A key finding of this study was that early initiation of breastfeeding was more common in the urban area than in the rural. A similar finding has been reported from Tanzania where the percentage of initiation of breastfeeding during the first hour after birth was estimated to be 82% in an urban area and 52% in a rural. Only 10% of the urban mothers discarded colostrum compared to 43% of the rural mothers
]. Delayed initiation of breastfeeding and discarding of colostrum has also been found to be very common in a rural area in Bangladesh. Only 12 % the mothers used colostrum for the first feeding of their newborns and a relationship was found between mother knowledge and the practice of giving colostrum
]. In Vietnam, comparisons between breastfeeding patterns in rural and urban areas have not previously been published. A study of Vietnamese women in Australia suggested that the proportion of early initiation of breastfeeding was low due to mothers having negative views on colostrum. Only 25.7% thought that colostrum was healthier for babies than formula, 64.9% said that it was equally healthy and 40% gave their babies formula milk in the hospital
]. In Vietnam, the level of education of mothers in urban areas is generally higher than in rural areas. This might indicate that there is a difference in knowledge about colostrum and the value of early breastfeeding. Vietnam began to implement the policy of “Baby-Friendly Hospitals’ in 1995, which is strongly supportive of breastfeeding
]. In our study, the proportion of urban mothers who delivered in hospitals was higher than in the rural area
], which could have contributed to a higher level of early breastfeeding in urban areas. Birth weight, number of household assets and Caesarean section were associated with the pattern of early initiation of breastfeeding in the present study. We also knew that mean birth weight was higher in the urban area than in the rural area
], Caesarean section was more common
] and household income was higher
]. The factors associated with initiation of breastfeeding thus differ between the urban and rural areas. This may partly explain the differences we found in the early initiation of breastfeeding.
The percentages of initiation of breastfeeding during the first hour after birth in the present study were much lower in both areas than the 73.6% found in a rural area of Vietnam in 2002
] and the 61.7% reported in a cross-sectional study of National Institute of Nutrition in 2010
]. This may indicate that the level of early initiation of breastfeeding does not improve.
An important finding of this study is that exclusive breastfeeding during the first three months was more common in the rural area than in the urban one. This is in line with results from China where exclusive breastfeeding was more common in a rural area (61%) than in an urban (38%)
]. The opposite was reported from Tanzania where the mean duration of exclusive breastfeeding was longer in the urban setting (23 days) than in the rural (9 days)
Some factors can be suggested to be associated with the differences of exclusive breastfeeding between the two sites. The use of Caesarean section as delivery method has been seen to increase the risk for not breastfeeding in Vietnam and China
]. After surgery, the babies are often taken away from the mother. Mothers can also be worried about side effects of medicines like postoperative antibiotics which may pass to their babies through the breast milk
]. In the present study the median duration of exclusive breastfeeding of children delivered using Caesarean section was significantly shorter than in other groups in both settings. The percentage of women having Caesarian section was substantially higher in the urban area (38.9%) than in rural area (12.2%)
]. Caesarian section could be one of the factors behind the differences found in exclusive breastfeeding between the two sites in our study.
Another factor may be marketing of formula milk which has been shown to affect the breastfeeding behaviors of mothers
]. Mothers are given the impression that formula milk is as good as, or better than, breast milk
]. Marketing of formula milk may be more aggressive in urban areas than in rural areas in Vietnam. Economic conditions are also better in the urban area. Financial constraints may to a higher extent prevent women from buying formula milk in the rural areas
The associations between household economic condition and duration of exclusive breastfeeding found in this study might partly explain the differences of breastfeeding practices of infants between the two settings.
Another factor behind the differences of breastfeeding practices between the two sites may be education. An earlier study in rural area of Vietnam showed that non-exclusive breastfeeding women had less education than exclusively breastfeeding women
]. In the present study, the median duration of exclusive breastfeeding for the group of the highest level of education in the urban area was shortest. The Cox regression analysis pointed to a significant influence in the urban boy stratum. In the rural area, the result was the opposite: the median duration of exclusive breastfeeding for the group with the highest level of education was the longest. A problem for the interpretation of these results is that the statistical significance is very much dependent on numbers of observations. For education, the distributions are radically different between the urban and rural areas. Two reasonable hypotheses could be that the higher educated women in the urban area, who are the majority, tend to give exclusive breastfeeding shorter than others, and that the rather few women with higher education in the rural area for unclear reasons, breastfeed exclusively longer than rural women with low education.
The duration of exclusive breastfeeding by mothers with three antenatal care visits or more was shorter than the duration of exclusive breastfeeding of mothers with less than three visits. The result may indicate that many antenatal visits did not necessarily give mothers more information about breast feeding. A study in Vietnam found that lack of information and misunderstanding of mothers about breastfeeding were barriers to exclusive breastfeeding
The results of this article show that exclusive breastfeeding decreased rapidly with increasing child age and was uncommon at six months of age at both sites. Similar results have been seen in China and in other studies in Vietnam. The percentage of children with exclusive breastfeeding dropped from 83.6% at the age of one week to zero at week 24 in a previous study in rural Vietnam
]. The percentages of infants less than 6 months of age, who were exclusively breastfed, was 19.6% in Vietnam in 2010
]. In China, exclusive breastfeeding at six months of age dropped to 0.2% in an urban area and to 7.2% in a rural area
]. The most important reason was that the mothers had to return to work
]. Vietnamese mothers have a legal right to four months maternity leave
], which is insufficient in relation to the WHO recommendation about six months of exclusive breastfeeding. Mothers commonly see formular milk as the best choice for the child when they return to work
]. Another reason for giving complementary food was discussed in China, suggesting there is a belief that it will improve weight gain and lead to healthier babies
]. A Chinese tradition is also that friends and relatives come to visit the mother and child after delivery. The most popular gift is infant milk formula. This is one reason for the extensive use of early formula milk in China
The last major finding of this study is that most infants in both areas are reported to be given any breastfeeding for the first 12 months. Towards the end of the first year, breastfeeding is most rapidly declining in the urban area. Similar results were seen in Tanzania. Mean duration of breastfeeding was 27 ± 5 months in a rural compared to 24 ± 5 months in an urban area
]. The opposite results were found in the USA: the prevalence of breastfeeding was significantly lower in a rural area than in an urban area
]. Results from National Institute of Nutrition in Vietnam showed that 77% of infants in 2009–2010 continued breastfeeding at 12 months of age and that 22% continued breastfeeding at 24 months of age
]. In Tanzania, reasons to stop breastfeeding early were that the child was considered old enough, mothers started a new pregnancy, the child refused the breastfeeding, infant or maternal illness or that mothers did not want to continue breastfeeding
]. In Vietnam, some common reasons to stop breastfeeding have been found to be perceived insufficient breast milk supply, mothers return to work, that infants stopped taking breast milk and the mother’s health condition
]. Even though the educational level of mothers was higher in the urban area, we found that any breastfeeding was lower in the urban compared to the rural area and also lower than data from National Institute of Nutrition in Vietnam
]. One important reason behind that finding could be that urban mothers returned to work early.
Boys are considered more important than girls in Vietnam
], but the present study found that boys were rather given less breastfeeding than girls in both sites at all ages. A reason may be that formula feeding is considered better than breastfeeding and hence preferred for the boys.
One limitation of the present study is the restriction to one year of follow-up. A second limitation of the study is that it is based on interview data from the mothers. Even if the interviewers were carefully trained to ask for data e.g. on additional foods from the whole period after birth or last interview, respectively, recall bias could not be excluded.
Moreover, it could not be excluded that hospital staff may have given early formula meals without the knowledge of the mother, particularly to babies born with Caesarean section. However, the present study shares these methodological problems with most other published breast feeding studies. Consequently, results from this study allows for comparison to data from other studies.
In conclusion, exclusive breastfeeding is still low in rural and more common in urban Vietnam. Intervention programs to promote breastfeeding are necessary particularly regarding early initiation and prolonged breastfeeding. To improve the latter a prolonged period of maternity leave to at least until the infant is six month old would be desirable.