Determinants of Exclusive Breastfeeding among Infants under Six Months in Nepal: Multilevel Analysis of Nationally Representative Household Survey Data

Background The benefits of exclusive breastfeeding (EBF) practices have been universally documented, with evidence of one positive impact on a child’s optimal growth, development, and survival. However, EBF practice in Nepal has fluctuated and declined in the last 25 years. Along with the individual factors, it is also important to acknowledge that the EBF practices are affected by multiple community-level factors. Understanding these factors is essential to designing breastfeeding promotion programs to improve child health outcomes in Nepal. This study investigated individual and community-level determinants of EBF practices among infants aged 0-5 months in Nepal. Method We used the dataset from the Nepal Demographic and Health Survey 2022. Information on exclusive breastfeeding in the past 24- hours was available for 540 infants aged 0-5 months. A multilevel mixed-effect logistic regression was used to identify individual and community-level factors associated with EBF practices among infants aged 0-5 months in Nepal. Result The 24-hour prevalence of EBF among infants aged 0-5 months was 57.46% (95% Confidence Interval (CI): 52.18, 62.57). The prevalence decreased with age; it was 81.2% at one month and 40.6% at five months. Several individual and community-level factors appeared significant. The infant’s age was inversely associated with EBF prevalence at the individual level. In multilevel logistic regression, infants aged three months (Adjusted Odds Ratio (AOR): 0.14, 95% CI: 0.05, 0.40), four months (AOR: 0.11, 95% CI: 0.04, 0.28), and five months -(AOR: 0.07, 95% CI: 0.03, 0.20) had a lower likelihood of receiving EBF relative to infants less than one-month-old. At the community level, mothers from communities with moderate ANC ≥ 4 coverage (AOR: 3.30, 95% CI: 1.65, 6.57) and high ANC ≥ 4 coverage (AOR: 2.70, 95% CI: 1.40, 5.22) had higher odds of EBF compared to communities with low coverage. Similarly, communities with moderate levels of maternal employment (AOR: 2.67, 95% CI: 1.34, 5.30), high levels of maternal employment (AOR: 2.34, 95% CI: 1.10, 4.99), and moderate levels of poverty (AOR: 2.20, 95% CI: 1.13, 4.28) were positively associated with EBF. Regional variation was evident, with infants in Lumbini province having lower odds of EBF (AOR:0.32, 95% CI: 0.13, 0.77) compared to Koshi province, whereas those in Sudurpaschim having higher odds (AOR: 2.20, 95% CI: 1.13, 4.28). Around 9% Variation in EBF was observed while mapping across clusters in this study. Conclusion Our study demonstrated various individual and community-level factors impacting EBF practices in Nepal, underscoring the need for improving EBF programs. It highlighted unique community-level factors such as ANC coverage, poverty, and maternal employment as the factors influencing EBF practices, and it showed around 9% variability in EBF practices. Future breastfeeding promotion efforts should focus on older infants and communities with low poverty levels and low coverage of recommended ANC ≥ 4 visits. Furthermore, context-specific adaptation of such efforts might be required as there was variation between the communities.