Breastfeeding practices of women in developing countries are critical determinants of child survival

Item

Title: Breastfeeding practices of women in developing
countries are critical determinants of child survival
extracted text: SDA-RF-CH-1.47

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Background

Breastfeeding practices of women in developing
countries are critical determinants of child survival, mater
nal reproductive health, and population growth rates.
Breastfeeding for the first two years of life and beyond
protects the young child from infection, provides an ideal
source of nutrients, is a cost-effective and safe form of
feeding, fosters mother-child bonding, and lowers the risks
of early childhood deaths. In children not breastfed at all,
the risk of early death from diarrhea, respiratory disease.
and other common childhood illnesses rises dramatically
compared with children who are exclusively breastfed.
Breastfeeding also benefits the mother by helping the uterus
to retract, which can reduce postpartum blood loss, and
delaying the return of menses, thereby preventing a subse
quent closely spaced pregnancy. Indeed, the length and
nature of breastfeeding directly affect fertility, with the
period of amenorrhea being longer the longer a woman
breastfeeds her child and the longer she waits before
introducing other foods and liquids. Thus, for poor coun
tries where the prevalence of contraceptive use is low,
appropriately managed breastfeeding should be a key
component of reproductive health programs.
The purpose of the present study is to report and
compare breastfeeding and related young child feeding
practices in developing countries around the world. The
breastfeeding practices examined are those associated with
international breastfeeding recommendations and indicators, and encompass the timing of initiation of breastfeed
ing, the practice of exclusive breastfeeding, the frequency
A and duration of breastfeeding, the age of introduction and
f
types of complementary foods and liquids, and bottle
feeding. Other outcomes examined, related to fertility
control, include the duration of postpartum amenorrhea,
bstinence from sexual relations, insusceptibility to pregancy, and the proportion of women meeting the lactational
tnenorrhea method (LAM) criteria. The data are derived
■pm surveys conducted by the Demographic and Health
urveys (DHS) program in 37 countries in sub-Saharan
nca, the Near East/North Africa, Asia, and Latin
Derica/Caribbean from 1990 to 1996. For countries with
o DHS surveys during that period, or with a prior DHS or
FS (World Fertility Survey) survey, trends in breastfeedpractices in those countries are also analyzed. Over a
ter of a million children under the age of five years are
tded in the analyses.

1.1

OPTIMAL INFANT AND CHILD FEEDING
PRACTICES

Among the most important infant feeding practices as
defined by WHO and UNICEF are initiation of breastfeed
ing within about 1 hour of birth; frequent, on-demand
feeding (including night feeds); exclusive breastfeeding
(defined as breast milk only and no other foods or liquids)
for about the first 6 months of life; breastfeeding comple
mented with locally available and hygienically prepared,
appropriate foods from the age of around 6 months; in
creased breastfeeding during illness and recovery'; and
continued breastfeeding for up to 2 years of age or beyond,
while receiving nutritionally adequate and safe complemen
tary foods (WHA, 1994; WHO/UNICEF, 1990).

Early initiation of breastfeeding is important because
it fosters mother-infant bonding and takes advantage of the
newborn’s intense sucking reflex and alertness immediately
postpartum, which permits the newborn to benefit within
the first hour of life from the nutritional, antibacterial, and
antiviral properties of colostrum (Righard and Alade, 1990).
Early initiation of breastfeeding also stimulates breast milk
production and causes the uterus to retract, which can
reduce postpartum blood loss. Delayed initiation of
breastfeeding may result in the newborn being provided
with other sources of nourishment that can introduce
infection and delay lactogenesis (milk arrival) (PerezEscamilla et al., 1996).
Frequent, on-demand breastfeeding, including night
feeds, is important to ensure both that an infant receives
sufficient breast milk and that the supply of breast milk is
maintained. Frequent feedings also can help to prevent
problems of engorgement and sore nipples. On-demand
feeding is important to ensure that newborns regain their
birth weight (de Carvalho et al., 1983). Infants should be
breastfed 8 to 10 times every 24 hours and even more
frequently during the first month of life.
Exclusive breastfeeding, defined as breast milkas the
only source of infant food or liquid, meets nutritional
requirements (Cohen et al., 1994), satisfies fluid needs even
in hot and humid climates (Sachdev et al., 1991), and
protects against illness (Huffman and Combest, 1990) for
about the first 6 months of life. Exclusively breastfed
infants are 14 times less likely to die from diarrhea com
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pared with formula-fed infants and 4 times less likely to die
compared with partially breastfed infants (Victora et al.,
1987). Thus, exclusive breastfeeding is the infant feeding
behavior most predictive of infant survival in conditions of
poverty or poor sanitation.

At about 6 months of age, breast milk alone will no
longer satisfy the energy, protein, and micronutrient
requirements of most infants (IDECG, 1996). Local foods
that are rich in energy, protein, and micronutrients, hygienically prepared, and soft to eat need to be provided. During
the transitional period when complementary foods are being
introduced, on-demand and frequent breastfeeding should
continue to ensure that infants receive all the benefits of
breastfeeding. The increased diarrheal morbidity that is
often associated with the introduction of other foods and
liquids can be prevented with proper hygiene.
The recommended duration of breastfeeding has
recently received considerable attention because of several
studies that show that children who are breastfed beyond
the second year of life are more likely to suffer from
malnutrition. A review of the studies, however, shows most
to have serious methodological flaws (Grummer-Strawn,
1993). Both WHO and UNICEF recommend that because
of its many nutritional and immunological benefits breast
feeding should continue into the second year of life and
beyond. Breastfeeding beyond 6 months of age should be
complemented with energy and other nutrient-dense
weaning foods.

1.2

INTERNATIONAL BREASTFEEDING
INDICATORS

The international community has identified a
number of breastfeeding indicators that now form the basis
for much of the current breastfeeding data collection and
research effort. The formulation of indicators was in
response to a growing need for comparability and coherence
of breastfeeding data from around the world. Better
comparability of data contributes to an assessment of the
global breastfeeding situation and provides policy-makers
and program managers a common set of measures to
monitor and evaluate their progress.
The formulation of current breastfeeding indicators
has evolved over nearly a decade, marked by a number of
key events. They include initial efforts, in 1988, by the
Interagency Group for Action on Breastfeeding (IGAB) to
develop breastfeeding indicators; the Innocenti Declaration

of 1990, which stressed the importance of exclusivi
breastfeeding for the first 4 to 6 months of life and urgec
the international community to draw up strategies fot
promoting breastfeeding and monitoring and evaluatinj
their progress; a WHO informal consultation in 1993 t<
assess the state of trend monitoring through databases and
information resource systems; the 1992 International
Conference on Nutrition which, in the World Declaration
and Plan of Action for Nutrition, called for the collection.
analysis, and dissemination of updated and reliable informa
tion on infant and young child feeding, especially breast
feeding prevalence and duration; and the Forty-seventh
World Health Assembly resolution WHA47.5, of 1994, that
requested WHO to support member states in monitoring
infant and child feeding practices and trends in health
facilities and households, in keeping with the new standarc
breastfeeding indicators (WHO, 1996).
In response to the increasing need and desire to
monitor breastfeeding practices and trends, -WHO now
compiles a Global Data Bank on Breastfeeding, which
includes indicator-based data col lected from households and
from health facilities. The household-level indicators as
defined by WHO are presented in Table 1.1. Full defini
tions of the terms used in the indicators are presented in
Appendix A.

1.3

SOURCE OF DATA

One of the most comprehensive sources of national
household-level breastfeeding and infant feeding data is the
Demographic and Health Surveys (DHS). The DHS
program began in 1984 and continues to the present. The
program has evolved through a series of five-year phases
that are referred to in this report as DHS-I, DHS-II, and
DHS-III. DHS-I includes surveys conducted from 1984 to
1989; DHS-II includes surveys conducted from 1988 to
1993; DHS-III includes surveys conducted from 1992 to
1997. A year of overlap exists between each 5-year phase
because some surveys began late in one phase and over
lapped into the subsequent phase. The current, or fourth, 5year phase of the DHS program is called MEASURE/
DHS+.

In this report, data are presented from 37 countries
with DHS surveys'conducted between 1990 and 1996 (i.e.,
surveys from DHS-II and DHS-III). The data were col
lected by trained interviewers using household and individ
ual questionnaires. Data on socioeconomic and demo
graphic characteristics of respondents’ households come

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from the household interview. The individual question
naire, administered to women age 15 to 49 within the
household, provides information on the specific characteris
tics of respondents, fertility, mortality, family planning, and
child health and nutrition. Women who have given birth
within five years preceding the interview are specifically
asked about breastfeeding and complementary feeding
practices, ante- and postnatal care, childhood illnesses and
treatment patterns, immunization, and postpartum durations
of amenorrhea and sexual abstinence. Those women and
the children bom within five years are weighed and mea
sured for height (or length, for children less than two years
old).

Table 1.1 WHO global data bank on breastfeeding. Breastfeeding indicators derived from households

Definition

Description
Ever-breastfed rate

Infants less than 12 months old who were ever breastfed

Mean duration of breastfeeding

Average duration of breastfeeding in months

Median duration of breastfeeding

Age in months when 50% of children are no longer breastfed

Exclusive breastfeeding rate at 1 month

Infants 1 month old who are exclusively breastfed

Exclusive breastfeeding rate at 2 months

Infants 2 months old who are exclusively breastfed

Exclusive breastfeeding rate at 3 months

Infants 3 months old who are exclusively breastfed

Exclusive breastfeeding rate at 4 months

Infants 4 months old who are exclusively breastfed

Exclusive breastfeeding rate at 5 months

Infants 5 months old who are exclusively breastfed

Exclusive breastfeeding rate at 6 months

Infants 6 months old who are exclusively breastfed

Exclusive breastfeeding rate < 4 months

Infants less than 4 months old who were exclusively breastfed in the last 24 hours

Predominant breastfeeding rate

Infants less than 4 months old who were predominantly breastfed in the last 24 hours

Timely complementary feeding rate

Infants 6-9 months old who received complementary foods in addition to breast milk in
the last 24 hours

Children 12-15 months old who were breastfed in the last 24 hours
Children 20-23 months old who were breastfed in the last 24 hours

Infants less than 12 months old who are receiving food or drink from-a bottle

1996

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