Disparities in early initiation of breast feeding and prelacteal feeding: A study of low- and middle-income countries

Barriers and drivers to exclusive breastfeeding in Kyrgyzstan: a qualitative study with mothers and health workers

BACKGROUND

The WHO/UNICEF global nutrition target for exclusive breastfeeding for six months is at least 70% of infants by 2030. However, global prevalence rates are 48% with variations between countries and within regions. Kyrgyzstan has consistently high early breastfeeding initiation rates, yet exclusive breastfeeding for six months is 46%. This qualitative study addressed two research questions: (1) What are the barriers and drivers for mothers to exclusive breastfeeding in the first six months? (2) What are the barriers and drivers for health workers in primary care facilities to supporting exclusive breastfeeding in the first six months?

METHODS

The study took place from April to June 2023 in five sites (mix of urban and rural). Ten focus group discussions with 40 primary care health workers and 20 in-depth interviews with mothers of a child currently aged 6-12 months who initiated breastfeeding with this child were conducted. Mothers were purposively selected to represent four groups of infant feeding practices in the first six months: (1) exclusive breastfeeding, (2) breastfeeding alongside other fluids/solids, (3) breastfeeding alongside infant formula, (4) breastfeeding followed by switching to formula only. The Capability-Opportunity-Motivation-Behaviour (COM-B) model was the underpinning theoretical framework. Data were analysed using the Framework approach.

RESULTS

The study uncovered important misperceptions amongst mothers who were not exclusively breastfeeding (groups 2-4). These existed alongside a perceived inability to resolve physical challenges of breastfeeding and social pressure to supplement breastmilk with fluids/solids or formula. Half of all mothers felt uncomfortable breastfeeding in public. Health workers were recommending and supporting women with exclusive breastfeeding during multiple antenatal and postnatal interactions during the initial six months. They were knowledgeable and motivated to do this. Moreover, they felt well supported with training, resources, and legislation with just a few mentioning workplace time or space challenges. Very few doctors appeared to currently be meeting with formula industry representatives.

CONCLUSIONS

This theory-informed qualitative study focusing on mother and health worker perspectives provided important insights into the individual and contextual barriers and drivers to exclusive breastfeeding for the first six months in Kyrgyzstan. These insights have informed recommendations for tailored interventions for both groups.

Beliefs, Experiences, and Practices of Lady Health Workers in Facilitating Breastfeeding in Rural Communities in Pakistan

Pakistan has extremely poor breastfeeding indicators: fewer than half of infants under 6 months are exclusively breastfed, only 20% of infants are breastfed within the first hour of life, and nearly half are never fed colostrum. The country's high infant morbidity and mortality is in part due to this suboptimal infant feeding. A network of lady health workers (LHWs) employed by the government facilitate maternal and child health programs, including breastfeeding support in their communities. This study describes LHWs' perspectives and experiences regarding breastfeeding. We conducted semi-structured interviews with 14 LHWs and used thematic qualitative analysis to code and analyze the data. Our research revealed that LHWs use their role as members of the community and involve influential members of the family to build trust. Frequent home visits beginning prenatally help them address misconceptions about infant feeding. While they have strong knowledge about the benefits of breastfeeding and the importance of colostrum, they demonstrate gaps in their knowledge regarding breast conditions, the safe preparation of human milk substitutes, the physiology of milk production, and supporting mothers who are separated from their baby. Future training should address these areas where LHWs lack knowledge to help mothers facilitate early and exclusive breastfeeding. With adequate training, LHWs are uniquely positioned to use their role as trusted members of the community to effectively counsel families on the importance of breastfeeding and support the clinical needs of women during the perinatal time.

Do various types of prelacteal feeding (PLF) have different associations with breastfeeding duration in Indonesia? A cross-sectional study using Indonesia Demographic and Health Survey datasets

INTRODUCTION

Prelacteal feeding (PLF) is anything other than breastmilk given to newborns in the first few days of birth and/or before breastfeeding is established. PLF comes in many forms and is known as a challenge to optimal breastfeeding. Interestingly, both breastfeeding and PLF are common in Indonesia. This study investigated the association between PLF (any PLF, formula, honey, water and other milk) and breastfeeding duration.

METHODS

This study used Indonesia Demographic and Health Surveys data from 2002, 2007 and 2017. Sample sizes were 5558 (2007), 6268 (2007) and 6227 (2017) mothers whose last child was aged 0-23 months. We used Cox regression survival analysis to assess the association between PLF and breastfeeding duration, estimating hazard ratios (HR) for stopping earlier.

RESULTS

Overall PLF was prevalent (59%, 67% and 45% in 2002, 2007 and 2017, respectively), with formula being the most common (38%, 50% and 25%). No association between any PLF and breastfeeding duration in 2002 (HR 0.90 (95% CI 0.70 to 1.16)), but in 2007 and 2017, mothers who gave any PLF were more likely to stop breastfeeding earlier than those who did not (HR 1.33 (95% CI 1.11 to 1.61) and 1.47 (95% CI 1.28 to 1.69), respectively), especially in the first 6 months (HR 2.13 (95% CI 1.55 to 2.92) and 2.07 (95% CI 1.74 to 2.47), respectively). This association was more consistent for milk-based PLF. For example, HR in 2017 was 2.13 (95% CI 1.78 to 2.53) for prelacteal formula and 1.73 (95% CI 1.39 to 2.15) for other milk. The associations were inconsistent for the other PLF types. Prelacteal water showed no association while prelacteal honey showed some association with a longer breastfeeding duration in 2002 and 2007.

CONCLUSION

The impact of PLF on breastfeeding duration varied by type. While this study supports current recommendations to avoid PLF unless medically indicated, the potential consequences of different PLF types on breastfeeding outcomes should be clearly communicated to healthcare providers and mothers. Further research should explore the reasons for the high PLF prevalence in this setting.

Pre-lacteal feeding practice and its associated factors among mothers with children under the age of two years in Dubti town, Afar region, North East Ethiopia: a community based mixed study design

Background

Pre-lacteal feeding prevents the early initiation of breastfeeding and exclusive breastfeeding. It is understudied in Afar, a pastoral region in northeast Ethiopia. The study assessed the prevalence of pre-lacteal feeding practice and its associated factors among mothers with children under the age of two years in Dubti, North East Ethiopia.

Methods

A community-based mixed-study design was employed. A systematic sampling technique was used to recruit 370 study participants for the quantitative study, while purposive sampling was used to select 17 study participants for the qualitative study. Logistic regression analysis was used to determine the association between independent variables and dependent variable. The results of logistic regression analysis were presented as an odd ratio with a 95% CI. A P-value <0.05 was used as a cutoff point to determine statistical significance. The qualitative data were analyzed using a thematic approach.

Results

Pre-lacteal feeding was practiced by 36% of mothers. Afar ethnicity (AOR = 2.5, 95% CI: 1.2-5.1), an extended family size (≥5) (AOR = 1.73, 95% CI: 1.02-2.9), a birth interval of less than 2 years (AOR = 2.77, 95% CI: 1.59-4.82), the first birth order of an indexed child (AOR = 3.87, 95% CI: 2.14-7.0), male-indexed children (AOR = 2.95, 95% CI: 1.67-5.2), and no antenatal care visits (AOR = 2.67, 95% CI: 1.67), or once or twice antenatal visits were significantly associated with pre-lacteal feeding practice. Breastfeeding counseling (AOR = 0.38, 95% CI: 0.2-0.7) and delivery at a health institution (AOR = 0.3, 95% CI: 0.17-0.55) were protective factors of pre-lacteal feeding practice. The most common pre-lacteal foods were dairy products, water, and certain plant species. Cultural beliefs are the main reason for practicing these pre-lacteal feedings.

Conclusion

A significant number of study participants practiced prelacteal feeding. A public health campaign emphasizing the importance of antenatal care follow-ups should be initiated. Breastfeeding counseling and delivery in a health facility should also be strengthened. Community health education about the disadvantages of pre-lacteal feeding practices should be provided to reduce traditional beliefs.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Estimating the prevalence of exclusive breastfeeding with data from household surveys: Measurement issues and options

The importance of breastfeeding for infant and maternal health is well established. The World Health Organization recommends that all infants be exclusively breastfed until they reach 6 months of age. The standard indicator to measure adherence to this criterion is the percentage of children aged 0-5 months who are currently being exclusively breastfed. This paper proposes supplementary measures that are easily calculated with existing survey data. First, for an accurate assessment of the WHO recommendation, we estimate the percentage of infants who are being exclusively breastfed at the exact age of 6 months. Second, an adjustment is proposed for prelacteal feeding. These two modifications, separately and in combination, are applied to data from 31 low-and middle-income countries that have participated in the Demographic and Health Surveys Program since 2015. There is considerable variation in the effects across countries. The modifications use existing data to provide a more accurate estimate than the standard indicator of the achievement of the exclusive breastfeeding until 6 months recommendation.

Prelacteal feeding and its relationship with exclusive breastfeeding and formula consumption among infants in low- and middle-income countries

Background

Early feeding practices are important determinants of optimal feeding patterns later in life. We aimed to investigate if giving any fluids or foods other than breast milk during the first three days after birth (prelacteal feeds) affects exclusive breastfeeding and consumption of formula among children under six months of age in low and middle-income countries (LMICs).

Methods

We conducted a retrospective cohort study using data from 85 nationally representative Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) in LMICs (2010-2019). We considered three exposures: any prelacteal feeding (PLF), milk-based only prelacteal feeding (MLK), and water-based only prelacteal feeding (WTR), according to the DHS/MICS definition. The outcomes were exclusive breastfeeding, based on the World Health Organization definition, and consumption of formula among infants under six months of age. We used Poisson models adjusting for sociodemographic indicators, antenatal care, birth assistance, and early initiation of breastfeeding to estimate the effects of the exposures on the outcomes. Findings were grouped by each country, as well as by regions of the world and national income classification.

Results

We included data from 91 282 children. PLF, MLK, and WTR had a prevalence of 33.9% (95% confidence interval (CI) = 33.6-34.2), 22.2% (95% CI = 21.9-22.4), and 9.4% (95% CI = 9.2-9.6), respectively. Exclusive breastfeeding and consumption of formula had a prevalence of 35.2% (95% CI = 34.9-35.5) and 27.7% (95% CI = 27.4-28.0), respectively. In the crude analysis, children who were given PLF were 40% less likely to be exclusively breastfed (prevalence ratio (PR) = 0.60; 95% CI = 0.56-0.64) and nearly twice more likely to receive formula (PR = 1.89; 95% CI = 1.72-2.08); the direction of the associations was the same across income groups and regions of the world. In the adjusted analysis, the observed crude effects were only slightly reduced (exclusive breastfeeding - PR = 0.62; 95% CI = 0.59-0.66, consumption of formula - PR = 1.72; 95% CI = 1.59-1.85). MLK showed a stronger impact on the outcomes than PLF, especially for formula consumption (adjusted PR = 1.81; 95% CI = 1.67-1.97) and in low-income countries. WTR was only negatively associated with exclusive breastfeeding (adjusted PR = 0.69; 95% CI = 0.63-0.75), but not with formula consumption (adjusted PR = 1.09; 95% CI = 0.99-1.20).

Conclusions

Feeding babies prelacteal foods shortens exclusive breastfeeding duration and increases the likelihood of formula consumption in children under six months of age in LMICs. Pro-breastfeeding interventions must be prioritized during antenatal care and throughout the stay in the maternity facility to properly protect, support, and promote exclusive breastfeeding since birth.

Early initiation of breastfeeding is inversely associated with public and private c-sections in 73 lower- and middle-income countries

Although studies in low- and middle-income countries (LMICs) have examined the effects of c-sections on early initiation of breastfeeding (EIBF), the role of the place of birth has not yet been investigated. Therefore, we tested the association between EIBF and the type of delivery by place of birth. Data from 73 nationally representative surveys carried out in LMICs between 2010 and 2019 comprised 408,013 women aged 15 to 49 years. Type of delivery by place of birth was coded in four categories: home vaginal delivery, institutional vaginal delivery, c-section in public, and c-section in private health facilities. We calculated the weighted mean prevalence of place of birth and EIBF by World Bank country income groups. Adjusted Poisson regression (PR) was fitted taking institutional vaginal delivery as a reference. The overall prevalence of EIBF was significantly lower among c-section deliveries in public (PR = 38%; 95% CI 0.618-0.628) and private facilities (PR = 45%; 95% CI 0.54-0.566) compared to institutional vaginal deliveries. EIBF in c-sections in public facilities was slightly higher in lower-middle (PR = 0.650, 95% CI 0.635-0.665) compared to low (PR = 0.544, 95% CI 0.521-0.567) and upper-middle income countries (PR = 0.612, 95% CI 0.599-0.626). EIBF was inversely associated with c-section deliveries compared to institutional vaginal deliveries, especially in private facilities compared to public ones.

Effects of COVID-19 Pandemic on Nutritional Status, Feeding Practices, and Access to Food Among Infants and Children in Lower and Middle-Income Countries: a Narrative Review

Purpose of Review

The COVID-19 pandemic has affected children across the planet and the consequences on their health, nutritional status, and social structure have been more pronounced in low- and middle-income countries (LMICs). This review will focus on the effects of the COVID-19 pandemic on infant growth and feeding practices and access to food and obesity prevalence among children in LMICs. An electronic search was performed on MEDLINE and Embase to identify relevant articles in the English language.

Recent Findings

A higher prevalence of infections by the SARS-CoV-2 virus and a lower mortality rate were found in children in LMICs compared to western countries. In 2020, 22% and 52% of the wasting and deaths in children under 5 years of age in LMICS came from the sub-Saharan Africa region, respectively. Despite the decrease in stunting from 40% in 1990 to 24.2% in 2019, the prevalence remains above 30% in LMICs. Regarding breastfeeding practices in LMICs, many organizations recommend breastfeeding for infants and children born to infected mothers with SARS-CoV-2. This pandemic has resulted in higher food insecurity and disruption to access to health care and nutrition-related programs from schools; this situation has been more detrimental for younger children from LMICs.

Summary

Given the devastating effects of the COVID-19 pandemic on the nutritional status, higher food insecurity, and lack of access to health care for infants and children in LMICs, efforts from government, world organizations, and non-for-profit institutions should be implemented to ameliorate the effects of this pandemic.