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 Table of Contents  
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 70-74

Determinants of exclusive breastfeeding among lactating women in sub-Himalayan region

1 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India
2 Department of Microbiology, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh, India

Date of Web Publication11-Jan-2017

Correspondence Address:
Dr. Sunil Kumar Raina
Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Tanda, Himachal Pradesh
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DOI: 10.4103/1119-0388.198128

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Introduction: Trend of faltering growth in children begins in the critical period of first 2 years of life, and a major cause is due to faulty feeding practices. Breastfeeding is one of the most important determinants of child survival, birth spacing, and prevention of childhood infections. Aim: To determine factors influencing exclusive breastfeeding (EBF). Methodology: The Multiple Indicator Cluster Survey technique with thirty clusters proposed by the World Health Organization was used for the purpose of this study. Results: EBF was reported by 48.1% (101/210) of mothers. Among the 55% who initiated breastfeed in an hour of birth, 56.5% were EBF as compared to 43.5% were non-EBF and this difference was statistically significant (P - 0.01). As the education status of mothers increased from primary to matriculate the proportion of EBF decreased. Conclusions: Poor feeding practices are present across all socioeconomic groups, and a significant difference was observed with the age of mother, education status of both parents, occupation of father, and time of initiation of breastfeeding.

Keywords: Determinants, exclusive breastfeeding, sub-Himalayan

How to cite this article:
Kaushal A, Singh M, Sharma P, Chander V, Raina SK. Determinants of exclusive breastfeeding among lactating women in sub-Himalayan region. Trop J Med Res 2017;20:70-4

How to cite this URL:
Kaushal A, Singh M, Sharma P, Chander V, Raina SK. Determinants of exclusive breastfeeding among lactating women in sub-Himalayan region. Trop J Med Res [serial online] 2017 [cited 2018 Feb 24];20:70-4. Available from: http://www.tjmrjournal.org/text.asp?2017/20/1/70/198128

  Introduction Top

Children are considered as one of the vulnerable or special risk groups. The risk is connected with growth, development, and survival in infants and children. Given the magnitude of child undernutrition in India, one of the key preventive interventions is the promotion of infant and young child feeding practices. The first 2 years of life are considered a "critical window of opportunity" for the prevention of growth faltering. Optimal breastfeeding and complementary feeding practices together allow children to reach their full growth potential.[1]

The global recommendations of the World Health Organization (WHO) are that (1) all infants should start breastfeeding within 1 h of birth (early initiation of breastfeeding [EIBF]) and (2) be exclusively breastfed (EBF; only breast milk, no other liquids or solids, not even water, with the exception of oral rehydration solution or drops/syrups of vitamins, minerals, or medicines) up to 6 months of age, then partially breastfed thereafter as a part of a comprehensive complementary feeding strategy up to 2 years of age.[2]

EIBF is low-cost and has substantial potential to reduce neonatal and early infant morbidity[3],[4],[5],[6],[7] and mortality.[8],[9],[10] Despite these benefits, only 23.4% of infants in India are breastfed within an hour of birth.[11] An adequate supply of human breast milk is known to satisfy virtually all the nutritional needs of an infant at least for the first 6 months of life. In India, breastfeeding beyond 6 months up to 2 years or beyond along with other good practices like addition of safe, hygienic adequate and timely complementary food is important to prevent malnutrition in young children.

The present study was conducted to find out EBF practice in rural areas of District Kangra (Himachal Pradesh). The differential study included the type of family, income of family, education of parents, occupation of parents, and place of delivery.

  Methodology Top

Kangra district is situated in the Eastern part of the Himachal Pradesh. It is located within the 30° 22' 40" to 33° 12' 40" North latitude and 75° 45' 55" to 79° 4' 20" East longitude. Kangra district occupies an area of 5739 km2 .

The study was conducted in Shahpur block of Kangra district. Shahpur happens to be the rural training facility for undergraduate and internship program under the Department of Community Medicine of our college. The population of Shahpur is 138,362 as per 2011 census.[12]

The study population consisted of mothers whose baby was more than 6 months of age but <1 year of age. Around 4000 children spread across all villages of Shahpur and children between 6 months and 1 year of age were considered eligible for inclusion in this study. Infants with specific feeding problems (cleft lip and palate), thus requiring infant formula or bottle feeding, were excluded from the study. The Multiple Indicator Cluster Surveys (MICSs) technique with thirty clusters proposed by the WHO for coverage evaluation was used.[13],[14] In this thirty cluster technique before the sampling begins, the population was divided into a set of nonoverlapping subpopulations with a defined geographic boundaries (villages) called clusters. After this, thirty of these clusters are sampled with probability proportionate to the size of the population in the cluster. A cluster of thirty villages was taken from Shahpur block. In case of an insufficient number of children in a single village, the children in the adjoining village were included in this study. The areas were mapped and different directions identified in the selected ward/village. One direction was selected randomly. The first house on the left side was approached and a house-to-house survey was conducted to include secondary sampling units, i.e. mothers of children aged 6 months to 1 year. Once the desired number was achieved, the process was stopped. Thus, as per the recommendations of the WHO for MICS, a sample size of 210 mothers was recruited.

The study was conducted for the duration of 3 months from June 1, 2014, to August 31, 2014. This was a cross-sectional analytical study. Before conducting an interview, verbal consent was obtained from them.

The study has been approved by the Institutional Ethics Committee.

  Results Top

In our study, 48.1% (101/210) of the mothers gave a history of EBF. Around half of the mothers (54.6%) with EBF were of age group 21-30 years. Majority of husbands (81.9%) of the lactating mothers were educated up to matriculate and above. Of these, 48.8% of the children were EBF until the age of 6 months [Table 1].
Table 1: Determinants of exclusive breastfeeding among lactating women

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As the education status of participants increased from primary to matriculate the proportion of EBF decreased. There were 86.2% mothers who were educated up to matriculate and above, and 43.1% of them gave EBF to their children. Majority of fathers (37.6%) were skilled workers out of which only 35.4% of their infants were given EBF as compared to 64.6% non-EBF and the difference was statistically significant (P - 0.00) [Table 1].

Most of the lactating mothers in the present study were homemakers (91.9%). Almost equal proportion of these homemakers was EBF as those who were not. Among those who were involved in agriculture, 72.7% could not EBF their infant as compared to 27.3% EBF, but this difference was statistically not significant.

There was a difference in EBF patterns depending on the place of delivery; however, the difference was statistically not significant. Among the one-fifth of those who delivered at home, majority 57.3% mothers gave EBF as compared to 79% of those who delivered in government hospitals among which 45.8% were EBF [Table 1].

Around 55% (115/210) of study population initiated breastfeeding within 1 h of delivery. Among them, 56.5% (65/115) were EBF for 6 months. Majority of mothers who initiated breastfeeding 1 day were not EBF (83.7%; 23/28) [Table 1].

The major reason given by mothers for non-EBF was a lack of breast milk (47.7%) followed by "breast milk was not adequate for infant" (29.4%). Lack of knowledge of EBF was also one of the reasons given by 11.9% women (not included in Table).

  Discussion Top

About half of the study participants (48.1%) reported EBF given to their infants. This was less as compared to both District Level Household Survey-3 (58.1%) and 4 (62%) data of Himachal Pradesh. Somewhat similar prevalence of 46% was reported in National Family Health Survey-3.[11] Moreover, 43.1% was reported from Peninsular, Malaysia; however, the definition of EBF included only 1 month duration prior to the interview.[15] A cohort study from six sites of low- and middle-income countries reported an overall rate of 75% of EBF, but they included EBF rate at 42 days of life only as it was an ongoing study.[16] A study from Ethiopia also revealed a higher prevalence rate (70.02%).[17] Foo et al. reported EBF at 21% in Singapore which is quite low.[18] A very low prevalence of 10.4% was reported in a cohort study at Nova Scotia, Canada; however, this was similar to their national average and 15.5% in Africa.[19],[20],[21]

The study identified five predictors significantly associated with EBF. Most of these are intertwined with social determinants of health. Maternal age group 21-30 years EBF their infants. The reason being this is the optimum age of marriage and childbirth among women in India. It was seen that higher percentage of formally educated mothers recorded non-EBF as compared to EBF. A similar situation was observed among Indian sites of cohort study where a higher proportion of EBF was observed among primary and secondary educated mothers as compared to those highly educated.[16] Several reasons that include aggressive promotion of baby foods by commercial interests, lack of support to women at family and workplaces, and inadequate skilled health-care support.[17] Contrasting observations in a North Ethiopia study and Nova Scotia cohort study reported a higher proportion of mothers who attended formal school were EBF their infants as compared to illiterates.[18],[20]

Among infants whose fathers had a high formal education, the EBF proportion was significantly higher. This could be because in Asian setting that too in rural India, the husband plays a major role in decision making about family and household matters. Hence, higher the education of husband it will be beneficial for the infant. The occupation of father was also observed to be a determinant of EBF with self-employed or those having their own business had a higher proportion of EBF infants, and part time workers had a higher proportion of non-EBF infants. Majority of mothers were homemakers, and this was not a significant determinant of EBF as almost similar proportion were EBF and not feeding. Agampodi et al. and Mascarenhas et al. reported an association with parental education and women's employment from Sri Lanka and Brazil, respectively.[22],[23]

EIBF (within 1 h) was also observed to be a determinant in EBF. Mothers who initiated late breastfeeding (after 1 day) were less likely to EBF. Similar findings were reported in a population-based cohort study in Nova Scotia.[20] The factors which affect EIBF are somewhat same for EBF.[24]

A study on EBF done in Mekelle[25] revealed that delivery place was a determinant factor for EBF; however, this study showed that delivery place was not statistically associated with EBF. Similar findings were reported by a study in North Ethiopia. The reason being the majority of deliveries are conducted at government setting in Himachal Pradesh (India) and less proportion of privatization in this state in addition to effective implementation of maternal and child benefit package.

The onset of malnutrition occurs in the very early years of growth. Even during first 6 months of life, when most children are breastfed, 20-30% is underweight. While breastfeeding provides optimal nutrition to the child and prevents infections, the timely initiation and age-appropriate complementary feeding can substantially reduce stunting and related burden of disease.[1] EBF also acts as a primary prevention intervention against morbidity and mortality related to three major conditions, i.e. neonatal infections, diarrhea, and pneumonia.

EBF practices have not shown a significant rise in past two decades to be anywhere near universal coverage. To enhance optimal infant and young child feeding practices, the key interventions are carried out at the community level. Hence, it is important to train our Accredited Social Health Activist/Auxiliary Nurse Midwife/Anganwadi Workers to deal differently with different level of social determinants which determine the pattern of feeding in the community. This will help to attain the prescribed goal of 80% EBF.[1]

The cross-sectional type being the limitation of the study recommends further prospective studies to develop causation of these factors.

  Conclusions Top

Poor feeding practices are significantly associated with age of mother, education status of both parents, occupation of father, and time of initiation of breastfeeding.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Government of India, Ministry of Health and Family Welfare. Guidelines for enhancing optimal infant and young child feeding practices. New Delhi: National Rural Health Mission, Ministry of Health and Family Welfare, Government of India; 2013.  Back to cited text no. 1
World Health Organization. Global Strategy on Infant and Young Child Feeding; 2002. Available from: http://www.who.int/nutrition/topics/global_strategy/en/. [Last accessed on 2016 Mar 31].  Back to cited text no. 2
Mullany LC, Katz J, Li YM, Khatry SK, LeClerq SC, Darmstadt GL, et al. Breast-feeding patterns, time to initiation, and mortality risk among newborns in Southern Nepal. J Nutr 2008;138:599-603.  Back to cited text no. 3
Keino S, Plasqui G, Ettyang G, van den Borne B. Determinants of stunting and overweight among young children and adolescents in sub-Saharan Africa. Food Nutr Bull 2014;35:167-78.  Back to cited text no. 4
Hajeebhoy N, Nguyen PH, Mannava P, Nguyen TT, Mai LT. Suboptimal breastfeeding practices are associated with infant illness in Vietnam. Int Breastfeed J 2014;9:12.  Back to cited text no. 5
Lamberti LM, Fischer Walker CL, Noiman A, Victora C, Black RE. Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 2011;11 Suppl 3:S15.  Back to cited text no. 6
Garcia CR, Mullany LC, Rahmathullah L, Katz J, Thulasiraj RD, Sheeladevi S, et al. Breast-feeding initiation time and neonatal mortality risk among newborns in South India. J Perinatol 2011;31:397-403.  Back to cited text no. 7
Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS. Effect of early infant feeding practices on infection-specific neonatal mortality: An investigation of the causal links with observational data from rural Ghana. Am J Clin Nutr 2007;86:1126-31.  Back to cited text no. 8
Edmond KM, Kirkwood BR, Tawiah CA, Owusu Agyei S. Impact of early infant feeding practices on mortality in low birth weight infants from rural Ghana. J Perinatol 2008;28:438-44.  Back to cited text no. 9
Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics 2006;117:e380-6.  Back to cited text no. 10
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India. Vol. II. Mumbai: International Institute of Population Sciences (IIPS); 2007.  Back to cited text no. 11
Himachal Pradesh - Census of India. Available from: http://www.censusindia.gov.in. [Last accessed on 2016 Mar 31].  Back to cited text no. 12
Bennett S, Woods T, Liyanage WM, Smith DL. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat Q 1991;44:98-106.  Back to cited text no. 13
Multiple Indicator Cluster Survey (MICS). Statistics and Monitoring. UNICEF. Available from: http://www.unicef.org/statistics/index_24302.html. [Last accessed on 2016 Mar 31].  Back to cited text no. 14
Tan KL. Factors associated with exclusive breastfeeding among infants under six months of age in peninsular malaysia. Int Breastfeed J 2011;6:2.  Back to cited text no. 15
Patel A, Bucher S, Pusdekar Y, Esamai F, Krebs NF, Goudar SS, et al. Rates and determinants of early initiation of breastfeeding and exclusive breast feeding at 42 days postnatal in six low and middle-income countries: A prospective cohort study. Reprod Health 2015;12 Suppl 2:S10.  Back to cited text no. 16
Breast Feeding Promotion Network of India. Dark Cloud and Silver Lining. BPNI Bulletin; 2012. p. 36. Available from: http://www.bpni.org/Bulletin/Bulletin_36.pdf. [Last accessed on 2016 Jun 10].  Back to cited text no. 17
Teka B, Assefa H, Haileslassie K. Prevalence and determinant factors of exclusive breastfeeding practices among mothers in Enderta woreda, Tigray, North Ethiopia: A cross-sectional study. Int Breastfeed J 2015;10:2.  Back to cited text no. 18
Foo LL, Quek SJ, Ng SA, Lim MT, Deurenberg-Yap M. Breastfeeding prevalence and practices among Singaporean Chinese, Malay and Indian mothers. Health Promot Int 2005;20:229-37.  Back to cited text no. 19
Brown CR, Dodds L, Attenborough R, Bryanton J, Rose AE, Flowerdew G, et al. Rates and determinants of exclusive breastfeeding in first 6 months among women in Nova Scotia: A population-based cohort study. CMAJ Open 2013;1:E9-17.  Back to cited text no. 20
Diallo FB, Bell L, Moutquin JM, Garant MP. The effects of exclusive versus non-exclusive breastfeeding on specific infant morbidities in Conakry. Pan Afr Med J 2009;2:2.  Back to cited text no. 21
Agampodi SB, Agampodi TC, Piyaseeli UK. Breastfeeding practices in a public health field practice area in Sri Lanka: A survival analysis. Int Breastfeed J 2007;2:13.  Back to cited text no. 22
Mascarenhas ML, Albernaz EP, Silva MB, Silveira RB. Prevalence of exclusive breastfeeding and its determiners in the first 3 months of life in the South of Brazil. J Pediatr (Rio J) 2006;82:289-94.  Back to cited text no. 23
Kaushal A, Raina SK, Sharma VC, Bhardwaj A. Determinants of initiation of breast feeding among lactating women in sub-Himalayan region. J Med Soc 2014;28:77-80.  Back to cited text no. 24
  Medknow Journal  
Hailemariam B, Bazie M, Alemayehu B, Haftu B. Determinants of breastfeeding practices among mothers attending public health facilities, Mekelle, Northern Ethiopia. IJPSR 2013;4:650-60.  Back to cited text no. 25


  [Table 1]


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