-
the first six months of life as a public health measure feed exclusively to the recommended six months, it is
and thereafter continued up to two years of age and important to understand the factors that influence
beyond with timely, adequate and safe complementary exclusive breastfeeding. Various factors have been found
foods [1]. According to Malaysia Third National Health to be associated between exclusive breastfeeding and
and Morbidity Survey 2006 (NHMS III), the prevalence breastfeeding initiation and duration; socio-demographic
of infants who initiated breastfeeding within one hour of factors (education level, urban versus rural residence,
birth was 63.7% (95% CI: 61.4, 65.9) while the preva- monthly household income and parity); biosocial factors
lence among children less than 12 years ever breastfed (breastfeeding support); cultural factors (beliefs, norms
and attitudes towards breastfeeding) and employment
policies [3-7].
Correspondence: [email protected]
Community Medicine Division, International Medical University, Bukit Jalil,
There is limited published data regarding exclusive
57000 Kuala Lumpur, Malaysia breastfeeding determinants in Malaysia. This study was
© 2011 Tan; 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.
Tan International Breastfeeding Journal 2011, 6:2 Page 2 of 7
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conducted to identify determinants of exclusive breast- and occupancy rate) and psychosocial variables
feeding in a group of mother-infant pairs attending (husbands’ support toward breastfeeding, bed-sharing
maternal and child health section of the government practice) were collected. The interview was conducted
health clinics in Klang, Malaysia. in ‘Bahasa Malaysia’ as it was the national language and
widely used by the respondents. For mothers of Chinese
Methods ethnicity not well versed in ‘Bahasa Malaysia’, the inter-
This was a cross-sectional study conducted in Klang, view was conducted in Mandarin language. In order to
Malaysia involving 682 mother-infant pairs with infants ensure no eligible mother-infant pairs were missed from
up to six months attending the Maternal and Child the interview, the author attended the clinics at least fif-
Health (MCH) section of the government health clinics teen minutes before the immunization session started.
over four months in 2006. An analysis of bed-sharing Liaison with the nurses at the clinics was also made to
practices has already been published [8]. In Klang, there ensure that all eligible mother-infant pairs were inter-
are eight government health clinics with their subsidiary viewed. Socio-demographic data were also collected
community clinics providing health needs for the com- from all eligible mother-infant pairs who refused to par-
munity. Two of the health clinics including their sub- ticipate in the study. A yellow sticker was placed on the
sidiary community clinics were chosen for the study by right upper corner of the infants’ immunization card
random selection where one health clinic (Bukit Kuda after the interview to prevent interviewing the same
Health Clinic) serves an urban population while the mother-infant pair during the entire four months of
other (Kapar Health Clinic) serves a rural population. data collection.
The sampling method used was universal sampling. All In this study, exclusive breastfeeding was defined as
eligible mother-infant pairs who attended the clinics dur- the infant having received only breast milk from the
ing the study period were included in the study. Data col- mother (either directly from the breast or expressed)
lection was carried out according to a schedule that was and no other liquids or solids with the exception of
prepared. Data was collected from the two identified drops or syrups consisting of vitamins, mineral supple-
areas in the study at alternate weeks with designated days ments, or medicines over the one month period prior to
for each clinic. The specific days selected for data collec- the interview. A recall over a one month period was
tion for each clinic coincided with the days when immu- used in this study because this duration coincided with
nization was scheduled for the infants. the immunization days where infants were called in
The inclusion criteria in the study included all every month for the first six months of life.
mother-infant pairs visiting Bukit Kuda and Kapar Bed-sharing was defined as an infant sharing a bed
Health Clinic including the subsidiary community clinics with mother within arm’s reach of the mother. A bed
between 19 June and 19 October 2006. Mother-infant was defined as either a sleeping mattress placed on a
pairs were excluded from the study if mothers were less bed frame or a sleeping mattress placed on the floor.
than 18 years old, have a child with congenital malfor- Mothers were defined as a ‘bed-sharer’ if they shared a
mation, infants more than six months old, infant taken bed with their infant for three or more times a week for
care of by caregivers during night time and infant not all or part of the night.
accompanied by mother at the clinic. Occupation was defined as the working status of the
After consent from eligible mothers, a face-to-face mother. Working encompasses any form of employment
interview using a pre-tested pre-coded structured ques- with contribution to income tax.
tionnaire was conducted by the author in the clinics at All data in the questionnaire were coded and entered
respective days during the study period. The question- into Statistical Package for the Social Sciences (SPSS)
naire was pre-tested among 35 mother-infant pairs from version 11.0. The dependent variable was exclusive
another health clinic in the same district. Data regard- breastfeeding. Univariate associations between various
ing maternal socio-demographic variables (area of resi- factors and exclusive breastfeeding adjusting for infant
dence, ethnicity, age, body mass index, marital status, age were identified and multiple logistic regression was
education level, occupation, monthly household income used to construct the model to examine the indepen-
and smoking status), paternal socio-demographic vari- dent association of various factors to exclusive breast-
ables (ethnicity, age, education level, occupation, smok- feeding while simultaneously controlling for potential
ing status), biomedical variables (parity, number of confounders. The statistical test used was binary logistic
antenatal visits, mode of delivery, infant gender, infant regression and the level of significance was set at p <
gestational age, infant birth weight, breastfeeding class 0.05. Odds ratio (OR) and 95% Confidence Interval (CI)
attendance), household variables (number of people were calculated as a measurement of association
staying in the house, number of rooms in the house, between an independent variable and the outcome. All
number of children under 12 years staying in the house variables associated with exclusive breastfeeding in the
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univariate analyses were included in the initial multivari- Table 1 The socio-demographic characteristics of
ate model. Variables were excluded from the final logis- respondents (n = 682)
tic model if they were not associated with exclusive Characteristics n %
breastfeeding and their removal from the model did not Maternal age (years)
materially affect the association of other variables in the < 25 140 20.5
model based on the algorithm proposed by Hosmer and 25 - 34 445 65.3
Lemeshow [9]. 34 - 43 97 14.2
The project received ethical approval from the University Area of residence
Malaya Medical Faculty Ethics Committee and Medical Urban 407 59.7
Research Committee Ministry of Health Malaysia. Signed Rural 275 40.3
informed consent was obtained from all the participants. Maternal ethnicity
Confidentiality of the data and the privacy of mothers were Malay 415 60.9
respected at all times. Chinese 128 18.7
Indian 109 16.0
Other 30 4.4
Results
Maternal education level
Among 712 eligible mother-infant pairs during the study
Diploma/Degree 109 16.0
period, 682 respondents were included in the study giv-
Secondary school 533 78.1
ing a response rate of 95.8%.
Primary school 40 5.9
Table 1 showed the socio-demographic characteristics
Maternal occupation
among the respondents. The mean (SD) maternal age was
Working 289 42.4
28.4 (5.1) years. Among those interviewed, 59.7% of the
Not working 393 57.6
mother-infant pairs were from urban area while 40.3%
Maternal BMI (kg/m2)
were from rural area. Malays formed the largest ethnic
<18.5 41 6.0
group (60.9%) followed by Chinese, Indian and other eth-
18.5 - 24.9 446 65.4
nic groups (22 Indonesian, 5 Thailand, 2 Burmese and 1
>24.9 195 28.6
Caucasian). The majority of the mothers (78.1%) had sec-
Monthly household income (RM)
ondary school level education, were not working (57.6%)
>3,500 52 7.6
and from a monthly household income of between
1,500 - 3,500 451 66.1
RM1,500 and RM3,500 (66.1%). Maternal Body Mass
<1,500 179 26.3
Index (BMI) ranged between 15.0 and 47.9 kg/m2. Almost
Parity
two thirds of the mothers were multiparous (63.8%). The
Primiparous 247 36.2
majority of mothers gave birth by normal vaginal delivery
Multiparous 435 63.8
(84.9%) and with normal birth weight of between 2,500 g
Mode of delivery
and 4,000 g (85.2%). There were slightly more male infants
Vaginal 579 84.9
(53.7%) than female infants (46.3%); the age of infants at
Instrumental/LSCS 103 15.1
interview ranged from one to six months.
Infant gender
From this study, the prevalence of exclusive breastfeed-
Male 366 53.7
ing among mothers with infants aged between one and
Female 316 46.3
six months was 43.1% (95% CI: 39.4, 46.8). The preva-
Infant birth weight (g)
lence of exclusive breastfeeding when stratified by infant
<2,500 86 12.6
age from one to six months ranged between 32.4% and
2,500 - 4,000 581 85.2
63.3% with the highest among one month old infants and
>4,000 15 2.2
lowest among six month old infants (Table 2).
Infant age (months)
The following were associated with exclusive breastfeed-
One 139 20.3
ing in bivariate analysis adjusting for infant age: area of
Two 111 16.3
residence, maternal ethnicity, education level, occupation,
Three 123 18.0
monthly household income, maternal smoking status, par-
Four 96 14.1
ity, infant gestational age, husbands support on breastfeed-
Five 102 15.0
ing, number of children under 12 years saying in the
Six 111 16.3
house, occupancy rate and bed-sharing practice (Table 3).
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Table 2 Prevalence (95% CI) of exclusive breastfeeding growth faltering, micronutrient deficiencies and common
by infant age childhood illnesses such as diarrhoeal diseases, as a child is
Characteristics Prevalence (95% CI) of exclusive introduced to solid foods in addition to breast milk [12-14].
breastfeeding In this study, the overall prevalence of exclusive breast-
Infant age (months) feeding among mothers with infants up to six months of
One 63.3 (55.2, 71.4) age was 43.1%. This result was higher compared to the
Two 43.2 (33.9, 52.6) national figure [2]. Other studies reported prevalence of
Three 36.6 (28.0, 45.2) exclusive breastfeeding between 12.5% and 48% [15-17].
Four 40.6 (30.6, 50.6) Under the Malaysia National Study, a 24 hour recall per-
Five 37.3 (27.7, 46.8) iod was used. The WHO has developed a set of defini-
Six 32.4 (23.6, 41.3) tions and indicators of infant feeding patterns that can be
Infant age (one to six 43.1 (39.4, 46.8) applied in assessing breastfeeding practices in household
months)* surveys using the 24 hour recall methodology [18]. In
* the prevalence is age-standardised. this study, data on breastfeeding was based on feeding
practice over a period of one month prior to the
All the variables associated with exclusive breastfeed- interview which is a non-standard practice to collect
ing in the infant age-adjusted analyses were included in breastfeeding data. The validity of data on exclusive
a multivariate model. Variables that were significantly breastfeeding based on 24 hour periods has also been
associated with exclusive breastfeeding include area of questioned [19]. Aarts et al. reported a wide discrepancy
residence, maternal ethnicity, maternal occupation, on the prevalence of exclusive breastfeeding between cur-
maternal smoking status, parity, infant gestational age, rent status based on a 24-hour recording and exclusive
husbands support on breastfeeding and bed-sharing breastfeeding since birth [20]. Several factors may have
practice (Table 3). Interaction test was performed led the study to overestimate the prevalence of exclusive
among the variables in the multivariate final model breastfeeding of the population. Since the interview was
which showed no interactions. Mothers from rural area conducted face-to-face, by the author who is a medical
were more likely to exclusively breastfeed compared to doctor, in the health clinics which strongly promote
mothers from urban area (OR = 1.16; 95% CI: 1.03, exclusive breastfeeding, information bias is possible.
1.89). Chinese mothers were 0.12 times less likely to A recall period of one month may lead to recall bias
exclusively breastfeed compared to Malay mothers among respondents. The majority of the respondents
(OR = 0.20; 95% CI: 0.11, 0.35). Non-working mothers were Malays, of low family income and not working.
were 3.5 times more likely to exclusively breastfeed Selection bias may have occurred as studies have showed
compared to working mothers (OR = 3.66; 95% CI: 2.45, that these factors were strongly associated with exclusive
5.46). Non-smoking mothers were five times more likely breastfeeding in Malaysia [2,15-17].
to exclusively breastfeed compared to smoking mothers This study identified seven factors associated with
(OR = 5.18; 95% CI: 1.59, 45.05) while multiparous exclusive breastfeeding. Mothers from rural area more
mothers were almost twice more likely to exclusively commonly exclusively breastfeed compared to mothers
breastfeed compared to primiparous mothers (OR = from urban area which was supported by many articles
1.68; 95% CI: 1.17, 2.42). Mothers with term infants (≥ and reports [2,3,7]. Chinese mothers exclusively breast-
37 weeks gestation) were twice as likely to exclusively feed the least among the ethnic groups in the study. In
breastfeed compared to mothers with preterm infants (< Malaysia, it is customary for Chinese mothers to employ
37 weeks gestation) (OR = 1,74; 95% CI: 1.05, 3.01). an experienced helper to take care of the infant and the
Mothers with supportive husbands on breastfeeding household needs during the first month of confinement.
were four times more likely to exclusively breastfeed This situation leads to reduced effort and opportunity
compared to non-supportive husbands (OR = 4.20; 95% for breastfeeding. Non-working mothers were positively
CI: 1.12, 15.75). Mothers who practiced bed-sharing associated with exclusive breastfeeding. This association
with their infants were 1.5 times more likely to exclu- has been reported by Senarath et al [21] for Timor-
sively breastfeed compared to mothers who did not Leste, Ong et al [6] and Chen [22] for Singapore. This
practice bed-sharing (OR = 1.50; 95% CI: 1.12, 2.37). result does not necessarily mean that working leads to
failure to exclusively breastfeed. Additional factors such
Discussion as weaning in preparation to return to work, maternal
Adequate nutrition is critical for child health and develop- fatigue and the difficulty in juggling the demands of
ment. The period from birth to two years of age is particu- work and breastfeeding may also contribute to this
larly important because of the rapid growth and brain issue. In Malaysia, working mothers are given only two
development [10,11]. The period is often marked by months maternity leave and facilities for breastfeeding at
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Table 3 Logistic regression of determinants of exclusive breastfeeding

Variables Exclusive breastfeeding Non-exclusive breastfeeding Age-adjusted Multivariate
(n = 294) (n = 388)
n (%) n (%)
OR 95% CI Adj OR 95% CI
Area of residence
Urban 167 (41.0) 240 (59.0) 1.00 - 1.00 -
Rural 127 (46.2) 148 (53.8) 1.23 1.08, 1.68 1.16 1.03, 1.89
Maternal ethnicity
Malay 218 (52.5) 197 (47.5) 1.00 - 1.00 -
Chinese 20 (15.6) 108 (84.4) 0.17 0.10, 0.28 0.20 0.11, 0.35
Indian 39 (35.8) 70 (64.2) 0.50 0.33, 0.78 0.05 0.29, 0.75
Other 17 (56.7) 13 (43.3) 1.18 0.56, 2.50 1.00 0.45, 2.26
Maternal education level
Diploma/Degree 37 (33.9) 72 (66.1) 1.00 - n/s
Secondary school 237 (44.5) 296 (55.5) 1.56 1.01, 2.40
Primary school 20 (50.0) 20 (50.0) 1.95 1.17, 4.06
Maternal occupation
Working 73 (25.3) 216 (74.7) 1.00 - 1.00 -
Not working 221 (56.2) 172 (43.8) 3.80 2.73, 5.30 3.66 2.45, 5.46
Monthly household income (RM)
>3,500 5 (9.6) 47 (90.4) 1.00 - n/s
1,500 - 3,500 188 (41.7) 263 (58.3) 6.68 2.61, 17.08
<1,500 101 (56.4) 78 (43.6) 12.10 4.61, 31.80
Maternal smoking status
Yes 1 (5.3) 18 (94.7) 1.00 - 1.00 -
No 293 (44.2) 370 (55.8) 14.24 1.89, 107.16 5.18 1.59, 45.05
Parity
Primiparous 81 (32.8) 166 (67.2) 1.00 - 1.00 -
Multiparous 213 (49.0) 222 (51.0) 1.97 1.42, 2.72 1.68 1.17, 2.42
Infant gestational age (weeks)
<37 20 (29.4) 48 (70.6) 1.00 - 1.00 -
≥37 274 (44.6) 340 (55.4) 1.93 1.12, 3.34 1.74 1.05, 3.01
Husbands support on breastfeeding
No 3 (10.0) 27 (90.0) 1.00 - 1.00 -
Yes 291 (44.6) 361 (55.4) 7.22 2.17, 23.99 4.20 1.12, 15.75
No children < 12 staying in house
1 73 (34.4) 139 (65.6) 1.00 - n/s
2-4 193 (46.3) 224 (53.7) 1.64 1.16, 2.31
>4 28 (52.8) 25 (47.2) 2.13 1.16, 3.92
Occupancy rate (person per room)
<1.5 46 (32.6) 95 (67.4) 1.00 - n/s
1.5 - 4.0 238 (45.1) 290 (54.9) 1.69 1.15, 2.51
>4.0 10 (76.9) 3 (23.1) 6.86 1.80, 26.08
Bed-sharing practice
No 45 (24.9) 136 (75.1) 1.00 - 1.00 -
Yes 249 (49.7) 252 (50.3) 2.99 2.04, 4.37 1.50 1.12, 2.37
OR: odds ratio; CI: confidence interval; n/s: not significant.
Adj OR: adjusted odds ratio; adjusted for area of residence, maternal ethnicity, maternal occupation, maternal smoking status, parity, infant gestational age,
husbands support on breastfeeding, bed-sharing practice and infant age.

work places are not acceptable or flexible. This situation studies [24,25]. This study found that exclusive breast-
would deter working mothers from exclusively breast- feeding was more common among mothers with more
feeding as compared to housewives [23]. than one child. Studies conducted in Malaysia and Hong
Non-smoking mothers were more likely to breastfeed Kong reported similar findings where mothers with their
than mothers who smoked in this study as in other first child were less knowledgeable and skilful in
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breastfeeding [26,27]. This caused low self confidence Acknowledgements

The author gratefully acknowledges the willing assistance and cooperation
among mothers to breastfeed their infants. It is common
given by all the mothers in the study, the District Officer of Health, Klang
for mother-in-laws to accompany mothers during the District and all the nurses. This study would not have been possible without
confinement period especially after the first delivery. their assistance.
Their lack of support for breastfeeding could influence
Competing interests
mothers not to breastfeed [28]. The authors declare that they have no competing interests.
Exclusive breastfeeding was more common among
Received: 7 April 2010 Accepted: 2 February 2011
mothers with supportive husbands on breastfeeding
Published: 2 February 2011
compared to non-supportive husbands. In Malaysia or
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doi:10.1186/1746-4358-6-2
Cite this article as: Tan: Factors associated with exclusive breastfeeding
among infants under six months of age in peninsular malaysia.
International Breastfeeding Journal 2011 6:2.

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