Prevalence and factors associated with complementary feeding practices among children aged 6–23 months in India: a regional analysis

Globally, childhood undernutrition is a major public health issue, particularly in developing countries [1]. In 2016, the World Health Organisation (WHO) estimated that 52 million children younger than 5 years were wasted, 17 million were severely wasted, 155 million were stunted and approximately 5% of under 5 deaths could be attributed to malnutrition [2]. Complementary feeding is described as the introduction of safe and nutritionally-balanced solid, semi-solid or soft foods in addition to breast milk for children aged 6–23 months [2]. Appropriate complementary feeding has been linked to optimal childhood nutrition. However, inappropriate complementary feeding practices remain an important aetiology for childhood undernutrition, a major source of disease burden among children under 2 years of age in many developing countries, including India [1, 3].

Appropriate complementary feeding is not only essential for child growth but also provides the foundations required for good health throughout life [2]. Evidence from South Asia suggests that there are wide disparities in complementary feeding practices. For example, India had the lowest proportion of children (15%) who met the minimum dietary diversity (MDD), followed by Nepal (34%) and Bangladesh (42%), while the highest proportion of children who met the MDD was in Sri Lanka (71%) [4]. The study also indicated that India had the lowest percentage of minimum acceptable diet (MAD, 9%) among breastfed children compared with Sri Lankan (68%), Bangladeshi (40%) and Nepalese (32%) children [4]. Although India has taken various steps (e.g., the implementation of the Integrated Child Development Scheme [2] and Anganwadi Services Scheme [5]) to improve the nutritional status of children, evidence suggests that appropriate complementary feeding practices remain low [6, 7]. This indicates the need for additional studies to examine why complementary feeding practices have not improved in the country. 

Previous nationwide studies conducted in India that utilised the 2005–2006 India Demographic and Health Survey (DHS) reported that limited access to health services, low socioeconomic status and no or low maternal education were associated with inappropriate complementary feeding practices [6, 7]. The findings from these studies may not be strictly applicable to the current Indian population due to wide differences in the sample sizes between the 2005–2006 and 2015–2016 India DHS. In the 2015–2016 India DHS, which is the data source for this study, approximately 572,000 households were selected from 1,210.2 million people based on the 2011 census list [8] compared with the 2005–2006 India DHS which selected about 110,000 households from 1,028 million people based on the 2001 census frame [9]. More importantly, the 2015–16 India DHS has been documented to serve as the standard for future nationwide surveys in India [8, 9]. This approach will provide valuable nationally representative data for investigating prevalence and factors associated with various health outcomes (including complementary feeding practices) in India.

To the authors’ knowledge, no past studies have provided a detailed regional analysis of the prevalence of complementary feeding practices, nor has there been an investigation of factors associated with complementary feeding outcomes by region based on the most recent nationally representative data for India (2015–16 India DHS). A detailed regional analysis is needed in India, given the significant disparities in the socioeconomic indicators in the country which has been shown to influence child health and nutritional status [10, 11]. The present study aimed to investigate the prevalence and factors associated with complementary feeding practices by region in India.

The present study found significant regional differences in the prevalence of complementary feeding practices among infants and young children aged 6–23 months in India, with the highest prevalence observed in the Southern and North-Eastern regions. Similarly, the analyses showed wide regional variations in the factors associated with complementary feeding practices in India, possibly reflecting differences in the socio-economic and cultural characteristics previously reported in Indian communities [10, 11, 19, 20]. Birth order was one of the most consistent factors associated with MDD, MMF and MAD in most regions. Key modifiable factors (higher household wealth status, higher maternal education, skilled-assisted deliveries and frequent ANC visits) that were associated with complementary feeding practices also varied across the regions in India.

Higher maternal education was associated with the introduction of complementary foods among mothers from the Southern, Central and Northern regions in India. This finding was consistent with previous reports from Ghana [21], Ethiopia [22‐24], and five European countries [25]. However, studies from Nepal [26] and Lebanon [27] suggested that there was no significant association between higher maternal education and complementary feeding practices. The relationship between higher maternal education and appropriate complementary practices could be due to the promotion of optimal maternal and child nutrition, and subsequent uptake of health information and health-seeking behaviour of educated mothers [28]. The present study also indicated that higher household wealth status was strongly associated with MDD, MMF and MAD, with marked variations across the regions in India. This finding possibly demonstrates the impact of household socioeconomic variability on childhood nutrition in many Indian communities [29]. Evidence from Pakistan [30] has suggested that there was a strong relationship between maternal education and socioeconomic status with malnutrition among children younger than 5 years, where educated mothers demonstrated better knowledge of child nutrition and; they were more likely to translate that information into practice [28].

In this study, frequent ANC (≥4) visits were associated with the introduction of complementary foods to infants of mothers from the Eastern and Central regions. Mothers who had at least four ANC visits were more likely to introduce complementary foods and have children who were more likely to meet the MDD compared with mothers who had no ANC visits. These findings may be attributed to a number of factors relating to non-use of ANC, including low maternal education, the cost associated with attending ANC service and a lack of awareness of the importance of ANC among mothers [31‐34]. Similarly, a study conducted in India indicated that lower ANC visits were related to delayed introduction of complementary foods [6]. Studies from Nepal [35] and Ethiopia [24] found a similar influence of ANC visits on the introduction of complementary feeding practices. In Pakistan, however, fewer ANC visits increased the odds of meeting MMF in children [36]. The identification of relevant health service factors for specific health outcomes has implications for improving health outcomes among vulnerable populations. Therefore, effective nutrition education and counselling (often provided during ANC visits) are needed in many Indian communities and should focus on at-risk regions and populations to maximise impacts of nutritional interventions (such as improving mothers’ infant feeding knowledge and practices) [37, 38]. In Bangladesh, for example, intensive counselling that was combined with a nationwide mass media campaign substantially improved the proportion of children who met MAD from 16 to 50%, an improvement of 68% [39]. Moreover, the involvement of various movie stars to promote appropriate complementary feeding practices through audio-visual media in Indian communities has been flagged as a strategy that needs to be explored to improve complementary feeding practices [40].

The present study showed that approximately 16% of mothers received assistance from a health professional during delivery. The small proportion of mothers who received skilled-assisted delivery compared to previous regional reports (50%) [16, 41], is possibly a reflection of the high prevalence of home deliveries in India [16]. This study also showed that skilled-assisted delivery increased the odds of introducing complementary foods to infants compared with mothers who had no skilled-assisted delivery in the Southern region of India, likely reflecting one of the importance of skilled-assisted birthing. In contrast, non-skilled assisted delivery increased the odds of meeting the MDD and MAD among infants of mothers from the East and Central regions in India. This indicates that women delivering in health facilities may not have been appropriately counselled about appropriate IYCF options or it could be a reflection of the availability and accessibility of local food types for infants. Mothers who had skilled-assisted delivery should benefit fully from the counselling provided by health professionals that involved IYCF practices [42]. In addition, skilled-assisted delivery offers the mother a unique opportunity to access appropriate child feeding information which can improve the mother’s capacity to challenge unfavourable information and infant feeding attitudes in the community [43]. Improving maternal health capacity and resources (such as increased skilled-assisted delivery for mothers) across Indian regions would not only have a significant impact on maternal health but also on complementary feeding practices.

Another finding of this study was that children in higher birth order (second and above) were more likely to be introduced to complementary feeding compared with those in the first-birth order, irrespective of the Indian region. A previous study conducted among Ethiopian women found significant associations between higher birth order and MDD [44]. Similarly, a community-based study found that higher birth order was associated with MAD [27], suggesting that an increased level of awareness of appropriate complementary feeding practices can be gained through experience from previous childbirth. Mothers became more experienced after nurturing their first babies, and this can possibly be translated to improve complementary feeding practices [27]. This implies that efforts aimed at improving complementary feeding practices in India should also target nulliparous mothers to maximise results of IYCF interventions.

The study indicated that higher maternal age (≥25 years) was associated with complementary feeding practices, with variations across the regions in India. Specifically, while older mothers were less likely to introduce complementary foods to their infants in the West and Central regions, Northern and Central, older mothers were more likely to have infants who met the MDD and MAD compared to younger mothers (< 25 years) in those regions. Such significant effects of maternal age on complementary feeding suggests that the mother’s experience may play a significant role in appropriate IYCF practices. Our findings are consistent with evidence from Nepal which indicated that children of older mothers (≥35 years) were more likely to meet MDD and MAD compared with children of younger mothers (< 20 years) [35]. Our study findings imply that IYCF policy and interventions should also focus on younger mothers who are likely to be primiparous women with little experience in IYCF practices.

The present study also indicated that women autonomy over household earnings and power over household purchases were associated with complementary feeding practices, with demonstrable regional variations across India. Specifically, our study demonstrated that children of mothers who had power over household earnings and decision making were more likely to meet MMF compared to their counterparts from Central India. Similar findings were observed in the Southern region for MDD. These results may be attributable to high maternal education, the freedom to exchange information and interact with other people outside of the family at social gatherings or markets and exposure to media [45, 46]. Also, higher power over the financial resources and mass media exposure may indicate a higher likelihood of better resources allocated for child nutrition [26, 45, 47, 48]. Our findings were consistent with various regional studies in India which indicated that maternal autonomy was associated with childhood nutrition [49‐51].

Various methodological limitations need to be considered when interpreting the study results. First, the information on the survey was based on interviews and subjective responses from mothers, and the results may be affected by recall bias. However, the analyses were restricted to the most recent child, alive and living with the respondent to reduce the potential effect of recall bias on the observed association. Second, the number of ANC visits were recalled by the mother who may have underestimated or overestimated the actual number of ANC visits. This may lead to a possible measurement misclassification bias, with subsequent under- or overestimation of the association between frequency of ANC visits and complementary feeding practices. Third, we were unable to assess all potential confounding factors (such as the type of local foods and cultural practices relating to IYCF, health worker’s knowledge of IYCF practices or family support systems and dynamics). This may have an impact on the association between the exposure and outcome variables. Lastly, the establishment of temporal association in this study is impossible given the use of cross-sectional data, where both the exposure and outcome variables were collected concurrently.

Despite these limitations, the study has strengths. Our study used the most recent and nationally representative data (NFHS-4) for India. The NFHS-4 data were obtained from a larger sample compared to previous national surveys, indicating that our findings are more representative of the Indian population in guiding up-to-date and evidence-based policy interventions. The data used are comparable across regions in India given that they were collected by trained personnel who used standardized questionnaires and methodology. The study findings are unlikely to be affected by selection bias as the survey yielded high responses rates, over 94%.

The study found regional variations in prevalence and factors associated with complementary feeding indicators across India. Southern region followed by the North Eastern region had a higher prevalence of complementary feeding practices compared with other regions. Mothers with higher education, those from wealthier households and mothers who made frequent ANC visits were more likely to have appropriate complementary feeding practices compared with mothers with no schooling, those from poorer households and mothers who made no ANC visits across Indian regions. This study suggests that efforts to improve complementary feeding practices must be context-specific and should target mothers with vulnerabilities, including those from poorer socioeconomic backgrounds and no ANC visits. Findings from this study would assist policy decision-makers and public health managers in resource allocation to improve complementary feeding practices in India.