The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) to six months of age [1, 2]. During this six month period, no other liquid, semi solid or solid food or breastfeeding substitute should be given to the infants except for medicine and/or oral rehydration solution. EBF is beneficial to the health and wellbeing of infants and mothers [3]. Children who are not breastfed exclusively for six months have a higher risk of gastrointestinal infections, respiratory illness, morbidity and death [4–6], as well as atopic eczema [5, 7], allergy, asthma, type II diabetes [8], leukemia [9] and obesity in later life [3] than EBF infants. EBF is estimated to prevent approximately one-tenth of child deaths and could play an important role in meeting India’s Millennium Development Goal 4 of reducing child mortality. Cognizant of the high prevalence of inappropriate child feeding practices and the importance of exclusive breastfeeding, the Indian Government developed the Infant and Young Child Feeding (IYCF) guideline in 2004 [10], and improving infant and young child feeding practices with a strong emphasis on promotion of exclusive breastfeeding for 6 months, is a priority under the governments various flagship programs such as Integrated Child Development Services (ICDS) and the National Rural Health Mission (NRHM). Since then, varying levels of interventions, giving due emphasis to key messages of exclusive breastfeeding, are being given both at health institution and community level.

Despite the numerous recognized advantages of appropriate feeding practices, the rates of EBF in India continue to be low [11]. The success of a nutrition program depends on identification of modifiable factors susceptible to intervention. Importantly, studying inhibiting risk factors that determine the duration of EBF would serve as the basis for designing and implementing effective programs targeting individuals, families and communities at increased risk for suboptimal feeding behaviors. In addition, it would evaluate the success of ongoing programs and of various other activities promoting breastfeeding.

A number of international studies have identified several socio-demographic determinants of EBF. Some of the most common factors found to be associated with EBF are the economic status of family; education of mother; occupation of mother; utilization of antenatal care services; place of residence and access to information [12–15]. While studies assessing factors associated with continuation of breastfeeding during infancy and beyond have been conducted at the national level in developing countries like Timor-Leste [16], Bangladesh [17, 18], and Nepal [19], there are very few studies at the national level from India exploring changes that may have occurred in EBF practices evaluated at two time points when the National Family Health Survey (NFHS) in 1992–93 (NFHS-1) and 2005–06 (NFHS-3) were carried out. The NFHS are equivalent to the Demographic and Health Surveys in most other countries. This paper examines changes in EBF between the two large scale surveys and the effect of predictor variables in the context of the WHO and Government of India feeding guidelines and recommendations [1, 10].

In the NFHS-1, 27.7 per cent children were first order births, 18.3 per cent were born with birth spacing of < 2 years and more than half (59.9 %) were to mothers who had accessed antenatal/natal care. One in every five (21.1 %) infants was perceived by the mothers to be smaller than large/average size at birth. In the NFHS-3, a nearly equal proportion (30.4 %) were first order births, 26.9 per cent were with birth spacing < 2 years and around three-quarters (71.6 %) of children were born to mothers who had received antenatal/natal care. The proportion of infants who were perceived by the mothers as small at birth was 22.9 per cent, similar to what was found in NFHS-1.

Table 1 depicts that in both the surveys, the children with more advantage in terms of their mother being more educated, belonging to high standard of living, urban residence or use of health services like antenatal and natal care, belonged to medium/low post neonatal mortality rate (PNMR) states.

Having evidence of the large variations in exclusive breastfeeding practices and the extent to which selected socio-demographic and obstetrical factors account for such variation could lead to more effective interventions. The current study examined changes in the rate and determinants of EBF in 19 states of India including 18 bigger states and the national capital region of Delhi based on the data collected from two nationally representative large scale demographic surveys carried out 13 years apart.

Our analysis revealed that despite breastfeeding promotion programs, EBF in India continues to be low. A marginal improvement was observed from 46.3 per cent in NFHS-1 to 48.6 per cent in NFHS-3 in the proportion of infants < 6 months old who were exclusively breastfed which was significantly lower than the WHO/UNICEF recommendation of 90 per cent. The EBF rates in India were similar to that reported by countries from the neighbouring region with Pakistan reporting 37.1 per cent [28], Bangladesh 42.5 per cent and Nepal 53.1 per cent [29].

An increase in EBF at each month of age was evident between the two surveys. However, this difference in EBF rates narrowed from four months of age onwards. Such findings were also reported earlier from India [30] and Pakistan [28]. The possible reason for this could be that mothers introduced complementary feeding for their infants under the assumption that breast milk alone might not satisfy the needs of infants as they grow older. It indicated an urgent need for improvement especially from 4-6 months when the EBF rates rapidly decline.

Our study assessed the effect of changes over time of a total of eight socio-economic, demographic and health care utilization factors on exclusive breastfeeding between the two surveys. In the NFHS-1, besides small size of the baby at birth and gainful employment of mother, for all other factors when compared to the reference category, EBF was seen to be significantly lower at different ages of the infant. At age one month, the duration of EBF was shorter in children born to older and urban educated women with a high standard of living index, birth spacing < 2 years and those who had availed antenatal health services or delivered in a health facility. At four months of age which is the critical period when EBF rates drop, instead of older mothers, very young mothers with a medium/high standard of living index had a negative association with EBF.

Over time there was a change in the determinants of EBF. In NFHS-3,a significantly lower proportion of infants living in urban areas, short preceding birth interval and belonging to higher wealth quintile as per SLI were exclusively breastfed at one month of age. At the same age, in children of older, less educated and mothers in gainful occupation, the proportion of EBF was significantly greater. In the age segment 1-4 months, EBF was significantly lower in infants born to older mothers with medium SLI and small size at birth. Mothers’ being in gainful occupation was the only factor associated with a higher proportion of infants being exclusively breastfed. As the child grew older, association of EBF was seen with fewer variables and at six months of age, children whose mothers were more educated, living in urban areas, from medium SLI household and availing antenatal/natal care were less likely to be exclusively breastfed than their counterpart while children of mothers who were in gainful occupation were likely to be breastfed longer. Chudasama et al. [30] reported parity, delivery interval more than 24 months, early maternal age, lower socio-economic status, low paternal education and occupation as a risk factor for early cessation of EBF.

As urbanization and modernization of society is believed to influence the life style, the present study tried to examine this by considering woman’s place of residence as rural or urban. In rural areas, people live together in a village and their beliefs and religious practices may have a strong influence on their behaviour and social habits. A significant association that infants in urban area as compared to rural area are less likely to be breastfed at the different ages of the infant emerged in the two surveys and is also reported from other countries. For instance, in a study carried out in Malaysia, mothers from rural area were more likely to exclusively breastfeed compared to mothers from urban area (OR = 1.16; 95 % CI 1.03, 1.89) [12].

Several studies report non-gainful occupation of mother as a predictor of exclusive breastfeeding [15, 31]. However, our analysis indicated a significant higher proportion of infants of mothers in gainful occupation were exclusively breastfed. This association was present in both the surveys and in all three age segments studied. An explanation for this could be increased knowledge and awareness of EBF through interaction with colleagues at workplace. Under the Maternity Benefit Act 1961, women in India are entitled to 12 weeks paid maternity leave and since 2008, this has increased to 180 days for government employees. However, these benefits are variable in the organized and unorganized sector and policies guaranteeing maternity entitlements to women working outside the formal sector need to be implemented [32].

Increasing household wealth level as measured by the validated SLI had an inverse association and led to a progressive increase in the likelihood of stopping exclusive breastfeeding. This effect was seen at all ages up to six months in the NFHS-1 for mothers living in high and medium PNMR states. In the later NFHS-3 carried out in 2005-06, no association with SLI was seen in the high PNMR states at all ages but high/medium SLI was associated with a lower proportion of exclusive breastfeeding in the medium/low PNMR states. This is consistent with previous reports of adverse impact of high SLI on duration of breastfeeding in developing countries [17, 29, 33–35]. This could be due to greater affordability in high SLI household to foods other than breast milk. The lack of association of SLI observed in the later survey in the high PNMR states could be due to focused efforts to promote EBF in these states.

Contrary to other studies [36], a lower proportion of infants born to mothers who received antenatal care during pregnancy or were born in a medical facility received EBF in the NFHS-1. However, this changed over time and in NFHS-3, no association between EBF and utilisation of health services was apparent. Government policies that have led to improvements in health care services and an increase in institutional delivery have contributed towards this. Antenatal and postnatal care was associated with higher EBF rates in Sri Lanka but in Nepal antenatal visits were found to have a negative influence [29]. Antenatal contact with a health professional provides an opportunity to counsel a woman to establish and continue EBF and lack of breastfeeding counselling was significantly associated with decreased rates of EBF at 4 and 6 months in rural north India [37]. Providing correct information in simple language by a well-trained care provider will prevent problems and help women to succeed in breastfeeding [37, 38].

The other change observed between the two surveys was the influence of mother’s education on EBF. Infants born to literate mothers had a less likelihood of being exclusively breastfed in NFHS-1which was not significant in NFHS-3. While infants of less literate mothers in medium/low PNMR states were more likely to be exclusively breastfed at one month of age, the reverse was seen in more literate mothers at six months of age in high PNMR states. In a study carried out in Ghana and in urban slums in India, mother’s education was associated with higher likelihood of EBF [36, 39].

The strength of this study is the use of validated questionnaire and nationally representative data set over two time points, very high survey response rates, low rates of missing and excluded data and appropriate adjustments for sampling design made in the analysis. The study limitations are the recall bias for exclusive breastfeeding data in NFHS-1, particularly for children who have died. The recommendation to collect data on breastfeeding practices only from children who are currently being breastfed [23, 24] could lead to an over or underestimation in the proportion of infants exclusively breastfeeding since some infants who were given other liquids irregularly may have moved in or out of the criteria in the 24 h before the survey [40–42]. This exposure misclassification could result in biased measures of association seen in such large scale surveys [43, 44]. In addition, the cross-sectional nature of this study prevents drawing causal inferences from the association between the determinant factors and exclusive breastfeeding.

The rate of EBF in India continues to be sub-optimal with no appreciable gains in the last 13 years. Our study indicated that determinants of EBF change over time. The factors identified with non-compliance of EBF were living in urban areas, shorter birth intervals and belonging to higher wealth index. Interventions that seek to increase exclusive breastfeeding should be more focused on mothers with infant’s 4-6 months of age and in those who are most at risk of early discontinuation of breastfeeding. EBF needs to be supported through an integrated approach meeting the different needs and regions of this vast country and especially in states with high neonatal mortality rates where these practices are deficient. Several successful intervention models and strategies to promote EBF have been evaluated and there is a need to scale-up and implement the most appropriate and culturally acceptable ones to universalise optimal infant feeding practices. In addition, providing maternity entitlements to women would actualize the rights of mothers and infants to breastfeed.