Factors Associated with Complementary Feeding Practices among Mother of Aged 6 to 23 Months Old
3. Result
3.1. Children characteristics and maternal characteristics
The characteristics of children and the mothers are listed in Table 1. It shows that more than half of children in this study were male (57.2%), aged between 6-11 months old. Only 37 children (11.4%) had low birth weight, and 11 children (3.4%) had a birth length <48 cm.
Whereas, majority of the mothers (71.4%) had secondary education and above, aged ≥ 20 years old (85.8%), unemployed (95.7%), and married (95.4%). Most of the families in this study were Sundanese, and diverse Muslims. About 85% of children were from a nucleus family. Additionally, 72.6% of families had low income.
3.2. Complementary feeding practices in children aged 6-23 months old
The CF practices of the children aged 6-23 months are shown in Table 1. It shows that
Table 2. Chi-square analysis of complementary feeding practices indicators with children and maternal characteristics. CharacteristicsMMFMDDMAD NoYes P-valueNoYes P-valueNoYes P-value N%n%n%n%n%n% Sex of the child0.659 0.724 0.352 Male4459.514256.69258.29456.311155.27560.5 Female3040.5109 43.46641.87343.79044.84939.5 Birth weight 0.136 0.080 0.004* < 2500 gram1216.225102314.6148.4 3115.46 4.8 ≥ 2500 gram6283.82269013585.415391.617084.611895.2 Birth length0.717 0.831 0.450 < 48 cm3 4.1 8 3.2 5 3.2 6 3.6 8 4 3 2.4 ≥ 48 cm7195.924396.815396.816196.41939612197.6 Age of the child (in month) 0.540 0.138 0.425 6-113141.91184779507041.99547.35443.5 12-172229.77730.74025.35935.35627.94334.7 18-232128.45622.33924.73822.85024.92721.8 Educational level0.757 0.042*0.005* Primary 2229.77027.95333.53923.46833.82419.4 Secondary and above 5270.318172.110566.512876.613366.29980.6 Marital Status0.712 0.225 0.075 Married7094.624095.615396.8157941959711592.7 Divorced 4 5.4 114.4 5 3.2 106 6 3 9 7.3 Ethnicity 0.535 <0.001* 0.009* Sundanese547319276.513686.111065.9 16280.68467.7 Other20275923.52213.95734.13919.44032.3 Religion0.039*0.001*0.002* Muslim6689.22419615698.715190.419697.511189.5 Others (Protestant and Catholic)8 10.8104 2 1.3 169.6 5 2.5 1310.5 Occupational status0.903 0.009*0.848 Employed3 4.1 114.4 2 1.3 127.2 9 4.5 5 4 Unemployed7195.924095.615698.715592.819295.511996 Number of family member0.467 0.912 0.607 ≤ 4 members 577720380.912679.713480.215979.110181.5 ˃ 4 members 17234819.13220.33319.84220.92318.5
Table 2. Chi-square analysis of complementary feeding practices indicators with children and maternal characteristics. (cont.) CharacteristicsMMFMDDMAD NoYes P-valueNoYes P-valueNoYes P-value N%n%n%n%n%n% Family Structure0.873 0.263 0.067 Nuclear family6486.521384.913887.313983.217687.610181.5 Extended family7 9.5 249.6 159.5 169.6 199.5 129.7 Others 3 3.9 145.6 5 3.2 127.2 6 3.0 118.9 Household Income 0.417 0.855 0.806 Low income 5168.918573.711448.312251.714572.19173.4 High income 2331.16626.34427.84526.95827.93326.6 *p-value <0.05 Table 3. Factors associated with complementary feeding practices indicators. MMFMDDMAD AOR(95% CI)p-valueAOR(95% CI)p-value AOR(95% CI)p-value Birth weight < 2500 gram- - 1 ≥ 2500 gram- - 1.992 (0.946-4.197)0.070 Educational level Primary - 1 1 Secondary and above - 1.627(0.970-2.730)0.0651.690(1.008-2.835)0.047 Ethnicity Sundanese- 1 1 Other- 2.737(1.486-5.044)0.0013.033(1.632-5.638)<0.001 Religion Muslim3.009(1.134-7.983)0.0271 1 Others (Protestant and Catholic)1 3.611(0.745-17.501)0.1113.063(0.626-14.984)0.167 Occupational status Employed- 5.587(1.203-25.944)0.028- Unemployed- 1 - R2 0.022R2 0.132R2 0.120
the majority of the children received inappropriate CF practices for MDD, MAD, and MMF. Nevertheless, more than half children (51.3%) achieved minimum dietary diversity (MDD), and more than one-third (38.1%) fulfilled the MAD. Moreover, 77.2% of children met the recommended MMF.
Interestingly, all children received ISSF.
3.3. Complementary feeding practice of children aged 6-23 months
The Chi-square analysis results are shown in Table 2. The results show that only religion was associated with MMF (p = 0.039). While educational level (p= 0.042), ethnicity (p= <0.001), religion (p= 0.001), and occupational status (p= 0.009) were found to be associated with MDD.
For MAD, the significant association were found among children’ birth weight (p= 0.004), educational level (p= 0.005), ethnicity (p= 0.009), and religion (p= 0.002).
3.4. Factors associated with complementary feeding practices among children aged 6-23 months Further analyses with multiple logistic regression found that Muslim mothers had 3.01 higher odds of practicing the MMF (AOR 3.01.
95% CI: 1.13-7.98). For MDD indicators, the result show that mother with other ethnicity than Sundanese and employed mother had 2.74 odds and 5.59 odds higher in practicing dietary diversity to their child (AOR 2.74. 95% CI: 1.49-5.04; AOR 5.59. 95% CI 1.20-25.94), respectively.
Similar results were observed for practicing MAD, mother with other ethnicity than Sundanese were 3.03 higher odd of practicing MAD (AOR 3.03.
95% CI: 1.63-5.64), and mothers who had secondary education and above were 1.69 higher odds of practicing MAD. (Table 3)
4. Discussion
From the nine indicators set by WHO [2, 13], this study focuses on four core indicators in assessing CF practice aged 6-23 months, which are ISSSF, MDD, MMF, and MAD. This study revealed that mothers were implement feeding practice according to the recommendations of the ISSSF and MMF indicators of above 70%. This
result was similar with a study conducted by Ahmad in Aceh Indonesia findings that MMF practices in that area reached to 74% but only 50% mothers practicing for the timely introduction of solid, semi-solid and soft food [14]. Another study in Latin American and the Caribbean showed that ISSSF was best performed among other four indicators of complementary feeding studied, from 10 out of 11 countries that evaluated, the prevalence of ISSSF above 80%.
Next, performance by MMF was moderate, with 4 countries out of 14 showing prevalence above 80% [15].
The proportions of children receiving MDD and MAD were still very low at 51.4% and 38.2%, respectively. The results of this proportion are in line with several studies conducted in several different regions in Indonesia [14, 16, 17]. As research results conducted in Sumedang Indonesia, the proportion MDD and MAD were only 32.8%
[16], and MDD and MAD were 49.7% and 39.8%, respectively in Aceh Indonesia [16]. Based on Indonesian national survey from DHS in 2017, the prevalence of MAD was only 26% which consists of 72% MMD and 29.8% MDD [17].
Child feeding must adhere to MMF and MDD standards. The minimum meal frequency standard for daily consumption for children aged 6-8 months was ≥ 2 times, for age 9-23 months
≥ 3 times, and ≥ 4 times for non-breastfed children with a minimal diversity of 5 of out 8 groups. Based on this indicator, this study showed that 7 out of 10 children (77.2%) met the MMF, but with poor dietary diversity (51.3%). When compared to the standard of MAD with the criteria of both the frequency and diversity, almost 4 out of children (38.1%) met the criteria.
Numerous factors contributed to the inappropriate or poor CF practice of children aged 6 to 23 months. Study in rural area in Southern Berlin found that complementary feeding practices were positively associated with child’s age but not with socioeconomics factors such as mother’s education, ethnicity and employment status [18]. A study found that poor CF practice, particularly on MDD and MAD, was influenced by younger age (6-11 months old), mother's age, low socioeconomic status, and poor health and
nutrition services [19]. On the other hand, the mother's knowledge, perception, attitude, belief, and skill, as well as the health service and the home environment, were related to the CF practice of children older than 6 months old [20].
However, social norms and cultural aspects of the society also had an impact on CF practice.
The low percentage of proper CF practice in Aceh was attributed to socio-cultural aspects of the local community, such as the introduction of food taste to newborns at the age of seven days by giving honey, sugar, salt, and fruit extract [21].
This study found a significant association between mother’s religion with the odds of MMF.
In addition, the mother’s occupation status and ethnicity were significantly associated with the odds of MDD. Similarly, mother’s ethnicity and religion were also associated with the odds of MAD. However, this study found no association on the age of child, mother’s educational level, number of family, family structure and household income.
5. Conclusion
In summary, CF practices of children aged 6-23 months were sub-optimal. Among nine indicators of CF practices recommended by WHO, only MMF had high proportion (77.2%).
The other indicators, namely MDD and MAD.
Suboptimal CF practices were found among children aged 6-23 months old in Cikarang Timur. Indonesia. These findings shows that a positive association between mother’s education level and MAD practicing.
The findings of this study may provide and use as a baseline information to develop a guide for nutritional education programs to enhance CF practices, and can also be compared across regions in terms of CF practices among children between the ages of 6 and 23 months.
Recommendation
Strengthening national policies to educate women at least to the secondary level might be a cost-effective intervention for improving IYCF practices. These results highlight the need to increase the knowledge and CF practice of the mothers in the area through a specific training on
food preparation skills, and maximizing food processing according to local ingredients, practices, and culture. In addition, the training should also emphasize on the frequency, variation, preparation, and processing food to infants and children in accordance with WHO recommendations for infant and young child feeding practices.
Acknowledgements
We are grateful to the 325 mothers of children aged 6-23 months old of the participants. to the research assistant and nutrition staff at Lemahabang Public Health Center for their support and help in data collection.
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