EBF, DIARE, ISPA

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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: [email protected]: 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

JHPN196

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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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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JHPN198

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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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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JHPN200

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)

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