The results presented in this paper show which demographic, social, and economic factors are significantly related to exclusive breastfeeding practices in Pakistan. The significant factors identified within this study include maternal age, region, maternal education, watching television, and child size. Additionally, our paper presents the results of the survival analysis where we use parametric techniques to model the duration of EBF against its factors. The comparison shows that the results of the parametric survival analysis are better predictors of EBF and its factors than the results of the binary logistic regression.
These results can be used to identify the reasons why EBF levels remain low in Pakistan and subsequently, compromise infant and maternal health. Identification of these factors allows health and education policy ministries to actively target these factors so that child health indices within the country can be improved; to this end, the appropriate departments and institutes need to devise national and provincial level strategies to combat the ill-effects of improper child nutrition and feeding practices.
Significant factors and impact on EBF
It is widely acknowledged that education plays the most important role in enhancing or compromising infant health. The low levels of literacy in Pakistan combined with high rates of poverty, especially in rural areas, are a major hindrance towards proper child nutrition practices [16]. Low literacy levels often prove dangerous to the feeding practices for the infant; for instance, in rural areas, it is a common cultural and societal belief that breastfeeding should be delayed because many consider that colostrum is stale milk and fresh milk would arrive on the third day after birth [17]. During this waiting period, the newborn is usually fed traditional and ceremonial foods such as honey, glucose, and butter mixed with sugar, which is a dangerous practice since such liquids contain a high risk of contamination [1]. Problems such as these can be alleviated by proper information regarding infant care and nutrition in rural areas, especially in the regions of Balochistan, Khyber Pakhtunkhwa, and Sindh. However, the problems of illiteracy and poverty are rooted in more systemic problems [18]; regardless, the condition can be improved by a targeted health campaign directed solely towards raising awareness about proper childcare feeding practices. This can include specific messages provided to women about breastfeeding as an important source of nutrition for their child and can highlight some of the dangerous impacts of traditional and cultural feeding practices which are considered safe and healthy [19]. Mothers should also be encouraged to breastfeed as long as possible and should be educated about the protective benefits of colostrum and the hazardous habits of feeding infants supplements other than breast milk should be strongly discouraged.
There have been similar studies conducted within Pakistan that have identified a host of factors that contributes towards unhealthy feeding practices among infants and children. Another study identified several important demographic and socioeconomic factors; these factors were breastfeeding status, age, number of living children, residence, education, wealth, information sources about breastfeeding practices, assistance during delivery, and place of delivery. The study used a multiple logistic regression analysis to highlight the significant factors for breastfeeding practices in Pakistan, whereas this study uses comprehensive and comparative statistical measures to study a range of demographic and socio-economic factors and their relationship with breastfeeding practices [20].
Our study also supports a variety of previous studies which found maternal education to be an important factor for determining infant health and breastfeeding practices. This is despite the perception that, in Pakistan, educated and wealthy women located in urban areas are likely to stop breastfeeding earlier, as compared to women located in rural areas [21]. This practice of supplemental feedings and early stoppage of exclusive breastfeeding could have a significant trickling down effect since women who belong to the higher income classes are often role models for women who belong to the lower-income class groups. Regardless, the results do show that educated women are likely to breastfeed for a longer duration than uneducated women. Our results also show that women who watch television are likely to breastfeed for a longer duration; these findings are correlated with those of education since information regarding breastfeeding and proper nutrition can be gained from television. However, watching television can also prove to be detrimental to the duration of EBF since.
Marketing campaigns for formula milk are often presented very attractively; this is contradictory to the practice of EBF and results in a gap between knowledge and practice regarding breastfeeding practices in the country [22].
Our study finds that the size of the child is also a significant factor in EBF duration and that women with smaller babies at birth tend to breastfeed for a longer duration. This is because children who are perceived large at birth are less likely to develop undernutrition problems later in life as compared to children who are perceived as small at the time of birth [23]; thus, mother’s perception of the size of the child is a cause of bias towards the signs of nutrition and may lead to unhealthy feeding habits as a result of this perception, including a reduced duration of EBF.
Proper nutrition and feeding habits for infants should also be dispensed at hospitals and health service providers so that staff can educate mothers about infant nutrition needs and the role of breastfeeding. Additionally, the duration of EBF can also be increased in Pakistan through community health workers, who can provide counseling to women during antenatal, natal, and postnatal home visits, since the majority of births in Pakistan take place at home [24]. Health care policy should also seek to dismantle traditions and cultural norms which are harmful towards EBF practices; this can be achieved by public service messages addressed towards women located in both the urban and rural areas of Pakistan. Mothers should be made aware that there is no need for supplemental breastfeeding during the first five months and should be informed that the infant requires only breast milk for all of its nutrition needs during this time [25].
Some of the adverse effects of changing lifestyles, supplementary feeding practices, and perceived insufficiency of breastfeeding should also be reduced or targeted through public service health campaigns and messages. These campaigns need to focus on women across all groups of society, with special emphasis on rural and lower-middle-income class groups.
There is also a dire need to improve the health care infrastructure of Pakistan, which is a primary factor towards the contribution of infant malnutrition and suboptimal infant feeding practices. The government needs to address this on an urgent basis since the situation of health care facilities in rural areas is poor and in need of critical attention. Maternal care centers in rural areas are sadly deprived and suffer from an acute shortage of medical staff, equipment, information, and infrastructure [26]. These conditions need to be drastically improved if Pakistan’s statistics regarding maternal and infant care are to be amended.
Some limitations of this study include are that it focused on secondary data and is thus restricted by previously settled sample size structure and questionnaires. Several factors cause the duration of exclusive breastfeeding, but only selected factors were the subject of this research. Also, this study uses a cross-sectional design, which limits its ability to establish causation among the variables. A study that uses a time-series analysis would be able to identify cause-and-effect relationships among the important independent variables. Lastly, this paper uses a quantitative study design, which does not adequately explore the traditional norms and values pervading the society which are often the most acute determinants of child care and nutrition. Future studies can thus apply qualitative and mixed designs to incorporate these effects into the investigation of breastfeeding practices in Pakistan. This can also be accomplished by applying a broader dataset towards the question at hand and can use quantile regression to enhance results.