*3.2. Sample Characteristics*

The distribution of maternal age (years) was: 15–19 (6.8%), 20–34 (67.5%), 35–49 (25.7%). The majority (78.6%) of participants resided in rural areas. About one-third (34.6%) of mothers and just over a quarter (28.5%) of fathers received no education. The majority of women had no paid employment (73.2%) and followed Roman Catholic as their religion (98.2%). More of them came from poorer (45.4%) than middle class (39.6%) and rich households (15%). Most respondents did not read newspaper (70.3%), listen to the radio (59.9%), or watch television (68.6%) at all.

Slightly more than half (52.7%) of mothers had high parity ( 4), with only 17.4% being first time motherhood. Only 52% of the women had paid four or more ANC visits. There were more male (52.9%) then female (47.1%) infants. The majority of infants were born at home (74.2%) by vaginal delivery (98.3%). Surprisingly, only about a quarter (26.6%) of women could make decision by themselves with regard to health-related matters. Although 56% of mothers perceived their newborn as average size, 18.5% believed they were small size. Most mothers (88.8%) initiated breastfeeding within one hour of delivery. Only a small proportion (2.9%) of mothers continued to smoke at the time of the survey.

A number of socio-demographic and health-related variables appeared to be associated with the prevalence of exclusive breastfeeding according to Chi-square tests. These included residential location (*P* = 0.014), ecological region (*P* < 0.001), maternal occupation (*P* < 0.001), wealth status (*P* = 0.003), frequency of listening to the radio (*P* = 0.007), frequency of watching television (*P* = 0.004), and decision making on health (*P* = 0.026).

### *3.3. Factors Affecting Exclusive Breastfeeding*

Stepwise logistic regression analysis further confirmed that infant age, ecological region, maternal occupation, perceived size of newborn, and decision making on health were significantly associated with exclusive breastfeeding; results of which are shown in Table 2. In particular, increase in infant age could reduce the likelihood of exclusive breastfeeding, consistent with the previous observation on the decline in exclusive breastfeeding prevalence by advancing infant age in Table 1. When compared to the capital city Dili, mothers from other regions were more likely to exclusively breastfeed their infants. On the other hand, mothers who maintained employment seemed less likely to continue exclusive breastfeeding than their non-working counterparts. Those mothers who perceived their newborn as either large or small size were also less likely to exclusively breastfeed. Finally, mothers who could decide health-related matters by themselves tended to exclusively breastfeed, which was not the case for others whose decisions were made by someone else.

#### **4. Discussion**

This study found that half (49.0%, 95% CI 45.4% to 52.7%) of the infants aged five months or below were exclusively breastfed at the time of the 2009–2010 DHS, which appeared to increase substantially from the previously reported 24-h recall prevalence rate of 30.77% (95% CI 27.2% to 34.5%) in 2003 [14]. According to the report by UNICEF [22], the proportion of exclusively breastfed children of 0–5 months during the period 2000–2007 was 43% in East Asia and Pacific, 44% in South Asia, and 39% overall in developing countries. However, the differences in survey period between countries should be taken into account. The apparent increase in exclusive breastfeeding prevalence may be attributable to a number of changes in Timor-Leste since 2003. The country has become more stable after the conflict, with social and health services being restored [9,11]. While it is encouraging to note the improvement in exclusive breastfeeding practice, the rate is still much lower than the recommended 90% by the WHO [23].


**Table 2.** Factors associated with exclusive breastfeeding in Timor-Leste, 2009–2010 (*n* = 975).

EBF: exclusive breastfeeding. \* From backward stepwise logistic regression; variables excluded were: maternal age, residential location, maternal education, paternal education, religion, sex of infant, wealth status, frequency of reading newspaper/magazine, frequency of listening radio, frequency of watching television, birth order, frequency of antenatal care visit, maternal tobacco smoking, method of delivery, place of delivery.

The prevalence of exclusive breastfeeding declined with increasing infant age, from 68.0% at less than one month to 24.9% at five months. The inverse association between infant age and exclusive breastfeeding practice was also observed in other Asian countries such as Bangladesh, China and Nepal [18,24,25]. According to the local culture, it is common that Timorese infants are introduced complementary foods at about the 4th month. The decision is usually made by the senior women of the family such as the grandmother or grandmother-in-law.

Mothers residing in Dili were less likely to breastfeed exclusively when compared with mothers from other regions. Such regional differences have been reported by previous studies in Timor-Leste and other Asian countries [14,17]. Dili is the capital and economic center of the country, where infant formulas are readily accessible at supermarkets. Besides, the capital city citizens are more exposed to advertisement of infant formula, consequently leading to the early cessation of exclusive breastfeeding [26].

Moreover, women who maintained employment after giving birth were less likely to provide exclusive breastfeeding to their infants than their non-working counterparts. Similarly, Chinese mothers who had to return to their office job before six months were unlikely to breastfeed their infant exclusively [24]. Another qualitative study from Bangladesh reported that caretakers introduced formula, cow or buffalo milk when mothers attended work [27]. Working mothers in Timor-Leste are entitled to less than three months of maternity leave. This short duration makes it difficult to continue exclusive breastfeeding.

Newborns perceived to be non-average size by their mothers were less likely to be exclusively breastfed. Experience in other countries has similarly shown that preterm and low birth weight infants are breastfed for shorter duration [28]. Mothers may experience a number of barriers to breastfeed smaller infants, for instance, poor sucking, infants being kept separately for intensive care, illness, and lack of confidence [29], which may lead to the early introduction of complementary foods.

In this study, Timorese mothers who could decide health-related matters tended to continue exclusive breastfeeding, when compared with those that relied on the advice from someone else. This finding was consistent with the literature, which suggested that the ability of a woman to make decision on utilization of services can lead to better maternal and child health outcomes [19,30].

Several issues should be considered when interpreting the results. This study utilized the dataset from the latest national survey with a representative sample and a high response rate, while complex sample analysis was performed to account for the sampling strategy and sample weight [21]. Therefore, the findings are generalizable to the entire country. However, the 24-h recall would inevitably induce over-reporting of exclusive breastfeeding at six months [31] so that caution should be taken [2]. The DHS data nonetheless remain the only available information to estimate exclusive breastfeeding rate in many developing countries.

There is an immediate need of breastfeeding promotion programs in Timor-Leste. Given the high infant and child mortality in the country [11], improving the practice of exclusive breastfeeding will reduce such burden and partially overcome the problem of under-nutrition. Antenatal counseling on breastfeeding and peer support network are recommended [32]. Because the majority of births occur at home, home visits by health workers/volunteers would be an effective option to consider by healthcare planners to further promote exclusive breastfeeding and to increase its duration.

#### **5. Conclusions**

Slightly less than half the infants in Timor-Leste were exclusively breastfed within 24-h preceding the latest national survey. This represented a significant improvement in exclusive breastfeeding practice since 2003 when the country restored peace. Mothers should be provided with continuous support to sustain their initial high rate of exclusive breastfeeding for six months. It is desirable to target mothers who are working, who perceive their newborns as non-average size and those residing in the capital Dili for breastfeeding promotion programs. In addition, mothers must be involved in the decision making process so that they can sustain breastfeeding exclusively.
