Determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among Indonesian children

Animal source food consumption and its determinants among children aged 6 to 23 months in sub-Saharan African countries: a multilevel analysis of demographic and health survey

INTRODUCTION

Child undernutrition is a major public health problem in sub-Saharan Africa. Children who eat animal-based foods have higher intakes of various nutrients that are important for optimal linear growth. However, the prevalence of animal-source food consumption was low across many countries. Therefore, this study aimed to determine the prevalence of good consumption of animal-source foods and its determinants among children aged 6 to 23 months in sub-Saharan African countries.

METHODS

A cross-sectional pooled dataset using recent demographic and health surveys from 19 sub-Saharan African countries was employed. A total weighted sample of 65,742 children aged 6 to 23 months was included in the study. Data extracted from the recent DHS data sets were cleaned, recorded, and analyzed using STATA/SE version 14.0 statistical software. Descriptive analysis was carried out to present both individual and community-level variables using frequencies and percentages. A multilevel mixed-effects logistic regression was used to determine the factors associated with the outcome variable. Finally, variables with a p-value less than 0.05 and an adjusted odds ratio with a 95% confidence interval were declared statistically significant.

RESULTS

In this study, 43.1% (95% CI: 42.7-43.5%) of children aged 6 to 23 months consumed animal-source foods. Factors like maternal education [AOR = 1.36; 95% CI (1.28, 1.44)], maternal occupation [AOR = 1.24; 95% CI (1.18, 1.31)], exposure to media [AOR = 1.30; 95% CI (1.24, 1.36)], wealth index [AOR = 1.16; 95% CI (1.10, 1.23)] & [AOR = 1.28; 95% CI (1.21, 1.36)], owned a mobile telephone [AOR = 1.23; 95% CI (1.17, 1.29)], ANC visits [AOR = 1.20; 95% CI (1.15, 1.25)], place of delivery [AOR = 1.09; 95% CI (1.04, 1.14)], PNC checkup [AOR = 1.34; 95% CI (1.28, 1.39)], the current age of the child [AOR = 1.99; 95% CI (1.85, 2.14)], [AOR = 3.34; 95% CI (3.14, 3.56)], & [AOR = 4.3; 95% CI (4.10, 4.66)], birth interval [AOR = 0.92; 95% CI (0.87, 0.97)], residence [AOR = 1.43; 95% CI (1.35, 1.50)], community illiteracy [AOR = 0.91; 95% CI (0.86, 0.96)], and community poverty [AOR = 1.07; 95% CI (1.01, 1.14)] were significantly associated with consumption of animal-source foods.

CONCLUSION

Less than half of children aged 6 to 23 months consumed any type of animal-source foods in sub-Saharan African countries. Higher educational level, non-agricultural work, exposure to media, high economic status, having a mobile telephone, attending 4 + ANC visits, health facility delivery, PNC checkups, older children, a birth interval of 24 months, urban residency, community literacy, and low community poverty were determinates of good consumption of animal source foods. Women empowerment, dissemination of nutrition-related information through mass media, promotion of health facility delivery, and improving utilization of maternal health services are recommended to improve infant and child feeding practices.

Factors associated with infant and young child feeding practices in children aged 6-23 months in Indonesia: A nationwide study

INTRODUCTION

Children-related nutrition raises significant attention due to the low implementation of infant and young child feeding (IYCF) practices. However, the factors affecting the low implementation of IYCF remains limited globally. This study aimed to identify factors influencing IYCF in children aged 6-23 months in Indonesia.

METHODS

We conducted a cross-sectional study using data from the 2017 Indonesian Demographic and Health Survey. A total of 4943 responses were included. We employed binary logistic regression to determine the factors affecting IYCF practices in children aged 6-23 months. The results are reported as odds ratios (OR) with a 95% confidence interval (CI) and a significance level of p < 0.05.

RESULTS

Several factors significantly influenced IYCF practices among children aged 6-23 months, including the age of the child (OR: 0.42; 95% CI: 0.27-0.65), middle wealth index (OR: 1.85; 95% CI: 1.12-3.08), regional disparities (OR: 0.43; 95% CI: 0.23-0.77), place of residence (OR: 1.77; 95% CI: 1.17-2.68), and a history of childhood diseases like fever (OR: 1.65; 95% CI: 1.05-2.58).

CONCLUSION

This study highlights the significance of various factors related to IYCF practices among children aged 6-23 months. These factors include maternal aspects such as wealth index, child-related factors like age, a history of childhood illnesses such as fever, and environmental factors such as regional disparities and place of residence.

PRACTICE IMPLICATIONS

Paediatric nurses can contribute to enhancing maternal knowledge by providing education on the importance of infant and child feeding practices, beginning early in the child's life.

Socio-economic inequalities in and factors associated with minimum dietary diversity among children aged 6-23 months in South Asia: a decomposition analysis

OBJECTIVE

This study aimed to determine the factors associated with minimum dietary diversity (MDD) and estimate the socioeconomic inequalities in MDD among children from five South Asian countries.

DESIGN

Cross-sectional.

SETTING

The study used the most recent round of secondary databases of Demographic Health Survey data of Bangladesh (2017-2018), India (2019-2021), Maldives (2016-2017), Nepal (2018) and Pakistan (2017-2018).

PARTICIPANTS

This study used information on MDD and other explanatory variables from a total of 136 980 (weighted) children aged 6-23 months.

METHODS

Multivariable logistic regression was employed to identify the factors associated with MDD and concentration index (CIX) and Lorenz curve were used to measure the socioeconomic inequalities in MDD.

RESULTS

The overall weighted prevalence of MDD in South Asia was 23.37%. The highest prevalence of MDD was found among children from Maldives (70.7%), while the lowest was in Pakistan (14.2%). Living in affluent versus poor households, having a mother who is employed versus a mother who is unemployed, exposure to various forms of media (newspapers and magazines), seeking antenatal care (ANC) more than four times compared with those who sought ANC less than four times and having children older than 4 years old are the most common significant factors associated with MDD deficiency. This study found the value of the CIX for MDD (MDD: CI=0.0352; p<0.001) among children with a higher socioeconomic status, suggesting inequality in MDD in favour of the more among well-off households.

CONCLUSION

Inequality in the prevalence of MDD favours the affluent. Health policy and intervention design should prioritise minimising socioeconomic inequalities concerning the MDD. In addition, policy-makers should prioritise the associated factors of MDD such as education, wealth status, employment, media exposure while designing intervention or policies.

Minimum dietary diversity and consumption of ultra-processed foods among Brazilian children 6-23 months of age

The study aimed to estimate the prevalence of minimum dietary diversity (MDD) and consumption of ultra-processed foods in children 6-23 months of age according to sociodemographic variables. Three indicators of complementary feeding of 4,354 children from the Brazilian National Survey on Child Nutrition (ENANI-2019) were built based on a questionnaire about food consumption on the day before the interview: MDD, consumption of ultra-processed foods, and MDD without the consumption of ultra-processed foods. The prevalence and 95%CI were calculated, stratified by macroregion; race/skin color, education and work status of the mother or caregiver; enrollment in the Brazilian Income Transfer Program; household food security; sanitation; and child enrollment in daycare/school. The overall prevalence of MDD was 63.4%, with lower prevalences among children who lived in the North Region (54.8%), whose mothers or caregivers had 0-7 years of education (50.6%), and lived under moderate or severe food insecurity (52.6%). Ultra-processed foods were consumed by 80.5% of the children, with the highest prevalence in the North Region (84.5%). The prevalence of MDD without ultra-processed foods was 8.4% and less prevalent among children with black mothers or caregivers (3.6%) and among those whose mother or caregiver had 8-10 years of education (3.6%). The most frequently consumed food groups from the MDD indicator were grains, roots and tubers (90.2%), dairy products (81%) and those from ultra-processed food were sweet or salty cookies/crackers (51.3%) and instant flours (41.4%). The ubiquitous presence of ultra-processed foods in the diets of Brazilian children and the low frequency of diversified foods, especially among the most vulnerable populations, indicate the need to strengthen policies and programs to ensure adequate and healthy infant nutrition.

Wealth- and education-related inequalities in minimum dietary diversity among Indonesian infants and young children: a decomposition analysis

Background

Over the last two decades, Indonesia has experienced remarkable economic growth. However, the percentage of infants and young children meeting the minimum dietary diversity (MDD) criteria has stagnated. Despite the growing body of evidence of the association between MDD and socioeconomic factors, there is little information about socioeconomic inequalities in MDD in Indonesia.

Objectives

The current study seeks to quantify the wealth- and education-related inequalities in MDD among infants and young children in Indonesia and determine the contribution of different factors to these disparities.

Methods

We included a total of 5038 children aged 6–23 months of the 2017 Indonesia Demographic and Health Survey. We measured wealth- and education-related inequalities using the concentration curve and Wagstaff normalised concentration index. Using a concentration index decomposition analysis, we then examined factors contributing to wealth- and education-related inequalities in MDD.

Results

The concentration indices by household wealth and maternal education were 0.220 (p < 0.001) and 0.192 (p < 0.001), respectively, indicating more concentration of inequalities among the advantaged population. The decomposition analysis revealed that household wealth (29.8%), antenatal care (ANC) visits (16.6%), paternal occupation (15.1%), and maternal education (11.8%) explained the pro-rich inequalities in MDD in Indonesia. Maternal education (26.1%), household wealth (19.1%), ANC visits (14.9%), and paternal occupation (10.9%) made the most considerable contribution to education-related inequalities in MDD.

Conclusions

There is substantial wealth- and education-related inequalities in MDD. Our findings suggest an urgent need to address the underlying causes of not reaching dietary diversity by promoting infant and young child feeding equity in Indonesia.

Factors associated with complementary feeding practices among children aged 6-23 months in Indonesia

BACKGROUND

Complementary foods with breastfeeding are foods or drinks given to children aged 6-23 months to meet their nutritional needs. The non-optimal provision of complementary feeding influences malnutrition in children of this age.

AIMS

To analyze the factors associated with complementary feeding practices among children aged 6-23 months in Indonesia.

METHODS

A cross-sectional design was employed using data from the 2017 Indonesia Demographic and Health Survey. A total of 502,800 mothers with children aged 6-23 months were recruited through multistage cluster sampling. Data were analyzed using a logistic regression test to determine the correlation between predisposing, enabling, and reinforcing factors and complementary feeding practices.

RESULTS

A prevalence values of analysis showed that approximately 71.14%, 53.95%, and 28.13% of the children met MMF, MMD, and MAD, respectively. The probability of achieving minimum dietary diversity (MDD) was high in the following: children aged 18-23 months (odds ratio [OR] = 9.58; 95% confidence interval [CI] = 7.29-12.58), children of mothers with higher education (OR = 5.95; 95% CI = 2.17-16.34), children from households with upper wealth index (OR = 2.53; 95% CI = 1.85-3.48), children of mothers who received childbirth assistance by professionals (OR = 1.63; 95% CI = 1.20-2.20), and children of mothers who had access to the Internet (OR = 1.26; 95% CI = 1.06-1.50). Moreover, children from households with the upper wealth index (OR = 1.40; 95% CI = 1.03-1.91), children whose mothers were employed (OR = 1.19; 95% CI = 1.02-1.39) living in urban areas (OR = 1.28; 95% CI = 1.06-1.54) and children of mothers who received childbirth assistance by professionals (OR = 1.33; 95% CI = 0.98-1.82) were more likely to meet Minimum Meal Frequency (MMF). Finally, children aged 18-23 months (OR = 2.40; 95% CI = 1.81-3.17), of mothers with higher education (OR = 3.15; 95% CI = 0.94-10.60), from households with upper wealth index (OR = 1.41; 95% CI = 1.05-2.90) and born with professional childbirth assistance (OR = 1.82; 95% CI = 1.21-2.75) were significantly associated with minimum acceptable diet (MAD).

CONCLUSIONS

The findings revealed that the prevalence of MDD and MAD in Indonesia was low. Strategies such as improving health services, economic conditions, and education level of mothers are needed to improve infant and young child feeding in Indonesia.

Socio-economic inequalities in minimum dietary diversity among Bangladeshi children aged 6-23 months: a decomposition analysis

This study aimed to measure the socio-economic inequalities in having minimum dietary diversity (MDD) among Bangladeshi children aged 6-23 months as well as to determine the factors that potentially contribute to the inequity. The Bangladesh Demographic and Health Survey (BDHS) 2017-2018 data were used in this study. A sample of 2405 (weighted) children aged 6-23 months was included. The overall weighted prevalence of MDD was 37.47%. The concentration index (CIX) value for inequalities in MDD due to wealth status was positive and the concentration curve lay below the line of equality (CIX: 0.1211, p < 0.001), where 49.47% inequality was contributed by wealth status, 25.06% contributed by the education level of mother, and 20.41% contributed by the number of ante-natal care (ANC) visits. Similarly, the CIX value due to the education level of mothers was also positive and the concentration curve lay below the line of equality (CIX: 0.1341, p < 0.001), where 52.68% inequality was contributed by the education level of mother, 18.07% contributed by wealth status, and 14.69% contributed by the number of ANC visits. MDD was higher among higher socioeconomic status (SES) groups. Appropriate intervention design should prioritize minimizing socioeconomic inequities in MDD, especially targeting the contributing factors of these inequities.

Trends and Determinants of Dietary Diversity in Children Aged 6-59 Months in Ethiopia: Analysis of 2005-2016 Demographic and Health Survey

Background

Dietary diversity may be associated with health and optimum growth in children.

Objectives

In this study we analyzed the trends and determinants of minimum dietary diversity (MDD) among Ethiopian children aged 6 to 59 mo.

Methods

Ethiopian Demographic Health Survey (EDHS) data of 3 consecutive years (2005, 2011, and 2016) were analyzed. A total of n = 2396 (2005), n = 3385 (2011), and n = 3723 (2016) children aged 6 to 59 mo were included for measurement of trends and identification of the determinants of MDD. The associations between the study factors and MDD were investigated using multiple logistic regression analysis.

Results

The proportion of children who fulfilled the MDD decreased from 2.46% in 2005 to 1.57% in 2011 but sharply increased to 7.82% in 2016. Adjusted regression analysis revealed that exposure of mothers to media, particularly watching television, maternal education, and household wealth were associated with a greater likelihood of mothers providing diversified diets to their children across the 3 y of EDHS data.

Conclusions

A decrease in MDD was observed from the years 2005 to 2011, after which a sharp increase was noted in 2016. In all 3 y of the EDHS, media exposure, maternal education, and household wealth were the consistent factors positively affecting dietary diversity among children aged 6 to 59 mo. Future intervention programs to increase dietary diversity in children should emphasize improving access to media exposure, education, and antenatal care visits.

Individual and community-level factors associated with animal source food consumption among children aged 6-23 months in Ethiopia: Multilevel mixed effects logistic regression model

Background

Diversified diet in childhood has irreplaceable role for optimal growth. However, multi-level factors related to low animal source food consumption among children were poorly understood in Ethiopia, where such evidences are needed for decision making.

Objectives

To investigate the magnitude and individual- and community-level predictors of animal source food (ASF) consumption among children aged 6–23 months in Ethiopia.

Methods

We utilized a cross-sectional pooled data from 2016/19 Ethiopia Demographic and Health Surveys. A stratified two-stage cluster design was employed to select households with survey weights were applied to account for complex sample design. We fitted mixed-effects logit regression models on 4,423 children nested within 645 clusters. The fixed effect models were fitted and expressed as adjusted odds ratio with their 95% confidence intervals and measures of variation were explained by intra-class correlation coefficients, median odds ratio and proportional change in variance. The deviance information criterion and Akaike information Criterion were used as model fitness criteria.

Result

in Ethiopia, only 22.7% (20.5%-23.9%) of children aged 6–23 months consumed ASF. Younger children aged 6–8 months (AOR = 3.1; 95%CI: 2.4–4.1), home delivered children (AOR = 1.8; 1.4–2.3), from low socioeconomic class (AOR = 2.43; 1.7–3.5); low educational level of mothers (AOR = 1.9; 95%CI: 1.48–2.45) and children from multiple risk pregnancy were significant predictors of low animal source consumption at individual level. While children from high community poverty level (AOR = 1.53; 1.2–1.95); rural residence (AOR = 2.2; 95%CI: 1.7–2.8) and pastoralist areas (AOR = 5.4; 3.4–8.5) significantly predict animal source food consumption at community level. About 38% of the variation of ASF consumption is explained by the combined predictors at the individual and community-level while 17.8% of the variation is attributed to differences between clusters.

Conclusions

This study illustrates that the current ASF consumption among children is poor and a multiple interacting individual- and community level factors determine ASF consumption. In designing and implementing nutritional interventions addressing diversified diet consumption shall give a due consideration and account for these potential predictors of ASF consumption.

Methodological Aspects of Diet Quality Indicators in Childhood: A Mapping Review

Diet quality indicators (DQIns) are tools that aim to assess an individual's overall diet quality. Previous reviews focused mainly on health-related outcomes but did not provide detailed information about components, assessment variables, or important methodological issues for the development and application of DQIns in the pediatric age. The current mapping review aims to provide comprehensive guidance regarding DQIns developed through a priori methodology in children aged ≤14 y that have been applied worldwide. A mapping review was conducted, whereby 1665 original articles describing the development, modifications, and updates of DQIns, published up to June 26, 2020, in English and Spanish, were retrieved. A total of 139 articles were identified and classified into 13 subgroups. There were 10 overall DQIns: Healthy Eating Indexes (n = 25), Dietary Diversity Scores (n = 20), Diet Quality Indexes (n = 16), Food Variety Scores (n = 11), Healthy and Unhealthy Scores (n = 11), Feeding and Eating Indexes (n = 10), Diet Quality Scores (n = 5), Nutritional Adequacy and Micronutrients Indexes (n = 5), Dietary Guidelines Indexes (n = 5), and Other Healthy Diet Indexes (n = 13). Three additional subgroups of dietary and lifestyle indicators found were Mediterranean Diet Indexes (n = 10), Diet-Lifestyle Indexes (n = 5), and Breakfast Quality Indexes (n = 3). This compilation of DQIns will help researchers select the most appropriate tool for future epidemiological studies by considering a careful selection of information about the assessment components, scoring methods, and key methodological issues. The main limitations of this review are that, due to its nature, a risk-of-bias assessment was not performed and the article screening was completed in 2 databases (PubMed/MEDLINE and Scopus). More research is needed to identify health-related outcomes associated with DQIns in the pediatric population, using clearer and more standardized methodological criteria.

Trends and determinants of minimum dietary diversity among children aged 6-23 months: a pooled analysis of Indonesia Demographic and Health Surveys from 2007 to 2017

OBJECTIVE

To examine minimum dietary diversity (MDD) trends and determinants among children aged 6-23 months.

DESIGN

Secondary analysis of the Indonesia Demographic and Health Surveys (IDHS) between 2007 and 2017. The primary outcome was MDD, the consumption of at least five out of eight food groups (MDD-8). We included a total of 5015 (IDHS 2007), 5050 (IDHS 2007) and 4925 (IDHS 2017) children aged 6 to 23 months to estimate trends of MDD-8 and to identify factors associated with MDD-8. We used multiple logistic regression analysis adjusted for the complex sampling design to investigate the association between the study factors and MDD-8.

SETTING

Indonesia.

PARTICIPANT

A total of 14 990 children aged 6-23 months.

RESULTS

Over the 10 years, the percentage of children who consumed a diversified diet was 53·1 % in 2007, 51·7 % in 2012 and 53·7 % in 2017. Multivariate analyses showed that older age children, higher maternal education, maternal weekly access to media, paternal non-agricultural occupation, history of at least four antenatal care visits and wealthier households were associated with the increased odds of MDD-8. Children living in rural areas, Sulawesi and Eastern Indonesia, were less likely to eat a diversified diet.

CONCLUSIONS

The proportion of children meeting MDD-8 has stagnated in the last decade. Child, parental, health care, household and community factors are associated with MDD-8. Therefore, nutrition education programmes and behaviour change communication activities should target mothers and families from socio-economically and geographically disadvantaged populations.

The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study

Background: Despite the known importance of breastfeeding for women's and children's health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF's Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia's national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a "Social Return on Investment (SROI)" study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia's initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.

Young Children Feeding Practices: An Update from the Sultanate of Oman

Despite proven benefits, most countries fail to meet international targets for appropriate complementary and Breast Feeding (BF) practices. This study assessed feeding practices of children under two years of age and correlated them with family parameters in Oman, a high income country in the Eastern Mediterranean Region. Methods: Data from this study originated from the latest Oman National Nutrition Survey (ONNS). Assessment of children and their mothers’ socioeconomic, anthropometric, and nutritional variables was conducted at the household level. Evaluated feeding practices included age appropriate BF, diet diversity, and minimum acceptable diet (MAD). Results: Pairs of mothers and infants (n = 1344) were assessed. Early BF, exclusive BF at 6 months, infant formula, and iron rich meals were provided to 81, 29, 44, and 84% of children, respectively. Age appropriate BF and MAD were found in 58% and 35% of children, respectively. Low maternal education, younger age, low household income, and governorate negatively affected diet acceptability. Conclusion: Omani children successfully received early BF postpartum and consumed iron rich meals. Yet, rates of exclusive BF rates at six months and MAD for children under two were low. Comprehensive strategies should be placed to assess and influence children feeding practices in the Sultanate.

Formal maternal employment is associated with lower odds of exclusive breastfeeding by 14 weeks postpartum: a cross-sectional survey in Naivasha, Kenya

BACKGROUND

In many low- and middle-income countries, improvements in exclusive breastfeeding (EBF) have stalled, delaying reductions in child mortality. Maternal employment is a potential barrier to EBF.

OBJECTIVES

We evaluated associations between maternal employment and breastfeeding (BF) status. We compared formally and non-formally employed mothers in Naivasha, Kenya, where commercial floriculture and hospitality industries employ many women.

METHODS

We conducted a cross-sectional survey among mothers (n = 1186) from September 2018 to October 2019 at 4 postpartum time points: at hospital discharge (n = 296) and at 6 wk (n = 298), 14 wk (n = 295), and 36 wk (to estimate BF at 24 wk; n = 297) postpartum. Mothers reported their BF status and reasons for EBF cessation. We used multivariable logistic regression models to test the association between formal maternal employment and 3 outcomes: early BF initiation (within 1 h of birth), EBF at each time point, and continued BF at 9 mo. Models were informed by a directed acyclic graph: a causal diagram used to characterize the relationship among variables that influence the independent (employment) and dependent (BF status) variables.

RESULTS

EBF did not differ by employment status at hospital discharge or at 6 wk postpartum. However, formally employed mothers were less likely than those not formally employed to report EBF at 14 wk (59.0% compared with 95.4%, respectively; AOR: 0.19; 95% CI: 0.10, 0.34) and at 24 wk (19.0% compared with 49.6%, respectively; AOR: 0.25; 95% CI: 0.14, 0.44). The prevalence of continued BF at 36 wk did not differ by group (98.1% for formally employed compared with 98.5% for non-formally employed women; AOR: 0.80; 95% CI: 0.10, 6.08). The primary reasons reported for early EBF cessation were returning to work (46.5%), introducing other foods based on the child's age (33.5%), or perceived milk insufficiency (13.7%).

CONCLUSIONS

As more women engage in formal employment in low- and middle-income countries, additional supports to help prolong the period of EBF may be beneficial for formally employed mothers and their children.

Climate Change, Food Supply, and Dietary Guidelines

Food production is affected by climate change, and, in turn, food production is responsible for 20-30% of greenhouse gases. The food system must increase output as the population increases and must meet nutrition and health needs while simultaneously assisting in achieving the Sustainable Development Goals. Good nutrition is important for combatting infection, reducing child mortality, and controlling obesity and chronic disease throughout the life course. Dietary guidelines provide advice for a healthy diet, and the main principles are now well established and compatible with sustainable development. Climate change will have a significant effect on food supply; however, with political commitment and substantial investment, projected improvements will be sufficient to provide food for the healthy diets needed to achieve the Sustainable Development Goals. Some changes will need to be made to food production, nutrient content will need monitoring, and more equitable distribution is required to meet the dietary guidelines. Increased breastfeeding rates will improve infant and adult health while helping to reduce greenhouse gases.

Maternal diets matter for children's dietary quality: Seasonal dietary diversity and animal-source foods consumption in rural Timor-Leste

Improving the dietary quality of women and children is essential to reduce all forms of malnutrition. In this study, we assessed seasonal child and maternal dietary diversity and consumption of animal-source foods (ASF), using 1,236 observations from combined data collected among 167 mother-child dyads in rural Timor-Leste. We used generalized linear and logistic mixed-effects models to examine the dietary differentials of mothers and children in two agricultural livelihood zones and across the seasons, as well as to identify household and agroecological characteristics associated with children's dietary quality in relation to their mothers'. We found dietary quality to be marginally better in coastal than in mid-altitude zones. However, women's diets were strikingly poor, and their intake of ASF was lower than among children. Mothers exhibited preferential allocation patterns of specific ASF, dairy products and eggs, to children. The intake of ASF was predicted by seasonality. Flesh foods and red meat were much more likely to be consumed during the dry season, when cultural ceremonies are often performed. We found a positive and strongly significant association between children's dietary indicators-dietary diversity score, minimum dietary diversity and ASF consumption, and those of their mothers'. Maternal dietary quality and educational attainment, more so than agroecological characteristics, were explanatory factors of children's diet. Our study highlights that addressing the dietary quality of children in Timor-Leste would benefit from improving women's diets through better access to nutritious foods and to secondary education.

Evaluation of a Package of Behaviour Change Interventions (Baduta Program) to Improve Maternal and Child Nutrition in East Java, Indonesia: Protocol for an Impact Study

BACKGROUND

Over the past decade, the prevalence of stunting has been close to 37% in children aged <5 years in Indonesia. The Baduta program, a multicomponent package of interventions developed by the Global Alliance for Improved Nutrition, aims to improve maternal and infant nutrition in Indonesia.

OBJECTIVE

This study aims to assess the impact of the Baduta program, a package of health system strengthening and behavior change interventions, compared with the standard village health services on maternal and child nutrition.

METHODS

The impact evaluation uses a cluster randomized controlled trial design with 2 outcome assessments. The first uses cross-sectional surveys of mothers of children aged 0-23 months and pregnant women before and after the interventions. The second is a cohort study of pregnant women followed until their child is 18 months from a subset of clusters. We will also conduct a process evaluation guided by the program impact pathway to assess coverage, fidelity, and acceptance. The study will be conducted in the Malang and Sidoarjo districts of East Java, Indonesia. The unit of randomization is the subdistricts. As random allocation of interventions to only 6 subdistricts is feasible, we will use constrained randomization to ensure balance of baseline covariates. The first intervention will be health system strengthening, including the Baby-Friendly Hospital Initiative, and training on counseling for appropriate infant and young child feeding (IYCF). The second intervention will be nutrition behavior change that includes Emo-Demos; a national television (TV) advertising campaign; local screening TV spots; a free, text message service; and promotion of low-cost water filters and hygiene practices. The primary study outcome is child stunting (low length-for-age), and secondary outcomes include length-for-age Z scores, wasting (low weight-for-length), anemia, child morbidity, IYCF indicators, and maternal and child nutrient intakes. The sample size for each cross-sectional survey is 1400 mothers and their children aged <2 years and 200 pregnant women in each treatment group. The cohort evaluation requires a sample size of 340 mother-infant pairs in each treatment group. We will seek Gatekeeper consent and written informed consent from the participants. The intention-to-treat principle will guide our data analysis, and we will apply Consolidated Standards of Reporting Trials guidelines for clustered randomized trials in the analysis.

RESULTS

In February 2015, we conducted a baseline cross-sectional survey on 2435 women with children aged <2 years and 409 pregnant women. In February 2017, we conducted an end-line survey on 2740 mothers with children aged <2 years and 642 pregnant women. The cohort evaluation began in February 2015, with 729 pregnant women, and was completed in December 2016.

CONCLUSIONS

The results of the program evaluation will help guide policies to support effective packages of behavior change interventions to prevent child stunting in Indonesia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/18521.

Determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among Indonesian children

Global child feeding practices remain suboptimal. In this study, we assess the determinants of age-inappropriate breastfeeding, dietary diversity, and consumption of 3+ types of animal source foods (ASFs) using 11,687 observations from combined data from the Indonesian Demographic Health Survey of 2012 and 2017. We used linear and logistic regression after adjusting for the complex sampling design. Child's age and quality of antenatal care (ANC) were associated with all outcomes. Socio-economic status and labour force participation were positively associated with higher dietary diversity score, ASF consumption, and age-inappropriate breastfeeding. More ANC visits and having consultation at ANC were associated with more dietary diversity. Higher women's knowledge level was associated with more dietary diversity and consuming more ASF. Compared with western Indonesia, more children in eastern Indonesia were age-inappropriately breastfed and had lower dietary diversity. The Indonesian government needs to develop programmes to improve child feeding particularly in eastern Indonesia, focusing on improving dietary diversity and ASF consumption in poorer households and on prolonging breastfeeding in richer households. Women's labour force participation should be encouraged, but programmes for working mothers are also needed to support continued breastfeeding and to express breast milk. ANC and postnatal programmes need improved consultation sessions for child feeding.