Exclusive breastfeeding (EBF) means that the infant receives only breast milk. No other liquids or solids are given, not even water, with the exception of oral rehydration salt solution, or drops/syrups of vitamins, minerals or medicines (WHO, 2012a). World Health Organization (WHO) recommends exclusive breastfeeding for the infants up to first six months to achieve optimal growth, development and health (WHO, 2011). Breastfeeding (BF) is also an integral part of the reproductive process with important implications for the health of mothers. Review of evidence has shown that EBF for 6 months is the best way of feeding infants (WHO, 2012b).
In developing countries, breastfeeding helps prevent as much as 13% of all under-five deaths there-by making it an essential component of childhood mortality prevention strategies (Jones, Steketee, Black, Bhutta, Morris & Bellagio Child Survival Study Group, 2003). Further, in order to achieve the United Nations Millennium Development Goal 4 to reduce child mortality by two thirds, it is vital that we address neonatal mortality through evidence-based, proven interventions such as promotion of breastfeeding (Edmond, et al., 2006). Children who are exclusively breastfed have lower chance of having childhood cancers, including leukemia and lymphoma. Breastfeeding also offers a benefit that cannot be measured: a natural love between mother and child from the very beginning of the child's life. It provides hours of closeness and nurturing every day, laying the foundation for a caring and trusting relationship between mother and child (UNICEF, n.d.).
Breast milk promotes sensory and cognitive development, and protects the infant against infectious and chronic diseases. EBF reduces infant mortality due to common childhood illnesses such as diarrhoea or pneumonia, and helps for a quicker recovery during illness. These effects can be measured in both resource-poor and wealthy societies (Kramer, et al., 2001,).
Factors that interact with the protective effect of breastfeeding include environmental, cultural and economic characteristics. The protective effect of breastfeeding is most important in populations with high infant mortality, high illiteracy, poor sanitation facilities, poor nutritional status, and generally low economic status (Victora, et al., 1999).
Several studies have identified factors associated with breastfeeding. A study conducted by Patil, Hasamnis, Pathare, Parmer, Rashid and Narayan (2009) in slum of India showed that home delivery, initiation of breastfeeding within one hour of birth, and giving colostrum to the baby were independently associated with exclusive breastfeeding.
A study done by Ban, Andrea, Mark and Hala (2010) in Canada showed that caesarean section and maternal employment were negatively associated with exclusive breastfeeding and the mothers choosing to deliver at home were more likely to continue exclusive breastfeeding for 6 months.
Another study conducted in Dhaka, Bangladesh looked at the effects of community-based peer counseling on exclusive breastfeeding practices. Results showed a significant increase in women who breastfed exclusively. Seventy percent of children in the intervention group were exclusively breastfed, compared to only 6% in the control group (Haider, Ashworth, & Kabir et al., 2003).
The culture of giving water to young babies seems to be associated with hospital practices. In a study by Almroth, Mohale & Latham (2000) to obtain data on water supplement for babies in Lesotho, grandmothers reported that nurses were the source of advice for giving water and that they themselves have never given water to their own young babies as they considered it unnecessary and harmful.
At recent, breastfeeding promotion, protection and support actions have been implemented as a strategy to reduce child mortality and improve child's health in many countries.
Breastfeeding comes under essential care methods for newborns and it is a unique source of nutrition and plays a crucial role in the growth, development and survival of infants. Exclusive breastfeeding for the first six months of life can help protect newborns and infants from disease, reduce the risk of mortality and promote healthy child development. The percentage of women who started breastfeeding within one hour of birth increased from 36 per cent in 2006 to 50 per cent in 2009 (Bangladesh Bureau of Statistics & UNICEF, 2009). The percentage of women who started breastfeeding within one day of birth increased from 82 per cent in 2006 to 89 per cent in 2009 (Bangladesh Bureau of Statistics & UNICEF, 2009).
Bangladesh Demographic and Health Survey (BDHS) 2007 had shown that the initiation of breastfeeding varies with household wealth, place of delivery and birth attendant. The children born in a health facility, those whose births attendant by a health professional, and children in highest wealth quintile have a lower likelihood of breastfeeding within one hour of birth or within one day of birth. The survey had shown that 62% of the children received a prelacteal food and 92% of children received first milk or colostrum (NIPORT, Mitra and Associates, & Macro International, 2007).
The prevalence of EBF remained unchanged prior to publication of BDHS 2007. It was around 45% in the 1993-94 and 1999-2000 BDHS surveys and then declined to 42% in the 2004 BDHS. There has been no notable improvement in EBF till 2007 when it was 43% (NIPORT, Mitra and Associates, & Macro International, 2007).
The preliminary report of BDHS 2011 shows that there has been a substantial increase in exclusive breastfeeding from 43% in 2007 to 64% in 2011. However, the recommendation to exclusively breastfeed for the first six months of life is met only by 64 percent of children under two years (NIPORT, Mitra and Associates, & Macro International, 2011). Complementary foods are introduced at an early age. Among infants less than two months, 85 percent are being exclusively breastfed, while other infants are given water (6 percent), other milk (7 percent), and complementary foods (2 percent) in addition to breast milk. Bottle feeding is not uncommon in Bangladesh; around one in five infants (6-9 months) is fed with a bottle with a nipple (NIPORT, Mitra and Associates, & Macro International, 2011).
Justification of the study
Breastfeeding practices are important determinants of nutritional status of children. When babies are exclusively breastfed for up to six months, the benefits are higher. Exclusive breastfeeding provides the best nutrition, health and growth for infants.
EBF is poorly understood phenomenon from community and health provider perspective because of its strong and complex socio cultural, economic, psychological, environmental and health associated determinants. Various malpractices such as giving prelacteal foods like honey, sugar water, or mustard oil immediately after birth are few determinants of low EBF prevalence. A study by Giashuddin and Kabir (2004) shows that, 70% of mothers in Bangladesh do not practice exclusive breastfeeding. Cultural practices like giving pre-lacteal feeds, or the provision of other foods in addition to breast milk in the first three days of life, are extensively prevalent and nearly 62% of newborns are given such feeds. These feeds include sugar or glucose water (42%), milk other than breast milk (36%) and honey (33%).
There has been an noticeable increase in the level of exclusive breastfeeding from 43 percent in 2007 to 64 percent in 2011. About 4 percentage of the increase is explained by a change in the age pattern in the sample with a higher proportion of infants 0-3 months in the 2011 sample compared to the 2007 sample. Other possible explanations include influence of a national media campaign that started in December 2010 and reached peak intensity in February 2011. Additionally, there is the possible effect of several intensive programs that focus on maternal and newborn care and child health, including improved feeding, that have been implemented for the 1-2 years before the survey and cover only about 25 percent of the country's population. The reasons for the large change are only speculative at this point and need to be investigated further (NIPORT, Mitra and Associates, & Macro International, 2011).
To understand the issue, this study was aimed to find out the prevalence of EBF and factors that affect EBF in a small scale which helps further to explore in a large scale.
Discussion
Exclusive breastfeeding is the best recommended infant feeding method for the first six months of life and has a protective effect against morbidity and mortality. But it has not yet been universally practiced and the reduction in the rate of exclusive breastfeeding is taken as serious problem, especially in developing countries (Vafaee, Khabazkhoob, Moradi & Najafpoor, 2010).
Exclusive breastfeeding is safe, inexpensive and emotionally satisfying means of feeding to the babies. It has been shown that in countries where lactation support is available, exclusive breastfeeding has improved significantly over time (WHO, 2002). This study enabled to ascertain the prevalence of exclusive breastfeeding and to determine the factors associated with exclusive breastfeeding within first six months of life. In the present study prevalence of exclusive breastfeeding was lower 36%, compared to 64% at national level (NIPORT, Mitra and Associates, & Macro International, 2011). The BDHS results were from the whole nation which includes nutrition intervention and non-intervention districts. The present study was conducted in a non-intervention district which did not have any nutrition and breastfeeding promotion programs. This might be the reason why prevalence of exclusive breastfeeding was low in our study. On the contrary, the results of our study (EBF prevalence 36%) can be the default since the issue of higher prevalence of 64% in BDHS 2011 is plagued with a sample size problem (more younger infants) and the respondents coming from areas with and without nutrition interventions. Additionally other reasons for low prevalence in our study may include lack of support from family members, lack of advice from health staffs during ANC visits and deliveries in non baby friendly institutions. The baby friendly hospital initiative was established by WHO and UNICEF in 1991 as a hospital-based intervention to increase breastfeeding rates. In baby friendly hospitals breastfeeding is supported, practiced, protected and promoted (UNICEF, 2013).
Chudasama et al. reported from Gujrat, India, prevalence of exclusive breastfeeding at 37% (2009a). Another study from India among rural women in Tamil Nadu showed the prevalence to be 34% (Radhakrishnan & Balamuruga, 2012) which is similar to our study. The reasons for similar results in India and Bangladesh could be that both the study sites were rural and both countries have similar type of cultural practices. In 2004, a study by Medhi et al. on Assam tea garden workers showed the same to be 69%. Studies have also been conducted in developed countries. A study from Canada (Ban, Andrea, Mark & Hala, 2010) found prevalence of exclusive breastfeeding to be 14% which is very low. The reasons behind the very low prevalence reported in this Canadian study might be response bias because interviews were conducted through computer-assisted telephones. In contrast a study from Boston reported the prevalence as 37% (Merewood, et al., 2007) which is similar to our study. The study was hospital based and the author found that the likelihood of breastfeeding at six months was decreased by the presence of feeding problems in the hospital which included lack of privacy, sore nipples of the mothers and a sleepy baby. These factors were prevalent because of lack of support by health staffs in the hospital.
In Bangladesh, 43% of mothers had initiated breastfeeding within one hour of birth (NIPORT, Mitra and Associates, & Macro International, 2007). We also found similar figures (46%) in our study. A higher percentage of mothers gave colostrum (96%) in the present study compared to a national figure of 92% (NIPORT, Mitra and Associates, & Macro International, 2007). The present study showed prelacteal feeding was low (19%) compared to national figure 62% (NIPORT, Mitra and Associates, & Macro International, 2007).
Statistically significant differences were not observed between those who exclusively breastfed and those who do not with respect to variables that are considered to be supportive for breastfeeding such as maternal education, number of ANC visits, breastfeeding support and education, and place of delivery which was similar to a study conducted in India (Chudasama, et al., 2009b).
Factors like education of the mother, maternal employment status had shown a direct influence on exclusive breastfeeding in the study done in India (Radhakrishnan & Balamuruga, 2012) but present study did not find any relationship.
Our study showed that mothers giving birth at health centers were less likely to exclusively breastfeed their children than mothers giving birth at homes. A similar result was found in Canada (Ban, et al., 2010). This relationship was attributed to the negative influence of infant formula supplementation.
In addition to the place of delivery, type of delivery was also related to exclusive breastfeeding status. The children who were delivered by caesarean section were less likely to be exclusively breastfed than those who were normal delivered. Ideally, all hospitals are required to practice ten steps to successful breastfeeding recommended by WHO (WHO, 2013) but it is seldom practiced. This could be one of the reasons why mothers who delivered by caesarean section did not practice exclusive breast feeding. Additionally, the hospital and clinics in the study area where mothers usually deliver were not baby friendly health institutions. In these institutions the baby is usually taken care of by the attendants until the mother is fully recovered and discharged from the operating room. As a result, the baby may be fed prelacteals even before breastfeeding is initiated for the first time. Likewise, the mother and her family often think that breast milk itself is not sufficient and infant formula is necessary which is easily available around the hospital premises. A study from China (Liqian, et al., 2009) has reported that after surgery mothers feel pain around the incision area and there is difficulty in movement because of catheterization and intravenous lines. The authors of this study argue that this could be a reason for non exclusive breastfeeding. Similar explanation could also be valid for our study. Researchers from Nepal (Chandrashekhar, et al., 2007) have also reported low exclusive breastfeeding rates among mothers who are delivered by caesarean section. Further studies are needed to better understand the influence of caesarean section on exclusive breastfeeding.
We found that the children from households belonging to the richer wealth quintile were more likely to be exclusively breastfed than those belonging to poorest wealth quintile. This finding contrasts finding from another study (WHO, 2010; NIPORT, Mitra and Associates, & Macro International, 2004) according to which prevalence of exclusive breastfeeding is higher among children belonging to poorest wealth quintile. We think that the more or less equal distribution of sample population in all wealth quintiles may have led to such findings. Furthermore, mothers belonging to richer wealth quintile may have better education level, easier access to media and health services which may have increased their awareness and made them relatively more conscious about exclusive breastfeeding.
There is an intrinsic relation between exclusive breastfeeding and its determinants but the present study did not aim to discuss those in detail. The present study alerts us that even though there is no any relation with its determinants, the prevalence of EBF is very low which needs to be addressed. Further studies are necessary to investigate other several factors which are known to have relation with exclusive breastfeeding. In addition other psychological and anthropological questions also need to be answered (which are not considered in this study).
The limitation of the study include the use of 24-hour recall data for the calculation of exclusive breastfeeding which may be inadequate. Secondly, we could have also increased the sample size by decreasing the allowable margin of error but it was not feasible due to time constraints. Despite the limitation, the strength of the study was the use of unbiased sample size with stratification, appropriate sampling design and analysis plan, selection of the study area where there was no nutrition intervention which gives us more appropriate results. If the study would have conducted in a nutrition intervention area then the information collected would have been greatly influenced by the programme activities. Another strength of our study is that it was conducted in a DSS area which enabled us to use a computerized database of households with eligible respondents. It was well maintained and updated weekly. The use of trained human resources from ICDDR, B was an added advantage.
