Research Article: The Influence of Seasonality and Community-Based Health Worker Provided Counselling on Exclusive Breastfeeding – Findings from a Cross-Sectional Survey in India

Date Published: August 11, 2016

Publisher: Public Library of Science

Author(s): Aritra Das, Rahul Chatterjee, Morchan Karthick, Tanmay Mahapatra, Indrajit Chaudhuri, Jacobus van Wouwe.


Exclusive breastfeeding (EBF) during the first six months of life is considered a high impact but low-cost measure for reducing the morbidity and mortality among children. The current study investigated the association of seasonality and frontline worker(FLW) provided counselling with practice of EBF in Bihar, India.

We used the ‘Lot Quality Assurance Sampling’ technique to conduct a multi-stage sampling survey in 8 districts of Bihar. Regarding EBF, mothers of 0–5 (completed) months old children were asked if they had given only breastmilk to their children during the previous day, while mothers of 6–8 (completed) months old children were inquired about the total duration of EBF. We tested for association between EBF during the previous day with season of interview and EBF for full 6 months with nursing season. We also assessed if receiving counselling on EBF and complementary feeding had any association with relevant EBF indicators.

Among the under-6 month old children, 76% received EBF during the previous day, whereas 92% of 6–8 (completed) months old children reportedly received EBF for the recommended duration. Proportion of 0–5 (completed) month old children receiving only breastmilk (during last 24 hours) decreased significantly with increasing age and with change of season from colder to warmer months. Odds of receiving only breastmilk during the previous day was significantly higher during the winter months (Adjusted odds ratio(AOR) = 1.50; 95% CI = 1.37, 1.63) compared to summer. Also, the children nursed primarily during the winter season had higher odds of receiving EBF for 6 months (AOR = 1.90, 95% CI = 1.43, 2.52) than those with non-winter nursing. Receiving FLW-counselling was positively associated with breastfeeding exclusively, even after adjusting for seasonality and other covariates (AOR = 1.82; 95% CI = 1.67, 1.98).

Seasonality is a significant but non-modifiable risk factor for EBF. However, FLW-counselling was found to increase practice of EBF irrespective of season. Scale-up of FLW-counselling services, with emphasis on summer months and mothers of older infants, can potentially reduce the impact of seasonality on EBF.

Partial Text

Adequate nutrition, especially of the newborns, is a fundamental requirement for ensuring that the children realize their potential of developing into healthy adults. Globally, about 35% under-five mortalities are attributed to malnutrition.[1] A number of global and region-specific health interventions—such as universalizing early initiation of breastfeeding, breastfeeding exclusively during the first six months of life and age-appropriate frequency and quantity of complementary feeding from sixth month onwards—have focused on improving the nutritional status of children.[2, 3] In India, one of the key objectives of the ‘Integrated Child Development Services (ICDS)’ scheme has been to improve the nutritional status of children up to 6 years of age.[4] Unfortunately, in spite of such efforts, childhood nutritional indicators in India remained poor—with stunted, wasted and underweight children, respectively, accounting for about 48%, 20% and 43% of the total under-five year old population.[5] Amidst this grim premise, identification of the causes of childhood undernutrition and implementation of targeted measures to lessen its burden need to be prioritized.

The present analysis utilized data from 20793 mothers of 0–5 month old children and 10130 mothers of 6–8 month old children. Table 1 depicts the socio-demographic and breast feeding related characteristics of the study participants. We found that, in both 0–5 and 6–8 month age groups, about 86% participating families were Hindus. Only about 17% families lived in a ‘Pucca’ or brick-built house. Figures for parental educational status were quite poor—while about 26%-27% fathers studied beyond eighth standard, among mothers only 14%-15% had same level of education. About 76% mothers of 0–5 month olds reported that they breastfed their children exclusively during previous 24 hours. However, among the mothers of 6–8 month olds more than 92% claimed that they did not give any liquid/semi-solid food other than breastmilk during the first 6 months. Reported coverage of FLW-provided counselling on exclusive breastfeeding (mothers of 0–5 month olds) and counselling on initiation of complementary feeding (mothers of 6–8 month olds) were both about 31%.

Exclusive breastfeeding is widely recognized as an inexpensive, contamination-free, immunity boosting and emotionally satisfying way of providing adequate nutrition to infants during the first half year of life, especially in resource-poor settings. Our results show that more than 81% children in their second month of life were breastfed exclusively during the past 24 hours. This was much higher than that reported from a nationally representative survey conducted in 2005–06.[5] The increased proportion observed in this study could be attributed to the breastfeeding awareness campaigns that might have improved acceptability of EBF over the years. Moreover, as mentioned before, the current study was conducted in one of the most impoverished regions of India. It could be the case that even if some of the mothers wanted to substitute or supplement breastmilk, which is free, economic constraints might have prevented them from doing so.[20, 35] The reported prevalence of EBF for WHO recommended duration (i.e. 6 months) was also found to be higher in the current study compared to previous findings from India.[36–39] However, we must admit that the information on EBF for full six month duration has lesser validity than the data on breastfeeding during past 24 hours. The data on EBF for 6 months (based on long recall period) is prone to greater amount of recall bias and depends heavily on the mothers’ ability to determine the age of the child accurately—an unlikely scenario given the poor educational status of the participating mothers. Still, bearing in mind the prevailing socio-economic situation, it seems likely that the proportion of mothers practicing EBF is greater in Bihar compared to the national average. We also observed that the practice of breastfeeding exclusively (24 hour recall) gradually declined with increasing age of the child. This decreasing trend was similar to that reported in National Family Health Survey (NFHS-3) and also in a study from neighboring Bangladesh.[5, 33]