Explaining determinants, impact on breastfeeding, and trends over time of prelacteal feeding practice in Indonesia: a mixed methods study
Keywords: breast-feeding
DHS
prelacteal
pre-lacteal
breastfeeding
Indonesia

Background
Prelacteal feeding (PLF) is any feed other than breastmilk given to newborns within the first few days of birth and/or before breastfeeding is established. PLF has been recognised as one of the challenges to optimal breastfeeding, hence the World Health Organisation (WHO) recommends against it unless medically indicated. In Indonesia, breastfeeding practice is gradually improving, yet PLF prevalence is higher than the global average. However, research about PLF from Indonesia is limited. Moreover, existing literature showed that type of PLF varies across settings, but most studies analysed it as a single entity. This thesis aims to explain the determinants, impact on breastfeeding, and trends over time of PLF practice in Indonesia, overall and by different type.
Methods
My thesis used a mixed methods approach. The quantitative components used the Indonesia Demographic and Health Surveys (IDHS) datasets from 2002, 2007, 2012, and 2017. The qualitative component used in-depth interviews with Indonesian health professionals to understand the role of the health care service in preventing inappropriate PLF practice.
Results
The PLF prevalence in Indonesia decreased from 68% in 2002 to 45% in 2017. The most common PLF types were formula, honey, water, and other milk. Some determinants of PLF varied by type and sometimes showed opposite directions of association. Higher wealth quintiles, first child, and caesarean birth especially at a private facility were consistent determinants for prelacteal formula and other milk in most survey years. In contrast, home birth was a determinant for prelacteal honey and water. Meanwhile, any PLF, particularly formula and other milk, were consistently associated with shorter duration of any breastfeeding and non-exclusive breastfeeding at 0-6 months. However, these associations were not consistent for prelacteal honey and water. Interviews with health professionals revealed complexity in PLF practice, where definition, justification, and consequences for giving PLF were sometimes unclear. Health facilities, particularly the health professionals, played a crucial role in reducing inappropriate PLF, although this depended on the health professional skills, services available, and influences from the mother’s families. The decrease in PLF practice in recent years was reported to be largely contributed to by Indonesia’s breastfeeding laws and mothers’ increasing commitment to breastfeeding. Nevertheless, remaining challenges include lack of acknowledgment and support towards addressing breastfeeding difficulties in the first days.
Conclusion
PLF is a complex challenge to breastfeeding that is often overlooked in Indonesia, a country where breastfeeding is culturally favoured and protected by law. PLF is not a single entity, hence identifying vulnerable groups and circumstances for different PLF types is helpful for health professionals in preventing inappropriate PLF practice. Information about the impact on breastfeeding of different PLF types is often not clarified, together with information about options to address potential breastfeeding difficulties. My DPhil thesis findings support current recommendations to avoid PLF without medical indications. However, discussion about the risks and benefits of PLF in relation to breastfeeding difficulties in the first days and ways to overcome them deserves more attention.