Breastfeeding Indicators

Introduction

In the new WHO 2021 IYCF indicator guideline, there are 7 indicators related to breastfeeding practices list as below. This article will demonstrate how the riycf package can apply to calculating those indicators in a steps-by-step approach.

Ever Breastfeed (EvBF)
Early Initiation Of Breastfeeding (EIBF)
Exclusive Breastfeed For The First Two Days After Birth (BEF2D)
Exclusive Breastfeeding Under Six Months (EBF)
Mixed Milk Feeding Under Six Months (MixMF)
Continious Breastfeeding 12-23 Months (CBF)
Bootle Feeding 0-23 Months (BoF)

Dataset Set-up

Firstly, load the required libraries for data analysis work. We will use riycf package for the IYCF indicator generation work.

library(riycf)

For this guideline demonstration, we will use the sample dataset provided by the CARE Myanmar team on IYCF modules. A detailed description of the variable’s name and variable labels are mentioned in the documentation. Use the following syntax to check for the dataset description.

?iycfData

df <- iycfData
head(df[1:5])
#>   csex calc_age_months child_bf child_eibf child_eibf_hrs
#> 1    1               5        1          0             NA
#> 2    1               4        1          0             NA
#> 3    1               2        1          0             NA
#> 4    1               0        1          0             NA
#> 5    1               2        1          0             NA
#> 6    1               2        1          0             NA

This dataset contains 359 observations and 46 variables, and all variables were organized based on the WHO IYCF sample questionnaire. We tried to mention explicitly matching function inputs parameters and question numbers from the WHO IYCF sample question. If your dataset did not have the same variables as the WHO sample one, please apply the most relevant ones in the respective input parameter.

Breastfeeding Indicator Calculation

Ever Breastfeed (EvBF)

According to the WHO definition, this is the proportion of under 2 years old children (< 24 months) who were ever breastfed. Therefore, this indicator only accounts for under 2 years old children, and the children outside of this age range should not include in the indicator calculation. To get this indicator, we will use the get_evbf function as follows. We need two input parameters to calculate this indicator; child age in month and child was ever breastfed or not (Questions 1 from WHO IYCF questionnaires).

df$evbf <- get_evbf(q4 = df$child_bf, 
                    age = df$calc_age_months)
table(df$evbf)
#> 
#>   0   1 
#>   8 145

We can also check whether this is correct or not using some manual data checking. There are 153 under 2 years old children available in this sample dataset.

length(which(df$calc_age_months < 24))
#> [1] 153

Among them, 108 were breastfeeding, and the other 45 didn’t. Therefore, the get_evbf function yields the same result as our manual check, and you can go ahead and use it for reporting purposes.

length(which(df$calc_age_months < 24 & df$child_bfyest == 1))
#> [1] 108
length(which(df$calc_age_months < 24 & df$child_bfyest == 0))
#> [1] 45

Early Initiation Of Breastfeeding (EIBF)

This early breastfeeding initiation only accounts for the children under 2 years old who were put to the breast within one hour of birth. We need three parameters to calculate this indicator using the get_eibf function. Because, according to the indicator definition, it allowed the two conditions to determine as EIBF; put immediately to the breast or within one hour. Although this information is asked by one question (Question 2 from the WHO IYCF sample questionnaires), the response was normally recorded into three categories; one for immediately, one for recording hours, and the other for the days. We will use the first two variables related to WHO question number 2 (immediately and hours record) in this function. Look below for how to use this function.

df$eibf <- get_eibf(age = df$calc_age_months, 
                    q2 = df$child_eibf, 
                    q2_hour = df$child_eibf_hrs)
table(df$eibf)
#> 
#>   0   1 
#>  33 102

Again, we will make some manual checking on whether the result we got from get_eibf was correct or not. 102 children met the indicator definition conditions, the other 33 did not, and 8 observations had missing information on the variable required for the q2 parameter.

length(which(df$calc_age_months < 24 & (df$child_eibf == 0 | df$child_eibf_hrs == 0)))
#> [1] 102
length(which(df$calc_age_months < 24 & df$child_eibf != 0 & df$child_eibf_hrs != 0))
#> [1] 33
length(which(df$calc_age_months < 24 & is.na(df$child_eibf)))
#> [1] 8

Exclusive Breastfeed For The First Two Days After Birth (BEF2D)

The indicator count for under 2 years old children who were breastfed exclusively for the first two days after birth. Here, the exclusively breastfeeding condition was taken from the mother or caregiver’s self-reported answer, not like the calculation of the standard exclusive breastfeeding indicator (which will calculate in the following topic) calculation using the other different liquid and solid food recall variables. I will use the get_ebf2d function for this one. It requires two input parameters, age and Question 3 from WHO IYCF sample questionnaires - which capture the information about the children who were exclusively breastfed in their first two days of life.

df$ebf2d <- get_ebf2d(q3 = df$bf_2days, 
                      age = df$calc_age_months)
table(df$ebf2d)
#> 
#>   0   1 
#>  44 109

The manual check and our get_ebf2d function got the same result.

length(which(df$calc_age_months < 24 & df$bf_2days == 0))
#> [1] 109
length(which(df$calc_age_months < 24 & df$bf_2days == 1))
#> [1] 44

Exclusive Breastfeeding Under Six Months (EBF)

Contract to previous breastfeeding indicator, this indicator needs more than one step of calculation as the indicator definition demands it. The EBF indicator only considers under 6 months children who were exclusively breastfed yesterday. The child did not receive any liquids or foods during the previous day except breastmilk. We need four input parameters; age and breastfeeding and liquids and foods consumption of the previous day.

Liquid consumption

First, we need to calculate the liquid and food consumption status from the 24 hours diet recall from IYCF questionnaires. For this calculation, we can use the get_dummy function and include all the food items variables to get the respective liquid or solid (or semi-solid) food consumption status. If the child receives any food items from the inputs foods items, the function will return as 1, and if not, 0.

Below is the sample code to get the dummy variables to calculate the liquid consumption status. I used all the liquid recall questions as input parameters in this calculation (from Question 6A to Question 6J in WHO IYCF sample questionnaires). Whoever received any liquids from input parameters will score as 1 and did not 0.

Please note that the input parameter for the get_dummy function is list type. We need to create a list of liquid variables we can include in our analysis first and then apply that list in the get_dummy function to calculate the dummy variable, which indicates whether the child received any liquid on the previous day.

liquid <- list(df$child_vitdrop, df$child_ors, df$child_water, df$child_juice, 
               df$child_broth, df$child_porridge, df$child_bms, df$child_milk, 
               df$child_mproduct, df$child_liquid)

df$liquid_food <- get_dummy(var_list = liquid)
table(df$liquid_food)
#> 
#>   0   1 
#>  24 138

Soild or semi-solid food consumption

For solid and semi-food consumption status, I used all the variables from 24 hours solid (or semi-solid) food recall Question 7A to Question 7R in WHO IYCF questionnaires. If the child got any food from this list, indicated as 1, and if he/she didn’t, 0.

solid <- list(df$child_rice, df$child_potatoes, df$child_pumpkin, 
              df$child_beans, df$child_leafyveg, df$child_mango, df$child_fruit, 
              df$child_organ, df$child_beef, df$child_fish, df$child_insects, 
              df$child_eggs, df$child_yogurt, df$child_fat, df$child_plam, 
              df$child_sweets, df$child_condiments)

df$solid_food <- get_dummy(var_list = solid)
table(df$solid_food)
#> 
#>   0   1 
#>  31 131

Calculation Of EBF indicator

Now, we got all the input parameters required for EBF indicator calculation. This get_ebf function will identify the children who exclusively breastfed during the previous day, which means they only got breastmilk and no liquid or solid food feedings.

df$ebf <- get_ebf(q4 = df$child_bfyest, 
                  age = df$calc_age_months, 
                  liquid_food = df$liquid_food, 
                  solid_food = df$solid_food)
table(df$ebf)
#> 
#>  0  1 
#> 25 15

You can also cross-check the result with the below manual calculation syntax. The dataset has 40 under 6 months children, and among them, only 15 were exclusively breastfed.

length(which(df$calc_age_months < 6))
#> [1] 40
length(which(df$calc_age_months < 6 & df$child_bfyest == 1 & 
               df$liquid_food == 0 & df$solid_food == 0))
#> [1] 15

Mixed Milk Feeding Under Six Months (MixMF)

This indicator count for all under 6 months old children who received formula and/or animal milk in addition to breastmilk during the previous day. We can use the get_mixmf function to calculate this indicator. According to the definition, we need four parameters; age, breastfeeding status, infant formula (Question 6B), and animal milk (Question 6C) consumption status from the previous day.

df$mixmf <- get_mixmf(q4 = df$child_bfyest, 
                      age = df$calc_age_months, 
                      q6b = df$child_bms, 
                      q6c = df$child_milk)
table(df$mixmf)
#> 
#>  0  1 
#> 37  3

Below is the manual calculation for checking the get_mixmf function result. Of 40 under 6 months old children, only 3 children get mixed milk feeding.

length(which(df$calc_age_months < 6 & df$child_bfyest == 1 & 
               (df$child_bms == 1 | df$child_milk ==  1)))
#> [1] 3

Continious Breastfeeding 12-23 Months (CBF)

This continuous breastfeeding indicator only accounts for the age range between 12-23 months. Children out of this age range will not consider in the indicator calculation. We will use the get_cbf function, and it requires only two input parameters; child age and breastfeeding status from the previous day.

df$cbf <- get_cbf(q4 = df$child_bfyest, 
                  age = df$calc_age_months)
table(df$cbf)
#> 
#>  0  1 
#> 31 33

Out of 64 children 12-23 months old, only 33 were continuously breastfed after one year of their age. Below is the manual calculation syntax, and you will see that we got the same results as what the get_cbf function did.

length(which(df$calc_age_months >= 12 & df$calc_age_months < 24))
#> [1] 64
length(which(df$calc_age_months >= 12 & df$calc_age_months < 24 & 
               df$child_bfyest == 1))
#> [1] 33

Bootle Feeding 0-23 Months (BoF)

This is the last indicator in the breastfeeding session, and it counts for the children (under 2 years old) who received the bottle feeding during the previous day. With the get_bof function, we can calculate this indicator and its only require two input parameters; child age and bottle feeding status (Question 5).

df$bof <- get_bof(q5 = df$bf_bottle, 
                  age = df$calc_age_months)
table(df$bof)
#> 
#>   0   1 
#> 129  24

Among 153 under 2 years old children, only 24 were fed from the bottle with a nipple during the previous day.

length(which(df$calc_age_months < 24 & df$bf_bottle == 1))
#> [1] 24

Nicholus Tint Zaw