Effect of peer support group in sustaining exclusive breastfeeding practice among women of reproductive age, Kenya

INTRODUCTION

Early initiation of breastfeeding with continuous exclusive breastfeeding for six months after delivery is known for protection towards long and short term illness, this in turn saves life also dollars for health care services.¹ WHO and UNICEF encourages mothers to start breastfeeding in the first hour after delivery.¹ A systematic review published in 2013 to 2014 established that putting the neonate on breastmilk early (described in the reviews as putting babies on breast milk 24 hours after delivery) was linked to low incidence of neonate deaths.^2,3 Nevertheless, globally only 50% of the mothers initiate breastfeeding within 24 hours after delivery.⁴

A study in rural Ghana, assessing if the timing of initiation of breastfeeding and type (exclusive, predominant, or partial) is linked to the risk of neonatal mortality. Indicated breastfeeding initiated within the first day of birth in 71%, were exclusively breastfed during the neonatal period. In the same study they noted the neonatal death was fourfold higher in children given milk based fluids or solids in addition to breast milk. The study also showed an increasing risk of neonatal death associated with an increasing delay in the initiation of breastfeeding from 1 hour to 7 days after delivery. The late initiation of breastfeeding after day one was linked with a 2.4-fold increase of neonatal death. The effect demonstrated in the study was similar when model refitted excluding neonates at high risk of death (congenital abnormalities, premature, unwell at the time of interview, unwell on the day of birth) or deaths during the first week (days 2-7) were excluded.⁵ Therefore, concluding 16% of neonatal deaths could be saved if all infants were breastfed from day 1 and 22% if breastfeeding started within the first hour. Similarly, in rural Bangladesh, a study to determine the effect of timing of breastfeeding initiation on early newborn sepsis. In the study sepsis was determined by use of the neonatal danger signs by "The young-infants clinical science study group". The initiation of breastfeeding timing was within 1hr, 1-24 hour, 24-48hour, and more than 48hour after delivery. The study illustrated an increase in incidence of sepsis as initiation of breastfeeding was delayed from 1hour (12.0%), 24 hours (15.7%), 48 hours (27.7%) to more than 48hours (36.7%) after delivery. This demonstrates early initiation of breastfeeding within the first one hour after delivery confers protective effect on neonatal sepsis during the first 7 days after delivery.⁶ This also concurs with a study done in Chipinge district, Zimbabwe to determine early breastfeeding initiation and the risk of neonatal sepsis within the first week of life revealed a significant link between early breastfeeding initiation and neonatal sepsis in the first week of life. Concluding that the delay in initiating breastfeeding increases the risk of neonatal sepsis as demonstrated by Pearson correlation at 0.01 levels (2 tailed) at day 3 and day 7, and indicating that about 33 % neonatal deaths can be prevented if breastfeeding is initiated within an hour after delivery.⁷

According to Horta and Victora when a child is breastfed continuously for six months with no other liquids or solids it helps the infant survive and sustain good health. Breast milk provides a child with essential nutrients, which protects the child from illness such as diarrheal, pneumonia and respiratory infections, contributing to primary causes of childhood mortality.^4,8 Globally, 40% of children are fed on breast milk only in their first six months of life, with no other liquids or solids. Poor practices in breastfeeding among lactating mothers is attributed to 11.6% of deaths among the under 5 years of age which is comparable to 804 000 mortalities in the same age of children in 2011.⁹

In their systematic review and meta-analysis study Smithers argues that infants 0-5 months of age who do not or partially breastfed do have a risk of death from diarrhoea and other infections.¹⁰ Poor breastfeeding practice among mothers has been attributed to 1.4 million deaths among the children and a 44 million disability adjusted life years (DALYs), contributing to a 10% of children below 5 years of age.¹¹ Observations of under nutrition related to restriction of growth in foetal, wasting, stunting, vitamin A and Zinc deficiency alongside poor breastfeeding practice contributes to a mortality of 3.1 million among children yearly which is equivalent to 45% of deaths in 2011.¹² In 2018, WHO estimated that under nutrition contributed to 45% of child deaths. The Bellagio child survival series acknowledged that by optimizing breastfeeding practices among mothers this could avert mortality among the under 5 years up to 13%.¹³ This finding concur with the conclusions which reported that poorly breastfed infants 0-5 months of age, had a significantly greater danger of death due to infections of all cause in relation to those who are fed on breast milk only. More so children months 6-23 of age who never breastfeed had an increased risk of death due to all cause than those children reported to have continued breastmilk past 6 months of age thus good breastfeeding practice among mothers provides protection towards the children, Smithers argues that infants who do not or partially breastfed do have a risk of death from diarrhoea and other infections.¹⁰

In spite the several well-known benefits of breastfeeding few lactating mothers are able to feed infants who are below six months only on breastmilk. In 1992 WHO and UNICEF launched the baby-friendly hospital initiative (BFHI) to address the practice gap in breastfeeding. Recommending the counselling and linking of mothers into breast feeding mother peer support group for continuous support to sustain exclusive breastfeeding practice after discharge from the hospital.¹⁴ Peer support and counselling is recognized by the WHO and UNICEF as a key action to sustain feeding of infants on breastmilk only with no other liquids or solids for six months after delivery and provision for continuity for up to the age of 2 years.¹⁴ Peer support group for mothers was singled out as one of the interventions which promote and support mothers to sustain feeding the baby on breast milk at least six months with no other liquids or solids by building the mothers breastfeeding self-efficacy and confidence.¹⁵ The Kenya demographic health survey indicates 2.5% of infants from the Eastern Region where the study site is located were fed on breast milk at least six months with no other liquids or solids after delivery, which is below 61 the Kenyan national percentage.¹⁶ The aim of this study was to determine the effect of using peer support group to initiate breastfeeding within the 1^st hour after delivery and sustain exclusive breastfeeding for six months after delivery to improve survival, and reduce morbidity and mortality among the children.

METHODS

Study design

A cross sectional descriptive study was undertaken at baseline to define the demographic characteristics, time of initiating breastfeeding and exclusive breastfeeding practice for 6 months after delivery data. A quasi-experimental intervention study undertaken between the years 2022 to 2023 in Mbooni and Kilome sub-County (intervention and control site) respectively in Makueni County Eastern Region, Kenya.

Study population and sampling size

The study population included pregnant women from the 2^nd trimester, and the mother baby pair till 6 months after delivery. The sample size was determined by use of Kelsey et al formula for cohort study determination.¹⁷ The required sample size was estimated to be 353 participants. The study enrolled 360 participants in the control group and 361 participants in the intervention group by use of systematic sampling technique. The participants were assigned to a peer support group by use of simple random technique.

Study recruitment procedure

Participants were enrolled into the study from the antenatal clinic during the 2^nd trimester of their pregnancy. The mothers were randomly assigned to a peer support group. The peer support group met monthly until 6 months after delivery with guidance from a nurse and nutritionist. A peer support guide was developed in accordance with WHO/UNICEF infant and young child feeding policy to guide each session. The guide was packaged to equip the mothers with concepts on initiating breastfeeding within the 1^st hour after delivery and sustaining exclusive breast feeding for 6 months after delivery. These included knowledge on the benefits of exclusive breastfeeding and breastfeeding to the child, mother, family community, early initiation of breast feeding after delivery, the art of positioning, latching and attachment during breastfeeding sessions, the frequency and duration of exclusive breastfeeding, the problems associated with breastfeeding and their coping mechanism, expressing breast milk and storage for use, and the act of sustaining exclusive breastfeeding practice for six months after delivery. At each session the mothers watched a video from the global health media on breastfeeding practice. During the sessions the mothers discussed and shared their knowledge and experience on the practice of exclusive breastfeeding.

Data collection

Quantitative data was collected by use of self-administered questionnaires from participants who gave a written consent to participate in the study. Confidentiality and privacy of participants was highly observed throughout the study period. Approval to conduct the study was obtained from KNH-UoN (Kenyatta national hospital university of Nairobi) ethical research committee, NACOSTI (National Commission for Science, Technology and Innovation) also the Makueni county director of health in Kenya. During the research, informed consent was sought from the study participants, and those unwilling to participate in the research process were not compelled to do so. This research was non-invasive, and the data collection forms did not bear the name of the respondents; they were identified by a study identity code number. Respondents’ data was used with strict confidentiality and for the sole purpose of meeting the objectives of this study.

Data analysis

Quantitative data was collected and analyzed using the statistical package for social sciences (SPSS), version 26. The significance level was set at p<0.05, with a 95% confidence interval (CI). A Mantel-Haenszel common odds ratio estimate calculated to determine the effect of peer support group on time of initiating breastfeeding after delivery and an independent t-test to determine the effect of the peer support group on exclusive breastfeeding practice.

RESULTS

The study enrolled 721 participants (361,360) in the intervention and control sites respectively.

The sex distribution of the children between the two study sites was not statistically different. The male children in intervention and control sites formed 49.7% and 50.3% of the population respectively (p=0.881). Majority of the mothers reported to have attended school. The proportion of the mothers who attended school in the intervention and control site was 99.7% and 98.9% respectively (p=0.217).

The mean age of the mothers in intervention and control site was not statistically significantly different. The average age of a mother in both areas was approximately 28 years (p=0.432). The respondents in both study sites received antenatal care (16 weeks) at approximately four months of gestation (p=0.91).

Mantel-Haenszel common odds ratio estimate were calculated to determine the effect of peer support group on time of initiating breastfeeding after delivery. Chi-square value 36.093 DF: 1 after intervention. The Mantel-Haenszel common odds ratio estimate was asymptotically normally distributed under the common odds ratio of 1.000 assumption. So was the natural log of the estimate. After the intervention, neonates from the intervention site were 6.364 times more likely to have been initiated to breastfeeding within one hour after delivery compared to those from control site (natural log estimate 1.851) (OR: 6.364; 95% CI: 3.285 to 12.326). At baseline there was no statistically significant difference between both study sites. Timely initiation of breastfeeding at the intervention site improved from 72.3% at baseline to 97% after intervention.

The exclusive breastfeeding practice at baseline mean score for the intervention site was 54.1% while that of the control site was 60.78%. At post intervention the practice mean score in the intervention site improved to 83.04% while that of the control site improved to 62.68%. The practice in the intervention group was better than the control group post intervention (p<0.001).

DISCUSSION

This study demonstrates the effectiveness of peer support group as an intervention to support mothers to initiate breastfeeding within the 1^st hour after delivery and sustain the practice of exclusive breastfeeding for at least six months after delivery with no other liquids or solids. Remarkably the act of feeding infants on breastmilk at least six months with no other liquids or solids after delivery is subjected to several environmental and psychosocial elements.^18,19 In the interpretation of Hector et al numerous elements which have an effect on breastfeeding practice namely societal influence, group dynamics, and individual factors which impact on the efforts of mothers to feed their infant on breastmilk only with no other liquids or solids for six months after delivery.²⁰ This study addressed factors which include timely initiation of breast feeding after delivery, benefits of exclusive breastfeeding to (child, mother, family community). The skill in improving the practice namely positioning, latching and attachment. Frequency of breastfeeding and duration of exclusive breastfeeding. Delineated problems associated with breastfeeding and their coping mechanism. Deliberated on the skill of expressing breast milk and storage. WHO recommends knowledge level of 90% to support the mothers make informed decision on exclusive breastfeeding.

This study through the peer support group delivered knowledge to the mothers to initiate breast feeding within the 1^st hour after delivery. After the intervention, neonates from the intervention site were 6.364 times more likely to be initiated to breastfeeding within one hour after delivery compared to those in the control site (natural log estimate 1.851) (OR: 6.364; 95% CI: 3.285 to 12.326). This study agrees with a review by Chapman et al which concluded there was an improvement in the initiation of breastmilk and continuation of feeding the infant on breastmilk only with no other liquids or solids for six months after delivery in studies which engaged peer counsellors.²¹ The social network in form of peer support are important to first time mothers who are adolescents, Volpe and Bear in their study reported 65% of adolescent mothers within the peer support group initiated breastfeeding to their infants after delivery, in comparison to 15% in the control group.²² Similarly, Chapman et al., in their study noted women who were not certain on breastfeeding their infants after delivery after an encounter with the peer counsellors they were 7.4 times likely to introduce breastmilk to the infant after delivery.²³ Notably, the public health institutions in Addis Ababa, Ethiopia documented 58.3% of those who sustaining exclusive breastfeeding practice after discharge initiated breastfeeding within one hour of birth.²⁴

In this study the average age of the mothers is 28 years and the mothers received antenatal care (16 weeks) at approximately the fourth month of their gestation, the peer support group was initiated at the 2^nd trimester, this is critical in sight of delivering information and skills on breastfeeding which influence the attitude and practice after delivery. Likewise, a systematic review which indicated the delivery of breastfeeding information in a mixed setting had an increased effect in promoting exclusive breastfeeding with accelerated efforts on delivery of the information at the postnatal period.²⁵

The results of the study indicate exclusive breastfeeding practice for 6 months after delivery at baseline the mean score for the intervention site was 54.11% while that of the control site was 60.78%. At post intervention the practice mean score in the intervention site was 83.04% while that of the control site was 62.68%. Indicating the practice of exclusive breastfeeding with no other liquids or solids for six months after delivery in the intervention group improved more than the control group post intervention (p<0.001). The key noted challenges to feeding infants on breastmilk only with no other liquids or solids for six months after delivery are failure to information on the significances and deficiency in the skill. Myths, customs and beliefs have also been cited as potential challenges to exclusive breastfeeding. Similarly, the study by Kushwaha et al demonstrated peer support groups initiated during pregnancy and through to post deliver is critical to change behaviour and promote the exclusivity and the length of breastfeeding. The peer support nurture breastfeeding and the peers comprehend the complications and deliver guidance which is reasonable as they share similar experience.²⁶ Similarly, a Bangladesh study concluded a substantial rise in the feeding of infants on breastmilk only with no other liquids or solids for six months after delivery as a consequence of peer counselling based at the community level.²⁷ Likewise, another study in Bangladesh also demonstrated individualized psychotherapy on feeding the infant on breastmilk only with no other liquids or solids for six months after delivery increased the practice.²⁸ Similarly, in a systematic review by Jolly et al found a significant result in feeding infant on breastmilk only with no other liquids or solids for six months after delivery in low and middle income countries through peer support.²⁹ This is similar to findings by Fairbank et al that also reported the importance of peer support in increasing breastfeeding outcome in low income group mothers.³⁰ Likewise, a review of a meta-analysis from countries of low and middle income indicate peer support at the community level was important in improving the practice of feeding the baby on breast milk at least six months with no other liquids or solids after delivery compared to those who were not in peer support.³¹ A study done in Norwegian, observed improvement in feeding the infant on breastmilk only with no other liquids or solids for six months after delivery after initiating community breastfeeding initiative health³². Equally, multiple behaviour change interventions have been implemented in different modalities to improve the practice of breastfeeding.^33-36

Limitations

The study relied on self-reported measures, so are participants to recall and social desirability biases, potentially affecting the accuracy of the results.

CONCLUSION

This study highlighted the importance of establishing peer support group to engage the mothers during ante natal period and post-delivery to build the skill to initiate the neonate on breastmilk within the 1^st hour after delivery and sustain exclusive breastfeeding for six months with no other liquids or solids after delivery. The study concluded the peer support group is imperative in supporting mothers through the uncertainty on initiation of breastfeeding after delivery and nurturing exclusive breast feeding practice for six months with no other liquids or solids after delivery. The peers are able to comprehend the complications and deliver guidance which is reasonable as they share similar experiences. Likewise, devise ways of dealing with breastfeeding challenges that they face once they are discharged from health facility. Peer support groups also give continuous support and encouragement among the mothers to develop a positive attitude and generate self-confidence. This in turn will accelerate the nutritional global targets

Recommendations

The study recommends the establishment of peer support groups during the antenatal period, with a guided structure to build capacity and act as an avenue to share personal experience and support each other for a positive change. Also integrating the groups to the community level. Future research is recommended on the use of telehealth to sustain exclusive breastfeeding for six months with no other liquids or solids after delivery.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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