Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

Breanna Louise Hollow; Max K Bulsara; Prakash Dev Pant; Hilary Jane Wallace

doi:10.1371/journal.pgph.0001824

. 2023 Apr 17;3(4):e0001824. doi: 10.1371/journal.pgph.0001824

Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

Breanna Louise Hollow ¹, Max K Bulsara ², Prakash Dev Pant ³, Hilary Jane Wallace ^1,^4,^*

Editor: Shela Hirani⁵

PMCID: PMC10109470 PMID: 37068091

Abstract

Infant and Young Child Feeding (IYCF) breastfeeding guidelines of the World Health Organization (WHO) have been promoted in Nepal since the early 1990s. This study investigated whether antenatal and perinatal service delivery in Nepal are associated with early initiation of breastfeeding and age-appropriate feeding practice (exclusive breastfeeding to six months; introduction of complementary foods at six months with continued breastfeeding to two years). Data from the 2016 Nepal Demographic and Health Survey (NDHS) were analysed using multivariable logistic regression. The unit of analysis was an interviewed woman and her last-born child aged 0–23 months. We examined number of antenatal visits, place and type of delivery, infant-mother skin-to-skin contact post-delivery, and breastfeeding observation and counselling by a healthcare provider within two days post-delivery. Of 1938 mother-infant dyads, 1073 (55.4%) commenced breastfeeding within one hour of delivery and 1665 (85.9%) were engaged in age-appropriate feeding. Breastfeeding within one hour of delivery was associated with infants delivered vaginally (aOR: 4.76, 95% CI: 2.96–7.65), infant-mother skin-to-skin contact post-delivery (aOR:2.10, 95% CI: 1.63–2.72) and observation of breastfeeding by a healthcare provider within two days post-delivery (aOR: 1.58, 95% CI: 1.20–2.08). Age-appropriate feeding was lowest amongst mothers with infants aged 4–5 months (40.8%) compared to those with infants aged 0–1 month (aOR: 0.158, 95% CI: 0.083–0.302). Antenatal and perinatal service delivery were not significantly associated with age-appropriate feeding. Further promotion of infant-mother skin-to-skin contact post-delivery (including after caesarean delivery) and observation of early breastfeeding may increase the rate of breastfeeding within one hour of delivery. Promotion of exclusive breastfeeding in antenatal and perinatal services and additional postnatal support should be considered to increase exclusive breastfeeding of infants to six months. These improvements may be achieved through enhanced implementation of the Baby Friendly Hospitals Initiative and effective training and sufficient practice for skilled birth attendants.

Introduction

In 2003 the World Health Organisation (WHO), in collaboration with UNICEF, developed the Infant and Young Child Feeding (IYCF) guidelines [1] based on research underscoring the foundational role of breastfeeding in improving child development, mortality and morbidity [2]. These guidelines recommend that all mothers should be supported to:

Initiate breastfeeding as soon as possible after birth, ideally, within the first hour after delivery;
Exclusively breastfeed their infants for the first six months of life, and;
Introduce nutritionally adequate complementary (solid) foods at six months, together with continued breastfeeding up to two years of age or beyond.

Systematic reviews have consistently shown that breastfeeding within one hour of delivery is linked with lower all-cause and infection-related neonatal mortality [3, 4]. In a multinational meta-analysis of 136,047 breastfed newborns [5], newborns breastfed within the first hour post-delivery had a 33% lower risk of dying than those breastfed between two and 23 hours after birth. Exclusive breastfeeding up to six months is associated with a lower incidence of infantile gastrointestinal infection [6], the second leading cause of post-neonatal deaths in children under five [7]. Similarly, exclusive breastfeeding to six months with breast and complementary feeding to 24 months, has been linked to lower rates of malnutrition and childhood stunting [8].

Nepal adopted several public health policies over the past three decades in an attempt at increasing breastfeeding practice according to IYCF recommendations. In 1992, the Mother’s Milk Substitutes Act, which established a Breastfeeding Protection and Promotion Committee (BPPC), saw health service collusion with milk-substitute manufacturers criminalised, and formalised the place of breastfeeding promotion strategies within hospitals [9]. Two years later the UNICEF Baby Friendly Hospitals Initiative (BFHI) [10] was implemented and increased breastfeeding coverage across South Asia [11], a previously low-uptake region [12]. The program’s success is primarily attributed to its birth attendant training course, coupled with the facilitation of infant-mother skin-to-skin contact post-delivery [11, 13]. A core skill in the National Policy on Skilled Birth Attendants (Nepal) [14] is that a skilled birth attendant will “assist women and their newborns in initiating and establishing early and exclusive breastfeeding, including educating women and their families and other helpers in maintaining successful breastfeeding”. In 2006 the rate of breastfeeding within one hour of delivery was 35% and the percentage of infants who were breastfed exclusively up to six months, 53% [15]. Some improvement was observed in 2011, where the figures neared 45% and 70% respectively [16].

Previous studies have explored demographic factors contributing to breastfeeding practice in Nepal, but few have examined the association with exposure to antenatal and perinatal service delivery [12, 17–19]. Demographic and Health Survey (DHS) data is a powerful population-based resource to examine health service delivery and the association with maternal and child health outcomes. This study aimed to evaluate whether specific elements of antenatal and perinatal service delivery (number of antenatal visits, type and place of delivery, infant-mother skin-to-skin contact post-delivery, and breastfeeding counselling and observation within the first two days post-delivery) are positively associated with the breastfeeding within one hour of delivery and current coverage with age-appropriate feeding practice in Nepali infants up to 24 months of age.

Methods

Data sources

Data were obtained from the 2016 Nepal Demographic and Health Survey (NDHS), a nationally representative cross-sectional household survey, funded by the US Agency for International Development (USAID) [20]. The 2016 NDHS sampling frame was a modified version of the Nepal Central Bureau of Statistic’s 2011 National Population and Housing Census [20]. Data were stratified and selected in two stages in rural areas and three stages in urban areas. In urban areas, wards were the primary sampling units (PSU), from which one enumeration area (EA) was derived. Households were subsequently selected from EAs. In rural areas, wards were the PSU from which households were selected directly. Only households containing a woman aged 15–49 the night before survey administration were eligible for interview. Of the 13089 women eligible, 12862 completed the survey, representing a response rate of 98% [20]. For results to be nationally, regionally, and provincially representative, weighting factors have been calculated and added to the DHS datafiles. Full details of the NDHS sampling design are discussed elsewhere [20].

The present study used the Children’s Recode DHS file (KR file) with the addition of 11 food security variables from the Individual Women’s Data file (IR file). The KR file includes one record for every child (alive or dead) of an interviewed woman born in the five years preceding the survey [20]. In this study, only last-born children up to 23 completed months, who were still alive and living with their mother, were included for analysis (n = 1930).

Outcome variables

The outcome, early initiation of breastfeeding, defined by WHO as “breastfeeding within the first hour of life” [21], was derived from the DHS question; “How long after birth did you first put (name of child) to the breast?” [20]. Infants put to the breast within one hour of birth were deemed to comply with early initiation of breastfeeding.

The outcome, adherence to IYCF-recommended feeding practice, was defined according to the child’s age. For children 0–5 completed months of age (i.e., under six months), feeding practice was appropriate if the child was exclusively breastfed at the time of survey administration. A child was determined to be “exclusively breastfed” if they had received breastmilk in the 24 hours preceding the interview but nothing else. Feeding with non-breastmilk liquids (including water) in this period, precluded children from this group [22]. For children aged 6–23 completed months (i.e., 6 months to under 24 months), feeding practice was deemed appropriate if the child had received breastmilk and “complementary foods” in the 24 hours prior to survey administration. According to WHO guidelines, complementary foods include both solid and semi-solid foodstuffs [1].

Explanatory variables

Explanatory variables for breastfeeding outcomes were adapted from the conceptual framework of Bhandari et al. [18] (see Fig 1).

Variables related to antenatal and perinatal service delivery were informed by the WHO breastfeeding practice guidelines [21] and the WHO recommendations on antenatal care for a positive pregnancy experience [23]: number of antenatal visits (0 visits; 1–3 visits; 4 visits; 5–7 visits; 8+ visits), place of delivery (health facility; not in a health facility), type of delivery (vaginal; caesarean), infant-mother skin-to-skin contact post-delivery (child put directly on the bare skin of the mother’s chest immediately after the birth) (yes; no), breastfeeding counselling (yes; no) by any healthcare provider within the first two days post-delivery, and breastfeeding observation (yes; no) by any healthcare provider within the first two days post-delivery.

The selection of potential confounding variables was informed by literature review and identification of factors shown to be associated with breastfeeding practice in Nepal previously [12, 17–19]. Child-level factors included sex (m; f), age, size at birth (very small/small; average; large) and birth interval (first birth episode; 18 months or less; 19–36 months; 37 months+). Maternal and perinatal level factors included mother’s age (15–19; 20–29; 30–39; 40–49), mother’s occupation (did not work/household duties; agricultural work [paid and unpaid]; non-agricultural work [paid]), mother’s highest education level (no education; primary; secondary; higher education), and place of delivery (home; health facility). Household level factors included the wealth quintile (poorest; poorer; middle; richer; richest), husband’s highest education level (no education; primary; secondary; higher education), ethnicity (Brahman/Chhetri; other Terai castes; Dalits; Newar; Janajati; Muslim and other) and food security (secure; not secure). The food security variable was coded in accordance with Pandey & Fusaro [24]. Food was “secure” if the summed Household Food Insecurity Access Scale (HFIAS) score was 0; food was “insecure” for any score between 1 and 27 [24]. Community level factors included ecological zone (mountains; hills; Terai), province (1–7) and place of residence (rural; urban).

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Data were weighted using sampling weights in accordance with DHS guidelines [25]. All analyses used the Complex Sample Analysis module to account for the multi-stage sample design [25].

All variables were treated as categorical variables. Descriptive summaries were displayed using frequencies and percentages. Cross-tabulations and Chi-square tests were performed for the two binary outcome variables, breastfeeding within one hour of delivery and age-appropriate feeding practice, by each explanatory variable. Explanatory variables with a p-value of < 0.1 were included in univariable and multivariable logistic regression analyses. The child’s sex was included a priori in the regression analyses [18]. Unadjusted and adjusted odds ratios (OR) were computed with 95% confidence intervals. In multivariable model testing, potential collinearity of explanatory variables was explored using Chi-square tests when the coefficient estimates were very unstable. Where two variables were highly associated with each other, one of the variables was removed from the multivariable logistic regression model.

Since the recommendations for infant and young child feeding change at 6 months of age, we subsequently applied the same analytical approach to two subgroups based on age: 0–5 completed months (exclusive breastfeeding) and 6–23 completed months (continued breastfeeding with complementary foods).

Ethical approval

The 2016 NDHS survey protocol was approved by the Nepal Health Research Council (NHRC) and the ICF Institutional Review Board (ICF-IRB). The present study received ethics approval from the University of Notre Dame Australia, Fremantle, Human Research Ethics Committee (Ref. 2020-065F). Permission for the use of the 2016 NDHS dataset was granted by the DHS Program. Prior to the DHS interview, participants provided informed consent [22].

Results

Table 1 presents the socio-demographic characteristics of the sample population. Of the 1938 children included in this study, 1043 (53.8%) were male and 895 (46.2%) were female. Two-thirds of mothers were 20–29 years of age (n = 1311; 67.7%), with 284 (14.7%) aged 15–19 years. About half of mothers either did not work or performed household duties (n = 913; 47.1%), while 41.4% were engaged in agricultural work (n = 803) and 11.4% in non-agricultural paid work (n = 221). The sample contained a mixture of urban (53.8%) and rural (46.2%) residents.

Table 1. Characteristics of the sample population and distribution of factors influencing breastfeeding within the first hour of birth and age-appropriate infant and young child feeding (IYCF) practice.

		N (%)	Breastfeeding within first hour N (%)^b	P-value^c	Age-appropriate feeding practice N (%)^b	P-value^c
Total		1938 (100)	1073 (55.4)		1665 (85.9)
*Child factors*
Sex ^d				0.146		0.978
	Male	1043 (53.8)	560 (53.7)		895 (85.9)
	Female	895 (46.2)	513 (57.3)		769 (85.9)
Current Age (months)						<0.0005
	0-1month	159 (8.2)	N/A		127 (79.4)
	2-3months	160 (8.2)			115 (72.3)
	4-5months	124 (6.4)			51 (40.8)
	6-8months	235 (12.1)			196 (83.4)
	9-11months	264 (13.6)			250 (95.1)
	12-17months	504 (26.0)			482 (95.6)
	18-23months	492 (25.4)			444 (90.2)
Size at birth ^d				0.199		0.627
	Very small/small	331 (17.1)	172 (52.0)		290 (87.6)
	Average	1318 (68.0)	727 (55.2)		1124 (85.3)
	Large	288 (14.9)	173 (60.1)		250 (86.8)
Birth interval				0.828		0.158
	First birth episode	792 (40.9)	437 (55.2)		684 (86.4)
	18 months or less	100 (5.2)	60 (60.0)		79 (79.0)
	19-36months	428 (22.1)	233 (54.3)		360 (84.1)
	37months+	617 (32.0)	343 (55.6)		542 (87.7)
*Maternal factors*
Current age (years) ^d				0.575		0.016
	15–19	284 (14.7)	157 (55.3)		229 (80.6)
	20–29	1311 (67.7)	728 (55.5)		1136 (87.0)
	30–39	314 (16.2)	176 (56.1)		271 (86.3)
	40–49	29 (1.5)	12 (41.4)		28 (100)^b
Occupation				0.011		0.001
	Did not work/household duties	913 (47.1)	465 (50.9)		749 (82.0)
	Agricultural work (paid and unpaid)	803 (41.4)	481 (59.9)		719 (89.4)
	Non-agricultural work (paid)	221 (11.4)	126 (57.0)		197 (89.1)
Highest education level ^d				0.074		0.901
	No education	555 (28.6)	275 (49.5)		473 (85.2)
	Primary	380 (19.7)	220 (57.7)		324 (85.3)
	Secondary	707 (36.5)	415 (58.7))		612 (86.6)
	Higher education (tertiary +)	295 (15.2)	163 (55.3)		255 (86.4)
*Antenatal and perinatal service delivery*
Number of antenatal visits				0.189		0.159
	0 visits	69 (3.6)	36 (52.2)		64 (92.8)
	1–3 visits	483 (24.9)	248 (51.3)		406 (84.1)
	4 visits	580 (30.0)	343 (59.0)		513 (88.4)
	5–7 visits	634 (32.7)	361 (56.9)		540 (85.2)
	8+ visits	172 (8.9)	85 (49.7)		141 (82.0)
Type of delivery				<0.001		0.854
	Vaginal	1742(89.9)	1029 (59.0)		1496 (85.9)
	Caesarean	195 (10.1)	44 (22.6)		169 (86.2)
Place of delivery				<0.001		0.084
	Home	666 (34.4)	316 (47.5)		567 (85.1)
	Health facility	1178 (60.8)	709 (60.2)		1025 (87.0)
	Other	94 (4.8)	47 (50.5)		73 (77.7)
Child put on mother’s bare skin after birth ^e				<0.001		0.521
	No	695 (35.9)	281(40.4)		592 (85.2)
	Yes	1222 (63.0)	789 (64.6)		1054 (86.3)
	Don’t know^g	21 (1.1)	22 (N/A)
Breastfeeding counselling from any healthcare provider during first 2 days				0.002		0.339
	No	882 (45.5)	445 (50.4)		751 (85.1)
	Yes	1049 (54.1)	627 (59.8)		912 (86.9)
	Don’t know^g	6(0.3)
Observation of breastfeeding by any healthcare provider during first 2 days				<0.001		0.344
	No	959 (49.5)	477 (49.8)		816 (85.1)
	Yes	974 (50.3)	596 (61.3)		847 (87.0)
	Don’t know^g	5(0.2)
*Household level factors*
Wealth quintile				0.133		0.218
	Poorest	405 (20.9)	252 (62.2)		364 (89.7)
	Poorer	408 (21.0)	221 (54.2)		352 (86.3)
	Middle	444 (22.9)	230 (52.3)		379 (85.4)
	Richer	398 (20.6)	227 (57.0)		334 (83.9)
	Richest	283 (14.6)	144 (51.4)		237 (83.7)
Husband’s education level ^f				0.025		0.794
	No education	255 (13.1)	131 (51.4)		220 (86.6)
	Primary	435 (22.5)	218 (50.2)		368 (84.6)
	Secondary	863 (44.6)	516 (59.9)		748 (86.6)
	Higher education (tertiary +)	377 (19.5)	209 (55.9)		322 (85.2)
	Don’t know^g	2 (0.1)
Ethnicity				0.001		<0.001
	Brahman/Chhetri	524 (27.0)	322 (61.6)		464 (88.7)
	Other Terai Castes	387 (20.0)	178 (46.1)		316 (81.4)
	Dalits	268 (13.8)	150 (56.4)		223 (83.2)
	Newar	61 (3.1)	20 (32.8)		58 (95.1)
	Janajati	546 (28.2)	319 (59.0)		487 (89.2)
	Muslim and other	151 (7.8)	83 (54.6)		117 (77.0)
Food Security				0.911		0.493
	Secure	791 (40.8)	435 (55.4)		674 (85.2)
	Not secure	1147 (59.2)	637 (55.7)		991 (86.4)
*Community level factors*
Ecological zone ^d				0.031		0.007
	Terai	1065 (55.0)	555 (52.4)		887 (83.3)
	Mountain	127 (6.5)	78 (61.9)		112 (88.2)
	Hill	746 (38.5)	440 (59.2)		665 (89.3)
Province				<0.001		<0.001
	Province 1	335 (17.3)	173 (51.6)		285 (84.8)
	Province 2	501 (25.8)	227 (45.6)		394 (78.6)
	Province 3	305 (15.7)	175 (57.9)		266 (87.2)
	Province 4	162 (8.4)	89 (54.9)		147 (90.7)
	Province 5	354 (18.3)	213 (60.2)		318 (89.6)
	Province 6	118 (6.1)	81 (68.6)		104 (88.1)
	Province 7	162 (8.4)	115 (71.9)		151 (93.2)
Type of place of residence				0.111		0.852
	Urban	1042 (53.8)	600 (57.9)		894 (85.7)
	Rural	895 (46.2)	473 (52.9)		771 (86.0)

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Notes:

Bold text indicates P-value <0.1 and included in subsequent regression models.

N/A Not applicable.

^a Column percentage.

^b Row percentage.

^c P-value from complex sample chi-squared tests.

^d One missing value excluded from analysis.

^e Two missing values excluded from analysis.

^f Five missing value excluded from analysis.

^g ‘Don’t know’ values excluded from further analysis.

More than half of the women delivered in health facilities (n = 1178; 60.8%) and most had vaginal deliveries (n = 1742; 89.9%). Infant-mother skin-to-skin contact post-delivery was reported to have occurred in only 63.0% (n = 1222) of births. Just over half (n = 1049; 54.1%) received some counselling regarding breastfeeding from a healthcare provider during the first two days post-delivery and 50.3% (n = 974) were observed breastfeeding by a healthcare provider during the first two days post-delivery. Nearly three quarters (71.5%) of women attended at least 4 antenatal checks (n = 1386), with only 8.9% attending the WHO-recommended [23] 8 or more visits (n = 172). Overall, 55.4% of infants were breastfed within one hour of delivery, but in infants born by caesarean delivery the rate was only 22.6%. The variables significantly associated with breastfeeding within one hour of delivery in univariable analysis included: mother’s occupation (p = 0.011), place of delivery (p<0.001), type of delivery (p<0.001), infant-mother skin-to-skin contact post-delivery (p<0.001), counselling regarding breastfeeding within two days post-delivery by a healthcare provider (p = 0.002), observation of breastfeeding within two days post-delivery by a healthcare provider (p<0.001), ethnicity (p = 0.001), ecological zone (p = 0.031) and province (p<0.001). Since counselling regarding breastfeeding within two days of delivery and observation of breastfeeding within two days of delivery were highly associated with each other (p<0.0005), only one of these variables, observation of breastfeeding within two days of delivery, was included in the multivariable model.

After adjustment, infants put on their mother’s bare skin immediately after birth had 2.10 times the odds of being breastfed within one hour of delivery compared with those who were not (95% CI: 1.63,2.72) (Table 2). The observation of breastfeeding by a healthcare provider within two days of delivery was also associated with increased odds of having been breastfed within the first hour (aOR = 1.58, 95% CI:1.20,2.08). Those infants delivered vaginally had markedly greater odds of being breastfed within the first hour, compared with those delivered via caesarean section (aOR: 4.76, 95% CI: 2.96,7.65).

Table 2. Unadjusted and adjusted odds ratios for factors influencing breastfeeding within one hour post-delivery and age-appropriate infant and young child feeding (IYCF) practice (n = 1938).

	Breastfeeding within first hour Unadjusted OR (95% CI)	Breastfeeding within first hour Adjusted OR (95% CI)	Age-appropriate feeding practice Unadjusted OR (95% CI)	Age-appropriate feeding practice Adjusted OR (95% CI)
*Sex of child*
Male	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
Female	1.160 (0.95–1.42)	1.24 (1.00–1.54)	1.00 (0.74–1.37)	0.99 (0.679–1.435)
*Age of child (months)*
0–1 month	N/A		1.00 Ref	1.00 Ref
2–3 months			0.67 (0.36–1.26)	0.68 (0.35–1.32)
4–5 months			0.18 (0.01–0.33) ^***	0.16 (0.08–0.30) ^***
6–8 months			1.27 (0.72–2.26)	1.31 (0.72–2.39)
9–11 months			4.83 (2.12–10.97) ^***	5.09 (2.25–11. 50) ^***
12–17 months			5.57 (2.74–11.32) ^***	5.60 (2.73–11.47) ^***
18–23 months			2.39 (1.31–4.39) ^**	2.46 (1.31–4.64) ^**
*Age of mother (years)* ^a
15–19	0.99 (0.74–1.31)		0.65 (0.45–0.92) ^*	0.85(0.52–1.40)
20–29	1.00 Ref		1.00 Ref	1.00 Ref
30–39	1.02 (0.75–1.40)		0.96 (0.64–1.46)	0.90 (0.56–1.43)
40–49	0.57 (0.26–1.26)		10.60 (1.41–79.56) ^*	7.35 (1.14–47.29) ^*
*Mother’s highest education level*
No education	1.00 Ref	1.00 Ref	1.00 Ref
Primary	1.39 (0.99–1.96)	1.25 (0.86–1.82)	1.00 (0.65–1.56)
Secondary	1.45 (1.05–1.99) ^*	1.10 (0.80–1.52)	1.13 (0.78–1.61)
Higher education	1.25 (0.82–1.90)	1.00 (0.62–1.60)	1.11 (0.66–1.88)
*Mother’s occupation*
Did not work/ household duties	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
Agricultural work (paid and unpaid)	1.44 (1.15–1.80) ^**	1.21 (0.94–1.57)	1.86 (1.35–2.56) ^***	1.27 (0.83–1.95)
Non-agricultural work(paid)	1.29 (0.87–1.90)	1.26 (0.83–1.91)	1.80 (1.02–3.18) ^*	1.15 (0.62–2.13)
*Husband’s highest education level*
No education	1.00 Ref	1.00 Ref	1.00 Ref
Primary	0.95 (0.68–1.32)	0.79 (0.55–1.13)	0.85 (0.53–1.38)
Secondary	1.41 (0.99–2.00)	1.16 (0.82–1.64)	1.01 (0.65–1.58)
Higher education	1.17 (0.76–1.81)	0.93 (0.60–1.46)	0.91 (0.55–1.49)
*Type of delivery*
Caesarean	1.00 Ref	1.00 Ref	1.00 Ref
Vaginal	4.95 (3.31–7.43) ^***	4.76 (2.96–7.65) ^***	0.96 (0.59–1.55)
*Place of delivery*
Home	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
Health facility	1.67 (1.29–2.15) ^***	1.29 (0.94–1.78)	1.17 (0.85–1.62)	1.10 (0.75–1.62)
Other	1.13 (0.67–1.90)	0.95 (0.55–1.63)	0.60 (0.31–1.15)	0.66 (0.29–1.53)
*Child put on mother’s bare skin immediately after birth* ^b
No	1.00 Ref	1.00 Ref	1.00 Ref
Yes	2.69 (2.16–3.33) ^***	2.10 (1.63–2.72) ^***	1.10 (0.83–1.46)
*Breastfeeding counselling from any healthcare provider during first 2 days*
No	1.00 Ref		1.00 Ref
Yes	1.46 (1.17–1.83) ^***		1.16 (0.86–1.57)
*Observation of breastfeeding by any healthcare provider during first 2 days*
No	1.00 Ref	1.00 Ref	1.00 Ref
Yes	1.60 (1.28–2.00) ^***	1.58 (1.20–2.08) ^**	1.16 (0.85–1.58)
*Ethnicity*
Brahman/Chhetri	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
Other Terai Castes	0.53 (0.37–0.78) ^**	1.18 (0.70–1.97)	0.56 (0.37–0.87) ^**	0.75 (0.44–1.29)
Dalits	0.80 (0.55–1.16)	1.16 (0.76–1.76)	0.63 (0.38–1.04)	0.60 (0.35–1.02)
Newar	0.31 (0.13–0.75) ^*	0.46 (0.19–1.10)	2.49 (0.58–10.73)	2.39 (0.61–9.42)
Janajati	0.88 (0.65–1.20)	1.21 (0.87–1.67)	1.06 (0.67–1.66)	1.07 (0.66–1.74)
Muslim and other	0.76 (0.50–1.14)	1.55 (0.89–2.68)	0.44 (0.27–0.71) ^***	0.54 (0.29–1.02)
*Ecological zone* ^a
Terai	0.76 (0.58–0.98) ^*	0.98 (0.68–1.42)	0.60 (0.43–0.85) ^**	0.86 (0.56–1.30)
Mountain	1.12 (0.75–1.67)	1.28 (0.76–2.14)	0.92 (0.47–1.80)	0.82 (0.42–1.60)
Hill	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
*Province*
Province 1	0.79 (0.50–1.24)	0.70 (0.42–1.14)	0.83 (0.45–1.52)	0.96 (0.53–1.76)
Province 2	0.62 (0.41–0.93) ^*	0.51 (0.29–0.87) ^*	0.54 (0.31–0.96) ^*	0.98 (0.50–1.91)
Province 3	1.00 Ref	1.00 Ref	1.00 Ref	1.00 Ref
Province 4	0.90 (0.59–1.38)	0.79 (0.51–1.22)	1.44 (0.71–2.93)	1.65 (0.84–3.25)
Province 5	1.12 (0.74–1.68)	0.85 (0.54–1.32)	1.27 (0.69–2.35)	1.93 (1.02–3.67) ^*
Province 6	1.61 (1.01–2.56) ^*	1.40 (0.88–2.24)	1.14 (0.58–2.22)	1.69 (0.81–3.51)
Province 7	1.85 (1.23–2.77) ^**	1.31 (0.83–2.07)	2.04 (1.07–3.89) ^*	3.11 (1.54–6.30) ^**
Factors included in model		Sex of child, mother’s highest education level, mother’s occupation, husband’s highest education level, type of delivery, place of delivery, child put on mother’s bare skin immediately after birth, observation of breastfeeding by healthcare provider during first 2 days, ethnicity, ecological zone, province		Sex of child, age of child (months), age of mother (years), mother’s occupation, place of delivery, ethnicity, ecological zone, province

Open in a new tab

Notes:

Bold text indicates statistically significant result.

*p<0.05

** p<0.01

*** p<0.001.

N/A Not applicable.

^a 1 missing value that was excluded from analysis.

^b 2 missing values that were excluded from analysis.

Overall, there was a high level of adherence to age-appropriate feeding practice according to the IYCF guidelines (85.9%) (Table 1). However, there were differences according to the age of the child. Exclusive breastfeeding of infants aged 0–1 month was 79.4% but was only 40.8% in infants aged 4–5 months. The rate of continued breastfeeding with complementary feeding ranged from 83.4% (6–8 months) to 95.6% (12–17 months).

The variables identified by Chi-square tests to be significantly associated with age-appropriate feeding practice included: the age of the child (p<0.0005), the mother’s age (p = 0.016), the mother’s occupation (p = 0.001), ethnicity (p<0.001), ecological zone (p = 0.007) and province (p<0.001).

After adjustment, the current age of the child significantly influenced the odds of age-appropriate feeding practice (Table 2). Mothers with infants aged 4–5 months had significantly lower odds of exclusive breastfeeding than those with infants aged 0–1 month (aOR = 0.16, 95% CI: 0.08,0.30). No variables related to antenatal or perinatal service delivery (number of antenatal visits, delivery in a health facility, vaginal delivery, infant-mother skin-to-skin contact post-delivery, the observation of breastfeeding within the first two days after delivery) were significantly associated with age-appropriate feeding practice.

The results of the analyses performed on the two age subgroups, 0–5 months (exclusive breastfeeding) and 6–23 months (continued breastfeeding with complementary foods), are presented in S1 Table (Chi-square analyses) and S2 Table (multivariable logistic regression analyses). The results of the main analysis (aggregated age-group) are included for comparison. In summary, the results for exclusive breastfeeding (0–5 months) after adjustment were almost identical to the main analysis, with mothers with infants aged 4–5 months having significantly lower odds of exclusive breastfeeding than those with infants aged 0–1 month (aOR = 0.16, 95% CI: 0.09,0.30). No variables related to antenatal or perinatal service delivery were significantly associated with exclusive breastfeeding after adjustment. In the 6–23 month age-group the variables associated with continued breastfeeding with complementary foods were also very similar to those of the main analysis after adjustment, noting minor differences in demographic associations. Children aged 6–8 months and 18–23 months had significantly lower odds of receiving both breastmilk and complementary foods (aOR = 0.20, 95% CI: 0.09,0.45 and aOR = 0.41, 95% CI: 0.20,0.85 respectively) compared to those aged 12–17 months (95.6% receiving both breastmilk and complementary foods). No variables related to antenatal or perinatal service delivery were significantly associated with continued breastfeeding with complementary foods after adjustment.

Discussion

The aim of this study was to determine whether antenatal and perinatal service delivery are associated with early breastfeeding initiation and age-appropriate feeding practice amongst Nepali mother-infant dyads. Our analysis showed that several perinatal services were significantly associated with early breastfeeding initiation after adjustment for confounders: vaginal delivery, infant-mother skin-to-skin contact post-delivery, and the observation of breastfeeding within the first two days after delivery. By contrast, while some demographic factors (child’s age, mother’s age and province) were significantly associated with age-appropriate feeding practice, none of the antenatal or perinatal service delivery factors examined (number of antenatal visits, delivery in a health facility, vaginal delivery, infant-mother skin-to-skin contact post-delivery, the observation of breastfeeding within the first two days after delivery) were significantly associated after adjustment for confounders.

Breastfeeding within the first hour after delivery

Although vaginal delivery has been associated with early initiation of breastfeeding in Nepal previously [17, 26], the association of infant-mother skin-to-skin contact post-delivery with breastfeeding within one hour of delivery has not previously been demonstrated in this population. The low rate of infant-mother skin-to-skin contact post-delivery after caesarean delivery observed in our study (37.4% compared to 63.0% overall) may help explain the lower rate of breastfeeding within the first hour after caesarean section compared to vaginal delivery. Although the temporality of the relationship between observation of breastfeeding by a healthcare provider in the first two days after delivery and breastfeeding within the first hour cannot be discerned here, it is plausible that breastfeeding within one hour of delivery may be facilitated when health professionals are available for observation and troubleshooting post-delivery.

Unlike previous research that demonstrated improved odds of early initiation of breastfeeding with health facility delivery [17], higher maternal education [12, 19] and large infant size at birth [12], these were not significant explanatory variables in the present study after adjustment. The observation of breastfeeding by a healthcare provider within the first two days post-delivery and infant-mother skin-to-skin contact post-delivery were more common for births within a health facility than not in a health facility (71.5% vs. 17.4% and 76.6% vs. 43.9% respectively); this confounding may explain why health facility delivery was not significant in this analysis.

The low rate (55.6%) of Nepali newborns breastfed in the first hour of life could be related to gaps in the provision of infant-mother skin-to-skin contact post-delivery and breastfeeding observation by healthcare professionals [10, 27]. The relationship between infant-mother skin-to-skin contact post-delivery and breastfeeding within one hour of delivery has been observed in other South Asian countries [28, 29] and supports the WHO recommendation for infant-mother skin-to-skin contact post-delivery for the initiation and establishment of breastfeeding [21]. Further prospective studies and service improvement activities focussing on the implementation of breastfeeding policies in Nepal are needed to improve the rate of newborns breastfed in the first hour of life, including the WHO / UNICEF Baby Friendly Hospital Initiative [10] and the training of skilled birth attendants. A recent study has shown skilled birth attendants in Nepal are not receiving either effective training or sufficient practice to stay clinically competent and knowledgeable [27].

Age-appropriate feeding practice

The lower odds of exclusive breastfeeding of infants aged 4–5 months compared to those aged 0-1 month may reflect the challenges of exclusive breastfeeding as infants approach 6 months of age. Less than half of infants (40.8%) were exclusively breastfed at 4–5 months; other studies in Nepal have also demonstrated decreased exclusive breastfeeding approaching 6 months post-birth [19, 30]. Multiple psychological, social, physiological and financial barriers to exclusive breastfeeding may exist. Lack of time for breastfeeding due to work and mothers’ perception of inadequate milk supply have been identified as the main reasons for starting complementary food early in Nepal [30, 31]. Physiologically, 24-hour milk intake does not increase in many infants between 3 and 6 months and may lead to a misconception of inadequate milk supply [32]. The lack of association between antenatal or perinatal service delivery and exclusive breastfeeding to 6 months of age in our study suggests a need to include information about exclusive breastfeeding in these services and to provide additional postnatal support. Another study found very few mothers received any information on breastfeeding during antenatal visits in Nepal [30].

From 6–23 months of age the continuation of breastfeeding plus “complementary foods” ranged from 83–96%, indicating that from 6 months of age onwards age-appropriate feeding is mostly being achieved but with room for improvement in the timely introduction of complementary foods at age 6 months, and continued breastfeeding until two years of age.

Strengths and limitations

The NDHS is a large-scale population-based survey that attempts to be nationally representative by means of multi-stage sampling. However, some limitations warrant consideration. Due to the cross-sectional design, this study cannot determine whether relationships between explanatory and outcome variables are causal. Other limitations relate to the presence of measurement bias. The variables “observation of breastfeeding by any healthcare provider within the first two days post-delivery” and “breastfeeding counselling by any healthcare provider within the first two days post-delivery” were measured in a dichotomous “yes/no” format and the exact timings of observation or counselling were not recorded. However, in our analysis we assumed that breastfeeding observation and counselling preceded the event, “breastfeeding within the first hour”. Also, the size of the infant at birth was self-reported by the mother as small / very small, average, or large, which is inaccurate and subjective. Although this study attempted to minimise potential recall bias by including only last-born children born in the 24 months preceding the survey, recall bias may still exist. Unmeasured confounders may also have influenced the associations observed. This study was focussed on breastfeeding outcomes and did not evaluate the nutritional quality or quantity of complementary foods. Future longitudinal observational studies may offer opportunities to demonstrate cause-effect relationships between antenatal and perinatal healthcare delivery and breastfeeding outcomes.

Conclusions for practice

This study highlights a positive association between perinatal service delivery and initiation of breastfeeding within the first hour after delivery. Further promotion of infant-mother skin-to-skin contact post-delivery (including after caesarean delivery) and early breastfeeding observation and counselling, may increase the rates of breastfeeding within one hour of delivery from just over 50% and, downstream, improve infant health. We also identified a large gap in exclusive breastfeeding of infants aged 4–5 months of age which was not associated with the number of antenatal visits or perinatal service delivery. The promotion of exclusive breastfeeding in these services, and additional postnatal support for breastfeeding mothers with infants approaching 4–5 months of age, should be considered to address the low rate (40.8%) of exclusive breastfeeding observed in this group.

These service improvements could be achieved by strengthening the implementation, monitoring and supervision of the 10 steps of the WHO / UNICEF Baby Friendly Hospitals Initiative (BFHI) [10]. Similarly, the strengthening of training and sufficient practice for skilled birth attendants [27] in breastfeeding support will be important to improve breastfeeding outcomes.

Supporting information

S1 Table. Distribution of age-appropriate infant and young child (IYCF) feeding practice according to infant age group.

(DOCX)

Click here for additional data file.^{(49.7KB, docx)}

S2 Table. Adjusted odds ratios for age-appropriate infant and young child feeding (IYCF) feeding practice according to infant age group.

(DOCX)

Click here for additional data file.^{(25.6KB, docx)}

Acknowledgments

We thank the Australian Government for providing BH with a short-term mobility scholarship from the Endeavour Leadership Program to undertake research training in Nepal. We are also grateful to the DHS program, funded by USAID, for conducting the survey in Nepal and making their data available to us for research purposes.

Data Availability

Nepal Demographic and Health Survey 2016 [Dataset]. NPKR7HFL.SAV (kids recode); NPIR7HFL.SAV (individual recode). Rockville, Maryland: Ministry of Health, New ERA, and ICF [Producers]. ICF [Distributor], 2017. Available from https://dhsprogram.com/data/dataset/Nepal_Standard-DHS_2016.cfm?flag=0.

Funding Statement

The authors received no specific funding for this work.

References

1.World Health Organization (WHO), United Nations Children’s Fund (‎‎UNICEF). Global Strategy for Infant and Young Child Feeding. 2003. Available from: https://www.who.int/publications/i/item/9241562218 [Google Scholar]
2.United Nations Children’s Fund (UNICEF). Infant and Young Child Feeding Program Guide. 2011. Available from: https://www.ennonline.net/attachments/1470/unicef-iycf-programming-guide-may-26-2011.pdf [Google Scholar]
3.Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13 Suppl 3:S19. doi: 10.1186/1471-2458-13-S3-S19 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Khan J, Vesel L, Bahl R, Martines JC. Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity-a systematic review and meta-analysis. Matern Child Health J. 2015;19(3):468–79. doi: 10.1007/s10995-014-1526-8 [DOI] [PubMed] [Google Scholar]
5.Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM, et al. Delayed breastfeeding initiation and infant survival: A systematic review and meta-analysis. PLoS One. 2017;12(7):e0180722. doi: 10.1371/journal.pone.0180722 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012(8):CD003517. doi: 10.1002/14651858.CD003517.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
7.World Health Organization (WHO). Fact sheet: Child mortality (under 5 years). 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-under-5-mortality-in-2020 [Google Scholar]
8.Tiwari R, Ausman LM, Agho KE. Determinants of stunting and severe stunting among under-fives: evidence from the 2011 Nepal Demographic and Health Survey. BMC Pediatr. 2014;14:239. doi: 10.1186/1471-2431-14-239 [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Government of Nepal. Policy—Mother’s Milk Substitutes (Control of Sale and Distribution) Act, 2049. 1992. Available from: https://extranet.who.int/nutrition/gina/en/node/8783 [Google Scholar]
10.World Health Organization (WHO), United Nations Children’s Fund (‎‎UNICEF). Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services–the revised Baby-friendly Hospital Initiative. 2018. Available from: https://www.unicef.org/media/95191/file/Baby-friendly-hospital-initiative-implementation-guidance-2018.pdf [Google Scholar]
11.Subedi N. Baby-Friendly Hospital Initiative: Situation in Nepal. Health Prospect. 2012;11:53–4. [Google Scholar]
12.Adhikari M, Khanal V, Karkee R, Gavidia T. Factors associated with early initiation of breastfeeding among Nepalese mothers: further analysis of Nepal Demographic and Health Survey, 2011. Int Breastfeed J. 2014;9(1):21. doi: 10.1186/s13006-014-0021-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
13.World Health Organization (WHO). Ten steps to successful breastfeeding. 2018. Available from: https://www.who.int/activities/promoting-baby-friendly-hospitals/ten-steps-to-successful-breastfeeding [Google Scholar]
14.Ministry of Health, Nepal [MoHP], Dept of Health Services, Family Health Division. National Policy on Skilled Birth Attendants. 2006. Available from: https://km.mohp.gov.np/sites/default/files/2018-07/SBA_Policy_2006.pdf [Google Scholar]
15.Ministry of Health, Nepal [MoHP] Nepal Demographic and Health Survey, 2006. 2007. Available from: https://dhsprogram.com/pubs/pdf/FR191/FR191.pdf [Google Scholar]
16.Ministry of Health, Nepal [MoHP] Nepal Demographic and Health Survey, 2011. 2012. Available from: https://dhsprogram.com/pubs/pdf/FR257/FR257%5B13April2012%5D.pdf [Google Scholar]
17.Ghimire U. The effect of maternal health service utilization in early initiation of breastfeeding among Nepalese mothers. Int Breastfeed J. 2019;14:33. doi: 10.1186/s13006-019-0228-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Bhandari S, Thorne-Lyman AL, Shrestha B, Neupane S, Nonyane BAS, Manohar S, et al. Determinants of infant breastfeeding practices in Nepal: a national study. Int Breastfeed J. 2019;14:14. doi: 10.1186/s13006-019-0208-y [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Acharya P, Khanal V. The effect of mother’s educational status on early initiation of breastfeeding: further analysis of three consecutive Nepal Demographic and Health Surveys. BMC Public Health. 2015;15:1069. doi: 10.1186/s12889-015-2405-y [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Ministry of Health, Nepal [MoHP]. Nepal Demographic and Health Survey, 2016. 2017. Available from: https://dhsprogram.com/pubs/pdf/FR336/FR336.pdf [Google Scholar]
21.World Health Organization (WHO). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. 2017. Available from: https://apps.who.int/iris/handle/10665/259386 [PubMed] [Google Scholar]
22.Demographic and Health Survey (DHS) Program. Analysing DHS Data. 2020. Available from: https://dhsprogram.com/data/Guide-to-DHS-Statistics/Analyzing_DHS_Data.html [Google Scholar]
23.World Health Organization (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. [PubMed] [Google Scholar]
24.Pandey S, Fusaro V. Food insecurity among women of reproductive age in Nepal: prevalence and correlates. BMC Public Health. 2020;20(1):175. doi: 10.1186/s12889-020-8298-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Croft TN, Marshall AMJ, Allen CK, et al. Guide to DHS Statistics. DHS Program. 2018. Available from: https://dhsprogram.com/data/Guide-to-DHS-Statistics/ [Google Scholar]
26.Pandey S, Tiwari K, Senarath U, Agho KE, Dibley MJ, South Asia Infant Feeding Research Network. Determinants of infant and young child feeding practices in Nepal: secondary data analysis of Demographic and Health Survey 2006. Food Nutr Bull. 2010;31(2):334–51. doi: 10.1177/156482651003100222 [DOI] [PubMed] [Google Scholar]
27.Rajbhandari R, Rai S, Hathi S, Thapa R, Rai I, Shrestha A. The quality of skilled birth attendants in Nepal: High aspirations and ground realities. PLoS One. 2019;14(4):e0214577. doi: 10.1371/journal.pone.0214577 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Karim F, Billah SM, Chowdhury MAK, Zaka N, Manu A, Arifeen SE, et al. Initiation of breastfeeding within one hour of birth and its determinants among normal vaginal deliveries at primary and secondary health facilities in Bangladesh: A case-observation study. PLoS One. 2018;13(8):e0202508. doi: 10.1371/journal.pone.0202508 [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Singh K, Khan SM, Carvajal-Aguirre L, Brodish P, Amouzou A, Moran A. The importance of skin-to-skin contact for early initiation of breastfeeding in Nigeria and Bangladesh. J Glob Health. 2017;7(2):020505. doi: 10.7189/jogh.07.020505 [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Ulak M, Chandyo RK, Mellander L, Shrestha PS, Strand TA. Infant feeding practices in Bhaktapur, Nepal: a cross-sectional, health facility based survey. Int Breastfeed J. 2012;7(1):1. doi: 10.1186/1746-4358-7-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Singh Bhandari M, Manandhar P, Tamrakar D. Practice of breastfeeding and its barriers among women working in tertiary level hospitals. Journal of the Nepal Medical Association. 2019;57:8–13. doi: 10.31729/jnma.4035 [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Kent JC, Hepworth AR, Sherriff JL, Cox DB, Mitoulas LR, Hartmann PE. Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation. Breastfeed Med. 2013;8:401–7. doi: 10.1089/bfm.2012.0141 [DOI] [PubMed] [Google Scholar]

PLOS Glob Public Health. doi: 10.1371/journal.pgph.0001824.r001

Decision Letter 0

Melissa Morgan Medvedev

24 Nov 2022

PGPH-D-22-01442

Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

PLOS Global Public Health

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We invite you to submit a revised version of your manuscript, taking into consideration the comments received from the three reviewers. In particular, we agree with the comment of reviewer #1 regarding the need to clarify the indicator related to observed feeding and counselling, and highlight this as a limitation. Please provide a rationale for why you decided to treat antenatal care as a dichotomous variable. Finally, please consider disaggregating the variable, age-appropriate breastfeeding practice, by age category.

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Reviewer #1: Overall:

This paper presents an analysis of an important area. Early initiation of exclusive breastfeeding and age-appropriate breastfeeding are well recognised as interventions to reduce infant and child morbidity and mortality. As such it deserves to be published and authors should be given a chance to resubmit.

Major comments

Overall the paper would benefit from some clarity in the indicators. In particular, the indicator related to observed feeding and counselling. This is often referred to in a confusing way, especially when in relation to skin to skin contact and early initiation of breastfeeding. The indicator is defined as being measured over 2 days compared to the first hour after birth. The association is therefore difficult to interpret unless we assume that the observation took place within the first hour after birth. Please do consider making clearer throughout the text and also highlighting it as a limitation.

I also find the order in which results are presented hard to follow. I think presenting skin to skin, then early initiation, then age appropriate feeding practices is a more logical order and would improve the flow of the paper.

Minor comments

Abstract – I don’t think the abstract concisely captures the main points of the paper. Some reworking would benefit the paper and make it more inviting to readers

Table 1 - Please define weights for size at birth

Line 201 – the term recent is confusing in this sentence

Lines 220-223 – please could you elaborate on the meaning of this a little more

Page 17 (sorry, line numbers disappeared) – I think the discussion on supply could benefit from further information. Are there physiological reasons for diminished supply or is it due to mixed feeding. Do other studies exist or is this a research gap in this context? Is it mothers perception of supply? Please define how this is determined.

Page 18 – 3rd paragraph – please pull apart and comment more clearly on what is needed in terms of early breastfeeding advice. For example, is it the responsibility of skilled birth attendants to promote immediate skin to skin and the support the mother within the first hour following birth with attachment and feeding? Also how can this be improved for women with non vaginal deliveries? Would promotion of skin to skin and early attachment among obstetricians performing caesareans help? Similarly, with those who do not have skilled attendance. Are there local or regional examples of good practice and impact that can be cited?

Reviewer #2: This is a well written artcile which meets all of the Journal's publication criteras like originality, not been previously done, not published elsewhere etc. It has also applied rigorous statistical methods for analysis and explains the process in the text. The sample size is big enough and criterias for selection of respondents have been explained well. The primary data it uses is a publicly shared one and it has been mentioned and source has been cited in the article.

Reviewer #3: This manuscript examines factors related to antenatal and perinatal service delivery and breastfeeding outcomes using the 2016 Nepal DHS. The paper is well written. The analysis is conducted using a fairly standard approach, with selection of factors for the multivariable model based on both theory and significance testing in unadjusted models and appropriately adjusts for survey weights and the cluster design of the survey. Findings from the analysis are generally aligned with expectations based on previous studies in Nepal and globally. I just have a few thoughts that I think could improve the paper.

Lines 165-167: The sentence beginning with “Where two explanatory variables” needs further explanation. It’s not clear exactly what this means but if whether the reason to select one variable is due to multicollinearity concerns, I would recommend looking at the VIF for each variable.

I have a couple of concerns about the “age-appropriate breastfeeding practice” outcome variable. I can see how on its surface it seems like it might be useful as a general reflection of the proportion of under-24 month olds that are being fed according to guidelines. However, the variable is very influenced by age, as illustrated in the proportion of infants/young children that adhere to it in Table 1: there is a steep rise from 6 months onward that corresponds to the inclusion of complementary foods in its makeup. For this reason, it seems to me that a presentation of this variable disaggregated by age category would be more useful, you may find that different factors are associated with it for different age groups.

I am curious why you elected to treat ANC receipt as a dichotomous variable.

Line 230.. and elsewhere isn’t it age appropriate “feeding” not “breastfeeding” given that complementary foods?

Table 2. I assume there are typos in the OR’s for age in months here for older age groups.

Table 2. Is there a reason to not include the unadjusted OR’s for the age-appropriate feeding practices here? (they are blank)

Given that significance testing was used to determine which variables were included in final models, when reflecting on these findings vs. previous studies I’d suggest also looking at the unadjusted coefficients.. because the relative strength of associations and other variables that are included in your models are influencing what gets selected.

**********

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PLOS Glob Public Health. 2023 Apr 17;3(4):e0001824. doi: 10.1371/journal.pgph.0001824.r002

Author response to Decision Letter 0

23 Jan 2023

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0001824.r003

Decision Letter 1

Caroline Bull

10 Feb 2023

PGPH-D-22-01442R1

Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

PLOS Global Public Health

Dear Dr. Wallace,

Please submit your revised manuscript by Mar 11 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

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Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

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Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #1: The authors have addressed most of my comments and concerns

Reviewer #3: I'm pasting my responses to the issues that i still have questions about below each of the previous responses beginning with OK (i wish we'd numbered them)

I am curious why you elected to treat ANC receipt as a dichotomous variable.

This was due to the original WHO recommendation of a minimum of 4 antenatal visits (0-3; 4+). We have now

disaggregated this variable into 0-3, 4, 5-7, 8+ to provide more granular information, and to reflect the new WHO

(2016) recommendation of 8+ antenatal visits (see lines 193-195 and Table 1). The new coding did not change

the relationship of number of antenatal visits with either outcome.

“Variables related to antenatal and perinatal service delivery were informed by the WHO breastfeeding

practice guidelines (21) and the WHO recommendations on antenatal care for a positive pregnancy

experience (23): number of antenatal visits (0-3 visits; 4 visits, 5-7 visits, 8+visits)…”

OK- at the time of this survey (2016) Nepal was recommending (and recording) 4 visits on ANC cards, this is changing. I do think there is value in assessing a finer stratification for those with <4 visits rather than lumping 0-3 together.. as 0 visits suggests non use of health services completely which is very different than seeking some care.. and 4 was “complete” adherence to recommendations at the time.

Line 230.. and elsewhere isn’t it age appropriate “feeding” not “breastfeeding” given that complementary foods?

We are focussed on the breastfeeding component and defined age-appropriate IYCF breastfeeding practice from

6-23 months as continued breastfeeding with complementary foods. We did not evaluate the quality or quantity

of complementary foods in this study, so did not wish to refer to age-appropriate ‘feeding’.

I find this confusing.. if complementary foods are included in the indicator, it’s more than just breastfeeding.

Table 2. I assume there are typos in the OR’s for age in months here for older age groups.

No – these are correct. We think the reviewer is referring to Age of mother (40-49 years). In this age-group the

numbers are very small and hence the 95% confidence interval of the odds ratio is very wide.

OK What I am looking at are the unadjusted OR’s and the corresponding 95% CI’s for age groups 12-17 months and 18-23 months. The 95% CI’s do not include the OR coefficients within their bounds.

Table 2. Is there a reason to not include the unadjusted OR’s for the age-appropriate feeding practices here?

(they are blank)

Not sure what the reviewer means here – have carefully checked Table 2 as submitted. Both unadjusted and

adjusted ORs are blank for variables that were not included in the models.

OK What I am suggesting is rather than leaving blank space for something that was actually tested, that you include the unadjusted OR’s in that space. This also would enable comparison vs.previous studies (as mentioned below).

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Reviewer #1: No

Reviewer #3: No

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PLOS Glob Public Health. 2023 Apr 17;3(4):e0001824. doi: 10.1371/journal.pgph.0001824.r004

Author response to Decision Letter 1

6 Mar 2023

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PLOS Glob Public Health. doi: 10.1371/journal.pgph.0001824.r005

Decision Letter 2

Shela Hirani

22 Mar 2023

Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

PGPH-D-22-01442R2

Dear Authors,

We are pleased to inform you that your manuscript 'Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey' has been provisionally accepted for publication in PLOS Global Public Health.

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Best regards,

Shela Hirani, PhD, IBCLC, RN

Academic Editor

PLOS Global Public Health

***********************************************************

Reviewer Comments (if any, and for reference):

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

Reviewer #1: Yes

Reviewer #3: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #1: No further comments

Reviewer #3: looks fine now thank you

**********

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. Distribution of age-appropriate infant and young child (IYCF) feeding practice according to infant age group.

(DOCX)

Click here for additional data file.^{(49.7KB, docx)}

S2 Table. Adjusted odds ratios for age-appropriate infant and young child feeding (IYCF) feeding practice according to infant age group.

(DOCX)

Click here for additional data file.^{(25.6KB, docx)}

Attachment

Submitted filename: Response to reviewers.docx

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Attachment

Submitted filename: Response to reviewers comments.docx

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Data Availability Statement

[pgph.0001824.ref001] 1.World Health Organization (WHO), United Nations Children’s Fund (‎‎UNICEF). Global Strategy for Infant and Young Child Feeding. 2003. Available from: https://www.who.int/publications/i/item/9241562218 [Google Scholar]

[pgph.0001824.ref002] 2.United Nations Children’s Fund (UNICEF). Infant and Young Child Feeding Program Guide. 2011. Available from: https://www.ennonline.net/attachments/1470/unicef-iycf-programming-guide-may-26-2011.pdf [Google Scholar]

[pgph.0001824.ref003] 3.Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13 Suppl 3:S19. doi: 10.1186/1471-2458-13-S3-S19 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref004] 4.Khan J, Vesel L, Bahl R, Martines JC. Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity-a systematic review and meta-analysis. Matern Child Health J. 2015;19(3):468–79. doi: 10.1007/s10995-014-1526-8 [DOI] [PubMed] [Google Scholar]

[pgph.0001824.ref005] 5.Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM, et al. Delayed breastfeeding initiation and infant survival: A systematic review and meta-analysis. PLoS One. 2017;12(7):e0180722. doi: 10.1371/journal.pone.0180722 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref006] 6.Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012(8):CD003517. doi: 10.1002/14651858.CD003517.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref007] 7.World Health Organization (WHO). Fact sheet: Child mortality (under 5 years). 2022. Available from: https://www.who.int/news-room/fact-sheets/detail/levels-and-trends-in-child-under-5-mortality-in-2020 [Google Scholar]

[pgph.0001824.ref008] 8.Tiwari R, Ausman LM, Agho KE. Determinants of stunting and severe stunting among under-fives: evidence from the 2011 Nepal Demographic and Health Survey. BMC Pediatr. 2014;14:239. doi: 10.1186/1471-2431-14-239 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref009] 9.Government of Nepal. Policy—Mother’s Milk Substitutes (Control of Sale and Distribution) Act, 2049. 1992. Available from: https://extranet.who.int/nutrition/gina/en/node/8783 [Google Scholar]

[pgph.0001824.ref010] 10.World Health Organization (WHO), United Nations Children’s Fund (‎‎UNICEF). Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services–the revised Baby-friendly Hospital Initiative. 2018. Available from: https://www.unicef.org/media/95191/file/Baby-friendly-hospital-initiative-implementation-guidance-2018.pdf [Google Scholar]

[pgph.0001824.ref011] 11.Subedi N. Baby-Friendly Hospital Initiative: Situation in Nepal. Health Prospect. 2012;11:53–4. [Google Scholar]

[pgph.0001824.ref012] 12.Adhikari M, Khanal V, Karkee R, Gavidia T. Factors associated with early initiation of breastfeeding among Nepalese mothers: further analysis of Nepal Demographic and Health Survey, 2011. Int Breastfeed J. 2014;9(1):21. doi: 10.1186/s13006-014-0021-6 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref013] 13.World Health Organization (WHO). Ten steps to successful breastfeeding. 2018. Available from: https://www.who.int/activities/promoting-baby-friendly-hospitals/ten-steps-to-successful-breastfeeding [Google Scholar]

[pgph.0001824.ref014] 14.Ministry of Health, Nepal [MoHP], Dept of Health Services, Family Health Division. National Policy on Skilled Birth Attendants. 2006. Available from: https://km.mohp.gov.np/sites/default/files/2018-07/SBA_Policy_2006.pdf [Google Scholar]

[pgph.0001824.ref015] 15.Ministry of Health, Nepal [MoHP] Nepal Demographic and Health Survey, 2006. 2007. Available from: https://dhsprogram.com/pubs/pdf/FR191/FR191.pdf [Google Scholar]

[pgph.0001824.ref016] 16.Ministry of Health, Nepal [MoHP] Nepal Demographic and Health Survey, 2011. 2012. Available from: https://dhsprogram.com/pubs/pdf/FR257/FR257%5B13April2012%5D.pdf [Google Scholar]

[pgph.0001824.ref017] 17.Ghimire U. The effect of maternal health service utilization in early initiation of breastfeeding among Nepalese mothers. Int Breastfeed J. 2019;14:33. doi: 10.1186/s13006-019-0228-7 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref018] 18.Bhandari S, Thorne-Lyman AL, Shrestha B, Neupane S, Nonyane BAS, Manohar S, et al. Determinants of infant breastfeeding practices in Nepal: a national study. Int Breastfeed J. 2019;14:14. doi: 10.1186/s13006-019-0208-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref019] 19.Acharya P, Khanal V. The effect of mother’s educational status on early initiation of breastfeeding: further analysis of three consecutive Nepal Demographic and Health Surveys. BMC Public Health. 2015;15:1069. doi: 10.1186/s12889-015-2405-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref020] 20.Ministry of Health, Nepal [MoHP]. Nepal Demographic and Health Survey, 2016. 2017. Available from: https://dhsprogram.com/pubs/pdf/FR336/FR336.pdf [Google Scholar]

[pgph.0001824.ref021] 21.World Health Organization (WHO). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. 2017. Available from: https://apps.who.int/iris/handle/10665/259386 [PubMed] [Google Scholar]

[pgph.0001824.ref022] 22.Demographic and Health Survey (DHS) Program. Analysing DHS Data. 2020. Available from: https://dhsprogram.com/data/Guide-to-DHS-Statistics/Analyzing_DHS_Data.html [Google Scholar]

[pgph.0001824.ref023] 23.World Health Organization (WHO). WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Available from: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. [PubMed] [Google Scholar]

[pgph.0001824.ref024] 24.Pandey S, Fusaro V. Food insecurity among women of reproductive age in Nepal: prevalence and correlates. BMC Public Health. 2020;20(1):175. doi: 10.1186/s12889-020-8298-4 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref025] 25.Croft TN, Marshall AMJ, Allen CK, et al. Guide to DHS Statistics. DHS Program. 2018. Available from: https://dhsprogram.com/data/Guide-to-DHS-Statistics/ [Google Scholar]

[pgph.0001824.ref026] 26.Pandey S, Tiwari K, Senarath U, Agho KE, Dibley MJ, South Asia Infant Feeding Research Network. Determinants of infant and young child feeding practices in Nepal: secondary data analysis of Demographic and Health Survey 2006. Food Nutr Bull. 2010;31(2):334–51. doi: 10.1177/156482651003100222 [DOI] [PubMed] [Google Scholar]

[pgph.0001824.ref027] 27.Rajbhandari R, Rai S, Hathi S, Thapa R, Rai I, Shrestha A. The quality of skilled birth attendants in Nepal: High aspirations and ground realities. PLoS One. 2019;14(4):e0214577. doi: 10.1371/journal.pone.0214577 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref028] 28.Karim F, Billah SM, Chowdhury MAK, Zaka N, Manu A, Arifeen SE, et al. Initiation of breastfeeding within one hour of birth and its determinants among normal vaginal deliveries at primary and secondary health facilities in Bangladesh: A case-observation study. PLoS One. 2018;13(8):e0202508. doi: 10.1371/journal.pone.0202508 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref029] 29.Singh K, Khan SM, Carvajal-Aguirre L, Brodish P, Amouzou A, Moran A. The importance of skin-to-skin contact for early initiation of breastfeeding in Nigeria and Bangladesh. J Glob Health. 2017;7(2):020505. doi: 10.7189/jogh.07.020505 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref030] 30.Ulak M, Chandyo RK, Mellander L, Shrestha PS, Strand TA. Infant feeding practices in Bhaktapur, Nepal: a cross-sectional, health facility based survey. Int Breastfeed J. 2012;7(1):1. doi: 10.1186/1746-4358-7-1 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref031] 31.Singh Bhandari M, Manandhar P, Tamrakar D. Practice of breastfeeding and its barriers among women working in tertiary level hospitals. Journal of the Nepal Medical Association. 2019;57:8–13. doi: 10.31729/jnma.4035 [DOI] [PMC free article] [PubMed] [Google Scholar]

[pgph.0001824.ref032] 32.Kent JC, Hepworth AR, Sherriff JL, Cox DB, Mitoulas LR, Hartmann PE. Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation. Breastfeed Med. 2013;8:401–7. doi: 10.1089/bfm.2012.0141 [DOI] [PubMed] [Google Scholar]

PERMALINK

Antenatal and perinatal service delivery associations with breastfeeding outcomes in Nepal: Analysis of the 2016 Nepal Demographic and Health Survey

Breanna Louise Hollow

Max K Bulsara

Prakash Dev Pant

Hilary Jane Wallace

Roles

Abstract

Introduction

Methods

Data sources

Outcome variables

Explanatory variables

Fig 1. Adapted conceptual framework for breastfeeding outcomes in Nepal [18].

Statistical analysis

Ethical approval

Results

Table 1. Characteristics of the sample population and distribution of factors influencing breastfeeding within the first hour of birth and age-appropriate infant and young child feeding (IYCF) practice.

Table 2. Unadjusted and adjusted odds ratios for factors influencing breastfeeding within one hour post-delivery and age-appropriate infant and young child feeding (IYCF) practice (n = 1938).

Discussion

Breastfeeding within the first hour after delivery

Age-appropriate feeding practice

Strengths and limitations

Conclusions for practice

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Melissa Morgan Medvedev

Roles

Author response to Decision Letter 0

Decision Letter 1

Caroline Bull

Roles

Author response to Decision Letter 1

Decision Letter 2

Shela Hirani

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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