education, and life expectancy [2]. Approximately 40% of Afghans did not make enough money to meet their basic requirements, such as food, and were therefore living in poverty in 2013–2014 [1]. Consequently, many Afghans, notably the 16% of the population under five (whose nutrition, growth, and development determine the country's development and prosperity opportunities), are at risk of food and nutrition insecurity due to conflict and economic downturn [3]. Consequently, the rate of child stunting continues to be intolerably high, with 20% of children under five years old suffering from severe stunting and 40% having stunted growth [4]. Moreover, since 2004, the child wasting rate has been constant at 10% [5,6] This indicates that most children and infants in Afghanistan do not get adequate nutrition.

Suboptimal eating results in child and infant mortality. Notably, the mortality rate of children and infants among children under five in Afghanistan is mediated by low nutritional status as well as diseases such as pneumonia and diarrhoea, among others. Moreover, breastfeeding status is one of the highly significant causes of neonatal and child deaths in Afghanistan [7,8]. The current statistics have shown that only 43% of Afghan newborns aged 0-5 months receive breast milk [1,3]. More alarming are the complementary feeding practices whereby only 16 percent of infants aged 6 to 23 months receive meals that meet the required minimal frequency and variety of feedings [1]. This calls for considering young infants' nutritional needs, especially those of breastfeeding age, in this country.

Several studies have suggested that the level of breastfeeding among the women of Afghanistan is influenced by certain factors based on demography. For instance, according to the statistics collected in the 2015 Demographic and Health Survey, child-feeding practices in Afghanistan vary from one region of the country to another. Another finding from the work conducted was that the wealth index was a significant determinant of the optimal breastfeeding practices in households with lower levels of wealth index who seemed to practice poor breastfeeding practices compared to those with higher wealth index [3]. Likewise, the gender of the baby affects South Asian women’s breastfeeding habits, where girls are exclusively breastfed more than boys [9]. Similarly, a cross-sectional study involving participants from five South Asian countries, including Afghanistan, conducted by Hossain and Mihrshahi (2024) [10], established that raising maternal education of the mother had different positive effects on breastfeeding. This infers that the mother's education level could influence Afghan women's breastfeeding habits. However, there is a limited number of empirical and recent studies that have examined the factors influencing breastfeeding practice among women of reproductive age in Afghanistan, which in turn points to a literature gap. Therefore, this study seeks to address this gap by assessing how women's breastfeeding practices in Afghanistan are influenced by demographic factors, including geographical location (provinces), wealth index, gender of the baby, and the mother’s education level.

Methods

Data source and study variables

The study used data from outside websites, i.e., the Multiple Indicator Cluster Survey (MICS) (2022-2023). This survey was carried out in Afghanistan as a part of a global MICS survey by the UNICEF Afghanistan Country Office in partnership with the National Statistics and Information Authority, with funding from the Afghanistan Reconstruction Trust Fund and World Bank Group. The data was collected using four types of questionnaires i:e, households, women, children under five and children aged 5-17. The data is collected from the end of September 2022 to 28 February 2023. For this research, only children under-5 data is used, which is filled by the mothers or caretakers of all the children under the age of five years living in the house. The sample includes 33,398 children and 32,989 Mothers or caretakers with a 98.8 per cent response rate-the 2019 NSIA Sampling frame using satellite imagery. The structure is based on the MICS6 standard questionnaires and customized into local languages "Pashto" and "Dari" from the standard English Model.

Variables and data analysis

There are two types of variables used in this study, and they are:

Dependent: The outcome variable is whether the child has ever been breastfed, classified as yes coded as one and no Coded as 2. Yes, it is for those children who have ever been breastfed, while no is for those who have never been breastfed.

Independent: The factors affecting breastfeeding practices among mothers were the following:

The child's gender was assessed and grouped into two groups: male coded as one and female coded as 2. The area of living of the family also influences the outcome. It was categorized as urban (coded as 1) and rural (coded as 2). The Education level of the women was used to identify the effects on the nursing behaviours of mothers and is divided into three parts: pre-primary/ ECE or none is labelled as 1, a secondary level of education was labelled as 2 and higher-level studies were labelled as 3. The wealth index quintile was also Measured and consisted of of three subgroups: 1 is for the poor, two is for the middle, and 3 is for the rich. In this analysis, the 34 provinces of Afghanistan were used to measure the discrepancies and regional variations in breastfeeding habits. Each province, such as Kabul, Herat, Khost, Urozgan, and others, represents a distinct geographical unit with unique characteristics. These are designated as the number from 1 to 34.

Data Analysis was carried out by using the IBM SPSS Version-29.0 software. The chi-square test determines the significance of the dependent and independent factors. The regression analysis is performed and interpreted in terms of Odds ratio and P-value with a 95% confidence interval to measure the degree of association between the Outcome and independent variables.

Results

Table 1 shows the comprehensive view of children and mothers' socioeconomic and characteristics distribution. A large majority (87.1%) of the sample group have been breastfeeding compared to 12.9%, indicating the increased trend of this nursing practice in the surveyed population. On the other hand, a mere 2.1% of mothers attended the early childhood education program in contrast to 98.8%, highlighting the significant gap in women’s education regarding maternal literacy. The demographic is predominantly rural, with 84.9% (28355) children living in these areas and a small proportion less than one-third (15.1%) living in cities. The gender distribution of the interviewed children is approximately equal, with a slight increase in males, with 51% males and 49% females showing no significant gender imbalance in the given dataset.

Table 1: Distribution of demographics of mother and child characteristics

Most mothers’ education is at primary or pre-primary level, with 90.3% falling into this category. Only a limited number of mothers have reached the secondary (7.4%) and higher (2.3%) education levels. This suggests the critically low levels of advanced educational attainments in mothers.

The above table reveals the economic background disparities: 47.4% of the children come from poor households, with 22.1% from middle-income and 30.4% from high-income families. This indicates that nearly half of the children live in poverty. This distribution of population could have affected their accessibility to opportunities.

Figure 1: Distribution of sample in numbers across various provinces of Afghanistan

Figure 1 illustrates the distribution of samples in numbers across various provinces of Afghanistan. It reveals notable variations in the frequencies, with Panjsher having the lowest frequency at 2.0% (656) and Kandhar having the highest percentage, 4.2% (1382). Provinces like Daykundi, Logan and Zabul are notable as each contributes over 3% to the total interviewers with numbers 733, 1171 and 1236 respectively. Conversely, provinces such as Smanghan (764), Baghlan (740) and Balkh (741) exhibit lower representation, with percentages hovering around 2% each of the overall occurrence.in summary, this distribution provides a glimpse into the diversity of the population included in this study. This heterogenicity offers a concise overview of the analyzed population.

The chi-square analysis indicates no statistically significant association between the region (urban or rural) and the breastfeeding practice, as the p-value is more significant than 0.05 (p-value=0.06).

Table 2: Chi-square analysis was used to find the association between the child's being breastfed and independent factors

The above-presented table summarizes the results of chi-square analyses conducted to explore the relationship between the practice of breastfeeding and several independent variables, including region, gender of the baby, mother's education level, wealth index, and province and significant associations are denoted with an asterisk (*).

On the other hand, there is a significant association between the mother's education level and breastfeeding (p-value=0.005*). This indicates that the level of education attained by the mother is related to the likelihood of her child being breastfed, which means higher education levels are associated with higher breastfeeding rates (89%). Similarly, a significant association is found between the child's gender and breastfeeding, as the p-value is 0.03. This implies that there is a difference in the proportion of breastfed boys and girls. Breastfeeding is a practice that appears to be independent of wealth as no significant association is observed between the wealth index and breastfeeding (p-value=0.24). This suggests that the family's economic status does not significantly impact the decision to breastfeed.

The chi-square analysis reveals significant associations between the practice of breastfeeding and the province in which the child resides, which means that the likelihood of a child being breastfed varies considerably from one province to another. Areas like Parwan, Maidan Wardak, Logar, Baghlan, Bamyan, Ghazni, Daykundi, Urozgan, Zabul, Jawazjan, Faryab, Baghdis, Herat, and Farah show significant association as the p-value is less than 0.05 which indicates that the child in these provinces has higher rates of breastfeeding as compared to the national trends (Table 2).

Table 3: Binary logistic regression analysis of demographics of mother and child with dependent variable

The binary logistic regression analysis in Table 3 reveals two significant factors associated with whether a child has ever been breastfed. Firstly, gender plays an important role, with female children being 1.09 (9% higher odds) times more likely to have ever been breastfed compared to male children (95% CI: 1.01-1.19, p-value = 0.03). Secondly, the education level of the mother significantly impacts breastfeeding practices. Specifically, children of women with secondary education are 0.77 times (23% lower odds) more likely to have ever been breastfed than those whose mothers have only primary education (95% CI: 0.65-0.91, p-value = 0.003).

In Table 4, 'all other provinces' is designated as the reference category, coded as '1.' The regression analysis presented in Table 4 reveals significant regional differences in the likelihood of children ever being breastfed in Afghanistan. Children in Parwan, Takhar, Kunduz, Panjsher, Bamyan, Sar-e-pul, Ghor, Daykundi, Jawazjan, Faryab, Baghdis, Herat, and Farah are significantly more likely to have been breastfed, with Herat having the highest odds ratio of 11.02 (95% CI: 5.31-23.65, p-value < 0.001). In contrast, children in Maidan Wardak, Logar, Nangarhar, Nooristan, Baghlan, Khost, Samanghan, Urozgan, Zabul, and Helmand are significantly less likely to have been breastfed, with Nangarhar showing the lowest odds ratio of 0.19 (81% lowest odds) (95% CI: 0.16-0.22, p-value < 0.001).

Table 4: Regression analysis of children ever breastfed in different Afghanistan provinces

Discussion

The demographic analysis of mothers and children in Afghanistan reveals essential trends in breastfeeding practices. A notable 87.1% of children in the sample have been breastfed, but only 1.2% of mothers attended early childhood education programs, highlighting a significant gap in maternal education. The majority of the population is rural (84.9%), with an almost equal distribution of male (51%) and female (49%) children. Most mothers have only primary education (90.3%), with a small percentage having secondary (7.4%) or higher education (2.3%). Economically, 47.4% of children come from poor households, 22.1% from middle-income, and 30.4% from wealthy families, indicating that nearly half of the children are living in poverty. Chi-square and binary logistic regression analyses identify key factors influencing breastfeeding. Significant associations are found between gender and mother's education level: female children are 1.09 times more likely to be breastfed than males, and children of mothers with secondary education are 0.77 times less likely to be breastfed compared to those whose mothers have only primary education. Additionally, regional disparities are evident. Provinces such as Parwan, Takhar, Kunduz, Panjsher, Bamyan, Ghazni, Ghor, Jawazjan, Faryab, Baghdis, Herat, and Farah show higher

likelihoods of children being breastfed, with Ghazni showing the highest odds ratio of 18.37. Conversely, children in Maidan Wardak, Logar, Nangarhar, Nooristan, Baghlan, Khost, Samanghan, Urozgan, Zabul, and Helmand are less likely to be breastfed, with Nangarhar having the lowest odds ratio of 0.19. These findings underscore significant disparities in breastfeeding practices based on gender, maternal education, and regional factors.

The prevalence of children ever being breastfed in Afghanistan in this study is 87%, which, while significant, is lower than the rates found in several other countries. For instance, Pakistan reports a much higher prevalence of 99%, indicating a very high level of breastfeeding practices in the country [11]. Similarly, Qatar demonstrates a strong commitment to breastfeeding, with 96% of children ever breastfed [12], and the United Arab Emirates follows closely with a prevalence of 95% [13]. Moreover, lower breastfeeding rates than those observed in Afghanistan can be found in other regions. For example, Oman reports a significantly lower prevalence of breastfeeding at 47%, which is notably below the 87% found in Afghanistan [14]. The findings of this research coincide with many other studies. Notably, the low education levels of mothers in primary and secondary education (9.7%) were also reported in another study in South Asia in which only 11% of mothers achieved this level of education in Afghanistan [15].

In comparison with our results, a similar negative association between higher education level and breastfeeding practices was also reported in other countries, Bangladesh, which depicted that the mothers with low levels of education were more likely to stick to breastfeeding their child [16]. In contrast, some countries like Indonesia [17], Ghana [18] and China [19] found a positive association with higher odds. Additionally, according to our analysis, females are slightly more likely to be breastfed, similar to results found in a survey in Ethiopia [20]. Another study in Indonesia showed a strong association between gender and breastfeeding practices [21]. Following our results, we found no association between the wealth index and the breastfeeding practice, specifically regarding whether a child has ever been breastfed. This outcome is at odds with findings from other regions where economic status has been shown to influence breastfeeding behaviours. For instance, studies in Bangladesh [22] and Pakistan [11] have demonstrated that mothers from wealthier households are more likely to breastfeed, indicating that a higher wealth index may be associated with nursing practice.

Interestingly, our study also observed notable regional disparities within Afghanistan, suggesting that geographic location might have a more pronounced influence on breastfeeding practices than wealth alone. For instance, provinces such as Zabul, Sar-e-pul, Ghor, Nimroz, Kapisa, Jawzjan, Badghis, Panjshir, Bamyan, and Kabul demonstrated statistically significant p-values compared to other regions. These areas exhibited distinct breastfeeding practices, with varying rates of nursing observed across different provinces. This regional contrast is not unique to Afghanistan. Similar patterns have been observed in other countries as well. In Saudi Arabia, breastfeeding practices also varied significantly across different regions, including the North, South, Central, West, and East areas [23]. Specific cities like Abha [24], Al-Taif [25], and Riyadh [26] displayed differing breastfeeding rates and practices. Similarly, substantial regional differences in breastfeeding practices have been documented in Pakistan. Research by Arif et al. [27] and Noh et al [28], reported significant variations in breastfeeding rates across Pakistan’s provinces, including Punjab, Sindh, Khyber Pakhtunkhwa (KPK), and Balochistan.

Strengths and limitations

This study has several strengths. The large sample size includes data from throughout the provinces, so this paper's results apply to the whole country. There is limited research on this topic, so that it will help researchers and policymakers. But, there are also some potential limitations as the data is taken from open sources, so it is difficult to verify the authenticity of the data. It may suffer from inconsistencies, which might lead to biases in conclusions. Although there are plenty of studies around the globe, there is a lack of already available work on the issue of breastfeeding in Afghanistan, which makes it more demanding.

Conclusion

This study uses data from the MICS to investigate the factors influencing breastfeeding practices among Afghan women. It specifically emphasizes the significant role of socio-demographic, economic and regional factors impacting breastfeeding behaviours in Afghanistan.

In Afghanistan, the prevalence of breastfeeding among children under five is notably high, at 87.1%. Factors such as gender and maternal education exert significant influence on breastfeeding practices. Cultural norms favouring girls are evident, as female children are 9% more likely to be breastfed. Mothers who have completed secondary education are 23% less inclined to breastfeed compared to those with primary education, indicating a necessity for focused educational interventions. There are regional discrepancies; for instance, provinces such as Parwan and Takhar exhibit higher breastfeeding rates than Maidan Wardak and Nangarhar. To encourage the mothers of Afghanistan, it is recommended that targeted region-specific initiatives be developed that consider local-specific socioeconomic conditions and cultural norms to promote breastfeeding. This initiative tailored interventions according to regional disparities.

Furthermore, the government should make legislation to implement the policy of compulsory breastfeeding-friendly areas in healthcare centers, public areas, and workplaces. Also, walk-in breastfeeding support clinics or centers should be provided to help nursing mothers. These centres should also run educational programs for pregnant ladies regarding the benefits of early initiation of breastfeeding and continued breastfeeding.

Addressing the complex determinants of breastfeeding practices in Afghanistan requires a comprehensive approach involving policymakers, healthcare providers, communities, and researchers. By implementing targeted interventions and supportive policies, Afghanistan can improve maternal and child health outcomes nationwide through improved breastfeeding practices.

Abbreviations

MICS: Multiple Indicator Cluster Survey

KPK: Khyber Pakhtunkhwa

Supporting information: None

Ethical Considerations: Anglia Ruskin University granted ethical approval for this study.

Acknowledgments: None

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contribution statement: All authors (A, ADP, MC, RH, AN, RK) contributed equally and attest they meet the ICMJE criteria for authorship and gave final approval for submission.

Data availability statement: The Multiple Indicator Cluster Survey (MICS) website (https://mics.unicef.org) makes all of the data related to this study’s conclusions available upon request.

Additional information: No additional information is available for this paper.

Declaration of competing interest: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Clinical Trial: Not applicable

Consent for publication: Note applicable

References