Abstract
BACKGROUND: This study aims to investigate the measurement of breastfeeding prevalence indicators using Demographic and Health Surveys (DHS) data, focusing on early initiation, exclusive breastfeeding, and continued breastfeeding indicators as reported by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) and on the discrepancies arising from small changes in their definition. METHODS: Two hundred sixty DHS samples from 78 countries were analyzed to re-calculate usual indicators reported by WHO and UNICEF: early initiation of breastfeeding (EIB), exclusive breastfeeding under 6 months (EBF), and continued breastfeeding between 1 and 2 years (CBF12 and CBF24). Additionally, alternative estimates of the same indicators, slightly changing their definition, were calculated to test their robustness. RESULTS: The WHO and UNICEF indicators for early initiation (EIB) primarily capture cases where breastfeeding is initiated "immediately" after birth, omitting those initiated within 0 or 1 hour. This discrepancy leads to substantial underestimation of levels in some regions, particularly South Asia, and in trends. Furthermore, sizable discrepancies between exclusive breastfeeding (EBF) indicators arise from the inclusion or exclusion of plain water in the definition, with significant variations across regions, especially in West and Middle Africa. However, continued breastfeeding indicators showed consistency across definitions, proving them robust for international comparisons and time trend estimations. CONCLUSION: This study highlights the importance of understanding how breastfeeding indicators are defined and calculated using DHS data. Researchers should be cautious when using WHO and UNICEF indicators for early initiation and exclusive breastfeeding, as they may underestimate prevalence due to their narrow definition. Continued breastfeeding indicators, on the other hand, are less affected by small changes in definitions and provide reliable measures for cross-country comparisons and trend analyses. These findings underscore the need for standardized robust definitions and transparent reporting of breastfeeding indicators in global health assessments.