Open Access Highly Accessed Research article

Influence of neighbourhood purchasing power on breastfeeding at four months of age: a Swedish population-based cohort study

Gerd Almquist-Tangen15*, Ulf Strömberg2, Anders Holmén2, Bernt Alm15, Josefine Roswall35, Stefan Bergman4 and Jovanna Dahlgren5

Author Affiliations

1 Child Health Care Unit, Region Halland SE-434 80, Kungsbacka, Sweden

2 Research and Development Department, Halland, Sweden

3 Department of Paediatrics, Halland Hospital, Halmstad, Sweden

4 Research and Development Centre, Spenshult Hospital, Oskarström, Sweden

5 Department of Paediatrics, Institute for Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

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BMC Public Health 2013, 13:1077  doi:10.1186/1471-2458-13-1077

Published: 15 November 2013



Parental socioeconomic status (SES) is an important determinant in child health, influencing beneficial factors such as breastfeeding. A better understanding of the influence of neighbourhood-level SES measures, relating to spatial determinants, might lead to targeted actions to promote breastfeeding during infancy.


A cross-sectional study analysis the association between breastfeeding at four months of age and neighbourhood purchasing power, taking account of individual-level variables including maternal age, smoking and parental level of education. Data were obtained from a prospective population- based cohort study recruited from birth in 2007–2008 in the Halland region, southwestern Sweden. Questionnaire data on the individual-level variables and the outcome variable of breastfeeding at four months (yes/no) were used (n = 2 407). Each mother was geo-coded with respect to her residential parish (there are 61 parishes in the region) and then stratified by parish-level household purchasing power. It emerged that four neighbourhood characteristics were reasonable to use, viz. <10%, 10-19%, 20-29% and ≥ 30% of the resident families with low purchasing power.


The proportion of mothers not breastfeeding at four months of age showed a highly significant trend across the neighbourhood strata (p = 0.00004): from 16.3% (< 10% with low purchasing power) to 29.4% (≥ 30% with low purchasing power), yielding an OR of 2.24 (95% confidence interval: 1.45-3.16). After adjusting for the individual-level variables, the corresponding OR = 1.63 (1.07-2.56) was significant and the trend across the strata was still evident (p = 0.05). A multi-level analysis estimated that, in the neighbourhoods with ≥ 30% of the families with low purchasing power, 20% more mothers than expected, taking account of the individual-level factors, reported no breastfeeding at four months of age (≥ 95% posterior probability of an elevated observed-to-expected ratio).


The neighbourhood purchasing power provided a spatial determinant of low numbers of mothers breastfeeding at four months of age, which could be relevant to consider for targeted actions. The elevated observed-to-expected ratio in the neighbourhoods with the lowest purchasing power points toward a possible contextual influence.

Breastfeeding; Child health; Neighbourhood purchasing power; Prevention; Spatial determinant