Implementation of Steps 1-9 to Successful Breastfeeding Reduces the Frequency of Mild and Severe Episodes of Diarrhea and Respiratory Tract Infection Among 0-6 Month Infants in Democratic Republic of Congo

Abstract

Introduction: Global initiatives to improve breastfeeding practices have focused on the Ten Steps to Successful Breastfeeding. The aim of this study was to assess the effect of implementing Baby-Friendly Hospital Initiative (BFHI) steps 1-9 and BFHI steps 1-10 on incidence of diarrhea and respiratory illnesses in the first 6 months of life.

Methods: We reanalyzed a cluster randomized trial in which health-care clinics in Kinshasa, Democratic Republic of Congo, were randomly assigned to standard care (control group), BFHI steps 1-9, or BFHI steps 1-10. Outcomes included episodes of diarrhea and respiratory illness. Piecewise Poisson regression with generalized estimation equations to account for clustering by clinic was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI).

Results: Steps 1-9 was associated with a decreased incidence of reported diarrhea (IRR 0.72, 95% CI 0.53, 0.99) and respiratory illness (IRR 0.48, 95% CI 0.37, 0.63), health facility visits due to diarrhea (IRR 0.60, 95% CI 0.42, 0.85) and respiratory illness (IRR 0.47, 95% CI 0.36, 0.63), and hospitalizations due to diarrhea (IRR 0.42, 95% CI 0.17, 1.06) and respiratory illness (IRR 0.33, 95% CI 0.11, 0.98). Addition of Step 10 attenuated this effect: episodes of reported diarrhea (IRR 1.24, 95% CI 0.93, 1.68) and respiratory illness (IRR 0.77, 95% CI 0.60, 0.99), health facility visits due to diarrhea (IRR 0.76, 95% CI 0.54, 1.08) and respiratory illness (IRR 0.75 95% CI 0.57, 0.97), and hospitalizations due to respiratory illness (IRR 0.48 95% CI 0.16, 1.40); but strengthened the effect against hospitalizations due to diarrhea (IRR 0.14, 95% CI 0.03, 0.60).

Conclusions: Implementation of steps 1-9 significantly reduced incidence of mild and severe episodes of diarrhea and respiratory infection in the first 6 months of life, addition of step 10 appeared to lessen this effect.

Trial registration: NCT01428232.

Keywords: Baby-Friendly Hospital Initiative (BFHI).; Breastfeeding; Diarrhea; Infants; Respiratory illness.

Figure 1.

Prevalence of exclusive breastfeeding among mother-infant pairs between 0–24 weeks by clinic randomization. Exclusive breastfeeding was defined as breastfeeding with no additional fluid or food. Exclusive breastfeeding was assessed at 1 hour after birth, 2–3 days after birth, age 1, 6, 10, 14, 18, and 24 weeks. For Baby-Friendly Hospital Initiative (BFHI) steps 1–9, health-care staff from antenatal and maternity care (i.e. delivery rooms and post-partum wards) were trained using the WHO/UNICEF materials. For BHFI steps 1–10, health-care staff were trained using the WHO/UNICEF materials and additionally distributed flyers containing culturally appropriate messages developed to address the keys behaviors that were identified as main contributors to the sub-optimal breastfeeding practices in the pretrial survey to women and their families. Control clinics provided the standard of care.