Just over a third (35.6%) of females in Canada who gave birth between 2012 and 2018 met the public health recommendation to breastfeed exclusively for six months, while 62.2% did some breastfeeding for at least six months. Lower breastfeeding rates were found among females who were socially disadvantaged, such as females who were single or had lower levels of education. The largest drop in exclusive breastfeeding occurred during the first month and after the fourth month, and the most frequent reason given for breastfeeding cessation was insufficient breast milk. The following discussion focuses on exclusive breastfeeding but equally applies to any breastfeeding, as the results for any breastfeeding paralleled those for exclusive breastfeeding.
The 2012 World Health Assembly (WHA) set a target of 50% six-month exclusive breastfeeding by 2025 and 70% by 2030 [12]. Although the rate of 35.6% observed in this study is below these targets, it indicates an increase in exclusive breastfeeding from observed rates of 14.4% and 26% in 2006–2007 and 2011–2012, respectively. [6, 8]. Other countries also remain below the WHA targets, with the United States, Australia and Sweden reporting rates of 25.6%, 29% and 15% in 2017 [13,14,15]. As the years studied precede the COVID-19 pandemic, we were not able to study the pandemic’s impact on breastfeeding rates. Although continued breastfeeding was recommended even if COVID-19 is suspected or confirmed [16, 17], pandemic-related restrictions may have negatively impacted the amount of breastfeeding support available to females [18]. Future work to assess if and how the pandemic affected Canadian breastfeeding rates is warranted.
A review of the determinants of breastfeeding practices highlighted that successful protection, promotion and support of breastfeeding is influenced at a structural level by sociocultural and market contexts; at a settings level by health services, family and communities, and work environments; and at the level of the individual [19]. We did not study this broad range of determinants, but our findings that higher educational attainment, being married, living in certain provinces/territories and being of a particular population group, increase the prevalence of breastfeeding mirror those found in other studies [3, 8, 20, 21] and reinforce the importance of sociocultural contexts in influencing breastfeeding practices. Despite having similar findings to past studies it is important to note these trends persist. Normal pre-pregnancy BMI, which may reflect dietary patterns, and not smoking during pregnancy were also associated with increased breastfeeding. Such individual-level factors are also known to be significantly influenced by social and economic conditions throughout the life course [22]. Collectively, these sociocultural and socioeconomically influenced factors point to the need to identify and remove structural barriers that impede breastfeeding. In particular, addressing lower breastfeeding rates among socially disadvantaged females can contribute to reducing a cycle of disadvantage, as these females and their children experience the considerable benefits of breastfeeding.
At the settings level, breastfeeding practices are influenced by factors such as employment conditions and health services [19]. During the years covered by this study, Canada’s maternity/parental leave policy provided females employment-protected leave for up to one year following the birth of their child, paid at 55% or higher of pre-leave earnings [23]. Although this policy is not fully inclusive, as eligibility requirements and low rates of pre-leave pay effectively exclude some females, it nevertheless may have contributed to our finding that return to work was not one of the main reasons for cessation of breastfeeding. Canada, however, fairs less favourably with regard to the Baby Friendly Hospital Initiative (BFHI), referred to in Canada as the Baby Friendly Initiative (BFI) [24]. The BFI comprises 10 health facility-based interventions to protect, promote and support breastfeeding, with substantial evidence that they collectively improve exclusive breastfeeding [25]. In 2017, only 4.7% of births in Canada occurred in a BFI-designated health facility [26] though almost all births (97.9%) in Canada occur in a hospital [27]. The WHO recommends that countries scale up BFI implementation to universal coverage and ensure sustainability, as one strategy to increase breastfeeding exclusivity and duration [28].
Our study touched on three elements of the BFI: enabling females and infants to remain together, having access to ongoing support, and supporting females to manage common difficulties [24]. With regard to females and infants remaining together, among the variables studied, co-sleeping had the strongest association with six-month breastfeeding. Females who co-slept daily had a 2.6 times greater adjusted prevalence of exclusive breastfeeding for six months compared to females who never co-slept. There has been strong messaging against co-sleeping following studies that showed an increased risk of injury to the infant or Sudden Infant Death Syndrome (SIDS) [29]. However, messaging is now shifting towards informing parents on how to arrange a safe sleep environment in both co-sleeping and non co-sleeping environments [29, 30].
The largest declines in exclusive breastfeeding occurred in the first month and after four months, and the most common reasons for cessation were insufficient milk supply and difficulty with breastfeeding. These findings are similar to those of other studies [8, 10, 20, 21], and emphasize the need for early and continued postpartum breastfeeding support. Although over 50% of females in our and other studies [10] perceive insufficiency in their milk supply, biologically less than five percent of females are unable to produce adequate milk to meet the nutritional needs of their infant [7]. As an unintended consequence, introducing other liquids or solids can interrupt breast milk production [8]. Early and ongoing access to skilled breastfeeding support (e.g., lactation consultants) and peer-supports (e.g. community-based breastfeeding programs) can assist females in addressing perceptions of insufficient milk and other breastfeeding difficulties thereby increasing breastfeeding exclusivity and duration [20, 31]. The decline in exclusive breastfeeding after four months suggest this is another important time to reassert that breastmilk alone meets (most) babies’ nutritional needs up to six months of age. There is no evidence that introducing foods other than breastmilk prior to six months improves infant health [32].
Improving exclusive breastfeeding rates not only requires interventions that support females but also data systems for monitoring breastfeeding trends and assessing the impact of interventions. The CCHS provides a national picture but in-depth assessment of local barriers and facilitators to breastfeeding are also needed. For example, our results suggest that breastfeeding may be more of a social norm in British Columbia and the Yukon than in other parts of the country. Investigating the factors that contribute to this could inform breastfeeding promotion in other jurisdictions, noting that interventions must be adapted to the local context. Routine well-baby visits, which include discussion about children’s eating habits and nutritional needs, occur at 2, 4, 6, 9, 12 and 18 months, and at 2 years. These visits could serve as a source of data on breastfeeding as well as an opportunity to encourage exclusive breastfeeding until six months.
Limitations of study
Many maternal characteristics were measured at the time of the survey (2017–2018) which could potentially be five years after the birth. Our analysis implicitly assumes that these characteristics reflect the female’s characteristics at the time of the index birth which may not be the case. For example, perceived mental health at the time of the survey (which was found not to be significantly associated with six-month breastfeeding) may not reflect postpartum mental health which has been found to influence breastfeeding behaviour [33]. Additionally, due to the self-reported nature of the survey, reports of breastfeeding experiences may be subject to recall bias and social desirability bias. The CCHS also excludes select groups such as those living in institutions or living on Indigenous reserves. We cannot assume our estimates extend to excluded subgroups; however these exclusions only account for 2% of the Canadian population 12 and over. CCHS also does not capture the breastfeeding experiences of people who do not identify as female. Due to the cross-sectional nature of the survey temporality cannot be determined. As our study used 2017–2018 data, we were unable to assess the impact of the COVID-19 pandemic on breastfeeding rates. Finally, CCHS data facilitated the study of only a limited number of maternal characteristics that could influence breastfeeding behaviour. Not being able to account for other characteristics such as parity, postpartum mental health or receipt of breastfeeding support at birth, makes our results subject to residual confounding from unmeasured factors. Despite these limitations, the nationally representative nature of the CCHS and its inclusion of questions on breastfeeding make it a valuable source of data for monitoring trends in the duration of breastfeeding in Canada and for studying some of the factors associated with breastfeeding cessation.
