Maternal exposure to intimate partner violence and breastfeeding practices in 51 low-income and middle-income countries: A population-based cross-sectional study

Background Intimate partner violence (IPV) against women is a major global health issue, particularly in low- and middle-income countries (LMICs), that is associated with poor physical and mental health, but its association with breastfeeding practices is understudied. Both the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life. Breastfeeding within the first hour of birth is critical to newborn survival, and exclusive breastfeeding for 6 months is recognised to offer significant health benefits to mothers and their infants. We examined the association of maternal exposure to IPV with early initiation of breastfeeding (within 1 hour of birth) and exclusive breastfeeding in the first 6 months. Methods and findings We assessed population-based cross-sectional Demographic and Health Surveys (DHS) from 51 LMICs. Data from the most recent DHS in each country (conducted between January 2000 and January 2019) with data available on IPV and breastfeeding practices were used. By WHO region, 52.9% (27/51) were from Africa, 11.8% (6/51) from the Americas, 7.8% (4/51) from the Eastern Mediterranean, 11.8% (6/51) from Europe, 11.8% (6/51) from South-East Asia, and 3.9% (2/51) from the Western Pacific. We estimated multilevel logistic regression models for any IPV and each type of IPV separately (physical violence, sexual violence, and emotional violence), accounting for demographic and socioeconomic factors. Depending on specification, the sample size varied between 95,320 and 102,318 mother-infant dyads. The mean age of mothers was 27.5 years, and the prevalence of any lifetime exposure to IPV among mothers was 33.3% (27.6% for physical violence, 8.4% for sexual violence, and 16.4% for emotional violence). Mothers exposed to any IPV were less likely to initiate breastfeeding early (adjusted odds ratio [AOR]: 0.88 [95% CI 0.85-0.97], p < 0.001) and breastfeed exclusively in the first 6 months (AOR: 0.87 [95% CI 0.82-0.92], p < 0.001). The associations were similar for each type of IPV and were overall consistent across infant's sex and WHO regions. After simultaneously adjusting for all 3 types of IPV, all 3 types of IPV were independently associated with decreased likelihood of early breastfeeding initiation, but only exposure to physical violence was independently associated with a decreased likelihood of exclusively breastfeeding in the first 6 months. The main limitations of this study included the use of cross-sectional datasets, the possibility of residual confounding of the observed associations by household wealth, and the possibility of underreporting of IPV experiences attenuating the magnitude of observed associations. Conclusions Our study indicates that mothers exposed to any form of IPV (physical, sexual, or emotional violence) were less likely to initiate breastfeeding early and breastfeed exclusively in the first 6 months. These findings may inform the argument for antenatal screening for IPV in LMICs and the provision of services to not only improve mothers' safety and well-being, but also support them in adopting recommended breastfeeding practices. Author summaryWhy was this study done? Intimate partner violence is common in low- and middle-income countries and may affect women's choice or ability to breastfeed. We sought to examine the association between mothers' exposure to intimate partner violence and breastfeeding practices (early initiation of breastfeeding and exclusive breastfeeding in the first 6 months). What did the researchers do and find? We used nationally representative survey data from 51 low- and middle-income countries conducted between January 2000 and January 2019. Mothers exposed to intimate partner violence were less likely to engage in recommended breastfeeding practices including initiating breastfeeding within the first hour of birth and breastfeeding exclusively in the first 6 months. What do these findings mean? In low- and middle-income countries, health professionals working with pregnant women may need to identify those who have experienced intimate partner violence and offer tailored support for breastfeeding practices.