Determinants of exclusive breastfeeding in rural South India

For optimal growth and development, the World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first 6 months of life. During this period, no other liquids or breastfeeding substitutes should be given to infants except for medicine or oral rehydration solution [1]. There is evidence to suggest that infants who are breastfed exclusively have 13% reduced risk of mortality compared to non-exclusively breastfed infants in low and middle income countries (LMICs) [2].

While breastfeeding rates have improved globally, disparities in breastfeeding practices persist particularly in rural and low resource settings [3‐8]. In LMICs, only 37% of children are breastfed exclusively for the first 6 months of life [9] and India is no exception. According to the National Family and Health Survey-4, on average only 56% of Indian mothers practiced EBF for the full 6 months [10]. As India leads the world in the number of preterm births, under 5 years malnutrition, and neonatal mortality, understanding the factors associated with exclusive breastfeeding can help improve the nutritional status for millions of infants. Furthermore, understanding factors that influence EBF practices can contribute to achieving the United Nations Sustainable Development Goal 3 (SGD3) of reducing neonatal mortality to at least as low as 12 neonatal deaths per 1000 live births by 2030 [11].

To identify factors associated with EBF in rural India, we assessed sociodemographic, birth characteristics, and breastfeeding practices among a cohort of 1292 rural mother-infant dyads in Mysore District in the south Indian state of Karnataka.

In this study of mother-infant dyads from a rural region of southern India, less than half of mothers practiced exclusive breastfeeding, which is lower than the national rate of 56.0% and Karnataka’s rural population rate of 58.2% [16]. The reasons for low rates of EBF among this population are unknown and warrant further study. The low rate of EBF is particularly concerning given the large percentage of preterm births (43.2%) found in this study and makes increasing exclusive breastfeeding an urgent priority. Similar to findings in other breastfeeding studies conducted in India and globally, EBF rates increased with greater maternal age [17‐21]. Our finding that women who delivered via caesarian section had higher odds of EBF though not statistically significant, differ from previous findings. Women with caesarian sections may have higher odds of EBF due to longer time spent in the hospital and perhaps greater opportunity to be coached in breastfeeding practices by healthcare providers. A range of 7 to 10 antenatal visits was associated with the highest odds of exclusive breastfeeding. Studies on the association between EBF and number of antenatal visits in India and other regions of South Asia are discordant [9, 19]. The benefits of breastfeeding should be emphasized during the initial antenatal visit to increase EBF rates among all mothers. Contrary to a breastfeeding study based on a nationally representative sample [19], lower education conferred greater odds of EBF in the present study. In general, higher rates of breastfeeding are associated with lower income and less formal education [9]. For women in rural Karnataka, we suspect higher odds of breastfeeding among women with no education to be related to the economic benefits of breastfeeding.

In the present study, the mothers most frequently reported discontinuation of EBF due to insufficient breastmilk. Mothers most frequently used complementary foods such as infant formula, animal milk, or water to wean or terminate breastfeeding. The feeling that breastmilk was insufficient is a common phenomenon worldwide and a typical response is to give the infant supplements from a very early age [18, 22, 23]. The mother’s concern about milk insufficiency may be explained by poor education regarding techniques to increase breastmilk. Despite these widespread concerns women are encouraged to continue breastfeeding as maternal milk production is finely tuned to the demand of the infant and therefore, consistent and exclusive breastfeeding is critical for stimulating milk production [24].

This study fills an important gap in knowledge regarding prevalence and determinants of EBF among rural women in the southern India. The large sample size and low loss to follow up rate confers greater statistical power and generalizability. The questionnaire was based on validated items from the India’s National Family Health Survey-3 [16]. There are limitations that should be considered when interpreting the results of this study. Participants were asked about breastfeeding practices at 15 days and 6 months after birth. It is possible that there is some degree of recall bias associated with the timing of the interviews and social desirability bias as some respondents may have over reported exclusive breastfeeding. The sample of mothers and infants was drawn from a single subdistrict in southern India, limiting the generalizability of this data to other regions of the world. In addition, the study did not assess physiological, psychological and social factors thought to influence breastfeeding. Future studies should explore factors such as parents and in-laws perceptions of breastfeeding [17], postnatal counseling [17], cultural and traditional practices, and nipple problems among rural South Indian women to identify where potential interventions could be initiated.

The results of this study reveal the need for health promotion to focus on the benefits of exclusive breastfeeding for both the infant and mother. Education should target new mothers and family members as the previous research suggests a strong influence of mother’s parents and in-laws on child rearing practices [17]. Breastfeeding education provided during pregnancy should be evaluated so that mothers learn the best techniques and benefits of breastfeeding.