This study assessed determinants of exclusive breastfeeding in children of 6 months of age in Malawi using cross–sectional household MDHS data collected in 2015–2016. In the MDHS report, it was indicated that the prevalence of EBF was 61.4%. However, the current study reveals that the prevalence of EBF is 51.4%. This discrepancy came about because MDHS analyzed data from women with children under 6 months of age, while this analysis used data for women with children who completed 6 months from birth.
We find that EBF declines with age; this trend has been consistent in different studies. In Tanzania, Ethiopia and Nigeria, the prevalence of EBF was found to be decreasing with increase in age [3, 5, 13]. The reason for this trend mostly has been that mothers perceive that breast milk alone would not be enough for the perceived demands of the growing child.
MDHS defined EBF as giving baby only breastmilk for the first 6 months of life. Based on this definition, the study identified four factors to be associated with exclusive breastfeeding in Malawi. These factors are age of the mother, ethnicity of the mother, sex of the infant and number of children of the mother.
Usually, an adolescent mother is considered less likely to continue EBF in comparison to older women due to the higher likelihood of young women being single and due to the urgency of attending school . By contrast, we did not observe a relationship between individual age bands of the mother and EBF. However, age of the mother on exclusive breastfeeding is significant. This association has been noted in Western countries .
In Quito, Ecuador, about 62.9% of adolescent mothers exclusively breastfed their infants within the first 6 months of life . This rate is higher than the one estimated for all mothers in Ecuador (43.8%)  and higher than the EBF prevalence reported in other countries among adolescent mothers, ranging from 52% in the United States of America to 13.8% in Brazil .
In the present study, mothers who are Tumbukas and Ngonis were more likely to practice exclusive breastfeeding as compared to other ethnic groups. Cultural factors are thus at play even within a country: between countries other cultural variations have been noted, such as giving water plus breast milk by some communities in Nigeria to quench the child’s thirst . In Ghana, it was also reported that the low practice of exclusive breastfeeding in all regions could be attributed to cultural beliefs . Mothers or relatives usually give water and other concoctions to infants as a perceived way of quenching their thirst or as a sign of welcoming them into the world .
In Nairobi, Kenya, all other ethnic groups apart from the Kamba were more likely to stop breastfeeding their infants compared to Kikuyu women . There is no established reason for this but it could be multi-factorial, including cultural practices related to breastfeeding and child rearing like giving babies herbals to boost their immunity.
It has been argued that HIV prevalence would lead to early cessation of EBF . Mothers who are HIV positive are more likely to stop exclusive breastfeeding. In Malawi, HIV prevalence is low in the northern region (where Tumbukas and Ngonis are largely found) than southern and central . This has been attested by MPHIA Survey of 2015–2016 which reported that overall prevalence of HIV in northern region was 7.4%, central region 22.5% and in southern region 49% . Therefore, this could partially explain why Tumbukas and Ngonis might practice EBF more than others, despite the strong emphasis in public health messaging about EBF in the context of prevention of maternal to child transmission of HIV.
Mothers with female infants have higher odds of practicing EBF compared to those with boys. Evidence from different studies in Nigeria agrees that sex of the baby significantly affects the rate of EBF whereby female infants were more likely to be exclusively breastfed than male infants . Another study in Nairobi, Kenya reports that boys were more likely to be introduced to complementary feeding early compared to girls . It was further argued that anecdotal evidence indicated that boys are introduced to complementary foods early because breast milk alone does not meet their feeding demands, which could be the same case with Malawi.
In the current study, the number of children was statistically significant in predicting the rate of exclusive breastfeeding the infants of 6 months in Malawi. Mothers having 3 to 4 children were more likely to breastfeed their children compared to those with 1 to 2 and over 4 children. Though there are no reported studies to support this finding, it could be that the marital, family or social conditions for mothers with 3 to 4 children are more favorable in some way. Further, ethnographic research is needed to understand the social and family dynamics that might support EBF.
The results reveal a markedly decreased rate of EBF with increase in the age of infants. Therefore, there is a need for targeted interventions. Community breastfeeding groups may help to maintain breastfeeding by supporting mothers with breastfeeding problems right in their communities. The “10 steps to successful breastfeeding” program implemented under the Baby Friendly Hospital Initiative (BFHI) program may be ripe for re-examination and revival in the Malawi setting.
Health education and awareness campaigns to sensitize communities on implications of some cultural practices on the lives of babies need to be intensified. Other interventions could be the use of mass media, targeted health surveillance assistants’ home visits and strengthening of male involvement through appreciating the importance of EBF and extending support to partners to maintain this.
However, intervention studies need to be designed and formally tested to assess the impact of community support groups in promoting exclusive breastfeeding up to 6 months after women have been discharged from the hospital. Again, the timing of immunization schedules could be assessed to see if breastfeeding advice and support can be combined with vaccination visits.
Qualitative research could be used to investigate perceptions of mothers and their motivation in EBF. Additionally, there is need for longer term nutritional surveillance on healthy outcome of children with EBF and those without EBF.
Study strengths and limitation
The use of cross-sectional data only allows associations to be established, but not causality. However, the key strength of this study was that it used MDHS dataset which is nationally representative, and provided reliable estimates at the national and regional levels, for urban and rural areas, and for each of the 28 districts. Additionally, appropriate adjustment for sampling design, including sampling weights was employed and there was a very high response rate (98%) to the survey interview.