|Year : 2014 | Volume
| Issue : 2 | Page : 78-84
Determinants of child feeding practices in Pakistan; secondary data analysis of demographic and health survey 2006-07
Mubashir Zafar1, Zafar Fatmi2, Khalid Shafi3
1 School of Public Health, Dow University of Health Sciences, Karachi, Pakistan
2 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
3 Department of Community Medicine, Dow University of Health Sciences, Karachi, Pakistan
|Date of Web Publication||6-May-2014|
School of Public Health, Dow University of Health Sciences Karachi
Source of Support: None, Conflict of Interest: None
Background: In Pakistan, poor infant and young child feeding practices are contributing to the burden of infectious diseases and malnutrition.
Objective: This study aimed to estimate the determinants of selected feeding practices and key indicators of breastfeeding in Pakistan.
Materials and Methods: Total 5718 children aged 0 to 23 months from the Pakistan Demographic and Health Survey of 2006-2007 were included. WHO recommended infant and young child feeding indicators were estimated, and selected feeding indicators were examined against a set of individual-, household-, and community-level variables using univariate and multivariate analyses.
Results: Only 26.3% of mothers initiated breastfeeding within the first hour after birth, 97.6% had ever breastfed, 92.5% were currently breastfeeding, and 62.7% were currently bottle feeding. Bottle feeding rates were higher among infants whose mothers partner had worked (OR = 1.66), had ever been employed (OR = 1.17), birth order > 5 (OR = 1.25) and in the Richest wealth quintiles (OR for the richest = 2.34). The likelihood of not initiating breastfeeding within first hour after birth was higher for mothers those who were not visited to the antenatal clinic (OR = 1.54), no post natal visits (OR = 1.45), working mother (OR = 1.76), delivery at facility based centre (OR = 1.95), richer households (OR = 1.77), birth order > 5 (OR = 1.67), and formally married women (OR = 2.31).
Conclusions: Breastfeeding practice indicators suggest that there is need for promotion of correct/recommended breastfeeding practices in the community. Breast feeding promotion should targeted those women who have younger age and working in the urban areas.
Keywords: Breastfeeding, child, mother, Pakistan, PDHS
|How to cite this article:|
Zafar M, Fatmi Z, Shafi K. Determinants of child feeding practices in Pakistan; secondary data analysis of demographic and health survey 2006-07. J Med Nutr Nutraceut 2014;3:78-84
|How to cite this URL:|
Zafar M, Fatmi Z, Shafi K. Determinants of child feeding practices in Pakistan; secondary data analysis of demographic and health survey 2006-07. J Med Nutr Nutraceut [serial online] 2014 [cited 2020 Mar 31];3:78-84. Available from: http://www.jmnn.org/text.asp?2014/3/2/78/131958
| Introduction|| |
The beneficial effects of breastfeeding are well known to health care professionals around the world. It is generally believed that breastfeeding directly promotes the overall health of child and results in decreased childhood morbidity and mortality. Breastfeeding is an important determinent of the nutritional status of the child, which in turn influences growth and development of child.  Early initiation of breastfeeding impacts on the health status of the child because the first milk colostrum contains antibodies that will protect the child from disease. Prolonged breastfeeding is also beneficial because it contains components which strengthen the child's immune system.  Many problems are associated with bottle feeding in the developing world, specifically in areas where sanitation condition is poor. Risk for contaminated water mix with milk is increased and this leads to increase morbidity and mortality of child.  Poor nutritional status is one of the most important health problems in Pakistan. In Pakistan, infectious diseases such as diarrhea and acute respiratory infections are the main cause of mortality and morbidity particularly in infants under 1 year of age. , Under nutrition among children under 5 years of age remains a major problem.  The importance of breastfeeding in the prevention of infectious diseases and under nutrition during infancy is well known. , The World Health Organization (WHO) infant feeding guidelines recommend that infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health.  Although breastfeeding is almost universal in Pakistan, the rates of exclusive breastfeeding of infants under 6 months of age are low. Cultural practices include feeding prelacteal foods, such as honey, sugar water, or mustard oil, immediately after birth, and this contributes to the low prevalence of exclusive breastfeeding. , Recent data show that 38% of children aged 2-3 months are exclusively breastfed and 23% of children are given complementary foods before the sixth month.  In addition, rates of bottle feeding are high, with 30% of infants aged 2-3 months being bottle fed. The rate of consumption of baby formula in infants aged 4-7 months has almost doubled since 2000 and is highest in urban areas. 
| Objective|| |
To estimate the prevalence of determinants of selected incorrect feeding practices and key indicators of breastfeeding practices in Pakistan.
| Materials and Methods|| |
Secondary data analyses of the PDHS 2006-07 were done. It was carried out under scientific and administrative supervision of National institute of Population studies (NIPS), during the time period 2006 to 2007.  This survey was collected information about demographic factors, socio-economic factors, and health status from a nationally representative probability sample of households.
The study design for this survey was a stratified, multistage, cluster sampling of households. Households consist of all urban and rural areas of four provinces of Pakistan. All ever-married women aged 12-49 years having one child born in last 5 years were eligible respondents for the women's questionnaire. The sample had yield interviewed with 10,000 ever married women aged 12-49. In first stage, 1000 sample points (clusters) were selected, 390 in urban areas and 610 rural areas, second stage, 100000 households were selected. As primary sampling unit was household; a national household weighing factor was used to maximize representativeness of the sample.
Data were collected according to a standard protocol. Two core survey questionnaires were used, i.e., the Household Questionnaire and the Woman's Questionnaire were translated into local languages and field tested. Subsequently, filled questionnaires were back-translated to English. These questionnaires were used in all four provinces of Pakistan. To minimize language barriers, the survey was administered by trained interviewers either in Urdu or principal language of the area or preferred language of the household. Further details of sampling design, training of survey team, survey management, and quality control measures are separately documented in the country reports published by NIPS. For our analyses, the respondents were evermarried women aged between 12 and 49 years who had given birth to at least one child. All these participants were asked about births during 5 years prior to the survey (interview) date. For each birth, details about place of birth, birth weight, gender and size of the baby at birth were asked.
The study was approved by the Ethical review committee of Dow university of Health Sciences, Karachi before conducting the study. Confidentiality was maintained and parents/guardian of participants was accordingly informed about their test results. Participants who are diagnosed with latent tuberculosis infection study were provided free treatment. No financial compensation was provided by the research study.
Studies feeding practice indicators and determinants of incorrect of feeding practices
Infant and young child feeding indicators as described by WHO  were estimated. These indicators include the timely first suckling rate (proportion of infants less than 12 months of age who first suckled within 1 hour after birth), the ever-breast rate (proportion of infants less than 12 months of age who were ever breastfed), the current breastfeeding rate (proportion of children less than 24 months of age who are currently breastfed), bottle feeding rate (proportion of infants less than 12 months of age who received any food or drink from bottle in previous 24 hours).
The explanatory variables were classified into two levels: Individual and household. The individual-level attributes included the child's sex, age; the mother 's age, whether she worked in the past 12 months, and her marital status; and the educated or not by the mother and the father had employed or not. Data on the number of antenatal clinic visits, place of delivery, mode of delivery, birth order of child, and postnatal contacts with health care providers were also obtained. The household wealth index was included as household-level variables. The wealth index  was constructed using principal components analysis to determine the weights for the index based on information collected about several household assets and facilities. This index was divided into five categories (quintiles) and each household was assigned to one of these categories.
Analyses were performed using SAS software version 9.1. Chi-squared tests were used to test the significance of association. In the univariate analyses, odds ratios with 95% confidence intervals were calculated in order to assess the unadjusted risk of selected adverse feeding practice outcomes due to studied variable/determinants. Multiple logistic regression was used in a stepwise backwards model to estimate the odds ratios adjusted for independent variables, and those with P < 0.05 were retained in the final model. Weight the sample because sample population not equally distributed, so subsampling technique were used from main sample.
| Result|| |
Socio-demographic characteristics of the sample
[Table 1] lists the individual and household characteristics of the surveyed children. Approximately one-third (27.36%) mothers were literate and 40.46% had worked. Male and female children of all age groups were almost equally represented in the sample. A total of 80.25% of the mothers had made at least one antenatal clinic visit during the pregnancy. Of the total births, 58.66% were home deliveries, and 41.34% had received assistance at birth from a trained health professional. Postnatal visits around 68.34% mothers had visit to health facility.
|Table 1: Individual- and household-level characteristics of children 0-24 months of age, PDHS 2006-07 (n=5718)|
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Infant and young child feeding indicators, 2006-07
As shown in [Table 2], of the total of 5718 children aged 0-23 months, a high proportion (92.5%) had been breastfed during the past 24 hours. A very high proportion (97.6%) of infants had ever been breastfed, but only 26.3% had initiated breastfeeding within the first hour after birth, indicating that a considerable proportion had been given either nothing or prelacteal foods immediately after birth.
|Table 2: Breastfeeding indicators among children 0 to 24 months of age, PDHS 2006-07|
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Differentials feeding indicators
[Table 3] summarizes the breastfeeding practice indicators according to individual-, household-, and community-level characteristics. The proportion of infants who were ever breastfed were greater in mother's age of 15-34 years, illiterate, normal delivery of baby, housewives, birth order 1-5, and delivery at home. The rate of timely initiation of breastfeeding was higher among children of more educated parents. The rate of timely initiation was lower for infants whose birth order was five or greater and it was higher for infants born in health facilities than for children born at home. Antenatal care was associated with a higher rate of timely first suckling. There was a high rate of current breastfeeding among mother's age of 15-34 years, illiterate, normal delivery of baby, housewives, birth order, delivery at home and there was little variation across the subcategories of wealth quintiles and ethnicity.
|Table 3: Rates of timely fi rst suckling, current breastfeeding, ever breastfeeding and bottle feeding by individual and household characteristics, PDHS 2006-07|
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The bottle feeding rate also did not differ according to the investigated health care characteristics, such as, place of delivery, among wealth quintile, sex of child, working status, but it more in whose husband worked, and Punjabi mothers in subcategory of ethnicity.
Determinant feeding indicators: Univariate and multivariate analyses
Unadjusted and adjusted odds ratios were calculated to estimate the effect of the independent variables on of two adverse infant feeding outcomes: Bottle-fed and no timely initiation of breastfeeding.
Risk factors of bottle feeding
As shown in [Table 4] the likelihood of bottle feeding after birth was higher in infants whose mothers had worked (OR = 1.17; 95% CI, 1.01 to 1.36; P < 0.03), birth order greater than five (OR = 1.25; 95% CI, 1.06 to 1.46; P = <.05).
|Table 4: Univariate and multivariate analysis showing association of bottle feeding with individual, household and community level characteristics, PDHS 2006-07|
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Risk factors for delayed initiation of breastfeeding
[Table 5] shows that the rate of no timely initiation of breastfeeding was higher in mothers of formerly married (divorce, widow (adjusted OR = 2.31; 95% CI, 1.29 to 4.39; P = 0.01).
|Table 5: Univariate and multivariate analysis showing association breastfeeding with individual, household and community level characteristics, PDHS 2006-07|
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| Discussion|| |
The results show that many important feeding indicators in Pakistan were at suboptimal level and it requires further improvement in order to fulfill the goal of optimal feeding for all infants and young children in Pakistan. This secondary data analysis shows that breastfeeding is almost universal in Pakistan, but the rates of timely initiation are very low. This pattern has been documented in other Middle eastern countries including UAE. 
Optimal infant and young child feeding is especially significant for Pakistan because of the high rates of infectious diseases. Breastfeeding has a highly protective effect against these illnesses.  Although almost all of the infants had ever breastfed, less than one-third were breastfed within 1 hour after birth. This low rate is a cause for distress and needs to be improved. Recent data have shown that the rate of timely initiation of breastfeeding is somewhat higher in Pakistan (26.34%) than in India (24%)  but is lower than that in Nepal (33.44%).  In Pakistan, the data presented here suggest that women who had more antenatal clinic visits were more likely to initiate breastfeeding in a timely manner. This reemphasizes that increasing the utilization of ante-natal care would have a positive effect on breastfeeding promotion. Further interventions to encourage women delivering at home to initiate early breastfeeding, possibly through education of key family members and traditional birth attendants and peer support, will be needed to improve rates of early initiation of breastfeeding, because the majority of deliveries in Pakistan take place at home.
An established approach to promoting appropriate breastfeeding practices in Pakistan is through the use of local peer counselors to provide information and support to mothers. , A recent meta-analysis of individual peer counseling for the promotion of exclusive breastfeeding found that the odds of exclusive breastfeeding in mothers receiving the counseling was "substantially increased in the neonatal period (15 studies; odds ratio [OR] 3.45; 95% CI 2.20-5.42, P < 0 .0001; random effects) and at 6 months of age (nine studies; 1.93, 1.18-3.15, P < 0.0001). , This approach needs to be scaled up in Pakistan to support breastfeeding, especially for women who have limited contact with health services.
The large geographic variation in breastfeeding rates may need to be studied further. Rapid urbanization and migration of the rural population to Karachi for work may have had an impact on breastfeeding rates, as most women in urban settings have to start work soon after delivery. Similarly, there seems to be a trend toward more educated and wealthy mothers being less likely to exclusively breast-feed their babies than less educated and less wealthy mothers, which suggests that interventions should be targeted at these women. In comparison with other countries in the region, Pakistan lags behind both India (46%)  and Bangladesh (53%).  Bottle feeding is common in Pakistan; more than 65% of children less than 12 month of age are fed with bottle with a nipple. Bottle feeding practices may potentially result in increased morbidity because of unsafe water and preparation facilities. The prevalence of bottle feeding in Pakistan is high, especially among families of higher socioeconomic status. Working mothers also have a significantly higher prevalence of bottle feeding and this indicates that legislation requiring employers to provide facilities for breastfeeding or expressing breast milk may have a positive effect in Pakistan. Marketing of breast milk substitutes in private facilities in cities such as Karachi and Lahore is common. Although there is legislation to limit the marketing of breast milk substitutes in Pakistan, there have been many breaches in recent years and continued monitoring is necessary. Peer counseling to support breastfeeding is one such approach that needs urgent evaluation in rural and urban populations in Pakistan.
| Conclusion|| |
Pakistan is a society in transition and traditional practices are being abandoned in favor of a more westernized lifestyle. The prevalence of most infant feeding indicators in Pakistan was low and need improvement in order to gain the full benefits of breastfeeding for child health and nutrition. A targeted breastfeeding promotion should start and messages focus on young mothers because they are most vulnerable group. It is also important to understand the factors responsible for the low rates of important breastfeeding indicators in women with better education and higher socioeconomic status, as this information should guide the design of interventions for this target group of women. The use of peer counseling to support appropriate breastfeeding should be scaled up.
| Acknowledgment|| |
The author is indebted to Professor Nighat Nisar of department of community medicine, Dow University of Health Sciences, Karachi, Pakistan for their help to carrying out your study.
| References|| |
Ashraf RN, Jalil F, Khan SR, Zaman S, Karlberg J, Lindblad BS, et al
. Early child health in Lahore, Pakistan: V. Fedding patterns. Acta Paediatr Suppl 1993;82:Suppl 390:47-61.
Boerma JT, Rutstein SO, Sommerfelt AE, Bicego GT. Bottle use for infant feeding in developing countries: Data from the demographic and health surveys. Has the bottle battle been lost? J Trop Pediatr 1991;37:116-20.
VanDerslice J, Popkin B, Briscoe J. Drinking-water quality, sanitation, and breast-feeding: Their interactive effects on infant health. Bull World Health Organ 1994;72:589-601.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS; Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65 -71.
Global Strategy for Infant and Young Child Feeding. World Health Organization, UNICEF 2003. Available from: http://whqlibdoc.who.int/publications/2003/9241562218.pdf. [Last accessed on 2010 May 4].
World Health Organization. Indicators for Assessing Breastfeeding Practices: Report of an Informal Meeting 11-12 June 1991. Geneva: WHO; 1991.
Patel A, Badhoniya N, Khadse S, Senarath U, Agho KE, Dibley MJ; South Asia Infant Feeding Research Netwoork. Infant and young child feeding indicators and determinants of poor feeding practices in India: Secondary data analysis of National Family Health Survey 2005-06. Food Nutr Bull 2010;31:314-33.
Pandey S, Tiwari K, Senarath U, Agho KE, Dibley MJ; South Asia Infant Feeding Research Network. Determinants of infant and young child feeding practices in Nepal: Secondary data analysis of Demographic and Health Survey 2006. Food Nutr Bull 2010;31:334-51.
Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al
.; Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child under nutrition and survival. Lancet 2008:371:417-40.
National institute of population studies. Available from: http://nips.gov.pk. [Last accessed on 2013 Nov 4].
UNICEF Statistics, Multiple Indicator Cluster Surveys (MICS) - Monitoring the situation of women and children 2008. Available from: http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html#64. [Last accessed on 2012 Nov 4].
Shahraban A, Abdulla K, Björksten B, Hofvander Y. Pattern of breast feeding and weaning in the United Arab Emirate. J Trop Pediatr 1991;37:13-6.
National Nutrition Programme Monitoring Report. Government of the People's Republic of Bangladesh. Dhaka: 2005.
UNICEF Statistics, Multiple Indicator Cluster Surveys (MICS) - monitoring the situation of women and children 2008. Available from: http://www.unicef.org/infobycountry/bangladesh_bangladesh_statistics.html#64. [Last accessed on 2013 Nov 4].
Bangladesh Breastfeeding Foundation. Surveillance study on breastfeeding and complementary feeding situation and nutritional status of mothers and children in Bangladesh-11 th
Round Survey. Dhaka: 2005.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]