This analysis found that the prevalence of EBF among children aged 0–5 months was 57.46%, and only 40.6% among those aged 5th months were exclusively breastfed. In the past 10 years, EBF practices have decreased markedly from 70% in 2011 to 56% in 2022 [19]. The GoN has endorsed key policy documents, particularly the National Nutrition Strategy (2004), the Infant and Young Child Feeding (IYCF) strategy of 2014, and the Multi-Sector Nutrition Plan-III (2023–2030) prioritizing early, exclusive, and extended breastfeeding to improve maternal and child health and nutrition [49]. Our analysis presented a further decline (57%) in the rate of EBF practice [14]. Interestingly, this estimate of EBF was lower than the South Asian regional average (61%) [12], India (65%) [50], but it was higher than Pakistan (48%) [51]. This indicates that the promotion and protection of EBF practices need urgent attention, as most of the child deaths are attributed to suboptimal breastfeeding [52]. Contributing factors to the declining rate of EBF in Nepal may include the aggressive marketing of BMS [53], poor quality of antenatal care [54–56], lack of skilled breastfeeding counselling in health facilities [52, 54], and sociocultural beliefs favouring mixed feeding [22, 29].
This paper explored the association of individual and community-level determinants with EBF practices. We observed that the infant’s age was significantly associated with EBF practices among infants aged 0–5 months. The factor related to EBF was the infant’s age. The odds of EBF practices decreased with the infant’s increasing age in our study. Some previous studies in Ethiopia, Timor-Leste, Nepal, India, and Tanzania also found that higher age groups were negatively associated with EBF practices [22, 50, 57–59]. Previous NDHS 2016 also showed the same decline in EBF with infants getting older. A comparison between these two surveys regarding the pattern of drop in EBF showed that the proportion of infants exclusively breastfed during the NDHS 2022 deteriorated in all months, excluding the first twenty-nine days and the later sixth month (see supplementary table 2). This could be due to wrong perceptions among mothers and caretakers about the insufficiency of breast milk in meeting the requirements of growing infants [60]. Moreover, this could be attributed to a lack of knowledge about the adverse implications of the early introduction of complementary feeding [22, 29, 36, 45, 50, 61]. Understanding the common age at which EBF gradually subsides and ultimately stops can help design effective interventions considering the infant’s age factor. This allows for concentrated efforts to encourage EBF practices and ensure they continue until the infant is six months old, as recommended.
At the community level, such as province, community poverty level, community maternal employment, and community ANC coverage, affected EBF practices after adjusting for the effects of individual-level variables. Community-level ANC coverage had a higher influence on promoting EBF practices at the individual level. Two distinct direct and indirect mechanisms could explain these differences in association. Under the direct mechanism, health service providers might have offered the mother appropriate information about using subsequent maternal health services (such as institutional delivery and postnatal care), further promoting EBF. In an indirect mechanism, there might have been a spillover effect since women receiving these services might share knowledge and experience with other women, positively influencing the adoption of EBF. In Nepal, people often stay in clusters based on ethnicity, education, and wealth status. Subsequently, women within the specific cluster consistently use particular types of health services health workers provide. In contrast, women in another cluster may not have access to similar health services, resulting in differences in EBF practices. This could be a key factor for cluster disparity detected in this study, concurrent with previously published studies [22, 29, 61].
Maternal employment positively influenced individual-level EBF practices, even after adjusting for other individual and community variables, aligned with another study in Ethiopia [36]. This could be attributed to the relatively higher number of mothers engaged in agricultural work (39%) than those in professional white-collar work (4.5%). Agricultural work often involves a flexible work schedule and proximity of the workplace to home, which is beneficial for the effective continuation of breastfeeding [62]. However, this finding is against other studies done in Indonesia, [25] Latin America, [63] and Ethiopia [64]. Mothers living in communities with moderate and high levels of poverty had higher odds of EBF practices. The potential explanation for this positive association could be that relatively poor communities have less access to BMS [65, 66].
At the community level, lower odds of EBF were found among infants aged less than six months from Lumbini province than in Koshi. Geographical variability in EBF practices has also been reported in other studies [21–23, 45, 61]. Despite its access to roads, and other social services, including a relatively better human development index, Lumbini province has performed poorly in most maternal and child health indicators [14, 67, 68], and it is unclear why this province has underperformed, signalling the need for further research.
Some public health implications can be drawn from our findings. This analysis quantified the variability in the proportion of EBF practices at the community level, implying that infants in adjacent geographical areas resemble breastfeeding practices and that Nepal is heterogeneous regarding breastfeeding practices. This also reflected that there could be socio-cultural differences in communities that often influence EBF practices. Hence, studies can be designed to examine how this variation operates in smaller regions to increase the proportion of mothers practicing EBF. Moreover, targeted interventions in these smaller areas can be developed and rolled out to meet the nutrition-related SDG 2030 targets. It is essential to identify what works for whom and under what circumstances, and the mechanisms that make specific breastfeeding promotion strategies and interventions successful and not others. Nepal’s restructuring after federalism involved autonomy in decision-making and implementation in the social development sector, including health and nutrition at the local level, providing an excellent opportunity to support such context-specific interventions.
Despite its strengths, our study has a few limitations. First, this study could not include important explanatory variables crucial for determining EBF practices, such as breastfeeding problems, encouragement to breastfeed, and breastfeeding information due to their unavailability in this round of the NDHS, which were captured in the previous study [30]. Secondly, this cross-sectional study cannot establish a causal relationship between EBF practices and the explanatory variables considered in the study. Thirdly, estimates of EBF were based on the 24-hour recall method, which might have overestimated the proportion of EBF in this study [69]. However, this method is still acceptable in low- and middle-income countries [70]. Finally, we used a multivariable mixed-effect logistic regression model, accounting for the correlation of EBF practices within the cluster. However, it needed to precisely identify the contextual factors affecting the EBF practices. Despite this, our study demonstrated the existence of contextual factors and quantified their influence on EBF practices.