Breastfeeding Education and Support to Improve Early Initiation and Exclusive Breastfeeding Practices and Infant Growth: A Cluster Randomized Controlled Trial from a Rural Ethiopian Setting

Abstract

Although peer-led education and support may improve breastfeeding practices, there is a paucity of evidence on the effectiveness of such interventions in the Ethiopian context. We designed a cluster-randomized trial to evaluate the efficacy of a breastfeeding education and support intervention (BFESI) on infant growth, early initiation (EI), and exclusive breastfeeding (EBF) practices. We randomly assigned 36 clusters into either an intervention group (n = 249) receiving BFESI by trained Women’s Development Army (WDA) leaders or a control group (n = 219) receiving routine care. The intervention was provided from the third trimester of pregnancy until five months postpartum. Primary study outcomes were EI, EBF, and infant growth; secondary outcomes included maternal breastfeeding knowledge and attitude, and child morbidity. The intervention effect was analysed using linear regression models for the continuous outcomes, and linear probability or logistic regression models for the categorical outcomes. Compared to the control, BFESI significantly increased EI by 25.9% (95% CI: 14.5, 37.3%; p = 0.001) and EBF by 14.6% (95% CI: 3.77, 25.5%; p = 0.010). Similarly, the intervention gave higher breastfeeding attitude scores (Effect size (ES): 0.85SD; 95% CI: 0.70, 0.99SD; p < 0.001), but not higher knowledge scores (ES: 0.15SD; 95% CI: −0.10, 0.41SD; p = 0.173). From the several growth and morbidity outcomes evaluated, the only outcomes with significant intervention effect were a higher mid-upper arm circumference (ES: 0.25cm; 95% CI: 0.01, 0.49cm; p = 0.041) and a lower prevalence of respiratory infection (ES: −6.90%; 95% CI: −13.3, −0.61%; p = 0.033). Training WDA leaders to provide BFESI substantially improves EI and EBF practices and attitude towards breastfeeding.

Interventions to improve infant and young child feeding practices in Ethiopia: a systematic review

“…Nine cluster randomised trials were assessed for risk of bias using the Cochrane RoB 2.0 tool. Overall, studies by Muluye et al , 94 and Passarelli et al 95 judged as high risk of bias, while studies by Abdulahi et al 91 and Kim et al 89 had a low risk of bias. Two cluster randomised studies had a high risk of bias in the domains for randomisation.…”

“…In the eligible studies, n=23, the majority of the interventions were provided in the form of BCC using nutrition education, 81 82 92 93 95 community mobilisation, 76 78 87 89 health education materials 74 80 82 83 91 and mass media communication. 79 89 Other interventions were also provided in the form of peer/group support and training of mothers, 91–93 promotion of chicken husbandry and home gardening, 95 productive safety net programme (in-cash/food rations), 84 strengthening of healthcare system, 78 80 85–87 training and supervision of healthcare providers, 76 78 83 and food preparation and practical demonstration sessions. 81 82 88 91 94 96 Additionally, two studies used the health belief model (HBM) as a mode of intervention delivery for BCC 81 90 ( table 1 ).…”

“…A total of 23 studies were included, and of these, 14 were quasi-experimental studies, 74-87 and 9 were cluster randomised trials. [88][89][90][91][92][93][94][95][96] Four studies for EBF 77 83 85 91 and six studies for EIBF 77 79 80 85 86 91 showed that community-based and facility-based interventions delivered in the form of BCC (such as policy advocacy, interpersonal communication, community mobilisation and mass media campaigns) and health service strengthening had an impact on infants. Two studies for the introduction of complementary foods, 79 93 six studies for MDD 79 89 90 92 94 96 and three studies for MMF 88 89 92 indicated significant effects of BCC on infants and young children.…”

“…Among the 23 included studies, 14 were quasiexperimental studies, [74][75][76][77][78][79][80][81][82][83][84][85][86][87] while the remaining 9 were cluster randomised trials. [88][89][90][91][92][93][94][95][96] At least one interventional study was conducted in Southern Nations Nationalities and Peoples' Region (SNNPR), 77-79 81 82 84-86 90 Oromia, 74 77 78 83-88 91 95 Amhara, 76-78 84-87 89 92 93 95 Tigray 77 79 84-87 95 and Afar 80 regions, but we did not find published interventional studies conducted in either Addis Ababa and Dire Dawa city administrations, Harari, Benishangu1, Gambella, or Somali regions.…”

“…Eight studies reported the effect of interventions to improve EIBF. 76 77 79 80 85-87 91 A health facility level intervention in the Afar region that integrated nutrition information into health professional guidelines and also provided family education and counselling booklets resulted in a significant improvement in EIBF in the experimental group compared with the control group (OR=1.70; 95% CI: 1.17 to 2.46; p=0.005). 80 Kim et al 79 showed that interventions delivered through advocacy and policy dialogues, interpersonal communication and community mobilisation, and mass communication improved EIBF.…”