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J HEALTH POPUL NUTR 2007 Jun;25(2):195-204ISSN 1606-0997 | $ 5.00+0.20
INTERNATIONAL CENTRE FOR DIARRHOEALDISEASE RESEARCH, BANGLADESH
Prevalence of Exclusive Breastfeeding inBangladesh and Its Association with Diarrhoeaand Acute Respiratory Infection: Results of the
Multiple Indicator Cluster Survey 2003
Seema Mihrshahi1,2,3, Naomi Ichikawa4, Muhammad Shuaib5, Wendy Oddy2,6,
Rose Ampon1, Michael J. Dibley7, A.K.M. Iqbal Kabir3, and Jennifer K. Peat1
1Childrens Hospital at Westmead, Sydney, NSW, Australia, 2Curtin University of Technology, Perth, WA,
Australia, 3ICDDR,B, GPO Box 128, Dhaka 1000, Bangladesh, 4Office of Emergency Programmes, United
Nations Childrens Fund, New York, USA (formerly with Planning, Monitoring and Evaluation Section,
United Nations Childrens Fund, Dhaka, Bangladesh), 5Institute of Statistical Research and Training,
University of Dhaka, Dhaka, Bangladesh, 6Telethon Institute of Child Health, Perth, WA, and7University of Newcastle, Newcastle, NSW, Australia
ABSTRACT
The objective o this study was to investigate the association between the prevalence o exclusive
breasteeding and morbidity (diarrhoeal diseases and acute respiratory inection) in inants aged 0-3
month(s) using the Multiple Indicator Cluster Survey (MICS) 2003 data rom Bangladesh. The study
population included 1,633 inants aged 0-3 month(s). The prevalence o diarrhoea and acute respira-
tory inection was compared using the chi-square tests between inants aged 0-3 month(s) who were
exclusively breasted and inants who were not exclusively breasted. Logistic regression was used to
adjust or conounders and or calculating adjusted odds ratios. To adjust or cluster sampling and
reduced variability, the adjusted chi-square value was divided by the design eect, and a re-estimated
p value was calculated. The prevalence o diarrhoea and acute respiratory inection in this sample
o 0-3-month old inants in Bangladesh was 14.3% and 31.2% respectively. The prevalence o both
illnesses was signiicantly associated with lack o exclusive breasteeding. The adjusted odds ratio or
diarrhoea was 0.69 (95% conidence interval [CI] 0.49-0.98, p=0.039), and the adjusted odds ratio
or acute respiratory inection was also 0.69 (95% CI 0.54-0.88, p=0.003). Only 192 inants (11.7%
o total sample) were exclusively breasted at the time o interview, and 823 inants (50.3%) were
never exclusively breasted. The prevalence o prelacteal eeding was 66.6%. The results conirmed
a protective eect o exclusive breasteeding against inectious diseases-related morbidity in inancy
and showed that requently-collected cross-sectional datasets could be used or estimating eects. The
low prevalence o exclusive breasteeding in Bangladesh needs to be improved to decrease child
morbidity.
Key words: Acute respiratory inections; Breasteeding; Cluster surveys; Cross-sectional studies; Diar-
rhoea; Diarrhoea, Inantile; Inant-eeding practices; Bangladesh
Correspondence and reprint requests should beaddressed to:Dr. Seema MihrshahiClinical Epidemiology UnitChildrens Hospital at WestmeadLocked Bag 4001Westmead NSW 2145AustraliaEmail: smihrshahi@yahoo.comFax: 61-2-98453082
INTRODUCTION
In Bangladesh, inectious diseases, such as di-
arrhoea and acute respiratory inections, are a
cause o more than two-thirds o all deaths in
children aged less than one year (1). The im-
portance o breasteeding in the prevention o
inectious diseases during inancy is well-docu-
mented (2-7). Breastmilk provides protection
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Mihrshahi S et al.Reduction of infectious diseases by exclusive breastfeeding
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against pathogens by providing antibacterial
and antiviral substances that stimulate the in-
ants immune system (6). A meta-analysis o
data rom three developing countries showed
that inants who were not breasted had a six-
old greater risk o dying rom inectious diseas-
es in the irst two months o lie than those whowere breasted (3), and a similar protective e-
ect o breasteeding has been shown in studies
o morbidity rom inectious diseases (8-10). A
recent estimate rom the Bellagio Child Survival
Study Group, which used results o systematic
reviews rom low- and middle-income countries,
predicted that exclusive breasteeding in the irst
six months o lie and continued breasteed-
ing or the irst year could prevent 1.3 million
child deaths worldwide, making promotion o
breasteeding a key strategy o child-survival pro-
grammes (11).
Exclusive breasteeding means that the inant
receives no solids or liquids apart rom breast-
milk with the exception o vitamins, minerals,
or medicines (12). Inants who are exclusively
breasted are less likely to be exposed to contami-
nated oods and liquids, and this contributes to
reductions in the incidence and severity o in-
ectious diseases. Currently, the recommendation
rom the Global Strategy or Inant and Young
Child Feeding, developed by World Health Or-
ganization (WHO) and United Nations ChildrensFund (UNICEF), is that inants should be exclu-
sively breasted or the irst six months o lie
(13). Ater six months, inants should receive
nutritionally-adequate and sae complementary
oods while continuing to be breasted or up to two
years o age or beyond. Recent estimates predict
that current breasteeding patterns are ar below
the recommended levels especially in Arica and
Asia where rates o exclusive breasteeding or
the irst six months are less than 40% (14).
Factors that interact with the protective eect obreasteeding include environmental, cultural
and economic characteristics. The protective e-
ect o breasteeding is most important in popu-
lations with high inant mortality, high illitera-
cy, poor sanitation acilities, poor nutritional
status, and generally low economic status (6). The
population o Bangladesh its all o these criteria
(15).
Surveys o child-eeding practices rom Bangla-
desh showed an almost universal continuation
o any breasteeding up to two years o age (15).
However, cultural practices include the eeding
o prelacteal oods, such as honey, sugar water,
or mustard oil immediately ater birth contri-
buting to the low prevalence o exclusive breast-
eeding (16). Current data show that 38% o
children aged 2-3 months are exclusively breast-ed, and 23% o children are given complemen-
tary oods beore the sixth month (15). In addition,
rates o bottleeeding are high with 30% o in-
ants aged 2-3 months being bottleed. The rate
o consumption o baby ormula in inants aged
4-7 months has almost doubled since 2000 and
is highest in urban areas (15).
This paper describes the inant-eeding practices
in Bangladesh using the Multiple Indicator Clus-
ter Survey (MICS) 2003 data and investigates
the association between exclusive breasteedingand child morbidity, in particular diarrhoea and
acute respiratory inection.
MATERIALS AND METHODS
Data analysis
Cross-sectional data rom the Multiple Indicator
Cluster Survey (MICS) rom Bangladesh collected
in 2003 were used or analyzing the associa-
tion between breasteeding and diarrhoea and
acute respiratory inection in inants aged 0-3
month(s).
Data of multiple indicator cluster surveys
MICS are nationally representative surveys o
households, women, and children and com-
monly include over 5,000 households. The sur-
veys include inormation about the duration and
patterns o breasteeding and complementary
eeding practices, childhood illnesses, education,
vaccination coverage, and sanitation. Bangladesh
Bureau o Statistics, under the Monitoring the
Situation o Children and Women Project, sup-
ported by UNICEF, collected data or the MICS2003 in Bangladesh rom 63,420 households.
UNICEF Bangladesh provided the datasets.
Prevalence of exclusive breastfeeding
The MICS 2003 provides two types o data or
calculating the prevalence o exclusive breast-
eedingone allowing or prelacteal eeding and
the other not allowing or prelacteal eeding,
the true rate o exclusive breasteeding. This
classiication is to enable valid comparisons with
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Mihrshahi S et al.Reduction of infectious diseases by exclusive breastfeeding
Volume 25 | Number 2 | June 2007 197
other surveys, such as the demographic and
health surveys (DHSs) which allow or prelacteal
eeding in their calculation o rate o exclusive
breasteeding. For the purposes o this analysis,
the deinition o exclusive breasteeding includ-
ed those children who had been given prelacteal
oods.
Table 1 shows the questions relating to the out-
comes (morbidity) and study actors (breasteed-
ing); all these questions were taken rom Part B
o the survey, the questionnaire relating to chil-
dren aged less than ive years.
Table 1. Questions relating to explanatory variables and outcomes
Variable Question(s)
Breasteeding status
Prelacteal eeding Q12: (For children aged 0-23 month(s)) Did you give honey/sugarwater/mustard oil/other to your child immediately ater birth?
Initiation o breasteeding Q12a: (For children aged 0-23 month(s)) Was your child given breastmilk
within three days o birth ?
Duration o breasteeding Q13: How long had the child been breasted? (months)
Duration o exclusive
breasteeding outcomes
Q13a: (For children aged 0-23 month(s)) How long was the child
exclusively breasted? (months)
Prevalence o diarrhoea Q5: Did the child have loose watery motions three or more times in
a day during the last two weeks?
Prevalence o acute
respiratory inection
Q10: Did your child have cough and/or diiculty breathing in the
last two weeks?
Q11: I yes, what was happening to the child?
Multiple responses with the ollowing symptoms: simple cough,
runny nose, ever, ast breathing, chest indrawing, inability to eat/
drink, or convulsions, excessive sleepiness
A derived variableProbable acute respiratory in-
ectionwas deined as a positive response to
Q10 and a positive response to one or more o
the ollowing symptoms as assessed by Q11: e-
ver, ast breathing, chest indrawing, inability
to eat/drink or convulsions or excessive sleepi-
ness.
Statistical analysis
Data were analyzed using the SPSS sotware
(version 13.0) (SPSS Inc., Chicago, IL). The prevalence
o diarrhoea and acute respiratory inection in
the last two weeks was compared using the chi-
square tests between children aged 0-3 month(s)
who were exclusively breasted and children
who were not exclusively breasted. Univariate
odds ratios (95% conidence interval [CI]) were
calculated. Logistic regression was used or
adjusting or gender and age o child, number
o siblings in household, stratum, ownership
o household, source o drinking-water, place o
disposal o aeces, and education o mother, and
multivariate odds ratios are also reported.
To adjust or cluster sampling and reduced vari-
ability in the sample, a one-way ANOVA was
used or calculating the intraclass correlation co-
eicient (ICC). This was then used in the ol-
lowing equation or the design eect to be cal-
culated.
Design eect=1 + (m-1) * ICC where m=average
cluster size
A re-estimated chi-square value was then calcu-
lated by dividing it by the design eect. A re-es-
timated p value was also calculated.
Ethical approval
Ethical approval or this analysis was obtained
rom Human Research Ethics Committees o Cur-
tin University o Technology, Perth, Western Aus-
tralia and ICDDR,B, Dhaka, Bangladesh.
RESULTS
In total, 1,633 children aged three months or
under had data available or analysis during the
MICS 2003 period between 7 March 2003 and
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Table 2. Demographic characteristics o chil-
dren/amilies (n=1,633) surveyed
Characteristics No.Percen-
tage
Gender o child
Male
Female
790
843
48.4
51.6
Age (months) o child
0
1
2
3
334
368
396
535
20.5
22.5
24.2
32.8
Birth registeredYes
No
118
1,515
7.2
92.8
Stratum
Rural
Metro-citynon-slum
Metro-cityslum
Districturban
Tribal
1,128
118
55
276
56
69.1
7.2
3.4
16.9
3.4
Education o mothers*
Illiterate
PrimarySecondary
Higher
670
410485
29
42.0
25.730.4
1.8
Education o household
heads
Illiterate
Primary
Secondary
Higher
859
348
357
69
52.6
21.3
21.9
4.2
Ownership o household
Own house
Rent
1,372
261
84.0
16.0
Source o drinking-water
Tubewell/tap/ringwell
Pond/river/other
Both
1,549
75
10
94.9
4.5
0.6
Place o disposal o aeces
Latrine/hole/fxed place
No fxed place
1,210
423
74.1
25.9
*n=1,594 as in 39 cases the mother was not
the primary carer o the child
23 September 2003. Characteristics o the popu-
lation are described in Table 2. Most (n=1,515,
or 92.8%) o the children were not registered at
birth by a local authority.
The prevalence o breasteeding practices among
the amilies surveyed is shown in Table 3. More
than 99% o the children were still breasteeding
at the time o interview, but only 34.5% were
being exclusively breasted (prelacteal eeding
included). I the WHO deinition o exclusive
breasteeding is used, only 192 (11.7%) childrenwere exclusively breasted at the time o inter-
view, In total, 823 (50.3%) inants were never
exclusively breasted, 1,450 (88.8%) inants were
given breastmilk within three days o birth, and
66.6% o inants were given a prelacteal eed o
honey/sugar water or mustard oil ater birth.
Table 4 shows the prevalence o exclusive breast-
eeding and illness by age o the child. The prev-
alence o exclusive breasteeding in inants aged
three months was less than 20%. The prevalence
o diarrhoea and acute respiratory inection was
highest in inants aged three months and ol-
lowed a linear trend with increasing age.
The relationship between exclusive breasteeding
and the prevalence o diarrhoea and acute res-
piratory inection is shown in Table 5. In total,
14.3% o the children had diarrhoea in the last
15 days. Over hal (53.6%) o the children in
the survey had cough or diiculty breathing in
the last 15 days, and 509 (31.2%) children had
probable acute respiratory inection.
The prevalence o diarrhoea in this population
was signiicantly associated with lack o exclusivebreasteeding. The unadjusted odds ratio was
0.54 (95% CI 0.39-0.74, p
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Mihrshahi S et al.Reduction of infectious diseases by exclusive breastfeeding
Volume 25 | Number 2 | June 2007 199
Table 3. Prevalence o breasteeding practices in 1,633 inants
Breasteeding practice No. Percentage
Any breasteeding 1,620 99.2
Exclusive breasteeding (with prelacteal eed) 564 34.5
Exclusive breasteeding (WHO defnition) 192 11.7
Prelacteal eed given 1,088 66.6
Breastmilk given within 3 days o birth 1,450 88.8
WHO=World Health Organization
rom exclusive breasteeding were age o the in-
ant, stratum (rural), and education o mother.
DISCUSSION
These results conirm a protective eect o ex-
clusive breasteeding against inectious diseas-
es-related morbidity in inancy. The observed
protection remained even ater adjustment or a
number o conounders, including demographic
variables (age and gender o child), socioeco-
nomic variables (education o mother, stratum,
ownership o household), and sanitation vari-
ables (source o drinking-water and place o dis-
posal o aeces). The results showed that children,
aged 0-3 month(s), who are exclusively breasted
were less likely to have suered rom diarrhoea
(adjusted OR=0.69, 95% CI [0.49-0.98]) or an
acute respiratory inection [adjusted OR=0.69,
(95% CI 0.54-0.88)] than inants who were not
exclusively breasted. The results are consistent
with those o other studies on the associationbetween mode o eeding and morbidity in chil-
dren (8-10).
In peri-urban Mexico City, a home-based peer-
counselling intervention was conducted to in-
crease rates o exclusive breasteeding (8). At three
months o age, the proportion o inants exclu-
sively breasted in intervention groups was more
than double the proportion in control groups,
and this resulted in a two-old decrease in diar-
rhoeal illness (26% vs 12%, p=0.029). This was
comparable with the MICS 2003 analysis wherethe prevalence o diarrhoeal illness in the exclu-
sively breasted group was reduced by almost hal
(16.7% vs 9.8%, p
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Table
4.Prevalenceoexclus
ivebreasteedingandillnessbyag
eochild
Age
(months)
Exclusiv
e
breasteed
ing
Prevalenceo
diarrhoea
Exclusivelybreasted
inantswithdiarrhoea
Prevalenceoacute
respiratoryinection
Exclusivelybreasted
inan
tswithARI
No.
%
No.
%
No.
%
No.
%
No.
%
0
184
55.1
15
4.5
8
4.3
56
16.8
28
15.2
1
159
43.2
36
9.8
13
8.2
103
28.0
46
28.9
2
117
29.5
73
18.4
13
11.1
131
33.1
21
17.1
3
104
19.4
110
20.6
21
20.2
219
40.9
35
33.7
ARI=Acuterespiratoryinecti
on
Table
5.Unadjustedandadju
stedoddsratiosordiarrhoeaand
acuterespiratoryinectioninthe
last2weeksininantsexclusively
breastedat0-3
month(s)comparedwithinantswhowerenotexclusivelybreasted(n=1,633)
Disease
No.with
symptoms
Percentage
Prevalenceinthelast
2weeks
Percentage
odier-
ence
Odd
sratio
(95%
CI)
pvalue
Adjustedo
dds
ratio*
(95%CI)
pvalue
Non-exclusively
breastedgroup
%
Exclusively
breastedgroup
%
Diarrhoea
234
14.3
16.7
9.8
6.9
0.54(0
.39-0.74)
Recommended