To determine the survival, prevalence and associated factors of exclusive breastfeeding practices in South India

ABSTRACT

Context:

Exclusive breastfeeding (EBF) provides protection to the child from risk of obesity, overweight, type II diabetes and helps in enhancing brain development, learning capabilities and also reduces gastrointestinal infections. Breast problems, societal barriers, insufficient support, poor knowledge, mode of delivery and community beliefs are associated.

Aim:

To determine the survival and prevalence of exclusive breast-feeding practice and their associated factors.

Settings and Design:

An ambispective community-based observational study was conducted.

Materials and Methods:

A sample of 441 mothers was estimated with a prevalence of EBF of 54.9% based on the National Family Health Survey 2015–16.

Study Procedure:

The selected mothers with an infant less than one year of age and those with infants less than six months were interviewed retrospectively and prospectively and information on the duration of EBF, demography and factors associated were collected.

Statistical Analysis Used:

The data were analysed using IBM SPSS, version 22. The Chi-square test and binary logistic regression were used to determine the associated factors for EBF. A P value of <0.05 was considered significant.

Results:

EBF survival rate was good till three months and decreased drastically after five months. EBF practice in the present study was 69.4%. Birth order, maternal age, birth weight, paternal education and religion were significantly associated with EBF.

Conclusion:

Primary health care providers in the community should also consider the cultural factors and educate the mothers on the practice of EBF to reduce morbidity and mortality and promote better health for a healthy, strong, younger population.

Introduction

Exclusive breastfeeding (EBF) for the first 6 months provides all required nutrients for a newborn. It is very much required that the infant should receive only breast milk as per recommendations of World Health Organisation (WHO) and American Academy of Paediatrics (AAP). EBF provides protection against many childhood diseases.

Many studies show that 35% of infants worldwide are exclusively breastfed in the first four months, it was 23.2% at 6 months in a study by Dinesh Dharel et al.[1,2] Studies have shown that EBF decreased with age and cultural factors play a role.[3,4,5] EBF provides infants health benefits and many factors influence their survival.[6,7]

Considering the clinical implications of EBF, its implementation has obstacles and the health policy and decision-makers should make efforts to promote EBF. This study aimed to determine the survival of EBF and its determinants. The findings can be useful for health policies and decision-makers in choosing appropriate measures to promote EBF.

Material and Methods

An ambispective observational study was conducted in a rural population. A sample size of 441 was determined using single population proportion formula [n = [(Za/2) ²*P (1-P)]/d²] by assuming a 95% confidence level of Zα/2 = 1.96, the estimated prevalence of EBF (P) as 54.9% based on National Family Health Survey 2015–16, considering 5% margin of error (d).

Sampling procedure

From five taluks, two taluks were randomly selected by lottery method, and from these two taluks, three primary health centres were selected randomly. A list of mothers with less than one year child was prepared with the help of Accredited Social Health Activist (ASHA) workers and auxiliary nurse midwives (ANMs) of the primary health centre (PHC). A simple random sampling technique was used to select respondents to be interviewed within the selected primary health centres. The questionnaire was first prepared in English and translated to the local Kannada language and finally retranslated to English by a person who can speak both languages. Written informed consent was obtained from mothers. Ethical clearance was obtained from the institutional ethical committee.

Mothers with an infant less than one year of age were interviewed and demographic information and factors associated with EBF were collected using a structured interviewer-administered questionnaire, and data on EBF was collected using their recall response method. Mothers having less than 6 months infant were followed for six months and information on the above-mentioned aspects was recorded by periodical visits by ASHA workers and also through mobile phone contacts prospectively.

Inclusion criteria

All mothers with one year child and children below 6 months of age.

Exclusion criteria

Mothers with psychotic conditions.

Statistical analysis

The data were analysed by using SPSS Statistics 22 IBM Corp, Armonk, NY. Quantitative data were presented by mean and standard deviation (SD) and categorical data by percentages. Kaplan–Meier’s survival analysis, Chi-square test and binary logistic regression method were used to determine the associated factors for EBF practice. A P value of <0.05 was considered statistically significant.

Results

The Kaplan–Meier survival curve shows [Figure 1] that the mean and median duration of EBF was found to be 6 months and 6.805 months, respectively [Table 1]. The EBF practice in the present study was 69.4%. 13.8% of mothers exclusively breastfed their babies for 4 months. Almost 70% of mothers gave EBF for more than or equal to six months duration. Their mean age was 23.8 years (SD = 3.2), and the majority were primiparous (48.7%) and had an education of matriculation and above (58.5%).

Figure 1.

Survival of duration of exclusive breastfeeding

Table 1.

Kaplan–Meier survival estimates of exclusive breastfeeding duration

Mean				Median
Estimate	Std. Error	95% Confidence Interval		Estimate	Std. Error	95% Confidence Interval
		Lower Bound	Upper Bound			Lower Bound	Upper Bound
6. 680	0.09	6.64	6.97	6.00.	0.07.	5.00.	6.02

EBF decreased with an increase in maternal age and the association was found to be statistically significant. There was no statistical association between the educational status of parents and EBF. Occupation of the mother was significantly associated with EBF. Religion has a significant association with EBF. The proportion of EBF decreased with an increase in parity. EBF was better among mothers who had at least four antenatal care (ANC) visits. The association between birth interval and EBF was statistically significant [Table 2].

Table 2.

Bi-variate analysis of factors associated with exclusive breastfeeding

Demographic Variables	Total (n)	Exclusive breastfeeding given (No.)	Exclusive breastfeeding given (%)	Chi-square Value	P
Maternal age
18-22 Years	170	56	32.9
23-28 Years	241	77	31.9	8.736	0.013*
> 28 Years	30	02	06.6
Education of mother
Illiterate	53	14	26.4
Primary	23	09	39.1
Middle School	59	26	44.1
Higher Secondary	48	11	22.9	7.783	0.163
Matriculation	244	71	29.1
Graduation and above	14	04	28.57
Occupation of the mother
Unskilled Worker	134	46	34.3
Skilled Worker	02	0	00
Agriculture	41	20	48.8	14.186	0.014*
Business	02	0	00
Service	24	10	41.7
House Maker	238	59	24.8
Parity
1	215	70	32.5
2	162	55	33.9	8.001	0.018*
3 and above	64	10	12.2
ANC Visits
≤4 Visits	361	114	31.6	0.876	0.349
> 4 Visits	80	21	26.2
Birth Interval
Ist Child	197	66	33.5
1-2 Years	126	42	33.3	11.431	0.010*
3-4 Years	90	15	16.7
> 4 Years	28	12	48.8

* Significant P value at 5% level of significance

The present study revealed that EBF was better among mothers who had at least four antenatal visits (adjusted odds ratio (AOR) -1.357). The birth weight of the present child (P = 0.041) was associated with EBF. In the present study, the birth order of the child was significantly associated with EBF (P = 0.029) indicating more infants with higher birth order received EBF for at least 6 months. Maternal age was found to be associated with EBF (P = 0.028) indicating a lower maternal age increased the chance of providing EBF. Education of parents does not show any significance but higher educated mothers exclusively breastfed their babies better. EBF increased with parity but was not significant (AOR 1.396). EBF and place of delivery did not show any association. The present study revealed that mothers’ occupations as housemakers have exclusively breastfed their babies more compared to employed mothers [Table 3].

Table 3.

Binary logistic regression showing associated factors of exclusive breastfeeding duration

Factors	B	S.E.	Adjusted Odds ratio	95% C.I. for AOR		P
				Lower	Upper
ANC Visits	0.305	0.297	1.357	0.758	2.429	0.305
Birth Weight	-0.511	0.250	0.600	0.367	0.979	0.041*
Birth interval	-0.037	0.283	0.964	0.554	1.677	0.896
Birth Order	1.450	0.665	4.264	1.157	15.713	0.029*
Maternal age	0.500	0.227	1.648	1.057	2.570	0.028*
Education of Mother	0.144	0.097	1.155	0.954	1.397	0.139
Education of Father	-0.213	0.096	0.808	0.670	0.976	0.027*
Mothers Occupation	0.099	0.062	1.104	0.977	1.248	0.111
Fathers Occupation	0.143	0.093	1.153	0.962	1.383	0.124
Parity	0.333	0.644	1.396	0.395	4.932	0.605
Place of delivery	-0.069	0.133	0.933	0.720	1.210	0.603

AOR: Adjusted odds ratio. * Significant P values

Discussion

In the present study, 70% of mothers gave EBF for more than or equal to six months duration. According to studies by Mashail BA et al. and Getnet Mekuria et al., EBF practice among developing countries varies from 10% to 77%. In Ethiopia, 49% of infants were exclusively breastfed for the first six months, while 56.9% were exclusively breastfed for the first four months. Primary health care professionals should recommend mothers and their families to complete EBF for at least 6 months.[8,9] Radhakrishnan et al.[10] in their study found that the prevalence of EBF among rural Tamil Nādu was 69.35%. Few countries like Iran Beruwala (Kalutara), Lebanon, Nigeria, Bangladesh and a study in Canadian province recorded a very low EBF compared to other developing countries, the slow-growing economy could be a major factor.

Predictors of EBF

The birth order of the present child, indicating more infants with higher birth order received EBF for at least 6 months and this was found to be statistically significant. Mothers with more than one child preferring more to exclusively breastfeed their babies can be attributed to the counselling received during antenatal visits to the health centres or household visits by the health care providers. A cross-sectional study conducted by Surender Reddy et al. also observed birth order as a predictor of EBF. Priyantha J Perera et al. in a Sri Lanka study found no statistically significant association between birth order and EBF.[11,12]

In the present study, maternal age was also found to be significantly associated with EBF indicating lower the maternal age, the chance of providing EBF for at least six months increased and higher maternal-aged mothers’ availability of adequate breast milk could be the reason for not completing EBF for six months. A similar observation also made in a retrospective study conducted by Naomi Kitano et al.[13] also revealed that older maternal age and lower parity were independently associated with EBF. Mothers need to be educated regarding the advantages of EBF, only breast milk is sufficient in the first six months which also protects the child from infections. By increasing the antenatal visits and strengthening mother and child care services by the government at the rural health centre level, EBF can be promoted.

The birth weight of the present child was significantly associated with EBF. Mothers delivering babies with lower birth weight have exclusively breastfed their babies better and the reason could be they have the knowledge of EBF and its advantages. Nemera et al.[14] in a cross-sectional study found that factors like paternal education, maternal age, ANC, place of delivery and time of initiation of breastfeeding were significantly associated with EBF. Madhavi et al.[15] in a hospital-based study made a similar observation of a statistically significant association between birth weight and EBF. During ANC visits, counselling should be given to mothers of low-birth-weight babies regarding demand feeding by which frequency of exclusive feeding can be increased.

Paternal education of matriculation and above was also found to be significantly negatively associated with EBF. As in most of the literate class with better economic status go for early initiation of weaning compared to illiterates whose economic status and elders’ advice also contributes to the continuation of EBF. Mothers with matriculation or higher education to some extent have better compliance to exclusivity but this was not found statistically significant. A similar observation was also made by OjongIdang Neji et al.[16] that EBF does not show any statistically significant association with education. Irrespective of their educational status, mothers have minimal knowledge of EBF. A study conducted by Gopujkar et al.[17] in a scientific report mentioned a similar finding that fathers and mothers with education are less likely to provide EBF for more than 6 months. A study by Radhakrishnan et al. in Tamil Nādu also found no impact of education on EBF. Surender Reddy et al. also observed that EBF was many times more among women with lower education compared to mothers having higher education status.[10,11] Most of the studies observed that the higher the education, the less the compliance to EBF but in the present study, mothers having an education level of matriculation and above had better compliance to EBF. Since low compliance to EBF was observed among higher educated class compared to illiterates, there is a need to appraise educated mothers on the benefits of EBF and also disadvantages of early weaning.

The majority of the mothers who belonged to the Hindu religion have a significant association with EBF which decreased with other religions. A study by Kyei Arthur et al.[18] stated that demographic characteristics like education and religion were associated with EBF. The number of antenatal visits during pregnancy had contributed towards increased EBF among mothers but was not found to be statistically significant. The counselling, doctors’ advice and door-to-door visit of health care providers had contributed towards increased EBF.

In the present study, EBF increased with parity but was not statistically significant. In a similar observation also made by Hackman et al.,[19] multipara mothers had a longer intended EBF. Multipara mothers were observed to have better knowledge and experience of EBF and its advantages. Surender Reddy et al.[11] also observed a significant positive association between parity and EBF. Madhavi N et al. and Manjula L et al. in their study, observed a significant association between parity and EBF.[15,20] Increase in parity mothers will have better knowledge and awareness towards EBF well supported by elders in the family could be attributed to better EBF among multi-para mothers.

EBF was almost similar among mothers delivered in government hospitals, private hospitals and other places which include home deliveries. Place of delivery does not seem to have any influence on EBF. Maharlouei N et al.[21] in a prospective study concluded that birthplace, mother’s occupation and caesarean type of delivery significantly reduced the duration of EBF. In a cross-sectional study, Teka et al.[22] also found that place of delivery was not significantly associated with EBF. The advice, counselling and repeated contact with health care providers happen better in government health facilities compared to private health facilities.

Occupation of both mothers and fathers has a significant role in the provision of EBF. The present study revealed that housemakers have exclusively breastfed their babies more compared to employed mothers and unskilled employed father’s babies have better compliance with EBF but this was not statistically significant. In a study by Getahun et al.,[23] mothers with occupations as daily workers were found to be statistically positively associated with EBF. In the present study, working mothers have a problem in providing EBF, may be the place of work and time matter compared to unemployed mothers and housemakers. The provision should be made to the working class having infants in the form of the place and time to feed their infants which also supports in enhancing EBF.

In the present study, EBF was better among mothers who had at least four ANC visits. Sarita Dhakal et al.[1] observed that EBF was almost five times more among mothers receiving ANC. The counselling given to mothers during ANC visits could be the reason for better compliance. Biks et al.[24] also observed a positive association between ANC and EBF. More antenatal visits boost the extent of EBF in the form of better information, advice, counselling and facility availability with ANC service.

Conclusion and Recommendations

Health policy makers should encourage and promote EBF among employed mothers and educated mothers. Health care providers should facilitate health education for mothers at the household level on EBF for six months during the antenatal period and during delivery and should continue even during the postnatal period. This will help in reducing the burden of infant infections, malnutrition, morbidity and mortality among infants and promote better health and creates a platform for a healthy, strong, younger population, which in turn reduces the economic burden.

Limitations

The present study had a few limitations. We had to trust the mothers’ recalling ability regarding EBF information as we had no other way to cross-check.

But in this study, uniquely, we used ambispective design to address the duration of EBF partly by prospective nature.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.