Exclusive breastfeeding practices in relation to social and health determinants: a comparison of the 2006 and 2011 Nepal Demographic and Health Surveys

The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) up to six months of age [1, 2]. During this six-month period, no liquid, semisolid or solid food or breastfeeding substitute should be given to the infants except for medicine and/or oral rehydration solution. EBF has been considered beneficial to the health and wellbeing of infants and mothers [3]. A child who is EBF for six months is more likely to be protected from gastrointestinal infections, respiratory illness, morbidity and death [4–6]. EBF can also protect the child from atopic eczema [5, 7], the risk of allergy, asthma, type II diabetes [8], leukaemia [9] and obesity in later life [3].

Rates of infant mortality (46 per 1000 live births) and an under five mortality (54 per 1000 live births) [10, 11] are high in Nepal. EBF is estimated to prevent approximately 10% of child deaths and as such plays important role in meeting Nepal’s Millennium Development Goals (MDGs) 4 of reducing child mortality between 1996 and 2015 from 162 to 38 per 1,000 lives birth [4]. Therefore, it is important that EBF until six months of age is encouraged and supported by the health sector, families and communities in Nepal, however very little is known about the determinants of EBF in Nepal. A number of internationals studies have identified a number of socio-demographic determinants of EBF. Some of the most common factors found to be associated with EBF are: the economic status of family; education of mother; occupation of mother; utilisation of antenatanal care; place of residence; and access to information [12–15]. Similarly, the father’s socio-economic characteristics such as father’s education and occupation have also been reported to influence the EBF rates [16, 17]. Updated knowledge about the determinants of EBF in Nepal could aid in the better design of infant nutrition programs. The objectives of the current study were to describe the changes in the proportion of EBF according to age for ≤5 months infants and to compare socio-economic and health factors associated with EBF in the 2006 and 2011 surveys.

This study used data from the Nepal Demographic and Health Surveys (NDHS) collected in 2006 and 2011 [11, 18]. The NDHS is nationally representative cross sectional study conducted every five years. It used a multistage cluster sampling design and internationally validated instruments.

For administrative purposes, Nepal is divided into 75 districts that are further divided into village development committees (VDC) and municipalities within the districts [11]. The VDC and municipalities are further divided into wards and sub-wards. For data collection purposes, the wards, sub-wards and groups of sub-wards were the primary sampling unit (PSU) in the rural areas. For urban areas, the wards were divided into sub wards to construct a PSU. A list of households was obtained for each PSU. The sampling procedure in 2006 and 2011 included two stages. In 2006 a total of 260 PSU were selected in stage one using a systematic sampling probability proportionate to the population size, with 82 urban and 178 rural PSU’s selected. In second stage, 30 urban households and 36 rural households were selected randomly for interview within each PSU. In the 2011 survey, the PSU were referred to as enumeration areas (EA). In first stage of sampling, a total of 289 EA were selected using a systematic sampling, including 95 urban and 194 rural EAs. In second stage, 35 households in urban and 40 household from rural areas were randomly selected from each EA for interview. Details of clustering and sample selection are explained in the respective reports [11, 18].

Nutrition in early childhood is essential not only for the immediate health of the child but also for the long term benefits. EBF confers protection against infectious diseases such as gastroenteritis and respiratory illness as well as other chronic diseases in the long term [31] while preventing up to 10% of all child deaths. Therefore, WHO and UNICEF recommend exclusive breastfeeding for the first six months and continued breastfeeding thereafter [1, 2]. To reach the Millennium Development Goal targets for child survival, Nepal needs to reduce infant mortality from 108 per 1000 live births in 1990 to 34 per 1000 live births by 2015 [32]. The infant mortality was 46 per 1000 live births in Nepal in 2011 [11]. This reduction from 46 to 34 (in 2015) can in part be achieved through a greater adoption of the recommended breastfeeding practice.

In this study, only 66.3% in 2011 and 53.2% in 2006 of infants were EBF within 0–5 months. While it is encouraging to note that there was a 13% increase in the rate of EBF it is still significantly lower than the WHO/UNICEF recommended level of 90% [2, 12, 14]. Nevertheless, the EBF rate among ≤5 months infants is higher in Nepal compared to Bangladesh (46%), India (47%) and Pakistan (50%) [33]. When examined for the age specific changes in the rate of EBF, the data showed a rapid decline in the EBF around the age of four months which is similar to the findings from India [17] and Pakistan [34]. At the age of five months, the rate of EBF in Nepal had dropped to 33.1% in 2011. Our findings suggest that achieving the WHO/UNICEF target of EBF for six months is challenging.

The infant’s age, ecological region, father’s occupation, parity, and place of delivery significant determinants in 2006 for providing EBF; however, only the infant’s age was significantly associated with EBF in 2011. When age of infant was removed from the model, wealth status, ANC visits, sex of infant, iron consumption during pregnancy, and mode of delivery were significant determinants of providing EBF in 2006.

The increase in the rate of EBF amongst younger infants (≤4 months) could in part be attributable to the changes in child health programs implemented in Nepal since 2006. Childhood and newborn illness management programs such as the Community Based Integrated Management of Childhood Illness (CB-IMCI) and Community Based Newborn Care Program (CB-NCP) are two major programs that focus on breastfeeding [35, 36]. The CB-IMCI program was implemented nationwide in 2008 [32]. CB-NCP program started in 2007 and has been underway to scale up gradually to all 75 districts in Nepal [37]. These programs recommend that the health workers assist mothers by providing knowledge and skills to breastfeed. Such support from the health workers would encourage mothers to exclusively breastfeed their infants for longer.

The association of father’s occupation with EBF has been inconsistent [17, 38]. This study found similar inconsistencies, whereby father’s occupation was associated with EBF in 2006 but not in 2011. Fathers who work in professional, clerical, service, and manual occupations usually go outside the home in search of work and the burden of work may be higher for the women in the household leaving less time for them to EBF the infants. There have been no studies that have examined the effect of father’s occupation on breastfeeding in Nepal. Father’s increased knowledge and being in a paid occupation have been found to have a positive impact on breastfeeding in other countries [39–41]; however, in this study the infants whose fathers were from agriculture occupation were likely to be EBF than the others. The father’s impact of EBF is an area of increasing research in developed countries [41] and is an area that needs further exploring in developing countries including Nepal, as a potential contributor to improving EBF rates.

Parity was a significant predictor of providing EBF in the 2006 survey. It was shown that the mothers who have had previous child birth were more likely to provide EBF compared to the first time mothers. The multiparous mothers have already had experience in breastfeeding and maybe better able to manage EBF with their other household tasks [14, 42]. The ecological differences in EBF practices found in this study may be an important consideration in the context of Nepal. People in the Mountain regions live a life characterised by greater hardship due to extreme cold weather, harder physical work, and less access to basic services [11]. This might leave mothers less time to exclusively breastfeed their child. The geographic differences have been shown to have an impact on EBF practices in Sri Lanka [43] and other countries [12, 34]. This study also found that female infants were less likely to be EBF. There is a strong gender preference for sons within South Asian cultures and it has been suggested that that boys might be given more time for infant feeding than the girls [44, 45]. These cultural factors might impact EBF adversely.

Obtaining antenatal care (ANC) services for mother is the first step in the continuum of care for mother and child. ANC visits provide mothers an opportunity to discuss with health workers their problems and other health issues. It also gives an excellent opportunity for health workers to educate mothers about nutrition and EBF. The time lag between antenatal visits and initiation of EBF, of course, is long; however, different studies have found an association of ANC and exclusive breastfeeding practices. Our study reported that the mothers who had four or more ANC visits were more likely to have EBF their infant. This finding is similar to other studies from Egypt [46], Ghana [47], and Nigeria [12].

In this study, vaginal (normal) delivery was associated with higher EBF practice. Similar finding was reported from a Vietnamese study where the mothers who delivered normally (without requiring caesarean section) were more likely to exclusively breastfeed children [48]. Mode of delivery might have effect on breastfeeding in several ways. The mothers who have been undergoing surgical procedure might not feel well to breastfed after surgery, or might be under influence of anaesthesia. Mother’s difficulty in holding baby due to fresh wound might be another barrier to breastfeed successfully [42].

Mothers who delivered in home were more likely to EBF than their counter parts delivering in health facility. The vast majority (>80%) of childbirth in 2006 survey occurred at home. The mothers who are highly educated, who lived in the city and who are from higher wealth section of the populations may deliver at the health facility [18]. In this study, wealthier mothers were less likely to EBF their infants. There have been several studies which report and argue that the mothers who are poor are more likely to EBF as they do not have other option such as infant formula [12, 13]. Due to intensive marketing of milk substitutes, mothers who are comparatively well-off may feel encouraged to introduce such breast milk substitute [13]. Nevertheless, within the Nepalese society, breastfeeding has always been a universal practice and traditionally it has always been considered one of the most important factors that established the relationship between mother, child and siblings [49]. Therefore, the mothers who delivered in home may strictly follow the cultural practice of breastfeeding.

There are several strengths of this study. It is based on data from national demographic and surveys that used internationally validated questionnaires, it applied international EBF definitions combined with a strong methodology [50]. It had a high response rates (>94%) indicating generalizability of the research findings to the entire nation. The current study provides a comparison of the 2006 and 2011 surveys and examines the changes in the determinants of EBF in Nepal which has not been reported before. This comparison gives indication for future interventions and provides a benchmark for future comparisons. This study also suggests methodological consideration by using different ways of examining the determinants of EBF. Like most observational studies, this study has some limitations. The cross sectional nature of the study prevents it from making causal inferences. All the information in NDHS surveys are based on interviews; it is possible that some responses could suffer from recall bias and/or socially desirable responses [51]; however, interview method is most widely used method for collecting information on breastfeeding. Another major limitation of NDHS is 24-hour recall of information. It has been reported previously that such 24-hour period prevalence of EBF is likely to overestimate the EBF rate [52]. Cohort studies with repeated measure are recommended to report a more accurate rate of exclusive breastfeeding for six months [52]. The small sample size is a major issue in current NDHS studies to report EBF rate. It is possible that due to smaller number of sample size in 2011 a number of important independent variables were not significant. A reasonable improvement in NDHS can be achieved by including large enough sample for each month of age of the infant so that findings could be relied on to report the rate of EBF by infant’s age. Further improvement could be made by establishing sentinel sites to report EBF rate by age and complement the NDHS data [52].

Half of the infants 0–5 months (53.2%) in 2006 and 66.3% in 2011 were exclusively breastfed. There was increase in the rate of EBF from 2006 to 2011. However, the 2011 EBF rate is still far below the WHO recommended goal of 90% [2]. The current study suggests the need for further interventions to promote exclusive breastfeeding. Antenatal counselling could be feasible approach that can improve the EBF practices in Nepal [53–57]. The infant’s age was a consistent determinant of EBF in both 2006 and 2011. Mothers could be supported/encouraged to maintain breastfeeding till 6 months and provided with skills through existing primary health care outreach clinics (held 2–5 clinics each month) and immunization clinics (held 3–5 clinics each month) in the local communities [58]. Given the current >90% routine immunization coverage in Nepal, reaching the majority of the mothers for breastfeeding promotion programs through immunization clinics to maintain breastfeeding until 6 months is a feasible option that needs further consideration [58]. These outreach clinics (immunization clinics and primary health care) are run by village health workers and maternal and child health workers. To promote EBF to 6 months through these groups of health workers, health program managers should consider capacity building to provide them with the necessary skills to support mothers.

Current child health promotion programs in Nepal focus on the mothers. Involving fathers and other significant relatives in the family unit, including the mothers-in-law, may also improve the rate of EBF. A study from Nepal has suggested that the younger females (daughters-in-law) were expected to follow the decision made by their mothers-in-law about attendance to antenatal care and other maternal and child health issues [59]. Older women in Nepal such as mothers-in-law generally have less education than their daughters-in-law [59] and therefore, breastfeeding promotion programs should include them in the programs as a method of increasing the overall EBF rate. Educating fathers has been found beneficial in increasing breastfeeding practice elsewhere [41, 60] and it is an important new area of intervention to be considered in Nepal. Fathers who are involved in decision making can support their wife’s decision to breastfeed for longer. These results have highlighted some key social determinants which could be relevant to increasing EBF outcomes at six months and beyond; and made recommendation for further action which would warrant further investigation.

VK holds an MPH degree. He has been working in child health programs in Nepal for more than five years. Newborn care and child nutrition is the focus of his work in Nepal and MPH studies. Yun Zhao is a senior lecturer in the School of Public Health and teaches in the postgraduate programs. She has an MSc and PhD in statistics. Kay Sauer is a senior lecturer in the School of Public Health and coordinates the MPH/DrPH programs. She has an MSc and PhD in Behavioural Sciences.