Factors associated with the introduction of prelacteal feeds in Nepal: findings from the Nepal Demographic and Health Survey 2011

Exclusive breastfeeding (EBF) for first six months of life is beneficial to child and mother [1, 2]. EBF protects a child from under nutrition and gastroenteristis. In the long run, EBF is protective against a number of chronic disease such as leukaemia, type 2 diabetes, and obesity [3, 4]. Breastfeeding also has proven benefits for the neurocognitive development of the child, protection from childhood respiratory illness and protection for the mother from breast cancer. EBF also saves the cost associated with illnesses that arise out of the above mentioned illnesses [5]. For these reasons, the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and Ministry of Health and Population Nepal recommend and promote exclusive breastfeeding for first six months of life and continuation of breastfeeding thereafter [6–8].

Any food provided to a newborn before the initiation of mother’s breastfeeding is considered to be a prelacteal feed. The type of prelacteal feeds depends on the culture. It may include ghee (refined butter), honey, sugar, sugar juice, unboiled cow/goat milk etc [9]. The practice of prelacteal feeding is a major cultural practice still prevalent in many places throughout South Asia regions [9–12]. All prelacteal feeds are provided for non nutritional reasons such as clearing the throat/bowel; or thinking that mother’s milk is insufficient or the colostrum is too heavy for the newborn to digest [9]. Prelacteal feeds have lesser nutrient and immunological value; and are often likely to introduce contaminants [9].

Introduction of prelacteal feeds is a known barrier to continuation of exclusive breastfeeding. By definition, a child provided with prelacteal feeds is not exclusively breastfed. Knowledge on the determinants of introduction of prelacteal feeds is essential to promote exclusive breastfeeding and early initiation of breastfeeding [13, 14]. To date, only one study from Nepal has reported on the determinants of prelacteal feeds [15]. That study had a small sample size and was confined to few village development committees (10 of 77) from one of the 75 districts in Nepal. A larger representative study covering the entire country is essential in Nepal so that findings can be generalized to the entire country. This study aimed to identify the determinants of prelacteal feeds amongst young children aged under three years using data from the Nepal Demographic Health Survey (NDHS) 2011.

The child dataset of NDHS 2011 [16], a nationally representative cross-sectional survey based on multi stage cluster sampling was used. In the first stage of the sampling, the enumeration areas (EA) were selected. A total of 95 urban and 194 rural EAs were included in the survey. In stage two, households were selected based on the EAs. The NDHS utilises three sets of validated questionnaires to collect data and includes a household questionnaire, a mother’s questionnaire and a men’s (father’s) questionnaire. The child dataset used in this study included all the relevant information on child health from all of three questionnaires. The current NDHS 2011 has a response rate of 95.3%. Details of sampling technique, selection of households, questionnaire and validation procedure are published in the survey report [16].

Benefits of initiation of breastfeeding within one hour of birth, exclusive breastfeeding for six months and the continuation of breastfeeding along with complementary feeding after six months have been well documented and meet international guidelines [1, 6, 7, 23, 24]. However, in some cultures including Nepal there is a preference for the introduction of prelacteal feeds [12, 14, 15, 25]. This study reported a prevalence of prelacteal feeding (21.3%) which is lower than two previous Nepalese study (39%) [15] in Kapilvastu but more than another Nepalese study (14%) [14]. In the former study of Kapilvastu, the overall community had a lower education status and also less access to health education and information. This is in contrast to Chandrashekhar et al. [14] whose population was characterised as one of the most educated (82% as of 2012) and highly accessible urban area of Nepal [26]. This setting is among the top five most developed districts in Nepal [26]. It has two major municipalities, two tertiary hospitals, has driveable roads in most of the places and a good coverage of television and newspapers. Neither study was based on a national data, therefore, due to such differences, the national prevalence of prelacteal feeds is likely to be different from the previous studies. Based on our study one in four children were provided with prelacteal feeds which presents a challenge to achieve the WHO recommended 90% rate of practice of exclusive breastfeeding among under six months children [2].

Economic status and the mother’s education status were significant factors associated with the introduction of prelacteal feeds in this study. This finding is similar to many other studies which show the protective effect that lower economic status has on exclusive breastfeeding [27, 28]. The lower socio-economic groups may have less access to the expensive prelacteal feeds such as ghee or honey and therefore exclusive breastfeeding is the only option available to them [27]. This might be a reason for the reported lower prelacteal feeding practice rates amongst the poorest wealth groups in Nepal. There was a protective effect from education up to high school education similar to other studies reported from developing countries [29, 30]. However, a notable finding was that the practice of introduction of prelacteal feeds was not significantly different between mothers who did not have formal education and the mothers who had higher education. Further studies need to explore the reason for such higher levels of prelacteal feeds among the highly educated mothers. Nevertheless, this finding indicates that there is need to focus on both of these groups while implementing breastfeeding promotion programs. This is crucial as mothers with higher education are conventionally not a target group of health promotion programs.

The association of ANC visits with birth order, birth interval, ecological region and development region are important findings to consider. Attending the recommended antenatal care visits where exclusive breastfeeding is encouraged should decrease prelacteal feeds and facilitate mothers to get information from the midwives and health workers. Visiting antenatal/maternal and child health (MCH) clinics where they have better access to and exposure to health information and education materials may be the reason that there was a lower prevalence of prelacteal feeds among the mothers who had attended four or more antenatal care visits [31].

First time mothers were more likely to introduce prelacteal feeds in this study. It is likely that the first time mothers have less skill and knowledge of newborn care and proper infant feeding practice [32] and they may rely more on the older women in the household and community who are likely to be less educated than their daughters-in-law and may be more likely to follow the culture and traditions [33].

Regional differences in breastfeeding and newborn care practices could be in part a function of access to service, inequitable distribution of service, information and resources and geographic differences. Mothers from the Far western region of Nepal were less likely to provide prelacteal feeds. The Far western development region of Nepal has some of the poorest areas in the country and is characterised by a harsh terrain with less access to driveable roads, greater reliance on an animal based transport system, and a lower density of the health facilities with the highest child mortality rates [34, 35]. The current findings could be a reflection of a large number of mothers from poorest socio-economic groups and a lack of access to expensive prelacteal feeds such as ghee, honey or glucose solution. There is a further need to explore why the prelacteal feeds were introduced to fewer children in the Far western region than other regions of Nepal and how this has influenced the duration of exclusive breastfeeding practice in the region.

The current study found that the mothers from Terai/Plain region were more likely to provide the prelacteal feeds to their newborn. A previous Nepalese study [15] also reported a higher (39%) proportion of mothers introducing prelacteal feeds. The majority of population of the plain/Terai area is similar to the population reported by the study of Kapilvastu district [15]. The majority of the communities in the Terai/Plain area includes a different ethnic group called Madhesi (originating from the Plains of Nepal) [36]. This group is generally less educated, have a lower social development status and more likely to follow the traditional practices of prelacteal feeding [36]. A study based in the southern area of Nepal (plains of central development region) reported that despite having all mothers breastfeeding, the initiation of breastfeeding within one hour (3.4%) and the practice of exclusive breastfeeding (72% of the infants were partially breastfed) were poor [36]. Further analysis was not possible as separate record for the Madhesi group was not available in the dataset.

One in four children were provided with prelacteal feeds in Nepal. The prelacteal feeds included milk other than breastmilk, tea, fruit juice, sugar/salt solution, grip water, sugar/glucose solution and plain water. The recommended four antenatal care visits, mother’s education, working status of mother, lower wealth status of family and being from far western development region were protective against the introduction of prelacteal feeds. However, being from the Terai/plain region, being a first time mother and being from the central development region was significantly associated with the introduction of prelacteal feeds. Breastfeeding promotion is essential to promote/encourage the practice of exclusive breastfeeding and reduce the practice of providing prelacteal feeds [39]. The importance of increasing antenatal care visits as a method to increase the practice of exclusive breastfeeding [22, 39] should also be noted in future program planning.