Climate Change, Food Supply, and Dietary Guidelines.

Food production is affected by climate change, and, in turn, food production is responsible for 20-30% of greenhouse gases. The food system must increase output as the population increases and must meet nutrition and health needs while simultaneously assisting in achieving the Sustainable Development Goals. Good nutrition is important for combatting infection, reducing child mortality, and controlling obesity and chronic disease throughout the life course. Dietary guidelines provide advice for a healthy diet, and the main principles are now well established and compatible with sustainable development. Climate change will have a significant effect on food supply; however, with political commitment and substantial investment, projected improvements will be sufficient to provide food for the healthy diets needed to achieve the Sustainable Development Goals. Some changes will need to be made to food production, nutrient content will need monitoring, and more equitable distribution is required to meet the dietary guidelines. Increased breastfeeding rates will improve infant and adult health while helping to reduce greenhouse gases.

Dietary Inflammatory Index and Epithelial Ovarian Cancer in Southern Chinese Women: A Case-Control Study.

The association between inflammatory properties of diet and ovarian cancer risk has been investigated in some Western populations. However, little evidence is available from Asian women whose ovarian cancer incidence rates are low and dietary and lifestyle patterns are very different from their Western counterparts. We aimed to examine whether more pro-inflammatory diets, as indicated by higher dietary inflammatory index (DII®) scores, are associated with increased odds of epithelial ovarian cancer in southern China. A case-control study was conducted during 2006-2008 in Guangzhou, Guangdong Province. Energy-adjusted DII (E-DII) scores were calculated based on dietary intake assessed by a validated food frequency questionnaire administered to 500 incident epithelial ovarian cancer patients and 500 hospital-based controls. Logistic regression models were used to assess the relationship between E-DII scores and odds of ovarian cancer. Positive associations were observed between higher E-DII scores and ovarian cancer odds, using both continuous DII scores (odds ratio (OR) 1.87; 95% confidence interval (CI) 1.65, 2.13) and by DII tertiles (ORtertile3vs1 7.04, 95% CI: 4.70, 10.54, p for trend < 0.001). Likewise, a more pro-inflammatory diet was associated with a higher chance of serous and mucinous ovarian tumors. Our results suggest that a pro-inflammatory diet was associated with increased odds of developing epithelial ovarian cancer in southern Chinese women. The findings add to epidemiological evidence for the role of dietary inflammatory potential in ovarian cancer development.

WeChat-based intervention to support breastfeeding for Chinese mothers: protocol of a randomised controlled trial.

BACKGROUND: Exclusive breastfeeding for the first 6 months of life is the optimal way to feed infants. However, recent studies suggest that exclusive breastfeeding rates in China remain low and are well below the recommended target. There has been evidence that a lack of awareness of, or exposure to, breastfeeding information is associated with poor breastfeeding practices. WeChat, the most widely used social networking platform in China, has shown some potential to promote health behaviours. We thus hypothesised that a breastfeeding intervention program delivered via WeChat would achieve at least a 10% increase in exclusive breastfeeding prevalence at 6 months compared to the control group. METHODS: A two-arm, parallel, multicentre randomised controlled trial of 1000 pregnant women will be conducted at four maternity hospitals of Chengdu, China. Eligible women who consent to participate in the trial will be recruited at 28-30 weeks of gestation, and randomly allocated to either the intervention group (participants receive breastfeeding-related information from WeChat) or the control group (participants receive non-breastfeeding information from WeChat) using a central randomisation system on a 1:1 ratio at each participating site. The primary outcomes are exclusive breastfeeding rate and full breastfeeding rate at 6 months postpartum. All randomised participants will be included in the outcome analyses with missing data being imputed based on the best-case and worst-case scenarios. Multilevel mixed regression models will be used in the primary analyses to assess the effectiveness of intervention program on the breastfeeding rates. DISCUSSION: This trial uses the most widely used social media program as a means of delivering messages to mothers to increase exclusive breastfeeding in China. Increasing exclusive breastfeeding will contribute to meeting the health and environmental goals of the Sustainable Development Guidelines. Trial registration ClinicalTrials.gov, NCT04499404. Registered 5 August 2020-Retrospectively registered, https://clinicaltrials.gov/show/NCT04499404.

Physical activity and sedentary behaviour during pregnancy are associated with gestational weight gain in Vietnamese women.

BACKGROUND AND OBJECTIVES: Gestational weight gain is known to impact maternal and child health outcomes. Energy intake and energy expenditure are major components of clinical nutrition in relation to weight gain during pregnancy. The study was to determine the association of physical activity and sitting time during pregnancy with gestational weight gain in Vietnamese women. METHODS AND STUDY DESIGN: A multicentre prospective cohort study was conducted in Vietnam from 2015 to 2017. A total of 1873 women with a singleton pregnancy were included. Physical activity and sitting exposures during pregnancy were determined using an interviewer-administered validated questionnaire. Multiple regression analysis was performed to assess physical activity and sitting time in relation to gestational weight gain, adjusting for the confounding effects of maternal characteristics and total energy intake during pregnancy. RESULTS: The mean weight gain was 12.9 (Standard deviation 4.1) kg throughout pregnancy. Pregnant women with prolonged sitting time gained an average of 0.6 kg more weight (p=0.016 for highest versus lowest tertiles). Conversely, women who were physically active, in terms of having higher tertiles of total physical activity, moderate-to-vigorous-intensity, household/ caregiving activities, and occupational physical activity, experienced significantly less gestational weight gain (p<0.05 for highest versus lowest tertiles). CONCLUSIONS: Inverse associations were found between gestational weight gain and physical activity (i.e. intensities and several domains), whereas gestational weight gain tended to increase with longer sitting time. Therefore, being physically active and less sedentary is important to regulate weight gain during pregnancy.

Caesarean delivery associated with adverse breastfeeding practices: a prospective cohort study.

Caesarean delivery rates are increasing in many Asian countries. This study investigated the effects of caesarean section on breastfeeding practices from delivery to twelve months postpartum. A prospective cohort study was conducted on 2030 pregnant women recruited from three cities in Vietnam during 2015-2017. The overall caesarean rate was 38.1%. Mothers who underwent caesarean section were more likely to give prelacteal feeds to their infants (adjusted odds ratio (OR) 13.91, 95% confidence interval (CI) 10.52-18.39) and as a result have lower rates of early initiation of breastfeeding (adjusted OR 0.04, 95%CI 0.02-0.05). Having a caesarean section reduced the likelihood of (any, predominant and exclusive) breastfeeding from discharge to 6 months postpartum. After 1 year, the any breastfeeding rate was still lower in the caesarean delivery (70.2%) compared with the vaginal delivery group (72.9%), p = .232. Vietnamese women who give birth by caesarean section need extra support to initiate and maintain breastfeeding.IMPACT STATEMENTWhat is already known on this subject? Early initiation of breastfeeding, and 'exclusive' or 'predominant' breastfeeding rates at discharge are lower in mothers delivering by caesarean section compared to vaginal delivery. Prelacteal feeding rates are higher following caesarean section. However, the association between 'any' breastfeeding duration and caesarean delivery has not been established.What the results of this study add? This study showed that caesarean delivery reduced all breastfeeding rates from discharge to six months and any breastfeeding rate at 12 months postpartum in Vietnamese women.What the implications are of these findings for clinical practice and/or further research? Further breastfeeding interventions are needed during the postpartum period for mothers who deliver by caesarean section.

Determinants of in-hospital feeding practices in Shiraz, Iran: Results of a prospective cohort study.

BACKGROUND: In-hospital feeding practices have been shown negatively to affect breastfeeding exclusivity and duration. The purpose of this study was to report the prevalence and determinants of delayed breastfeeding, provision of traditional prelacteal foods, and use of infant formula in hospital. METHODS: Between June 2014 and March 2015, 700 women were recruited from three public and two private maternity hospitals in Shiraz, Iran. Data were collected at recruitment via face-to-face interviews and extracted from medical records. Multivariable logistic regression was used to explore the association of feeding practices with a variety of maternal characteristics and hospital practices. RESULTS: Only 32.2% of infants were breastfed within 1 hour of birth, with 40.8% receiving a traditional prelacteal food, and 34.9% given formula during their hospital stay. Compared with infants delivered vaginally, those delivered by cesarean were more likely to have experienced delayed breastfeeding and received formula, but less likely to have received traditional prelacteal foods. Infants who did not experience skin-to-skin contact were more likely to have experienced delayed breastfeeding and received traditional prelacteal foods and formula in hospital. CONCLUSIONS: Although four out of the five hospitals were designated as Baby-Friendly, several of the 10 Steps to Successful Breastfeeding were not adhered to. The high rate of cesarean delivery was a barrier to the early initiation of breastfeeding and the majority of infants did not experience early skin-to-skin contact. Maternity care practices should be reviewed and include a clear breastfeeding care plan for women who undergo a cesarean delivery.

Gestational diabetes incidence and delivery outcomes in Western China: A prospective cohort study.

BACKGROUND: Few studies have examined the age-standardized incidence of gestational diabetes mellitus (GDM) for comparison between populations. Information on delivery outcomes is also lacking for Chinese women with GDM. Therefore, the present study aimed to determine age-standardized GDM incidence and assess its association with maternal and neonatal outcomes. METHODS: A total of 1901 pregnant women were recruited in Chengdu, Sichuan Province. GDM was diagnosed between 24 and 28 weeks' gestation using oral glucose tolerance tests. Age-standardized incidence rates of GDM were calculated using the direct method. Delivery outcomes were extracted from medical records and compared between the GDM and non-GDM groups. RESULTS: The age-standardized GDM incidence was 18.3% (95% CI 15.6-21.1) and increased with maternal age and prepregnancy body mass index (BMI). Women with GDM experienced longer length of stay in hospital, shorter gestation at delivery, and a higher risk of cesarean delivery. Their newborns were more likely to be macrosomic or small for gestational age, and to require neonatal intensive care. CONCLUSIONS: The incidence of GDM was high in Western China, especially among older and overweight women. Moreover, women with GDM had higher rates of adverse delivery outcomes. The findings lend further support for the screening, prevention, and management of GDM in Chinese women.

Problems and Prospects: Public Health Regulation of Dietary Supplements.

Dietary supplements are a global business worth more than US$100 billion annually. These supplements are taken by up to 50% of adults and perhaps one-third of children in economically advanced economies. Definitions of dietary supplements differ from country to country, and regulation is generally lax and often seems to be directed more toward promoting commerce than protecting public health. Supplements may directly cause toxic reactions or may interact with other supplements or pharmaceuticals. Some supplements are found to have been contaminated with heavy metals, and others do not contain the expected quantities of active ingredients. In general, supplements are not needed except in cases of established deficiencies, and excess of some nutrients can increase cancer rates. There are important public health reasons for taking some supplements, including folate and iodine in pregnancy. This review discusses the public health concerns associated with dietary supplements and suggests directions for further regulation.

Dietary inflammatory index and risk of oesophageal cancer in Xinjiang Uyghur Autonomous Region, China.

Diet has been shown to have an effect on both inflammation and oesophageal cancer. This study investigated the association between the dietary inflammatory index (DII®) and the risk of oesophageal cancer in Xinjiang Uyghur Autonomous Region, China. A case-control study was conducted during 2008-2009 in Urumqi and Shihezi. DII scores were calculated based on dietary intake assessed by a validated FFQ administered to 359 incident oesophageal cancer patients and 380 hospital-based controls. Higher DII scores indicate more pro-inflammatory diets. Logistic regression analyses were performed to assess the association between DII scores and oesophageal cancer risk. Oesophageal cancer patients had a significantly higher median DII score (-0·35; interquartile range (IQR)=-2·25, 1·86) than that of controls (-1·41; IQR -3·07, 0·40). Multivariable logistic analysis revealed a positive association between higher DII scores and oesophageal cancer risk (ORQuartile 4 v. 1 2·55; 95 % CI 1·61, 4·06; P trend<0·001). A pro-inflammatory diet appears to be associated with an increased risk of oesophageal cancer in Xinjiang Uyghur Autonomous Region. Specific carcinogenic mechanisms are discussed. Accumulating evidence, to which the study contributes, indicates that encouraging the intake of more anti-inflammatory foods may be a strategy to protect against oesophageal cancer in this high-risk area of China.

Dietary patterns during pregnancy and risk of gestational diabetes: a prospective cohort study in Western China.

BACKGROUND: Previous research has demonstrated the association between maternal dietary patterns and gestational diabetes (GDM), but evidence in Asian populations remains limited and inconsistent. This study investigated the association between dietary patterns during early pregnancy and the risk of GDM among pregnant women in Western China. METHODS: A prospective cohort study was conducted among 1337 pregnant women in Western China. Dietary intakes were assessed at 15-20 weeks of gestation using a validated food frequency questionnaire. GDM was diagnosed by oral glucose tolerance tests at 24-28 weeks of gestation. Exploratory factor analysis was performed to derive dietary patterns, and logistic regression models were used to examine the association between dietary patterns and GDM. RESULTS: A total of 199 women (14.9%) developed GDM. Three dietary patterns were identified, namely, a plant-based pattern, a meat-based pattern and a high protein-low starch pattern. Notwithstanding a lack of association between dietary patterns and GDM risk in the whole cohort, there was a significant reduction in GDM risk among overweight women (BMI ≥24 kg/m2); the odds ratio being 0.29 (95% confidence interval 0.09 to 0.94) when comparing the highest versus the lowest score of the high protein-low starch pattern. CONCLUSIONS: There was no significant association between early pregnancy dietary patterns and GDM risk later in pregnancy for women in Western China, but high protein-low starch diet was associated with lower risk for GDM among women who were overweight at pre-pregnancy.

Application of a Frailty Modeling Approach to Correlated Breastfeeding Duration Data.

BACKGROUND: Correlated breastfeeding duration data are very common in infant feeding research using cohort designs. Intracluster correlation within the same clustering group is expected and needs to be taken into account in statistical analysis; otherwise, the corresponding statistical inferences may be subject to an increased Type I error. OBJECTIVES: The aims of this study were to illustrate the necessity of adjusting for the intracluster correlation in correlated breastfeeding duration data analysis and to demonstrate different frailty modeling approaches. METHODS: An introduction to shared frailty models was presented under the assumption of proportional hazards (PH). Then, two different approaches-the Cox frailty model (semiparametric approach) and the parametric frailty model (parametric approach)-were used to fit the data from a maternal cohort in Nepal as an illustrative example. RESULTS: For the semiparametric approach, random effects denoting the variations in the hazard of breastfeeding cessation shared by mothers living in the 27 distinct communities were estimated and graphically presented. Compared with the conventional Cox model, Cox frailty model reduced the chance of Type I error occurring, providing a better model fit in the presence of correlated survival data. Among candidate parametric approaches, a Weibull PH model with a gamma frailty term was selected as an appropriate model fitting the breastfeeding data. DISCUSSION: Shared frailty models can be used in other research areas in the presence of correlated time-to-event data. Model selection depends on the assumption of PH, the specification of the baseline hazard function, and also the study purpose.

Baby-friendly hospital practices are associated with duration of full breastfeeding in primiparous but not multiparous Iranian women.

There is evidence that the Baby-Friendly Hospital Initiative (BFHI) results in improved breastfeeding outcomes in Western countries, but little is known of its impact in Middle-Eastern countries. This study investigated the impact of BFHI practices on duration of full breastfeeding in a cohort of 700 Iranian mothers recruited between June 2014 and March 2015 from maternity hospitals in Shiraz and followed-up prospectively for 6 months. At baseline, mothers self-reported exposure to 7 of the BFHI Ten Steps to Successful Breastfeeding (Steps 3 to 9). Data on breastfeeding outcomes were collected at baseline, 1, 3, 4, and 6 months postpartum. Cox regression analysis was conducted to determine the impact of individual and cumulative BFHI Steps on the duration of full breastfeeding, defined as the number of weeks since discharge that an infant received only breast milk and no complementary formula or food. Mothers reported experiencing on average 3.9 (SD 1.13, range 1 to 7) Steps, and only 28% of infants were fully breastfed at 6 months. There was a protective inverse relationship for primiparous (p for trend = .022) but not multiparous mothers (p for trend = .069), between the number of Steps a woman was exposed to and the likelihood of her discontinuing full breastfeeding within 6 months postpartum. Greater exposure to BFHI practices potentially could increase primiparous mothers' chances of fully breastfeeding to 6 months. Continual monitoring of the BFHI Steps and repeated education of healthcare staff are required to ensure that Iranian mothers receive adequate breastfeeding support.

A Time-varying Covariate Approach for Survival Analysis of Paediatric Outcomes.

BACKGROUND: Conventional survival analysis is commonly applied in the analysis of time-to-event data in paediatric studies, where the exposure variables of interest are often treated as time-fixed. However, the values of these exposure variables can vary over time and time-fixed analysis may introduce time-dependent bias. METHODS: Time-dependent bias is illustrated graphically considering two scenarios in longitudinal study settings for paediatric time-to-event outcomes. As an illustrative example, the time-varying covariate approach was applied to survival analysis of breast-feeding data (n = 695) collected in China between 2010 and 2011, with an emphasis on the effects of covariates 'solid foods introduction' and 'maternal return to work' on breast-feeding duration up to 12 months postpartum. RESULTS: Time-varying exposures could occur before or after the occurrence of an event of interest so that time-fixed analysis can lead to biased and imprecise parameter estimates. In the illustrative example, the reduced risk of 'solid foods introduction' (hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.50, 0.75) on breast-feeding cessation and an absence of an association with 'maternal return to work' (HR 0.99, 95% CI 0.73, 1.36) from the time-fixed analysis reversed (HR 1.50, 95% CI 1.17, 1.93) and became significant (HR 1.45, 95% CI 1.06, 2.00), respectively, based on the time-varying covariate model. CONCLUSIONS: The time-varying covariate approach is preferable for survival analysis of time-to-event data in the presence of time-varying exposures.

Protective effects of breastfeeding against acute respiratory tract infections and diarrhoea: Findings of a cohort study.

AIM: The objective of this paper is to identify associations between breastfeeding and acute respiratory tract infections (ARTIs) and diarrhoea. METHODS: A cohort of 458 mothers was recruited at the antenatal clinics at Indira Gandhi Memorial and Abdul Rahman Dhon Kaleyfaanu Hospitals. Mothers were interviewed 'face-to-face' at 36 weeks of gestation and at 1, 3 and 6 months after delivery. The questionnaires included demographic information about parents, infant feeding methods and breastfeeding duration. The number of episodes of ARTIs and diarrhoea was also recorded. Ethics approval was obtained from the National Research Committee of the Maldives and Curtin University Human Research Ethics Committee. Descriptive, univariate, logistic and survival analyses were used to assess the effects of breastfeeding on infant ARTIs and diarrhoea. RESULTS: The partial, predominant and exclusive breastfeeding rates at 1 month were 98.9, 67.6 and 26.9%, respectively. The risk of acquiring ARTIs is significantly reduced when the infants were predominantly breastfed for 3 months (adjusted odds ratio (OR): 0.56, 95% of adjusted OR: 0.34-0.94) and 6 months (adjusted OR: 0.45, 95% of adjusted OR: 0.24-0.84). The risk of getting diarrhoea is significantly reduced even when the babies were partially breastfed for 6 months (adjusted OR): 0.31, 95% of adjusted OR: 0.11-0.90). Kaplan Meier curves demonstrated that the risk lowers with longer duration of breastfeeding. CONCLUSION: Breastfeeding need to be promoted because the risk of infant morbidity is negatively associated with the duration of breastfeeding.

Does Caesarean Section Affect Breastfeeding Practices in China? A Systematic Review and Meta-Analysis.

Objectives To ascertain the association between caesarean delivery and breastfeeding practices in China. Methods We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Electronic databases of CNKI, Medline, EMBASE, CINAHL, ProQuest and Science Direct were searched and screened to identify relevant articles from January 1990 to June 2015. Both fixed and random effect meta-analysis techniques were used to estimate the pooled effect size between caesarean delivery and breastfeeding outcomes at different time points. Sensitivity analysis and publication bias test were also conducted. Results Forty six studies were eligible for the qualitative synthesis of systematic review; among them, 27 studies were included for the meta-analysis. At the early postpartum period, the odds of exclusive breastfeeding after caesarean section was 47% (pooled OR 0.53, 95% CI 0.41, 0.68) lower than that after vaginal delivery. At 4 months postpartum, the odds of breastfeeding was similarly lower (pooled OR 0.61, 95% CI 0.53, 0.71) for caesarean mothers. Substantial heterogeneity among studies was detected for both breastfeeding outcomes. Subgroup analyses stratified by study design, time points of breastfeeding outcomes and definitions of breastfeeding all confirmed the negative association between caesarean section and breastfeeding prevalence. Conclusions In China, breastfeeding practices were affected adversely by caesarean delivery. Therefore, health policy to improve breastfeeding outcomes should take this into consideration.

Breastfeeding beyond the big smoke: Who provides support for mothers in rural Western Australia?

INTRODUCTION: Despite strong and growing evidence for the benefits of exclusive breastfeeding to 6 months of age, few infants in developed countries reach this milestone. Although breastfeeding practice and its determinants are well described for women in metropolitan areas, there is limited evidence for rural and regional areas of Australia. This paper describes the influence of advice and support on breastfeeding duration for women in rural areas of Western Australia in the first 6 months of their infants' lives. METHODS: A cohort of 427 women and their infants were recruited from hospitals in regional Western Australia and followed up for a period of 12 months. Information about feeding methods was gathered in hospital and at a further seven follow-up contacts. RESULTS: Women who had attended antenatal classes were less likely to have ceased exclusively breastfeeding before 6 months than those who had not attended classes (aHR: 0.61, 95% CI: 0.41-0.91). No significant associations were found between provision of information alone and duration of breastfeeding. Breastfeeding advice and support in the first 6 months was most commonly sought from Child Health Nurses, General Practitioners and friends. CONCLUSIONS: Antenatal group education is effective in supporting breastfeeding duration for rural women and should be a key priority for rural health service providers. Health professionals are common sources of breastfeeding support postnatally, however creating and maintaining positive and supportive social networks for mothers might also contribute to increasing the proportion of rural infants who meet the World Health Organization guidelines for exclusive breastfeeding.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study.

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

Implications of methodological differences in measuring the rates of exclusive breastfeeding in Nepal: findings from literature review and cohort study.

BACKGROUND: Correct measurement and continuous monitoring of exclusive breastfeeding are essential to promote exclusive breastfeeding. Measuring exclusive breastfeeding is a complex issue as rates can vary according to the definition, measurement period, questions asked, and infant's age. This article reviewed the methodology of reporting exclusive breastfeeding in Nepal, and compared exclusive breastfeeding rates using data from a cohort study undertaken in western Nepal. METHODS: A literature review was first conducted on studies published during 2000-2014. In our cohort study, 735 mother-infant pairs were recruited within the first month postpartum and followed up during the fourth and sixth months. RESULTS: The majority of studies in Nepal, including national surveys, used the World Health Organization (WHO) recommended definition (only breastmilk with the exception of medicine and vitamin syrup), and the most common measurement period was a 24-h recall. Our data demonstrated that the exclusive breastfeeding rate during the sixth month was 8.9% using the recall-since-birth method but was 18.7% using the 24-h recall method. Substantial differences in rates were also found during the first (66.3% vs 83.9%) and fourth months (39.2% vs 61.1%). CONCLUSION: We found that recent studies reporting exclusive breastfeeding in Nepal varied considerably in methodology. The most commonly used measurement, the 24-h recall, leads to over-estimation of the prevalence of exclusive breastfeeding when compared to the recall-since-birth method. A common standard of reporting exclusive breastfeeding is clearly needed for evidence-based decision making.

The supplemental use of infant formula in the context of universal breastfeeding practices in Western Nepal.

BACKGROUND: While the initiation of breastfeeding is universal in Nepal, little has been reported on formula feeding practices. This study aimed to report the prevalence of, and factors associated with, the use of infant formula as supplementary feeds in the Western region of Nepal. METHODS: A community-based cohort study was conducted to collect infant feeding information among 735 postpartum mothers using structured questionnaires. Complete formula feeding data were collected from 711 women in the first, fourth and sixth month postpartum. Factors independently associated with formula feeding were investigated using multiple logistic regression. RESULTS: All mothers were breastfeeding their infants at the time of recruitment. The prevalence of formula feeding was 7.5 % in the first month and 17 % in the sixth month. About a quarter of mothers (23.8 %) reported providing infant formula at least once during the first six months of life. Infant formula was used commonly as top-up food. Stepwise logistic regression showed that infants born to families residing in urban areas (adjusted odds ratio (aOR): 2.14; 95 % confidence interval (CI): 1.37 to 3.33), mothers with higher education (aOR: 2.08; 95 % CI: 1.14 to 3.80), and infants born by caesarean section (aOR: 1.96; 95 % CI: 1.21 to 3.18) were at greater risk of formula feeding. CONCLUSION: The current findings indicate that health workers should support mothers to initiate and continue exclusive breastfeeding particularly after caesarean deliveries. Furthermore, urban health programs in Nepal should incorporate breastfeeding programs which discourage the unnecessary use of formula feeding. The marketing of formula milk should be monitored more vigilantly especially in the aftermath of the April 2015 earthquakes or other natural disasters.

Adverse obstetric symptoms and rural-urban difference in cesarean delivery in Rupandehi district, Western Nepal: a cohort study.

BACKGROUND: The burden of maternal morbidity is high in developing countries including Nepal. This study investigated obstetric complications and rural-urban difference in cesarean delivery rate in Western Nepal. METHODS: A community-based cohort study was conducted in the Rupandehi district of Western Nepal during January-October, 2014, by interviewing 735 mothers within one month postpartum. The prevalence of obstetric complications was reported via frequency distribution, while factors associated with cesarean delivery were assessed using logistic regression analysis. RESULTS: The prevalence of adverse obstetric symptoms during antenatal, intranatal and postnatal periods were 19.7%, 27.8% and 21.6%, respectively. In total, 81 (11.0%) mothers reported having stillbirths. The cesarean delivery rate was 14.1% overall but was four times higher in the urban (23.0%) than in the rural areas (5.8%). Prolonged labor (19.0%) and heavy bleeding (16.7%) were common among rural women. Logistic regression analysis confirmed that cesarean section was more likely for mothers residing in urban areas than in rural areas (adjusted odds ratio 3.41; 95 % confidence interval 2.01 to 5.78). CONCLUSIONS: About one in five mothers reported some adverse obstetric symptoms. Obstetric problems were more common in the rural areas, whereas cesarean delivery rate was much higher in the urban areas. Further investigations are required to determine whether these cesarean sections are medically warranted or provider induced.