823539

research-article2019
JHLXXX10.1177/0890334418823539Journal of Human LactationLauria et al.

Original Research
Journal of Human Lactation

Breastfeeding Prevalence at Time

1­–8
© The Author(s) 2019
Article reuse guidelines:
of Vaccination: Results of a Pilot Study in sagepub.com/journals-permissions
DOI: 10.1177/0890334418823539
https://doi.org/10.1177/0890334418823539

6 Italian Regions journals.sagepub.com/home/jhl

Laura Lauria, MSc1, Angela Spinelli, MSc1,

Marta Buoncristiano, PhD1, Mauro Bucciarelli1,
and Enrica Pizzi, MSc.1

Abstract
Background In Italy, there is no widespread standardized national monitoring system for breastfeeding practices.
Research Aims To estimate breastfeeding indicators according to World Health Organization recommendations and
associated socioeconomic factors, highlighting the potential and limitations of vaccination centers as sources of data.
Methods A cross-sectional study was conducted in the vaccination centers of 13 Local Health Districts in Italy. Data on
breastfeeding practices were collected via structured questionnaires between February and November, 2015, from 14191
mothers recruited during vaccination appointments for the 1st, 2nd and 3rd doses against Diphtheria, Tetanus, and Pertussis, and
for the 1st dose against Measles, Mumps, and Rubella. Crude breastfeeding rates and direct age standardized rates were compared.
Logistic regression models were used to explore socio-demographic characteristics associated with breastfeeding indicators.
Results Overall, 14191 mothers were recruited, with a response rate higher than 94%. Exclusive breastfeeding rates among
children aged 2-3 months and 4-5 months were 44.4% and 25.8%, respectively; breastfeeding rates among children aged
11-12 and 13-15 months were 34.2% and 24.9%; 10.4% never breastfed. Strong geographical and socioeconomic differences
were found. Some differences also emerged between crude and standardized rates.
Conclusions We conclude that a survey system in vaccination centers is practicable and its use could produce, with
standardized methodology, representative regional and national breastfeeding estimates that could monitor progress towards
present and future targets.

Keywords
breastfeeding, breastfeeding rates, epidemiological methods

Introduction environmental advantages to children, women, and society

The beneficial effects of breastfeeding (BF) on both the baby’s
and the mother’s health are widely recognized (Victora et al.,
2016). Both WHO and UNICEF recommend exclusive breast-
feeding (EBF), when possible, up to 6 months and, after intro-
ducing nutritionally adequate and safe complementary food,
continuing BF up to 2 years or beyond. In addition, in 2002,
WHO Member States adopted the “Global Strategy for Infant
and Young Child Feeding”, which recommends national poli-
cies to promote, protect, and support adequate infant and
young child feeding (WHO & UNICEF, 2003). Despite this,
BF practices are still far from those recommended by the
WHO, and show wide variations within the European region
(Bagci Bosi et al., 2015). In 2012, the WHO identified six
global nutrition targets for 2025. One of these six goals is to
increase the rate of EBF in the first 6 months to at least 50%
(WHO, 2014). This goal is a priority for national health sys-
tems because BF is one of the highest impact interventions
providing short-term and long-term health, economic, and
(Rollins et al., 2016).
International organizations and communities have under-
taken various initiatives to promote, protect, and support BF
(WHO, 2014; EU Project on Promotion of Breastfeeding in
Europe, 2008). Nevertheless, the lack of updated and stan-
dardized data between and within countries hinders monitor-
ing and comparisons and the evaluation of the effectiveness
of interventions (Gupta et al., 2017; Flaherman et al., 2011;
Khanal et al., 2016). Although in 2008 the WHO defined
indicators for assessing BF practices (WHO, 2008), full
1
National Centre for Disease Prevention and Health Promotion, Italian
National Institute of Health, Rome, Italy
Date submitted: April 18, 2018; Date accepted: December 16, 2018.
Corresponding Author:
Laura Lauria, Istituto Superiore di Sanità (National Institute of Health),
Viale Regina Elena, 299, 00161, Rome, Italy.
Email: laura.lauria@iss.it
2 Journal of Human Lactation 00(0)
adherence has not yet been reached. The need to improve the
standard methodology for monitoring and collecting BF data
has been identified as critical for accelerating progress
(Cattaneo et al., 2009). More recently, based on the high
number of countries which have no data on EBF collected
according to international standards, the WHO/UNICEF, in
collaboration with the Global Breastfeeding Collective, have
set a target for 75% of countries to be reporting on exclusive
breastfeeding at least every five years by 2030 (WHO &
UNICEF, 2017). They also call on stakeholders to implement
seven actions of which one is to “Strengthen monitoring sys-
tems that track the progress of policies, programs, and fund-
ing towards achieving both national and global breastfeeding
targets” (WHO & UNICEF, 2017).
In Italy, the promotion of, protection of, and support for
breastfeeding is part of national policies such as the National
Strategic Programme for Mother and Child Health (Progetto
Obiettivo Materno Infantile; POMI) Ministerial Decree of 24
April 2000 and the National Strategy Gaining Health:
Making Healthy Choices Easy (Guadagnare Salute – Rendere
Facili le Scelte Salutari) Ministerial Decree of 4 May 2007.
A review published in 2000 showed that the data available
then failed to represent the actual prevalence and duration of
breastfeeding (Cattaneo, Davanzo, & Ronfani, 2000) and,
even today, in Italy estimates of the prevalence of breastfeed-
ing are limited to local or regional experiences or selected
populations (Ministero della Salute, 2015; Lauria, Spinelli &
Grandolfo, 2016).
In order to ensure continuity, completeness and standard-
ized methods in the national estimates of BF and other recog-
nized determinants of health, the Italian Ministry of Health
promoted and financed a national survey system for children
under 2 years of age, and entrusted its coordination to the
National Institute of Health. This is to be implemented by
collecting data within vaccination centers during scheduled
compulsory vaccinations – In Italy, some pediatric vaccina-
tions are compulsory and are provided free of charge at the
vaccination centers. The national survey system will obtain
estimates of the prevalence of breastfeeding at regional and
national level. This pilot study has been conducted to test the
feasibility and sustainability of a system which, it is hoped,
will produce nationally representative estimates of BF and
other indicators of child health.
The aim of this paper is to estimate breastfeeding indicators
according to World Health Organization recommendations
and associated socioeconomic factors highlighting the poten-
tial and limitations of vaccination centers as sources of data.
Methods
Design
A cross-sectional pilot study was carried out among mother-
child pairs recruited during compulsory vaccination appoint-
ments in selected Local Health Districts (LHD). This study
Key Messages
•• There is a lack of standardized measures and meth-
ods to monitor breastfeeding practices in Italy.
•• Vaccination centers are good sites to generate esti-
mates of breastfeeding indicators according to
World Health Organization criteria.
•• Breastfeeding estimates found in this study are far
from complying with the World Health Organization
recommendations, and are highly variable between
the areas where the mothers live. Exclusive breast-
feeding strongly declines during the first 6 months
of life and breastfeeding during the first year of life.
•• A survey system in vaccination centers could gen-
erate standard breastfeeding estimates that could
serve to monitor progress towards present and
future targets.
design enabled information to be collected on breastfeeding
among participating mothers of children of specific age
ranges, according to WHO criteria (WHO, 2008).
Approval of the protocol was obtained from the
Institutional Ethics Committee of the National Institute of
Health.
Setting
This study was conducted in 6 Italian regions where about
half of all births occur, Lombardy (north), Veneto (north),
Marche (center), Campania (south), Puglia (south) and
Calabria (south). Each region implemented the pilot survey
in 1 to 4 of its Local Health Districts (LHD), making a total
of 13 LHDs with different socioeconomic and maternal care
characteristics. All the vaccination centers in the selected
LHDs were included in the survey.
Sample
The target population was mothers of children under 2 years
of age. Only children accompanied by their mother were
included in the study. In the case of twins, the mother was
asked to refer only to the first child vaccinated. No other
exclusion criteria were applied. For each district, the number
of first doses of compulsory vaccine against Diphtheria,
Tetanus, and Pertussis (DTP) administered in the year pre-
ceding the survey (corresponding to about 95% of births),
was used to estimate the sample size. A district level repre-
sentativeness was chosen. Sample size was estimated to
achieve, for a binomial variable of 0.5, a standard error of
0.025 with a 95% confidence interval of 0.45-0.55. A pseudo-
random procedure was used to select children: from when
the survey began, in February 2015, all eligible children
were selected until the desired sample size was reached. This
Lauria et al. 3

Table 1.  Participants’ Characteristics Grouped by Geographic Location (N = 14191)

Educational level
With economic
<30 years Nulliparous Low Medium Unemployed Foreigners Difficulties
Locationa N n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Ven_2N 2498 428 (17.1) 1258 (50.7) 449 (18.0) 1226 (49.1) 596 (24.0) 555 (22.4) 875 (36.3)
Lom_1N 1749 376 (21.7) 946 (56.1) 315 (18.1) 642 (36.9) 311 (17.9) 646 (37.3) 780 (45.4)
Mar_4C 3882 908 (23.5) 2066 (54.6) 709 (18.3) 1701 (44.0) 879 (22.7) 861 (22.8) 1738 (45.3)
Cam_2S 2358 574 (24.4) 1304 (55.4) 469 (20.0) 1118 (47.6) 664 (28.2) 204 (8.7) 1083 (45.9)
Pug_2S 2041 540 (26.5) 1128 (55.7) 496 (24.3) 1016 (49.9) 646 (31.7) 91 (4.5) 1182 (58.0)
Cal_2S 1663 512 (31.1) 800 (48.9) 440 (26.7) 833 (50.5) 564 (34.1) 300 (18.5) 1006 (61.1)
Total_13 14191 3337 (23.6) 7502 (53.7) 2878 (20.4) 6536 (46.2) 3660 (25.9) 2657 (19.0) 6664 (47.6)

Note. Missing values for each of the variables were: Mother’s age=53; parity=222; educational level=58; employment status=52; citizenship=214;
economic difficulties=191.
a
The location identifiers refer to the region, the number of participating local health districts for that region, and the region’s geographical location:
Ven_2N= Veneto, 2 districts, northern Italy; Lom_1N= Lombardia, 1 district, northern Italy; Mar_4C= Marche, 4 districts, central Italy; Cam_2S=
Campania, 2 districts, southern Italy; Pug_2S= Puglia, 2 districts, southern Italy; Cal_2S= Calabria, 2 districts, southern Italy.

procedure was also used to select the other 3 samples in each
LHD: the 2nd and 3rd doses of DTP and the 1st dose of the
vaccine against Measles, Mumps, and Rubella (MMR), as
well as other vaccines. The four vaccination appointments,
according to the 2015 Italian vaccination schedule, are pro-
grammed at 2-3 months of age, 4-5 months, 11-12 months,
and 13-15 months. Overall, 14191 mothers were recruited.
The response rate was higher than 94% in all the areas. About
3% of the children were excluded because they were not
accompanied by their mother. The median age of the children
of the four selected samples show wide variability among
areas: from 69 days (Cam_2S) to 93 days (Pug_2S) for the
first DTP dose, from 137 days (Cam_2S) to 162 days
(Cal_2S) for the second DTP dose, from 331 days (Cam_2S)
to 380 days (Ven_2N) for the third DTP dose and from 403
days (Cam_2S) to 486 days (Cal_2S) for the first MMR
dose. For the other vaccines, the range of the median age is
much greater, from 274 days (Pug_2S) to 517 (Lom_1N; see
column a in the table in Supplementary Materials). The vari-
ability of the age distributions, as implied by the ranges
between the 10th and the 90th percentile, is also heteroge-
neous. From the overall sample, specific ages were selected
to analyze BF indicators (see column b in the table in
Supplementary Materials) regardless of the type of vaccine
and the dose, resulting in a final sample of 11698 participants
for subsequent analysis (unless otherwise indicated). The
socio-demographic characteristics of the participants varied
by geographical area, as shown in table 1. In the areas in the
north and center of the country, participants tend to be older,
more educated and more likely to be employed; they also
reported economic difficulties with lower frequency and the
proportion of foreign women was higher.
Measurement
Using WHO criteria, BF information was collected from the
previous 24 hours. Children who had taken only breastmilk
were classified as exclusively breast-fed. Additionally, par-
ticipants who were not breastfeeding at the time of the inter-
view were asked if they had ever breastfed. This information
was used to calculate the proportion of children never breast-
fed. EBF and BF percentages were calculated at different
children’s ages. As suggested by WHO, age groups are
described in intervals of months completed; WHO also rec-
ommends that EBF under 6 months of age should be disag-
gregated for age groups 0-1 month, 2-3 months, and 4-5
months (WHO, 2008). According to the vaccination sched-
ule, we cannot sample 0-1 month old children. Thus, EBF
can only be estimated for the age groups of 2-3 months (60-
120 days) and 4-5 months (121-180 days). The latter is con-
sidered a proxy for the proportion of children exclusively
breastfed for the full 6 months as suggested by WHO. BF can
also be reported at 11-12 months (330-390 days) and 13-15
months (391-480 days) and is defined as the proportion of
children who received breastmilk during the previous day.
Given that the children’s ages in the questionnaire were
reported in completed months plus days, we have first trans-
lated the age into approximate days and then we have used
the cut-off within parenthesis to analyze BF indicators.
Data Collection
At the reception in the vaccination center, and before being
enrolled, all the mothers were given a brief presentation of the
study by trained health professionals. In particular, the objec-
tives were described and information was given about the insti-
tution promoting the study and about data protection. This
information was also included on the front page of the question-
naire. At the end of the presentation, the mothers were asked if
they agreed to complete the questionnaire or not. Both accep-
tance or refusal to participate in the study were registered.
Data were collected between February and November
2015. Information on BF and socioeconomic factors was col-
lected by interviewing the mothers at the vaccination sessions,
4 Journal of Human Lactation 00(0)
using a questionnaire. The first section of the questionnaire
was completed by the health personnel who recorded whether
or not the child was accompanied by his/her mother. Other
sections related to: vaccination attitude, breastfeeding, tobacco
and alcohol consumption during pregnancy and lactation,
reading aloud, infant sleep position, and folic acid before and
during pregnancy. The final section was on the socio-
demographic characteristics of the mother and included
employment, educational level (low - less than high school,
medium - high school, high - university degree or more), citi-
zenship (Italian, Foreign) and perceived economic difficulties
(none, some/many). Mothers were interviewed only once: i.e.,
a mother recruited and interviewed at the first dose of DTP and
intercepted again at the 2nd dose of DTP for the same child or
for the vaccination of another child was not interviewed again.
All the interviews were conducted by trained health staff
involved in the administration of the vaccines.
The interview methods were adapted to reflect the differ-
ent operational and functional organizations of the vaccina-
tion centers but they all generated the same final record
format. The different methods used for the interviews were:
(1) the information was collected during the medical history
taking and recorded directly on a computer; (2) a paper ques-
tionnaire, also translated into several languages, was used for
a face to face interview with a health operator; (3) the ques-
tionnaire was self-completed by the mothers in the presence
of a health operator. The use of the specially designed soft-
ware enabled the progress of data collection to be monitored
for each district and for each vaccine dose, and recruitment
to be limited to the pre-determined sample size.
Data Analysis
The descriptive analyses of BF and EBF are shown by group-
ing the data of districts belonging to the same region
(although they are not representative of the whole region).
For each of the six sampled areas we have stated their region,
the number of districts included in the study, and their geo-
graphic area (northern, central or southern Italy: Lom_1N,
Ven_2N, Mar_4C, Cam_2S, Pug_2S, Cal_2S).
All the analyses are weighted with the reciprocal local
health district’s sampling fractions which were calculated
using the sampled children by age classes. Assuming that the
cohorts of births per month are similar, the sampling fraction
was estimated by the ratio between the number of children of
a specific age (i.e. 4-5 months) sampled in a district and the
number of births in the same district. The breastfeeding indi-
cators were compared between regions using the design-
based F test. In order to show the effect on the estimates of a
possible different age distribution of children between geo-
graphical areas, direct age standardization was also applied,
where appropriate, to BF rates, based on 10 days’ age groups,
by using the overall population sampled as a standard.
Logistic regression models were used to explore factors
associated with the prevalence of EBF at 4-5 months of age,
BF at 11-12 months of age, and never breastfed on the pooled
samples (without any selection on age). All the analyses
were performed using Stata version 11.0 statistical software
(StataCorp, 2009).
Results
Data obtained on vaccination attitude, tobacco and alcohol
consumption during pregnancy and lactation, reading aloud,
sleep position, and folic acid consumption is not reported
here.
BF practices vary between the LHD in the north and
south of the country (Table 2). The percentage of children
aged 2-3 months exclusively breastfed was 44.4% (n=1581),
ranging from 30.0% (n=165) (Pug_2S) to 53.5% (n=561)
(Mar_4C). The prevalence of EBF at 4-5 months was 25.8%
(n=745), varying from 9.6% (n=27) (Cal_2S) to 36.9%
(n=297) (Mar_4C). Standardization by age influences, in
particular, EBF prevalence in the area of Cam_2S, reducing
prevalence at 2-3 months from 33.3% to 30.0% and at 4-5
months from 20.9% to 17.2%. Differences between breast-
feeding indicators by regions are all statistically significant
(p<0.001). Standardization by age had some effect on the
estimates of BF of which the most important was at 4-5
months in the three areas in the south, and at 11-12 months
in the areas of Ven_2N, Cam-2S and Cal_2S. In table 2, the
prevalence of participants who have never breastfed, esti-
mated on the pooled samples aged 2-15 months, is also
reported. Participants who never breastfed were 1206 or
10.4% of the total. This prevalence ranged from 6.3%
(n=194) (Mar_4C) to 20.0% (n=310) (Pug_2S), and tends to
be lower in the northern and central LHDs, and higher in the
southern ones. In table 3 we show 3 indicators, EBF at 4-5
months, BF at 11-12 months and never breastfed, stratified
by the socio-demographic characteristics of the participants,
with the results of logistic regression models. Participants
who are significantly less likely to exclusively breastfeed
their children at 4-5 months are those with less education
(medium=24.1% vs high=32.4%, OR=0.80 (95%CI: 0.65-
0.99) and low=17.2%, OR=0.57 (95%CI: 0.41-0.77)).
Participants who are significantly more likely to breastfeed
their children aged 11-12 months are unemployed (unem-
ployed=38.8% vs employed=32.2%, OR=1.26; 95%
CI: 1.02-1.57) and have foreign citizenship (foreign=48.0%
vs Italian=29.6%, OR=2.24; 95% CI: 1.76-2.85). A border-
line association was found with perceived economic diffi-
culties, suggesting the presence of confounding. In fact,
those who are unemployed and foreign are more likely to
perceive economic difficulties (not reported in the table).
Participants who are significantly more likely to have never
breastfed their children have medium or lower levels of edu-
cation (medium=10.7% vs high=7.7%, OR = 1.47; 95% CI:
1.24-1.75; and low =14.8%, OR=2.17; 95% CI: 1.75-2.68),
and Italian citizenship (foreign=7.7% vs Italian=11.2%,
OR =0.72; 95%CI: 0.58-0.89).
Lauria et al. 5

Table 2.  Weighted Prevalences of Exclusive Breastfeeding (EBF) and any Breastfeeding (BF) at Different Ages by Sampled Geographic
Location (Age Standardized Prevalences)

Children Children Children

Children Children aged 11-12 aged aged
aged 2-3 months aged 4-5 months months 13-15 months 2-15 months

Never
  EBF BF EBF BF BF BF Breastfed

% (age % (age % (age % (age

Locationa n standard.) n standard.) n standard.) n standard.) n %
Ven_2N 562 43.8 (45.0) 72.1 (72.4) 600 21.8 (20.2) 62.6 (62.6) 477 26.5 (34.0) 611 18.0 (18.4) 2227 8.1
Lom_1N 441 50.0 (48.7) 76.8 (75.8) 394 28.7 (28.7) 64.5 (63.2) 331 37.3 (39.5) 285 32.5 (31.8) 1387 9.1
Mar_4C 1074 53.5 (50.8) 78.1 (76.3) 807 36.9 (38.0) 73.9 (74.9) 775 40.2 (39.0) 616 29.5 (28.1) 3128 6.3
Cam_2S 568 33.3 (30.0) 58.9 (54.2) 533 20.9 (17.2) 46.6 (42.7) 265 22.1 (18.1) 365 14.2 (15.0) 1673 13.6
Pug_2S 550 30.0 (31.7) 53.1 (55.0) 416 16.2 (17.8) 47.7 (50.9) 313 35.8 (35.1) 374 20.8 (19.5) 1603 20.0
Cal_2S 553 36.1 (36.7) 66.9 (67.6) 269 9.6 (11.0) 50.4 (54.0) 315 35.4 (38.1) 204 23.0 (24.6) 1298 14.4
Total_13 3748 44.4 70.6 3019 25.8 61.5 2476 34.2 2455 24.9 11316 10.4

Note. Differences of breastfeeding indicators by geographic location are all statistically significant (p <0.001);
a
The location identifiers refer to the region, the number of participating local health districts for that region, and the region’s geographical location:
Ven_2N= Veneto, 2 districts, northern Italy; Lom_1N= Lombardia, 1 district, northern Italy; Mar_4C= Marche, 4 districts, central Italy; Cam_2S=
Campania, 2 districts, southern Italy; Pug_2S= Puglia, 2 districts, southern Italy; Cal_2S= Calabria, 2 districts, southern Italy.

Table 3.  Adjusted Odds Ratios of Three Different Breastfeeding Indicators

Model 1 Model 2 Model 3

Exclusive Breastfeeding at 4-5 Any Breastfeeding at Never Breastfed Estimated on

months 11-12 months Overall Sample (2-15 months)

N=2895 N=2344 N=10824

n % Never
Mothers’ Characteristics n % EBF ORa 95% CI n % BF ORa 95% CI Breastfed ORa 95% CI
Educational Level
 high 1003 32.4 1   791 34.7 1 3684 7.7 1  
 medium 1348 24.1 0.80 0.65-0.99 1094 32.5 0.91 0.73-1.13 5029 10.7 1.47 1.24-1.75
 low 544 17.2 0.57 0.41-0.77   459 35.8 0.91 0.69-1.21 2111 14.8 2.17 1.75-2.68
Economic Difficulties
 none 1620 28.8 1 1223 33.8 1 5821 10.0 1  
 some/many 1275 22.3 0.86 0.70-1.05 1121 34.0 0.82 0.67-1.0 5003 11.1 0.95 0.82-1.09
Employment Status
 employed 2218 27.7 1 1693 32.2 1 8086 9.8 1  
 unemployed   677 19.6 0.83 0.65-1.07   651 38.8 1.26 1.02-1.57 2738 12.3 1.12 0.96-1.31
Citizenship
 Italian 2396 26.4 1 1833 29.6 1 8801 11.2 1  
 Foreign   499 23.5 0.98 0.75-1.28   511 48.0 2.24 1.76-2.85 2023 7.7 0.72 0.58-0.89

Note: Records with an incomplete information were: model 1=224; model 2=132; model 3= 874.
a
Odds Ratios were also adjusted by mother’s age, parity, and Local Health District of residence.

Discussion with respect to the area of residence, with lower prevalences

This study reports on breastfeeding indicators in Italy and the
use of vaccination centers for recruiting mothers and gather-
ing data on breastfeeding. For EBF and BF, there are three
general conclusions. The first is that there is great variability
seen in the LHDs in the south of the country, as observed in
other studies (Lauria, Spinelli & Grandolfo, 2016; ISTAT,
2013; Giovannini et al., 2003). This variability may, in part,
be explained by the different distributions of the socio-demo-
graphic characteristics of the population living in these areas,
6 Journal of Human Lactation 00(0)
and in part by differences in the healthcare services, in par-
ticular in antenatal care services which, in Italy, are not
homogeneous, despite the fact that the healthcare system
guarantees free assistance to all pregnant women. The sec-
ond is that there is a very strong decline of EBF during the
first 6 months of life, and of BF during the first year of life.
The third is that if these indicators reflect the true status of
the prevalence of BF in Italy, these rates are far from com-
plying with WHO and UNICEF (2003) recommendations or
the 2025 WHO goals (WHO, 2014), even in the areas where
the prevalence of breastfeeding is higher.
However, in recent years BF indicators in Italy, although
not always conforming to WHO definitions and/or based on
data collected with different methods, have improved. The
BF indicators estimated in the years 2000 and 2013 using
data collected by the Italian National Institute of Statistics,
in which women who had delivered in the last 5 years were
recruited, imply that the number of women who have
breastfed, regardless of duration, increased from 81.1% to
85.5% and that the average duration of breastfeeding in
months increased from 6.2 to 8.3 (Ministero della Salute,
2015). From two population based follow-up studies con-
ducted between 2008 and 2011 in 25 Local Health Units in
Italy (Lauria, Spinelli & Grandolfo, 2016), BF and EBF
rates were estimated at discharge, at 3 and 6 months (BF
rates: 91.6%, 71.6%, 57.7%, respectively; EBF rates:
57.2%, 48.6%, 5.5%). This implies a slight improvement in
comparison with a previous national study conducted in
1999, in which it was reported that at 3 and 6 months BF
rates were 66% and 47%, and EBF rates were 47% and 5%
(ISTAT, 2013). In 2014, the Italian Ministry of Health con-
ducted a survey among all 21 regions about the availability
of breastfeeding data. Data at discharge were available for
12 regions but only four had data at 3 or 6 months of age,
implying a lack of national standardized monitoring
(Giovannini et al., 2003). In general, estimates of BF are far
below the WHO goals and show geographical and social
differences (Lauria et al., 2013). A limitation of this study
is that we cannot make a direct comparison of our results
with the results of the above studies. This will be overcome
when the survey system is activated in many or all Italian
regions.
Promotion activities should be targeted to take into
account the social inequalities which affect BF in Italy and
other industrialized countries (Ibanez et al., 2012). The
results of the logistic regression models for our data suggest
that the mother’s educational level has a statistically signifi-
cant independent association with BF indicators during the
first months of life (ever breastfed and EBF), when mother-
hood is still protected by law in that the right to abstain from
work is guaranteed from two months before the expected
date of delivery up to at least 3 months after giving birth.
This highlights the importance, even during pregnancy, of
education about the advantages of BF, for example, in ante-
natal classes. This type of education can empower mothers to
BF and can be offered regardless of the impact of external
factors such as economic conditions and work. BF at one
year of age is, however, more affected by economic factors
(economic difficulties and employment status) than cultural
factors. There are many other factors which could affect the
behavior of mothers, such as breast attachment at birth and
breastfeeding duration, which are potential confounders and
which we have not considered in this study. Some of these
are related to medical assistance and its organization, such as
the high rate of caesarean sections, particularly in the south
of the country, the availability of rooming-in, variations in
availability of antenatal care, home care in the puerperium,
and so on.
Vaccination seems to offer a valid opportunity to inter-
cept children aged less than 2 years and to produce esti-
mates of BF indicators according to WHO criteria. In Italy,
almost 95% of children are vaccinated before 2 years of
age. Conducting surveys during vaccination appointments
also allows for the possibility of using a network of services
and staff already present and working in a structured man-
ner across the country, thus reducing implementation costs.
In addition, data on socio-demographic factors, modifiable
risk factors related to BF that contribute to the study of the
multidimensional complexities of behavior toward BF, and
other determinants of babies’ health can be collected
simultaneously.
Some national policies and programs aimed at breastfeed-
ing and raising awareness in the population of its importance,
such as the National Programme ParentsPlus (GenitoriPiù),
2007/2009, were started over ten years ago, and have resulted
in “the prevalence of breastfeeding under the age of 6
months” being included as indicator in the Italian National
Prevention Plan 2014-2018 (Presidenza del Consiglio dei
Ministri, 2014). In light of the findings of this pilot study, if
these types of surveys were to be implemented nationally,
new BF indicators could be considered for inclusion in the
Prevention Plan.
The response rate for this study was high in all areas,
regardless of the ways in which the data were collected, indi-
cating that the survey was acceptable for mothers. It is impor-
tant to stress that particular attention must be paid to the ages
of children sampled at vaccine visits. Although the vaccina-
tion schedule has been established equitably throughout the
country, strong differences are evident between geographic
areas (and between LHDs in the same area) in children’s age
distribution at the same vaccine visit. These differences may
be due to slight local differences in the schedule of the vac-
cination or in the organization of the vaccination services, or
due to vaccinations being delayed. For the other non-manda-
tory vaccines, age distribution varies even more across LHDs.
These differences need to be checked and taken into account
when analyzing and comparing the prevalence of BF which is
heavily dependent on a child’s age (Di Mario et al., 2017). In
order to estimate BF prevalence, we first extracted age groups
of two or three months from the global sample and then used
Lauria et al. 7
direct standardization (using age groups of 10 days) for fur-
ther adjustment and comparison.
Limitations
A limitation on the use of vaccine services for recruiting
mother-child pairs for the survey is that we can only produce
estimates for ages specified in the vaccination schedule. For
example, it is not possible to estimate BF under 6 months
since the vaccination centers do not include children 0-1
month (for whom BF prevalence should be much higher).
Although it is not part of the present analysis, as data have
not yet been accumulated, it should be possible to use record
linkage techniques to follow the progress of a child, not only
in terms of vaccination record, but also other related events,
including breastfeeding. The time points must necessarily be
those specified in the vaccination schedule, rather than pre-
defined breastfeeding intervals, but it might be possible to
analyze the data as though they were obtained from a follow-
up study.
Limitations in the study design also include a possible
bias due to the exclusion from the sample of the 5% of births
that are not covered by vaccination, which could be a very
select group, and the non-respondents and children not
accompanied by mothers–a total of 13% of births. These
exclusions could be reduced in the light of the new Ministerial
Decree of 7 June 2017, n. 73 which, in order to counteract the
reduction in vaccination coverage in Italy and to keep it
above 95%, has made 10 vaccines mandatory, including one
at six months (Decreto legge, 2017).
Another potential limitation of this pilot study is the dif-
ferent methods of data collection adopted which could affect
the estimates of breastfeeding prevalence. However, it was
not possible to evaluate this potential bias because the same
collection method was used in all vaccination centers of each
district. In order to minimize a possible effect, even in the
case of a self-administered questionnaire, the healthcare pro-
fessionals involved in the vaccination sessions were asked to
be present during the completion of the questionnaire and to
respond to any requests for clarification by the participant
mothers and to verify the completeness of the questionnaires.
When these surveys are rolled out in other regions, a unified
method of data collection would be preferable.
Conclusions
This survey system, if implemented in all vaccination cen-
ters, could yield, with standardized methodology, representa-
tive regional and national BF estimates that could serve to
monitor progress towards present and future targets.
Acknowledgments
Special thanks to the working groups of the participating regions for
their support in implementing the pilot study in their Local Health
Districts and to the health personnel of the vaccination centers for
their support in data collection.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The
research was promoted and financed by the Italian Minister of
Health.
Supplemental Material
Supplemental material for this article is available online.
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