Discussion

In our study, the rate of exclusive breastfeeding up to six months was 34.5%, whereas it was 47.6% in the rural areas of the same district during 2012-2013 [16]. In a community based study in 2008, conducted in Bankura, West Bengal, the prevalence of EBF was 57.1% [19]. Another study in South India reported 27% EBF in 2015 [20]. In Bangladesh, situated nearby North 24 Parganas, the rate of EBF in Mirzapur was 36% in 2011. The rate was lower than the national average of 64% in Bangladesh [21]. The prevalence of EBF in our study conducted in 2016 was 13.1% less compared to the district average during 2012-2013 [16]. The rate was also 7.8% less than the state average of 52.3% during 2015-2016 [13]. In India, using the NFHS 4 questionnaire, women were asked several questions about the duration of any breastfeeding, and infant feeding in the previous 24 hours [18]. At the age of six months, NFHS 4 measured rate of the EBF using 24 hour recall method. This was not out of limitation [13]. Agampodi, et al. showed that actual exclusive breastfeeding rates were lower than those derived from the 24 hour recall method [22]. We strictly adhered to the definition of EBF as per the WHO guidelines and retrospectively estimated the rate of EBF for one month, two months and so on up to six months and more, with a known limitation of recall bias [1,2]. However, the findings were very close to some other findings of studies conducted surrounding the geographical areas of our study during similar periods. Our finding was quite lower than the NFHS 4 report conducted during the same period. So, it raised a question on the accuracy of the information collected through NFHS or DLHS using 24 hour recall method. In the 24 hour recall method used in NFHS 4, there was a possibility of a higher rate of reporting. The 24 hour recall method was a proxy indicator towards the actual estimation of EBF. Only correct information could properly help for planning a program, for example, IYCF or Reproductive and Child Health (RCH) program of the state. We, therefore, needed more accurate information on EBF. The most accurate way to estimate the actual exclusive breastfeeding rate is to through a prospective cohort study of newborn babies for up to 6 months of age. Our study, therefore, gives a justification to go for a prospective cohort study to measure the accurate rate of EBF among the newborns till their age of six months.

We identified three important influencers of EBF. They were sex of the child (male or female), type of family (joint and nuclear) and age group (younger age group <= 24 years and elder group >= 24 years). Out of these three, multivariate logistic regression analysis identified two factors (age and type of the family) to be important predictors of EBF.

First, we have discussed about the role of the gender. The gender discrimination still prevailed in the study area. Among 38 male children, 36.8% were put on EBF. Among 58 female children, 34.5% were put on EBF. Gender as a social issue influenced adherence to initiation of EBF and its continuation in a study in Haryana in India [23]. In Chandigarh, male gender was found as a risk factor for pre-lacteal feeding and delayed initiation (beyond the first hour) of breastfeeding [24]. If the newborn was a girl, the mother either refused to feed the baby immediately or reacted reluctantly. Gender preference affected not only the female baby, but also the male baby. Because of son preference, the family followed all rituals in case of a boy baby that ultimately delayed the timely start of breastfeeding [25]. Exclusive breastfeeding was practised among overall 52.5% children, and whereas, 41.5% among boys and 27.1% among girls up to six months. The gender difference was statistically significant [26]. The Child Disparity Index in India with respect to the breastfeeding was 0.040, 0.041, 0.042 in NFHS 1, NFHS 2, NFHS 3 respectively [27]. Any effective healthcare program for mother and child had to focus on preparing their health workforce so that gender disparity did not prevail. Birth preparedness by the health workers and community health volunteers showed the positive impact of the breastfeeding practices [27,28]. Even though the gender difference was not high in our study, it was indicative that the difference prevails. If the study area could have been wider, more concrete conclusions could have been made. In West Bengal, the present study findings recommend for sensitization of health workforce so that promotional activities are carried out among mothers and family members are sensitized about the importance of EBF for both male and female children.

In our study, mothers from nuclear family (47.1%) were more likely to give EBF to children than the mothers from the joint family (29.0%). In a study in Lyon and in the Paris in 2015, it was found that the family environment, especially the husband, appeared to have the greatest influence on the EBF decision [29]. The nuclear family had a higher rate of EBF than the joint family in our study and being revealed out as an important predictor [p = 0.02; OR: 0.25 (0.08-0.80)]. The encouragement from other family members was also associated with higher breastfeeding initiation rates [29]. In our study in a joint family, the rate of EBF was lower. In other words, the influence of family members was negative to EBF. Support from fathers in supporting the initiation and continuation of breastfeeding was recognized [30]. From the joint family perspectives, more research was needed to fully understand the matter and even the relationship between the father and mother in connection with the EBF [31,32]. Our study opened an opportunity to further research; why in a joint family rate of EBF was lower.

In our study, the age of the mother was an important predictor of EBF. Younger mothers up to 24 years were more likely (64.7%) to complete EBF till six months than the elder mothers (29.0%) [p = 0.01; OR: 5.98 (1.78-20.03)]. Zielinska in his study in 2017 found that non-exclusive breastfeeding was associated with maternal age under 20 years. Maternal age from 26 to 30 years had a very high chance of compliance with EBF [33]. In our study, we got similar observations. For younger mothers, they might have less exposure to health promotion activities and had poor knowledge as well. Poor knowledge about the benefit of EBF had detrimental effects on the compliance to EBF [33]. Our study, therefore, recommends adequate promotional activities among mothers of all age groups with focus on the younger age group.

Apart from the above three influencers of the EBF, we have discussed above, in our study, we identified important barriers of EBF those were mentioned by the lactating mothers from their own experiences. Two most important barriers were caesarean section delivery (37.1%) and the perception of having insufficient milk secretion (29.0%). In a tertiary care hospital in Haryana, major barriers to the initiation of breastfeeding were obstetric complications leading to caesarean section and neonatal complications [23]. In another study in Chandigarh in India, caesarean section was found to be a leading barrier of EBF [24]. Unlike other studies, one important barrier that could not be identified in our study was neonatal complications. However, our study identified a new barrier, the perception of having insufficient milk secretion. This finding could contribute to the planning of health education among the mothers and training of health workers.