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Environmental factors, maternal attributes, and children's age at introduction of supplementary foods in rural and urban Maharashtra and Gujarat

G. Subbulakshmi and S. A. Udipi

Abstract

We studied the influence of environmental conditions on age at introduction of supplementary foods in 1,762 children. The conditions included religion, type of family, income, and use of health services as well as maternal age, literacy status, and work outside the home. All these factors resulted in frequent delays in the introduction of supplementary foods' even to later than 12 months of age, and in the poor nutrition and health status of children. The study implies that nutrition education is essential for creating an awareness of desirable weaning practices among mothers.

Introduction

The environment plays a great role in a child's growth and health. Micro-environmental conditions such as poor housing and sanitation have been implicated in the synergism of malnutrition and infection [1] The influence of the macro-environment, including social, economic, and cultural variables, on child-rearing practices is well established. In addition, various maternal attributes have been shown to be the most important cause of malnutrition [2, 3].

It has been reported that growth faltering begins in Indian children around 6 months of age and that the combined effect of environmental factors and maternal attributes is primarily responsible for the poor growth of children. The present study analyses various socio-economic factors that influence child-feeding practices in India.

The authors are affiliated with the Department of Food Science and Nutrition at S.N.D.T. Women's University in Bombay, India.

Methods

A cross-sectional study was made of 1,762 children (ages 6 months to 21/2 years) randomly selected from rural and urban areas of the states of Maharashtra and Gujarat. The rural sample consisted of 172 children from twelve villages of Raigad district in Maharashtra and 252 children from six villages of Surat district in Gujarat. The urban sample included 1,019 children from six slums of Bombay, Maharashtra, and 319 children from four slums of Surat city, Gujarat. One or two children from each family were included in the study, depending on whether the sibling's age was in the range of 6 months to 21/2 years.

A pre-tested, semi-structured questionnaire was used, and information was collected by interviewing mothers in their local language. The findings reported here were part of a comprehensive study on 2,750 children from birth to 5 years of age. Accuracy of recall of weaning practices was fairly reliable, since children older than 21/2 years were not considered for data analysis.

Results and discussion

Socio-economic factors and introduction of supplementary food

The mean age of children at which supplementary foods were introduced was generally between 8 and 10 months in urban and rural areas of the two states (see FIG. 1. Mean age of children at introduction of supplementary foods in urban and rural Maharashtra and Gujarat). The difference between rural and urban areas, regardless of the state, was statistically significant using analysis of variance (P < 0.05). Regardless of the mean age, quite a few children did not begin to receive supplementary foods until after 12 months of age (see TABLE 1. Percentage of mothers introducing supplements at different ages in relation to area). This was especially noticeable in rural Maharashtra, where at least half the children received only breast milk until they were 1 year old.

TABLE 1. Percentage of mothers introducing supplements at different ages in relation to area

a. M = Maharashtra b. G = Gujarat

Such a practice of delayed weaning together with frequent infections would be responsible for the growth faltering that has been reported in children from many developing countries. Women in urban Maharashtra started supplementing children's diets earlier than those in urban Gujarat, whereas rural Maharashtrian women introduced supplementary foods a little later than the rural Gujarati women.

The types of supplementary foods (liquid, solid) in these two states differed. Cow's or buffalo's milk was the first food introduced by approximately 70% of the families in rural and urban areas of both states (table 2). Commercial milk formula was preferred in urban Maharashtra by a large proportion of mothers (24.6%) and a smaller proportion of rural mothers (10.3%). In rural and urban Gujarat, vegetable soup was second-most frequently preferred, after cow's or buffalo's milk. A strikingly high percentage of families (86%) fed their children adult meals in rural Gujarat (table 3). In rural Maharashtra, 46% of the children are fed commercial cereals such as Cerelac and Farex. Rice or suji gruel or porridge, especially prepared for the child, was served only in urban and rural Maharashtra and urban Gujarat.

TABLE 2. Percentage of mothers giving different liquid foods to children in urban and rural areas

a. M = Maharashtra
b. G = Gujarat

TABLE 3. Percentage of mothers giving different types of semi-solid/solid foods to children in urban and rural areas

a. M = Maharashtra b. G = Gujarat

In Gujarat, both rural and urban women had some knowledge of the importance of fruit or vegetable soup/water as a liquid supplement. There is a definite need to educate the rural mothers, however, regarding the dangers associated with shifting children to adult meals directly from buffalo's or cow's milk. On the other hand, the dependence of rural Maharashtrian women on more expensive processed commercial weaning cereals, in spite of their constrained economic circumstances, is of concern. These commercial weaning foods are expensive and provide children with less solid food than they require, thus increasing the risk of undernourishment. In addition, cereal foods were considerably overdiluted by the mothers to make them last longer

The mean age at introduction of supplementary food may have differed because a greater proportion of families in urban Gujarat had lower incomes than families in rural Gujarat. In Maharashtra, the urban sample was drawn from Bombay, where the mothers are more exposed to advertisements through the mass media, and have greater access to private practitioners and hospitals who advise the mothers.

Among the different religious groups in the sample, Christians introduced supplementary foods to their children at the youngest age (7.2 months) (see FIG. 2. Mean age of children at introduction of supplementary foods in different religious groups). For Hindus and Muslims, the age was about 9.6 months. This difference among religions was statistically significant (P c 0.05). Further analysis showed that the Christian families were slightly better off economically, and the mothers were literate.

The introduction of solids to children was delayed in the majority of nuclear families (table 4). Whereas more than two-thirds of the children had received supplementary foods before age 1 year in extended families, only about 56% in nuclear families did so at that age. The difference was statistically significant (P < 0.05).

TABLE 4. Percentage of mothers introducing solid foods at different ages, by family type

With an increase in family income, a significantly higher percentage of families (P < 0.05) chose early introduction of supplementary foods to children. In families with a low income (Rs 500 a month), about 45% of children were not given supplementary foods

TABLE 5. Percentage of mothers who introduced supplementary foods at different ages among beneficiaries and non-beneficiaries of developmental programmes at age 12 months. For these families and for those with a monthly income of Rs 1,000, the mean ages were 9.5 months and 8.5 months, respectively.

Developmental programmes such as the Integrated Child Development Services (ICDS) are operative in these areas. Nutrition education in various areas, including supplementary feeding, is also given to mothers of the beneficiary children. Other developmental agencies were operating only in urban Maharashtra. Of the urban Maharashtra children in the study, 303 were beneficiaries of voluntary agencies and 706 of the ICDS. The age at introduction of supplementary foods did not differ between children under the ICDS and those under other agencies. Hence, the data were pooled for comparison with non-beneficiaries.

Analysis of the data, after classifying the children on the basis of their being beneficiaries and non-beneficiaries, showed no differences between them with regard to the age at which supplementary foods were introduced (table 5). Further observations revealed that rural children from the non-beneficiary group were put on the adult family diet straight from breast milk. These findings suggest that greater emphasis must to be given to this particular component of nutrition education.

Maternal attributes and supplementary feeding

The age at which infants received supplementary food was influenced significantly by the mother's literacy status. While 63% of the children of literate mothers had received supplementary foods before age 1 year, the figure was 52% for children of illiterate mothers. This difference was again statistically significant (P < 0.001

TABLE 6. Percentage of mothers who introduced supplementary foods at different ages in relation to working status

The working status of the mothers had a slight influence on infant-feeding practices. Women working outside the home tended to wean their children earlier and introduce supplementary food earlier. While only 4.7% of the mothers who did not have jobs fed supplementary foods to their children before age 3 months, 9.4% of the working mothers did so. Further analysis of the data indicated that the number of hours spent by the mother on the job did not significantly influence the age at which the child was given supplementary foods (table 6). Mothers who worked part-time had more time to avail themselves of the public services, including education, offered by developmental programmes than those who worked full-time. Most of these programmes did not function in the evenings.

The birth order of the child significantly influenced the age of introduction of supplementary foods (P < 0.05). The mean age was around 8.6 months for the first child and increased progressively to about 10.9 months for the sixth child. Of interest, it was also observed that breast-feeding was continued for a longer duration (about 23 months) for children of birth order six. The next pregnancy could be one of the reasons for giving supplementary foods at a lower age to children in earlier birth order positions. Similar results have been reported in urban areas of Jammu [4]

The interplay of social, biological, and attitudinal factors thus influence infant-feeding practices and, consequently, child nutrition and health. Other studies have shown that parity is positively associated with length of breast-feeding [5]. Kerr and co-workers [6] described maternal attributes, including psychological functioning, which greatly influenced infant malnutrition.

The reasons given by the mothers for introducing supplementary foods are listed in table 7. Only a small percentage of mothers said it was because the child required it. The highest percentage were forced to change from breast milk to other foods because of another pregnancy. Even for mothers who were receiving some nutrition education, the percentage who weaned their children "because it was needed'' was much less than expected. Other investigators have reported similar reasons given by mothers from developing countries for giving supplementary food and ceasing breast-feeding [7-13].

TABLE 7. Reasons for introducing supplementary foods

For a large proportion of the children, the transition from breast milk to solid foods (that is, adult meals, often of unsuitable texture and consistency) was abrupt, usually due to the mother's pregnancy Such a practice adversely affects the child's health. Moreover, short birth intervals could affect the health of both the mother and the next infant. This is reinforced by the observation that 46% of the mothers introduced supplements because they had conceived again while they were breast-feeding. Although developmental programmes had some positive effect on child health, this was not significant with regard to supplementary feeding practices.

The results of this study reinforce the importance of maternal attributes. Education of mothers should be taken into account while planning and implementing any programme. There is an immediate need to create awareness among socio-economically disadvantaged mothers, especially in the rural areas, about appropriate supplementary feeding. Informal discussions and demonstrations-cum-teaching methods may be adapted to train mothers about preparation of low-cost, high-nutrient-density weaning foods for children.

References

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