Breastfeeding, besides being natural and inexpensive, serves as the ideal source of infant nutrition. It is not only easily digestible and meets the dietary requirements of the newborn but also provides a number of unique biological and psychological benefits to the mother and child ¹ . If an infant is provided only breast milk and no additional food, water, or other liquids (with the exception of medicines, if needed) up to the sixth month of life, then that infant is considered to be exclusively breastfed (EBF) ² . A plethora of evidence endorse early initiation and maintenance of EBF till the recommended age as a key intervention against childhood malnutrition, especially for the low- and middle-income countries ^{3, 4} . It has been estimated that, globally, optimal breastfeeding and complementary feeding practices have the potential to prevent more than 200,000 infant deaths annually ⁵ . However, despite substantial efforts, only about one-fourth of infants worldwide receive EBF for the recommended duration i.e. six months ⁶ .

Providing prelacteal feeding, defined as giving something other than breast milk to an infant during the first three days of life, is an established custom in rural India and other developing nation ^{7, 8} . As the definition suggests, provision of prelacteal feeding entails that an infant is not exclusively breastfed. Additionally, prelacteal feeding is associated with various other sub-optimal breastfeeding practices such as not giving colostrum to the neonate and delayed initiation of breast feeding ⁷ . Therefore, prelacteal feeding is widely recognized as an important determinant of childhood malnutrition and, subsequently, childhood morbidity and mortality ⁸ .

Although the uptake of EBF in India has increased during the recent years, it is still far from optimal ⁹ . It is often seen that children are put on EBF during initial months of infancy but EBF is not continued till the recommended age ⁹ . Therefore, understanding the determinants of continuation of EBF is important for identifying the areas of intervention for childhood nutrition programs in India. The present study aimed to determine the association between provision of prelacteal feeding and continuation of EBF among 3 months old children in Bihar, an impoverished Indian state.

CARE India, a non-government organization, in collaboration with the State Government of Bihar, initiated a project named Integrated Family Health Initiative (IFHI) in 2011 with the primary objective of reducing mortality and malnutrition among infants and mothers in Bihar. As part of the evaluation of IFHI, multiple population based cross-sectional surveys were undertaken to ascertain various health and developmental indicators in the state ¹⁰ . In total, five rounds of these surveys (Rounds I-V), using lot quality assurance sampling (LQAS) technique (a small sample survey design based on binomial distribution) ¹¹ , were conducted in eight districts (from total 38) of Bihar between 2011 and 2013. A two-stage sampling strategy was adopted in each of the survey rounds: 1) from the list of Anganwadi Centers (village-level ‘last mile’ health service delivery points) in each of the 137 study blocks (sub-districts), 19 Anganwadi Centers were selected using probability proportional to size (PPS) sampling; 2) In the next stage, at the selected Anganwadi Center catchment areas, four eligible households were identified through systematic sampling. An eligible household was defined as that containing mothers of infants of four different age strata: 0–2, 3–5, 6–8, and 9–11 completed months. The sampling methodology has been described in a previous article ¹² . In the current analysis, we used the information about infants aged 0–2 completed months during Round-II to Round-V of the LQAS survey (Extended data ¹³ ).

Two separate outcome indicators for EBF were used – 1) exclusive breastfeeding in the last 24 hours (previous day’s morning to current day’s morning), and 2) practice of EBF since birth (excluding the first 3 days of life). We tested the association of providing prelacteal feeding with the two outcome indicators using separate bivariate and multiple logistic regression models. The multiple logistic regression models were adjusted for the following covariates – child’s gender, number of living siblings, caste, religion, economic status of the household, maternal education level and season. Caste-wise, the families were classified into marginalized caste [scheduled castes (SC) / scheduled tribes (ST) / other backward castes (OBC)] and other/general caste. Religion categories were Hindu and non-Hindu. According to the level of education, mothers were classified into three categories – no formal education, school education up to eighth standard, and school education above eighth grade (middle school). Economic status was assessed using an asset index (AI) based on possession of 25 different household items. For calculation of AI, a relative weight was assigned to each of these items and an aggregated score was generated by adding the weighted score for each item possessed by a household. The cumulative asset scores were then log-transformed to create the AI. Based on the percentile distribution of AI, we then created AI tertiles and classified the families according to the AI tertile they belonged to – low, middle and high wealth ¹² . As seasonal variations have been reported to influence breastfeeding practices in rural Bihar ¹² , we further adjusted for the season of data collection. Based on the prevailing weather pattern in Bihar, we classified the interviews conducted during November to February as those conducted in ‘winter’ season, April to August as ‘summer’ and rest of the months as ‘autumn/spring’. All analyses were carried out using the survey data analysis procedures in SAS (version 9.4) using relevant sample weights and incorporating information about multi-stage sampling.

The current analysis utilized the information on 10,392 infants aged up to 3 months. Among these children, 8533 (82.11%) received only breastmilk during the previous 24 hours, while 5713 (54.97%) had been given nothing but breastmilk (excluding ORS and medicines) since the third day after birth. Out of 10,262 children for whom prelacteal feeding data was available, 2686 (26.17%) received some food other than breast milk during the first three days of life. Logistic regression analysis revealed that, compared to those without prelacteal feeding, infants who received prelacteal feeding had approximately 60% lesser odds of being breastfed exclusively during the previous 24 hours (adjusted odds ratio (AOR) = 0.39; 95% confidence interval (CI) = 0.33-0.47) and 80% lesser odds of receiving continued EBF since birth (AOR = 0.20; 95% CI = 0.17-0.24) [ Table 1].

EBF for the first six months has been recognized as a key intervention to meet India’s Millennium Development Goals (MDG) target regarding child malnutrition (MDG-1) and mortality (MDG-4) ¹² . Despite several programmatic measures, rate of increase in the uptake of EBF in India has been slow ¹⁴ . As India moves from the MDGs to the era of more demanding Sustainable Development Goals (SDG), identifying key intervention areas for improvement in EBF is an essential requirement for achieving the targets pertaining to childhood morbidity and mortality.

We found that about a quarter of families in rural Bihar provided prelacteal feed to neonates and those practicing prelacteal feeding were less likely to maintain EBF. Therefore, on one hand, awareness campaigns and other measures against the unwholesome practice of prelacteal feeding need to be reinforced; but more importantly, our findings suggest that the families proving prelacteal feed to neonates constitute a key group for targeted early interventions on EBF. In rural India, a team of ground level health workers called frontline workers (FLW) - comprising of Anganwadi workers (AWW) and Accredited Social Health Activist (ASHA) – help in reaching various services offered under ICDS and National Rural Health Mission programs to the mothers and children. As these cadre of health workers provide counselling on childhood nutrition e.g. EBF and complementary feeding during their pre- and post-natal home visits, they can be further equipped to intensify their focus on the families that report practicing prelacteal feeding. We recommend efforts to ensure active identification of these families during FLW home visits and to ascertain that they are subjected to EBF counselling and other programmatic measures on EBF maintenance.

Limitations - There were few limitations in the current study. First, owing to cross-sectional nature of the data we were often unsure about the temporal relation between the study parameters. This limited our ability to draw causal inferences from observed associations between dependent and predictor variables. Second, the information on breastfeeding practices was based on mothers’ report and not actual observation. Thus, there was possibility of social desirability bias as the mothers who were aware about EBF might have reported that they practiced the same even if they did not. The reported nature of data also made our analyses susceptible to recall bias - especially for the data on EBF for full six months. Finally, because the study was conducted in an economically backward region, the findings may not be generalizable to pan-India level and also among families belonging to higher socioeconomic strata.

The current study was approved by the `Institutional Committee for Ethics and Review of Research’ of Indian Institute of Health Management Research ( www.iihmr.org), Jaipur, India.

Verbal informed consent was obtained from each agreeing participant before the interview and measurements, after explaining the details of the study in a language that they could understand. Given that approximately 60% of the study participants did not have any formal education, the investigators opted for verbal consent instead of written consent.

The data underlying this study and data codebook is available from Open Science Framework.

OSF: Dataset 1. Data for Exclusive breastfeeding - LQAS R2-R5. https://doi.org/10.17605/OSF.IO/FM925 ¹³

This dataset is available under a CC0 1.0 Universal License.

Questionnaires used as part of this study are available from Open Science Framework.

OSF: Extended data. Data for Exclusive breastfeeding - LQAS R2-R5.

File - CARE LQAS Qre 0-2 R5_SA.pdf

https://doi.org/10.17605/OSF.IO/FM925 ¹³

Available under a CC0 1.0 Universal License