BREASTFEEDING MEDICINE Volume 9, Number 9, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2014.0028
Determinants of the Introduction of Prelacteal Feeds in the Maldives Raheema Abdul Raheem, Colin W. Binns, Hui Jun Chih, and Kay Sauer
Abstract
Background and Objectives: This study identified the determinants of the introduction of prelacteal feeds in the Maldives. Subjects and Methods: A cohort of 458 mothers was recruited from antenatal clinics at two major hospitals in Male´, the Maldives. The mothers were followed up after birth at 4 weeks, 3 months, and 6 months. The child’s birth, the type of infant delivery, the time breastfeeding was initiated, gender of the infants, types of prelacteal feeds, and feeding method were recorded. Results: After birth, 4.1% of infants received infant formula from the hospitals, whereas 10.6% and 7.4% of them received honey and dates, respectively, as prelacteal ritual feeds. Factors associated with introduction of ritual feeds as prelacteal feeds included the infant being a boy ( p = 0.05; adjusted odds ratio [AOR] = 1.78; 95% confidence interval [CI], 1.07–2.98), attitude toward prelacteal feeds ( p = 0.01; AOR = 2.87; 95% CI, 1.48– 5.58), and maternal employment ( p = 0.01; AOR = 2.3; 95% CI, 1.4–3.9). Higher maternal age was inversely associated with introduction of ritual feeds as a prelacteal feed ( p = 0.05; AOR = 0.5; 95% CI, 0.3–0.9). Introduction of infant formula as the prelacteal feed was positively associated with birth by cesarean section ( p = 0.01; AOR = 4.6; 95% CI, 1.6–13.3) and inversely associated with maternal mother’s feeding method being breastfeeding ( p = 0.05; AOR = 0.15; 95% CI, 0.04–0.6). Prelacteal feeding was associated with cessation of breastfeeding before 6 months ( p = 0.01; AOR 6.0; 95% CI, 1.64–21.80). Conclusions: Health professionals need to distinguish between religious and cultural practices in order to develop appropriate health education programs to reduce the unnecessary use of early additional feeds. Understanding the barriers related to the initiation of breastfeeding after cesarean section is also important. Introduction
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or optimal health and development the World Health Organization recommends exclusive breastfeeding until 6 months of age followed by the introduction of appropriate complementary foods while breastfeeding continues.1 Good early nutrition is important to overall lifetime health and in establishing the human microbiome, an important factor in the development of obesity and chronic disease.2 The introduction of complementary foods and/or infant formula before 6 months is a public health issue, especially in developing countries where access to affordable and safe formula and complementary foods is limited and appropriate health services in these countries are lacking.3,4 There is an extensive body of literature documenting the benefits of ‘‘exclusively breastfeeding’’ for both the infants and the mothers.5,6 Infants who were exclusively breastfed had higher intelligence, balanced nutrition, and protection against asthma, and the mothers experienced early return to prepregnancy weight, lower
rates of breast and ovarian cancer, and birth controlling effects.6,7 Moreover, early introduction of complementary food can cause diarrhea and related diseases, which in turn may lead to malnutrition and death.8 Exclusive breastfeeding in the first half-year of life and continued breastfeeding coupled with appropriate foods significantly reduces malnutrition-related deaths among children under 5 years old.6,9 In many countries the first food an infant receives is not breastmilk. This is due to the introduction of prelacteal feeds based on religious, cultural, and medical factors.10–12 The introduction of prelacteal feeds has been shown in some studies to reduce the duration of breastfeeding.13 UNICEF has initiated a program to promote colostrum feeding and maternal–infant contact soon after birth given the adverse consequences of these practices.14 In many Muslim communities a sweet food (Tahneek) is given to infants soon after birth as a ritual feed.15 A sample of 373 women recruited soon after birth in hospitals in Kuwait found that 76.4% received infant formula and 4.6% received
School of Public Health, Curtin University, Perth, Western Australia, Australia.
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glucose water as prelacteal feeds. Even though prelacteal feeds were given to the majority of infants, 92.5% of the mothers were able to initiate breastfeeding.16 The practice of giving prelacteal feeds is also common in Asian countries. A community-based study of prelacteal feeds among Hindhu and Muslim infants in rural Nepal showed that 39% of the mothers introduced prelacteal feeds, and the most common prelacteal foods were sugar water, sugarcane juice, or honey.17 Birth preparedness and the time of initiation of breastfeeding were associated with introduction of prelacteal feeds in this study.17 A review of prelacteal feeds in China found that the practice was common with the highest reported rate in Shandong Province in Eastern China, where 72% of the infants received prelacteal feeds before breastfeeding was initiated.18 Having a birth by cesarean section is also associated with infants being given prelacteal feeds. A study of prelacteal feeds in Hangzhou, China, found that mothers who had a cesarean section were often separated from their infants for up to 48 hours and that the infants were commonly given prelacteal feeds during this time.10 A cohort study of 9,446 mother–infant pairs across four Italian hospitals (Padua, Brescia, L’Aquila, and Udine) showed that the mothers who had a cesarean section were significantly more likely than the mothers who had a vaginal delivery to give infant formula as a first feed and to continue doing so at hospital discharge (adjusted odds ratio [AOR] = 3.74; 95% confidence interval [CI], 3.03–4.60).12 A study in El-Minia University Hospital in Egypt showed that the infants of 83.3% of women who delivered by cesarean section and 40% of women who delivered by spontaneous vaginal delivery were given prelacteal feeds.11 The Maldives is also a Muslim country, and the use of prelacteal feeds is common. There have not been any studies done in the Maldives to find out the types and determinants of the use of prelacteal feeds. Hence it is important to document the types of prelacteal feeds that were used and the associated factors. The purpose of this study is to find out the determinants of the introduction of prelacteal feeds in the Maldives. Subjects and Methods
A prospective cohort design was used to follow up 458 mothers selected from the antenatal clinics of the Reproductive Health Centre in the Indira Gandhi Memorial Hospital and ADK Hospital in Male´, the capital of the Maldives, to document the introduction of prelacteal feeds and the associated factors. In 2006, the total population of Maldives was 298,968, with 103,693 living on the island of Male´.19 There were 6,946 live births in the Republic of Maldives in 2008, and more than one-third were in Male´. There were on average six live births per day in Male´, and most of the deliveries took place in these two hospitals. Pregnant mothers attended the hospitals for their antenatal check-ups monthly until 35 weeks of gestation and then weekly from 36 weeks gestation until delivery. For this study the mothers were first contacted at their 36-week antenatal examinations. The exclusion criteria were mothers who were under 18 years old, who were critically ill, or who were unable to give informed consent. After delivery, the mothers were followed up at 1, 3, and 6 months, when they attended for their postnatal check-up and for their child’s immunization. Mothers who were missed were contacted by phone and
ABDUL RAHEEM ET AL.
asked questions based on a structured questionnaire. The exclusion criteria after birth were expanded to include mothers and babies who were seriously ill or where the infant died or spent more than 7 days in neonatal intensive care. The Iowa Infant Feeding Attitudinal Scale (IIFAS)20 was used to assess the knowledge and attitude toward infant feeding, at 36 weeks of pregnancy. The scores range from 17 to 48, 49 to 69, and 70 to 85 for ‘‘negative,’’ ‘‘neutral,’’ and ‘‘positive’’ attitude toward breastfeeding.20 Mothers were also questioned on the demographic and breastfeeding information, including maternal mother’s breastfeeding practice, at 36 weeks of pregnancy to assess the demographic and socioeconomic factors. At 1 month after infant delivery, the mothers were asked questions using the breastfeeding questionnaire, which includes questions on mother–infant bonding, knowledge, attitude, time breastfeeding was initiated, and factors associated with breastfeeding, including prelacteal feeding. These questionnaires have been previously used in breastfeeding studies in China, Australia, Vietnam, Kenya, and the Maldives.21–26 Breastfeeding definitions were consistent with those of the World Health Organization.1 Specifically, exclusive breastfeeding is defined as ‘‘the infant has received only breast milk from her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines.’’ Predominant breastfeeding is defined as ‘‘the infant’s predominant nourishment has been breast milk. However, the infant may also have received water or water based drinks (sweetened and flavoured water, teas, infusions, etc.); fruit juice or Oral Rehydration Salts (ORS) solution; drops and syrup form of vitamins, minerals and medicines; ritual fluids (in limited quantities). With the exception of fruit juice and sugarwater, no food based fluid is allowed under this definition.’’ Full breastfeeding was constituted by exclusive breastfeeding and predominant feeding. Any breastfeeding was defined as ‘‘the child has received breast milk (direct from breast or expressed). The infant may have received other solids or liquids.’’ Prelacteal feeds were defined as ‘‘any liquid or solid received before breast milk from the mother or a wet nurse, or expressed breast milk with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines as the first feed.’’ Complementary feeds were defined as ‘‘any liquid or solid received other than breast milk from the mother or a wet nurse, or expressed breast milk with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines.’’ All the questionnaires were translated into Dhivehi, the national language in the Maldives, and back-translated to assess accuracy. The IIFAS and demographic and breastfeeding questionnaire have been translated and used in previous studies in the Maldives.21 Ethics
The study was approved by the National Research Committee of Maldives, the Indira Gandhi Memorial Hospital, ADK Hospital, and the Curtin University Human Research Ethics Committee (approval number HR 146/2010). At recruitment, mothers were given an information sheet and were informed of the aim of the study. Participants were advised that it was voluntary to participate in the survey and that nonparticipation or withdrawal would not prejudice future
A COHORT STUDY OF PRELACTEAL FEEDS
treatment in any way. Informed consent was obtained from each participant prior to the face-to-face interview. Statistics
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 19 for Windows software (IBM, Armonk, NY). Frequency distributions of the data were generated, and the data were checked for outliers and errors. Descriptive statistics were used to describe continuous variables. Univariate analysis (including chi-squared and t tests) was used to compare differences between subgroups of interest. Multivariate logistic regression models were used to identify important variables affecting the introduction of prelacteal feeds. Confounding factors identified from the literature such as the IIFAS score, type of infant delivery, maternal experiences of stressful events in life, gender of the infant, maternal perception that honey or date should be given as the first feed, maternal age, and maternal employment were adjusted for in the analyses. The results from the multivariate logistic regression are presented as crude odds ratio and AOR with 95% CI to estimate the relative risk. The level of significance was set at 5%. The odds ratio is a measure of association widely used in many studies.17 Results
In total, 461 mothers were contacted and invited to participate in this study. Three mothers declined participation, giving a final sample of 458 mothers who participated in a face-to-face interview. At the end of the 6-month follow-up period, there was a dropout rate of 8.9%. The age of the mothers ranged from 19 to 41 years old with a mean of 27 years old (standard deviation = 4.6). Mothers in the Maldives are generally well educated, with 17.2% completing primary and 82.4% completing secondary or higher education. The cesarean section rate for the mothers was high at 44.9%. The distribution of the gender of the infants was 50.9% girls and 49.1% boys. Breastfeeding was initiated within 1 hour for majority of the infants delivered by vaginal birth (89.1%), whereas it is lower at 77.4% for infants delivered by cesarean section. Initiation of breastfeeding for infants who delivered by cesarean section was delayed, with 11.8% of them initiating between 1 and 4 hours after delivery compared with 7.9% of the infants delivered by vaginal delivery. The percentage for initiation of breastfeeding after 4 hours was higher at 10.8% in the infants were delivered by cesarean section in comparison with 2.9% for those infants who were delivered by vaginal birth (v2 = 13.62, p = 0.001). None of the mothers in the study had an IIFAS score lower than 49, indicating that the majority of the mothers had a neutral or positive attitude toward breastfeeding. Breastmilk was received by 76.9% of the infants as their first feed. At 1 week after birth, the ‘‘any breastfeeding’’ rate was 100%, the ‘‘full breastfeeding’’ rate was 78.1%, and the ‘‘exclusive breastfeeding’’ rate was only 34.8%. The practice of wet nursing still occurs in the Maldives, with two infants in the sample (0.2%) being fed in this way, usually by a close relative. In this study, 23% of the infants received prelacteal feeds. Zam Zam water was given to 0.2% of the infants as a ritual prelacteal feed. Zam Zam water is the holy water brought from Mecca. The Zam Zam well was built by Prophet Ibra-
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him on the spot where water sprang when Prophet Ismail thumped the ground with the soles of his feet. Glucose water and infant formula were given to 0.7% and 4.1% of the infants, respectively. The most common types of prelacteal feeds given were ritual feeds such as honey and tiny pieces of dates. These were given to 10.6% and 7.4% of the babies, respectively, on the first day they were born. Within the first week of birth, 39.1% and 15.5% of the infants had received honey and dates, respectively. Table 1 shows the factors associated with introduction of ritual feeds as prelacteal feeds. Boys were more likely to receive a ritual feed as their first feed. Mothers who agreed with the statement were more likely to give honey or dates as the first feed. Maternal age between 24 and 35 years decreased the likelihood of introducing ritual feeds as prelacteal feeds compared with mothers in the age group of 18–24 years. Employed mothers also were more likely to introduce ritual feeds as prelacteal feeds. Introduction of prelacteal feeds (ritual feeds) were not associated with the IIFAS score, type of infant delivery, or depression score at 36 weeks of pregnancy. In this study, 4.1% of the infants were fed infant formula as the prelacteal feed. Table 2 shows the factors associated with the introduction of infant formula as prelacteal feeds. Compared with mothers who had vaginal delivery, mothers who had undergone cesarean sections were significantly more likely to give their infants infant formula as the prelacteal feed. Maternal mother’s breastfeeding practice was inversely associated with the introduction of infant formula as the infant’s prelacteal feed. Introduction of infant formula was not associated with IIFAS score or maternal experiences of stressful life events. Multivariate analysis on the factors associated with cessation of breastfeeding showed that infants who were given infant formula as a prelacteal feed were more likely to stop breastfeeding before 6 months compared with infants who were not given infant formula as a prelacteal feed ( p = 0.01; AOR = 6.0; 95% CI, 1.64–21.80). Discussion
The Maldives is a Muslim country where breastfeeding is encouraged as part of Muslims’ religious beliefs (verse number 233 of the Holy Quran instructs women to breastfeed up to 2 years).27 In accordance with the Islamic beliefs, breastfeeding is almost universal in the Maldives. This explains the high rates of ‘‘any breastfeeding’’ rates and ‘‘full breastfeeding’’ rates at 1 month. The ‘‘exclusive breastfeeding’’ rate at 1 month was very low because of early introduction of complementary foods. The use of prelacteal feeds is very common in Muslim cultures and seems to be increasing in the Maldives15,21 with renewed interest in religious practices. Knowledge and attitudes about the choice of first feed affect breastfeeding practice. The practice is more commonly seen among younger mothers and employed mothers. It is a ritual practiced in many Muslim communities to give something sweet as the first feed (Tahneek). In Islam a religious practice is based on instructions given through the Holy Quran and the Sunnah (the way) of Prophet Muhammad (may peace be upon him). Cultural practices are ones that are practiced throughout one’s lifetime or according to the location of the practices. In this way a practice that originates from the religion can also become a cultural practice. However, practices that are not in the Holy
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ABDUL RAHEEM ET AL.
Table 1. Factors Associated with the Use of Ritual Feeds as Prelacteal Feeds Variable
Crude odds ratio
Honey or date should be given to infant as first feed Disagree 1.00 Agree 2.86 Neutral 1.32 Maternal age (years) 18–24 1 24–35 0.5 > 35 0.3 Maternal employment Housewife/self-employed 1 Government/private employment 2.1 Gender of the infant Girl 1.00 Boy 1.78 Depression score, antenatal ‡ 13 1 < 13 1.2 Type of delivery Vaginal 1 Cesarean 1.03 IIFAS score Medium 1 High 0.62
95% CI
Adjusted odds ratio
(95% CI)
(1.5–5.5)b (0.4–4.4)
1.00 2.87 1.60
(1.5–5.6)b (0.5–5.4)
(0.3–0.9)a (0.7–1.4)
1 0.5 0.3
(0.3–0.9)a (0.6–1.3)
(1.3–3.5)b
1 2.3
(1.4–3.9)b
(1.1–2.9)a
1.00 1.65
(1.0–3.0)a
(0.6–2.0)
1.1 1
(0.6–1.7)
1 1.1
(0.6–1.7)
(0.4–1.0)
1 0.7
(0.4–1.3)
(0.6–1.9)
All variables in the final model were variables for which the change in deviance was significant compared with the corresponding v2 on the relevant degrees of freedom. - 2 Log likelihood (deviance) = 3765.539, df = 8. a p < 0.05, bp < 0.01. CI, confidence interval; IIFAS, Iowa Infant Feeding Attitudinal Scale.
Quran and the Sunnah of Muhammad (may peace be upon him) are not religious practices in Islam. Such practices are just cultural practices. These cultural practices originate when a person who is believed to have enough knowledge about the religion does a malpractice. People perceive it as the right religious practice, and when it is practiced over time and by many people it becomes a cultural practice only.
According to the Sunnah of Prophet Mohammed (may peace be upon him), the prelacteal feeds given were dates. Hadith number 5347 in the book on general behavior states, ‘‘’A’isha reported that the new-born infants were brought to Allah’s Messenger (may peace be upon him). He blessed them and rubbed their palates with dates.’’28 It is believed that the piece of date is given only for the sweet taste, not for ingestion.15
Table 2. Factors Associated with the Use of Infant Formula as Prelacteal Feeds Variable
Crude odds ratio
Type of infant delivery Vaginal 1.00 Cesarean section 4.18 Maternal mother’s breastfeeding practice Did not breastfeed 1.00 Breastfed 0.21 EPDS score, antenatal ‡ 13 1.3 < 13 1 IIFAS score Medium 1 High 2.9
95% CI
Adjusted odds ratio
(95% CI)
(1.5–11.6)b
1.00 4.61
(1.6–13.3)b
(0.1–0.8)a
1.00 0.15
(0.04–0.6)a
(0.5–3.5)
(0.9–10.0)
1.4 1 1 3.0
(0.5–3.8)
(0.8–10.7)
All variables in the final model were variables for which the change in deviance was significant compared with the corresponding v2 on the relevant degrees of freedom. - 2 Log likelihood (deviance) = 114.964, df = 7. a p < 0.05, bp < 0.01. CI, confidence interval; EPDS, Edinburgh Postnatal Depression Scale; IIFAS, Iowa Infant Feeding Attitudinal Scale.
A COHORT STUDY OF PRELACTEAL FEEDS
Some Islamic scholars believe that the sugar from the small amount of date made into a paste and put on the upper palate has medicinal value. A recent randomized, double-blind, placebo-controlled trial also has shown that a small amount of dextrose applied inside a newborn’s mouth prevents neonatal hypoglycemia.29 However, the use of honey or water supplements as prelacteal feeds in many Muslim communities is a cultural practice rather than a religious practice, although it has evolved from religious practices.15 Giving honey to a child under 1 year of age carries a risk of Clostridium infection,30 and the low rate of exclusive breastfeeding may change the nature of the human microbiome, which is an important factor in determining obesity and chronic disease later in life.2 Similar cultural practices were seen in less developed areas of Pakistan where a concoction of honey and sometimes saliva, animal milk, water, desi ghee, and tea with herbs were given to infants in the first 3 days.31 As found in this study, having a cesarean section increases the likelihood of giving formula milk as the prelacteal feed at the hospital. The reason is that having birth by cesarean section delays the initiation of breastfeeding.32 The results also showed the use of infant formula as prelacteal feed results in early cessation of breastfeeding. The percentage of births by cesarean section in this study is slightly higher than the 41.11% reported in 2011 for the whole country of the Maldives.33 The World Health Organization’s recommended upper limit for the cesarean section rate is 15%,34 for medically unnecessary cesarean sections can have significant negative health implications for health equity within and across countries.35 Conclusions
Health professionals need to distinguish between religious and cultural practices in order to develop appropriate health education programs to reduce the unnecessary use of early additional feeds. Antenatal education programs need to include more information on the importance of exclusive breastfeeding and be better targeted at parents, maternal grandmothers, and healthcare workers. Future research needs to identify factors associated with the increasing number of cesarean sections as well as the barriers to initiation and continuation of breastfeeding after cesarean section. Such information can be used to increase breastfeeding rates, particularly the exclusive breastfeeding rates within the first 6 months after delivery. Acknowledgments
We thank the mothers who participated in this study and the staff from the Indira Gandhi Memorial Hospital and the ADK Hospital in Male´. We also thank for their support AusAid and their staff and Curtin University, without whom this study would not have been possible. Disclosure Statement
No competing financial interests exist. References
1. Daelmans B, Dewey K, Arimond M, et al. New and updated indicators for assessing infant and young child feeding. Food Nutr Bull 2009;30(2 Suppl):S256–2S62.
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2. Thompson AL. Developmental origins of obesity: Early feeding environments, infant growth, and the intestinal microbiome. Am J Hum Biol 2012;24:350–360. 3. Stewart RC. Maternal depression and infant growth: A review of recent evidence. Matern Child Nutr 2007;3:94–107. 4. Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: A cohort study from Goa, India. Arch Dis Child 2003; 88:34–37. 5. Kramer MS. ‘‘Breast is best’’: The evidence. Early Hum Dev 2010;86:729–732. 6. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding: A systematic review. Adv Exp Med Biol 2004;554:63–77. 7. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev 2012;8:CD003517. 8. Weisstaub G, Uauy R. Non-breast milk feeding in developing countries: Challenge from microbial and chemical contaminants. Ann Nutr Metab 2012;60:215–219. 9. Natchu UC, Liu E, Duggan C, et al. Exclusive breastfeeding reduces risk of mortality in infants up to 6 mo of age born to HIV-positive Tanzanian women. Am J Clin Nutr 2012;96:1071–1078. 10. Qiu LQ, Xie X, Lee A, et al. Infants’ first feeds in Hangzhou, PR China. Asia Pac J Clin Nutr 2007;16:458–461. 11. Sallam SA, Babrs GM, Sadek RR, et al. Knowledge, attitude, and practices regarding early start of breastfeeding among pregnant, lactating women and healthcare workers in El-Minia University Hospital. Breastfeed Med 2013;8:312– 316. 12. Zanardo V, Pigozzo A, Wainer G, et al. Early lactation failure and formula adoption after elective caesarean delivery: Cohort study. Arch Dis Child Fetal Neonatal Ed 2013;98:F37–F41. 13. Declercq E, Labbok MH, Sakala C, et al. Hospital practices and women’s likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health 2009;99: 929–935. 14. UNICEF. Programming Guide on Infant and Young Child Feeding. Nutrition Section, Programmes, UNICEF, New York, 2011. 15. Shaikh U, Ahmed O. Islam and infant feeding. Breastfeed Med 2006;1:164–167. 16. Dashti M, Scott JA, Edwards CA, et al. Determinants of breastfeeding initiation among mothers in Kuwait. Int Breastfeed J 2010;5:7. 17. Khanal V, Sauer K. Determinants of the introduction of prelacteal feeds in rural Nepal: A cross-sectional communitybased study. Breastfeed Med 2013;8:336–339. 18. Tang L, Hewitt K, Yu C. Prelacteal feeds in China. Curr Pediatr Rev 2012;8:304–312. 19. Ministry of Planning and National Development. Analytical Report 2006: Population and Housing Census of Maldives 2006. Male´, Republic of Maldives, Ministry of Planning and National Development, 2006:17. 20. De la Mora A, Russell DW. The Iowa Infant Feeding Attitude Scale: Analysis of reliability and validity. J Appl Soc Psychol 1999;29:2362–2380. 21. Abdulraheem R, Binns CW. The infant feeding practices of mothers in the Maldives. Public Health Nutr 2007;10:502– 507. 22. Scott JA, Aitkin I, Binns CW, et al. Factors associated with the duration of breastfeeding amongst women in Perth, Australia. Acta Paediatr 1999;88:416–421.
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23. Scott JA, Landers MC, Hughes RM, et al. Factors associated with breastfeeding at discharge and duration of breastfeeding. J Paediatr Child Health 2001;37:254–261. 24. Lakati A, Binns C, Stevenson M. Breast-feeding and the working mother in Nairobi. Public Health Nutr 2002;5: 715–718. 25. Duong DV, Binns CW, Lee AH. Breast-feeding initiation and exclusive breast-feeding in rural Vietnam. Public Health Nutr 2004;7:795–799. 26. Xu F, Binns C, Lee A, et al. Introduction of complementary foods to infants within the first six months postpartum in Xinjiang, PR China. Asia Pac J Clin Nutr 2007;16(Suppl 1): 462–466. 27. The Meaning of the Glorious Qur’an, 7th ed. United Kingdom: Islamic Dawa Centre International, 2011. 28. al Hajjaj MI, ed. Sahih Muslim: Book 25: The Book on General Behaviour (Kitab Al-Adab). Muslim Student Association, University of California, 2009. 29. Harris DL, Weston PJ, Signal M, et al. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): A randomised, double-blind, placebo-controlled trial. Lancet 2013; 382:2077–2083. 30. King LA, Popoff MR, Mazuet C, et al. [Infant botulism in France, 1991–2009]. Arch Pediatr 2010;17:1288–1292. 31. Khadduri R, Marsh D, Rasmussen B, et al. Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan. J Perinatol 2008;28:182–187.
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32. Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607–619. 33. Ministry of Health and Family. The Maldives Health Statistics 2012. Health Information Section, Policy Planning Division, Ministry of Health, Male´, Republic of Maldives, 2012:17–18. 34. World Health Organisation. Appropriate technology for birth. Lancet 1985;2:436–437. 35. Gibbons L, Beliza´n JM, Lauer JA, et al. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report 2010, Contract Number 30. World Health Organization, Geneva, 2010.
Address correspondence to: Raheema Abdul Raheem, PhD School of Public Health Curtin University GPO Box U1987 Perth, WA 6845, Australia E-mail: [email protected]
Determinants of the Introduction of Prelacteal Feeds in the Maldives Raheema Abdul Raheem, Colin W. Binns, Hui Jun Chih, and Kay Sauer
Abstract
Background and Objectives: This study identified the determinants of the introduction of prelacteal feeds in the Maldives. Subjects and Methods: A cohort of 458 mothers was recruited from antenatal clinics at two major hospitals in Male´, the Maldives. The mothers were followed up after birth at 4 weeks, 3 months, and 6 months. The child’s birth, the type of infant delivery, the time breastfeeding was initiated, gender of the infants, types of prelacteal feeds, and feeding method were recorded. Results: After birth, 4.1% of infants received infant formula from the hospitals, whereas 10.6% and 7.4% of them received honey and dates, respectively, as prelacteal ritual feeds. Factors associated with introduction of ritual feeds as prelacteal feeds included the infant being a boy ( p = 0.05; adjusted odds ratio [AOR] = 1.78; 95% confidence interval [CI], 1.07–2.98), attitude toward prelacteal feeds ( p = 0.01; AOR = 2.87; 95% CI, 1.48– 5.58), and maternal employment ( p = 0.01; AOR = 2.3; 95% CI, 1.4–3.9). Higher maternal age was inversely associated with introduction of ritual feeds as a prelacteal feed ( p = 0.05; AOR = 0.5; 95% CI, 0.3–0.9). Introduction of infant formula as the prelacteal feed was positively associated with birth by cesarean section ( p = 0.01; AOR = 4.6; 95% CI, 1.6–13.3) and inversely associated with maternal mother’s feeding method being breastfeeding ( p = 0.05; AOR = 0.15; 95% CI, 0.04–0.6). Prelacteal feeding was associated with cessation of breastfeeding before 6 months ( p = 0.01; AOR 6.0; 95% CI, 1.64–21.80). Conclusions: Health professionals need to distinguish between religious and cultural practices in order to develop appropriate health education programs to reduce the unnecessary use of early additional feeds. Understanding the barriers related to the initiation of breastfeeding after cesarean section is also important. Introduction
F
or optimal health and development the World Health Organization recommends exclusive breastfeeding until 6 months of age followed by the introduction of appropriate complementary foods while breastfeeding continues.1 Good early nutrition is important to overall lifetime health and in establishing the human microbiome, an important factor in the development of obesity and chronic disease.2 The introduction of complementary foods and/or infant formula before 6 months is a public health issue, especially in developing countries where access to affordable and safe formula and complementary foods is limited and appropriate health services in these countries are lacking.3,4 There is an extensive body of literature documenting the benefits of ‘‘exclusively breastfeeding’’ for both the infants and the mothers.5,6 Infants who were exclusively breastfed had higher intelligence, balanced nutrition, and protection against asthma, and the mothers experienced early return to prepregnancy weight, lower
rates of breast and ovarian cancer, and birth controlling effects.6,7 Moreover, early introduction of complementary food can cause diarrhea and related diseases, which in turn may lead to malnutrition and death.8 Exclusive breastfeeding in the first half-year of life and continued breastfeeding coupled with appropriate foods significantly reduces malnutrition-related deaths among children under 5 years old.6,9 In many countries the first food an infant receives is not breastmilk. This is due to the introduction of prelacteal feeds based on religious, cultural, and medical factors.10–12 The introduction of prelacteal feeds has been shown in some studies to reduce the duration of breastfeeding.13 UNICEF has initiated a program to promote colostrum feeding and maternal–infant contact soon after birth given the adverse consequences of these practices.14 In many Muslim communities a sweet food (Tahneek) is given to infants soon after birth as a ritual feed.15 A sample of 373 women recruited soon after birth in hospitals in Kuwait found that 76.4% received infant formula and 4.6% received
School of Public Health, Curtin University, Perth, Western Australia, Australia.
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glucose water as prelacteal feeds. Even though prelacteal feeds were given to the majority of infants, 92.5% of the mothers were able to initiate breastfeeding.16 The practice of giving prelacteal feeds is also common in Asian countries. A community-based study of prelacteal feeds among Hindhu and Muslim infants in rural Nepal showed that 39% of the mothers introduced prelacteal feeds, and the most common prelacteal foods were sugar water, sugarcane juice, or honey.17 Birth preparedness and the time of initiation of breastfeeding were associated with introduction of prelacteal feeds in this study.17 A review of prelacteal feeds in China found that the practice was common with the highest reported rate in Shandong Province in Eastern China, where 72% of the infants received prelacteal feeds before breastfeeding was initiated.18 Having a birth by cesarean section is also associated with infants being given prelacteal feeds. A study of prelacteal feeds in Hangzhou, China, found that mothers who had a cesarean section were often separated from their infants for up to 48 hours and that the infants were commonly given prelacteal feeds during this time.10 A cohort study of 9,446 mother–infant pairs across four Italian hospitals (Padua, Brescia, L’Aquila, and Udine) showed that the mothers who had a cesarean section were significantly more likely than the mothers who had a vaginal delivery to give infant formula as a first feed and to continue doing so at hospital discharge (adjusted odds ratio [AOR] = 3.74; 95% confidence interval [CI], 3.03–4.60).12 A study in El-Minia University Hospital in Egypt showed that the infants of 83.3% of women who delivered by cesarean section and 40% of women who delivered by spontaneous vaginal delivery were given prelacteal feeds.11 The Maldives is also a Muslim country, and the use of prelacteal feeds is common. There have not been any studies done in the Maldives to find out the types and determinants of the use of prelacteal feeds. Hence it is important to document the types of prelacteal feeds that were used and the associated factors. The purpose of this study is to find out the determinants of the introduction of prelacteal feeds in the Maldives. Subjects and Methods
A prospective cohort design was used to follow up 458 mothers selected from the antenatal clinics of the Reproductive Health Centre in the Indira Gandhi Memorial Hospital and ADK Hospital in Male´, the capital of the Maldives, to document the introduction of prelacteal feeds and the associated factors. In 2006, the total population of Maldives was 298,968, with 103,693 living on the island of Male´.19 There were 6,946 live births in the Republic of Maldives in 2008, and more than one-third were in Male´. There were on average six live births per day in Male´, and most of the deliveries took place in these two hospitals. Pregnant mothers attended the hospitals for their antenatal check-ups monthly until 35 weeks of gestation and then weekly from 36 weeks gestation until delivery. For this study the mothers were first contacted at their 36-week antenatal examinations. The exclusion criteria were mothers who were under 18 years old, who were critically ill, or who were unable to give informed consent. After delivery, the mothers were followed up at 1, 3, and 6 months, when they attended for their postnatal check-up and for their child’s immunization. Mothers who were missed were contacted by phone and
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asked questions based on a structured questionnaire. The exclusion criteria after birth were expanded to include mothers and babies who were seriously ill or where the infant died or spent more than 7 days in neonatal intensive care. The Iowa Infant Feeding Attitudinal Scale (IIFAS)20 was used to assess the knowledge and attitude toward infant feeding, at 36 weeks of pregnancy. The scores range from 17 to 48, 49 to 69, and 70 to 85 for ‘‘negative,’’ ‘‘neutral,’’ and ‘‘positive’’ attitude toward breastfeeding.20 Mothers were also questioned on the demographic and breastfeeding information, including maternal mother’s breastfeeding practice, at 36 weeks of pregnancy to assess the demographic and socioeconomic factors. At 1 month after infant delivery, the mothers were asked questions using the breastfeeding questionnaire, which includes questions on mother–infant bonding, knowledge, attitude, time breastfeeding was initiated, and factors associated with breastfeeding, including prelacteal feeding. These questionnaires have been previously used in breastfeeding studies in China, Australia, Vietnam, Kenya, and the Maldives.21–26 Breastfeeding definitions were consistent with those of the World Health Organization.1 Specifically, exclusive breastfeeding is defined as ‘‘the infant has received only breast milk from her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines.’’ Predominant breastfeeding is defined as ‘‘the infant’s predominant nourishment has been breast milk. However, the infant may also have received water or water based drinks (sweetened and flavoured water, teas, infusions, etc.); fruit juice or Oral Rehydration Salts (ORS) solution; drops and syrup form of vitamins, minerals and medicines; ritual fluids (in limited quantities). With the exception of fruit juice and sugarwater, no food based fluid is allowed under this definition.’’ Full breastfeeding was constituted by exclusive breastfeeding and predominant feeding. Any breastfeeding was defined as ‘‘the child has received breast milk (direct from breast or expressed). The infant may have received other solids or liquids.’’ Prelacteal feeds were defined as ‘‘any liquid or solid received before breast milk from the mother or a wet nurse, or expressed breast milk with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines as the first feed.’’ Complementary feeds were defined as ‘‘any liquid or solid received other than breast milk from the mother or a wet nurse, or expressed breast milk with the exceptions of drops or syrups consisting of vitamins, mineral supplements and medicines.’’ All the questionnaires were translated into Dhivehi, the national language in the Maldives, and back-translated to assess accuracy. The IIFAS and demographic and breastfeeding questionnaire have been translated and used in previous studies in the Maldives.21 Ethics
The study was approved by the National Research Committee of Maldives, the Indira Gandhi Memorial Hospital, ADK Hospital, and the Curtin University Human Research Ethics Committee (approval number HR 146/2010). At recruitment, mothers were given an information sheet and were informed of the aim of the study. Participants were advised that it was voluntary to participate in the survey and that nonparticipation or withdrawal would not prejudice future
A COHORT STUDY OF PRELACTEAL FEEDS
treatment in any way. Informed consent was obtained from each participant prior to the face-to-face interview. Statistics
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 19 for Windows software (IBM, Armonk, NY). Frequency distributions of the data were generated, and the data were checked for outliers and errors. Descriptive statistics were used to describe continuous variables. Univariate analysis (including chi-squared and t tests) was used to compare differences between subgroups of interest. Multivariate logistic regression models were used to identify important variables affecting the introduction of prelacteal feeds. Confounding factors identified from the literature such as the IIFAS score, type of infant delivery, maternal experiences of stressful events in life, gender of the infant, maternal perception that honey or date should be given as the first feed, maternal age, and maternal employment were adjusted for in the analyses. The results from the multivariate logistic regression are presented as crude odds ratio and AOR with 95% CI to estimate the relative risk. The level of significance was set at 5%. The odds ratio is a measure of association widely used in many studies.17 Results
In total, 461 mothers were contacted and invited to participate in this study. Three mothers declined participation, giving a final sample of 458 mothers who participated in a face-to-face interview. At the end of the 6-month follow-up period, there was a dropout rate of 8.9%. The age of the mothers ranged from 19 to 41 years old with a mean of 27 years old (standard deviation = 4.6). Mothers in the Maldives are generally well educated, with 17.2% completing primary and 82.4% completing secondary or higher education. The cesarean section rate for the mothers was high at 44.9%. The distribution of the gender of the infants was 50.9% girls and 49.1% boys. Breastfeeding was initiated within 1 hour for majority of the infants delivered by vaginal birth (89.1%), whereas it is lower at 77.4% for infants delivered by cesarean section. Initiation of breastfeeding for infants who delivered by cesarean section was delayed, with 11.8% of them initiating between 1 and 4 hours after delivery compared with 7.9% of the infants delivered by vaginal delivery. The percentage for initiation of breastfeeding after 4 hours was higher at 10.8% in the infants were delivered by cesarean section in comparison with 2.9% for those infants who were delivered by vaginal birth (v2 = 13.62, p = 0.001). None of the mothers in the study had an IIFAS score lower than 49, indicating that the majority of the mothers had a neutral or positive attitude toward breastfeeding. Breastmilk was received by 76.9% of the infants as their first feed. At 1 week after birth, the ‘‘any breastfeeding’’ rate was 100%, the ‘‘full breastfeeding’’ rate was 78.1%, and the ‘‘exclusive breastfeeding’’ rate was only 34.8%. The practice of wet nursing still occurs in the Maldives, with two infants in the sample (0.2%) being fed in this way, usually by a close relative. In this study, 23% of the infants received prelacteal feeds. Zam Zam water was given to 0.2% of the infants as a ritual prelacteal feed. Zam Zam water is the holy water brought from Mecca. The Zam Zam well was built by Prophet Ibra-
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him on the spot where water sprang when Prophet Ismail thumped the ground with the soles of his feet. Glucose water and infant formula were given to 0.7% and 4.1% of the infants, respectively. The most common types of prelacteal feeds given were ritual feeds such as honey and tiny pieces of dates. These were given to 10.6% and 7.4% of the babies, respectively, on the first day they were born. Within the first week of birth, 39.1% and 15.5% of the infants had received honey and dates, respectively. Table 1 shows the factors associated with introduction of ritual feeds as prelacteal feeds. Boys were more likely to receive a ritual feed as their first feed. Mothers who agreed with the statement were more likely to give honey or dates as the first feed. Maternal age between 24 and 35 years decreased the likelihood of introducing ritual feeds as prelacteal feeds compared with mothers in the age group of 18–24 years. Employed mothers also were more likely to introduce ritual feeds as prelacteal feeds. Introduction of prelacteal feeds (ritual feeds) were not associated with the IIFAS score, type of infant delivery, or depression score at 36 weeks of pregnancy. In this study, 4.1% of the infants were fed infant formula as the prelacteal feed. Table 2 shows the factors associated with the introduction of infant formula as prelacteal feeds. Compared with mothers who had vaginal delivery, mothers who had undergone cesarean sections were significantly more likely to give their infants infant formula as the prelacteal feed. Maternal mother’s breastfeeding practice was inversely associated with the introduction of infant formula as the infant’s prelacteal feed. Introduction of infant formula was not associated with IIFAS score or maternal experiences of stressful life events. Multivariate analysis on the factors associated with cessation of breastfeeding showed that infants who were given infant formula as a prelacteal feed were more likely to stop breastfeeding before 6 months compared with infants who were not given infant formula as a prelacteal feed ( p = 0.01; AOR = 6.0; 95% CI, 1.64–21.80). Discussion
The Maldives is a Muslim country where breastfeeding is encouraged as part of Muslims’ religious beliefs (verse number 233 of the Holy Quran instructs women to breastfeed up to 2 years).27 In accordance with the Islamic beliefs, breastfeeding is almost universal in the Maldives. This explains the high rates of ‘‘any breastfeeding’’ rates and ‘‘full breastfeeding’’ rates at 1 month. The ‘‘exclusive breastfeeding’’ rate at 1 month was very low because of early introduction of complementary foods. The use of prelacteal feeds is very common in Muslim cultures and seems to be increasing in the Maldives15,21 with renewed interest in religious practices. Knowledge and attitudes about the choice of first feed affect breastfeeding practice. The practice is more commonly seen among younger mothers and employed mothers. It is a ritual practiced in many Muslim communities to give something sweet as the first feed (Tahneek). In Islam a religious practice is based on instructions given through the Holy Quran and the Sunnah (the way) of Prophet Muhammad (may peace be upon him). Cultural practices are ones that are practiced throughout one’s lifetime or according to the location of the practices. In this way a practice that originates from the religion can also become a cultural practice. However, practices that are not in the Holy
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Table 1. Factors Associated with the Use of Ritual Feeds as Prelacteal Feeds Variable
Crude odds ratio
Honey or date should be given to infant as first feed Disagree 1.00 Agree 2.86 Neutral 1.32 Maternal age (years) 18–24 1 24–35 0.5 > 35 0.3 Maternal employment Housewife/self-employed 1 Government/private employment 2.1 Gender of the infant Girl 1.00 Boy 1.78 Depression score, antenatal ‡ 13 1 < 13 1.2 Type of delivery Vaginal 1 Cesarean 1.03 IIFAS score Medium 1 High 0.62
95% CI
Adjusted odds ratio
(95% CI)
(1.5–5.5)b (0.4–4.4)
1.00 2.87 1.60
(1.5–5.6)b (0.5–5.4)
(0.3–0.9)a (0.7–1.4)
1 0.5 0.3
(0.3–0.9)a (0.6–1.3)
(1.3–3.5)b
1 2.3
(1.4–3.9)b
(1.1–2.9)a
1.00 1.65
(1.0–3.0)a
(0.6–2.0)
1.1 1
(0.6–1.7)
1 1.1
(0.6–1.7)
(0.4–1.0)
1 0.7
(0.4–1.3)
(0.6–1.9)
All variables in the final model were variables for which the change in deviance was significant compared with the corresponding v2 on the relevant degrees of freedom. - 2 Log likelihood (deviance) = 3765.539, df = 8. a p < 0.05, bp < 0.01. CI, confidence interval; IIFAS, Iowa Infant Feeding Attitudinal Scale.
Quran and the Sunnah of Muhammad (may peace be upon him) are not religious practices in Islam. Such practices are just cultural practices. These cultural practices originate when a person who is believed to have enough knowledge about the religion does a malpractice. People perceive it as the right religious practice, and when it is practiced over time and by many people it becomes a cultural practice only.
According to the Sunnah of Prophet Mohammed (may peace be upon him), the prelacteal feeds given were dates. Hadith number 5347 in the book on general behavior states, ‘‘’A’isha reported that the new-born infants were brought to Allah’s Messenger (may peace be upon him). He blessed them and rubbed their palates with dates.’’28 It is believed that the piece of date is given only for the sweet taste, not for ingestion.15
Table 2. Factors Associated with the Use of Infant Formula as Prelacteal Feeds Variable
Crude odds ratio
Type of infant delivery Vaginal 1.00 Cesarean section 4.18 Maternal mother’s breastfeeding practice Did not breastfeed 1.00 Breastfed 0.21 EPDS score, antenatal ‡ 13 1.3 < 13 1 IIFAS score Medium 1 High 2.9
95% CI
Adjusted odds ratio
(95% CI)
(1.5–11.6)b
1.00 4.61
(1.6–13.3)b
(0.1–0.8)a
1.00 0.15
(0.04–0.6)a
(0.5–3.5)
(0.9–10.0)
1.4 1 1 3.0
(0.5–3.8)
(0.8–10.7)
All variables in the final model were variables for which the change in deviance was significant compared with the corresponding v2 on the relevant degrees of freedom. - 2 Log likelihood (deviance) = 114.964, df = 7. a p < 0.05, bp < 0.01. CI, confidence interval; EPDS, Edinburgh Postnatal Depression Scale; IIFAS, Iowa Infant Feeding Attitudinal Scale.
A COHORT STUDY OF PRELACTEAL FEEDS
Some Islamic scholars believe that the sugar from the small amount of date made into a paste and put on the upper palate has medicinal value. A recent randomized, double-blind, placebo-controlled trial also has shown that a small amount of dextrose applied inside a newborn’s mouth prevents neonatal hypoglycemia.29 However, the use of honey or water supplements as prelacteal feeds in many Muslim communities is a cultural practice rather than a religious practice, although it has evolved from religious practices.15 Giving honey to a child under 1 year of age carries a risk of Clostridium infection,30 and the low rate of exclusive breastfeeding may change the nature of the human microbiome, which is an important factor in determining obesity and chronic disease later in life.2 Similar cultural practices were seen in less developed areas of Pakistan where a concoction of honey and sometimes saliva, animal milk, water, desi ghee, and tea with herbs were given to infants in the first 3 days.31 As found in this study, having a cesarean section increases the likelihood of giving formula milk as the prelacteal feed at the hospital. The reason is that having birth by cesarean section delays the initiation of breastfeeding.32 The results also showed the use of infant formula as prelacteal feed results in early cessation of breastfeeding. The percentage of births by cesarean section in this study is slightly higher than the 41.11% reported in 2011 for the whole country of the Maldives.33 The World Health Organization’s recommended upper limit for the cesarean section rate is 15%,34 for medically unnecessary cesarean sections can have significant negative health implications for health equity within and across countries.35 Conclusions
Health professionals need to distinguish between religious and cultural practices in order to develop appropriate health education programs to reduce the unnecessary use of early additional feeds. Antenatal education programs need to include more information on the importance of exclusive breastfeeding and be better targeted at parents, maternal grandmothers, and healthcare workers. Future research needs to identify factors associated with the increasing number of cesarean sections as well as the barriers to initiation and continuation of breastfeeding after cesarean section. Such information can be used to increase breastfeeding rates, particularly the exclusive breastfeeding rates within the first 6 months after delivery. Acknowledgments
We thank the mothers who participated in this study and the staff from the Indira Gandhi Memorial Hospital and the ADK Hospital in Male´. We also thank for their support AusAid and their staff and Curtin University, without whom this study would not have been possible. Disclosure Statement
No competing financial interests exist. References
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Address correspondence to: Raheema Abdul Raheem, PhD School of Public Health Curtin University GPO Box U1987 Perth, WA 6845, Australia E-mail: [email protected]
