Exclusive breastfeeding practices and its determinants in Indian infants: findings from the National Family Health Surveys-4 and 5

Our analysis showed that 31.3% and 43% of Indian infants from the NFHS-4 and 5 surveys, respectively, were exclusively breastfed for up to 6 months of age (151–180 days) which is low when compared to the reported national prevalence for India of 54.9% and 63.7%, respectively (as per the NFHS-4 and 5) survey reports [16, 17]. The reasons for this lower prevalence estimates in our analysis can be explained by the fact that for estimating EBF practices at 6 months of age, we included only age-appropriate children, that is children aged between 151 and 180 days at the time of the survey.

Our analysis estimates are lower than estimates from other cross-sectional studies conducted across India that have reported EBF percentages for up to 6 months as ~ 50% [30, 31]. Our analysis showed that EBF was 61.5% and 43% at four and 6 months of age, respectively (NFHS-5 survey). This finding is similar to the study from the neighboring country of Sri Lanka where EBF at 4 months was higher (62%) when compared to 6 months (16%) [32]. It is to be reiterated that NFHS surveys are based on maternal recall. In a study by Andarge et al. which assessed recall period accuracies found that one week recall period gave a more accurate estimate of exclusive breastfeeding practice than a 24-hour recall among infants younger than 6 months of age. This study by Andarge et al. found that the EBF was estimated at 71% from a single 24-hour recall, an overestimate when compared to 47% EBF computed from repeated weekly surveillance [33]. Given that the NFHS surveys for breastfeeding are based on a 24-hour recall, EBF at six months of age in our analysis was estimated at 43% which is very high compared to EBF of 2% from a longitudinal birth cohort study with bi-weekly surveillance [18].

The present analysis showed that the differences in EBF practices based on the infant’s gender at 6 months of age was statistically significant in the NFHS-4 data but did not hold true for the NFHS-5 data. This result is consistent with an urban cohort study conducted in Vellore, southern India [18, 19]. This is a notable and encouraging finding that gender disparities that existed in the past may have narrowed now in the Indian setting. EBF practice among scheduled tribes is known to be high, and this is substantiated by the present analysis [34]. The majority of scheduled tribes belong to low socioeconomic background, and the reason for the high rate of exclusive breastfeeding in this population could be attributed to the reduced financial access to breastfeeding substitutes or formula foods [34]. It is interesting to note that EBF practices as per the NFHS-5 survey were significantly higher among mothers who delivered at public healthcare facilities when compared to those who delivered at private healthcare facilities or at home. This clearly indicates an improved and expanded access to maternal/breastfeeding counselling and care at public health facilities that are providing early education and motivation to mothers, perhaps becoming pivotal in sustaining continued EBF for up to 6 months of age [35, 36]. Also, there is a possibility that mothers who deliver at public health facilities cannot afford breastmilk substitutes compared to those delivering at private health facilities. The NFHS-5 data further has highlighted that a higher number of antenatal visits during pregnancy (≥ 4) implied a greater chance of the mothers going on to exclusively breastfeed their infants for up to 6 months suggesting that healthcare workers (anganwadi workers/peripheral health nurses/doctors) during antenatal visits and follow-ups are playing a key role in educating and encouraging the mothers-to-be about the benefits of EBF along with support through other maternal healthcare programs and postnatal care facilities provided by the government [36‐38].

Young mothers (< 24 years) seemed to less likely breastfeed their infants exclusively up to 6 months. This can perhaps be attributed to the lack of awareness about the benefits and misconceptions regarding EBF [39‐41]. The same was seen with infants born with lower birth weight perhaps explained by the fact that these are high-risk infants requiring nursery care and support, delaying the initiation and continuation of EBF, and possibly put on formula feeds during and after nursery care [39‐41]. According to the NFHS-5 data, the higher the birth order, lower was the EBF practice for up to 6 months. This can possibly be explained by the fact that an increased family size demands the mother getting back to household chores early or work to avoid loss of wages, and thereby being unable to exclusively breastfeed her infant for the recommended 6 months due to greater and conflicting demands.

The Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) act, 1992 as amended in 2003 (IMS act) aligns with the objectives of the International Code of Marketing of Breastmilk Substitutes [42]. The IMS act has played a crucial role in India in controlling the promotion and advertisement of CMFs. The act prohibits pregnant women or mothers being contacted directly for the purpose of promoting infant milk substitutes or infant foods [43]. Additionally, it provides recommendations for healthcare workers on how measures could be taken to prevent being influenced by baby food manufacturing companies [43]. Notably, India is one of the few countries in Asia to implement the guideline fully and has ensured that breastfeeding is strictly not undermined by the marketing of breastmilk substitutes [44]. In addition to protecting breastfeeding practices from being influenced or impacted by commercial promotion of CMFs, the IMS Act also regulates the marketing practices of baby food manufacturers [43]. Also, the implementation of the IMS Act by the Breastfeeding Promotion Network of India (BPNI) in 49 districts has helped improving EBF rates [45]. During the last 10 years (2010–2020), breastfeeding in India has increased by 5% as a result of the IMS Act, Maternity Benefits Act (adopted in 2017 to extend paid maternity leave for upto 26 weeks), and the government’s ‘Mother’s Absolute Affection’ campaign that promotes breastfeeding through counselling [46].

This analysis that used the extensive, nationally representative NFHS-4 and 5 survey datasets covering all states and union territories of India, allowed the comparison of changes over time in EBF practices, and further to deduce factors influencing EBF, and this is the major strength of the study. In this study only eligible children who belonged to appropriate age groups were considered for analyzing the prevalence of exclusive breast feeding. However, a few limitations must be considered when interpreting the results of this analysis. In cross sectional surveys like these, estimates of EBF are based on maternal recall and this recall bias could potentially overestimate the prevalence of EBF practices reported. Despite these inherent limitations, there is overwhelming evidence that the NFHS surveys have provided valuable information on key population and health issues and have been instrumental in building India’s decision-making capacity and policies on health [17]. It is to be noted that NFHS data are collected by intensively trained staff, and the NFHS-4 and 5 surveys have a high response rate [17].

Qualitative studies to understand the driving factors among populations that have shown high exclusive breastfeeding rates such as among mothers from scheduled tribes and those who delivered at public healthcare facilities will help throw light to scale up the same amongst mothers of low birthweight babies in other Indian settings and backgrounds. Interventions and support targeted towards young mothers, mothers with low birth weight babies, and strongly encouraging mothers to initiate breastfeeding immediately after birth are some of the premises to be worked upon to enhance exclusive breastfeeding rates for up to 6 months in the Indian setting.