According to this study exclusive breastfeeding rates at six months in a cohort of 286 Sri Lankan children living in a mixed urban and suburban area was 71.3%. However, on longitudinal analysis only 65.9% of babies were exclusively breastfed up to six months. The discrepancy resulted from disproportionately higher number of babies not on exclusive breastfeeding at four months, failing to attend the final follow up. Of the babies presented at four months, 72.4% were presented at six months, but of the babies not exclusively breastfed at four months, only 53.6% were presented at six months. This highlights the inaccuracy of estimating exclusive breastfeeding rate by cross sectional studies.
According to the UNICEF, only every third child living in the developing world is exclusively breastfed during first six months of life. According to our study and previous studies[4, 6], exclusive breastfeeding rates in Sri Lanka are much higher than quoted by UNICEF. The high exclusive breastfeeding rates recorded is probably due to dedication of health care workers and the commitment of government towards promoting exclusive breastfeeding. High female literacy rate in Sri Lanka is another important reason. A breastfeeding code promoting exclusive breastfeeding is in effect in Sri Lanka. A committee of experts and officials monitor activities related to infant feeding for any violations of the code. Appropriate action is taken against offenders.
Even under optimum conditions it is not possible to achieve 100% of exclusive breastfeeding due to other factors involved. Postpartum complications or medication taken by the mother may prevent breastfeeding. Occasionally there are some mothers who may need additional support to feed their babies. Failure in breastfeeding is due to incorrect feeding techniques compared to inadequacy of breast milk in most instances. Maternal anxiety due to fear of inadequate breast milk is an important factor for failure of lactation. Reassuring the mother and correcting the technique is sufficient in most cases of lactation failures. Lactation management centres established in some hospitals in Sri Lanka, play a major role in promoting exclusive breastfeeding. Fifty percent of the babies not exclusive breastfed at two months and 24.7% of the babies not exclusive breastfed at four months were started on formula milk or complementary food based on the mothers own judgment. This tendency was reported in a previous study as well.
When exclusive breastfeeding up to six months was implemented, the main concern was its ability to support growth up to six months. In our study a higher number of mothers had stopped exclusive breastfeeding due to growth faltering between two and four months than at four and six months. Growth charts used in Sri Lanka are based on WHO Multicentre Growth Reference Study (MGRS). The theory behind MGRS was that ‘growth of children from birth to five years depends mainly on nutrition, feeding practices, environment and health care than genetics or ethnicity. Some studies have shown that genetic factors do play a role in determining growth of a child. Two studies from Sri Lanka, recorded the mean birth weight of Sri Lankan children to be 2.8 and 2.9 kg respectively[14, 15]. This falls on the minus one standard deviation of MGRS charts. Therefore, we can assume growth charts based on MGRS are not appropriate for growth monitoring in Sri Lanka. Due to wrong interpretation of growth, some Sri Lankan children may be losing benefits of exclusive breastfeeding. We suggest that the decision to stop exclusive breastfeeding due to growth faltering should be made by a doctor with careful consideration of possible genetic influences.
A significant decrease in exclusive breastfeeding between four and six months was due to mothers commencing work. Expressed breast milk is an alternative only for few mothers as numbers of hours spent out of home is too long. In Sri Lanka, full pay maternity leave for lactating government workers cover only four calendar months and mothers who wish to extend maternity leave need to go on half or no pay leave. In the private sector maternity leave is less than this, because private sector employers have their own regulations regarding maternity leave. There are significant numbers of mothers engaged in informal employment, who receive no maternity benefits. If exclusive breastfeeding rates are to be improved maternity leave needs to be extended up to six months. An allowance paid to mothers not formally employed, but willing to continue exclusive breastfeeding until six months will also have a positive impact on exclusive breastfeeding. However, the main obstacle in implementing such changes are the economical constrains.
According to data from western countries older mothers have higher breastfeeding rates[16, 17]. In our study, mothers over 30 years of age had a lower exclusive breastfeeding rate compared to mothers less than 30 years of age. Higher employment rates among older mothers and increased work load at home may be possible reasons. Definite explanation cannot be given as we have not studied reasons for the lower exclusive breastfeeding rates among mothers over 30 years of age.
Mothers educated above GCE (O/L) had a lower exclusive breastfeeding rate compared to mothers who had a lower education levels. Although mothers with higher education are more likely to know benefits of exclusive breastfeeding, they are more likely to be employed as well. In our study, 21 out of 26 mothers who stopped exclusive breastfeeding based on their own judgement were educated above grade 11. Educated mothers seem to be more anxious about adequacy of breast milk, resulting in a lower threshold to stop exclusive breastfeeding.
First time mothers are more likely to have difficulties in establishing breastfeeding and often more anxious due to lack of experience. With the second born, they will be more confident about breastfeeding. Increased maternal age, increased house hold work, presence of other children and higher employment rates, may be contributing for the lower rate of exclusive breastfeeding after the second child.
According to the DHS done in 2006/07, exclusive breastfeeding rate in Sri Lanka between 0 to 5 months was 76%. A study done in 2009, in an area belonging to Colombo district, Sri Lanka, revealed an exclusive breastfeeding rate of 77.5% among babies between 4 to six months. In both these studies babies were recruited without selection and 24 hour recall method was used to assess exclusive breastfeeding rates. Children included in our study were born at term, without any medical problems. The main reason for the lower exclusive breastfeeding rates in our study is due to babies up to six months were included compared to other two studies. The populations involved in previous studies and time frame were also different from our study.
This study shows that assessing exclusive breastfeeding rates through a cross sectional study is subjected to errors. Even when a sample of children are followed up prospectively the exclusive breastfeeding rates may differ from actual figures due to drop outs. This is highlighted by this study. Exclusive breastfeeding rate among babies followed up till six months was 71.3% due to disproportionately higher number of babies not on exclusive breastfeeding dropping out from the study between four and six months. Therefore, this rate was exaggerated. On longitudinal analysis, dropout rate in exclusive breastfeeding was 34.1%, giving 65.9% of actual exclusive breastfeeding rate up to six months.
The major limitation of this study was high dropout rates. All attempts were made to minimize the dropout rates. Reminders were given about the follow up. Defaulted mothers were contacted and an alternate date was given. We did a longitudinal analysis on dropout rates to overcome the error due to dropouts. We compared the socio-demographic characteristics of dropouts with that of children who completed the follow up and found there was no significant difference.