Identifying the Associations of Currently Breastfeeding Status and Socio-Demographic Factors of Children 6 to 23 Months of Age in Bangladesh

Breastfeeding contributes to the immunological and cognitive development of the children along with the health of the mothers. In context of Bangladesh, the information regarding breastfeeding practice remains under the shade of other health issue. Therefore, this study aims to identify the associations of currently breastfeeding status and socio-demographic factors of children aged 6 to 23 months in Bangladesh. All data including currently breastfeeding status and sociodemographic factors were obtained from the data set of Bangladesh Demographic Health Survey (BDHS) 2011. A total of 2,227 children aged 6–23 months were selected for analysis by using different exclusion and inclusion sampling criteria. Chisquare test was performed to identify the correlation between mother’s breastfeeding status and the socio-demographic variables. The simple presentation of contingency analysis provides a true picture to the reader. Multilevel factors, such as, age of child, father’s education and employment status, socio-economic status, and place of residence were identified that incorporate the meaningful influences on mother’s breastfeeding status. The findings of this study will be considered by the stake holder to generate an effective strategies for the betterment of the future generation aged 6 to 23 months in future.


Introduction
According to the "Convention on the Rights of the Child", the children from all spheres of society have the right to proper nutrition for sound Volume 2, Issue 1, December 2017 growth and development (WHO, 2017).The initiation of breastfeeding within one hour of birth has been considered a vital element for children, which significantly reduces child mortality and helps to protect a baby from severe diseases (Victora, et al. 2016;Leon-Cava, et al. 2002).Breastfeeding for subsequent six months after birth protects children from diseases, like diarrhoea and gastrointestinal infections (Leon-Cava, et al. 2002;Horta and Victora, 2013).Contrary, breast milk has been proven as an important source of energy for the children aged 6 to 23 months (Dewey and Brown, 2003).World Health Organization (WHO) recommended children between 6 to 23 months of age must be fed breast milk along with complementary foods (WHO, 2009).
Lower rates of introduction of breastfeeding among children have been found in most of the countries around the world including Bangladesh (BDHS, 1997;Ahmed, et al. 1999;BBF, 2001).In Bangladesh, around 15.0% infants are fed breastmilk up to three months (Haider, et al. 1999).Poor breastfeeding status results in severe health complications, for example, malnutrition, diarrhoea, and child mortality among children (Patel, et al. 2015).The immunological and nutritional charactersitics of breastfeeding can protect children from nutritional hardship (Chowdhury et al.2016).
Multiple studies from Latin America, Africa and Asia identified the associations between breastfeeding and socio-economic factors, demographic factors, anthropometric factors and so on (Thulier and Mercer, 2009;Wright, et al. 1993;Scott and Binns, 1999).Practicing breastfeeding has been found among women with higher socio-economic status, settled in urban areas and had more than secondary education (Giashuddin and Kabir, 2004).
A bunch of studies highlighted breastfeeding as an important phenomenon.For example, workplace facilities provided by the organization affects the breastfeeding prac-tice of the Pakistani female worker (Soomro, 2015).Petry (2013) showed an analysis regarding breastfeeding rates and mother with low socio-economic status in the USA.Age of the respondents, level of education, occupation, monthly income, age of the child were associated with breastfeeding practice among rural women in a selected area of Bangladesh (Rahman, et al. 2014).Chowdhury. et al (2016), took into consideration similar variables to identify the level and determinants of complementary feeding based on meal frequency of the same age group.However, no significant study focused on precisely the relationship between socio-demographic variables and breastfeeding status.Therefore, the aim of the present study was to identify the relationship between currently breastfeeding status of children of age 6 to 23 months and socio-demographic status.The BDHS 2011 sample was drawn from adults from selected households.The survey was operated in 7 administrative regions (divisions): Southern region (Barisal), Southeastern region (Chittagong), Central region (Dhaka), Western region (Khulna), Midwestern region (Rajshahi), Northwestern region (Rangpur), and Eastern region (Sylhet) covering both rural and urban areas.Enumeration areas from the 2011 census were used as the primary sampling units for the survey.The survey was based on Volume 2, Issue 1, December 2017 multistage stratified sampling techniques of households.Mothers of households were asked to provide information about their children.Children who were born either in 2009 or later were included in this study.Each mother was asked to report about breastfeeding that her child had consumed during the day or night preceding the interview.When mothers had more than one child in the study sample, they were asked to report about the youngest child living with them.The detail sampling design and all other issues related to the BDHS were discussed elsewhere (BDHS, 2011).

Selection of sample (inclusion and exclusion criteria)
Children who were born after January 2006 or later were eligible for anthropometric (height and weight) measurements.The UNICEF provided all types of logistic supports.Some exclusion and inclusion criteria were followed to get the requisite sample.First, some criteria based on the WHO (2006) standards flag limits of z-scores were applied to measure implausible values of stunting, wasting and underweight.Second, completed data on height, weight and age were available only for 7,647children from a total of 8761 children below 5 years of age who were eligible for anthropometric measurements.Third, all under-five children outside the range of 6-23 months were excluded from present analysis.Fourth, from a total of 2,405 children aged 6-23 months, 178 children were excluded due to missing information.Therefore, our final sample for analysis was 2,227 children aged 6-23 months.

Independent and dependent variables
Independent variables were: age of child (6 -11 months, 12-17 months, 18-23 months); sex of child (male, female); birth order of child (first, second, third, fourth, fifth and above); size of the child (large, average, small -size of birth was reported for children who were born in health institutes, e.g.hospitals, clinics etc. and mothers' esti-mate were considered for those children who were born at home); mother's education (illiterate, literate); father's education (illiterate, literate); father's employment status (currently unemployed composed of employed, students etc.; labours composed of the farmer, agricultural worker, fisherman and rickshaw-puller etc.; service holders composed of the doctor, lawyer, accountant, teacher etc.; businessman); Socio -economic status (poor, middle, rich); food insecurity (yes, no) and place of residence (urban, rural).The dependent variable was : currently breastfeeding status of the mothers of children aged 6 to 23 months (yes, no).

Household food security indicators and socio-economic status
Five household food security indicators were selected using the Household Food Insecurity Access Scale.The technical working group of the BDHS 2011 systematically reviewed and modified the indicators to suit Bangladesh.The questions used were: (1) "In the past 12 months, did you have 3 square ('full-stomach') meals a day?"; (2) "In the past 12 months, did you have to skip entire meals because there was not enough food?"; (3) "In the past 12 months, did you have less food in a meal because there was not enough food?"; (4) "In the past 12 months, did you or any of your family members eat wheat or another grain in place of rice?"; and (5) "In the past 12 months, did you ask for food from relatives or neighbours to make a meal?"Each indicator had four options to select the best answer: never, rarely (1-6 times in the past 12 months), sometimes (7-12 times in the past 12 months), and often (few times each month).Firstly, answers to these questions were numerically coded and then simply added to compute a total score for each ever-married woman.For the first question, coded values were 3 = never, 2 = rarely, 1 = sometimes and 0 = often.Opposite coding were used for remaining questions with never = 0, rarely = 1, sometimes = 2 and often = 3.A household was classi-Volume 2, Issue 1, December 2017 fied as food insecure when a family reported any of the three options within the recall period of the past month: never = 3, rarely = 2 and sometimes = 1 for the first question and rarely = 1, sometimes = 2 and often = 3 for remaining four questions.According to our analysis, the total score ranged from 0 to 15.Any household with a total score of 0 was classified as food secure family.In contrast, any household with to-tal scores between 1 and 15 was considered as food insecure family.To facilitate analysis, a composite score ranging from a minimum of "0" to a maximum of "15," which was later classified as 2 categories, food secure (0), food insecure (>0) (BDHS 2011).The wealth index was used to measure household socioeconomic status.This index was constructed based on household assets, including ownership of durable goods (such as televisions and bicycles) and dwelling characteristics (such as source of drinking water, sanitation facilities, and construction materials).The techniques of principal components analysis were used to assign individual household wealth scores.These weighted values were then summed and rescaled to range from 0 -1 and later classified as poor, middle and rich (BDHS, 2011).

Statistical analysis
Descriptive statistics were presented percentages where appropriate, and Chisquare ( ) test was used to evaluate the association between outcome (currently breastfeeding mothers of children aged 6 to 23 months) and independent variables (covariates).SPSS 20.0 was used for all statistical analysis and they were statistically significant if they reached 5%.

Ethical issue
The The overall currently breastfeeding practice was approximately 94.3% (Table 2).
The associations between current breastfeeding status and socio-demographic factors of children aged 6 to 23 months were illustrated in Table 2.According to the results of Table 2, currently breastfeeding was significantly associated with the age of the children, father's education, father's occupation, socio-economic status and types of residence.In addition, currently breastfeeding practice was significantly lower among children aged 18-23 months (29.0%, p<0.001), children of uneducated fathers (25.8%, p=0.021) and currently unemployed fathers (2.2%, p<0.001), children from socio-economically middle class family (19.5%,p=0.008) and urban areas (29.9%, p<0.001).

Discussion
The study revealed that the overall currently breastfeeding practice among children aged 6 to 23 months was more than 90% in Bangladesh.The results also highlighted significant interclass variations in terms of breastfeeding practice that were found for several socio-demographic factors, such as, age, father's education, father's occupation, socio-economic status, types of residence.2016) considered some demographic indicators, such as, age of the child, sex, mother's education, mother's occupation, father's education to explain the breastfeeding status of children in Bangladesh, however, did not find any association.Poor breastfeeding practice in India was found to have an impact on child morbidities (Patel, et al. 2015).
Breastfeeding practice was found to have significantly lower proportion among children aged 18-23 months.Similar cohort existed in a study of Tanzania to describe the current breastfeeding status where children were breastfed at the lowest rate (46.2%) (Vitta, et al. 2016).The practice of breastfeeding decreased with increased aged.World Health Organization (WHO) suggested breast milk is important for children in addition to taking complementary foods 2 to 3 times every day.As complementary foods are recommended after 6 months of age, thus the practice of breastfeeding decreased with the age (WHO, 2017).Additionally, insufficient milk, getting pregnant while breastfeeding and be-ing a working mother may be some other reasons for poor breastfeeding practice (Alshebly and Sobaih, 2016).
Our study showed that breastfeeding practice among mothers increased with the increasing of the level of the father's education.An educated father can play a vital role in boosting his spouse by praising her about the effort, recognizing her sacrifice and helping her in household chores (Role of the Father in the Breastfeeding Family, 2017).He can develop a relationship with his child which can make the child calm and quiet and help his spouse in the breastfeeding process.A cross-sectional study in Southern Ethiopia on children aged less than 6 months found that fathers having secondary education or above were five times more likely to have a significant engagement in child's breastfeeding (Abera, et al. 2017).
Job status of the children's fathers is an important factor influencing breastfeeding of children.
Father's occupation was significantly associated with the mean level of complementary feeding among underweighted children 6 to 23 months in Bangladesh and the complement feeding includes breastfeeding (Chowdhury, et al. 2016;Rahman, et al. 2017).Leweis (1959) stated that a father with poor economic conditions had less emotional ties to his children and spent less time at home.Culture, lack of knowledge about breastfeeding of the mother and primary caregiver may define the state (Nankumbi and Muliira, 2015).Father's job status sometimes may affect mother's weaning practice of 6 to 23 months aged children (Zeleke, et al. 2017).However, our study found fathers within a low income group were more exposed to breastfeeding status.
A study declared that infant breastfeeding practice was influenced by higher socioeconomic status, higher maternal education and living in the urban area (Leon-Cava, et al. 2002).Mothers from rich families took a shorter time to breastfeed their children than the poor socio-economic sta-tus in India (Giashuddin and Kabir, 2003).Children from high socio-economic backgrounds get good care from their family because they have sufficient associates to support their young family members (Naomee, 2013), the absence of poverty, proper healthcare support and family planning (APA, 2017).But less emotional attachment to the parents due to engaging in the workforce sometimes hampers the children's proper feeding process.According to our result, almost two-thirds of the total respondents who breastfed their children found to live in a rural setup.A research carried out in both urban and rural parts of Bangladesh supports our findings that 85% of mothers from rural areas continued breastfeeding practice until two years, while 63% from urban (Khan, 1980).In a study in Timor results showed that place of residence was significantly associated with exclusive breastfeeding practice and the result is not consistent with our study findings (Kalam, 2014).Children are given care not only by their parents but also by the members of the extended family in rural areas (Nankumbi and Muliira, 2015).Relatives or neighbours can take care of the children and feed them when their mothers become unstable in rearing them (Javadifar, et al. 2016;Hamadani and Tofail, 2014).Because the interaction pattern of rural inhabitants is much stronger than the urban dwellers (Difference between Rural and Urban Life, 2015).Our study has some merits, for example, like the proper utilization of a huge quantity of nationally representative data.Simple and trustworthy use of contingency analysis of breastfeeding and socio-demographic factors that provide a clear understanding to the reader.The study has tried to disclose a new corner of a social phenomenon that may be used as a background of further research on this issue.

Limitations of the study
Our study did not overcome all the limitations.As for example, to identify the associations of currently breastfeeding status and socio-demographic factors of children, the data set of BDHS-2011 was used for analyzing instead of available data set of BDHS -2014.The quantitative nature of the study sometimes does not express all the indepth information of the respondents so that other methods like a case study can be used in current methodology.Some other parameters were needed along with the used indicators to discover the total scenario.

Conclusion
The present study illustrated the current breastfeeding status in terms of sociodemographic factors.Bangladesh government has followed a great strategy named Millennium Development Goal (MDGs) where children's and mother's health were a prime concern, likewise, Sustainable Development Goals (SDGs) need to be achieved within 2030 for socio-economic advancement.Health promotion and nutritional program through government and nongovernment organizations can ensure the proper breastfeeding practice among people.Proper breastfeeding can be ensured by undertaking social safety net programmes and community-based nutritional interventions, for example, food for education, food for work for slum dwellers etc.Both researchers and professionals can use the result for further investigations and relevant to other countries like Bangladesh.Policymakers can use the findings for making strategies to ensure appropriate breastfeeding of the children aged 6 to 23 months.

Competing Interests
The authors have declared there are no competing interests.

Contribution of authors
MRHKC was involved in initiation, preparation, data analysis and interpretation.MMR and SN did the literature review.Both MAI & SH helped in data analysis and proof reading.
Volume 2, Issue 1, December 2017 Data was extracted from the Bangladesh Demographic Health Survey (BDHS) 2011, which was a nationally representative cross -sectional survey.This survey was funded by the United States Agency for International Development (USAID), and conducted by the National Institute of Population Research and Training (NIPORT) under the Ministry of Health and Family Welfare, Bangladesh.All survey-related actions were implemented by a Bangladeshi research organization 'Mitra and Associate' with technical support from the ICF International of Calverton, Maryland, USA.