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Article

Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia

by
Md. Tariqujjaman
1,*,
Md. Mehedi Hasan
2,3,
Mustafa Mahfuz
1,
Tahmeed Ahmed
1 and
Muttaquina Hossain
1
1
Nutrition and Clinical Services Division, icddr,b, Dhaka 1212, Bangladesh
2
Institute for Social Science Research, The University of Queensland, Indooroopilly, QLD 4068, Australia
3
Australian Research Council Centre of Excellence for Children and Families over the Life Course, The University of Queensland, Indooroopilly, QLD 4068, Australia
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(7), 4350; https://doi.org/10.3390/ijerph19074350
Submission received: 11 February 2022 / Revised: 13 March 2022 / Accepted: 22 March 2022 / Published: 5 April 2022
(This article belongs to the Special Issue Protecting, Supporting and Promoting Appropriate Breastfeeding in the 21st Century)
Browse Figures
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Abstract

:
This study aimed to explore variations in Infant and Young Child Feeding (IYCF) practices between different South Asian Countries (SACs) and within their sociodemographic characteristics including place of residence, mother age, mother education, child sex, and wealth quintiles within the SACs. We extracted 0–23 months age children’s data from the nationally representative survey of Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. Among all SACs, the early initiation of breastfeeding (EIBF) practice was 45.4% with the highest prevalence in the Maldives (68.2%) and the lowest prevalence in Pakistan (20.8%). Exclusive breastfeeding (EBF) practice was 53.9% with the highest prevalence in Nepal (67%) and the lowest prevalence in Afghanistan (42%). Only 13% of children had a minimum acceptable diet (MAD), with the highest prevalence in the Maldives (52%) and the lowest prevalence in India (11%). We found higher IYCF practices among the mothers with secondary or higher levels of education (EIBF: 47.0% vs. 43.6%; EBF: 55.5% vs. 52.0%; MAD: 15.3% vs. 10.0%), urban mothers (MAD: 15.6% vs. 11.8%), and mothers from the richest households (MAD: 17.6% vs. 8.6%) compared to the mothers with no formal education or below secondary level education, rural mothers and mothers from the poorest households, respectively. Mothers from the poorest households had better EIBF, EBF, and continued breastfeeding at 1-year (CBF) practices compared to the mothers from the richest households (EIBF: 44.2% vs. 40.7%; EBF: 54.8% vs. 53.0%; CBF: 86.3% vs. 77.8%). Poor IYCF practices were most prevalent in Afghanistan, Pakistan, and India.

1. Introduction

The first two years of life are considered to be the “window of opportunity” for a child’s physical, social, emotional, cognitive, and brain development [1]. Appropriate Infant and Young Child Feeding (IYCF) practices are imperative for a child’s physical and cognitive development [2]. These include timely initiation of breastfeeding, exclusive breastfeeding for the first six months of life, the continuation of breastfeeding for two years, and the introduction of nutritionally adequate, safe, and age-appropriate solid, semisolid, or soft foods at six months of age [3].
South Asia is one of the hubs for poor nutritional status and suboptimal and inappropriate IYCF practices [4]. Nearly half of the global undernourished children are living in South Asian Countries (SACs) [5]. Besides, more than half of the children were not timely initiated to breastfeeding (61%) or exclusively breastfeeding (54%) in South Asia [6]. Only breastfeeding is not sufficient to meet all the nutritional requirements of children while growing. An additional diet is recommended to children from six months of age to maintain optimum growth and development [7]. Unfortunately, only half of the children in SACs were started to feeding complementary foods at six to eight months of their age as recommended [8]. Insufficient quantities and inadequate qualities of complementary foods and inappropriate feeding practices have a detrimental effect on a child’s health [9,10,11].
Significant disparities in terms of household poverty and parental education exist in complementary feeding practices in some countries such as Bangladesh, India, Pakistan, and Nepal [12]. However, less is known about the disparities for the full suits of WHO-core IYCF indicators in SACs individually or as a whole across other dimensions of inequality such as child’s gender, mother’s age, mother’s education, wealth quintiles, and place of residence. This clearly states the extent to which the between and within-country disparities exist in IYCF practices in SACs remain unexplored. The pooled regional and country-specific estimates and their subpopulation are particularly important for targeting locations/populations, allocating resources, designing and implementing interventions, and revisiting policies at the regional and country levels. The lack of evidence on all core IYCF indicators at regional or country levels hinders the design, implementation, and promotion of IYCF practices at a greater level in SACs. This study, therefore, aims to explore the between and within-country variations of WHO’s core IYCF indicators in SACs. The findings generated from this study would help the program managers, academia, development partners, and policymakers to set priorities and formulate appropriate strategies targeting vulnerable countries and sociodemographic vulnerable groups to improve IYCF practices.

2. Materials and Methods

2.1. Data Sources

We used nationally representative macro-level (aggregated) data from the most recent cross-sectional surveys conducted during 2015–2018 under the Demographic and Health Survey (DHS) program in Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. Together we called these countries SACs as per DHS classification [13]. We were unable to include other SACs such as Bhutan and Sri Lanka due to the restrictions in public use of DHS data. The DHS program provides population-based information on a wide range of monitoring and impact evaluation indicators in the areas of population, health and nutrition, and their potential determinants. The DHS generally applies a uniform procedure by using a stratified multistage cluster sampling technique to conduct the surveys. The detailed information of DHS methodology, sampling procedure, and questionnaires have been published elsewhere [14,15,16,17,18,19].

2.2. Study Population

The IYCF practices are generally measured for the youngest children of 0–23 months of age by asking a prescribed set of questions to their mothers. Hence, we excluded the children of more than two years of age and their mothers. Additionally, we excluded observations with any missing values in our studied variables. Therefore, the study population of this study was the youngest children under two years of age and their mothers aged 15 to 49 years old.

2.3. Measurement of IYCF Indicators

In this study, we examined variations in the WHO’s eight-core age-specific IYCF indicators; which included early initiation of breastfeeding (EIBF), exclusive breastfeeding under 6 months (EBF), continuing breastfeeding at 1 year (CBF), the introduction of solid, semisolid, or soft foods (ISSSF), minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich or iron-fortified foods (CIRF). All these indicators were dichotomous (yes/no). The DHS collected the information from mothers on IYCF indicators by the 24-h dietary recall questionnaire. We used the standard definitions of WHO for constructing the core IYCF indicators [3]. The detailed definition and calculation of the IYCF indicators are presented in Supplementary Table S1. In this study, the IYCF indicators were calculated taking only the complete observations for each indicator excluding the missing observations for the respective indicators.

2.4. Exposure Variables

We included a spectrum of sociodemographic equity dimensions including the sex of the indexed child (male and female), age and education of their mother, place of residence (rural and urban), and wealth quintiles (poorest (1st quintile), poorer, middle, richer, and richest (5th quintile)). We used the variables that the DHS constructed for defining these equity groups. The DHS constructed the household wealth quintiles based on household characteristics and ownership of assets by principal component analysis [20]. We further stratified mothers by their age as 15–24, 25–34 years, and ≥35 years, and educational status as below secondary (no education and primary) and secondary or above (secondary or higher). The mother’s education was categorized considering the distribution of the level of education (low percentage of illiterate-primary and higher merge into below secondary and secondary or higher, respectively).

2.5. Statistical Analyses

Data analyses included descriptions of the study population. We calculated the percentage of all WHO’s eight-core IYCF indicators for all SACs from the original survey data. Further, the percentages of IYCF indicators were calculated across a spectrum of sociodemographic equity dimensions for each of the SACs. We adjusted the effect of complex survey design including country-specific sampling weights and clusters while estimating the percentages and the respective confidence intervals.
For pooled dataset, we denormalized the sampling weight [21] and created a new population-level weight by dividing the sampling weight by the denormalized weight. We also constructed a unique cluster variable by combining country and cluster numbers. The population-level weight and unique cluster were used to calculate the pooled estimates. The population-level weight was performed to avoid the effect of countries with a large population (such as India) balancing the countries with a smaller population (such as the Maldives). The Taylor series linearization approach was used to estimate the confidence intervals (where necessary) both for pooled and country-specific analyses [22]. These approaches were frequently applied in previous studies [23,24].
We calculated the absolute differences by subtracting the estimates of one group (e.g., male) from the estimates of another group (e.g., female) to examine the extent of the variation in IYCF indicators within the SACs. We applied the adjusted Wald test to test the significance of the changes in the IYCF estimates between the equity subgroups. We calculated the relative ratio by dividing the estimates of group A (e.g., poorest, rural, mother’s below secondary education and male) by the estimates of group B (e.g., richest, urban, mother’s secondary+ education and female). The relative ratio greater than 1 denotes the IYCF practices were greater in group A compared to group B, whilst the ratio lower than 1 denotes the opposite. The chi-square test and one-way analysis of variance were performed to see any statistically significant differences of sociodemographic factors across all six countries. We performed all the statistical analyses by using statistical software Stata version 15.0 SE. We used “svy” prefix in Stata to adjust the effect of complex survey design. The p-value of <0.05 was considered to be statistically significant for all two-sided tests performed.

3. Results

3.1. Sociodemographic Characteristics of the Participants in SACs

The analysis included 120,830 mother–child dyads from 6 SACs. Overall, 48.7% of the mothers were aged between 25 and 34 years with the highest percentage in Pakistan (54.5%) and the lowest percentage in Bangladesh (39.3%) in this age group. More than half (52.6%) of mothers completed secondary or higher education with the highest percentage in the Maldives (84%) and the lowest percentage in Afghanistan (11%). About half of the children were female with a mean age of 11 months. One-third of the mothers lived in urban areas in all countries, except in the Maldives and Nepal where 10% and 54% of mothers respectively lived in urban areas. Overall, 25% of households belonged to the poorest quintile and 14% of households belonged to the richest quintile. Significant disparities of wealth categories across countries were observed (Table 1).

3.2. Pooled Prevalence of IYCF Practices in SACs

In SACs, overall, 45.4% of mothers practiced EIBF whereas the prevalence of EBF and CBF was 53.9% and 82.8%, respectively. More than half (50.2%) of the children started solid, semisolid, or soft foods at 6 to 8 months of age. Only 21.9% of children were fed diversified foods, and the prevalence of MMF was 39.9%. Only 12.8% of children had MAD and 21.4% had CIRF (Figure 1). Mothers from the poorest households had more EIBF, EBF, and CBF practices compared to the mothers from the richest households (EIBF: 44.2% vs. 40.7%; EBF: 54.8% vs. 53.0%; CBF: 86.3% vs. 77.8%). On the contrary, mothers from the poorest households had inappropriate complementary feeding (ISSSF, MDD, MMF, MAD, and CIRF) practices compared to mothers from the richest households (Figure 2A). Urban mothers had better IYCF practices (except for EBF and CBF) than rural mothers (Figure 2B). Mothers with secondary or higher education practiced better IYCF than mothers with no formal education or below secondary level education (Figure 2C).

3.3. Between-Country Variations of IYCF Practices in SACs

The prevalence of IYCF practices varied across the SACs. The Maldives and Nepal had the highest percentages of EIBF (68.2%) and EBF (66.5%), whereas Pakistan and Afghanistan had the lowest EIBF (20.8%) and EBF (41.9%) practice respectively. The highest prevalence of CBF was in Nepal (94.5%) and the lowest prevalence was in Pakistan (67.2%). The prevalence of ISSSF was highest in the Maldives (82%) and lowest in India (46.2%). Further, the highest prevalence of MDD, MAD, and CIRF practices was in Maldives (MDD: 71.4%, MAD: 52.1%, and CIRF: 69.5%, respectively). The lowest prevalence of MDD, MAD, and CIRF was in Pakistan (18.5%), and India (MAD: 10.7% and CIRF: 17%), respectively. In terms of MMF, the highest prevalence was in Bangladesh (79.1%) and the lowest prevalence was in India (34.6%) (Figure 1).

3.4. Within-Country Variations in IYCF Practices in Individual SACs across Subgroups

The IYCF practices varied across sociodemographic subgroups within SACs. We found a higher disparity in IYCF practices among the poorest vs. richest groups. The disparity was remarkable in Maldives, 44.8% for CBF (poorest: 83.9% vs. richest: 39.1%). In Pakistan, it was 18.3% for EBF (poorest: 53.9% vs. richest: 35.6%), and 26.9% for MAD (poorest: 6.3% vs. richest: 28.8%). The prevalence of breastfeeding-related indicators (EIBF, EBF, and CBF) was better among the poorest households; whereas complementary feeding indicators (ISSSF, MDD, MMF, MAD, and CIRF) were better among the richest households (Figure 2A).
The relative gaps concerning sociodemographic subgroups in IYCF practices were also visible in SACs (Figure 3A–D). The poorest/richest gaps were highest in Pakistan for EIBF and EBF; in the Maldives for CBF, MDD, MAD, and CIRF; and in Afghanistan for ISSSF and MMF (Figure 3A). The EIBF and CBF practices were better in the rural areas of Maldives and EBF in the rural areas of Bangladesh. On the contrary, the complementary feeding indicators (ISSSF, MDD, MMF, MAD, and CIRF) were better in the urban areas in Afghanistan, Bangladesh, India, and Pakistan compared to their rural counterparts (Figure 2B). The better EIBF and CBF were observed among mothers with below secondary level education in Afghanistan, Bangladesh, and the Maldives. The complementary feeding indicators were lower in below secondary educated mothers in all countries except Afghanistan for ISSSF (Figure 2C). Absolute differences in IYCF practices for male vs. female children were minimal in all SACs (Figure 2D). The relative gaps in terms of residence, mother education, and child sex in IYCF practices were presented in Figure 3B–D. The variations of IYCF practices across mothers age were presented in Table S2.

4. Discussion

We explored the variations in IYCF indicators in 6 SACs—Afghanistan, Bangladesh, India, Maldives, Nepal, and Pakistan. We found suboptimal IYCF practices in EIBF, EBF, MDD, MAD, and CIRF in SACs with wider variations across the countries. The breastfeeding practices (EIBF, EBF) in Pakistan and Afghanistan were poor and India had poor complementary feeding practices (ISSSF, MMF, MAD, and CIRF) compared to other SACs. Large gaps in IYCF practices were observed in the poorest vs. richest, urban vs. rural, and less than secondary vs. secondary or higher maternal education groups.
Our pooled estimate revealed, about 45% of mothers initiated breastfeeding within one hour of childbirth. In country-specific analysis, Maldives had the highest prevalence (68.2%) of EIBF and Pakistan had the lowest (21%) which aligns with a recent finding [25,26]. The wider variation of EIBF in SACs might be due to socio-cultural, geographical location, and economic conditions among different populations [27,28,29]. We found more than half of children were exclusively breastfed in SACs. The highest EBF practice was in Nepal and the lowest was in Afghanistan. The possible reasons behind the low prevalence of EBF in SACs especially in Pakistan and Afghanistan would be the lack of political security for the proper implementation of the breastfeeding programs, poor health system policies, marketing of breast milk substitutes (BMS), and harmful traditional feeding practices [30,31]. All the SACs have laws and policies for preventing harmful practices and unethical promotion and marketing of BMS. However, most of the SACs are struggling to enforce these laws due to a lack of dedicated budget and manpower, weak monitoring system, and unpublished monitoring results [32,33]. Intensifying the market monitoring system in each SACs with proper budget and trained manpower could be a way to enforce the BMS laws and policies and could improve breastfeeding practices [34].
Nearly half of the infants in SACs started complementary feeding at the right age (ISSSF), which is lower than a recent LMICs study [25] and an Indian study [35]. We found only 14% of children in SACs, met the minimum acceptable diet criteria with the highest percentage was in the Maldives and the lowest percentage was in India. The MDD, MMF, and CIRF percentages were also low, 24%, 40%, and 23%, respectively. The scenario is similar for individual SACs as well. There are several reasons for the variations in complementary feeding (ISSSF, MDD, MMF, MAD, and CRIF) practices in SACs. These include maternal knowledge, conception, religious belief, cultural beliefs, differences in socio-economic and cultural characteristics [36,37,38]. An Indian study revealed that female elderly persons insisted mothers start complementary feeding only after one year for their children [39]. Another study in Pakistan revealed a lack of maternal knowledge and cultural beliefs as major barriers to complementary feeding [40].
We found higher breastfeeding practices among rural mothers (EBF, CBF), mothers from the poorest households, and mothers with secondary or higher education (EIBF, EBF). In contrast, lower complementary feeding practices were observed in the poorest and rural households. These findings are consistent with other studies from Bangladesh, India, Nepal, Sri Lanka, and Pakistan [12,41]. The low breastfeeding practices in urban and the richest households might be the employment of the urban mothers [42,43,44] and the affordability to buy BMS in the richest households [30,32]. Excessive workload, caesarean section delivery, discouragement and criticism inadequate creche facilities at the workplace, inadequate caregivers at home, inadequate knowledge about expressed milk are barriers to EBF for employed mothers [44,45]. Evidence suggested a baby-friendly workplace for employed mothers was effective for improving EBF practices [46,47]. Also, better knowledge, education, counselling, home support, six-months maternity leave, and flexibility at work are the enablers of exclusive breastfeeding for employed mothers in LMICs [44,48]. However, the low rate of complementary feeding in rural and the poorest households might be explained by the low purchasing capacity of diversified foods due to low income [49,50]. Interventions to improve complementary feeding should focus on these two vulnerable groups. In addition, we found lower complementary feeding among mothers with no formal education or below secondary education. This finding is consistent with a Pakistani study [51]. The low rate of complementary feeding among mothers with no formal education or below-secondary educated mothers could be explained by their lack of knowledge regarding the appropriate time to start and feed diversified complementary foods to their children [52,53]. Additionally, unemployment and lack of decision-making power might be another reason for the low rate of complementary feeding among the less educated mothers [39].
Among the SACs, Maldives had better IYCF practices. The Maldives developed national IYCF guidelines for promoting appropriate IYCF practices, developed the capacity of health care providers by training them for providing counselling to the caregivers on breastfeeding and complementary feeding [54]. The Maldives also initiated the Integrated National Nutrition strategic plan (INNSP). This plan includes interventions on exclusive breastfeeding, complementary feeding, growth monitoring, and micronutrient supplementation, [54] created advocacy groups and provided refresher training among doctors, nurses who working in the obstetrics and pediatrics department in health facilities to promote EBF [55]. The INNSP of Maldives identified the determinants of inadequate nutrient intake by children including breastfeeding and complementary feeding and initiated different intervention strategies to address them [56]. Other SACs, especially Afghanistan, Pakistan, and India should strengthen their IYCF policies by identifying the gaps in their national policies and programs to achieve optimal IYCF.
This study has several strengths. Similar sociodemographic factors have been considered for subgroups analyses for both country-specific and pooled data. We used the latest nationally representative data and unique methodology of DHS for all countries which reflects the up-to-date scenario of IYCF indicators and makes the comparison more robust. The comparison of IYCF indicators among countries helped us to identify vulnerable countries in terms of IYCF practices in SACs. Additionally, the subgroup analyses in different countries helped us to recognize the vulnerable groups who need immediate attention. Finally, the nationally representative large sample size was used which makes the evidence representative and generalizable. This study has a few limitations as well. We used age-specific sub-samples for calculating different IYCF indicators which reduced the estimated sample size. However, these sub-samples were large enough for pooled and country-specific analyses to make the estimates representative. The IYCF indicators were calculated based on the 24-h dietary recall-based subjective response from the mothers that might have caused recall bias. Since WHO constructed the IYCF indicators based on these recall responses [3], it could be considered the best possible approach for a nationally representative survey context.

5. Conclusions

This study concludes that the prevalence of IYCF practices varied substantially between and within countries, with IYCF practices were suboptimal in Afghanistan, Pakistan, and India. The breastfeeding-related indicators were suboptimal among the richest, urban, and mothers with secondary or higher-level education. The complimentary feeding-related indicators were suboptimal among the poorest, rural, and mothers with no formal or below secondary level education. Designing and scaling-up of indicator-specific tailored interventions targeting the identified population who are most at risk need to be implemented to enhance IYCF practices. In addition, a surveillance system should be placed to continuously monitor the progress and gaps in IYCF practices between and within countries. Future research should consider the identification of other factors causing suboptimal IYCF practices for specific marginalized populations to better inform interventions and policies for upgrading IYCF practices in SACs.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph19074350/s1, Table S1: Description of WHO eight-core IYCF indicators; Table S2: Prevalence of IYCF indicators across mother’s age.

Author Contributions

M.T., M.M.H., and M.H. conceptualized the paper. M.T. and M.M.H. managed and analyzed the data. M.T. prepared the first draft. T.A., M.M., M.M.H., and M.H. critically reviewed, edited, and commented on the subsequent and the final version of the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by icddr,b under rainy day grant for young scientist category.

Institutional Review Board Statement

This study was approved by the Institutional Review Board of icddr,b. The ethical clearance for the DHS data collection was reviewed and approved by the ICF Institutional Review board. The ICF International also provided technical assistance to the survey as part of its DHS programs (MEASURE DHS). The DHS obtained informed consent from the respondents before the onset of the interviews.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data of this study are publicly available. Data can be downloaded at https://dhsprogram.com/data/available-datasets.cfm (accessed on 3 April 2020).

Acknowledgments

The authors are grateful to MEASURE DHS, Calverton, MD, USA for granting permission to use the DHS datasets. icddr,b is grateful to the Governments of Bangladesh, Canada, Sweden, and the UK for providing core/unrestricted support.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Deki, P. Factors Affecting Early Childhood Growth and Development: Golden 1000 Days. Adv. Pract. Nurs. 2016, 1, 1–4. [Google Scholar] [CrossRef]
  2. Ayana, D.; Tariku, A.; Feleke, A.; Woldie, H. Complementary feeding practices among children in Benishangul Gumuz Region, Ethiopia. BMC Res. Notes 2017, 10, 335. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  3. United Nations Children’s Fund (UNICEF); World Health Organization (WHO). WHO: Indicators for Assessing Infant and Young Child Feeding Practices; WHO and UNICEF: Geneva, Switzerland, 2007; Volume 2007, pp. 1–19. ISBN 978-92-4-159975-7. [Google Scholar]
  4. Aguayo, V.M.; Menon, P. Stop stunting: Improving child feeding, women’s nutrition and household sanitation in South Asia. Matern. Child Nutr. 2016, 12, 3–11. [Google Scholar] [CrossRef] [Green Version]
  5. United Nations Children’s Fund (UNICEF). Children in South Asia; UNICEF: New York, NY, USA, 2021. [Google Scholar]
  6. United Nations Children’s Fund (UNICEF). The State of the World’s Children 2016—A Fair Chance For Every Child; UNICEF: New York, NY, USA, 2016. [Google Scholar]
  7. Liu, X.; Liao, X.; Ren, Q.; Luo, M.; Yang, L.; Lin, J.; Chang, J. Concerns regarding complementary feeding practices among urban Chinese mothers: A focus group study in Xi’an. J. Health Popul. Nutr. 2018, 37, 20. [Google Scholar] [CrossRef] [PubMed]
  8. Aguayo, V.M. Complementary feeding practices for infants and young children in South Asia. A review of evidence for action post-2015. Matern. Child Nutr. 2017, 13, e12439. [Google Scholar] [CrossRef] [Green Version]
  9. Kabir, I.; Khanam, M.; Agho, K.E.; Mihrshahi, S.; Dibley, M.J.; Roy, S.K. Determinants of inappropriate complementary feeding practices in infant and young children in Bangladesh: Secondary data analysis of Demographic Health Survey 2007. Matern. Child Nutr. 2012, 8, 11–27. [Google Scholar] [CrossRef] [PubMed]
  10. Black, R.E.; Allen, L.H.; Bhutta, Z.A.; Caulfield, L.E.; de Onis, M.; Ezzati, M.; Mathers, C.; Rivera, J. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008, 371, 243–260. [Google Scholar] [CrossRef]
  11. Saleem, A.F.; Mahmud, S.; Baig-Ansari, N.; Zaidi, A.K.M. Impact of Maternal Education about Complementary Feeding on Their Infants’ Nutritional Outcomes in Low- and Middle-income Households: A Community-based Randomized Interventional Study in Karachi, Pakistan. J. Health Popul. Nutr. 2014, 32, 623–633. [Google Scholar] [CrossRef]
  12. Senarath, U.; Agho, K.E.; Akram, D.E.S.; Godakandage, S.S.P.; Hazir, T.; Jayawickrama, H.; Joshi, N.; Kabir, I.; Khanam, M.; Patel, A.; et al. Comparisons of complementary feeding indicators and associated factors in children aged 6–23 months across five South Asian countries. Matern. Child Nutr. 2012, 8, 89–106. [Google Scholar] [CrossRef]
  13. United States Agency for International Development (USAID); International Coaching Federation (ICF). DHS Program; USAID: Rockville, MD, USA, 2021. [Google Scholar]
  14. National Institute of Population Research and Training (NIPORT); Mitra and Associates; International Coaching Federation (ICF). Bangladesh Demographic and Health Survey 2014; NIPORT: Dhaka, Bangladesh; Mitra and Associates: Dhaka, Bangladesh; ICF: Rockville, MD, USA, 2016. [Google Scholar]
  15. International Institute for Population Sciences (IIPS); International Coaching Federation (ICF). National Family Health Survey (NFHS-4), 2015–2016; IIPS: Mumbai, India, 2017. [Google Scholar]
  16. Ministry of Health, Nepal; New ERA; International Coaching Federation (ICF). Nepal Demographic and Health Survey 2016; Ministry of Health, Nepal: Kathmandu, Nepal, 2017. [Google Scholar]
  17. National Institute of Population Studies (NIPS) [Pakistan]; International Coaching Federation (ICF). Pakistan Demographic and Health Survey 2017–2018; NIPS: Islamabad, Pakistan; ICF: Rockville, MD, USA, 2019. [Google Scholar]
  18. Ministry of Health (MOH) [Maldives]; International Coaching Federation (ICF). Maldives Demographic and Health Survey 2016–2017; MOH: Malé, Maldives; ICF: Rockville, MD, USA, 2018. [Google Scholar]
  19. Central Statistics Organization (CSO); Ministry of Public Health (MoPH); International Coaching Federation (ICF). Afghanistan Demographic and Health Survey 2015; Central Statistics Organization: Kabul, Afghanistan, 2017. [Google Scholar]
  20. Rutstein, O.S.; Johnson, K. DHS Comaparative Reports, The DHS Wealth Index; USAID: Rockville, MD, USA, 2004. [Google Scholar]
  21. Elkasabi, M.; Ren, R.; Pullum, T.W. Multilevel Modeling Using DHS Surveys: A Framework to Approximate Level-Weights; USAID: Rockville, MD, USA, 2020. [Google Scholar]
  22. Publication, A.S.P. Stata Survey Data Reference Manual; Stata Press: College Station, TX, USA, 2021; ISBN 9781597180931. [Google Scholar]
  23. Ezeh, O.K.; Ogbo, F.A.; Stevens, G.J.; Tannous, W.K.; Uchechukwu, O.L.; Ghimire, P.R.; Agho, K.E. Factors associated with the early initiation of breastfeeding in economic community of West African States (ECOWAS). Nutrients 2019, 11, 2765. [Google Scholar] [CrossRef] [Green Version]
  24. Agho, K.E.; Ezeh, O.K.; Ghimire, P.R.; Uchechukwu, O.L.; Stevens, G.J.; Tannous, W.K.; Fleming, C.; Ogbo, F.A. Exclusive breastfeeding rates and associated factors in 13 “economic community of West African states” (ECOWAS) countries. Nutrients 2019, 11, 3007. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  25. Zong, X.; Wu, H.; Zhao, M.; Magnussen, C.G.; Xi, B. Global prevalence of WHO infant feeding practices in 57 LMICs in 2010–2018 and time trends since 2000 for 44 LMICs. EClinicalMedicine 2021, 37, 1–9. [Google Scholar] [CrossRef] [PubMed]
  26. Analysis, C.A.T.; Mallick, L.; Wang, W.; Farid, S. Initiation of Breastfeeding in Low- and Middle-Income. Glob. Health Sci. Pract. 2020, 9, 308–317. [Google Scholar]
  27. Nguyen, P.H.; Avula, R.; Headey, D.; Tran, L.M.; Ruel, M.T.; Menon, P. Progress and inequalities in infant and young child feeding practices in India between 2006 and 2016. Matern. Child Nutr. 2018, 14, e12663. [Google Scholar] [CrossRef] [PubMed]
  28. Sharma, I.K.; Byrne, A. Early initiation of breastfeeding: A systematic literature review of factors and barriers in South Asia. Int. Breastfeed. J. 2016, 11, 17. [Google Scholar] [CrossRef] [Green Version]
  29. Asim, M.; Asim, M.; Asim, M.; Ahmed, Z.H.; Hayward, M.D.; Widen, E.M. Prelacteal feeding practices in Pakistan: A mixed-methods study. Int. Breastfeed. J. 2020, 15, 53. [Google Scholar] [CrossRef]
  30. Benedict, R.K.; Craig, H.C.; Torlesse, H.; Stoltzfus, R.J. Trends and predictors of optimal breastfeeding among children 0–23 months, South Asia: Analysis of national survey data. Matern. Child Nutr. 2018, 14, e12698. [Google Scholar] [CrossRef]
  31. Rahimi, B.A.; Mohamadi, E.; Stanikzai, M.H.H.; Wasiq, A.W. Determinants of Exclusive Breastfeeding Practices in Kandahar, Afghanistan: A Cross-Sectional Analytical Study. Int. J. Pediatr. 2020, 8, 11125–11140. [Google Scholar] [CrossRef]
  32. Torlesse, H.; Raju, D. Feeding of Infants and Young Children in South Asia; UNICEF: New York, NY, USA; World Bank Group: Washington, DC, USA, 2018. [Google Scholar]
  33. International Baby Foods Action Network (IBFAN); World Health Organization (WHO); United Nations Children’s Fund (UNICEF). Marketing of Breast-Milk Substitutes: National Implementation of the International Code; UNICEF: New York, NY, USA, 2020; ISBN 978-92-4-156532-5. [Google Scholar]
  34. Barenners, H.; Guenther, S.; Sophie, G. Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned? J. Hum. Lact. 2015, 32, 20–27. [Google Scholar] [CrossRef]
  35. Dhami, M.V.; Ogbo, F.A.; Diallo, T.M.O.; Olusanya, B.O.; Goson, P.C.; Agho, K.E. Infant and young child feeding practices among adolescent mothers and associated factors in India. Nutrients 2021, 13, 2376. [Google Scholar] [CrossRef]
  36. Neogi, D. A wider regional disparities in terms of Human Development Index and Human Poverty Index have been reported in the Human Development Report of the I. Int. J. Humanit. Technol. 2010, 4, 259–266. [Google Scholar]
  37. Malhotra, C.; Do, Y.K. Socio-economic disparities in health system responsiveness in India. Health Policy Plan. 2013, 28, 197–205. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  38. Jejeebhoy, S.J.; Sathar, Z.A. Women’s autonomy in India and Pakistan: The influence of religion and region. Popul. Dev. Rev. 2001, 27, 687–712. [Google Scholar] [CrossRef]
  39. Manikam, L.; Prasad, A.; Dharmaratnam, A.; Moen, C.; Robinson, A.; Light, A.; Ahmed, S.; Lingam, R.; Lakhanpaul, M. Systematic review of infant and young child complementary feeding practices in South Asian families: The India perspective. Public Health Nutr. 2018, 21, 637–654. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  40. Manikam, L.; Sharmila, A.; Dharmaratnam, A.; Alexander, E.C.; Kuah, J.Y.; Prasad, A.; Ahmed, S.; Lingam, R.; Lakhanpaul, M. Systematic review of infant and young child complementary feeding practices in South Asian families: The Pakistan perspective. Public Health Nutr. 2018, 21, 655–668. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  41. Dhami, M.V.; Ogbo, F.A.; Osuagwu, U.L.; Agho, K.E. Prevalence and factors associated with complementary feeding practices among children aged 6–23 months in India: A regional analysis. BMC Public Health 2019, 19, 1034. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  42. Tadesse, F.; Alemayehu, Y.; Shine, S.; Asresahegn, H.; Tadesse, T. Exclusive breastfeeding and maternal employment among mothers of infants from three to five months old in the Fafan zone, Somali regional state of Ethiopia: A comparative cross-sectional study. BMC Public Health 2019, 19, 1015. [Google Scholar] [CrossRef]
  43. Gebrekidan, K.; Hall, H.; Plummer, V.; Fooladi, E. Exclusive breastfeeding continuation and associated factors among employed women in North Ethiopia: A cross-sectional study. PLoS ONE 2021, 16, 1–16. [Google Scholar] [CrossRef]
  44. Gebrekidan, K.; Fooladi, E.; Plummer, V.; Hall, H. Enablers and barriers of exclusive breastfeeding among employed women in low and lower middle-income countries. Sex. Reprod. Healthc. 2020, 25, 100514. [Google Scholar] [CrossRef]
  45. Hasan, A.M.R.; Smith, G.; Selim, M.A.; Akter, S.; Uz, N.; Khan, Z.; Sharmin, T.; Rasheed, S. Work and breast milk feeding: A qualitative exploration of the experience of lactating mothers working in ready made garments factories in urban Bangladesh. Int. Breastfeed. J. 2020, 15, 93. [Google Scholar] [CrossRef]
  46. Kimani-Murage, E.W.; Wilunda, C.; Macharia, T.N.; Kamande, E.W.; Gatheru, P.M.; Zerfu, T.; Donfouet, H.P.P.; Kiige, L.; Jabando, S.; Dinga, L.A.; et al. Effect of a baby-friendly workplace support intervention on exclusive breastfeeding in Kenya. Matern. Child Nutr. 2021, 17, e13191. [Google Scholar] [CrossRef] [PubMed]
  47. Vilar-Compte, M.; Hernández-Cordero, S.; Ancira-Moreno, M.; Burrola-Méndez, S.; Ferre-Eguiluz, I.; Omaña, I.; Pérez Navarro, C. Breastfeeding at the workplace: A systematic review of interventions to improve workplace environments to facilitate breastfeeding among working women. Int. J. Equity Health 2021, 20, 110. [Google Scholar] [CrossRef] [PubMed]
  48. Benedict, R.K.; Craig, H.C.; Torlesse, H.; Stoltzfus, R.J. Effectiveness of programmes and interventions to support optimal breastfeeding among children 0–23 months, South Asia: A scoping review. Matern. Child Nutr. 2018, 14, e12697. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  49. Gatica-Domínguez, G.; Neves, P.A.R.; Barros, A.J.D.; Victora, C.G. Complementary Feeding Practices in 80 Low-and Middle-Income Countries: Prevalence of and Socioeconomic Inequalities in Dietary Diversity, Meal Frequency, and Dietary Adequacy. J. Nutr. 2021, 151, 1956–1964. [Google Scholar] [CrossRef]
  50. Ryckman, T.; Beal, T.; Nordhagen, S.; Murira, Z.; Torlesse, H. Affordability of nutritious foods for complementary feeding in South Asia. Nutr. Rev. 2021, 79, 52–68. [Google Scholar] [CrossRef]
  51. Ali, M.; Arif, M.; Shah, A.A. Complementary feeding practices and associated factors among children aged 6–23 months in Pakistan. PLoS ONE 2021, 16, 1–21. [Google Scholar] [CrossRef]
  52. Rao, S.; Swathi, P.M.; Unnikrishnan, B.; Hegde, A. Study of complementary feeding practices among mothers of children aged six months to two years—A study from coastal south India. Australas. Med. J. 2011, 4, 252–257. [Google Scholar] [CrossRef]
  53. Nguyen, P.H.; Avula, R.; Ruel, M.T.; Saha, K.K.; Ali, D.; Tran, L.M.; Frongillo, E.A.; Menon, P.; Rawat, R. Maternal and child dietary diversity are associated in bangladesh, vietnam, and ethiopia. J. Nutr. 2013, 143, 1176–1183. [Google Scholar] [CrossRef]
  54. World Breastfeeding Trends Initiative. Assessment Report, Maldives; International Baby Food Action Network (IBFAN) Asia: Delhi, India, 2015; Available online: https://www.worldbreastfeedingtrends.org/uploads/country-data/country-report/WBTi-Maldives-2015.pdf (accessed on 10 February 2022).
  55. Integrated National Nutrition Strategic Plan 2013–2017. Maldives. 2017. Available online: https://extranet.who.int/nutrition/gina/sites/default/filesstore/MDV%202016%20Integrated%20National%20Nutrition%20Strategic%20Plan.pdf (accessed on 10 February 2022).
  56. Jangid, M.; Neupane, S.; Scott, S.; Nguyen, P.H.; Kim, S.S.; Murira, Z.; Torlesse, H.; Menon, P. Are Data Available for Tracking Progress on Nutrition Policies, Programs, and Outcomes in Bangladesh? International Food Policy Research Institute: Washington, DC, USA, 2021. [Google Scholar]
Ijerph 19 04350 g001 550
Figure 1. Prevalence of IYCF practices in South Asian countries.
Figure 1. Prevalence of IYCF practices in South Asian countries.
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Ijerph 19 04350 g002 550
Figure 2. Absolute gaps in the prevalence of IYCF indicators across equity dimensions in South Asian countries. EIBF = Early initiation of breastfeeding, EBF = Exclusive breastfeeding, CBF = Continued breastfeeding at 1 year, ISSSF = Introduction of solid semi-solid and soft foods, MDD = Minimum dietary diversity, MMF=Minimum meal frequency, MAD = Minimum acceptable diet, CIRF = Consumption of iron-rich or iron-fortified foods. Note: Absolute gaps were calculated by subtracting the estimates/prevalence of IYCF indicators of the richest groups from the poorest (in panel (A)), of urban from rural (in panel (B)), of secondary+ education from below secondary education (in panel (C)) and of female from the male (in panel (D)). *** denotes p-value < 0.001, ** denotes p-value < 0.01, and * denotes p-value < 0.05.
Figure 2. Absolute gaps in the prevalence of IYCF indicators across equity dimensions in South Asian countries. EIBF = Early initiation of breastfeeding, EBF = Exclusive breastfeeding, CBF = Continued breastfeeding at 1 year, ISSSF = Introduction of solid semi-solid and soft foods, MDD = Minimum dietary diversity, MMF=Minimum meal frequency, MAD = Minimum acceptable diet, CIRF = Consumption of iron-rich or iron-fortified foods. Note: Absolute gaps were calculated by subtracting the estimates/prevalence of IYCF indicators of the richest groups from the poorest (in panel (A)), of urban from rural (in panel (B)), of secondary+ education from below secondary education (in panel (C)) and of female from the male (in panel (D)). *** denotes p-value < 0.001, ** denotes p-value < 0.01, and * denotes p-value < 0.05.
Ijerph 19 04350 g002
Ijerph 19 04350 g003 550
Figure 3. Relative gaps in the prevalence of IYCF indicators across equity dimensions in South Asian countries. EIBF = Early initiation of breastfeeding, EBF = Exclusive breastfeeding, CBF = Continued breastfeeding at 1 year, ISSSF = Introduction of solid semi-solid and soft foods, MDD = Minimum dietary diversity, MMF = Minimum meal frequency, MAD = Minimum acceptable diet, CIRF = Consumption of iron-rich or iron-fortified foods. Note: Relative gaps were calculated by dividing the estimates/prevalence of IYCF indicators of the poorest (Q1) groups by the richest (Q5) (in panel (A)), of rural (R) by urban (U) (in panel (B)), of below secondary education (NPE) by secondary+ education (SHE) (in panel (C)) and of male (M) by the female (F) (in panel (D)).
Figure 3. Relative gaps in the prevalence of IYCF indicators across equity dimensions in South Asian countries. EIBF = Early initiation of breastfeeding, EBF = Exclusive breastfeeding, CBF = Continued breastfeeding at 1 year, ISSSF = Introduction of solid semi-solid and soft foods, MDD = Minimum dietary diversity, MMF = Minimum meal frequency, MAD = Minimum acceptable diet, CIRF = Consumption of iron-rich or iron-fortified foods. Note: Relative gaps were calculated by dividing the estimates/prevalence of IYCF indicators of the poorest (Q1) groups by the richest (Q5) (in panel (A)), of rural (R) by urban (U) (in panel (B)), of below secondary education (NPE) by secondary+ education (SHE) (in panel (C)) and of male (M) by the female (F) (in panel (D)).
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Table
Table 1. Socio-demographic characteristics of the study participants.
Table 1. Socio-demographic characteristics of the study participants.
Characteristics Pooled Data
(2015–2018)		Afghanistan
(2015 ¥)		Bangladesh
(2017–2018 ¥)		India
(2015–2016 ¥)		Maldives
(2016–2017 ¥)		Nepal
(2016 ¥)		Pakistan
(2017–2018 ¥)		p-Value
n (%)
n = 120,830		n (%)
n = 11,762		n (%)
n = 3411		n (%)
n = 97,935		n (%)
n = 1147		n (%)
n = 1919		n (%)
n = 4656
Mother’s Age
15–24 years52,217 (43.2)4293 (37.6)1883 (55.1)43,310 (47.0)258 (20.1)1034 (52.6)1439 (31.6)<0.001
25–34 years58,794 (48.7)5454 (44.8)1328 (39.3)48,028 (47.5)704 (61.9)786 (42.2)2494 (54.5)
≥35 years9819 (8.1)2015 (17.7)200 (5.6)6597 (6.7)185 (18.1)99 (5.2)723 (13.9)
Mother’s Education
<Secondary57,216 (47.4)10,751 (89.3)1174 (34.0)41,308 (40.8)190 (16.4)900 (48.7)2893 (63.1)<0.001
≥Secondary63,614 (52.6)1011 (10.7)2237 (66.0)56,627 (59.2)957 (83.6)1019 (51.3)1763 (36.9)
Child Sex
Male63,146 (52.3)6111 (52.0)1769 (52.0)51,299 (52.5)574 (59.6)1038 (53.8)2355 (50.3)0.280
Female57,684 (47.7)5651 (48.0)1642 (48.0)46,636 (47.5)573 (50.4)881 (46.2)2301 (49.7)
Child age,
mean (sd)		11.3 (6.6)10.6 (6.6)11.2 (6.9)11.4 (6.6)11.7 (6.8)11.8 (6.8)10.8 (6.6)<0.001 *
Place of Residence
Urban30,159 (25.0)2920 (24.2)1167 (26.7)22,790 (27.5)114 (9.9)1089 (53.6)2079 (33.1)<0.001
Rural90,671 (75.0)8842 (75.8)2244 (73.3)75,145 (72.6)1033 (90.1)830 (46.5)2577 (67.0)
Wealth Quantile
Poorest29,792 (24.7)2019 (17.8)724 (20.5)25,225 (24.8)311 (27.1)486 (21.0)1027 (21.5)<0.001
Poorer28,187 (23.3)2667 (20.0)712 (21)23,044 (22.0)327 (28.5)407 (21.2)1030 (19.1)
Middle24,750 (20.5)2676 (21.5)627 (19.2)19,765 (20.2)328 (28.6)413 (23.0)941 (21.5)
Richer20,959 (17.3)2654 (21.5)684 (20.5)16,336 (18.1)120 (10.5)371 (20.5)794 (18.6)
Richest17,142 (14.2)1746 (19.3)664 (18.8)13,565 (14.8)61 (5.3)242 (14.4)864 (19.3)
¥ Survey year; sd = standard deviation; * p-value was generated from one-way analysis of variance; other p-values were generated from Chi-square test.
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Tariqujjaman, M.; Hasan, M.M.; Mahfuz, M.; Ahmed, T.; Hossain, M. Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia. Int. J. Environ. Res. Public Health 2022, 19, 4350. https://doi.org/10.3390/ijerph19074350

AMA Style

Tariqujjaman M, Hasan MM, Mahfuz M, Ahmed T, Hossain M. Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia. International Journal of Environmental Research and Public Health. 2022; 19(7):4350. https://doi.org/10.3390/ijerph19074350

Chicago/Turabian Style

Tariqujjaman, Md., Md. Mehedi Hasan, Mustafa Mahfuz, Tahmeed Ahmed, and Muttaquina Hossain. 2022. "Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia" International Journal of Environmental Research and Public Health 19, no. 7: 4350. https://doi.org/10.3390/ijerph19074350

APA Style

Tariqujjaman, M., Hasan, M. M., Mahfuz, M., Ahmed, T., & Hossain, M. (2022). Between and Within-Country Variations in Infant and Young Child Feeding Practices in South Asia. International Journal of Environmental Research and Public Health, 19(7), 4350. https://doi.org/10.3390/ijerph19074350

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