Association between lack
of exclusive breastfeeding
and diarrhoeal morbidity :
An analysis of national
datasets for
South Asia
Dr Seema Mihrshahi
School of Population Health
University of Queensland
[email protected]
Aim
to investigate the association between the
lack of exclusive breastfeeding and
morbidity (diarrhoeal disease) in infants
aged 0-6 months in the South Asian region
Background:
IYCF in South Asia is characterised by:
• less than ideal prevalence of exclusive
breastfeeding (ranging from 39-52%)
• low rates of initiation of breastfeeding
• a high prevalence of prelacteal feeding
in some countries
• early introduction of complementary
foods with low dietary diversity
• high rate of morbidity and mortality from
diarrhoeal diseases
Global causes of childhood deaths in 2010
Source: Liu et al. Lancet 2012; 379:2151-2161
Methods
•
•
•
Demographic and Health Survey (DHS) data from
Bangladesh 2007, Nepal 2006, Pakistan 2006-7;
National Family Health Survey 2005-6 from India
Exposure variable: Exclusive breastfeeding in infants
aged 0-6 months (24 hr recall)
Outcome variable: 2 week prevalence of diarrhoea
Has the child had diarrhoea in the last 2 weeks?
Methods 2
•
•
•
Confounders/covariates: gender, number of
siblings in household, urban/rural location, age
and education of mother, wealth index, place of
delivery, country, source of drinking-water*, place
of disposal of faeces*
Both individual country and pooled analysis
Multiple logistic regression analysis using STATA 11.0
*not used for pooled data as categories not harmonised
Prevalence of feeding practices among infants aged
0-6 months in Bangladesh, India, Nepal and Pakistan
Bangladesh
(n=510)
India
(n=4615)
n
n
%
Nepal
(n=473)
Pakistan
(n=947)
%
n
%
n
Overall
(N=6545)
%
n
%
Exclusive BF
218
42.7
2026
43.9
242
51.2
368
38.9
2854
43.6
Predominant BF
98
19.2
1158
25.1
90
19.0
161
17.0
1507
23.0
Partial BF
192
37.6
1326
28.7
139
29.4
392
41.4
2049
31.3
2
0.4
105
2.3
2
0.4
26
2.7
135
2.1
No BF
% Prevalence
Prevalence of diarrhoea among infants aged 0-6
months in Bangladesh, India, Nepal and Pakistan
Factors associated with diarrhoea among 0-6 month
old infants in four South Asian countries, 2005-07
individual country analysis
Country
Factors associated with morbidity from diarrhoea among 0-6 months infants
Bangladesh 2007
Higher risk
-
Lower risk
-
India 2005-06
Not exclusive breastfeeding
Exclusive breastfeeding
Crowded households (≥5 members)
Less crowded households (≤4 members)
No toilet facility in the household
Toilet facility in the household
Delivered at the health facility
Delivered at home
Nepal 2006
-
-
Pakistan 2006-07
Not exclusive breastfeeding
Exclusive breastfeeding
Working mother
Mother is not working
Poorer household
Wealthier household
Association between infant feeding practices and
diarrhoea during the previous 2 weeks among infants
aged 0-6 months in India, 2005-06 (n=4,615)
Type of feeding
Unadjusted
OR
95% CI
Adjusted
p
OR
95% CI
p
Exclusive breastfeeding
1.00
Predominant Breastfeeding
1.65
1.30, 2.11
***
1.53
1.17, 2.01
**
Partial Breastfeeding
1.50
1.21, 1.87
***
1.30
1.01, 1.68
*
No Breastfeeding
2.15
1.27, 3.65
**
2.11
1.18, 3.80
*
1.00
NS = Not Significant * p<0.05
** p<0.01
***p<0.001
Adjusted for infant’s age and gender, mother’s education level, type of place of residence, wealth index,
number of household member, type of toilet facility and place of delivery.
Pooled analysis:
final logistic
regression model
for the predictors
of diarrhoeal
disease
Variable
Exc BF
Gender
Mothers
age
Mothers
Education
Country
Wealth
Index
Place of
delivery
Adjusted OR
P value
No
1.51(1.21-1.85)
<0.001
Yes
1.0
-
Male
1.27 (1.04-1.53)
0.017
Female
1.0
-
15-19
1.0
-
20-34
1.30 (0.93-1.83)
0.120
35-49
1.20 (0.75-1.93)
0.445
None
1.39 (1.06-1.83)
0.017
Primary
1.35 (1.01-1.82)
0.043
Secondary
1.0
-
Bangladesh
1.0
-
India
2.73 (1.57-4.74)
<0.001
Nepal
3.10 (1.62-5.92)
0.001
Pakistan
8.70 (4.85-15.61)
<0.001
Poorest
1.0
-
Poor
1.13 (0.84-1.52)
0.423
Middle
1.18 (0.88-1.59)
0.261
Rich
0.83 (0.59-1.19)
0.321
Richest
0.72 (0.47-1.10)
0.125
Home
1.0
-
Health facility
1.10 (0.87-1.38)
0.438
Conclusions
•
•
•
•
Pooled OR for the risk of diarrhoea due to
not exclusive breastfeeding was 1.51 (1.211.85) p<0.0001
Other significant factors associated with
diarrhoea were mother’s education and
gender of the child
Factors that were associated with lack of
exclusive breastfeeding varied across
countries
Promotion efforts should be tailored to the
context
Limitations
•
•
•
Cross sectional analysis
Recall bias
Some important confounders were not
controlled for in the pooled analysis
(drinking water, toilet facilities)
Next steps
•
•
•
Harmonise the categories for important
confounders such as drinking water,
sanitation, toilet facilities for pooled data
Repeat analysis with latest datasets for
each county (+Sri Lanka)
Extend the analysis to use more IYCF
indicators ie. early introduction of solids,
dietary diversity
Thank you
•
•
•
University of Queensland Grant
Secondary analysis grant from SAIFRN
Co-authors: Kingsley Agho, Iqbal Kabir,
Upul Senarath, Kalpana Tiwari, Archana
Patel, Tabish Hazir, DS Akram, Seema Puri,
Michael Dibley