1. Brajesh Sharma [PhD Scholar]
Interactive Effects of Sanitation, Water and Breastfeeding on Child Health in Asia: Evidence from Demographic and Health Survey  
Brajesh Sharma [PhD Scholar]
INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES, MUMBAI, INDIA

2. Socio-economic & demographic profile
Country Profile
Socio-economic & demographic profile
Nepal
Bangladesh
Pakistan
Year
Urban Percent
8.40
9.40
11.5
26.0
30.2
38.6
Female literacy
20.0
52.7
41.9
54.9
40.0
HDI
0,168
0.548
0.185
0.570
0.305
0.538
GNI
195.90
694
324.4
958
565.9
1,275
TFR
4.6
2.6
3.44
2.3
5.36
3.8
IMR
79.0
46.0
87.0
43.0
94.0
74.0
Under five mortality
118 54
133
53.0
120.4
89.0
Four-ANC attendance
8.80
50.3
6.00
14.2
36.6
Institutional delivery
35.2
3.50
28.8
13.4
48.0
Immunization
43.3 87
59.0
86.0
35.1
54.0
MMR
539
281
569
176
431
178
Sources: Census, SRS, WHO, UNICEF, DHS and , India, Nepal, Bangladesh and Pakistan

3. Introduction
The promotion of proper infant feeding practices and the improvement of environmental sanitation have been two important strategies in the effort to reduce diarrhoeal morbidity among infants.
Breast-feeding protects infants by decreasing their exposure to water- and foodborne pathogens and by improving their resistance to infection; good sanitation isolates faecal material from the human environment, reducing exposures to enteric pathogens.
Taken together, breast-feeding and good sanitation form a set of sequential barriers that protect infants from diarrhoeal pathogens. Reducing the level of environmental contamination similarly reduces the risk of diarrhoea.
Good sanitation protects infants by creating a series of barriers to keep enteric pathogens out of their environment; excreta disposal facilities isolate human wastes; improved water supplies protect drinking-water from faecal contamination; and hand washing and personal hygiene reduce the transmission of enteric pathogens in the home.
Poor sanitation may pose more of a risk to those who are particularly vulnerable, i.e., non-breast-fed infants. Weaning foods and breast milk substitutes are more likely to be contaminated in areas where water supply, sanitation, and hygiene are lacking.

4. Consequently, mixed-fed and weaned infants living in poor sanitary conditions probably face considerably higher exposures to food bome pathogens than similarly fed infants in less contaminated environments.
Thus, exclusive breast-feeding may provide greater protection to infants living in highly contaminated environments. Breastfeeding is the biological reference point for infant feeding against which all other alternatives should be measured.
There is convincing evidence to show that premature weaning results in increased risk of disease and poorer outcomes for infants and their mothers both in the short and long term.
The effects of which are dose-related i.e. the more breast milk, the lower the risk of disease. The Issue like WASH is key to successful breastfeeding50% of malnutrition is linked to poor sanitation. Breastfeeding on demand provides all the water a baby needs, even in hot weather.
Mothers who do not wash their hands at appropriate times can pass harmful bacteria and pathogens to their infants during breastfeeding. Infants who are not breastfed are more vulnerable to infections and pathogens from contaminated water that cause diarrhoea. 

5. Proper infant feeding practices and improved sanitation are two important strategies to reduce diarrheal morbidity among infants. Breastfeeding protects infants by decreasing their exposure to food- and waterborne pathogens and by improving their resistance to infections.
Access to proper sanitation reduces exposure to enteric pathogens by separating excrement from the human environment.
Exposing infants to unsafe or contaminated drinking water, even in small amounts, nearly doubles their risk of diarrhoea (WHO).
Infants without piped water or toilets and not breastfed are five times more likely to die after one week than those who were breastfed.
Infants living in areas with poor sanitation who are mixed-fed have a higher risk of diarrhoea than infants in the same area who are only breast-fed. The risks of weaned infants are even higher .
Formula feeding requires access to clean water, hygiene and sanitation. Formula mixed with unsafe drinking water can cause bouts of newborn and child diarrhoea, which can lead to stunting, wasting, under nutrition, and even death. 

6. Improving the nutrition around the life course
World Breastfeeding Trend Initiative (WBTi)

7. Only 38% of infants (under six months) in Pakistan are exclusively breastfed, according to the preliminary findings of the Pakistan Demographic and Health Survey (PDHS)
This is indicative of the fact that there is hardly any improvement since PDHS , when the exclusive breastfeeding for six months was 37%.
The PDHS findings also show increase in bottle feeding rates in Pakistan from DHS-2007 to DHS-2012.
On the contrary, in Bangladesh, the rate of exclusive breastfeeding for six months is 64% while in Nepal it is 70 percent.
Bangladesh are able to increase the rates from 43% in 2007 to 64% in 2012 by commitment at all levels regarding feeding.
This is also possible because of the active involvement of the civil society and media in the campaigns for the promotion and protection of breastfeeding.

8. BANGLADESH

9. PAKISTAN

10. NEPAL

11. Need for the Study
It is all the more crucial when there is a lack of institutional arrangement of diet or access to children under-five children, because parental dietary preferences and behaviors shape children’s feeding practices, which can influence on the child’s nutrition status, morbidity and mortality.
So, this study attempts to answer that what improvement can be in diarrhea due to feeding practices, improved water and sanitation condition among children and what is the progress made in the area of feeding practices, socio-economic and demographically in these countries.
These are changing due to socio-economic, demographic characteristics, environmental and urbanization condition of mother to create a health outcome gap among children.
The study also aims to find out linkages which have a positive effect for improved diarrhea and to improve feeding practices among children and feeding of improved water and foods offered.
It will provide a well-established message that all families should receive guidance on feeding as part of preventive health services. With this aim, the study tries to find the answer of the following research questions and their comparative views across four selected countries of South Asia.

12. Objectives Research Questions Hypothesis
Is the protective effect of breast-feeding against diarrhoeal morbidity greatest where water quality and sanitary conditions are poor?
- Is the protective effect of improved water quality and sanitary conditions greatest when breastfeeding is not practised ?
What specific aspects of environmental sanitation are particularly important in protecting children who are not breast-fed?
Objectives
To investigate the effect of water, sanitation on breastfeeding practices among children in selected South Asian countries.
To understand the effect of breastfeeding, water and sanitation with socio-economic, environmental and demographic factors on diarrhea among children.
To examine the association between water, sanitation and breastfeeding practices with diarrhea among children in selected South Asian Countries.
Hypothesis
Hypothesis 1: The protective effect of breast-feeding is greatest where sanitary conditions are poor.
Hypothesis 2: The protective effect of good sanitary conditions is greatest among those not breast-fed.

13. Data and Method Data Source Methodology
Demographic and Health Surveys (DHS) conducted during in Nepal, Pakistan and Bangladesh information on children below 60 months old and from their mother’s age years. The mothers reported their children’s breastfeeding, liquid consumption, and non breast milk. So, the information collected on breastfeeding, exclusive and complimentary feeding has been used.
Methodology
Dependent: Breastfeeding group and Diarrheal condition in Yes on No categories
Independent: Age of women, education, husband education, interaction between water and sanitation , residence, wealth, religion, education, age of child,
Bi-variate: Used to see the effect of water, sanitation on feeding practices with selected socio-economic and demographic factors.
Logistic regression used in the analysis to understand the effect of water, sanitation and feeding practices on diarrheal condition.

14. Classification of water sources and sanitation facilities based on WHO/UNICEF guidelines.
Improved
Unimproved
Water source
Piped water connection to household, public taps or standpipes, boreholes or tube wells, protected dug well, protected spring and rainwater collection.
Unprotected dug well, unprotected spring, cart with small tank or drum, surface water (e.g., river, dam, lake, pond, stream, canal or irrigation channel) and bottled water.
Sanitation facility
Pour-flush system, piped sewer system, septic tank, ventilated improved pit latrine (VIP) and pit latrine with slab.
Pit latrine without slab, bucket, hanging toilet or latrine, no facilities, bush or field and shared or public facility
Exclusive breastfeeding: Children who were given nothing but breast milk in the 24 hours preceding the interview.
Full breastfeeding: Children who were given either breast milk alone or breast milk plus plain water in the 24 hours preceding the interview.
Complementary foods: Children who were breastfed and given solid or semi-solid foods in the 24 hours before the survey. Children may also be given non-breast milk.

15. Results
The figure is the distribution of different feeding practices including full breastfeeding, exclusive and complementary with improved water, sanitation and their improved interaction terms.
The exclusive breastfeeding very in all countries from 23 to 26 percent. Where full breastfeeding is 11 percent in Nepal, 16 percent in Pakistan and 17 percent in Bangladesh.
The distribution of complementary breastfeeding is around 35 percent in Pakistan, 26 in Bangladesh and 24 percent in Nepal.
The distribution of improve water and sanitation distribution is more than 92 percent and 70 percent respectively in Bangladesh, 81 percent and 77 percent in Pakistan and 84 percent and 45 percent in Nepal.
So, these distribution is very by the countries where in sanitation practices is low in Nepal, and improved water is less in Bangladesh. Only 11 percent last child of women are doing full breastfeeding in Pakistan.

16. BANGLADESH

19. Role of Water and Sanitation Condition and Feeding Practices for chance of diarrhea among children
The results of the trivariate analysis indicates that the children who are breastfeeding and living in an improved sanitation and water condition have the lower risk of diarrhea.
These distribution is around 38% in case of full breastfeeding, 48% with exclusive breastfeeding and almost half with complementary breastfeeding with improved sanitation condition in Bangladesh.
Where the condition of sanitation is unimproved there is high risk of diarrhea and these percentage is more than half in full breastfeeding category, and more than 68 percent in both exclusive and complementary group in Bangladesh.
These distribution is similar like sanitation in case of water condition. This is 41 percent, 53 percent and 55 percent with full breastfeeding, exclusive and complementary where water condition is improved.
The distribution is same and more like unimproved sanitation in case of unimproved water. Means if the children are taking breastfeeding full, exclusive and complementary feeding have lower risk of diarrhea as compared to children who have bad environment and not taking feeding.

23. Percentage distribution of Socio-economic, environmental and demographic factors among population in Bangladesh, Nepal and Pakistan

24. Multivariate Results :Logistic Regression
The results of analysis indicates that the breast-feeding may be most important if the sanitation barrier is not in place. Breast-feeding provides significant protection against diarrhoeal disease for infants in all environments.
Administration of even small portions of contaminated water supplements fully breast-fed infants nearly doubles their risk of diarrhoea.
Mixed-fed and weaned infants consume much greater quantities of supplemental liquids, and as a result, the protective effect of full breast-feeding is greatest when drinking-water is contaminated.
Similarly, full breast-feeding has stronger protective effects among infants living in crowded, highly contaminated settings.
Interaction terms in the model are used to estimate the effects of breast-feeding, water and sanitation at different levels on diarrhea .
The parameters are estimated using logistics model procedure to assess the risk of diarrhoea associated with different feeding patterns under good and poor environmental conditions with socio-economic and demographic characteristics.
Education, working condition, economic status age and urbanization have positive effect on almost every aspect of women’s status on reducing the diarrhea.

28. Summary
Full breast-feeding provides significant protection against diarrhoeal disease for infants living in all environments during the first 6 months of life.
Exclusive breast-feeding is by far the most protective. Adding even small quantities of contaminated water to the infant's diet can double the risk of diarrhoeal disease.
Nevertheless, full breast-feeding (i.e., supplementation with only non-nutritive liquids) is much more protective than mixed-feeding.
While mixed-fed infants are at a higher risk than fully breast-fed infants, they are still only half as likely to develop diarrhoea as completely weaned infants.
This inverse relationship between the level of breast-feeding and the risk of diarrhoea is probably due to two factors: reduced protection from maternal antibodies in breast milk and an increase in exposure to food bone pathogens.
Clearly, under certain circumstances breast-feeding did provide greater protection in poor sanitary conditions. Exclusive breast-feeding had a stronger protective effect when drinking-water was contaminated, and breast-feeding was more protective for infants living in crowded, highly contaminated settings.

29. In the present study, both water quality and sanitation are important risk factors for diarrhoea. Consumption of contaminated water, lack of private excreta disposal, and the presence of excreta in the yard were associated with the largest increases in risk.
As hypothesized, the protection provided by high-quality drinking-water and good sanitation in the community appear to be greatest for non-breastfed infants.
A high-quality water source is particularly important for mixed-fed and weaned infants since they consume the largest quantities of water.
Similarly, good community sanitation would benefit completely weaned infants the most since they face significantly higher risks from living in neighborhoods with poor sanitary conditions. Such highly contaminated environments may well increase the risk of weaning foods being contaminated.
Efforts to reduce diarrhoea should focus on reducing exposures, particularly foodborne exposures, through improvements in the choice of supplemental foods, preparation practices and storage methods, and better personal hygiene.
Increasing the availability of water and access to excreta disposal facilities can do much to enable families to improve hygienic conditions in the home and to reduce the level of contamination in the community.

30. Conclusion
The policy implications of these findings are clear. Full breast-feeding through the first 4-6 months should be encouraged as a means of protecting young infants in all settings from diarrhoeal disease.
Our analyses of the impact of water and sanitation indicated that children under 5 years old in households with access to both unimproved water sources and sanitation facilities had increased risk of morbidity and mortality than children with access to improved water sources and sanitation.
In addition to the effect of unimproved water and sanitation, the results revealed that households in rural areas, poor households, mother’s age at birth (<20 years old), mothers who perceived their newborns to be smaller than average at birth, and illiterate parents had a significantly higher risk .
The findings from the study showed that Water and Sanitation community-based interventions are needed to prevent child health, and that such interventions should target low socioeconomic households in these region.
In most low-income countries, early supplementation and weaning are most prevalent in these rural, urban squatter and slum areas. Thus, programmes that promote appropriate infant-feeding practices should consider targeting such communities.
“Food” is not a word it is an emotion

31. Thank you….