Indian Journal of Public Health

: 2020  |  Volume : 64  |  Issue : 3  |  Page : 285--294

Determinants of suboptimal breastfeeding in Haryana – An analysis of national family health survey-4 data

Jyoti Sharma1, Shivam Pandey2, Preeti Negandhi1,  
1 Additional Professor, Indian Institute of Public Health Delhi, Public Health Foundation of India, Gurgaon, Haryana, India
2 Scientist, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Jyoti Sharma
Indian Institute of Public Health Delhi, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon - 122 002, Haryana


Background: Infant and child feeding practices are a prevalent challenge in Haryana. Objectives: The present study aimed to determine factors associated with non-initiation of breastfeeding within 1 h of birth, no exclusive breastfeeding (EBF) and no continued breastfeeding in Haryana. Methods: National Family Health Survey-4 data for the state of Haryana was used for analysis. The outcomes were non-initiation of breastfeeding within 1 h of birth, no EBF, and no continued breastfeeding. Independent variables were categorized as sociodemographic, maternal, and child level factors. Each category of factors was added step-by-step to the logistic regression model for multivariable analysis. Results: Delayed initiation of breastfeeding was higher among poorer wealth quintiles. Home deliveries (adjusted odds ratio [AOR] = 1.90, 95% confidence interval [CI]-1.27–2.84), cesarean section (AOR = 2.22, 95% CI-1.46–3.40), body mass index (BMI) >25 kg/m2 (AOR = 1.62, 95% CI-1.13–2.33), and not receiving postnatal check-up (AOR 1.36, 95% CI-1.40–1.78) increases likelihood of delayed initiation of breastfeeding beyond 1 h of birth. Increased risk of non-EBF was associated with no postnatal check-ups and BMI >25 kg/m2. Risk of discontinuation of breastfeeding was significantly high with birth interval of <2 years (AOR = 1.52, 95% CI-1.08–2.14) and if babies did not receive postnatal check-up (AOR = 1.54, 95% CI-1.04–2.27). Conclusion: The study highlighted need for focused approach to counsel overweight/obese mothers, cesarean section, and home delivered mothers. Community awareness, adequate birth spacing, and postnatal visits are vital for improving exclusive and continued breastfeeding practices. Communities and health-care providers should provide adequate support to mothers for breastfeeding during the antenatal and postnatal periods.

How to cite this article:
Sharma J, Pandey S, Negandhi P. Determinants of suboptimal breastfeeding in Haryana – An analysis of national family health survey-4 data.Indian J Public Health 2020;64:285-294

How to cite this URL:
Sharma J, Pandey S, Negandhi P. Determinants of suboptimal breastfeeding in Haryana – An analysis of national family health survey-4 data. Indian J Public Health [serial online] 2020 [cited 2020 Dec 4 ];64:285-294
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Full Text


Breastfeeding is the first and most critical intervention for child's survival, healthy growth, and development.[1] Optimal breastfeeding, including initiation of breastfeeding soon after birth, providing exclusive breastfeeds for the first 6 months of life, and adding complementary feeds after 6 months while continuing breastfeeding till the age of 2 years, can prevent almost 12% of deaths, amounting to approximately 823,000 deaths in children younger than 5 years annually.[2],[3] In addition, optimal breastfeeding has proven to have positive effects on intelligence quotient, school performance, and income, thus translating into advantages for families and society.[2],[4],[5] Growing evidence suggests that breastfeeding may also help prevent overweight, obesity, and reduce incidence of chronic diseases such as diabetes,[6] ovarian, and breast cancer.[7]

Optimal breastfeeding is cost-effective to prevent child morbidity and mortality and ensure a healthy start to life. Newborns breastfed within 1 h after birth had 29% less chances of neonatal death, thus saving up to 22% of all newborn deaths.[8],[9],[10] The beneficial effects of early initiation of breastfeeding (EIBF) include not only exclusive breastfeeding (EBF) but also other independent mechanisms such as early exposure to colostrum, improved thermal contact with mother, improved nutrition and gastrointestinal system, thereby strengthening the immunological status of the newborn.[9],[11],[12]

Despite numerous benefits and efforts made at national and international levels to scale-up breastfeeding, only 40% of children worldwide and 42% of newborns in South Asia are breastfed within 1 h after birth, thus leaving 77 million newborns waiting for first critical contact with their mother.[13] National Family Health Survey (NFHS-4) shows that only 40% of all Indian newborns are breastfed within an hour of birth and 50% infants under 6 months of age are exclusively breastfed.[14]

Haryana, one of the India's richest states, witnessed a steady decline in poverty in recent years; however, health and social inequalities are still very high, and progress in health indicators continues to remain sluggish.[15] Poor state of infant and young child feeding is a particularly significant challenge in the state; the proportion of children being breastfed within 1 h of birth being only 42.4%. In this perspective the present study aimed at determining factors which might have influenced non-initiation of breastfeeding within 1 h of birth, non-EBF and no continued breastfeeding up to 1 year in Haryana using data from NFHS 4.

 Materials and Methods

This was a record-based study. NFHS-4 (2015–2016)[14] data, one of the largest cross-sectional surveys conducted by International Institute of Population Sciences, was used for the analyses, being the most recent and valid data, with infant feeding indicators from nationally representative sample of households. These data were compared with data of the previous two NFHS surveys (NFHS 2 and 3)[16],[17] to assess the changes in breastfeeding practices across Haryana from 1998 to 2015. The dataset was downloaded from the Demographic and Health Survey website following formal permission to use it for analyses.[18]

In Haryana, NFHS-4 data were collected across 21 districts between February and June 2015. The survey provided information of 17,332 households and 21,652 women aged 15–49 years (response rate -98.9%). The analyses for this study were restricted to data of children aged 6–23 months with the total weighted sample size of 2105.[15]

Outcome variables

Delayed initiation of breastfeeding among newborn, non-EBF up to first 6 months and no continued breastfeeding up to 1 year were the primary outcomes of the study. EIBF was defined as the proportion of children born in the last 2 years who were put to breast within 1 h of birth. EBF was defined as proportion of children born in the past 2 years who were exclusively breastfed during the first 6 months. Continued breastfeeding was defined as proportion of children born in the past 2 years fed breast milk up to 1 year of age.[19]

Independent variables

The independent variables were divided into three major groups. The first group included sociodemographic characteristics, with wealth index, religion, caste, and place of residence. Wealth index was based on scores for the presence of household assets, and availability of certain basic facilities such as clean drinking water. The index was used to classify households into five wealth quintiles (poorest, poorer, middle, richer, and richest) allowing the differentiation between poor and wealthy. Castes, religion, and place of residence were included as independent factors. The second group of factors was maternal, including maternal age, maternal education, place of delivery, delivery type, birth interval, maternal body mass index (BMI), and number of antenatal visits during last birth. Mother's age (years) was grouped into three categories (<19, 20–34, and >35 years) and maternal BMI (kg/m2) was grouped into three categories (<18.5, 18.5–24.9, >25). The third group of factors was related to newborns – gender, birth size, and receipt of postnatal check-up within 2 months after birth. All variables were used with their original categories for analyses.

Statistical analysis

All statistical analyses were conducted using STATA version 15 (StataCorp. 2017. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC.). Data analyses were performed using the survey “SVY” commands of Stata, allowing for adjustments of the complex NFHS-4 sampling design when estimating the standard errors and confidence intervals (CIs) around the prevalence estimates. The breastfeeding outcome indicators were expressed as dichotomous variables with category 1 as “no initiation of breastfeeding within 1 h”, and category 0 as “initiation of breastfeeding within 1 h”. No EBF during first 6 months and no continued breastfeeding were also categorized similarly.

The analyses were restricted to the individuals having nonmissing data. Every factor in each of the three groups was first independently examined for association with the outcomes of interest, using bivariate analyses. Factors which were statistically significant (P < 0.05 cut-off) on bivariate analysis or biologically plausible or reported in literature were included in multivariable analyses. The multivariable analysis was carried out in multiple steps using logistic regression analysis as follows: in the first step, only the sociodemographic variables (wealth quintiles, caste, religion, and place of residence) were included – Model 1. In the second step, statistically significant factors from Model 1 plus maternal and child factors were considered for analyses. This was Model 2, the final multivariable regression analyses model. At every step, adjusted odds ratios (AOR) were calculated for each significant risk factor, after adjusting for confounders and P < 0.05 was considered as cut off for statistical significance.


Progress in breastfeeding practices in Haryana

NFHS-4 data showed that despite almost 80% children being born in health institutions, only 42% children received mother's milk within 1 h after birth in Haryana. An almost two-fold increase was seen in the proportion of mothers initiating breastfeeding within 1 h of birth between 1998–1999 and 2005–2006, as well as between 2005–2006 and 2015–2016. EBF nearly tripled between NFHS 3 and 4.

Within the state, rural areas fared better than urban areas, and district-wide disparities continued to remain a major concern (from 2005-06 to 2015-16). The NFHS-4 data also highlighted the fact that while 70% children were exclusively breastfed for the first 2 months, only half the children (50.3%) were exclusively breastfed for the first 6 months, with a median duration of 2.4 months. The median duration of breastfeeding in the state was 31.5 months, with male children being breastfed for a longer duration (32.4 months) than females (26.2 months).

Risk factors associated with delayed initiation of breastfeeding, no exclusive breastfeeding, and no continued breastfeeding

Socioeconomic, maternal and child level factors

[Table 1] describes the distribution of children between 6 and 23 months for the three outcomes of the study with respect to socioeconomic, maternal, and child factors. Little less than half (42.9%) of the children belonged to families from the richest wealth quintile. A vast majority (84.2%) belonged to Hindu families. Almost two-thirds of the respondents resided in rural areas (64.4%). Most mothers (94.1%) were above the age of 20 years, with 25% mothers having >3 parity during the survey. Two-thirds of the mothers (66.3%) had completed at least secondary school education. Two-thirds of the mothers had a normal BMI (between 18.5 and 24.9 kg/m2), while 12.7% mothers had BMI >25 kg/m2. Notably, only 45% mothers completed 4 or more antenatal visits, but 85% mothers had an institutional delivery.{Table 1}

The proportion of children in the survey born through cesarean section was 13.7%. Boys and girls were almost equally represented in the dataset. Only 4.8% children were low birth weight; only 40.4% of them received post-natal check-up after birth.

Bivariate analyses showed significant association of delayed initiation of breastfeeding with the richer quintiles and scheduled caste. Overweight mothers, lack of antenatal check-ups, home deliveries, cesarean sections, parity, and mothers who were not visited in the postnatal period were significantly more likely to delay breastfeeding initiation. Postnatal check-ups were considered as a proxy variable for counseling of mothers by health-care providers, especially for home deliveries.

People from poor wealth quintile were only half as likely to not exclusively breastfeed their babies as the richer quintiles. Similarly, rural mothers, and mothers aged 15–19 years were less likely to not exclusively breastfeed their babies than other groups.

Factors significantly associated with non-continued breastfeeding up to 1 year were rural residence, <2 years birth interval, no antenatal or postnatal check-ups and parity <3.

A multivariable model was developed using a multistep approach with factors significantly associated with the three outcomes. As shown in the final model of [Table 2], women belonging to households of the richer wealth quintile were 30% less likely to delay initiation of breastfeeding, as compared to the poorer quintiles (AOR = 0.70, 95% CI-0.57–0.90). Mothers who delivered at home were almost twice as likely to delay the initiation of breastfeeding for their newborn babies (AOR = 1.90, 95% CI - 1.27–2.84), as well as mothers who had delivered through cesarean section (AOR = 2.22, 95% CI - 1.46–3.40). Mothers with BMI >25 (AOR = 1.75, 95% CI - 1.33–2.30) and those who had 1–2 children (AOR 1.33 95% CI - 1.04–1.71) were more likely to delay initiation of breastfeeding. In addition, babies who did not receive postnatal check-up also had a significantly higher rate of delayed initiation of breastfeeding (AOR 1.36, 95% CI-1.04–1.78).{Table 2}

Although EIBF was independently higher among rural mothers and lower among those who did not complete adequate antenatal visits, after adjustment for other factors, the difference was not statistically significant in the final regression model.

Sociodemographic variables (religion and caste) were not associated with non-EBF and non-continued breastfeeding [Table 3] and [Table 4]. The final regression model showed that mothers from the poorest households were significantly less likely to not exclusively breastfed their babies (AOR = 0.16, 95% CI - 0.03–0.77). Risk of non-EBF was significantly higher for mothers with 1–2 children AOR = 1.31, 95% CI - 1.02–1.68), home delivered babies (AOR = 1.94, 95% CI - 1.29–2.89), mothers with BMI >25 (AOR = 1.64, 95% CI - 1.14–2.35), and babies who did not receive post natal check-up (AOR = 1.37, 95% CI - 1.05–1.79).{Table 3}{Table 4}

Mothers in rural residences were 40% less likely to discontinue breastfeeding up to 1 year. Risk of discontinuation of breastfeeding was significantly high when preceding birth interval was <2 years (AOR = 1.52, 95% CI - 1.08–2.14), and if babies did not receive postnatal check-up (AOR = 1.54, 95% CI - 1.04–2.27).


Optimal breastfeeding is a crucial and cost-effective intervention that provides essential nutrition to newborns and reduces infant morbidities and mortality. As per NFHS-4 report, 42% children in Haryana received breastfeeds within 1 h of birth and 50.4% children were exclusively breastfed. Despite increases in proportions of EIBF and EBF observed in the State with time, absolute proportions suggest room for improvement.

Household, community, maternal, and health system level factors clearly influence breastfeeding practices.[20] Multivariable analysis showed that infants from rich households had significantly higher probability of receiving breastfeed within 1 h after birth. This could be due to better access and availability of good quality of health-care services. Similar findings have been reported from Bangladesh, with higher likelihood of delayed initiation of breastfeeding among poorer women.[21] In contrast, an urban area of Kolkata had earlier reported higher rate of EIBF among lower income group mothers.[22] Our analyses showed that poorer mothers exclusively breastfeed their infants for the first 6 months, which could be because of affordability issues. Most of the other sociodemographic factors had no significant association with delayed initiation of breastfeeding as well as with noncompliance to EBF and CBF, except rural mothers who were 40% less likely to have not continued breastfeeding for their children up to the 1st year. This finding is similar to earlier analysis of NFHS-3 data, demonstrating high likelihood of noncompliance of EBF among mothers from urban areas.[23] Bhanderi et al. reported early marriage, low maternal education, and working mothers as barriers for EBF.[24]L esser antenatal visits, cesarean section, late initiation of breastfeeding, and poor counseling of mothers regarding EBF also emerged as barriers to EBF for the first 6 months after birth.[21],[24],[25],[26]

Study findings further suggest that overweight/obese mothers were more likely to delay breastfeeding initiation and not breastfeed exclusively, as compared to mothers with normal BMI. Similar findings have been reported by previous studies from developed and developing countries.[27],[28],[29] Higher likelihood of cesarean section among overweight and obese mothers may further contribute to delayed breastfeeding initiation and non-EBF.[27] Furthermore, home deliveries, mothers who had not received postnatal check-ups and had 1–2 older children were also found to be more likely to delay initiation of breastfeeding. This practice was perhaps related to customs of the family and community, suggesting that education program for pregnant mothers should focus on benefits of optimal breastfeeding practices and they should receive adequate support for EIBF and EBF in antenatal and postnatal periods.

Health system-related factors strongly contribute to EIBF. Dismal early breastfeeding initiation rates despite high rate of institutional deliveries across the state further highlights the requirement of improved health-care service delivery with a focus on EIBF and EBF at the health facilities for all institutional live births.

Delivery by cesarean section is acknowledged as one of the significant barriers for EIBF. Our findings are aligned to a previous study which showed high likelihood of delayed initiation of breastfeeding among infants born by cesarean section; also higher risk of non-EBF among such babies, although nonsignificant.[30],[31],[32] Global evidence suggests that, with adequate support, cesarean section mothers can start breastfeeding within 1 h after birth.[33],[34] Counseling during ANC can help to improve optimal breastfeeding practices, but the association of ANC with BF practices was not significant in this study.

Immediate postnatal care of newborn is another critical window of opportunity to promote optimal BF practices. It is an opportunity for healthcare workers to counsel mothers about lactation and psychological difficulties faced by mothers. Our findings suggest strong significant association of postnatal care with delayed breastfeeding initiation, EBF and discontinuation of breastfeeding up to 1st year. Newborns not receiving postnatal care were 1.3 times more likely to have been breastfed after 1 h of birth and 1.5 times more likely to have discontinued breastfeeding up to 1 year. This calls for more attention to ensure appropriate postnatal care immediately after birth and for continued periods for the postnatal period by trained health-care providers.[35]

The Lancet series on breastfeeding highlighted that breastfeeding practices are responsive to synergies created through a continuum of interventions at the health system level, in communities and at home.[36] A systematic review on interventions to improve breastfeeding outcomes suggested providing individual and group counseling to mothers, supporting breastfeeding practices at the time of delivery, and knowledge and skills of the health-care providers on lactation were most effective interventions to improve breastfeeding outcomes.[37] In Haryana, there is need to continue strengthened antenatal and intranatal health services to provide proper counseling to mothers and improving knowledge and skills of health-care providers regarding the importance of breastfeeding and practices related to it. Cesarean sections require attention to ensure implementation of optimal breastfeeding practices. Strengthening maternal nutrition and child feeding component in pre-service and in-service training curriculum may help improving basic skills of health workforce. Skill-based training support on group and interpersonal counseling of ANMs and ASHAs can be an important intervention.[38] Private sector providers who deliver 28.4% newborns (NFHS-4)[15] in the state have a special role to play. They should ensure that childbirth and newborn care practices at their center are aligned with national guidelines[39],[40] to support optimal breastfeeding practices. Nonetheless, breastfeeding improvement interventions should focus on sensitization of communities, clinicians, and health-care providers about collective responsibility of ensuring EIBF, EBF, and CBF and need to provide adequate support to mothers.[41]

Large number of variables related to individuals, community, and health system made it possible to adjust for various confounders in multiple steps to account for the adjusted effect of breastfeeding practices in Haryana.

This study, however, had some inherent limitations. The information used for the analyses was derived from secondary data. In addition, certain exposures relevant to the outcome may not have been studied. Recall bias in recording of some information at the time of the survey also cannot be completely ruled out.


Study findings specifically highlight the need for focused approaches for counseling/education of overweight/obese mothers, mother having undergone cesarean section and home delivered mothers, and during postnatal period. These findings suggest need for strengthening mother- and child-friendly health systems, thus having implications on policy decisions. Detailed counseling of mothers, families, and health-care providers, especially for overweight mothers and cesarean section deliveries, can help improve optimal breastfeeding rates in the 1st year of life. Ensuring postnatal visits by frontline workers is also of paramount importance in contributing to improvement in maternal and newborn nutrition outcomes.


Authors are thankful to Dr Ranjana Singh, Associate Professor Indian Institute of Public Health Delhi for her suggestions for analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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