Prelacteal feeding and its relationship with exclusive breastfeeding and formula consumption among infants in low- and middle-income countries.

Background: Early feeding practices are important determinants of optimal feeding patterns later in life. We aimed to investigate if giving any fluids or foods other than breast milk during the first three days after birth (prelacteal feeds) affects exclusive breastfeeding and consumption of formula among children under six months of age in low and middle-income countries (LMICs). Methods: We conducted a retrospective cohort study using data from 85 nationally representative Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) in LMICs (2010-2019). We considered three exposures: any prelacteal feeding (PLF), milk-based only prelacteal feeding (MLK), and water-based only prelacteal feeding (WTR), according to the DHS/MICS definition. The outcomes were exclusive breastfeeding, based on the World Health Organization definition, and consumption of formula among infants under six months of age. We used Poisson models adjusting for sociodemographic indicators, antenatal care, birth assistance, and early initiation of breastfeeding to estimate the effects of the exposures on the outcomes. Findings were grouped by each country, as well as by regions of the world and national income classification. Results: We included data from 91 282 children. PLF, MLK, and WTR had a prevalence of 33.9% (95% confidence interval (CI) = 33.6-34.2), 22.2% (95% CI = 21.9-22.4), and 9.4% (95% CI = 9.2-9.6), respectively. Exclusive breastfeeding and consumption of formula had a prevalence of 35.2% (95% CI = 34.9-35.5) and 27.7% (95% CI = 27.4-28.0), respectively. In the crude analysis, children who were given PLF were 40% less likely to be exclusively breastfed (prevalence ratio (PR) = 0.60; 95% CI = 0.56-0.64) and nearly twice more likely to receive formula (PR = 1.89; 95% CI = 1.72-2.08); the direction of the associations was the same across income groups and regions of the world. In the adjusted analysis, the observed crude effects were only slightly reduced (exclusive breastfeeding - PR = 0.62; 95% CI = 0.59-0.66, consumption of formula - PR = 1.72; 95% CI = 1.59-1.85). MLK showed a stronger impact on the outcomes than PLF, especially for formula consumption (adjusted PR = 1.81; 95% CI = 1.67-1.97) and in low-income countries. WTR was only negatively associated with exclusive breastfeeding (adjusted PR = 0.69; 95% CI = 0.63-0.75), but not with formula consumption (adjusted PR = 1.09; 95% CI = 0.99-1.20). Conclusions: Feeding babies prelacteal foods shortens exclusive breastfeeding duration and increases the likelihood of formula consumption in children under six months of age in LMICs. Pro-breastfeeding interventions must be prioritized during antenatal care and throughout the stay in the maternity facility to properly protect, support, and promote exclusive breastfeeding since birth.

Disparities in early initiation of breast feeding and prelacteal feeding: A study of low- and middle-income countries.

BACKGROUND: Early initiation of breast feeding (EIBF) reduces the risk of neonatal mortality. However, only 45% of newborns are breast-fed within the first hour after birth and prelacteal feeding (PLF) is widely prevalent in low- and middle-income countries (LMICs). OBJECTIVE: To assess within- and between-country disparities in EIBF and PLF practices by household wealth and place of birth and to investigate the national-level correlation between these feeding indicators in LMICs. METHODS: Data from Demographic Health Surveys and Multiple Indicator Cluster Surveys (2010-2019) in 76 LMICs were used to investigate within-country disparities in EIBF, any PLF, milk-based prelacteal feeding (MPLF), and water-based prelacteal feeding (WPLF) by wealth quintiles and place of childbirth (institutional [private or public sector] or in-home) for children under two years. We examined the between-country Pearson's correlation between EIBF and types of PLF, later adjusted for per capita gross domestic product (GDP). RESULTS: No clear wealth-related differences were found for EIBF and WPLF; however, any PLF and MPLF were significantly higher in children belonging to the richest 20% of households but are also prevalent among lower income groups. Prevalence of any PLF was higher among institutional births in all LMICs, but especially for MPLF in private sector deliveries in East Asia & the Pacific, Eastern Europe & Central Asia, and Latin America & the Caribbean. WPLF was more common in all African regions. EIBF was inversely correlated with any PLF (r = -0.59, 95% CI -0.72, -0.42), MPLF (r = -0.41, 95% CI -0.58, -0.21) and WPLF (r = -0.34, 95% CI -0.53, -0.13). Adjustment for log-GDP did not affect the magnitude and direction of the results. CONCLUSION: Clear prorich disparities exist in the prevalence of PLF, especially MPLF. Children born in private sector facilities are more likely to receive MPLF. EIBF is negatively associated with PLF practices in LMICs. The promotion of better early feeding practices is urgent to achieve the Sustainable Development Goal to reduce neonatal mortality to 12 deaths per 1000 live births.

Ethnic inequalities in health intervention coverage among Mexican women at the individual and municipality levels.

BACKGROUND: Using data from Mexico, the country with the largest indigenous population in Latin America, we describe ethnic inequalities in coverage with women's health interventions at individual and municipal levels. METHODS: Cross-sectional study using data from the National Health and Nutrition Survey 2018 and the Mexican Intercensal Survey 2015. We selected five outcomes: modern contraceptive use, content-qualified antenatal care (ANCq), and skilled birth attendant (SBA) for women aged 15-49 years; Pap smear test and mammogram among women aged 25-64 and 40-69 years respectively. Municipalities were classified into three groups by the percentage of indigenous population: <10%, 10% - 39%, and ≥40%. We calculated crude and adjusted coverage ratios (CR) and 95% confidence intervals (CI) using Poisson regression. FINDINGS: Women living in municipalities with indigenous population ≥40% were poorer, less educated, and more rural. Coverage was lower for indigenous than non-indigenous for modern contraceptive use (CR: 0·73; CI 0·65-0·83), ANCq (CR: 0·72; CI 0·62-0·83), SBA (CR: 0·83; CI 0·77-0·90) and undergoing a mammogram (CR: 0·54; CI 0·41-0·71), but not for Pap smears (CR: 0·94; CI 0·83-1·07). Coverage with the five interventions increased as the municipal proportions of indigenous population decreased, both for indigenous and non-indigenous women. Coverage gaps at municipal level tended to be wider than at individual level. INTERPRETATION: Both indigenous and non-indigenous women living in municipalities with high proportions of indigenous people were systematically excluded from reproductive and maternal interventions. Our findings suggest that social and health interventions targeted at the individual level should be complemented by structural interventions in municipalities with high proportions of indigenous people, including strengthening health and social services.

Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years.

This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.

Delivery channels and socioeconomic inequalities in coverage of reproductive, maternal, newborn, and child health interventions: analysis of 36 cross-sectional surveys in low-income and middle-income countries.

BACKGROUND: Global reports have described inequalities in coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions, but little is known about how socioeconomic inequality in intervention coverage varies across multiple low-income and middle-income countries (LMICs). We aimed to assess the association between wealth-related inequalities in coverage of RMNCH interventions. METHODS: In this cross-sectional study, we identified publicly available Demographic Health Surveys and Multiple Indicator Cluster Surveys from LMICs containing information on household characteristics, reproductive health, women's and children's health, nutrition, and mortality. We identified the most recent survey from the period 2010-19 for 36 countries that contained data for our preselected set of 18 RMNCH interventions. 21 countries also had information on two common malaria interventions. We classified interventions into four groups according to their predominant delivery channels: health facility based, community based, environmental, and culturally driven (including breastfeeding practices). Within each country, we derived wealth quintiles from information on household asset indices. We studied two summary measures of within-country wealth-related inequality: absolute inequalities (akin to coverage differences among children from wealthy and poor households) using the slope index of inequality (SII), and relative inequalities (akin to the ratio of coverage levels for wealthy and poor children) using the concentration index (CIX). Pro-poor inequalities are present when intervention coverage decreased with increasing household wealth, and pro-rich inequalities are present when intervention coverage increased as household wealth increased. FINDINGS: Across the 36 LMICs included in our analyses, coverage of most interventions had pro-rich patterns in most countries, except for two breastfeeding indicators that mostly had higher coverage among poor women, children and households than wealthy women, children, and households. Environmental interventions were the most unequal, particularly use of clean fuels, which had median levels of SII of 48·8 (8·6-85·7) and CIX of 67·0 (45·0-85·8). Interventions primarily delivered in health facilities-namely institutional childbirth (median SII 46·7 [23·1-63·3] and CIX 11·4 [4·5-23·4]) and antenatal care (median SII 26·7 [17·0-47·2] and CIX 10·0 [4·2-17·1])-also usually had pro-rich patterns. By comparison, primarily community-based interventions, including those against malaria, were more equitably distributed-eg, oral rehydration therapy (median SII 9·4 [2·9-19·0] and CIX 3·4 [1·3-25·0]) and polio immunisation (SII 12·1 [2·3-25·0] and CIX 3·1 [0·5-7·1]). Differences across the four types of delivery channels in terms of both inequality indices were significant (SII p=0·0052; CIX p=0·0048). INTERPRETATION: Interventions that are often delivered at community level are usually more equitably distributed than those primarily delivered in fixed facilities or those that require changes in the home environment. Policy makers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. FUNDING: Bill & Melinda Gates Foundation and Wellcome Trust. TRANSLATIONS: For the French, Portuguese and Spanish translations of the abstract see Supplementary Materials section.

How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

BACKGROUND: The current focus on monitoring health inequalities and the complexity around ethnicity requires careful consideration of how ethnic disparities are measured and presented. This paper aims to determine how inequalities in maternal healthcare by ethnicity change according to different criteria used to classify indigenous populations. METHODS: Nationally representative demographic surveys from Bolivia, Guatemala, Mexico, and Peru (2008-2016) were used to explore coverage gaps across maternal health care by ethnicity using different criteria. Women were classified as indigenous through self-identification (SI), spoken indigenous language (SIL), or indigenous household (IH). We compared the gaps through measuring coverage ratios (CR) with adjusted Poisson regression models. RESULTS: Proportions of indigenous women changed significantly according to the identification criterion (Bolivia:SI-63.1%/SIL-37.7%; Guatemala:SI-49.7%/SIL-28.2%; Peru:SI-34%/SIL-6.3% & Mexico:SI-29.7%/SIL-6.9%). Indigenous in all countries, regardless of their identification, had less coverage. Gaps in care between indigenous and non-indigenous populations changed, for all indicators and countries, depending on the criterion used (e.g., Bolivia CR for contraceptive-use SI = 0.70, SIL = 0.89; Guatemala CR for skilled-birth-attendant SI = 0.77, SIL = 0.59). The heterogeneity persists when the reference groups are modified and compare just to non-indigenous (e.g., Bolivia CR for contraceptive-use under SI = 0.64, SIL = 0.70; Guatemala CR for Skilled-birth-attendant under SI = 0.77, SIL = 0.57). CONCLUSIONS: The indigenous identification criteria could have an impact on the measurement of inequalities in the coverage of maternal health care. Given the complexity and diversity observed, it is not possible to provide a definitive direction on the best way to define indigenous populations to measure inequalities. In practice, the categorization will depend on the information available. Our results call for greater care in the analysis of ethnicity-based inequalities. A greater understanding on how the indigenous are classified when assessing inequalities by ethnicity can help stakeholders to deliver interventions responsive to the needs of these groups.

Obstacles and opportunities for monitoring ethnicity-based inequalities in maternal health care: Lessons from Mexico.

BACKGROUND: Monitoring and reducing inequalities in health care has become more relevant since the adoption of the Sustainable Development Goals (SDGs). The SDGs bring an opportunity to put the assessment of inequalities by ethnicity on the agenda of decision-makers. The objective of this qualitative study is to know how current monitoring is carried out and to identify what factors influence the process in order to incorporate indicators that allow the evaluation of inequalities by ethnicity. METHODS: We conducted 17 semi-structured interviews with key informants from the health ministry, monitoring observatories, research centers, and international organizations, involved in maternal health care monitoring in Mexico. Our analysis was interpretative-phenomenological and focused on examining experiences about monitoring maternal health care in order to achieve a full picture of the current context in which it takes place and the factors that influence it. RESULTS: The obstacles and opportunities pointed out from the participants emerge from the limitations or advantages associated with the accuracy of evaluation, availability of information and resources, and effective management and decision-making. Technicians, coordinators, researchers or decision-makers are not only aware of the inequalities but also of its importance. However, this does not lead to political decisions permitting an indicator to be developed for monitoring it. As for opportunities, the role of international organizations and their links with the countries is crucial to carry out monitoring, due to political and technical support. CONCLUSIONS: The success of a monitoring system to help decision-makers reduce inequalities in health care depends not only on accurate evaluations but also on the context in which it is implemented. Understanding the operation, obstacles and opportunities for monitoring could be a key issue if the countries want to advance towards assessing inequalities and reducing health inequities with the aid of concrete policies and initiatives.