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close this book4th Report on the World Nutrition Situation - Nutrition throughout the Life Cycle (SCN; 2000; 138 pages)
View the documentADMINISTRATIVE COMMITTEE ON COORDINATION/SUB-COMMITTEE ON NUTRITION - (ACC/SCN) THE UN SYSTEM’S FORUM FOR NUTRITION
View the documentINTERNATIONAL FOOD POLICY RESEARCH INSTITUTE
View the documentFOREWORD
View the documentHIGHLIGHTS
View the documentCONTRIBUTORS
View the documentACKNOWLEDGEMENTS
View the documentLIST OF ABBREVIATIONS
View the documentPREFACE
Open this folder and view contentsCHAPTER 1: NUTRITION THROUGHOUT THE LIFE CYCLE
Open this folder and view contentsCHAPTER 2: MICRONUTRIENT UPDATE
close this folderCHAPTER 3: BREASTFEEDING AND COMPLEMENTARY FEEDING
View the document3.1 Evidence Linking Breastfeeding to Improved Outcomes
View the document3.2 Evidence Linking Complementary Feeding to Improved Outcomes
View the document3.3 Conceptualizing Infant Feeding Behaviours
View the document3.4 HIV and Infant Feeding
View the document3.5 Breastfeeding and Complementary Feeding Patterns and Trends
View the document3.6 Role of National and International Initiatives in Support of Optimal Infant Feeding
View the document3.7 Looking Forward: The Importance of Exclusive Breastfeeding
Open this folder and view contentsCHAPTER 4: NUTRITION AND HUMAN DEVELOPMENT
Open this folder and view contentsCHAPTER 5: NUTRITION OF REFUGEES AND DISPLACED POPULATIONS
Open this folder and view contentsAPPENDICES
View the documentREFERENCES
View the documentBACK COVER
 

3.5 Breastfeeding and Complementary Feeding Patterns and Trends

This section uses data from nationally representative household demographic and health surveys to provide trend information on breastfeeding, complementary feeding, and bottle feeding. Data are presented from national surveys conducted with technical support from the Demographic and Health Surveys (DHS). Current status data are used to determine infant feeding patterns to avoid problems associated with recall bias. Surveys from 1990 to 1996 reporting on current infant and childhood feeding patterns are available for 37 countries. Twenty-seven countries supported by DHS or World Fertility Surveys have multiple surveys that permit analysis of trends of breastfeeding initiation and of the median duration of breastfeeding covering the period 1975 to 1996. These data were published in June 1999 by Macro International in a report titled Breastfeeding and Complementary Feeding, and the Postpartum Effects of Breastfeeding.34 In addition, analysis of DHS data for Latin America and the Caribbean by the Pan American Health Organization permits presentation of trends in exclusive breastfeeding for the years 1986 to 1996.35

This review shows that breastfeeding initiation rates are very high in developing countries. The incidence of breastfeeding initiation exceeds 90% in almost every country and exceeds 95% in more than half of the countries. Breastfeeding initiation is universal in Sub-Saharan Africa. However, breastfeeding practices are far from optimal. The recommendation for exclusive breastfeeding is not widely practiced (Table 3.1). In general, the proportion of infants under four months of age who are exclusively breastfed is highest on average in Asia (up to 82% in Nepal) and the Near East/North Africa (63% in Morocco) followed by Latin America and Sub-Saharan Africa. There is significant variation within regions. For example, in Latin America and the Caribbean, the proportion of infants under four months of age who are exclusively breastfed ranges from less than 5% in Haiti to more than 50% in Bolivia, Guatemala, and Peru.

WHO and others recommend that all infants six to nine months of age be breastfed and also receive complementary foods. Data on “breastfeeding plus complementary foods” shown in Table 3.1 reflect the timing of introduction of complementary foods but provide no information about the quality of these foods. Again there is large variation within regions. For example, in Sub-Saharan Africa one-third of infants in Ghana and Mali are receiving complementary foods, compared with 90% or more in Kenya and Zimbabwe. In general, low prevalences for this indicator in Latin America and the Caribbean are because infants are no longer being breastfed rather than because they are not receiving complementary foods. Delayed introduction of complementary foods is a serious problem in some countries. Less than one-third of infants receive complementary foods by six to nine months in Bangladesh, India, and Pakistan, according to surveys conducted in the early 1990s.

TABLE 3.1: Breastfeeding and complementary feeding practices

Region, country, and date

Exclusive breastfeeding, < 4 months (%)

Breastfeeding plus complementary foods, 6-9 months (%)

Breastfeeding, 12-15 months (%)

Breastfeeding, 20-23 months (%)

Bottle feeding, <4 months (%)

Sub-Saharan Africa

         
 

Burkina Faso 1993

3.1

43.9

98.0

81.7

1.6

 

Cameroon 1991

7.3

77.1

80.7

37,8

17.8

 

Central African Republic 1994-95

4.4

93.1

96.6

54.8

2.3

 

Côte d’Ivoire 1994

3.4

66.2

94.9

47.5

4.5

 

Ghana 1993

8.3

35.7

94.6

55.4

23.9

 

Kenya 1993

17,0

90.1

91.3

57.6

16.4

 

Madagascar 1992

48.4

80.0

91.1

51.7

3.7

 

Malawi 1992

3.3

87.2

94.5

59.9

3.8

 

Mali 1995

12.2

32.9

94.3

62.8

2.9

 

Namibia 1992

21.6

64.7

69.1

24.8

31.1

 

Niger 1992

1.3

73.2

96.3

63.7

2.1

 

Nigeria 1990

1.4

51.7

86.9

46.3

33.6

 

Rwanda 1992

90.2

67.8

98.6

89.0

0.7

 

Senegal 1992-93

6.5

58.9

94.1

50.6

6.2

 

Tanzania 1991-92

32.5

58.7

94.7

59.5

4.1

 

Uganda 1995

70.4

63.6

88.5

45.0

5.6

 

Zambia 1992

13.3

87.6

91.1

34.9

3.2

 

Zimbabwe 1994

16.3

93.0

89.8

26.7

5.8

Near East/North Africa

         
 

Egypt 1992

54.0

52.3

77.9

42.4

19.9

 

Jordan 1990

32.0

48.1

48.3

17.2

29.8

 

Morocco 1992

62.9

35.1

64.6

31.7

23.1

 

Turkey 1993

13.9

47.1

47.5

18.2

29.4

Asia

         
 

Bangladesh 1993-94

53.5

29.4

96.1

91.2

0.0

 

India 1992-93

51.2

31.5

89.0

73.0

9.2

 

Indonesia 1994

47.6

85.8

88.8

76.6

10.6

 

Kazakhstan 1995

12.3

62.7

52.3

24.1

69.0

 

Nepal 1996

82.0

62.5

96.7

92.7

2.3

 

Pakistan 1990-91

25.1

29.2

79.7

59.4

26.2

 

Philippines 1993

33.1

52.1

58.2

24.2

43.0

Latin America/Caribbean

         
 

Bolivia 1993-94

54.0

78.0

74.7

42.7

34.7

 

Brazil 1996

40.8

11.6

34.8

18.8

50.9

 

Colombia 1995

15.7

61.5

42.8

18.8

72.0

 

Dominican Republic 1991

9.6

22.8

29.5

9.1

80.8

 

Guatemala 1995

50.7

55.7

78.0

54.0

26.4

 

Haiti 1994

3.3

84.1

82.4

26.7

36.4

 

Paraguay 1990

7.0

61.2

40.3

11.1

56.1

 

Peru 1996

61.4

72.2

81.6

45.8

28.6

 

Source: Abstracted or calculated from information presented in 34.

The prevalence of breastfeeding between 12 and 15 months is relatively high in all regions. In Sub-Saharan Africa 13 of the 18 countries reported here have breastfeeding rates exceeding 90%. For other regions, again, there is significant variation. In Latin America and the Caribbean, breastfeeding at 12-15 months ranges from a low of 30% in the Dominican Republic and 35% in Brazil to about 80% in Guatemala, Haiti, and Peru. Prevalences of breastfeeding among children 20 - 23 months of age are highest in Sub-Saharan Africa and Asia (over 50%) and lowest in Latin America and the Caribbean and the Near East/North Africa (about 25%).

Bottle feeding carries a significant risk of morbidity because of contamination36 and is therefore a useful indicator to follow. Bottle feeding is highly variable, depending on the region and the country. In general, it is lowest in Sub-Saharan Africa, although one-third of infants are bottle fed in the first four months in Namibia and Nigeria. Bottle feeding rates are very high in Latin America and the Caribbean. In four of the eight countries reported on, more than half of infants less than four months are bottle fed. A very high rate of bottle feeding is reported for Kazakhstan in Central Asia (69%), whereas rates are much lower elsewhere in Asia - for example, 9.2% in India.

TABLE 3.2: Trends in the median duration of breastfeeding

Region, country, and date

Median duration (months)

Sub-Saharan Africa

 
 

Cameroon 1978

17.8

 

Cameroon 1991

18.2

 

Ghana 1979-80

17.8

 

Ghana 1988

21.5

 

Ghana 1993

21.6

 

Kenya 1977-78

16.6

 

Kenya 1989

20.0

 

Kenya 1993

21.6

 

Mali 1987

18.6

 

Mali 1995

22.5

 

Nigeria 1982

17.0

 

Nigeria 1990

19.8

 

Rwanda 1984

20.9

 

Rwanda 1992

28.0

 

Senegal 1978

18.0

 

Senegal 1986

18.9

 

Senegal 1992-93

20.2

 

Uganda 1988-89

19.5

 

Uganda 1995

19.3

 

Zimbabwe 1988-89

19.1

 

Zimbabwe 1994

18.1

Near East/North Africa

 
 

Egypt 1980

15.3

 

Egypt 1988-89

19.8

 

Egypt 1992

19.8

 

Jordan 1976

10.9

 

Jordan 1990-91

12.1

 

Morocco 1980

15.9

 

Morocco 1987

15.4

 

Morocco 1992

15.5

 

Turkey 1978

11.7

 

Turkey 1993

11.7

Asia

 
 

Bangladesh 1975-76

25.8

 

Bangladesh 1993-94

36.0

 

Indonesia 1976

23.3

 

Indonesia 1987

23.3

 

Indonesia 1991

23.6

 

Indonesia 1994

23.7

 

Nepal 1976

24.2

 

Nepal 1996

31.3

 

Pakistan 1975

17.8

 

Pakistan 1990-91

18.5

 

Philippines 1978

14.1

 

Philippines 1993

15.4

Latin America/Caribbean

 
 

Bolivia 1989

16.4

 

Bolivia 1993-94

17.5

 

Brazil 1986

5.8

 

Brazil 1996

7.8

 

Colombia 1976

7.9

 

Colombia 1986

9.1

 

Colombia 1990

9.3

 

Colombia 1995

10.3

 

Dominican Republic 1975

8.4

 

Dominican Republic 1986

8.1

 

Dominican Republic 1991

5.9

 

Guatemala 1.987

20.6

 

Guatemala 1995

20.2

 

Haiti 1977

15.6

 

Haiti 1994

17.7

 

Paraguay 1979

12.4

 

Paraguay 1990

11.7

 

Peru 1977-78

14.5

 

Peru 1986

14.1

 

Peru 1991-92

18.1

 

Peru 1996

20.2

 

Source: 34.

Overall, data on trends in the median duration of breastfeeding show positive changes between 1975 and 1996 (Table 3.2). The high median duration of breastfeeding was maintained in many countries and actually increased in some. Increases in the median duration of breastfeeding measured over a ten-year period range from about one month in the Near East/North Africa to 2.5 months in Sub-Saharan Africa. When all countries were considered together, the median duration of breastfeeding increased at a rate of 1.7 months per decade. Work is under way to extend the analysis of trends in breast-feeding and complementary feeding by developing comprehensive indicators of care. This work is described in Box 3.1.

BOX 3.1

Approaches to Measuring and Quantifying Care

Care is defined as “the behaviours and practices of caregivers (mothers, fathers, siblings, and child-care providers) to provide the food, health care, stimulation, and emotional support necessary for children’s healthy growth and development.”37 Over the past decade, care has been increasingly recognized as a crucial input into child health and nutrition, along with food security, availability of health services, and a healthy environment.

In 1995 a special issue of the Food and Nutrition Bulletin presented an extensive review of the literature on care and its determinants and provided recommendations for protecting and enhancing the quality of care. A useful distinction has also since been made between “care resources” and “care practices.” The latter includes the following six main areas of caregiving behaviours: (1) care for women; (2) feeding/breastfeeding; (3) psycho-social and cognitive stimulation; (4) hygiene practices; (5) home health practices; and (6) food preparation and storage. Indicators for measuring care were also identified.

In 1997 WHO, along with IFPRI and the University of Ghana, undertook a survey in Accra using the food-health-care conceptual model to examine the determinants of child undernutrition. One of the greatest challenges was to identify an approach to measuring and quantifying care. Data on child feeding practices and use of preventive health services were collected, and the information was used to create an age-specific child-care index. The index was particularly useful in examining the importance of care for child undernutrition and in studying the determinants of caring practices in this population. The main findings were (1) good care practices for children 4 - 36 months of age were beneficial for child nutritional status and could partially compensate for the negative effects of low maternal schooling and poverty; (2) the most important constraint to good child care practices was maternal schooling; and (3) household socioeconomic factors, food security, maternal work, and other maternal characteristics did not interfere with caring practices in this population.38, 39

In collaboration with Cornell University and Emory University, IFPRI is now using DHS data sets to pursue its work in measuring and quantifying care. The focus is on using the information available on breastfeeding and complementary feeding to derive a child feeding index for various countries and regions around the world. Preliminary work shows promising results, and the findings should help improve our understanding of the role of care in the etiology of childhood undernutrition in different settings. The research will also help identify minimum data needs and useful indicators for measuring and quantifying care. The current focus is on child feeding practices because of data availability, but research is urgently needed on indicators and methodologies to quantify other more complex aspects of care, such as psychosocial and cognitive stimulation or care of women, which remain largely understudied.

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