138 Jornal de Pediatria - Vol. 76, Nº2, 2000
0021-7557/00/76-02/138
Jornal de Pediatria
Copyright © 2000 by Sociedade Brasileira de Pediatria
ORIGINAL ARTICLE
Prevalence of breastfeeding
in the city of São Carlos, São Paulo
Victoria Garcia Montrone,1 Cássia Irene S. Arantes2
Abstract
Objectives: to verify the prevalence of breast-feeding in the city of São Carlos, state of São Paulo,
Brazil.
Methods: LACMAT 3.3 software was used for the collection and treatment of data regarding
prevalence of breast-feeding. During the national vaccination day (August 15, 1998), we interviewed 3,326
people responsible for children 2 years old or younger.
Results: we verified that 52.4% of the children under 1 month of age were exclusively breast-fed. Out
of 532 children under 4 months of age, 73.3% were being breast-fed, 37.8% were being exclusively breastfed, and 17.3% were being predominantly breast-fed. We also observed that 31.7% of children under 4
months of age were being given food supplement, such as fruit and baby food. On the 5th month of age,
this percentage increased to 62.3%.
Conclusions: results in this study demonstrated that the status of breast-feeding in São Carlos is far
from the World Health Organization recommendations, thus confirming the need for healthcare policies
and actions towards promoting, protecting, and supporting breast-feeding at public healthcare services in
the municipality.
J Pediatr (Rio J) 2000; 76(2):138-42: breastfeeding, human milk, lactation, nutritional survey.
Introduction
It is unquestionable that breast-feeding is the best form
of nourishment for infants. In this sense, it also seems
certain that early interruption of breast-feeding is significant.
Even though most mothers understand the advantages of
breast-feeding, especially considering infant nutrition and
immunology, early weaning is still significant due to
problems related to the lactation process.
Early weaning represents a concern for governmental
healthcare policies, since it is directly related to infant
mortality and morbidity rates. Thus breast-feeding should
play an important role in programs aimed at reducing
coefficients of infant mortality. It is estimated that the
promotion of breast-feeding could save the lives of up to a
million children per year in developing countries.1
Many studies have indicated the efficacy of simple
campaigns for promoting, protecting, and supporting breastfeeding, independently of the period in which these
campaigns are carried out (during the prenatal, the
puerperium, or the neonatal period). 2 The Nursing
Department at Universidade Federal de São Carlos, and the
City Health Department of São Carlos, both interested in
1. Professor, Nursing Department, Universidade Federal de São Carlos
(UFSCar).
2. Assistant Professor, Nursing Department, UFSCar.
138
Prevalence of breastfeeding... - Montrone VG et alii
prioritizing breast-feeding campaigns in citywide healthcare
services, designed a program to be carried out at healthcare
units within the city. Initially, the program aimed at surveying
breast-feeding numbers within the city, in order to establish
parameters for assessing the effectiveness of the policies
implemented.
We adopted a survey method established according to
the World Health Organization recommendations for
assessing breast-feeding indicators during national
vaccination days. This method has already been used by
others.3,4 With this survey, our objective was to verify the
prevalence of breast-feeding in the city of São Carlos.
Methods
The municipality of São Carlos is located in central part
of the state of São Paulo. It has a total population of 175,295
inhabitants, is predominantly urban, and has an urbanization
rate of 94%.5
Our study was carried out on August 15, 1998, during
the national vaccination day. This constitutes an ideal
occasion for surveying a large number of mothers, and it
presents an opportunity for reaching a significant part of the
population being studied within a short period of time.
We interviewed 3,326 people responsible for children
with 2 years of age or younger at 13 different vaccination
units (out of 27) within the city of São Carlos. We selected
vaccination units with a higher number of children vaccinated
in this specific age group and from different areas of the
city, according to a report from the vaccination campaign of
June 1998.6 The collection of data thus was carried out at all
city healthcare units and at three schools located in peripheral
areas of São Carlos, distant from their healthcare unit of
reference. Consequently, our sample is representative of
the urban population of the municipality, though not
randomized.
Out of the whole group of interviewees, 1,709 had
children younger than 1 year of age, which corresponds to
62.8% of all children vaccinated within this age group. This
vaccination campaign was able to reach 96.1% of the target
population.7
The data collection was carried out by 26 students from
the Nursing School at Universidade Federal de São Carlos.
Students received training on how to fill out survey forms
and how to approach interviewees without inducing any
answers. In this sense, interviewees were approached being
informed that the student was carrying out a survey on infant
nutrition and being asked the following question: what did
the child have to eat and drink yesterday? This way, a direct
question regarding breast-feeding was avoided. The survey
form included information about date of birth, sex, and type
of nourishment the child received on the day prior to the
interview. The authors of this study coordinated the activities
of training and supervision of interviewers at each unit
throughout the vaccination day.
Jornal de Pediatria - Vol. 76, Nº2, 2000 139
Formatting of data and calculation of breast-feeding
rates related to the prevalence of breast-feeding were carried
out using the LACMAT software,8 which is based on EpiInfo 6.02. This software allows entering data as well as the
standardized and manual analysis of data. Breast-feeding
indicators were calculated for different age groups according
to the following World Health Organization definition9:
1. Exclusive breast-feeding: breast-feeding is the only
source of nourishment, not excluding the administration
of vitamins, minerals, or drugs;
2. Predominant breast-feeding: breast-feeding + water,
juice, tea, oral rehydration solution;
3. Full breast-feeding: exclusive breast-feeding +
predominant breast-feeding;
4. Complementary breast-feeding: breast-feeding + solid
or semisolid food supplement;
5. Breast-feeding: breast-feeding independently of the
consumption of any other lacteal supplement.
Results
Table 1 presents the breast-feeding status for children
from 0 to 23 months of age, and moving averages3 at 3
months of breast-feeding. The percentage of children with
less than 1 month of age and that were being breast-fed was
90.3%, with 52.4% on exclusive breast-feeding. Therefore,
9.7% of the children were already fully weaned at their 1st
month of age. Out of the 532 children with less than 4
months of age, 73.3% were being breast-fed, 37.8% were
being exclusively breast-fed, and 17.3% were being
predominantly breast-fed.
Table 1 also indicates that out of 821 children younger
than 6 months, 63.8% were being breast-fed by their mothers,
27.7% were being given exclusive breast-feeding, and
13.3%, predominant breast-feeding.
Figure 1 presents the percentage of children being given
exclusive breast-feeding, full breast-feeding, and breastfeeding according to the age group. It is possible to observe
a continuous decrease in all breast-feeding percentages.
Also, the percentage of children receiving full breastfeeding presented a more serious decrease than others, from
73.4% of children with less than 1 month of age to 8.3% of
children within 6 to 7 months of age.
Introduction of semisolids in the eating habits of children,
according to different age groups, is presented in Figure 2.
Our data indicate that the introduction of semisolids occurs
markedly after the 4th month of age. It is possible to verify
that 31.7% of children younger than 4 months of age were
being given some type of food supplement, such as fruits
and baby food. In the 5th month of age, this percentage
increases to 62.3%, indicating that the majority of children
within this age group were being given food supplements.
Prevalence of breastfeeding... - Montrone VG et alii
140 Jornal de Pediatria - Vol. 76, Nº2, 2000
Table 1 Age
group
(months)

Breast-feeding indicators in the city of São Carlos, São Paulo (1998)
Total
infants
Exclusive
breast-feeding
Predominant
breast-feeding
Breast-feeding
(3 months)
N
N
N
%
%
%
Moving
average
%
1
2
124
131
65
55
2.4
41.9
26
35
20.9
26.7
112
111
90.3
84.7
–
80.3
2  3
135
48
35.5
15
11.1
89
65.9
68.5

0
1
3

4
142
33
23.2
16
11.2
78
54.9
56.7
4  5
146
14
9.6
13
8.9
72
49.3
49.2
5  6
143
12
8.4
4
2.8
62
43.4
43.3

169
9
5.3
5
2.9
63
47.3
36.6
6
7
12

13
132
0
0.0
0
0.0
21
15.9
18.7
18

19
145
0
0.0
1
0.7
19
13.1
13.6
23

24
111
0
0.0
0
0.0
12
10.8
–
Total <4
532
201
37.8
92
17.3
390
73.3
–
Total<6
821
277
27.7
109
13.3
524
63.8
–
Discussion
Our results have demonstrated that the breast-feeding
status in São Carlos is far from achieving the World Health
Organization recommendations; that is, children should be
exclusively breast-fed up to 4 to 6 months of age, and should
continue to be breast-fed up to 2 years of age.
In comparison to nationwide indicators of breast-feeding
in Brazil, the results found in São Carlos are also lower.
According to Rea,10 the most adequate indicator for breastfeeding in Brazil should be the percentage of children
between 0 and 4 months of age being given exclusive
breast-feeding, which, according to the World Health
Organization, should be 100%. However, in Brazil, this
percentage was of 40.3% according to the 1996 national
survey on demography and health.11 In our study, we
observed a percentage of 37.8% for children younger than
4 months.
Figure 1 - Percentage of children with exclusive breast-feeding,
full breast-feeding, and breast-feeding according to
the group
Our results regarding full breast-feeding indicate a trend
that is comparable to that of Carvalhaes et al.4 in a study on
breast-feeding with a population of 1,550 children with less
than 1 year of age. That study was carried out in the city of
Botucatu, also in the state of São Paulo, which did not have
any organized healthcare policy for promoting breastfeeding. Those authors observed that in age groups from 2
to 3 months and from 6 to 7 months, the percentage of
children being given full breast-feeding was 47.1% and
18.7%, respectively. In our study, the percentage of children
Prevalence of breastfeeding... - Montrone VG et alii
Figure 2 - Percentage of children receiving semisolids according
to age group
being given full breast-feeding for those same two age
groups was 46.6% and just 8.2%, respectively.
Moving averages at 3 months were used to compare
percentages of infants with 3 and 6 months of age being
breast-fed (68.5% and 43.3%, respectively) with those of
Vieira et al.,3 indicating 85.7% and 65%, respectively, in
the city of Feira de Santana, state of Bahia, Brazil. In doing
so, we verified that in cities with policies for the promotion
of breast-feeding, such as Feira de Santana, it is possible to
obtain a positive effect on breast-feeding percentages.
As to what regards average duration of breast-feeding,
obtained considering the age (in months) at which the 3month moving average was £50%, it is possible to verify, in
Table 1, that it was of 5 months. This average indicates that
at 5 months of age, 50% of the infants had already been
weaned. This result is also considerably lower than that of
Vieira et al.3 (9 months). Our average duration of breastfeeding proves necessary to implement healthcare policies
towards promoting breast-feeding in the city of São Carlos.
We also observed that water and tea are being introduced
into the eating habits of infants at a very early age (Table 1).
This practice of early introduction of fluids in the eating
habits of infants is considered inappropriate. It interferes in
the lactation process and increases the risk for infant
morbidity and mortality while shortening the duration of
breast-feeding. According to Moura,13 tea is being used in
order to relieve pain from colic and to hydrate babies by
parents who are not aware that breast-feeding supplies all
the nourishment the infant needs. Moura emphasizes that
the earlier the introduction of water and tea to infants, the
higher the incidence of diarrhea. Our results indicate that
20.9% of babies younger than 1 month, and 26.7% of babies
younger than 2 months had been given water, tea, or juice.
We also observed an early introduction of semisolids in the
Jornal de Pediatria - Vol. 76, Nº2, 2000 141
eating habits of infants: from 4 to 5 months of age, over 60%
of babies were being given baby food (Figure 2).
In relation to children who were completely weaned, we
observed a marked increase from 15.3% to 45% within the
age groups of 1 to 2 months and of 3 to 4 months. Weaning
continued to increase after the 4th month of age, though not
as markedly. In another study carried out in São Carlos, in
1995, with a group of mothers being given medical assistance
at the city primary healthcare units, weaning rates were even
higher, indicating 45% for infants with 1 month of age, and
66% for infants with 3 months of age.14
Results on weaning in the city of São Carlos indicate the
importance of promoting educational assistance to mothers
concerning babies and their early months of life. This
assistance should be given before and after the baby is born.
It would also be advisable to have medical follow-up at the
homes of newborns who presented any problems. According
to Rea,10 one recommended practice (among other eight)
for increasing the duration of breast-feeding is to have
medical appointments at 1 week and at 1 month of age.
According to Arantes,15 activities towards the promotion of
breast-feeding should allow mothers to understand nursing
and to discuss difficulties they may encounter.
Surveying babies during the vaccination campaign day
yielded information regarding the breast-feeding status in
different areas of São Carlos. Data were obtained using a
precise and fast method, presenting lower costs and not
interfering in the vaccination activities. The methodology
used was, therefore, adequate for carrying out diagnosis and
for assessing campaigns aimed at promoting breast-feeding.
Our results indicate the need for implementing policies
of promoting, protecting, and supporting breast-feeding at
city healthcare services. These policies should aim at
increasing exclusive breast-feeding in infants with less than
6 months of age, and at increasing the total duration of
breast-feeding.
Acknowledgments
We would like to thank all students from the Nursing
School at Universidade Federal de São Carlos who
participated in the data collection for this study.
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Correspondence
Dra. Victoria Garcia Montrone
Universidade Federal de São Carlos – Dep. Enfermagem
Via Washington Luiz, km 235 – Caixa Postal 676
CEP 13565-905 – São Carlos, SP, Brazil
Phone/fax: + 55 16 260.8334
E-mail: [email protected]