Data Source:

The main source of data for this indicator has been through population-based household surveys collected through nationally or subnationally representative and structured questionnaires, such as:

• Demographic Health Surveys (DHS) (2)
• Multiple Indicator Cluster Surveys (MICS) (3)
• Reproductive Health Surveys (RHS)
• Other household surveys.

Population-based household survey data are the preferred data source for this indicator given the complexity of measurement to follow infants from birth to 6 months of life, especially in settings where utilization of health facility services is not very high (e.g., settings with a high prevalence of births occurring at home) or where private health sector data are excluded from routinely collected administrative data sources.

Key source of data: Depending on survey methodology, the key source of data is either: (a) eligible women of reproductive age (15–49 years) identified in the household survey for inclusion and interviewing using an individual women’s questionnaire; or (b) eligible children under the age of 5 years old (0–59 months) identified in the household survey for inclusion and interviewing using an individual child’s questionnaire. Eligible woman or children under 5 are considered eligible for the survey if they are either usual residents or visitors of the household who stayed there the night before the
interview.

The MICS questionnaire asks mothers/primary caregivers of all eligible children under the age of 5 years old about exclusive breastfeeding. In the DHS, eligible women (15–49 years old) are asked questions about exclusive breastfeeding for all living children who reside with them in the household that they have given birth to in the two years preceding the survey interview.

In the DHS Phase VII (2), eligible women (between 15 and 49 years old) who had a live birth during a specified reference period, typically 2–5 years prior to the time of interview, are asked “Did you ever breastfeed (NAME)?”, where “name” refers to the name of the live birth the individual woman had during the same reference period. For currently living children who reside with the woman in the household, a 24-hour recall of all solid and/or semi-solid foods and liquids consumed is asked similar to the description below for the MICS survey.

In the MICS (3), mothers or primary caregivers of the eligible children under 2 years old at the time of the survey interview are asked “Has (NAME) ever been breastfed?”, where “name” refers to the name of child. If the child was ever breastfed, women are then asked “Is (NAME) still being breastfed?” If the child is still being breastfed and is currently under 1 or 2 years of age, mothers/caregivers are asked to provide a 24-hour recall of all solids or liquids consumed by the infant the day prior to the interview, including drinking and/or eating any of the following during the prior day or night:

• Anything from a bottle with a nipple?
• ORS?
• Vitamin or mineral supplements or any medications?
• Breast milk?
• Plain water?
• Juice or juice drinks?
• Clear broth?
• Infant formula?
• Milk?
• Any other liquids?
• Yoghurt?
• Fortified baby food?
• Foods made from grains?
• Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
• White potatoes, white yams, manioc, cassava, or any other foods made from roots?
• Any dark green, leafy vegetables?
• Ripe mangoes, papayas, or other vitamin-A rich foods?
• Any other fruits or vegetables?
• Liver, kidney, heart, or other organ meats?
• Any other meat, such as beef, pork, lamb, goat, chicken, or duck?
• Eggs?
• Fresh or dried fish or shellfish?
• Any foods made from beans, peas, lentils, or nuts?
• Cheese or other food made from milk?
• Any other solid, semi-solid, or soft foods?

It is recommended that this list be customized for country and local contexts for liquids and solids that are available, including availability of local fruits and vegetables and brand names of infant formula and/or yoghurt.

If consumption of any liquids or solids is mentioned, mothers/caregivers are then asked: “How many times did (NAME) eat any solid, semi-solid or soft foods yesterday during the day or night?” The ministry of health (MoH) and national statistical offices (NSO) typically conduct household surveys and compile, analyze and report the results for this indicator in collaboration with the survey program (e.g. DHS, MICS, RHS) and funding agency.

Indicator definition and calculation: Information is collected in the questionnaire from the eligible women or mothers/caregivers based on a 24-hour recall of all solids and/or liquids consumed by the infant in the day or night prior to the interview. Only children who are less than 6 months old at the time of the interview are included in the indicator calculation.

The indicator calculated as follows:

(Number of infants 0−5 months of age who are exclusively breastfed / Total number of infants 0−5 months of age)

Frequency of measurement: Household surveys are typically conducted every 3–5 years.

Disaggregation at population level: By age (e.g. 0–1 month, 0–5 months), sex, place of residence (e.g. urban, rural), subnational administrative units (e.g. districts, provinces, regions), socioeconomic status (e.g. education level, household wealth quintile), age of woman at the time of delivery, births attended by skilled health personnel, number of antenatal (ANC) visits, timing of first ANC visit, and timing and location of the first postnatal health check.

Missing values: Missing or “don’t know” values for liquids and/or solids are assumed to indicate child is not exclusively breastfed.

Purpose:

Breastfeeding is one of the most important preventive health
measures for both mother and child. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life (and sustained for up to two years) to ensure optimal health for newborns (4). Breastfeeding provides essential nutrients to newborns, immunologic protection, and ensures optimal growth and development; it is economical, safe, and is associated with reduced newborn mortality and morbidity (5). Breastfeeding protects infants from infection and disease, such as diarrhea and pneumonia. Breastfeeding is also good for mothers; it helps mothers form attachment and bonding with their newborns and allows women to space their children and reduces the risk of ovarian and breast cancers (5,6). WHO recommends that all mothers are supported to breastfeed as soon as possible after delivery, and within the first hour, in order to support continued breastfeeding to six months or longer (6).

This indicator helps program management at global, national and subnational levels by monitoring and evaluating whether safe motherhood and maternal and newborn health (MNH) programs are on target with the levels and trends for exclusive breastfeeding. Monitoring this indicator demonstrates program efforts for promoting and supporting breastfeeding in health facilities and communities for provision of MNH services, which is also a reflection of provision of recommended essential interventions immediately after birth. With that, it should be noted that exclusive breastfeeding should be measured in combination with early initiation of breastfeeding, which is an indication of sustained breastfeeding (7).

Issue(s):

Unlike other maternal and newborn indicators, the strength of this indicator is that it does not suffer from the same issues of recall bias as it is asked according to a 24-hour recall of solids and liquids that the infant has consumed (8). However, asking only about liquids and solids consumed in the last 24 hours does not necessarily reflect accurate rates of exclusive breastfeeding. For example, an infant would be considered exclusively breastfed if they are currently breastfeeding and have not consumed any solids, semi-solids, or liquids in the last 24 hours, except for vitamins, minerals, medicines and/or ORS. However, this does not mean that the infant did not consume solids, semi-solids, and/or liquids more than 24 hours ago, and does not ascertain whether exclusive breastfeeding was maintained from birth to < 6 months of age. As a result, the 24-hour recall period to measure exclusive breastfeeding may slightly over estimate the percentage of exclusively breastfed infants.

Gender Implications:

The rate of exclusive breastfeeding, if disaggregated by sex, can be an indication of whether gender bias exists in the country.  In the south Gujarat region of India, researchers (9) found no gender bias in initiating breastfeeding, while others (10) report that termination of breastfeeding of female children is significantly earlier than of male children in urban India.  A study by Sen (11) reported gender differences in the duration of breastfeeding by women in rural India.  Breastfeeding of daughters was discontinued in the first six months more often than of sons. Sen identifies early discontinuation of exclusive breastfeeding as one of several factors ultimately contributing to a lower female/male sex ratio in India as compared to countries where son preference is not evident for (11).

For more information on this indicator, see the MoNITOR indicator reference sheet developed by the World Health Organization: Who-indicators (srhr.org).

References:

1. Global reference list of 100 core health indicators (plus health-related SDGs). Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/handle/10665/259951/WHO-HIS-IER-GPM-2018.1-eng.pdf), accessed 22 October 2020.
2. The DHS Program [website]. Rockville: ICF International; 2020 (http://www.dhsprogram.com/), accessed 21 October 2020.
3. Multiple Indicator Cluster Surveys (MICS) [website]. New York: UNICEF; 2020 (http://mics.unicef.org), accessed 21 October 2020.
4. WHO e-Library of Evidence for Nutrition Actions (eLENA): Early initiation of breastfeeding to promote exclusive breastfeeding. In: World Health Organization [website] (https://www.who.int/elena/titles/early_breastfeeding/en/), accessed 22 October 2020.
5. Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384(9940):347–70 (https://www.thelancet.com/journals/lancet/article/PIIS0140-
   6736(14)60792-3/fulltext), accessed 22 October 2020.
6. Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality. Lancet. 2000;355(9202):451–5 (https://pubmed.ncbi.nlm.nih.gov/10841125/), accessed 22 October 2020.
7. Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13(Suppl 3):S19 (https://doi.org/10.1186/1471-2458-13-S3-S19), accessed 22 October 2020.
8. Blanc AK, Diaz C, McCarthy KJ, Berdichevsky K. Measuring progress in maternal and newborn health care in Mexico: validating indicators of health system contact and quality of care. BMC Pregnancy Childbirth. 2016;16(1):255 (https://doi.org/10.1186/s12884-016-1047-0), accessed 21 October 2020.
9. Chudasama, R.K., Patel, P.C., Kavishwar, A.B., 2009, “Breastfeeding initiation practice and factors affecting breastfeeding in South Gujarat region of India,” The Internet Journal of Family Practice™ ISSN: 1528-8358.
10. Malhotra, R., Noheria, A., Amir, O., Ackerson, L.K., and Subramanian, S.V., 2008, “Determinants of termination of breastfeeding within the first 2 years of life in India: evidence from the National Family Health Survey-2,” Maternal Child Nutr, 4(3): 181-103.
11. Sen, A., 2001, “Many Faces of Gender Inequality,” Frontline 18, 22. UNICEF, UC Davis, USAID, IFPRI, WHO, 2007, Indicators for assessing infant and young child feeding practices, Geneva: WHO. (http://whqlibdoc.who.int/publications/2008/9789241596664_eng.pdf)