Neighbourhood data, reflecting contextual SES, were available at parish-level. It could not be assumed that each parish was a homogeneous spatial area in terms of SES. Nevertheless, it emerged that the method, when applied to categorising neighbourhood purchasing power, based on parish-level data, revealed a contextual effect. It is possible that, other spatial areas might have revealed a more pronounced contextual effect.
We considered neighbourhood purchasing power as the primary indicator of neighbourhood socio-economy. This indicator takes only resident families with at least one child (≤ 19 years of age) into account: the elderly population was ignored, which can be justified. In this study, low neighbourhood purchasing power was shown to be significantly associated with the risk of not breastfeeding at four months. The reason for choosing breastfeeding at four months is the WHO recommendation and, as a result, a measurement of compliance with optimal current infant feeding beliefs. The findings are consistent with a growing body of literature suggesting that the SES and neighbourhood areas have an effect on lifestyle behaviour such as breastfeeding [10, 19, 20]. Sweden ranks among the top countries in the Organisation of Economic Cooperation and Development (OECD) Better Life Index [21], with a high standard of living, well-educated population offering parents a well-developed parental insurance and parental leave programme. This study demonstrates that, despite these efforts, there are substantial SES differences and, for this reason, an updated report on health inequalities in Sweden has been produced.
The new finding in the present study is that neighbourhood purchasing power is still a determinant of breastfeeding when maternal age, smoking and parental education are adjusted for. We have shown substantial differences in maternal age, smoking and parental education across the neighbourhood household purchasing power strata. An expected gradient was observed between parental education and neighbourhood household purchasing power, i.e. families with lower neighbourhood purchasing power were associated with lower educational attainment. These findings are consistent with previous research documenting the SES gradient and educational attainment [22, 23]. Parental education is often presented as a proxy for socioeconomic position; individuals with a higher educational level will most frequently have higher incomes [23]. This demonstrates the need to take account of both parental income and individual characteristics when conducting similar studies. In this study we only had access to aggregated (parish-level) data on neighbourhood purchasing power, viz. the proportion of resident families with low household purchasing power. Our objective was to address the influence of neighbourhood purchasing power on breastfeeding at four months of age (with additional interest in the influence of maternal age and smoking and parental educational level). However, it would be of interest to study the influence of household purchasing power.
Lifestyle factors and behaviours that are adopted very early in life tend to persist throughout life [24]. Studies show that investing in quality programmes and services that support the family’s earliest development produces a higher rate of return than investments made later in life [25]. Household characteristics and health-related behaviour are linked with income [23]. However, this relationship is not yet fully understood [22]. Similar approaches have been used but at an individual level, the individual council tax valuation band in the UK (using the estimated value of an individual’s home), for example showed that this index governed maternal beliefs and intentions relating to breastfeeding [20, 26].
The elevated risk of low numbers of mothers breastfeeding at four months in the neighbourhoods with the lowest purchasing power, points toward a possible contextual influence, which could be relevant to consider when it comes to targeted actions. Low-income parents who are stretched by a lack of money may have less energy to persevere with breastfeeding or wrestling with children to put on seat belts [22]. Giving birth, breastfeeding and becoming a family occur within a social context and an understanding of this context is essential if health professionals are to work alongside mothers. A woman’s decision to breastfeed or not is influenced by what is socially acceptable, and this decision is open to social and cultural influences [9, 27]. Moreover, it appears that parents in the higher SES groups are more likely to have the same opinion and thereby comply with current food and feeding recommendations [9, 28].
Most mothers are knowledgeable when it comes to the benefits of breast milk and breastfeeding [9]. However, many studies have shown that the discontinuation of early breastfeeding may be due to several causes, such as breastfeeding difficulties, perceived inconsistent advice and the need to get back to work [15, 29, 30]. Most attempts to improve breastfeeding rates have focused on mothers and then especially on certain risk groups, i.e. young mothers, single mothers and mothers with low educational attainment [27, 31]. Breastfeeding interventions that have so far been shown to be the most effective are needs-based, informal repeat educational programmes [12]. However, the key challenge is the recruitment (and retention) of appropriately trained and qualified staff, who are equipped with neighbourhood specific, up-dated and evidence-based material.
The main strength of this study is that it is a large population-based survey, comprising participants from diverse socio-economic and ethnic backgrounds. Another strength is the ability to integrate several explanations in one analysis. The advantage of using neighbourhood purchasing power as a variable is that it takes account of family structure in a residential parish. The socio-economic statistics applied here were from 2010 (when the children were two to three years of age), which could be seen as a weakness, but this was only a minor concern as the neighbourhood characteristics appeared to be stable over the years [14]. The validity of studies showing a correlation between negative effects on children growing up in low SES neighbourhoods i.e. low birth weight, breastfeeding and childhood injury has been questioned because of confounders, reverse causality and individualistic fallacies [13, 32]. Nevertheless, the outcome data showed a more evident trend across strata based on neighbourhood purchasing power, as compared with the alternative neighbourhood characteristics.
Given the results, future interventions to promote breastfeeding should adopt a much broader social approach; not only encouraging positive norms for the mother but also engaging the mother’s social network, i.e. spouse, grandparents, friends and family, as well as health-care professionals. Furthermore, it is necessary to create breastfeeding friendly premises including the premises at the health care facilities, as well as removing external social barriers to breastfeeding outside the home, offering parental educational programmes and intensive home visiting programmes to mothers who have been assessed as needing additional support.
Policy-makers need to act on inequalities, especially among the child population, which, in the long run, is of economic benefit to society. In this paper we have been able to identify neighbourhood areas in need of expanded support. The challenge lies in offering universal measures, and yet at the same time adapting them, in both scope and design, to those with the greatest needs i.e. proportionate universalism [8]. In order for this to be effective we must make use of this method on a regular basis, monitoring breastfeeding rates, their changes and trends over time in order to address the vulnerable neighbourhood areas at an early stage, as well as monitoring the effect of the intervention programmes. The allocation of preventive resources should be reviewed.