Skip to main content


Int J Public Health, 09 September 2021

Urban-Rural Gaps in Breastfeeding Practices: Evidence From Lao People’s Democratic Republic

Jordyn T. Wallenborn,
Jordyn T. Wallenborn1,2*Camille B. ValeraCamille B. Valera3Sengchanh KounnavongSengchanh Kounnavong4Somphou SayasoneSomphou Sayasone4Peter Odermatt,Peter Odermatt1,2Günther Fink,Günther Fink1,2
  • 1Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
  • 2University of Basel, Basel, Switzerland
  • 3Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
  • 4Lao Tropical and Public Health Institute, Vientiane, Laos

Objectives: Breastfeeding rates are decreasing rapidly in many low and middle-income countries, disproportionately affecting urban residences. We use data from Lao People’s Democratic Republic to identify primary mechanisms underlying the urban-rural gap in breastfeeding practices.

Methods: We used data from the 2017 Lao Social Indicator Survey II. Residence was categorized as large-urban (>1 million), small-urban (<1 Million), and rural. Multivariable logistic regression provided odds ratios and 95% confidence intervals (CI) to identify factors attributing to the urban-rural differences in complying with World Health Organization’s breastfeeding recommendations for children <24 months.

Results: Mothers in large-urban residences had 3.78 (95% confidence intervals: 1.19, 11.95) and 4.67 (95% CI: 2.30, 9.46) higher odds of non-compliance with exclusive and complementary breastfeeding recommendations, respectively, than mothers living in rural areas in bivariate models. Breastfeeding differentials between small urban and rural residences were largely explained by differences in maternal education and household wealth.

Conclusion: Results of our paper suggest large disparities in breastfeeding practices between large-urban, small-urban, and rural residences.


Over the past decade, the world’s population has steadily become more urbanized—with 56% of the world now living in urban residences [1]. With rapid urbanization in many low- and middle-income countries (LMIC) comes rapid changes to social behavior and health [2], which may contribute to the rapid declines in breastfeeding in many areas [36].

A meta-analyses of breastfeeding practices in the 21st century shows that an increase in household income in LMICs is associated with lower rates of continued breastfeeding [3]. Given that economic development in LMIC is usually concentrated in urban areas[7], urbanization may affect breastfeeding in multiple ways. In China, for example, rapid economic growth coincided with an increase in marketing of breastmilk substitutes and significant changes in individual nutritional habits [4].

In the capital of Lao People’s Democratic Republic (Lao PDR) — the largest urban area in Lao PDR—less than a quarter (21.0%) of children aged 0–5 months were exclusively breastfed in 2017 [8] compared to 30% in 2012 [9]. This trend continues with complementary breastfeeding, where only 10% of children received breastmilk until age 20–23 months in 2017 compared to 16% in 2012. Nutritional status—a key indicator for adequate complementary feeding—increased in Vientiane. In 2017, 5% of children under five were stunted [8] compared to 3.6% in 2012 [9].

The urban-rural gap in breastfeeding practices has been at the forefront of current debates [1012]. In our study, we use nationally representative data from data from Lao PDR to: 1) estimate urban-rural differences in compliance with international breastfeeding recommendations, and 2) identify factors that contribute to the urban-rural differences in breastfeeding. We hypothesize, that socioeconomic factors, such as education and wealth, explain the large urban-rural gap in breastfeeding rates. Given that an increasingly large share of the global population lives in large (mega) cities, we separately analyze infant feeding behaviors in large and smaller urban areas.


A cross-sectional study was conducted using data from the 2017 Lao Social Indicator Survey (LSIS) II. LSIS II combines modules of the Multiple Indicator Survey (MICS) and the Demographic and Health Survey (DHS) to maximize survey generalizability and coverage. In collaboration with the Laotian Ministry of Health, the Lao Statistics Bureau and Ministry of Planning and Investment collected data from July to November 2017. LSIS I also combined MICS and the DHS modules and was conducted between 2011–2012 [9]. Data collection for LSIS III is unknown at this time. All women and men aged 15–49 years of age in Lao PDR were eligible. The overarching goal of LSIS II was collection of nationally comparable data on a variety of maternal and child health indicators. Six questionnaires were included in LSIS II. For our study purposes, we focused on the maternal questionnaire. All surveys had over a 99% response rate. More information on study methodology can be found elsewhere [13].

Our main outcome of interest was compliance with the World Health Organization (WHO) breastfeeding recommendations for children under 2 years of age to exclusively breastfeed for 6 months, followed by a combination of breastmilk and complementary foods and liquids until at least 2 years of age (i.e., complementary breastfeeding) [14]. The LSIS II collects detailed breastfeeding information on children under 2 years of age. Using the WHO international breastfeeding recommendations [14], we created a dichotomous (yes; no) variable to display compliance with these recommendations. First, we created a variable measuring compliance with the WHO recommendation to exclusively breastfeed for the first 6 months of life. Exclusive breastfeeding included infants who received breastmilk and no other liquids or supplements besides oral rehydration solution, vitamins, minerals, or other medicines. We also created a variable measuring compliance with WHO recommendations to complementary breastfed during 6–23 months of age. All children still being breastfed at the time of interview who also received at least one liquid or solid food were included in the complementary breastfeeding variable. All liquid and solid food consumption was self-reported by the mother.

Based on previous literature [6, 1517] and availability in LSIS II, the following predictors were investigated: marital status, maternal age, highest education attainment of the mother, wealth index, province, residence, attitudes towards domestic violence, prenatal care, skin to skin contact between mother and infant directly after birth, healthcare provider observing breastfeeding within 2 days after birth, healthcare provider counseled on breastfeeding within 2 days of birth, and place of birth. Categorization schemes of all predictors are found in Table 1.


TABLE 1. Population characteristics overall and by residence. Lao Social Indicator Survey II, Lao People's Democratic Republic, 2017.

Descriptive statistics, including frequencies and column percentages, were calculated to describe population characteristics overall and by residence status (large-urban; small-urban; rural). Chi-square tests were used to identify significant differences in predictors by residence. In order to reduce bias, preserve sample size, and increase statistical power[18], multiple imputation by chained equations (MICE) was used to generate datasets. Multivariable logistic regression provided odds ratios (OR) and 95% confidence intervals (CI) to identify factors associated with breastfeeding practices. Step-wise model building was used to identify factors that helped explain differences in urban-rural breastfeeding practices. The step-wise models included the following groupings: maternal demographics, child factors, socioeconomic status, and healthcare factors. A sensitivity analysis using complete cases was also conducted to substantiate our multiple imputation findings. A p-value of 0.05 signifies statistical significance. Data were analyzed using library CRAN, package mice in R[19] and SAS version 9.4 statistical software (SAS, Cary, NC).


Out of the 11,812 LSIS II participants, we identified 4,654 women with a child less than 24 months for participation in our study. Of these, 175 (4%) lived in a large-urban residence (i.e., Vientiane Capital), 1,099 (24%) in a small-urban residence, and 3,380 (73%) in a rural residence (Table 1). Maternal attainment of post-secondary education or more was significantly higher in large-urban residences (36.8%) than small-urban (27.1%) and rural (5.0%) residences. Large, significant disparities were also found in the wealth index, with almost three-quarters (70%) of residents in large-urban settings had the richest wealth index, compared with one-third (33.3%) in small-urban and 4.8% in rural settings. Skin-to-skin contact immediately after birth, breastfeeding counseling within 2 days after birth, and prenatal care were significantly higher in large-urban and small-urban residences. In large-urban settings, 80% of children 0–5 months were not exclusively breastfeed, compared to 51.1% in small-urban settings and 52.3% in rural settings. Similarly for children between 6-23 months, 70.1% were not complementary breastfeed in large-urban settings, 53.1% in small-urban settings, and 35.7% in rural setting (Table 1).

Table 2 displays the association between maternal demographic, child characteristics, socioeconomic status, and other health related factors and non-compliance with WHO’s recommendation to exclusively breastfeed during the first 6 months of life. Mothers in Vientiane Capital had 3.5 times the odds of non-compliance with exclusive breastfeeding recommendations in bivariate models (crude OR = 3.78; 95% CI: 1.19, 11.95) and when controlling for maternal demographic factors alone (adjusted OR = 3.56; 95% CI: 1.17, 10.88) compared to mothers residing in rural areas. After controlling for both maternal demographic characteristics and child factors, mothers in large-urban settings had 4.5 times the odds of non-compliance with exclusive breastfeeding recommendations (OR = 4.48; 95% CI: 1.36, 14.73). Once controlling for wealth index and maternal education, estimated associations were attenuated (OR = 2.43; 95% CI: 0.61, 9.64). For small-urban residences in other provinces, the bivariate association and models adjusting for maternal demographics alone or in combination with child factors showed a small increase in the odds of non-compliance with exclusive breastfeeding recommendations (adjusted OR for maternal and child factors = 1.16; 95% CI: 0.84, 1.59). After controlling for the additional socioeconomic variables, mothers who reside in a small-urban residence displayed odds of complying with WHO exclusive breastfeeding recommendations that were similar to mothers in rural areas (adjusted OR: 0.93; 95% CI: 0.61, 1.44). We found similar results from our complete case analysis (Supplementary Appendix Table S1).


TABLE 2. Predictors of non-Compliance with World Health Organization Recommendations to Exclusively Breastfeed during the first 6 months of life, Lao Social Indicator Survey II, Lao People's Democratic Republic, 2017.

Table 3 displays predictors of non-compliance with WHO’s recommendations to complementary breastfeed between 6 and 23 months. Mothers in a large-urban residence had 4.7 times the odds of not complying with complementary breastfeeding recommendations in the bivariate model (crude OR: 4.67; 95% CI: 2.30, 9.46). Similar associations were found when controlling for maternal demographics alone (adjusted OR: 4.16; 95% CI: 2.88, 6.02) or in combination with child factors (adjusted OR: 6.64; 95% CI: 3.29, 13.40). However, when controlling for the additional socioeconomic status factors (i.e., wealth index and maternal education), we again found that the association between large-urban residence and non-compliance with WHO’s complementary breastfeeding recommendations was attenuated (OR = 2.07; 95% CI: 0.84, 5.08). Mothers in a small-urban residence had 1.9 times the odds of non-compliance with WHO complementary breastfeeding recommendations in the bivariate model (crude OR: 1.88; 95% CI: 1.52, 2.35). Similar estimates were found when controlling for maternal demographics alone (adjusted OR: 1.78; 95% CI: 1.38, 2.29) or in combination with child factors (adjusted OR: 2.10; 95% CI: 1.45, 3.04). However, once controlling for the additional socioeconomic variables alone (adjusted OR: 1.01; 95% CI: 0.67, 1.51), or in combination with health factors (adjusted OR: 1.04; 95% CI: 0.70, 1.57), the difference between small-urban and rural residences was negligible. Our complete case analysis confirms the wealth relationship and differences in breastfeeding practices by residence (Supplementary Appendix Table S2).


TABLE 3. Predictors of Non-Compliance with World Health Organization Recommendations to Complementary Breastfeed between 6 and 23 months, Lao Social Indicator Survey II, Lao People's Democratic Republic, 2017.


Breastfeeding is decreasing rapidly in many urban LMIC settings. In this paper, we analyzed the relationship between residence and breastfeeding practices in Lao PDR as a somewhat representative LMIC facing rapid urbanization and falling breastfeeding rates. Our results highlight the rather pronounced gaps in breastfeeding behaviors between rural and urban areas. On average, children growing up in rural areas are more than twice as likely to be exclusively breastfed in the first 6 months, and also more than twice as likely to benefit from complementary breastfeeding from 6 to 23 months. While most of the breastfeeding gap between small urban and rural areas appears to be explained by differences in maternal education and wealth, the same does not appear to be true for larger urban areas, where substantial breastfeeding gaps are visible even when these factors are adjusted for.

Previous studies conducted in Lao PDR suggest that location of residence[20], encouragement of the child’s father [20], television advertisements [20], and formal labor commitments [21] influenced exclusive breastfeeding at 6 months postpartum. Evidence also suggests that ethnic background—which is closely related to geographic region—impact breastfeeding practices [20, 22]. Healthcare workers during antenatal care and in the delivery setting were also shown to have a significant impact on breastfeeding initiation [22]. However, current literature identifying factors influencing breastfeeding in Lao PDR is limited, with only one quantitative study [22] and two qualitative studies [20, 21] investigating these associations.

Over the last 30 years, the Ministry of Health in Lao PDR has attempted to increase breastfeeding rates through standard public health behavior change campaigns, including a Safe Motherhood program and a large UNICEF supported exclusive breastfeeding promotion campaign; however, these programs were largely unsuccessful [21]. Further, despite the integration of the WHO International Code of Marketing of Breastmilk Substitutes in Lao PDR, 40% of children aged 0–23 months in urban and wealthier households are given commercial breast milk substitutes, compared with 10.6% in rural areas [22].

Marketing of breastmilk substitutes may underline the socioeconomic drivers of poor breastfeeding practices. A qualitative study in Lao PDR found that 75% of mothers report watching television ads promoting infant formula from Thailand, and after seeing these ads, approximately half of mothers wanted to purchase infant formula [21]. Despite the adoption of the WHO International Code of Marketing of Breastmilk Substitutes in Lao PDR, a lack of regulation may undermine the codes effectiveness. Further, in emerging economies where families have disposable income, promotion of other breastmilk substitutes, such as baby food, have also been heavily marketed [23].

We also found that wealth index is a strong, and consistent predictor of compliance with WHO’s breastfeeding recommendations. Our results support a recent brief from WHO which states that more affluent women in LMIC’s breastfeed a shorter duration than poorer women [24]. Our results also suggest that the large differences in breastfeeding practices between women residing in urban vs rural areas can be partially attributed to socioeconomic status. Wealth index is a potential proxy for employment status, with wealthier women working more outside of the household. Participation in the female-workforce is a well-known and strong predictor of suboptimal breastfeeding practices[22, 25] — which could help explain our findings.


To our knowledge, our study is the second quantitative analysis of breastfeeding practices in Lao PDR—strengthening our understanding of the urban-rural gap in breastfeeding. The large and extensive dataset from LSIS II allows investigation of important confounding factors, such as wealth and breastfeeding promotion strategies used in breastfeeding interventions (i.e., early skin-to-skin contact). Unlike other breastfeeding research, LSIS II breastfeeding measurements does not suffer from recall bias since the information is cross-sectional (e.g., are the participants breastfeeding at time of interview?); however, temporality between factors cannot be established and causality is not determined. Similarly, residual confounding from maternal-infant bonding and employment status could not be investigated. Our study is also limited by the relatively small sample size from large urban areas. We hope that the substantial intra-urban differentials in breastfeeding behavior can be investigated in future research.


Results of our paper suggest large disparities in breastfeeding practices between large-urban, small-urban, and rural residences. Increasing education, rising household incomes as well as the trend towards large cities will likely result in rapidly declining breastfeeding rates over the next decade at the global level unless governments identify policy measures that counteract this trend. Additional research is needed in Lao PDR as well as in LMICs more generally to understand the mechanism behind rapidly declining breastfeeding rates in urban settings, and the role of socioeconomic status.

Ethics Statement

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

JW conceptualized and designed the study, carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. GF conceptualized and designed the study, and reviewed and revised the manuscript. PT, CV, SK, and SS reviewed the manuscript for important intellectual content, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.


We thank the Publication Fund of the University of Basel for Open Access for covering the open access publication fees.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at:


1.The World Bank. Urban Populations 2018 (2018). Available from: Accessed June 20, 2020.

2. City, BL, and Assessment, E. Urbanization and Health. Bull World Health Organ (2010) 88(4):245–6. doi:10.2471/blt.10.010410

CrossRef Full Text | Google Scholar

3. Victora, CG, Bahl, R, Barros, AJD, França, GVA, Horton, S, Krasevec, J, et al. Breastfeeding in the 21st century: Epidemiology, Mechanisms, and Lifelong Effect. The Lancet (2016) 387(10017):475–90. doi:10.1016/s0140-6736(15)01024-7

CrossRef Full Text | Google Scholar

4. Liu, J, Shi, Z, Spatz, D, Loh, R, Sun, G, and Grisso, J. Social and Demographic Determinants for Breastfeeding in a Rural, Suburban and City Area of South East China. Contemp Nurse (2013) 45(2):234–43. doi:10.5172/conu.2013.45.2.234

PubMed Abstract | CrossRef Full Text | Google Scholar

5. Oakley, L, Baker, CP, Addanki, S, Gupta, V, Walia, GK, Aggarwal, A, et al. Is Increasing Urbanicity Associated with Changes in Breastfeeding Duration in Rural India? an Analysis of Cross-Sectional Household Data from the Andhra Pradesh Children and Parents Study. BMJ open (2017) 7(9):e016331. doi:10.1136/bmjopen-2017-016331

PubMed Abstract | CrossRef Full Text | Google Scholar

6. Walters, D, Horton, S, Siregar, AYM, Pitriyan, P, Hajeebhoy, N, Mathisen, R, et al. The Cost of Not Breastfeeding in Southeast Asia. Health Policy Plan. (2016) 31(8):1107–16. doi:10.1093/heapol/czw044

PubMed Abstract | CrossRef Full Text | Google Scholar

7. Chen, Y, Luo, P, and Chang, T. Urbanization and the Urban-Rural Income Gap in China: A Continuous Wavelet Coherency Analysis. Sustainability (2020) 12(19):8261. doi:10.3390/su12198261

CrossRef Full Text | Google Scholar

8.Lao Statistics Bureau. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane, Lao PDR: Lao Statistics Bureau and UNICEF (2018).

9. Mo, H, Bureau, LS, and Lao, PDR. Lao Social Indicator Survey (LSIS) 2011–12. Vientiane, Lao PDR: Ministry of Health and Lao Statistics Bureau Vientiane (2012).

10. Gao, H, Wang, Q, Hormann, E, Stuetz, W, Stiller, C, Biesalski, HK, et al. Breastfeeding Practices on Postnatal Wards in Urban and Rural Areas of the Deyang Region, Sichuan Province of China. Int Breastfeed J (2016) 11(1):11. doi:10.1186/s13006-016-0070-0

PubMed Abstract | CrossRef Full Text | Google Scholar

11. Thu, HN, Eriksson, B, Khanh, TT, Petzold, M, Bondjers, G, Kim, CN, et al. Breastfeeding Practices in Urban and Rural Vietnam. BMC Public Health (2012) 12(1):964–8. doi:10.1186/1471-2458-12-964

PubMed Abstract | CrossRef Full Text | Google Scholar

12. Oommen, A, Vatsa, M, Paul, VK, and Aggarwal, R. Breastfeeding Practices of Urban and Rural Mothers. Indian Pediatr (2009) 46(10):891–4.

PubMed Abstract | Google Scholar

13.Lao Statistics Bureau. Lao Social Indicator Survey II 2017, Survey Findings Report. Vientiane: Statistics Bureau and UNICEF (2018). doi:10.18637/jss.v045.i03

CrossRef Full Text

14.World Health Organization. Breastfeeding (2018). Available from: Accessed June 20, 2020.

15. Masho, SW, Morris, MR, and Wallenborn, JT. Role of Marital Status in the Association between Prepregnancy Body Mass index and Breastfeeding Duration. Women's Health Issues (2016) 26(4):468–75. doi:10.1016/j.whi.2016.05.004

PubMed Abstract | CrossRef Full Text | Google Scholar

16. Wallenborn, JT, Ihongbe, T, Rozario, S, and Masho, SW. Knowledge of Breastfeeding Recommendations and Breastfeeding Duration: A Survival Analysis on Infant Feeding Practices II. Breastfeed Med (2017) 12(3):156–62. doi:10.1089/bfm.2016.0170

PubMed Abstract | CrossRef Full Text | Google Scholar

17. Cai, X, Wardlaw, T, and Brown, DW. Global Trends in Exclusive Breastfeeding. Int Breastfeed J (2012) 7(1):12. doi:10.1186/1746-4358-7-12

PubMed Abstract | CrossRef Full Text | Google Scholar

18. McCleary, L. Using Multiple Imputation for Analysis of Incomplete Data in Clinical Research. Nurs Res (2002) 51(5):339–43. doi:10.1097/00006199-200209000-00012

PubMed Abstract | CrossRef Full Text | Google Scholar

19. Buuren, SV, and Groothuis-Oudshoorn, K. Mice: Multivariate Imputation by Chained Equations in R. J Stat Softw (2010) 5(3):245–6.

Google Scholar

20. Putthakeo, P, Ali, M, Ito, C, Vilayhong, P, and Kuroiwa, C. Factors Influencing Breastfeeding in Children Less Than 2 Years of Age in Lao PDR. J Paediatr Child Health (2009) 45(9):487–92. doi:10.1111/j.1440-1754.2009.01547.x

CrossRef Full Text | Google Scholar

21. Lee, HM, Durham, J, Booth, J, and Sychareun, V. A Qualitative Study on the Breastfeeding Experiences of First-Time Mothers in Vientiane, Lao PDR. BMC Pregnancy Childbirth (2013) 13(1):223–9. doi:10.1186/1471-2393-13-223

PubMed Abstract | CrossRef Full Text | Google Scholar

22. Kounnavong, S, Pak-Gorstein, S, Akkhavong, K, Palaniappan, U, Berdaga, V, Conkle, J, et al. Key Determinants of Optimal Breastfeeding Practices in Laos. Fns (2013) 04(10):61–70. doi:10.4236/fns.2013.410a010

CrossRef Full Text | Google Scholar

23. Rollins, NC, Bhandari, N, Hajeebhoy, N, Horton, S, Lutter, CK, Martines, JC, et al. Why Invest, and what it Will Take to Improve Breastfeeding Practices?. The Lancet (2016) 387(10017):491–504. doi:10.1016/s0140-6736(15)01044-2

CrossRef Full Text | Google Scholar

24.World Health Organization. Breastfeeding in the 21st Century (2018).

25. Abigail, AH, Envuladu, EA, Adams, H, Inalegwu, E, Okoh, E, Agba, A, et al. Barriers and Facilitators to the Practice of Exclusive Breast Feeding Among Working Class Mothers: A Study of Female Resident Doctors in Tertiary Health Institutions in Plateau State J. Med. Res. (2013).

Google Scholar

Keywords: rural population, low-and middle-income countries, sociodemographic factors, urban areas, urbanization, breastfeeding, Lao people’s democratic republic

Citation: Wallenborn JT, Valera CB, Kounnavong S, Sayasone S, Odermatt P and Fink G (2021) Urban-Rural Gaps in Breastfeeding Practices: Evidence From Lao People’s Democratic Republic. Int J Public Health 66:1604062. doi: 10.3389/ijph.2021.1604062

Received: 02 March 2021; Accepted: 20 August 2021;
Published: 09 September 2021.

Edited by:

Carlos Rodriguez-Diaz, George Washington University, United States

Reviewed by:

Viroj Tangcharoensathien, Ministry of Public Health, Thailand

Copyright © 2021 Wallenborn, Valera, Kounnavong, Sayasone, Odermatt and Fink. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jordyn T. Wallenborn,

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.