Effects of antenatal care and institutional delivery on exclusive breastfeeding practice in northwest Ethiopia: A nested case-control study

International Breastfeeding Journal, Volume 10, No. 1, Year 2015

Interprétation

Background: For the first six months of life, breast milk is the ideal food to provide adequate quality and quantity of nutrients. Exclusive breastfeeding has a profound effect to reduce the risk of respiratory and gastrointestinal related morbidities as well as all-cause and infection-related neonatal mortalities. Despite the immense benefits of exclusive breastfeeding, the practice is suboptimal in Ethiopia. The aim of this study was to assess whether antenatal care and institutional delivery contributes to mothers’ practice of exclusive breastfeeding in rural communities of northwest Ethiopia. Methods: A community-based nested case-control study was conducted in northwest Ethiopia from November 2009 to August 2011. About 1769 mother-infant pairs were included and followed for six months after birth. Interviews with mothers were conducted in the first week, at 1st, 4th, and 6th month. Bivariate and multivariate logistic regression were carried out to determine associations between independent variables and exclusive breastfeeding practice. Results: Of the total respondents, 30.7 % (95 % CI: 27 %, 35 %) of mothers exclusively breastfed their infants. In multivariate analysis, own business activity (AOR= 3.06; 95 % CI: 1.29, 7.25), being a housewife (AOR= 3.41; 95 % CI: 1.28, 9.11), having antenatal care (AOR= 1.32; 95 % CI: 1.01, 1.73), giving birth in a health institution (AOR= 1.29; 95 % CI: 1.02, 1.62), and possessing a microfinance bank account (AOR= 2.35; 95 % CI: 1.80, 3.07) were positively associated with exclusive breastfeeding practice. Conclusions: Despite underutilization of maternal health services, these services contributed to mothers exclusive breastfeeding practice. Strengthening utilization of antenatal care and institutional delivery would have an added benefit in improving exclusive breastfeeding practice. Moreover involving mothers in business activities is important. A community-based nested case–control study was conducted in Dabat Health and Demographic Surveillance System (DHDSS) site which is located in Dabat district, northwest Ethiopia. The district has an estimated population of 145,458 individuals living in 27 rural and 3 urban kebeles (the smallest administration unit). The livelihood of the residents is mainly subsistence farming. The district has two health centers and twenty-nine health posts providing health services for the community. The DHDSS covers ten randomly selected kebeles (three urban and seven rural kebeles) in different ecological zones (high land, middle land, and low land). A total of 46,165 people were living in these kebeles, of which infants comprise about 3 % [33]. Dabat Rural Health Project (the current DHDSS) has been running a Health and Demographic Surveillance System since November 1996. The surveillance site is hosted by the University of Gondar and collects information on vital events like birth, death, migration, and pregnancy registrations and its outcome on a quarterly basis. This study was part of a larger prospective follow-up study investigating infant mortality carried out in the DHDSS site. The project included all pregnant women who lived in the DHDSS site (ten kebeles) in the second/third trimester of their pregnancy and were recruited from November 2009 to August 2011. Pregnancy status was confirmed through interview by data collectors. The details of the primary project have been published elsewhere [34, 35]. From the original cohort, mothers who exclusively breastfed their infants for the first six months were selected as cases, while mothers who did not exclusively breastfeed for the first six months were considered controls. A total of 1769 mother-infant pairs (543 cases and 1226 controls) were included in the study. In the original project, mothers were contacted six times in the prospective follow ups: at the first week after birth, 1st, 4th, 6th, 9th and 12th month. For the purpose of the current study, the first four follow-ups: at the first week after birth, 1st, 4th, and 6th months were used to ascertain exclusive breastfeeding practice. During each follow-up visit, mothers were asked a key question ”did you give any food/fluid for your child starting from date of birth up to today but it does not include any medication or supplements” and those who responded “No” in all of the four visits qualified as a “case”, otherwise considered as a “control” in this study. If the mother had given any food/fluid apart from breast milk, the data collectors helped the mother to recall when she had provided this additional food. The mothers’ socio-demographic and economic, household food security status, IYCF knowledge, use of maternal health service, and health care access data were collected at the commencement of the original prospective study. At their first week after birth; birth outcome, place of delivery, maternal and neonatal health care services (vaccination, antenatal and postnatal care) received, neonatal feeding practice (timing of initiation of breastfeeding and any prelacteal foods given), and maternal and neonatal health status related data were collected. At the first month, the following data were collected: health status, any postnatal visit received, number of postnatal visit, exclusive breastfeeding practice, health seeking behavior of the mothers, and any vaccination received. At the four months, exclusive breastfeeding practice, immunization, method of feeding (if any additional food other than breast milk was started), and health status related data were gathered. At six months, exclusive breastfeeding practice, initiation and type of complementary food, dietary diversity, hygiene and sanitation, and other related information were collected. In addition, death was registered at any visit. Structured, pretested, interviewer-administered questionnaires adapted from the UNICEF multiple indicator cluster survey were employed to collect data [36]. To maintain consistency, the questionnaire was first translated from English to Amharic, the native language of the study area, and back translated to English by professional translators and public health experts. Double data entry was also conducted. The collected data were checked for completeness by the field supervisors and investigators on a daily basis. Seventeen data collectors with high school education and three field supervisors with previous experience in data collection and supervision were recruited. Local informants who were permanent residents of the village were also recruited to assist data collectors and supervisors throughout the study period. They have provided information about completion of pregnancy as soon as possible regardless of gestational age and birth outcome. A five day intensive training about the study objectives, interview techniques, and ethical issues were conducted for data collectors, supervisors, and local informants. In this study, the exclusive breastfeeding status was ascertained based on the WHO recommendation, starting from the first day of life. An infant was considered to be exclusively breastfed when he or she had received only breast milk with no other liquids (including water) or solids. Early initiation of breastfeeding was defined as infants who initiated breastfeeding within an hour of birth [1]. The outcome variable of this study was exclusive breastfeeding practice with dichotomous category (yes/no). Potential predictor variables were age of the mother, marital status, maternal occupation and educational status, possession of microfinance bank account, place of residence, sex of infant, place of delivery, and antenatal care. Antenatal care for the index child was determined as whether the mother had at least one antenatal visit or not. Data were coded and entered into Epi-Info version 3.5.3 and exported to Stata Version 11 software for analysis. Descriptive statistics was used to characterize the study variables. A binary logistic regression was used to identify determinants of EBF practice. Variables with a p-value of < 0.2 in bivariate analysis were entered to multivariate analysis to control the possible effect of confounders. The Adjusted Odds Ratio (AOR) with 95 % Confidence Interval (CI) was computed to assess the strength of association, and a p-value of ≤ 0.05 was used to declare the statistical significance in the multivariate analysis. Ethical clearance was obtained from the Ethical Review Board of University of Gondar (Ref. No RPO 55/338/2001, and Date September 15, 2009) and, submitted to Dabat Research Center/DHDSS site. The objective of the study was explained, and informed verbal consent was obtained from each participant before the interviews took place. Participant records were coded and only accessed by the research team. Participants who were unwilling to participate and wanted to withdraw at any step of the interviews were able to do so without any restriction.

Résumé de l’IA

Study Justification:

– Breast milk is the ideal food for infants in the first six months of life, providing necessary nutrients and reducing the risk of various illnesses and mortalities.
– Exclusive breastfeeding is not widely practiced in Ethiopia, indicating a need for further investigation into the factors influencing this behavior.
– This study aimed to assess the impact of antenatal care and institutional delivery on exclusive breastfeeding practice in rural communities of northwest Ethiopia.

Highlights:

– The study found that 30.7% of mothers exclusively breastfed their infants.
– Factors positively associated with exclusive breastfeeding practice included own business activity, being a housewife, receiving antenatal care, giving birth in a health institution, and possessing a microfinance bank account.
– Despite underutilization of maternal health services, these services contributed to mothers’ exclusive breastfeeding practice.
– Strengthening the utilization of antenatal care and institutional delivery could further improve exclusive breastfeeding practice.
– Involving mothers in business activities is also important for promoting exclusive breastfeeding.

Recommendations:

– Encourage and support mothers to engage in business activities to enhance exclusive breastfeeding practice.
– Promote the utilization of antenatal care services among pregnant women to improve exclusive breastfeeding rates.
– Advocate for institutional delivery to increase the likelihood of exclusive breastfeeding.
– Implement strategies to improve access to microfinance services for mothers to support exclusive breastfeeding.

Key Role Players:

– Health centers and health posts in the study area.
– Community health workers and volunteers.
– Local government authorities responsible for maternal and child health programs.
– Non-governmental organizations working in the field of maternal and child health.

Cost Items for Planning Recommendations:

– Training programs for health workers and community volunteers.
– Awareness campaigns and educational materials for mothers and families.
– Support for microfinance initiatives targeting mothers.
– Monitoring and evaluation activities to assess the impact of interventions.
– Administrative and logistical support for implementing the recommendations.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a community-based nested case-control study with a large sample size. The study conducted interviews with mothers at multiple time points and used bivariate and multivariate logistic regression to determine associations between variables. The study also provides adjusted odds ratios and confidence intervals. To improve the evidence, the abstract could include more information about the study design, such as the sampling method and inclusion criteria. Additionally, it would be helpful to provide more details about the statistical analysis performed and any limitations of the study.

Abstrait

A community-based nested case–control study was conducted in Dabat Health and Demographic Surveillance System (DHDSS) site which is located in Dabat district, northwest Ethiopia. The district has an estimated population of 145,458 individuals living in 27 rural and 3 urban kebeles (the smallest administration unit). The livelihood of the residents is mainly subsistence farming. The district has two health centers and twenty-nine health posts providing health services for the community. The DHDSS covers ten randomly selected kebeles (three urban and seven rural kebeles) in different ecological zones (high land, middle land, and low land). A total of 46,165 people were living in these kebeles, of which infants comprise about 3 % [33]. Dabat Rural Health Project (the current DHDSS) has been running a Health and Demographic Surveillance System since November 1996. The surveillance site is hosted by the University of Gondar and collects information on vital events like birth, death, migration, and pregnancy registrations and its outcome on a quarterly basis. This study was part of a larger prospective follow-up study investigating infant mortality carried out in the DHDSS site. The project included all pregnant women who lived in the DHDSS site (ten kebeles) in the second/third trimester of their pregnancy and were recruited from November 2009 to August 2011. Pregnancy status was confirmed through interview by data collectors. The details of the primary project have been published elsewhere [34, 35]. From the original cohort, mothers who exclusively breastfed their infants for the first six months were selected as cases, while mothers who did not exclusively breastfeed for the first six months were considered controls. A total of 1769 mother-infant pairs (543 cases and 1226 controls) were included in the study. In the original project, mothers were contacted six times in the prospective follow ups: at the first week after birth, 1st, 4th, 6th, 9th and 12th month. For the purpose of the current study, the first four follow-ups: at the first week after birth, 1st, 4th, and 6th months were used to ascertain exclusive breastfeeding practice. During each follow-up visit, mothers were asked a key question ”did you give any food/fluid for your child starting from date of birth up to today but it does not include any medication or supplements” and those who responded “No” in all of the four visits qualified as a “case”, otherwise considered as a “control” in this study. If the mother had given any food/fluid apart from breast milk, the data collectors helped the mother to recall when she had provided this additional food. The mothers’ socio-demographic and economic, household food security status, IYCF knowledge, use of maternal health service, and health care access data were collected at the commencement of the original prospective study. At their first week after birth; birth outcome, place of delivery, maternal and neonatal health care services (vaccination, antenatal and postnatal care) received, neonatal feeding practice (timing of initiation of breastfeeding and any prelacteal foods given), and maternal and neonatal health status related data were collected. At the first month, the following data were collected: health status, any postnatal visit received, number of postnatal visit, exclusive breastfeeding practice, health seeking behavior of the mothers, and any vaccination received. At the four months, exclusive breastfeeding practice, immunization, method of feeding (if any additional food other than breast milk was started), and health status related data were gathered. At six months, exclusive breastfeeding practice, initiation and type of complementary food, dietary diversity, hygiene and sanitation, and other related information were collected. In addition, death was registered at any visit. Structured, pretested, interviewer-administered questionnaires adapted from the UNICEF multiple indicator cluster survey were employed to collect data [36]. To maintain consistency, the questionnaire was first translated from English to Amharic, the native language of the study area, and back translated to English by professional translators and public health experts. Double data entry was also conducted. The collected data were checked for completeness by the field supervisors and investigators on a daily basis. Seventeen data collectors with high school education and three field supervisors with previous experience in data collection and supervision were recruited. Local informants who were permanent residents of the village were also recruited to assist data collectors and supervisors throughout the study period. They have provided information about completion of pregnancy as soon as possible regardless of gestational age and birth outcome. A five day intensive training about the study objectives, interview techniques, and ethical issues were conducted for data collectors, supervisors, and local informants. In this study, the exclusive breastfeeding status was ascertained based on the WHO recommendation, starting from the first day of life. An infant was considered to be exclusively breastfed when he or she had received only breast milk with no other liquids (including water) or solids. Early initiation of breastfeeding was defined as infants who initiated breastfeeding within an hour of birth [1]. The outcome variable of this study was exclusive breastfeeding practice with dichotomous category (yes/no). Potential predictor variables were age of the mother, marital status, maternal occupation and educational status, possession of microfinance bank account, place of residence, sex of infant, place of delivery, and antenatal care. Antenatal care for the index child was determined as whether the mother had at least one antenatal visit or not. Data were coded and entered into Epi-Info version 3.5.3 and exported to Stata Version 11 software for analysis. Descriptive statistics was used to characterize the study variables. A binary logistic regression was used to identify determinants of EBF practice. Variables with a p-value of < 0.2 in bivariate analysis were entered to multivariate analysis to control the possible effect of confounders. The Adjusted Odds Ratio (AOR) with 95 % Confidence Interval (CI) was computed to assess the strength of association, and a p-value of ≤ 0.05 was used to declare the statistical significance in the multivariate analysis. Ethical clearance was obtained from the Ethical Review Board of University of Gondar (Ref. No RPO 55/338/2001, and Date September 15, 2009) and, submitted to Dabat Research Center/DHDSS site. The objective of the study was explained, and informed verbal consent was obtained from each participant before the interviews took place. Participant records were coded and only accessed by the research team. Participants who were unwilling to participate and wanted to withdraw at any step of the interviews were able to do so without any restriction.

Matériaux

N/A

Innovations

Based on the provided information, here are some potential recommendations for innovations to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop and implement mobile health applications that provide pregnant women and new mothers with access to important health information, reminders for antenatal care visits, and breastfeeding support.

2. Telemedicine Services: Establish telemedicine services to provide remote consultations and support for pregnant women and new mothers, especially those in rural areas with limited access to healthcare facilities.

3. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women and new mothers in rural communities. These workers can help promote exclusive breastfeeding practices and provide guidance on antenatal care and institutional delivery.

4. Maternal Health Vouchers: Introduce a voucher system that provides financial assistance to pregnant women, enabling them to access antenatal care and institutional delivery services. This can help reduce financial barriers and increase utilization of these services.

5. Maternity Waiting Homes: Establish maternity waiting homes near healthcare facilities to provide accommodation and support for pregnant women in the days leading up to delivery. This can ensure timely access to skilled birth attendants and reduce the risk of complications during childbirth.

6. Public-Private Partnerships: Foster collaborations between public and private healthcare providers to improve access to maternal health services. This can involve leveraging private sector resources and expertise to expand service delivery and reach underserved populations.

7. Health Education Campaigns: Launch targeted health education campaigns to raise awareness about the benefits of exclusive breastfeeding and the importance of antenatal care and institutional delivery. These campaigns can be conducted through various channels, including mass media, community outreach programs, and social media platforms.

8. Maternal Health Financing: Explore innovative financing mechanisms, such as microfinance or community-based health insurance, to ensure affordable and sustainable access to maternal health services. This can help overcome financial barriers and increase utilization of these services.

It is important to note that the implementation of these innovations should be context-specific and tailored to the local healthcare system and cultural practices.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to strengthen the utilization of antenatal care and institutional delivery. The study found that mothers who had antenatal care and gave birth in a health institution were more likely to practice exclusive breastfeeding. Therefore, improving access to antenatal care and promoting institutional delivery can have an added benefit in improving exclusive breastfeeding practice.

Additionally, involving mothers in business activities was also found to be important. This suggests that empowering mothers economically can contribute to better maternal and child health outcomes. Providing opportunities for income generation and entrepreneurship can help improve access to maternal health services and support exclusive breastfeeding practices.

Overall, the recommendation is to focus on improving access to antenatal care, promoting institutional delivery, and empowering mothers economically to enhance maternal health and exclusive breastfeeding practices.

AI Innovations Methodology

Based on the provided study, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and utilization of antenatal care: Promote the importance of antenatal care through community education campaigns and targeted messaging. Provide incentives or subsidies to encourage pregnant women to attend regular antenatal care visits.

2. Improve access to institutional delivery: Enhance the availability and quality of health facilities for safe deliveries. This can be achieved by increasing the number of health centers and health posts in rural areas, training and deploying skilled birth attendants, and ensuring the availability of essential obstetric care services.

3. Strengthen microfinance programs: Support and expand microfinance programs to empower women economically. This can help improve their access to maternal health services by providing financial resources for transportation, medical expenses, and other related costs.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of pregnant women receiving antenatal care, the percentage of deliveries in health institutions, and the percentage of women exclusively breastfeeding.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, or existing data sources.

3. Implement the recommendations: Introduce the recommended interventions, such as awareness campaigns, infrastructure improvements, and microfinance programs. Ensure proper implementation and monitor progress.

4. Collect post-intervention data: After a sufficient period of time, collect data on the indicators again to assess the impact of the interventions. This can be done using the same methods as the baseline data collection.

5. Analyze the data: Compare the baseline and post-intervention data to determine the changes in the indicators. Calculate the percentage increase or decrease in access to maternal health services and exclusive breastfeeding practice.

6. Evaluate the impact: Assess the overall impact of the recommendations on improving access to maternal health. Consider factors such as the magnitude of change, sustainability of the improvements, and any unintended consequences.

7. Refine and adjust: Based on the evaluation, refine the recommendations and interventions as needed. Continuously monitor and evaluate the impact to ensure ongoing improvement in access to maternal health.

By following this methodology, policymakers and healthcare providers can assess the effectiveness of different interventions and make informed decisions to improve access to maternal health services.

Auteur

Dima Health

Statistics:

Citations: 34

Identifiers:

DOI: 10.1186/s13006-015-0055-4

Research Areas:

Community Interventions, Disparities, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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